Complete Test Bank For Clinical Nursing Skills and Techniques 10th Edition by Anne Griffin Perry, Patricia A. Potter Chapter 1-43 Complete Guide
Table Of Content
Chapter 1. Using Evidence in Nursing Practice Chapter 2. Communication and Collaboration Chapter 3. Admitting, Transfer, and Discharge Chapter 4. Documentation and Informatics Chapter 5. Vital Signs Chapter 6. Health Assessment Chapter 7. Specimen Collection Chapter 8. Diagnostic Procedures Chapter 9. Medical Asepsis Chapter 10. Sterile Technique Chapter 11. Safe Patient Handling and Mobility (SPHM) Chapter 12. Exercise and Mobility Chapter 13. Support Surfaces and Special Beds Chapter 14. Patient Safety Chapter 15. Disaster Preparedness Chapter 16. Pain Management Chapter 17. End-of-Life Care Chapter 18. Personal Hygiene and Bed Making Chapter 19. Care of the Eye and Ear Chapter 20. Safe Medication Preparation Chapter 21. Nonparenteral Medications Chapter 22. Parenteral Medications Chapter 23. Oxygen Therapy Chapter 24. Performing Chest Physiotherapy Chapter 25. Airway Management Chapter 26. Cardiac Care Chapter 27. Closed Chest Drainage Systems Chapter 28. Emergency Measures for Life Support Chapter 29. Intravenous and Vascular Access Therapy Chapter 30. Blood Therapy Chapter 31. Oral Nutrition Chapter 32. Enteral Nutrition Chapter 33. Parenteral Nutrition Chapter 34. Urinary Elimination Chapter 35. Bowel Elimination and Gastric Intubation Chapter 36. Ostomy Care Chapter 37. Preoperative and Postoperative Care Chapter 38. Intraoperative Care Chapter 39. Wound Care and Irrigations Chapter 40. Impaired Skin Integrity Prevention and Care Chapter 41. Dressings, Bandages, and Binders Chapter 42. Home Care Safety Chapter 43. Home Care Teaching
Chapter 01: Using Evidence in Nursing Practice Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLETIPL CE E CHOICECHOI 1. Evidence-based practice is a problem-solving approach to making decisions about patient care MUL
that is grounded in: a. the latest information found in textbooks. b. systematically conducted research studies. c. tradition in clinical practice. d. quality improvement and risk-management data. ANS: B
The best evidence comes from well-designed, systematically conducted research studies described in scientific journals. Portions of a textbook often become outdated by the time it is published. Many health care settings do not have a process to help staff adopt new evidence in practice, and nurses in practice settings lack easy access to risk-management data, relying instead on tradition or convenience. Some sources of evidence do not originate from research. These include quality improvement and risk-management data; infection control data; retrospective or concurrent chart reviews; and clinicians‘ expertise. Although non–research-based evidence is often very valuable, it is important that you learn to rely more on research-based evidence. DIF: CognitiveLevel: Comprehension OBJ: Discuss the benefits of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment (management of care)
2. When evidence-based practice is used, patient care will be: a. standardized for all. b. unhampered by patient culture. c. variable according to the situation. d. safe from the hazards of critical thinking. ANS: C
Using your clinical expertise and considering patients‘ cultures, values, and preferences ensures that you will apply available evidence in practice ethically and appropriately. Even when you use the best evidence available, application and outcomes will differ; as a nurse, you will develop critical thinking skills to determine whether evidence is relevant and appropriate. DIF: CognitiveLevel: Application OBJ: Discuss the benefits of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment (management of care)
3. When a PICOT question is developed, the letter that corresponds with the usual standard of care is: a. P. b. I. c.
Q&A
BuyBuy andand SellSell youryour StudyStudy MaterialMaterial
c. CHOICE BLANK d. O. ANS: C
C = Comparison of interest. What standard of care or current intervention do you usually use now in practice? P = Patient population of interest. Identify your patient by age, gender, ethnicity, disease, or health problem. I = Intervention of interest. What intervention (e.g., treatment, diagnostic test, and prognostic factor) do you think is worthwhile to use in practice? O = Outcome. What result (e.g., change in patient‘s behavior, physical finding, and change in patient‘s perception) do you wish to achieve or observe as the result of an intervention? DIF: CognitiveLevel: Knowledge OBJ: Develop a PICO question. TOP: PICO KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
4. A well-developed PICOT question helps the nurse: a. search for evidence. b. include all five elements of the sequence. c. find as many articles as possible in a literature search. d. accept standard clinical routines. ANS: A
The more focused a question that you ask is, the easier it is to search for evidence in the scientific literature. A well-designed PICOT question does not have to include all five elements, nor does it have to follow the PICOT sequence. Do not be satisfied with clinical routines. Always question and use critical thinking to consider better ways to provide patient care. DIF: CognitiveLevel: Analysis OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
5. The nurse is not sure that the procedure the patient requires is the best possible for the situation. Utilizing which of the following resources would be the quickest way to review research on the topic? a. CINAHL b. PubMed c. MEDLINE d. The Cochrane Database ANS: D
The Cochrane Community Database of Systematic Reviews is a valuable source of synthesized evidence (i.e., pre-appraised evidence). The Cochrane Database includes the full text of regularly updated systematic reviews and protocols for reviews currently happening. MEDLINE, CINAHL, and PubMed are among the most comprehensive databases and represent the scientific knowledge base of health care. DIF: CognitiveLevel: Synthesis OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
6. The nurse is getting ready to develop a plan of care for a patient who has a specific need. The best source for developing this plan of care would probably be: a. The Cochrane Database. b. MEDLINE. c. NGC. d. CINAHL. ANS: C
The National Guidelines Clearinghouse (NGC) is a database supported by the Agency for Healthcare Research and Quality (AHRQ). It contains clinical guidelines—systematically developed statements about a plan of care for a specific set of clinical circumstances involving a specific patient population. The NGC is a valuable source when you want to develop a plan of care for a patient. The Cochrane Community Database of Systematic Reviews, MEDLINE, and CINAHL are all valuable sources of synthesized evidence (i.e., pre-appraised evidence). DIF: CognitiveLevel: Synthesis OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
7. The nurse has done a literature search and found 25 possible articles on the topic that she is studying. To determine which of those 25 best fit her inquiry, the nurse first should look at: a. the abstracts. b. the literature reviews. c. the ―Methods‖ sections. d. the narrative sections. ANS: A
An abstract is a brief summary of an article that quickly tells you whether the article is research based or clinically based. An abstract summarizes the purpose of the study or clinical query, the major themes or findings, and the implications for nursing practice. The literature review usually gives you a good idea of how past research led to the researcher‘s question. The ―Methods‖ or ―Design‖ section explains how a research study is organized and conducted to answer the research question or to test the hypothesis. The narrative of a manuscript differs according to the type of evidence-based article—clinical or research. DIF: CognitiveLevel: Application OBJ: Discuss elements to review when critiquing the scientific literature. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
8. The nurse wants to determine the effects of cardiac rehabilitation program attendance on the level of postmyocardial depression for individuals who have had a myocardial infarction. The type of study that would best capture this information would be a: a. randomized controlled trial. b. qualitative study. c. case control study. d. descriptive study. ANS: B
Qualitative studies examine individuals‘ experiences with health problems and the contexts in which these experiences occur. A qualitative study is best in this case of an individual nurse who wants to examine the effectiveness of a local program. Randomized controlled trials involve close monitoring of control groups and treatment groups to test an intervention against the usual standard of care. Case control studies typically compare one group of subjects with a certain condition against another group without the condition, to look for associations between the condition and predictor variables. Descriptive studies focus mainly on describing the concepts under study. DIF: CognitiveLevel: Synthesis OBJ: Discuss ways to apply evidence in nursing practice. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
9. Six months after an early mobility protocol was implemented, the incidence of deep vein thrombosis in patients was decreased. This is an example of what stage in the EBP process? a. Asking a clinical question b. Applying the evidence c. Evaluating the practice decision d. Communicating your results ANS: C
After implementing a practice change, your next step is to evaluate the effect. You do this by analyzing the outcomes data that you collected during the pilot project. Outcomes evaluation tells you whether your practice change improved conditions, created no change, or worsened conditions. DIF: CognitiveLevel: Application OBJ: Discuss ways to apply evidence in nursing practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe and Effective Care Environment (safety and infection control) MULTIPLE RESPONSE
1. To use evidence-based practice appropriately, you need to collect the most relevant and best evidence and to critically appraise the evidence you gather. This process also includes: (Select all that apply.) a. asking a clinical question. b. applying the evidence. c. evaluating the practice decision. d. communicating your results. ANS: A, B, C, D
EBP comprises six steps (Melnyk and Fineout-Overholt, 2010): 1. Ask a clinical question. 2. Search for the most relevant and best evidence that applies to the question. 3. Critically appraise the evidence you gather. 4. Apply or integrate evidence along with one‘s clinical expertise and patient preferences and values in making a practice decision or change. 5. Evaluate the practice decision or change. 6. Communicate your results.
DIF: CognitiveLevel: Analysis OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
2. In a clinical environment, evidence-based practice has the ability to improve: (Select all that apply.) a. the quality of care provided. b. patient outcomes. c. clinician satisfaction. d. patients‘ perceptions. ANS: A, B, C, D
EBP has the potential to improve the quality of care that nurses provide, patient outcomes, and clinicians‘ satisfaction with their practice. Your patients expect nursing professionals to be informed and to use the safest and most appropriate interventions. Use of evidence enhances nursing, thereby improving patients‘ perceptions of excellent nursing care. DIF: CognitiveLevel: Application OBJ: Discuss the benefits of evidence-based practice. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
3. During the application stage of evidence-based practice change, it is important to consider: (Select all that apply.) a. cost. b. the need for new equipment. c. management support. d. adequate staff. ANS: A, B, C, D
One important step for an individual or an interdisciplinary EBP committee is to consider the resources needed for a practice change project. Are added costs or new equipment involved with a practice change? Do you have adequate staff to make the practice change work as planned? Do management and medical staff support you in the change? If the barriers to practice change are excessive, adopting a practice change can be difficult, if not impossible. DIF: CognitiveLevel: Application OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) COMPLETION
1.
is a guide for making accurate, timely, and appropriate clinical decisions. ANS:
Evidence-based practice Evidence-based practice is a guide for making accurate, timely, and appropriate clinical decisions.
DIF: CognitiveLevel: Knowledge OBJ: Define the key terms listed. TOP: Evidence-Based Practice KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment (management of care)
2. Evidence-based practice requires good
.
ANS:
nursing judgment Evidence-based practice requires good nursing judgment; it does not consist of finding research evidence and blindly applying it. DIF: CognitiveLevel: Comprehension OBJ: Discuss the benefits of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment (management of care)
3. While caring for patients, the professional nurse must question
.
ANS:
what does not make sense Always think about your practice when caring for patients. Question what does not make sense to you, and question what you think needs clarification. DIF: CognitiveLevel: Analysis OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
4. A systematic review explains whether the evidence that you are searching for exists and whether there is good cause to change practice. In , all entries include information on systematic reviews. ANS:
The Cochrane Database A systematic review explains whether the evidence that you are searching for exists and whether there is good cause to change practice. In The Cochrane Database, all entries include information on systematic reviews. DIF: CognitiveLevel: Analysis OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
5. The researcher explains how to apply findings in a practice setting for the types of subjects studied in the section of a research article. ANS:
―Clinical Implications‖ Clinical Implications
A research article includes a section that explains whether the findings from the study have ―clinical implications.‖ The researcher explains how to apply findings in a practice setting for the types of subjects studied. DIF: CognitiveLevel: Application OBJ: Discuss elements to review when critiquing the scientific literature. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
6.
is the extent to which a study‘s findings are valid, reliable, and relevant to your patient population of interest. ANS:
Scientific rigor Scientific rigor is the extent to which a study‘s findings are valid, reliable, and relevant to your patient population of interest. DIF: CognitiveLevel: Application OBJ: Define the key terms listed. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
7. Patient fall rates are an example of an
.
ANS:
outcome measurement Data collected within a health care agency offer important trending information about clinical conditions and problems. Staff in the agency review the data periodically to identify problem areas and to seek solutions. DIF: CognitiveLevel: Application OBJ: Define the key terms listed. TOP: Quality Improvement KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
Chapter 02: Communication and Collaboration Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition MULTIPLE CHOICE
1. The patient is a 54-year-old man who has made a living as a construction worker. He dropped out of high school at age 16 and has been a laborer ever since. He never saw any need for ―book learning,‖ and has lived his life ―my way‖ since he was a teenager. He has smoked a pack of cigarettes a day for 40 years and follows no special diet, eating a lot of ―fast food‖ while on the job. He now is admitted to the coronary care unit for complaints of chest pain and is scheduled for a cardiac catheterization in the morning. Which of the following would be the best way for the nurse to explain why he needs the procedure? a. ―The doctor believes that you have atherosclerotic plaques occluding the major arteries in your heart, causing ischemia and possible necrosis of heart tissue.‖ b. ―There may be a blockage of one of the arteries in your heart, causing the chest
discomfort. He needs to know where it is to see how he can treat it.‖ c. ―We have pamphlets here that can explain everything. Let me get you one.‖ d. ―It‘s just like a clogged pipe. All the doctor has to do is ‗Roto-Rooter‘ it to get it cleaned out.‖ ANS: B
To send an accurate message, the sender of verbal communication must be aware of different developmental perspectives as well as cultural differences between sender and receiver, such as the use of dialect or slang. DIF: CognitiveLevel: Application TOP: Verbal Communication MSC: NCLEX: Psychosocial Integrity
OBJ: Explain the communication process. KEY: Nursing Process Step: Implementation
2. The nurse is assessing a patient who says that she is feeling fine. The patient, however, is wringing her hands and is teary eyed. The nurse should respond to the patient in which of the following ways? a. ―You seem anxious today. Is there anything on your mind?‖ b. ―I‘m glad you‘re feeling better. I‘ll be back later to help you with your bath.‖ c. ―I can see you‘re upset. Let me get you some tissue.‖ d. ―It looks to me like you‘re in pain. I‘ll get you some medication.‖ ANS: A
When assessing a patient‘s needs, assess both the verbal and the nonverbal messages and validate them. In this case, if you see a patient wringing her hands and sighing, it is appropriate to ask, ―You seem anxious today. Is there anything on your mind?‖ It is not enough to accept only the verbal message if nonverbal signals conflict, and it is inappropriate to jump to conclusions about what the nonverbal signals mean. DIF: CognitiveLevel: Application TOP: Nonverbal Communication MSC: NCLEX: Psychosocial Integrity
OBJ: Explain the communication process. KEY: Nursing Process Step: Implementation
3. Nonverbal communication incorporates messages conveyed by: a. touch. b. cadence. c. tone quality. d. use of jargon. ANS: A
Nonverbal communication describes all behaviors that convey messages without the use of words. This type of communication includes body movement, physical appearance, personal space, and touch. Cadence, tone quality, and the use of jargon are all part of verbal communication. DIF: CognitiveLevel: Knowledge TOP: Nonverbal Communication MSC: NCLEX: Psychosocial Integrity
OBJ: Explain the communication process. KEY: Nursing Process Step: Implementation
4. The patient is an elderly male who had hip surgery 3 days ago. He states that his hip hurts, but he does not like how the medicine makes him feel. He believes that he can tolerate the pain better than he can tolerate the medication. What would be the best response from the nurse?
a. Explain the need for the pain medication using a slower rate of speech. b. Explain the need for the pain medication using a simpler vocabulary. c. Explain the need for the pain medication, but ask the patient if he would like the doctor called and the medication changed. d. Explain in a loud manner the need for the pain medication. ANS: C
Suggesting, which is presenting alternative ideas for patient consideration relative to problem solving, can be effective in helping the patient maintain control by increasing the patient‘s perceived options or choices. Nurses often use elder-speak, which includes a slower rate of speech, greater repetition, and simpler grammar than normal adult speech, when caring for older adults. However, many older patients perceive this type of communication as patronizing. DIF: CognitiveLevel: Application OBJ: Identify the purpose of therapeutic communication, communication in various phases of the nurse-patient relationship, and special issues related to communication. TOP: Communication with the Elderly KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
5. When comparing therapeutic communication versus social communication, the professional nurse realizes that therapeutic communication: a. allows equal opportunity for personal disclosure. b. allows both participants to have personal needs met. c. is goal directed and patient centered. d. provides an opportunity to compare intimate details. ANS: C
Therapeutic communication empowers patients to make decisions but differs from social communication in that it is patient centered and goal directed with limited disclosure from the professional. Social communication involves equal opportunity for personal disclosure, and both participants seek to have personal needs met. Nurses do not share with patients intimate details of their personal lives. DIF: CognitiveLevel: Application OBJ: Develop skills for therapeutic communication in various phases of the nurse-patient relationship. TOP: Establishing the Nurse-Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
6. The nurse is explaining a procedure to a 2-year-old child. Which is the best approach to use? a. Showing the needles and bandages in advance b. Telling the patient exactly what discomfort to expect c. Using dolls and stories to demonstrate what will be done d. Asking the child to draw pictures of what he or she thinks will happen ANS: C
Some age-appropriate communication techniques for a 2-year-old child include storytelling and drawing. Showing the child needles or telling the child about discomfort would increase anxiety. Having a child draw what he expects does not explain what is going to happen. DIF: CognitiveLevel: Application
OBJ: Develop skills for therapeutic communication in various phases of the nurse-patient relationship. TOP: Establishing the Nurse-Patient Relationship—Pediatric Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
7. The nurse is about to go over the patient‘s preoperative teaching per hospital protocol. She finds the patient sitting in bed wringing her hands, which are sweaty, and acting slightly agitated. The patient states, ―I‘m scared that something will go wrong tomorrow.‖ How should the nurse respond? a. Redirect her focus to dealing with the patient‘s anxiety. b. Tell the patient that everything will be all right and continue teaching. c. Tell the patient that she will return later to do the teaching. d. Give the patient antianxiety medication. ANS: A
Anxiety interferes with comprehension, attention, and problem-solving abilities and thus interferes with the patient‘s care and treatment. To ensure the effectiveness of treatment, the nurse should try to help the patient understand the source of the anxiety. Ignoring the anxiety, medicating for it, and postponing the discussion are all inappropriate. DIF: CognitiveLevel: Application OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Establishing the Nurse-Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
8. The nurse is attempting to teach the patient and his family about his care after discharge. The patient and the family demonstrate signs of anxiety during the teaching session. The nurse should consider doing what? a. Using more gestures or pictures b. Focusing on the physical complaints c. Getting another staff member to speak to the patient d. Repeating information to the patient and the family at a later time ANS: D
Remember that patients and their family members who are under stress often require repeated explanations. Increasing gestures and pictures is additional stimulation that may increase anxiety. Physical complaints should be acknowledged, but dwelling on them can also increase the patient‘s anxiety. Involving another staff member would cause a break in the continuity of care. DIF: CognitiveLevel: Application OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Establishing the Nurse-Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
9. The patient is an elderly man who was brought to the hospital from an assisted-living community with complaints of anorexia and general malaise. The nurse at the assisted-living community reported that the patient was very ritualistic in his behavior and fastidious in his dress and always took a shower in the evening before bed. The patient became very angry and upset when the patient care technician asked him to take his bath in the morning. What does this behavior tell the nurse? a. The patient is exhibiting anxiety because of a change in his rituals. b. The patient is suffering from sensory overstimulation. c. The patient is basically an angry person. d. The patient has to follow hospital protocol. ANS: A
Patients often become ritualistic and intent on performing activities a certain way. Anxiety develops as a result of a specific event or a general pattern of change. DIF: CognitiveLevel: Analysis OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Gerontological Considerations—Anxiety KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity
10. The nurse is preparing to give an intramuscular injection to the patient in room 320. The patient care technician comes to the medication room and tells the nurse that the patient in room 316 is very angry with his roommate and is threatening to hit him. How should the nurse respond? a. Tell the patient care technician to calm the patient down until she can get there. b. Have the angry patient‘s roommate moved to another location. c. Tell the angry patient to calm down until she can get there. d. Tell the angry patient that he has to act civilized in the hospital, and that‘s that. ANS: B
A potentially violent patient needs to be in an environment with decreased stimuli and to have protection from injury to self and against others. Encourage other people, particularly those who provoke anger, to leave the room or area. De-escalation is a skill that cannot be delegated to nursing assistive personnel (NAP). DIF: CognitiveLevel: Application OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Communicating with the Angry Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
11. Which behavior should the nurse who is communicating with a potentially violent patient employ? a. Sit closer to the patient. b. Speak loudly and firmly. c. Use slow, deliberate gestures. d. Always block the door to prevent escape. ANS: C
Make sure that gestures are slow and deliberate rather than sudden and abrupt. There is less chance for misinterpretation of the message, and slow, deliberate gestures are less threatening. Keep an adequate distance between yourself and the patient to reduce your risk of injury and to avoid making the patient feel pressured. Try to talk in a comfortable, reassuring voice. Position yourself closest to the door to facilitate escape from a potentially violent situation. Do not block the exit; if the patient feels unable to escape, this may cause a violent outburst. DIF: CognitiveLevel: Application OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Communicating with the Angry Patient KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity
12. The patient is sitting at the bedside. He has not been eating and is just staring out of the window. The nurse approaches the patient and asks, ―What are you thinking about?‖ What type of communication technique is this? a. Restating b. Clarification c. Broad openings d. Reflection ANS: C
Broad openings encourage patients to select topics for discussion. They affirm the value of the patient‘s initiative. Restating is repeating a main thought that the patient has expressed. Clarification is attempting to put into words vague ideas or asking the patient to explain what he or she means. Reflection is directing back to the patient ideas, feelings, questions, or content. DIF: CognitiveLevel: Knowledge OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity
13. A patient tells the nurse, ―I want to die.‖ Which response is the most appropriate for the nurse to make? a. ―Why would you say that?‖ b. ―Tell me more about how you are feeling.‖ c. ―The doctor should be told how you feel.‖ d. ―You have too much to live for to think that way.‖ ANS: B
Broad openings encourage the patient to select topics for discussion and indicate acceptance by the nurse and the value of the patient‘s initiative. ―Why‖ questions can cause defensiveness and can hinder communication. Saying you will inform the doctor leads the conversation away from the patient‘s feelings. Saying the patient has too much to live for is false reassurance and negates the patient‘s feelings. DIF: CognitiveLevel: Application OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity
14. The patient states, ―I don‘t know what my family will think about this.‖ The nurse wishes to use the communication technique of clarification. Which of the following statements would fit that need best? a. ―You don‘t know what your family will think?‖ b. ―I‘m not sure that I understand what you mean.‖ c. ―I think it would be helpful if we talk more about your family.‖ d. ―I sense that you may be anxious about something.‖ ANS: B
The definition of clarification is attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse‘s understanding, or asking the patient to explain what he or she means. Repeating main thoughts expressed by patients is known as ―restating.‖ Using questions or statements that help patients expand on a topic of importance is known as ―focusing.‖ Asking a patient to verify the nurse‘s understanding of what the patient is thinking or feeling is known as ―sharing perceptions.‖ DIF: CognitiveLevel: Application OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity
15. A patient tells the nurse, ―I think that I must be really sick. All of these tests are being done.‖ Which response by the nurse uses the specific communication technique of reflection? a. ―I sense that you are worried.‖ b. ―I think that we should talk about this more.‖ c. ―You think that you must be very sick because of all the tests.‖ d. ―I‘ve noticed that this is an underlying issue whenever we talk.‖ ANS: C
Reflecting is directing back to the patient ideas, feelings, questions, or content, validating the nurse‘s understanding of what the patient is saying, and signifying empathy, interest, and respect for the patient. Asking the patient to confirm your sense of his or her anxiety is ―sharing perceptions.‖ Stating that ―we should talk about this more,‖ that is, putting forth questions or statements to expand on a topic, is ―focusing.‖ Pointing out underlying issues or problems that occur repeatedly is known as ―theme identification.‖ DIF: CognitiveLevel: Application OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity
16. The patient is admitted to the hospital with complaints of headache, nausea, and dizziness. She states that she has a final exam in the morning and needs to do well on it to pass the course, but she can‘t seem to get into it. She appears nervous and distracted, and is unable to recall details. She most likely is showing manifestations of anxiety. a. mild b. moderate c. severe d. panic state of ANS: C
Severe anxiety manifests as a focus on fragmented details, as well as headache, nausea, dizziness, inability to see connections between details, and poor recall. Mild anxiety manifests as increased auditory and visual perception, increased awareness of relationships, and increased alertness and ability to problem-solve. Moderate anxiety manifests as selective inattention, decreased perceptual field, focus only on relevant information, muscle tension, and diaphoresis. Panic state of anxiety manifests as an inability to notice surroundings, feelings of terror, and inability to cope with any problem. DIF: CognitiveLevel: Analysis OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Manifestations of Anxiety KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity
17. The patient is admitted to the emergency department for trauma received in a fist fight. He states that he could not control himself. He says that his wife left him for another man. He thinks it was because he was always too tired after working to do things. He says he has to work, and there is nothing he could do to change things. He says that he feels trapped in his job, but he knows nothing else. What was the altercation with the other man probably a manifestation of? a. Mild anxiety b. Depression c. Severe anxiety d. Moderate anxiety ANS: B
Symptoms of depression include apathy, sadness, sleep disturbances, hopelessness, helplessness, worthlessness, guilt, anger, fatigue, thoughts of death, decreased libido, ruminations of inadequacy, psychomotor agitation, verbal berating of self, spontaneous crying, dependency, and passiveness. Mild anxiety manifests as increased auditory and visual perception, increased awareness of relationships, increased alertness, and an increased ability to problem-solve. Moderate anxiety manifests as selective inattention, decreased perceptual field, focus only on relevant information, muscle tension, and diaphoresis. Severe anxiety manifests as a focus on fragmented details, headache, nausea, dizziness, an inability to see connections between details, and poor recall. DIF: CognitiveLevel: Analysis OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Manifestations of Depression KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE
1. Verbal communication includes which of the following? (Select all that apply.) a. Speech b. Personal space c. Body movement d. Writing ANS: A, D
Verbal communication includes both spoken word and written word. Nonverbal communication describes all behaviors that convey messages without the use of words. This type of communication includes body movement, physical appearance, personal space, and touch. DIF: CognitiveLevel: Analysis TOP: Verbal Communication MSC: NCLEX: Psychosocial Integrity
OBJ: Explain the communication process. KEY: Nursing Process Step: Assessment
2. In caring for patients of different cultures, it is important for the nurse to: (Select all that apply.) a. use appropriate linguistic services. b. display empathy and respect. c. use accurate health history-taking techniques. d. use patient-centered communication. ANS: A, B, C, D
The following factors are essential in providing effective care for culturally and linguistically diverse patients: (1) use of appropriate linguistic services (e.g., interpreter or bilingual health care workers) and/or other communication strategies, (2) display of empathy and respect for culturally and linguistically diverse patients, (3) use of accurate health history-taking techniques for diagnostic and treatment purposes and health teaching, and (4) use of patient-centered communication behaviors, including participatory decision making. It also is helpful to speak plainly and to avoid mimicking a patient‘s accent or dialect. DIF: CognitiveLevel: Comprehension OBJ: Identify the purpose of therapeutic communication, communication in various phases of the nurse-patient relationship, and special issues related to communication. TOP: Cultural Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
3. The nurse observes that the patient is pacing in his room with clenched fists. When asked ―What‘s wrong?‖ the patient states, ―There‘s nothing wrong. I just want out of here.‖ He then bangs his fist on the table and yells, ―I‘ve had it!‖ How should the nurse respond? (Select all that apply.) a. Tell the patient that he needs to calm down. b. Pause to collect her own thoughts. c. Block the doorway. d. Notify the proper authorities. ANS: B, D
Awareness and control of your own reaction and responses will facilitate more constructive interaction. Maintain an open exit. Position yourself closest to the door to facilitate escape from a potentially violent situation. Do not block the exit so the patient feels escape is unattainable; this may cause a violent outburst. An angry patient loses the ability to process information rationally and therefore may impulsively express anger through intimidation. If a strong likelihood of imminent harm to another is present upon discharge, notify the proper authorities (e.g., nurse manager). DIF: CognitiveLevel: Synthesis OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and
depressed patients. TOP: Communicating with the Angry Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity COMPLETION
1. The nurse is starting her first set of morning rounds. As she interacts with the patient, her questions revolve around his reactions to his disease process. She also asks if there is anything that she can do to make him more comfortable. This type of interaction is known as . ANS:
therapeutic communication Therapeutic communication is an application of the process of communication to promote the well-being of the patient. DIF: CognitiveLevel: Analysis OBJ: Identify guidelines to use in therapeutic communication. KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
TOP: Therapeutic Communication
2. An active process of receiving information that nonverbally communicates to the patient the nurse‘s interest and acceptance is classified as . ANS:
listening Definition: An active process of receiving information and examining one‘s reaction to messages received. Therapeutic value: Nonverbally communicates to the patient the nurse‘s interest and acceptance. DIF: CognitiveLevel: Knowledge OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity
3. The patient is talking about his fear of having surgery but is being vague and is using a lot of jargon. The nurse states, ―I‘m not sure what you mean. Could you tell me again?‖ This is an example of . ANS:
clarification Clarification is attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse‘s understanding, or asking the patient to explain what he or she means. This may help to clarify the patient‘s feelings, ideas, and perceptions, and may provide an explicit correlation between them and the patient‘s actions. DIF: CognitiveLevel: Application OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity
4. Directing the conversation back to patient ideas, feelings, questions, or content is known as . ANS:
reflection Reflection or directing back to the patient ideas, feelings, questions, or content validates the nurse‘s understanding of what the patient is saying and signifies empathy, interest, and respect for the patient. DIF: CognitiveLevel: Knowledge OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity
5. The patient tells the nurse that his mother left him when he was 5 years old. The nurse responds by saying, ―You say that your mother left you when you were 5 years old?‖ This is an example of . ANS:
restating Restating is a technique whereby the nurse repeats the main thought that the patient has expressed. It indicates that the nurse is listening, and validates, reinforces, or calls attention to something important that has been said. DIF: CognitiveLevel: Application OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
6. The patient has been agitated for the entire morning but refuses to say why he is angry. Instead, whenever the nurse speaks to him, he smiles at her while clenching his fist at the same time. The nurse states, ―I can see that you‘re smiling, but I sense that you are really very angry.‖ This is an example of . ANS:
sharing perceptions Sharing perceptions is asking the patient to verify the nurse‘s understanding of what the patient is thinking or feeling. It conveys to the patient the nurse‘s understanding and has the potential for clearing up confusing communication. DIF: CognitiveLevel: Application OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
7. Lack of verbal communication for a therapeutic reason is known as ANS:
.
therapeutic silence Lack of verbal communication for a therapeutic reason is known as therapeutic silence. It allows the patient time to think and gain insights, slows the pace of the interaction, and encourages the patient to initiate conversation, while conveying the nurse‘s support, understanding, and acceptance. DIF: CognitiveLevel: Comprehension TOP: Therapeutic Silence MSC: NCLEX: Psychosocial Integrity
OBJ: Explain the communication process. KEY: Nursing Process Step: Assessment
8. Anxiety that is the source of inattention, decreased perceptual field, and diaphoresis is classified as . ANS:
moderate anxiety Moderate anxiety is characterized by selective inattention, decreased perceptual field, the ability to focus only on relevant information, muscle tension, and/or diaphoresis. DIF: CognitiveLevel: Comprehension OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Anxiety KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity
Chapter 03: Admitting, Transfer, and Discharge Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The patient is scheduled to go home after having coronary angioplasty. What would be the most effective way to provide discharge teaching to this patient? a. Provide him with information on health care websites. b. Provide him with written information on what he has to do. c. Sit and carefully explain what is required before his follow-up. d. Use a combination of verbal and written information. ANS: D
For discharge teaching, use a combination of verbal and written information. This most effectively provides patients with standardized care information, which has been shown to improve patient knowledge and satisfaction.
DIF: CognitiveLevel: Application OBJ: Identify the ongoing needs of patients in the process of discharge planning. TOP: Admission to DischargeProcess
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
2. While preparing for the patient‘s discharge, the nurse uses a discharge planning checklist and notes that the patient is concerned about going home because she has to depend on her family for care. The nurse realizes that successful recovery at home is often based on: a. the patient‘s willingness to go home. b. the family‘s perceived ability to care for the patient. c. the patient‘s ability to live alone. d. allowing the patient to make her own arrangements. ANS: B
Discharge from an agency is stressful for a patient and family. Before a patient is discharged, the patient and family need to know how to manage care in the home and what to expect with regard to any continuing physical problems. Family caregiving is a highly stressful experience. Family members who are not properly prepared for caregiving are frequently overwhelmed by patient needs, which can lead to unnecessary hospital readmissions. DIF: CognitiveLevel: Analysis OBJ: Identify the ongoing needs of patients in the process of discharge planning. TOP: Medication Reconciliation
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity
3. The patient arrives in the emergency department complaining of severe abdominal pain and vomiting, and is severely dehydrated. The physician orders IV fluids for the dehydration and an IV antiemetic for the patient. However, the patient states that she is fearful of needles and adamantly refuses to have an IV started. The nurse explains the importance of and rationale for the ordered treatment, but the patient continues to refuse. What should the nurse do? a. Summon the nurse technician to hold the arm down while the IV is inserted. b. Use a numbing medication before inserting the IV. c. Document the patient‘s refusal and notify the physician. d. Tell the patient that she will be discharged without care unless she complies.
ANS: C
The Patient Self-Determination Act, effective December 1, 1991, requires all Medicare- and Medicaid-recipient hospitals to provide patients with information about their right to accept or reject medical treatment. The patient has the right to refuse treatment. Refusal should be documented and the health care provider consulted about alternate treatment. DIF: CognitiveLevel: Application OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility. TOP: Patient Self-Determination Act
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
4. An unconscious patient is admitted through the emergency department. How and when is identification of the patient made? a. Determined only when the patient is able b. Postponed until family members arrive c. Given an anonymous name under the ―blackout‖ procedure d. Determined before treatment is started ANS: B
If a patient is unconscious, identification often is not made until family members arrive. Delaying treatment can cause deterioration of the patient‘s condition. Blackout procedures are intended mainly to protect crime victims. DIF: CognitiveLevel: Application OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility.
TOP: The Unconscious Patient
KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
5. During admission of a patient, the nurse notes that the patient speaks another language and may have difficulty understanding English. What should the nurse do to facilitate communication? a. Use hand gestures to explain.
b. Request and wait for an interpreter. c. Work with the family to gather information. d. Complete as much of the admission assessment as possible using simple phrases. ANS: B
If the patient does not speak English or has a severe hearing impairment, the clerk must have access to an interpreter to assist during the admission procedure. Translation services are preferable to using family members to ensure correct translation of medical terminology. Hand gestures and simple phrases may not be adequate for everything that will be discussed at the time of admission. DIF: CognitiveLevel: Application OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility. TOP: The Patient Who Does Not Speak English KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
6. The patient has been admitted to the emergency department after being beaten and raped. She is agitated and is frightened that her attacker may find her in the hospital and try to kill her. What should the nurse tell her? a. She is safe in the hospital, and she needs to provide her name. b. She can be admitted to the hospital without anyone knowing it. c. Her records will be used as evidence in the trial. d. Since she has come to the hospital, she has to be examined by the doctor. ANS: B
A patient who has been a victim of crime can be admitted anonymously under an agency‘s ―blackout‖ or ―do not publish‖ procedure. HIPAA places limits on the institution‘s ability to use or disclose the patient‘s PHI. The Patient Self-Determination Act prohibits the hospital from requiring her to submit to an examination. DIF: CognitiveLevel: Analysis OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility.
TOP: Victim of Crime
KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity
7. The patient is admitted to the ICU after having been in a motor vehicle accident. He was intubated in the emergency department and needs to receive two units of packed red blood cells. He is conscious but is indicating that he is in pain by guarding his abdomen. To admit this patient, the nurse first will focus on: a. examining the patient and treating the pain. b. orienting the family to the ICU visitation policy. c. making sure that the consent forms are signed. d. informing the patient of his HIPAA rights. ANS: A
When a critically ill patient reaches a hospital‘s nursing division, the patient immediately undergoes extensive examination and treatment procedures. Little time is available for the nurse to orient the patient and family to the division, or to learn of their fears or concerns. DIF: CognitiveLevel: Analysis OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility.
TOP: Role of the Nurse
KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
8. The nurse is admitting the patient to the medical unit. The patient indicates that he has had several surgeries in the past and has been a diabetic for the past 15 years. He also stated that he is allergic to Morphine. What does this information prompt the nurse to do next? a. Provide the patient with an allergy armband and document his allergies. b. Postpone routine admission procedures immediately. c. Ask the patient if he wants a smoking room. d. Have all family or friends leave the room. ANS: A
Provide the patient with an allergy armband listing allergies to foods, drugs, latex, or other substances; document allergies according to hospital policy. Postpone routine admission procedures only if the patient is having acute physical problems. Smoking is prohibited throughout the hospital, and family or friends can remain if the patient wishes to have them assist with changing into a hospital gown or pajamas. DIF: CognitiveLevel: Analysis OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility.
TOP: Allergies
KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
9. At what age is separation anxiety a common problem? a. School-aged children b. Preschoolers c. Middle infancy d. Newborns ANS: C
Separation anxiety is most common from middle infancy throughout the toddler years, especially from ages 16 to 30 months. Preschoolers are better able to tolerate brief periods of separation, but their protest behaviors are more subtle than those of younger children (e.g., refusal to eat, difficulty sleeping, withdrawing from others). School-aged children are able to cope with separation but have an increased need for parental security and guidance. DIF: CognitiveLevel: Synthesis OBJ: Explain the role of the patient‘s family in the admission, transfer, or DischargeProcess. TOP: Pediatric Considerations
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity
10. The patient is being transferred from the emergency department to another institution for treatment. Which of the following cannot be delegated to nursing assistive personnel (NAP)? a. Helping the patient get dressed b. Gathering IV equipment to go with the patient
c. Escorting the patient to the transport area d. Assessing the patient‘s respiratory status before transport ANS: D
The assessment and decision making conducted during transfers cannot be delegated to nursing assistive personnel. NAP can assist the patient with dressing, can gather and secure the patient‘s personal belongings and any necessary equipment, and can escort the patient to the nursing unit or transport area. DIF: CognitiveLevel: Application OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility.
TOP: Delegation
KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
11. When does the plan for patient discharge from a health care facility begin? a. At admission b. After a medical diagnosis has been determined c. When the patient‘s physical needs are identified d. After a home environment assessment is completed ANS: A
Planning for discharge begins at admission and continues throughout the patient‘s stay in the agency. Separating the processes of admission and discharge is a critical error; the two are simultaneous and continuous. DIF: CognitiveLevel: Comprehension OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility.
TOP: Discharge Planning
KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
12. The phase of the DischargeProcess where medical attention dominates discharge planning efforts is known as the a. transitional
phase.
b. continuing c. acute d. multidisciplinary ANS: C
The DischargeProcess occurs in three phases: acute, transitional, and continuing care. In the acute phase, medical attention dominates discharge planning efforts. During the transitional phase, the need for acute care is still present, but its urgency declines and patients begin to address and plan for their future health care needs. In the continuing care phase, patients participate in planning and implementing continuing care activities needed after discharge. There is no multidisciplinary stage; the discharge planning process is comprehensive and multidisciplinary. DIF: CognitiveLevel: Comprehension OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility.
TOP: Discharge Planning
KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
13. Once a patient‘s discharge has been completed, which activity may be delegated to assistive personnel? a. Provision of prescriptions to the patient b. Completion of the discharge summary c. Gathering of the patient‘s personal care items d. Provision of instructions on community health resources ANS: C
The assessment, care planning, and instruction included in discharging patients cannot be delegated to nursing assistive personnel. The nurse may direct the NAP to gather and secure the patient‘s personal items and any supplies that accompany the patient. DIF: CognitiveLevel: Application OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility. KEY: Nursing Process Step: Implementation
TOP: Discharge Planning
MSC: NCLEX: Safe and Effective Care Environment
14. The nurse is providing discharge instruction to an 80-year-old patient and her daughter. The patient lives in a two-story home. When asked if the patient has difficulty climbing stairs, the patient says ―No,‖ but the nurse notices a look of surprise on the daughter‘s face. What should the nurse do in this circumstance? a. Speak with the daughter separately. b. Cancel the discharge immediately. c. Order a visiting nurse consult. d. Notify the physician. ANS: A
Patients and family members often disagree on the health care needs of a patient after discharge. Identifying these discrepancies early leads to more accurate development of the discharge plan. It is often necessary to talk with the patient and family separately to learn about their true concerns or doubts. DIF: CognitiveLevel: Application OBJ: Explain the role of the patient‘s family in the admission, transfer, or DischargeProcess. TOP: Discharge Planning
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
15. The patient has decided that he would like to create an advance directive. The nurse is asked if she would be a witness. What is the best response for the nurse to make to this request? a. Agree to be a witness. b. Refuse to be a witness. c. Contact social work. d. Contact the physician. ANS: C
A social worker often fulfills this requirement. Witnesses for an advance directive document should not be medical personnel, and direct refusal does not meet the nurse‘s obligation to meet the patient‘s needs. Referral to a department that can ensure this service is required. DIF: CognitiveLevel: Application
OBJ: Explain the purpose and importance of advance directives. TOP: Advance Directives
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. The patient is being admitted to the intensive care department with multiple fractures and internal bleeding. Which of the following are considered roles of the nurse in this situation? (Select all that apply.) a. Anticipate physical and social deficits to resuming normal activities. b. Involve the family and significant others in the plan of care. c. Assist in making health care resources available to the patient. d. Identify the psychological needs of the patient. ANS: A, B, C, D
The nurse identifies patients‘ ongoing health care needs; anticipates physical, psychological, and social deficits that have implications for resuming normal activities; involves family and significant others in a plan of care; provides health education; and assists in making health care resources available to the patient. Separating the processes of admission and discharge is a critical error; the two are simultaneous and continuous. DIF: CognitiveLevel: Application OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility. TOP: Admission to DischargeProcess
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
2. Under the Health Insurance Portability and Accountability Act (HIPAA), a patient must: (Select all that apply.) a. provide his true name before he can be treated. b. be informed of his privacy rights. c. have his personal health information used for treatment or payment only. d. be informed as to who can look at and receive health information.
ANS: B, C, D
HIPAA is a federal law designed to protect the privacy of patient health information, referred to as PHI, or protected health information. Three key concepts of HIPAA are (1) institutions are required to inform patients of the privacy rights they have and how the institution will handle their PHI; and (2) the institution and health care providers are to use or disclose the patient‘s PHI only for the purpose of treatment or payment or for health care operations. DIF: CognitiveLevel: Knowledge OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility.
TOP: HIPAA
KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
3. The patient is admitted to the unit for a cardiac catheterization. Which of the following can be delegated to nursing assistive personnel (NAP)? (Select all that apply.) a. Obtaining admission vital signs b. Preparing the patient‘s room c. Gathering and securing personal care items d. Orienting patient and family to the nursing unit ANS: B, C, D
The nursing assessment conducted during admission to a health care facility cannot be delegated to NAP. You cannot delegate admission vital signs as they provide a baseline for all further comparisons. The nurse directs NAP to (1) prepare the patient‘s room with necessary equipment before admission; (2) gather and secure the patient‘s personal care items; (3) escort and orient the patient and family to the nursing unit; and (4) collect ordered specimens. DIF: CognitiveLevel: Analysis OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility.
TOP: Delegation Considerations
KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. Which of the following are considered ―advance directives‖? (Select all that apply.)
a. Living will b. Power of attorney for health care c. Notarized handwritten document d. Nursing progress note ANS: A, B, C
Advance directives may include a living will, power of attorney for health care, or a notarized handwritten document. DIF: CognitiveLevel: Analysis OBJ: Explain the purpose and importance of advance directives. TOP: Advance Directives
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
5. The patient is being transferred from the intensive care unit to the acute care unit. The nurse must ensure that the following activities are completed: (Select all that apply.) a. providing the receiving nurse with a report before the transfer. b. determining any equipment needs for the patient during the transfer. c. providing an updated report after transferring the patient to the receiving unit. d. making sure a registered nurse accompanies the patient. ANS: A, B, C
When providing a ―hand-off‖ of a patient to another unit, it is essential that information about the patient‘s care, treatment, services, and current condition and any recent or anticipated changes are communicated accurately to meet patient safety goals. The nurse first provides a telephone report to the receiving nurse. This allows the receiving nurse to prepare for the patient (e.g., preparing the room, securing necessary equipment). As clinically appropriate, a nurse or technician accompanies the patient during transport, providing the receiving nurse with the patient‘s medical record; introducing the patient to the receiving nurse; and providing an updated report, including any changes in clinical status or plan of care. DIF: CognitiveLevel: Application OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility. KEY: NursingProcess Step: Implementation
TOP: Continuum of Care
MSC: NCLEX: Safe and Effective Care Environment
COMPLETION
1. Completing and documenting an accurate medication history from the patient is the important first step in the
process.
ANS:
medication reconciliation Medication reconciliation compares the patient‘s home medication list versus the medication orders at admission, transfer, or discharge to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. DIF: CognitiveLevel: Knowledge OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility. KEY: NursingProcess Step: Planning
TOP: Medication Reconciliation
MSC: NCLEX: Physiological Integrity
2. If a patient is having acute physical problems, postpone routine admission procedures until the patient‘s immediate needs are met. A
assessment is needed at this point.
ANS:
focused If a patient is having acute physical problems, postpone routine admission procedures until you meet the patient‘s immediate needs. Complete a focused assessment at this point. DIF: CognitiveLevel: Analysis OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility. KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Admission Process
3. When transferring a patient, the nurse must ensure that the patient will receive ANS:
continuity of nursing care When patients transfer, you need to ensure continuity of nursing care. The aim is to continue health care so as to avoid therapeutic interruptions that may hinder progress toward recovery. DIF: CognitiveLevel: Synthesis OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility. KEY: NursingProcess Step: Planning
TOP: Continuity of Care
MSC: NCLEX: Safe and Effective Care Environment
4. The greatest challenge in effective discharge planning is
_.
ANS:
communication The greatest challenge in effective discharge planning is communication. The communication problem is minimized when an organization has a discharge coordinator or a case manager who is responsible for discharge planning. DIF: CognitiveLevel: Comprehension OBJ: Describe the nurse‘s role in maintaining continuity of care through a patient‘s admission, transfer, and discharge from an acute care facility.
TOP: Discharge Planning
KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
5. A document that provides a patient‘s instructions in terms of future medical care or that designates another person(s) to make medical decisions if the individual loses decision-making capacity is known as an ANS:
advance directive
.
.
An advance directive is a document that provides a patient‘s instructions about future medical care or that designates another person(s) to make medical decisions if the individual loses decision-making capacity. An advance directive conveys the patient‘s choice in continuing medical care when the patient is unable to speak or make decisions. DIF: CognitiveLevel: Knowledge OBJ: Explain the purpose and importance of advance directives. TOP: Advance Directives
KEY: NursingProcess Step: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
Chapter 04: Documentation and Informatics Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The patient is a 24-year-old man who is diagnosed with possible HIV infection while being treated for active pneumonia. He has stated that the nurse may share test result information with his significant other but nothing else at this time. With whom may the nurse communicate regarding this information? a. The patient‘s parents b. The patient‘s significant other only c. No one in the hospital until the patient says so d. The patient‘s physician, significant other, and laboratory personnel ANS: D
All members of the health care team are legally and ethically obligated to keep patient information confidential. Do not discuss the patient‘s examinations, observations, conversations, or treatments with other patients or staff not involved in the patient‘s care, unless permission is granted by the patient. DIF: CognitiveLevel: Application OBJ: Describe measures to maintain confidentiality of patient information. TOP: Confidentiality
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
2. Which of the following is the best example of objective charting? a. ―The patient states that he has been having severe chest discomfort.‖ b. ―The patient is lying in bed and seems to be in considerable pain.‖ c. ―The patient appears to be pale and diaphoretic and complains of nausea.‖ d. ―The patient‘s skin is ashen and respiratory rate is 32 and labored.‖ ANS: D
A record or report contains descriptive, objective information about what you see, hear, feel, and smell. An objective description is the result of direct observation and measurement, such as ―respiratory rate 20 and unlabored.‖ Objective documentation should include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. The only subjective data included in a record are what the patient actually verbalizes. Write subjective information with quotation marks, using the patient‘s exact words whenever possible. For example, you record, ―Patient states, ‗my stomach hurts.‘‖ Avoid terms such as appears, seems, and apparently, which are often subject to interpretation. For example, the description ―the patient seems to be in pain‖ does not accurately communicate the facts to another caregiver. The phrase seems is not supported by any objective facts. DIF: CognitiveLevel: Analysis OBJ: List guidelines for effective communication and reporting. TOP: Objective Documentation
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
3. Which of the following is the best example of accurate documentation? a. ―Abdominal wound is 5 cm in length without redness, edema, or drainage.‖ b. ―OD to be irrigated qd with NS.‖ c. ―No complaint of abdominal pain this shift.‖ d. ―Patient watching TV entire shift.‖ ANS: A
The use of exact measurements in documentation establishes accuracy. For example, charting that an abdominal wound is ―5 cm in length without redness, edema, or drainage‖ is more descriptive than ―large wound healing well.‖ It is essential to know the institution‘s abbreviation list, and to use only accepted abbreviations, symbols, and measures (e.g., metric), so that all documentation is accurate and is in compliance with standards. For example, the abbreviation for every day (qd) is no longer used. If a treatment or medication is needed daily, the nurse should write out the word ―daily‖ or ―every day‖ on the written order or care plan. The abbreviation qd (every day) can be misinterpreted to mean O.D. (right eye). The term ―no complaint‖ may indicate stoicism on the part of the patient. He may have been in excruciating pain but never complained of it. It also creates a question related to the assessment skills of the nurse. It is essential to avoid unnecessary words and irrelevant details. For example, the fact that the patient is watching TV is only necessary to report when this activity is significant to the patient‘s status and plan of care. DIF: CognitiveLevel: Evaluation OBJ: List guidelines for effective communication and reporting. TOP: Accurate Documentation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. Patients on the unit have their vital signs taken routinely at 0800, 1200, 1600, and 2000. At 1000, a patient complains of feeling ―light-headed.‖ The nurse takes the patient‘s vital signs and finds blood pressure to be lower than usual. Within 15 minutes, the patient says that he feels better. The nurse rechecks the blood pressure and finds that it is now back to normal. How should the nurse handle documentation for this episode? a. Document the 1000 vital signs in the graphic record only. b. Not report the incident because it was a transient episode. c. Document the vital signs in the graphic and progress record. d. Document the vital signs as 12 o‘clock signs. ANS: C
When documenting a significant change on a flow sheet, you describe the change, including the patient response to nursing interventions, in the progress notes. For example, if a patient‘s blood pressure becomes dangerously low, record the blood pressure in the progress notes, as well as relevant assessment such as pallor and dizziness and any interventions performed to raise the blood pressure. Common issues in malpractice caused by inadequate or incorrect documentation include failing to give a report or giving an incomplete report to an oncoming shift and failing to document the correct time of events. DIF: CognitiveLevel: Application
OBJ: Identify the purpose of the patient record.
TOP: Flow Sheets and Graphic Records
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
5. The nurse manager is attempting to determine the staffing needs of the unit. One tool that she may use to determine the level of care needed would be: a. the standardized care plan. b. the acuity record. c. the patient care summary. d. flow sheets. ANS: B
Health care organizations use a patient acuity system as a method of determining the intensity of nursing care required for a group of patients. Acuity measurements for patients on a unit serve as a guide for determining staffing needs. An acuity recording system determines the hours of nursing care and the number of staff required for a nursing unit. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution‘s standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration. DIF: CognitiveLevel: Analysis
OBJ: Identify the purpose of the patient record.
TOP: Acuity Records
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
6. A guideline used to care for patients with similar health problems is known as the: a. acuity record. b. standardized care plan. c. patient care summary. d. flow sheet. ANS: B
Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution‘s standards of nursing practice, are preprinted, established guidelines that are used in caring for patients with similar health problems. Health care organizations use a patient acuity system as a method of determining the intensity of nursing care required for a group of patients. Acuity measurements for patients on a unit serve as a guide for determining staffing needs. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration. DIF: CognitiveLevel: Analysis
OBJ: Identify the purpose of the patient record.
TOP: Standardized Care Plans
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
7. The patient is ready to go home from the hospital. What does the nurse provide to the patient and his family before he leaves the facility? a. Discharge summary b. Standardized care plan c. Patient care summary d. Flow sheet ANS: A
When a patient is discharged from a health care institution, the members of the health care team prepare a discharge summary. A discharge summary provides important information related to the patient‘s ongoing health problems and need for health care after discharge. You enhance discharge planning when you are responsive to changes in patient condition and involve the patient and family in the planning process. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution‘s standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration. DIF: CognitiveLevel: Application
OBJ: Identify the purpose of the patient record.
TOP: Discharge Summary Forms
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
8. The patient has been in the hospital for a hip replacement. According to his critical pathway, he should have his Foley catheter discontinued on the fourth day after surgery. Instead, the patient has it removed on the third day and is voiding normally with no problems. This would be a sign of: a. a negative variance. b. positive case management. c. a positive variance. d. use of SBAR. ANS: C
Variances are unexpected occurrences, unmet goals, and interventions not specified within the critical pathway time frame that reflect a positive or negative change. A positive variance occurs when a patient progresses more rapidly than is anticipated in the case-management plan (e.g., use of a Foley catheter is discontinued a day early). A negative variance occurs when activities on the critical pathway do not happen as predicted, or outcomes are unmet (e.g., oxygen therapy is necessary for a new-onset breathing problem). Case management is a delivery model that coordinates and links health care services to patients and families while streamlining costs and maintaining quality. SBAR is a technique that provides a framework for communication between members of the health care team about a patient‘s condition. SBAR is a concrete mechanism used for framing conversations, especially critical ones, requiring a nurse‘s immediate attention and action. DIF: CognitiveLevel: Analysis OBJ: Describe the role of critical pathways in multidisciplinary documentation. TOP: Variances
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
9. Which is a primary difference between home care and hospital care? a. Documentation systems need to provide information for the home health nurse only. b. Documentation no longer affects reimbursement. c. Services are assumed and need less documentation. d. The patient and the family witness most of the care provided. ANS: D
One primary difference is that the patient and the family rather than the nurse witness most of the care provided. Documentation systems need to provide the entire health care team with the necessary information to work together effectively, supply quality control, and justify reimbursement from Medicare, Medicaid, or private insurance companies. DIF: CognitiveLevel: Analysis OBJ: Explain guidelines used in documentation of home care and long-term care. TOP: Home Care Documentation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
10. The nursing assistant tells the RN that when the patient‘s vital signs were taken, the patient complained that she was in a lot of pain. The nursing assistant then tells the nurse that she charted the patient‘s complaint when she charted the vital signs. What instruction does the nurse need to provide to the nursing assistant? a. The nursing assistant needs to make sure she uses the SBAR format when entering notes. b. Nursing assistants are not allowed to chart vital signs. c. Only the nurse can write in the progress notes. d. The nursing assistant needs to write using blue ink to distinguish from the RN note. ANS: C
The task of writing a progress note may not be delegated to nursing assistive personnel (NAP). The nurse instructs the NAP about what repetitive care activities should be documented on flow sheets, including vital signs, intake and output (I&O), and routine care related to ADLs. DIF: CognitiveLevel: Analysis TOP: Delegation
OBJ: Identify the purpose of the patient record.
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
11. The patient was in bed with all side rails up. During the night, the patient tried to get up to go to the bathroom and fell while trying to climb over the side rails. After meeting the patient‘s needs and assessing that the patient was not harmed, what step should the nurse take (if any)? a. Complete an incident report and put it in the medical record. b. Chart what happened and state that an incident report has been filled out. c. Do nothing because the patient was not harmed. d. Document what happened in the patient record without mentioning the incident report. ANS: D
Document in the patient‘s record an objective description of what you observed and follow-up actions taken without reference to the incident report. Incident reports are not a part of the permanent medical record but are an important source of risk-management data for identifying and addressing the causes of errors made in health care organizations. You complete the report even if an injury does not occur or is not apparent. DIF: CognitiveLevel: Analysis
OBJ: Complete an incident report accurately.
TOP: Incident Reports
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. Nursing documentation: (Select all that apply.) a. ensures continuity of care. b. provides legal evidence. c. evaluates patient outcomes. d. increases the risk of litigation. ANS: A, B, C
Nursing documentation ensures continuity of care, provides legal evidence, and evaluates patient outcomes. Effective documentation ensures continuity of care, maintains standards, and reduces errors. DIF: CognitiveLevel: Knowledge OBJ: List guidelines for effective communication and reporting. TOP: Communication
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Safe and Effective Care Environment
2. Nursing documentation must have which of the following characteristics? (Select all that apply.) a. Factual b. Organized c. Public d. Complete
ANS: A, B, D
Quality documentation and reporting have six characteristics: they are factual, accurate, complete, current, organized, and confidential. DIF: CognitiveLevel: Comprehension OBJ: List guidelines for effective communication and reporting. TOP: Guidelines for Reporting and Documentation KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
COMPLETION
1. A patient‘s private health information is legally protected by the
.
ANS:
Health Insurance Portability and Accountability Act (HIPAA) Health Insurance Portability and Accountability Act HIPAA HIPAA protects patients‘ private health information. This governs all areas of health information management, including, for example, reimbursement, coding, security, and patient records. DIF: CognitiveLevel: Application OBJ: Describe measures to maintain confidentiality of patient information. TOP: Confidentiality
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
2.
documentation should include your observations of patient behavior. ANS:
Objective
Objective documentation should include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. DIF: CognitiveLevel: Analysis OBJ: List guidelines for effective communication and reporting. TOP: Objective Documentation
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
3. The abbreviation for every day (
) is no longer used.
ANS:
qd The abbreviation for every day (qd) is no longer used. If a treatment or medication is needed daily, the nurse should write out the word ―daily‖ or ―every day‖ on the written order or care plan. The abbreviation qd (every day) can be misinterpreted to mean O.D. (right eye). DIF: CognitiveLevel: Application OBJ: List guidelines for effective communication and reporting. TOP: Accurate Documentation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
4. When making written entries in the patient‘s medical record, describe the nursing care provided and the
.
ANS:
patient‘s response The information within a recorded entry or a report must be complete, containing appropriate and essential information. Make written entries in the patient‘s medical record, describing nursing care that you administer and the patient‘s response. DIF: CognitiveLevel: Application
OBJ: List guidelines for effective communication and reporting. TOP: Complete Documentation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
5.
provide a quick, easy reference for health care team members in assessing the patient‘s status. ANS:
Flow sheets Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. DIF: CognitiveLevel: Application
OBJ: Identify the purpose of the patient record.
TOP: Flow Sheets and Graphic Records
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
6. Standardized care plans are effective ways to plan care for the patient. To be most effective, however, the SCP must be
.
ANS:
individualized to meet the patient‘s needs Always individualize each plan for a patient. Most standardized care plans allow for the addition of patient-specific outcomes and target dates for achieving these outcomes. DIF: CognitiveLevel: Application
OBJ: Identify the purpose of the patient record.
TOP: Standardized Care Plans
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
7.
provide a format for documenting a patient‘s health status and progress. ANS:
Progress notes
Health care team members use progress notes to monitor and record the progress of a patient's problems and response to interventions. DIF: CognitiveLevel: Analysis
OBJ: Identify the purpose of the patient record.
TOP: Patient Record
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
Chapter 05: Vital Signs Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The patient is brought to the emergency department complaining of severe shortness of breath. She is cyanotic and her extremities are cold. In an attempt to quickly assess the patient‘s respiratory status, the nurse should: a. remove the patient‘s nail polish to get a pulse oximetry reading. b. use a forehead probe to get a pulse oximetry reading. c. use a finger probe to get a pulse oximetry reading. d. check the color of the patient‘s nail polish before attempting a reading. ANS: B
Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacological vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Assess for factors that influence measurement of SpO2 (e.g., oxygen therapy; respiratory therapy such as postural drainage and percussion; hemoglobin level; hypotension; temperature; nail polish [Cieck et al., 2010]; medications such as bronchodilators). DIF: CognitiveLevel: Analysis OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. KEY: NursingProcess Step: Implementation
TOP: Pulse Oximetry
MSC: NCLEX: Physiological Integrity
2. A person‘s core temperature is considered the most accurate since it is: a. reflective of the surrounding environment. b. the same for everyone. c. controlled by the hypothalamus. d. independent of external influences. ANS: C
The core temperature, or the temperature of the deep body tissues, is under the control of the hypothalamus and remains within a narrow range. Skin or body surface temperature rises and falls as the temperature of the surrounding environment changes, and it fluctuates dramatically. Body tissues and cells function best within a relatively narrow temperature range, from 36° C to 38° C (96.8° F to 100.4° F), but no single temperature is normal for all people. For healthy young adults, the average oral temperature is 37° C (98.6° F). An acceptable temperature range for adults depends on age, gender, range of physical activity, hydration status, and state of health. DIF: CognitiveLevel: Analysis OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.
TOP: Core Temperature
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. The nurse takes the patient‘s temperature using a tympanic electronic thermometer. The temperature reading is 36.5° C (97.7° F). The nurse knows that this correlates with: a. 37.0° C (98.6° F) rectally. b. 37.0° C (98.6° F) orally. c. 36.0° C (97.7° F) axillary. d. 36.0° C (97.7° F) orally. ANS: B
It generally is accepted that axillary and tympanic temperatures are usually 0.5° C (0.9° F) lower than oral temperatures. It generally is accepted that rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures.
DIF: CognitiveLevel: Analysis OBJ: Discuss factors involved in selecting temperature measurement sites. TOP: Temperature Assessment
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette. The patient has just returned from his ―cigarette break.‖ The nurse is about to take the patient‘s temperature orally and should: a. wait about 20 minutes before taking his temperature. b. give him oral fluids to rinse the nicotine away before taking his temperature. c. give him a stick of chewing gum to chew and then take his temperature. d. take his oral temperature and record the findings. ANS: A
The nurse should verify that the patient has not had anything to eat or drink and has not chewed gum or smoked within the 15 minutes before oral temperature is measured. Oral food and fluids and smoking and gum can alter temperature measurement. DIF: CognitiveLevel: Synthesis OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.
TOP: Oral Temperature Assessment
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. When evaluating the patient‘s temperature levels, the nurse expects the patient‘s temperature to be lower: a. in the morning. b. after exercising. c. during periods of stress. d. during the postoperative period. ANS: A
Temperature is lowest during early morning. Muscle activity and stress raise heat production. Drugs may impair or promote sweating, vasoconstriction, or vasodilation, or may interfere with the ability of the hypothalamus to regulate temperature.
DIF: CognitiveLevel: Comprehension OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.
TOP: Temperature Assessment
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
6. When inserting a rectal thermometer, the nurse encounters resistance. The nurse should: a. apply mild pressure to advance. b. ask the patient to take deep breaths. c. remove the thermometer immediately. d. remove the thermometer and reinsert it gently. ANS: C
If resistance is felt during insertion, withdraw the thermometer immediately. Never force the thermometer. This prevents trauma to the mucosa. With the nondominant hand, separate the patient‘s buttocks to expose the anus. Ask the patient to breathe slowly and relax. This fully exposes the anus for thermometer insertion and relaxes the anal sphincter for easier thermometer insertion. DIF: CognitiveLevel: Application OBJ: Accurately assess a patient‘s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures.
TOP: Rectal Temperature Assessment
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
7. An appropriate procedure for measurement of an adult‘s temperature with a tympanic membrane sensor is: a. pulling the ear pinna down and back. b. moving into the ear in a figure-eight pattern. c. fitting the probe loosely into the ear canal. d. pointing the probe toward the mouth and chin. ANS: B
Move the thermometer in a figure-eight pattern. Pull the ear pinna backward, up, and out for an adult; fit the speculum tip snugly in the canal and do not move; and point the speculum tip toward the nose. DIF: CognitiveLevel: Application OBJ: Accurately assess a patient‘s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures.
TOP: Rectal Temperature Assessment
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
8. The patient is a 1-year-old male infant who is admitted with possible sepsis. The patient is irritable and agitates easily. What should the nurse do to assess the patient‘s temperature? a. Take an oral temperature before doing anything else. b. Take an axillary temperature using the upper axilla. c. Place the child in Sims‘ position for a rectal temperature. d. Take a rectal temperature as the last vital sign. ANS: D
Critically ill children sometimes have cool skin but a high core temperature because of poor perfusion to the skin. Children may assume the prone position for rectal temperature measurement. With children who cry or are restless, it is best to take temperature as the last vital sign. Use axillary temperatures for screening purposes only, not to detect fevers in infants and young children. Use the lower axilla to record temperature in side-lying infants. DIF: CognitiveLevel: Application OBJ: Accurately assess a patient‘s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures.
TOP: Temperature Assessment in Pediatric Patients
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
9. The patient is returning from a cardiac catheterization. The puncture site is in the right femoral artery. The patient is having vital signs assessed every 15 minutes. Along with vital signs, the nurse assesses the pedal pulses of the right and left feet. Which of the following would be of major concern?
a. Both pedal pulses were bounding. b. The femoral artery could be palpated. c. The right pedal pulse was weaker than the left. d. The radial artery pulse was 88. ANS: C
If a peripheral pulse distal to an injured or treated area of an extremity feels weak on palpation, the volume of blood reaching tissues below the affected area may be inadequate, and surgical intervention may be necessary. A full bounding pulse is an indication of increased volume. When the pulse wave reaches a peripheral artery, you can feel it by palpating the artery lightly against underlying bone or muscle. The pulse is the palpable bounding of the blood flow. The usual range for adults is 60 to 100 beats per minute. DIF: CognitiveLevel: Analysis OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.
TOP: Pulse Assessment
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
10. The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette. The patient has just returned from his ―cigarette break.‖ The nurse is about to take the patient‘s radial pulse and should: a. wait about 15 minutes before taking his pulse. b. use her thumb to detect the pulse and get an accurate count. c. press hard to detect the pulse and get an accurate count. d. take his pulse for 15 seconds and multiply by 4. ANS: A
If a patient has been smoking, wait 15 minutes before assessing pulse. Anxiety, activity, and smoking elevate heart rate. Assessing radial pulse rate at rest allows for objective comparison of values. Fingertips are the most sensitive parts of the hand for palpating arterial pulsation. The nurse‘s thumb has pulsation that interferes with accuracy. Pulse assessment is more accurate when moderate pressure is used. Too much pressure occludes pulse and impairs blood flow. If the pulse is regular, count the rate for 30 seconds and multiply the total by 2. If the pulse is irregular, count the rate for a full 60 seconds. Assess the frequency and the pattern of irregularity. DIF: CognitiveLevel: Analysis OBJ: Accurately assess a patient‘s radial and apical pulses.
TOP: Pulse Assessment
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
11. When evaluating the radial pulse measurement technique of the nursing assistant, the nurse identifies appropriate technique when the assistant: a. has the patient‘s arm elevated. b. positions the patient supine or sitting. c. applies significant pressure to the pulse site. d. counts the pulse for 15 seconds and multiplies by 4. ANS: B
Assist the patient to assume a supine or sitting position. If the patient is supine, place the patient‘s forearm straight alongside or across the lower chest or upper abdomen with the wrist extended straight. If the patient is sitting, bend the patient‘s elbow 90 degrees and support the lower arm on the chair or on the nurse‘s arm. Slightly extend or flex the wrist with the palm down until the strongest pulse is noted. Lightly compress against the radius, obliterate the pulse initially, and then relax pressure so the pulse becomes easily palpable. Pulse is assessed more accurately with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. If the pulse is regular, count the rate for 30 seconds and multiply the total by 2. If the pulse is irregular, count the rate for 60 seconds. Assess frequency and pattern of irregularity. DIF: CognitiveLevel: Comprehension
OBJ: Appropriately delegate vital sign measurements to nursing assistive personnel (NAP). TOP: Delegation of Pulse Assessment
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
12. The nurse is caring for an infant in the NICU. While taking vital signs, the nurse finds that the baby‘s heart rate is 195. The nurse calls the physician, knowing that the normal heart rate should be: a. 60 to 100 beats per minute. b. 100 to 160 beats per minute. c. 90 to 140 beats per minute. d. 220 beats per minute or higher. ANS: B
The infant‘s heart rate at birth ranges from 100 to 160 beats per minute at rest. By adolescence, the heart rate varies between 60 and 100 beats per minute and remains so throughout adulthood. By age 2, the pulse rate slows to 90 to 140 beats per minute. DIF: CognitiveLevel: Analysis OBJ: Accurately assess a patient‘s radial and apical pulses. KEY: NursingProcess Step: Assessment
TOP: Assessing Apical Pulse
MSC: NCLEX: Physiological Integrity
13. The patient has been in the hospital for several days for urosepsis. He has been responding favorably to treatment, and his vital signs have been ―normal‖ for 2 days. When the nurse takes his vital signs, however, the patient‘s apical pulse is 152 and regular. The nurse suspects that the: a. patient is having a reaction to his narcotic medication. b. patient may be suffering from hypothermia. c. patient‘s fever may have returned. d. patient may be an athlete. ANS: C
Fever or exposure to warm environments increases heart rate. Large doses of narcotic analgesics and hypothermia can slow heart rate. A well-conditioned patient may have a slower than usual resting heart rate, which returns more quickly to resting rate after exercise.
DIF: CognitiveLevel: Synthesis OBJ: Accurately assess a patient‘s radial and apical pulses. KEY: NursingProcess Step: Assessment
TOP: Assessing Apical Pulse
MSC: NCLEX: Physiological Integrity
14. What steps should the nurse take to conduct an assessment of a possible pulse deficit? a. A nurse measures the pulse after the patient exercises. b. Two nurses check the same pulse on opposite sides of the body. c. Two nurses assess the apical and radial pulses and determine the difference. d. The current pulse is compared with previous pulse measurements for differences. ANS: C
Locate apical and radial pulse sites. One nurse auscultates the apical pulse, and one nurse palpates the radial pulse. Both nurses count the pulse rate for 60 seconds simultaneously. Subtract the radial rate from the apical rate to obtain the pulse deficit. The pulse deficit reflects the number of ineffective cardiac contractions in 1 minute. If a pulse deficit is noted, assess for other signs and symptoms of decreased cardiac output. DIF: CognitiveLevel: Application
OBJ: Explain the implications of a pulse deficit.
TOP: PulseDeficit
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
15. An appropriate method of assessing a patient‘s respirations is for the nurse to: a. place the bed flat. b. remove all supplemental oxygen sources from documentation. c. explain to the patient that respirations are being assessed. d. gently place the patient‘s hand in a relaxed position over the upper abdomen. ANS: D
Place the patient‘s arm in a relaxed position across the abdomen or lower chest, or place the nurse‘s hand directly over the patient‘s upper abdomen. Be sure the patient is in a comfortable position, preferably sitting or lying with the head of the bed elevated 45 to 60 degrees. Sitting erect promotes full ventilatory movement. A position of discomfort may cause the patient to breathe more rapidly. Documentation should include any supplemental oxygen that the patient is receiving. Inconspicuous assessment of respirations immediately after pulse assessment prevents the patient from consciously or unintentionally altering the rate and depth of breathing. DIF: CognitiveLevel: Application
OBJ: Accurately assess a patient‘s respirations.
TOP: Respiratory Assessment
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
16. The nurse is about to take vital signs on a newborn patient in the nursery. She should: a. assess respiratory rate after taking a rectal temperature. b. observe the child‘s chest while the child is sleeping. c. call the physician if the rate is over 40. d. expect that the child will have short periods of apnea. ANS: D
An irregular respiratory rate and short apneic spells are normal for newborns. Assess respiratory rate before other vital signs or assessments are taken. Children up to age 7 breathe abdominally, so respirations are observed by abdominal movement. Average respiratory rate (breaths per minute) for newborns is 30 to 60; for infants (6 months to 1 year), 30 to 50; for toddlers (2 years), 25 to 32; and for children from 3 to 12 years, 20 to 30. DIF: CognitiveLevel: Analysis
OBJ: Accurately assess a patient‘s respirations.
TOP: Pediatric Considerations
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
17. The nurse should report an assessment of a. 14; adult patient b. 16; 8-year-old patient c. 25; toddler
respirations per minute for a(n)
.
d. 38; newborn ANS: B
Acceptable average respiratory rate (breaths per minute) for newborns is 35 to 40; for infants (6 months), 30 to 50; for toddlers (2 years), 22 to 32; and for children, 20 to 30. Adults average 12 to 20 respirations per minute. DIF: CognitiveLevel: Application OBJ: Identify ranges of acceptable vital sign values for infant, child, and adult. TOP: Respiratory Assessment
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
18. The patient is complaining of a severe headache. The nurse takes the patient‘s blood pressure and finds it to be 240/110. What is the pulse pressure? a. 110 b. 240 c. 130 d. 350 ANS: C
The difference between systolic pressure and diastolic pressure is the pulse pressure. For a blood pressure of 240/110, the pulse pressure is 130. The diastolic pressure is 110. The systolic pressure is 240. The sum of the systolic and diastolic pressures is 350. DIF: CognitiveLevel: Analysis OBJ: Accurately assess a patient‘s blood pressure using techniques of auscultation and palpation. TOP: Pulse Pressure
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
19. During his initial screening, the patient‘s blood pressure was noted to be elevated. Two months after the first assessment, he was noted to have a blood pressure of 150/92 and 166/96 at different times during the visit. It is now a month and a half later, and the nurse is concerned because the patient‘s initial blood pressure on this visit was 154/94. She is preparing to take a second blood pressure, understanding that another reading in this range could lead to a diagnosis of:
a. hypotension. b. prehypertension. c. hypertension. d. orthostatic hypotension. ANS: C
Hypertension is defined as systolic blood pressure (SBP) of 140 mm Hg or greater, diastolic blood pressure (DBP) of 90 mm Hg or greater, or taking antihypertensive medication (NHBPEP, 2003). One blood pressure recording revealing a high SBP or DBP does not qualify as a diagnosis of hypertension. However, if you assess a high reading (e.g., 150/90 mm Hg), encourage the patient to return for another checkup within 2 months. The diagnosis of hypertension in adults requires an average of two or more readings taken at each of two or more visits after an initial screening. Hypotension occurs when the systolic blood pressure falls to 90 mm Hg or below. Prehypertension is a designation for patients at high risk for developing hypertension. In these patients, early intervention through adoption of healthy lifestyles reduces the risk of or prevents hypertension. Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., light-headedness and dizziness) and low blood pressure when rising to an upright position. DIF: CognitiveLevel: Synthesis OBJ: Accurately assess a patient‘s blood pressure using techniques of auscultation and palpation. TOP: Hypertension
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
20. The patient is an 86-year-old woman who is being admitted for dehydration and pneumonia. The patient is lying in bed but tells the nurse that she needs to go to the bathroom. The nurse tells the patient that she will stay with her and will help her get there. The patient states, ―That‘s OK. I can make it on my own.‖ The nurse should: a. help the patient to the bathroom and stay with her. b. allow the patient to get up on her own and go to the bathroom. c. allow the patient to go to the bathroom and call for help if needed. d. insert a Foley catheter. ANS: A
Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., light-headedness and dizziness) and low blood pressure when rising to an upright position. Orthostatic changes in vital signs are good indicators of blood volume depletion. In severe cases of orthostatic hypotension, loss of consciousness may occur. Foley catheters are believed to be a major source of urinary tract infection. DIF: CognitiveLevel: Synthesis OBJ: Accurately assess a patient‘s blood pressure using techniques of auscultation and palpation. TOP: Orthostatic Hypotension
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
21. The nurse chooses a sphygmomanometer that has a circular gauge and a needle that registers the millimeter calibrations. This type of device is known as a(n)
manometer.
a. mercury b. electronic c. aneroid d. direct (invasive) ANS: C
The aneroid manometer has a glass-enclosed circular gauge containing a needle that registers millimeter calibrations. Metal parts in the aneroid manometer are subject to temperature expansion and contraction and must be recalibrated at least every 6 months to verify their accuracy. Before using the aneroid manometer, make sure the needle is pointing to zero. With mercury manometers, pressure created by inflation of the compression cuff moves the column of mercury up the tube against the force of gravity. Millimeter calibrations mark the height of the mercury column. Electronic or automatic blood pressure machines consist of an electronic sensor positioned inside a blood pressure cuff attached to an electronic processor. You measure arterial blood pressure either directly (invasively) or indirectly (noninvasively). The direct method requires electronic monitoring equipment and the insertion of a thin catheter into an artery. The risks associated with invasive blood pressure monitoring require use in an intensive care setting. DIF: CognitiveLevel: Knowledge OBJ: Accurately assess a patient‘s blood pressure using techniques of auscultation and palpation.
TOP: Manometers
KEY: NursingProcess Step: Diagnosis
MSC: NCLEX: Physiological Integrity
22. The nurse is working on the general surgical unit and is caring for a patient who has a right total mastectomy. To take the patient‘s vital signs and to accurately assess the patient‘s blood pressure, it will be necessary to: a. place the blood pressure cuff on the left upper arm. b. place the blood pressure cuff on the right upper arm. c. place the blood pressure cuff on the right lower arm. d. use direct (invasive) blood pressure measurement. ANS: A
Determine the best site for blood pressure assessment. Avoid applying the cuff to an extremity when intravenous fluids are infusing, an arteriovenous shunt or fistula is present, or breast or axillary surgery has been performed on that side. The risks associated with invasive blood pressure monitoring require use in an intensive care setting. DIF: CognitiveLevel: Application OBJ: Describe factors involved in selecting an extremity to measure blood pressure. TOP: Manometers
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
23. Which site is used to auscultate blood pressure? a. Radial b. Ulnar c. Brachial d. Temporal ANS: C
Place the stethoscope over the brachial artery to measure blood pressure. Use the radial site for the radial pulse, the ulnar site for the ulnar pulse, and the temporal site for the temporal pulse. DIF: CognitiveLevel: Application OBJ: Describe factors involved in selecting an extremity to measure blood pressure.
TOP: Brachial Pulse
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
24. The nurse is caring for a 2-year-old child who is admitted with croup and crying. To take the child‘s vital signs, the nurse should: a. place the pediatric blood pressure cuff on the left arm. b. place the blood pressure cuff on the right thigh. c. skip the blood pressure measurement. d. place the blood pressure cuff on the left thigh. ANS: C
Blood pressure is not a routine part of assessment in children younger than 3 years. The right arm is preferred for blood pressure measurement in children older than 3. Thigh blood pressure is the least preferred and the most uncomfortable method for children. DIF: CognitiveLevel: Analysis OBJ: Describe factors involved in selecting an extremity to measure blood pressure. TOP: Teaching Considerations
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
25. When the benefits of the different types of blood pressure monitoring devices are compared, which of the following patients would be the best candidate for noninvasive electronic blood pressure measurement? a. A 49-year-old postsurgical patient with no history of heart disease on q15min vital signs b. A 22-year-old patient undergoing active grand mal seizures c. A 68-year-old patient with diagnosed peripheral vascular disease d. A 54-year-old patient with chronic atrial fibrillation ANS: A
These devices are used when frequent assessment is required, as in critically ill or potentially unstable patients; during or after invasive procedures; or when therapies require frequent monitoring. Patients with irregular heart rate, peripheral vascular disease, seizures, tremors, and shivering are not candidates for this device.
DIF: CognitiveLevel: Analysis OBJ: Discuss the benefits and disadvantages of using an automatic blood pressure machine. TOP: Noninvasive Electronic Blood Pressure Measurement KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
26. The patient was found in an alley on a cold winter night and is admitted with hypothermia from environmental exposure. She is elderly and is having difficulty breathing. Her breath sounds are diminished, and the tip of her nose is cyanotic. The nurse wants to assess the oxygen level in the patient‘s blood. She decides to use the pulse oximeter. The best way to apply this to this patient would be with a(n): a. finger probe. b. earlobe sensor. c. forehead sensor. d. toe sensor. ANS: C
In adults, you can apply reusable and disposable oximeter probes to the earlobe, finger, toe, bridge of the nose, or forehead. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacological vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas. DIF: CognitiveLevel: Analysis OBJ: Accurately assess a patient‘s oxygenation status using pulse oximetry. TOP: Oxygen Saturation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
27. The patient is admitted in a near comatose state with a blood glucose level of 750. His respiratory rate is 42 breaths per minute, and his respiratory pattern is deep and regular. What is this type of breathing known as? a. Cheyne-Stokes respiration b. Biot‘s respiration c. Bradypnea d. Kussmaul‘s respiration
ANS: D
Respirations are abnormally deep, regular, and increased in rate. This is common in diabetic ketoacidosis. With Cheyne-Stokes respirations, respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. The respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses, and breathing slows and becomes shallow, climaxing in apnea before respiration resumes. With Biot‘s respirations, respirations are abnormally shallow for 2 to 3 breaths followed by an irregular period of apnea. With bradypnea, the rate of breathing is regular but abnormally slow (fewer than 12 breaths per minute). DIF: CognitiveLevel: Analysis
OBJ: Accurately assess a patient‘s respirations.
TOP: Breathing Patterns
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
28. What is a disadvantage of using the disposable sensor pad for pulse oximetry? a. It is less restrictive. b. It contains latex. c. It is less expensive to use. d. It is available in different sizes. ANS: B
A disposable sensor pad can be applied to a variety of sites, including the earlobe of an adult and the nose bridge, palm, or sole of an infant. It is less restrictive for continuous SpO2 monitoring. It is expensive and contains latex, which some patients may not be able to tolerate. The skin under the adhesive may become moist and may harbor pathogens. It is available in a variety of sizes, and the pad can be matched to infant weight. DIF: CognitiveLevel: Application OBJ: Accurately assess a patient‘s oxygenation status using pulse oximetry. TOP: Oxygen Saturation MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
KEY: NursingProcess Step: Implementation
1. The nurse is preparing to take the patient‘s temperature. Which of the following may cause the temperature to fluctuate? (Select all that apply.) a. Age b. Stress c. Hormones d. Medications ANS: A, B, C, D
Older adults have a narrower range of temperature than younger adults. A temperature within an acceptable range in an adult may reflect a fever in an older adult. Undeveloped temperature-control mechanisms in infants and children cause temperature to rise and fall rapidly. Stress elevates temperature. Women have wider temperature fluctuations than men because of menstrual cycle hormonal changes; body temperature varies during menopause. Some drugs impair or promote sweating, vasoconstriction, or vasodilation, or interfere with the ability of the hypothalamus to regulate temperature. DIF: CognitiveLevel: Analysis OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.
TOP: Temperature Assessment
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
2. Which of the following processes are involved in respiration? (Select all that apply.) a. Ventilation b. Diffusion c. Oximetry d. Perfusion ANS: A, B, D
Three processes are involved in respiration: ventilation, mechanical movement of gases into and out of the lungs; diffusion, movement of O2 and CO2 between the alveoli and the red blood cells; and perfusion, distribution of red blood cells to and from the pulmonary capillaries. DIF: CognitiveLevel: Comprehension
OBJ: Accurately assess a patient‘s respirations.
TOP: Respiratory Assessment
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. The nurse is about to teach the patient about risk factors for hypertension. Which of the following are risk factors for hypertension? (Select all that apply.) a. Obesity b. Cigarette smoking c. High blood cholesterol d. Renal disease ANS: A, B, C, D
People with a family history of hypertension, premature heart disease, lipemia, or renal disease are at significant risk. Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued exposure to stress from psychosocial and environmental conditions are factors linked to hypertension. DIF: CognitiveLevel: Knowledge OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.
TOP: Teaching Considerations
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. The nurse is about to take a patient‘s blood pressure. Which of the following conditions would cause the nurse to obtain a false high reading? (Select all that apply.) a. Bladder or cuff too narrow b. Bladder or cuff too wide c. Patient‘s arm below the level of the heart d. Inflating the cuff too slowly ANS: A, C, D
Bladder or cuff too narrow or too short, arm below heart level, or inflating the cuff too slowly will give a false high reading. A bladder or cuff too wide will give a false low reading. DIF: CognitiveLevel: Analysis OBJ: Accurately assess a patient‘s blood pressure using techniques of auscultation and palpation. TOP: Common Mistakes in Blood Pressure Assessment
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
1.
, a subjective symptom, is also referred to as a vital sign, along with the physiological signs. ANS:
Pain Pain, a subjective symptom, is also referred to as a vital sign, along with the physiological signs. DIF: CognitiveLevel: Comprehension OBJ: Identify when it is appropriate to assess each vital sign. KEY: NursingProcess Step: Assessment
TOP: Pain as a Vital Sign
MSC: NCLEX: Physiological Integrity
2. When heat loss mechanisms are unable to keep pace with heat production,
is
the result. ANS:
fever Fever occurs when heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature. DIF: CognitiveLevel: Analysis OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations.
TOP: Core Temperature
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. The nurse is taking a rectal temperature on an adult patient. She expects to insert the thermometer
_ inches.
ANS:
1.5 Gently insert the thermometer into the anus in the direction of the umbilicus 3.5 cm (1.5 inches) for an adult. Do not force the thermometer. DIF: CognitiveLevel: Application OBJ: Accurately assess a patient‘s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures.
TOP: Rectal Temperature Assessment
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
4. The patient has been sleeping and has been lying on his right side. The nurse is ready to take his temperature using a tympanic thermometer. She needs to insert the thermometer into his ear. ANS:
left If the patient has been lying on one side, use the upper ear. Heat trapped in the ear facing down will cause a false high temperature reading. DIF: CognitiveLevel: Application OBJ: Accurately assess a patient‘s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures.
TOP: Tympanic Membrane Temperature Assessment
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. An irregular heartbeat, often found in children, that speeds up with inspiration and slows down with expiration is known as a sinus ANS:
dysrhythmia
.
Children often have a sinus dysrhythmia, which is an irregular heartbeat that speeds up with inspiration and slows down with expiration. DIF: CognitiveLevel: Analysis OBJ: Accurately assess a patient‘s radial and apical pulses. TOP: Pulse Assessment—Pediatric Considerations KEY: NursingProcess Step: Assessment
6.
MSC: NCLEX: Physiological Integrity
is the sound of the tricuspid and mitral valves closing at the end of ventricular filling. ANS:
S1 S1 is the sound of the tricuspid and mitral valves closing at the end of ventricular filling, just before systolic contraction begins. DIF: CognitiveLevel: Application OBJ: Accurately assess a patient‘s radial and apical pulses. KEY: NursingProcess Step: Assessment
7.
TOP: Assessing Apical Pulse
MSC: NCLEX: Physiological Integrity
is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction. ANS:
S2 S2 is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction. DIF: CognitiveLevel: Application OBJ: Accurately assess a patient‘s radial and apical pulses. KEY: NursingProcess Step: Assessment
TOP: Assessing Apical Pulse
MSC: NCLEX: Physiological Integrity
8. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a
.
ANS:
PulseDeficit An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a PulseDeficit. PulseDeficits frequently are associated with dysrhythmias and warn of potentially decreased cardiac function. DIF: CognitiveLevel: Comprehension OBJ: Accurately assess a patient‘s radial and apical pulses. KEY: NursingProcess Step: Assessment
TOP: PulseDeficit
MSC: NCLEX: Physiological Integrity
9. To take a manual blood pressure, the nurse places the cuff of the
around the
patient‘s upper arm. ANS:
sphygmomanometer The most common technique of measuring blood pressure is auscultation using a sphygmomanometer and stethoscope. DIF: CognitiveLevel: Comprehension OBJ: Accurately assess a patient‘s blood pressure using techniques of auscultation and palpation. TOP: Sphygmomanometer
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
10. After applying the sphygmomanometer to the patient‘s upper arm, the nurse inflates the cuff to the proper level, and then, using a stethoscope, listens for the sounds. ANS:
Korotkoff
The most common technique used for measuring blood pressure is auscultation with a sphygmomanometer and stethoscope. As the sphygmomanometer cuff is deflated, the five different sounds heard over an artery are called Korotkoff phases. The sound in each phase has unique characteristics. Blood pressure is recorded with the systolic reading (first Korotkoff sound) before the diastolic reading (beginning of the fifth Korotkoff sound). DIF: CognitiveLevel: Application OBJ: Accurately assess a patient‘s blood pressure using techniques of auscultation and palpation. TOP: Korotkoff Sounds
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
11.
occurs when the systolic blood pressure falls to 90 mm Hg or below. ANS:
Hypotension Hypotension occurs when the systolic blood pressure falls to 90 mm Hg or below. Although some adults normally have a low blood pressure, for most people, low blood pressure is an abnormal finding associated with illness. DIF: CognitiveLevel: Knowledge OBJ: Accurately assess a patient‘s blood pressure using techniques of auscultation and palpation. TOP: Hypotension KEY: NursingProcess Step: Evaluation MSC: NCLEX: Physiological Integrity
12. The percent to which hemoglobin is filled with oxygen is known as ANS:
arterial blood oxygen saturation Pulse oximetry is the noninvasive measurement of arterial blood oxygen saturation—the percent to which hemoglobin is filled with oxygen. DIF: CognitiveLevel: Knowledge
.
OBJ: Accurately assess a patient‘s oxygenation status using pulse oximetry. TOP: Oxygen Saturation
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
Chapter 06: Health Assessment Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The nurse is visiting the patient for the first time this shift. She introduces herself and asks the patient several questions related to his condition. While doing so, and without being obvious, she is looking at the color of his eyes and is assessing his ears and nose for discharge and the symmetry of his mouth. Which assessment technique is the nurse using? a. Palpation b. Percussion c. Inspection d. Auscultation ANS: C
Inspection is the visual examination of body parts or areas. An experienced nurse learns to make multiple observations, almost simultaneously, while becoming very perceptive of abnormalities. Palpation uses the sense of touch. Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and to discover fluid in body cavities. Auscultation is listening with a stethoscope to sounds produced by the body. DIF: CognitiveLevel: Application OBJ: Describe the techniques used with each assessment skill.
TOP: Inspection
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
2. The patient is admitted with fever and acute lower abdominal pain. He has taken Tylenol but says he still feels feverish. Before taking the patient‘s temperature, the nurse may: a. touch the patient‘s skin with the dorsum of her hand.
b. touch the patient‘s skin with the pads of her fingers. c. palpate the skin using the bimanual method. d. tap the patient‘s skin using the fingertips. ANS: A
The dorsum (back) of the hand is more sensitive to temperature variations. The pads of the fingertips detect subtle changes in texture, shape, size, consistency, and pulsation of body parts. Bimanual palpation involves one hand placed over the other while pressure is applied. The upper hand exerts downward pressure as the other hand feels the subtle characteristics of underlying organs and masses. Seek the assistance of a qualified instructor before attempting deep palpation. Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and to discover fluid in body cavities. DIF: CognitiveLevel: Application OBJ: Describe the techniques used with each assessment skill.
TOP: Palpation
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
3. What should the nurse do when preparing to complete an assessment for a 16-year-old patient? a. Focus on illness behaviors. b. Plan for a diminished energy level. c. Treat the patient as an individual. d. Have the parents present throughout. ANS: C
Older children and adolescents tend to respond best when treated as adults and individuals and often can provide details about their health history and severity of symptoms. Routine examinations of children have a focus on health promotion and illness prevention, particularly in the care of well children with competent parenting and no serious health problems. The focus is on growth and development, sensory screening, dental examination, and behavioral assessment. Children who are chronically ill, disabled, in foster care, or foreign-born adopted may require additional assessment. The adolescent has a right to confidentiality. After talking with the parents about historical information, the nurse arranges to be alone with the adolescent to speak further privately and to perform the examination. DIF: CognitiveLevel: Application OBJ: Describe how to conduct a physical examination on patients from diverse cultures. TOP: Children and Adolescents
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The general survey begins with a review of the patient‘s primary health problems and an evaluation of the patient‘s vital signs, height and weight, general behavior, and appearance. It also provides information about the patient‘s illness, hygiene, skin condition, body image, and emotional state. Which of the following cannot be delegated to nursing assistive personnel? a. Reporting subjective signs and symptoms b. Measuring the patient‘s height and weight c. Monitoring I&O d. Obtaining initial vital signs ANS: D
Because the initial set of vital signs are part of the general health assessment they must be taken by the nurse. After that the NAP may take vital signs for a stable patient. The nurse directs NAP to report a patient‘s subjective signs and symptoms to the nurse, to measure the patient‘s height and weight, and to monitor oral intake and urinary output. DIF: CognitiveLevel: Application OBJ: Identify data to collect from the nursing history before an examination. TOP: Delegation Considerations MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
5. Petechiae are noted on the patient as a result of the nurse finding: a. bluish-black patches. b. tenting. c. pinpoint-sized red dots. d. large areas of raised, irritated skin. ANS: C
Petechiae appear as tiny, pinpoint-sized, red or purple spots on the skin caused by small hemorrhages in the skin layers and may indicate a blood-clotting disorder, a drug reaction, or liver disease. Bluish-black patches are more indicative of malignant melanoma. With reduced turgor, the skin remains suspended or ―tented‖ for a few seconds before slowly returning to place. This indicates decreased elasticity and possible dehydration. Large areas of raised, irritated skin are not characteristic of petechiae. DIF: CognitiveLevel: Application OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Petechiae
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
6. The nurse is assessing the patient by grasping a fold of skin on his forearm. She notices that the skin remains suspended for a longer than normal period. What could this indicate? a. Stage 1 pressure ulcer b. Increased blood flow to the area c. Localized vasodilation d. Dehydration ANS: D
With reduced turgor, the skin remains suspended or ―tented‖ for a few seconds before slowly returning to place. This indicates decreased elasticity and possible dehydration. A stage 1 pressure ulcer may cause warmth and erythema (redness) of an area. Skin temperature reflects an increase or decrease in blood flow. Normal reactive hyperemia (redness) is a visible effect of localized vasodilation, the body‘s normal response to lack of blood flow to underlying tissue.
DIF: CognitiveLevel: Analysis OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Assessment of Skin Hydration
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
7. The nurse is preparing to examine a patient who has chronic lung disease. She realizes that the patient most likely will need to be in which position for the examination? a. Sitting upright b. Supine c. Side-lying d. Prone ANS: A
Position the patient sitting upright. This promotes full lung expansion during examination. Patients with chronic respiratory disease will likely need to sit up throughout the examination because of shortness of breath. Only if the patient is unable to tolerate sitting would a supine position or a side-lying position be used. DIF: CognitiveLevel: Analysis OBJ: Describe proper positioning for the patient during each phase of the examination. TOP: Positioning for Examination of Thorax and Lungs KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
8. Which of the following may a nursing assistive personnel (NAP) be responsible for determining? a. Vital signs b. Cranial nerve function c. Neck vein distention d. Auscultation of bowel sounds ANS: A
Assistive personnel can be trained to count apical pulse and peripheral pulses after the nurse‘s initial assessment. Assistive personnel need to be instructed to recognize temperature and color changes, along with changes in peripheral pulses. Comprehensive heart and neck vessel assessment should not be delegated to assistive personnel. However, assistive personnel should know to report the development of abdominal pain or changes in the patient‘s bowel habits or dietary intake. DIF: CognitiveLevel: Comprehension OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Delegation
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
9. The nurse is caring for a patient who is recovering from an acute myocardial infarction. While providing cardiac education, the nurse realizes that the patient needs more education when he: a. describes changes in his behavior that may improve cardiovascular function. b. describes the schedule, dosage, and purpose of his medication. c. states that he will take his medication when he has chest pain or when his heart rate is greater than 100. d. describes the benefits of taking his medication regularly. ANS: C
The patient should not take medications for cardiovascular function intermittently. Medication should be taken on the regular prescribed schedule to prevent additional cardiac events. Describing changes in his behavior that may improve his cardiovascular function indicates that the patient understands steps he may take to improve his own health. The ability to accurately describe the schedule, dose, and purpose of his medication indicates that the patient understands his treatment. Understanding the benefits of taking his medication regularly should improve patient compliance with therapy. DIF: CognitiveLevel: Analysis OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Cardiovascular Disease MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Assessment
10. Which of the following is an expected outcome for a patient after cardiac assessment? a. Apical pulse rate equals 58 beats per minute b. Carotid bruits present c. PMI palpable at left fifth intercostal space at midclavicular line d. Jugular veins distended with patient in sitting position ANS: C
Locate the PMI by palpating with fingertips along the fifth intercostal space at the midclavicular line. Sinus bradycardia: Pulse rhythm is regular, but rate is slower than normal at 40 to 60 beats/min. Place bell of stethoscope over each carotid artery while auscultating for blowing sounds (bruit). Ask the patient to hold a breath for a few heartbeats so that respiratory sounds will not interfere with auscultation. Narrowing of the carotid artery lumen by arteriosclerotic plaques causes disturbance in blood flow. Blood passing through the narrowed section creates turbulence and emits a blowing or swishing sound. Normal veins are flat when the patient is sitting, and pulsations become evident as the patient‘s head is lowered. DIF: CognitiveLevel: Analysis OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Cardiovascular Assessment
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
11. Where is the pulmonic area for auscultation found? a. Second intercostal space on the right side b. Second intercostal space on the left side c. Third intercostal space (Erb‘s point) d. Fourth intercostal space along the sternum ANS: B
The pulmonic area is at the second intercostal space on the left side. The aortic area is at the second intercostal space on the patient‘s right side. The second pulmonic area is found by moving down the left side of the sternum to the third intercostal space, also referred to as Erb’s point. The tricuspid area is located at the fourth left intercostal space along the sternum. DIF: CognitiveLevel: Application OBJ: Use physical assessment techniques and skills during routine nursing care.
TOP: Heart Sounds
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
12. While performing a cardiovascular assessment on a patient with suspected left-sided congestive heart failure, the nurse is unable to palpate the PMI with the patient lying supine. What might her next step be? a. Have the patient turn onto his left side. b. Have the patient lean forward. c. Have the patient move to a sitting position. d. Palpate the PMI to the right of the midclavicular line. ANS: A
If palpating the PMI is difficult, turn the patient onto the left side. This maneuver moves the heart closer to the chest wall. Different positions help to clarify the types of sounds heard. Sitting position is best to hear high-pitched murmurs (if present). In the presence of serious heart disease, the PMI will be located to the left of the midclavicular line if related to an enlarged left ventricle. In chronic lung disease, the PMI is often to the right of the midclavicular line as a result of right ventricular enlargement. DIF: CognitiveLevel: Application OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Cardiovascular Disease
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
13. Which is the best position in which to place the patient to hear low-pitched cardiovascular sounds? a. Supine b. Sitting up c. Dorsal recumbent d. Left lateral recumbent ANS: D
Different positions help to clarify types of sounds heard. Sitting position is best to hear high-pitched murmurs (if present). Supine is a common position to hear all sounds. Left lateral recumbent is the best position to hear low-pitched sounds.
DIF: CognitiveLevel: Application OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Cardiovascular Disease
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
14. What technique should the nurse implement for assessment of the carotid artery? a. Massaging the arteries briskly b. Using the diaphragm of the stethoscope c. Palpating each carotid artery separately d. Placing the patient in a supine position ANS: C
Palpate each carotid artery separately with index and middle fingers around the medial edge of the sternocleidomastoid muscle. Ask the patient to raise the chin slightly, keeping the head straight. Note rate and rhythm, strength, and elasticity of the artery. Also note if the pulse changes as the patient inspires and expires. Do not vigorously palpate or massage the artery. Stimulation of the carotid sinus may cause a reflex drop in heart rate and blood pressure. Place the bell of the stethoscope over each carotid artery, auscultating for a blowing sound (bruit). To assess venous pressure, have the patient recline at a 45-degree angle and slowly recline into the supine position, avoiding neck hyperextension or flexion. Measure the distance between the angle of Louis and the highest point of vein pulsation. DIF: CognitiveLevel: Application OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Assessment of Carotid Artery
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
15. Which technique is most appropriate for a nurse to implement during the assessment of the abdomen? a. Assessing painful areas first b. Auscultating for 5 minutes over each quadrant c. Positioning the patient in a supine position with the arms behind or over the head d. Palpating painful masses or organ enlargement deeply and firmly
ANS: B
To auscultate bowel sounds, place the diaphragm of the stethoscope lightly over each of the four abdominal quadrants. Listen 5 minutes over each quadrant before deciding that bowel sounds are absent. Painful areas are assessed last. Manipulation of a body part can increase the patient‘s pain and anxiety and can make the remainder of the assessment difficult to complete. Placing the arms under the head or keeping the knees fully extended can cause the abdominal muscles to tighten. Tightening of muscles prevents adequate palpation. If masses are palpated, note size, location, shape, consistency, tenderness, mobility, and texture. DIF: CognitiveLevel: Comprehension OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Abdominal Assessment
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
16. How should the nurse document an exaggeration of the posterior curvature of the thoracic spine found during the assessment of a 90-year-old patient? a. Lordosis b. Osteoporosis c. Scoliosis d. Kyphosis ANS: D
Kyphosis is an exaggeration of the posterior curvature of the thoracic spine (hunchback). Lordosis is an increased lumbar curvature (swayback). Osteoporosis is a metabolic bone disease that causes a decrease in quality and quantity of bone. Scoliosis is a lateral curvature of the spine. DIF: CognitiveLevel: Application OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Curvature of the Spine MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Assessment
17. The patient is diagnosed with Bell‘s palsy. The nurse assesses the patient and notices drooping of the patient‘s right eye and the right side of his mouth. When the functions of the following nerves are compared, the most likely cause of these symptoms would be a dysfunction of the: a. facial nerve (CN VII). b. trigeminal nerve (CN V). c. oculomotor nerve (CN III). d. glossopharyngeal nerve (CN IX). ANS: A
Assess cranial nerve (CN) VII (facial) by noting facial symmetry. Have the patient frown, smile, puff out their cheeks, and raise their eyebrows. Expressions should be symmetrical; Bell‘s palsy causes drooping of the upper and lower face; cerebrovascular accident (CVA) causes asymmetry. Assess cranial nerve CN V (trigeminal) by applying light sensation with a cotton ball to symmetric areas of the face. Sensations should be symmetric; unilateral decrease or loss of sensation is possibly due to a CN V lesion or a lesion in higher sensory pathways. Assess CN III (oculomotor), IV (trochlear), and VI (abducens) by assessing extraocular movement (EOM) functioning. Ask the patient to follow the movement of your finger through the six cardinal positions of gaze; measure pupillary reaction to light reflex and accommodation using a penlight. These cranial nerves are most likely to be affected by increasing intracranial pressure (ICP), which causes a change in pupil response or pupil size; sometimes pupils change shape (more oval) or react sluggishly. ICP impairs EOMs. Damage to CN IX causes impaired swallowing; damage to CN X causes loss of gag reflex, hoarseness, and a nasal voice. When the palate fails to rise and the uvula pulls toward the normal side, this indicates a unilateral paralysis. DIF: CognitiveLevel: Synthesis OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Cranial Nerves
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
18. Measurement of the patient‘s ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve? a. Abducens b. Facial
c. Trigeminal d. Oculomotor ANS: C
The trigeminal nerve is tested by applying light sensation with a cotton ball to symmetric areas of the face. Sensations should be symmetric; unilateral decrease or loss of sensation may be caused by a CN V lesion. Assess CN III (oculomotor), IV (trochlear), and VI (abducens) by assessing extraocular movement (EOM) functioning. Ask the patient to follow the movement of your finger through the six cardinal positions of gaze; measure pupillary reaction to light reflex and accommodation using a penlight. The facial nerve is tested by having the patient smile, frown, puff out their cheeks, and raise and lower their eyebrows while you look for asymmetry. The oculomotor nerve is tested by assessing directions of gaze and by testing pupillary reaction to light and accommodation. DIF: CognitiveLevel: Application OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Cranial Nerves
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
19. How does a nurse appropriately measure intake and output? a. Recording 50% of ice chip consumption b. Checking urinary output every 24 hours c. Emptying the chest tube drainage every 2 hours d. Subtracting liquid medications from the total intake ANS: A
All liquids consumed must be counted including liquids with meals, gelatin, custards, ice cream, popsicles, sherbets, and ice chips (recorded as 50% of measured volume [e.g., 100 mL of ice chips equals 50 mL of water]) for the intake record. Liquid medicines such as antacids are counted as fluid intake, as are fluids with medications. The output record must include all fluids leaving the body. Instruct the patient (or family) to call the nurse to empty contents of the urinal, urine hat, or commode each time it is used so the fluid may be measured. Blood collected in a wound drain is also counted. Chest tube drainage is emptied ONLY when the container is nearly full. A closed system is necessary to maintain lung reexpansion.
DIF: CognitiveLevel: Application OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Intake
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
20. Which skin condition would cause a nurse to suspect chickenpox? a. Wheals b. Nodules c. Pustules d. Vesicles ANS: D
A vesicle is a circumscribed elevation of skin filled with serous fluid, smaller than 1 cm (e.g., herpes simplex and chickenpox). A wheal is an irregularly shaped, elevated area of superficial localized edema that varies in size (e.g., hive and mosquito bite); it is not characteristic of chickenpox. A nodule is an elevated solid mass, deeper and firmer than a papule, 1 to 2 cm (e.g., wart), and not characteristic of chickenpox. A pustule is a circumscribed elevation of skin similar to a vesicle but filled with pus; it varies in size (e.g., acne and staphylococcal infection) and is not characteristic of chickenpox. DIF: CognitiveLevel: Application OBJ: Discuss normal physical findings for patients across the life span. TOP: Primary Skin Lesions
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
21. Which patient position maximizes the nurse‘s ability to assess the patient‘s body for symmetry? a. Sitting b. Supine c. Prone d. Dorsal recumbent ANS: A
Sitting upright provides full expansion of the lungs and allows better visualization of symmetry of upper body parts. The supine position maximizes the nurse‘s ability to assess pulse sites. The prone position is used only to assess extension of the hip joint. The dorsal recumbent position is used for abdominal assessment because it promotes relaxation of abdominal muscles. DIF: CognitiveLevel: Application OBJ: Discuss normal physical findings for patients across the life span. TOP: Positions for Physical Assessment
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
22. During assessment of a patient with anemia, a nurse is alert for the presence of: a. pallor. b. jaundice. c. cyanosis. d. erythema. ANS: A
Pallor is a decrease in color caused by a reduced amount of oxyhemoglobin resulting from decreased blood flow caused by anemia or shock. Jaundice is caused by increased deposit of bilirubin in tissues caused by liver disease or destruction of red blood cells; it is not characteristic of anemia. Cyanosis is caused by an increased amount of deoxygenated hemoglobin due to heart or lung disease or a cold environment; it is not characteristic of anemia. Erythema is caused by increased visibility of oxyhemoglobin due to dilation or increased blood flow because of fever, direct trauma, blushing, or alcohol intake; it is not characteristic of anemia. DIF: CognitiveLevel: Application OBJ: Discuss normal physical findings for patients across the life span. TOP: Skin Color Variations
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
23. A nurse is documenting a patient‘s breath sounds. Crackles are heard as: a. loud, low-pitched, coarse sounds.
b. high-pitched, musical squeaks. c. dry, grating sounds on inspiration. d. fine, short, interrupted crackling sounds at the end of inspiration, expiration, or both. ANS: D
Fine crackles are high-pitched, fine, short, interrupted crackling sounds heard during the end of inspiration; they usually are not cleared with coughing. Rhonchi are loud, low-pitched, rumbling, coarse sounds heard most often during inspiration or expiration that may be cleared by coughing. Wheezes are high-pitched, continuous, musical sounds like a squeak heard continuously during inspiration or expiration; they are usually louder on expiration and do not clear with coughing. Pleural friction rub has a dry, grating quality heard best during inspiration; it does not clear with coughing and is heard loudest over the lower lateral anterior surface. DIF: CognitiveLevel: Application OBJ: Discuss normal physical findings for patients across the life span. TOP: Adventitious Breath Sounds
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
24. A student nurse is working with a patient who has asthma. The primary nurse tells the student that wheezes can be heard on auscultation. The student expects to hear: a. coarse crackles and bubbling. b. high-pitched musical sounds. c. dry, grating noises. d. loud, low-pitched rumbling. ANS: B
Wheezes are high-pitched, continuous, musical sounds like a squeak heard continuously during inspiration or expiration; they are usually louder on expiration. Coarse crackles and bubbling are not descriptive of wheezes. Dry, grating noises are heard with a pleural friction rub. Loud, low-pitched rumbling is characteristic of rhonchi. DIF: CognitiveLevel: Application OBJ: Discuss normal physical findings for patients across the life span.
TOP: Adventitious Breath Sounds
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
25. A nurse is documenting a patient‘s breath sounds. Rhonchi are heard as: a. loud, low-pitched, coarse sounds. b. high-pitched, musical squeaks. c. dry, grating sounds on inspiration. d. high-pitched, fine sounds at the end of inspiration. ANS: A
Rhonchi are loud, low-pitched, rumbling, coarse sounds heard most often during inspiration or expiration; they may be cleared by coughing. Wheezes are high-pitched, continuous, musical sounds like a squeak heard continuously during inspiration or expiration; they are usually louder on expiration and do not clear with coughing. Pleural friction rub has a dry, grating quality heard best during inspiration and does not clear with coughing; it is heard loudest over the lower lateral anterior surface. Fine crackles are high-pitched fine, short, interrupted crackling sounds heard during the end of inspiration; they usually are not cleared with coughing. DIF: CognitiveLevel: Application OBJ: Discuss normal physical findings for patients across the life span. TOP: Adventitious Breath Sounds
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. The purpose of the physical assessment is to: (Select all that apply.) a. compare the patient‘s status with previous findings. b. help the nurse gather additional data. c. help select the best nursing measures. d. teach patients about better health promotion. ANS: A, B, C, D
In acute care settings, you perform a brief physical assessment at the beginning of each shift to identify changes in the patient‘s status for comparison with the previous assessment. After gathering data, the nurse groups significant findings into patterns of data that reveal actual or risk nursing diagnoses. Each abnormal finding directs the nurse to gather additional data. The information is useful in selecting the best nursing measures to manage the patient‘s health problems. During the physical assessment is an ideal time to offer patient teaching and encourage promotion of health practices, such as breast and genital self-examination. DIF: CognitiveLevel: Comprehension
OBJ: Discuss the purposes of physical assessment.
TOP: Purpose of the Physical Assessment KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The nurse is preparing to examine a comatose patient on a ventilator. Before beginning the procedures, she: (Select all that apply.) a. speaks to the patient to minimize anxiety. b. drapes the body parts not being examined. c. encourages the patient to ask questions. d. uses medical terms to let the patient know that she is professional. ANS: A, B
Minimize patients‘ anxiety and fear by conveying an open, receptive, and professional approach. Using simple terms, thoroughly explain what you will do, what the patient should expect to feel, and how the patient can cooperate. Even if the patient appears unresponsive, it still is essential to explain your actions. Provide access to body parts while draping areas that are not being examined. DIF: CognitiveLevel: Application OBJ: List techniques to promote the patient‘s physical and psychological comfort during an examination.
TOP: Preparing the Patient
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
3. The patient has come to the clinic complaining of bleeding from what she calls a ―mole‖ on her neck. She states that her mother died from skin cancer at a fairly early age because she was fair-skinned and had a lot of exposure to the sun. Because of this, the patient has been going for tanning sessions regularly for several years to keep her dark and to protect her from the sun. The nurse prepares to examine the ―mole‖ while being especially watchful for: (Select all that apply.) a. uneven shape of the mole (asymmetry). b. ragged or blurred edges of the mole border. c. pigmentation that is not uniform. d. size of the mole. ANS: A, B, C, D
The warning signs of skin cancer using the ABCD mnemonic include: A for Asymmetry— look for uneven shape; B for Border irregularity—look for edges that are blurred, notched, or ragged; C for Color—pigmentation is not uniform; blue, black, brown variegated, tan, or areas of unusual color such as pink, white, gray, or red; and D for Diameter—greater than the size of a typical pencil eraser. Also, identify any skin lesion or nevi that starts to bleed or ooze or feels different (swollen, hard, lumpy, itchy, or tender to the touch). DIF: CognitiveLevel: Analysis OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Melanoma
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. While performing a physical examination, the nurse incorporates health promotion by teaching the patient about how to reduce the risk of lung cancer. The nurse explains that besides cigarette smoking, exposure to other substances may lead to this disease. Some of these substances are: (Select all that apply.) a. arsenic. b. asbestos. c. radiation. d. air pollution.
ANS: A, B, C, D
Explain to patients that exposure to radiation, arsenic, and asbestos from occupational, medical, and environmental sources; air pollution; history of tuberculosis; and secondhand smoke contribute significantly to lung cancer. DIF: CognitiveLevel: Knowledge OBJ: Discuss ways to incorporate health promotion and health teaching into an assessment. TOP: Lung Cancer
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
5. In teaching the patient about prevention of cervical cancer, the nurse teaches the patient about the risk factors for cervical cancer. Risk factors for cervical cancer include which of the following? (Select all that apply.) a. History of human papillomavirus (HPV) infection b. Multiple sex partners c. Smoking d. Multiple pregnancies ANS: A, C, D
Determine whether the patient has a history of human papillomavirus (HPV), condyloma acuminatum, herpes simplex, or cervical dysplasia; has multiple sex partners; smokes cigarettes; or has had multiple pregnancies. These are risk factors for cervical cancer. DIF: CognitiveLevel: Comprehension OBJ: Discuss ways to incorporate health promotion and health teaching into an assessment. TOP: Cervical Cancer
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
COMPLETION
1. The patient is 3 days post abdominal surgery. The nurse uses her stethoscope to listen for bowel sounds. This assessment technique is known as ANS:
.
auscultation Auscultation is listening with a stethoscope to sounds produced by the body. DIF: CognitiveLevel: Comprehension OBJ: Describe the techniques used with each assessment skill.
TOP: Auscultation
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
2. The female nurse is preparing to assess and possibly change a scrotal dressing on a 34-year-old patient. Before changing the dressing, she should
.
ANS:
have a third person of the patient‘s gender come into the room Have a third person of the patient‘s gender in the room during assessment of genitalia. This prevents the patient from accusing the nurse of behaving in an unethical manner. DIF: CognitiveLevel: Application OBJ: Make environmental preparations before conducting an assessment. TOP: Preparing the Patient
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
3.
is a major cause of lung cancer, cerebrovascular disease, heart disease, and chronic lung disease. ANS:
Smoking Smoking is a major cause of lung cancer, heart disease, and chronic lung disease (emphysema and chronic bronchitis). Smoking accounts for 29% of all lung cancer deaths in the United States. DIF: CognitiveLevel: Knowledge
OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Smoking
KEY: NursingProcess Step: Diagnosis
MSC: NCLEX: Physiological Integrity
4. When performing an assessment of the cardiovascular system, the nurse evaluates the skin and nails of the patient. Inadequate tissue perfusion is known as
.
ANS:
ischemia Inadequate tissue perfusion results in inadequate delivery of oxygen and nutrients to cells, a condition called ischemia. This is caused by constriction of vessels or by occlusion (blockage) from clot formation. DIF: CognitiveLevel: Knowledge OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Ischemia
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient has been immobile at home after having had leg trauma in an automobile accident and is now being admitted with calf pain and localized swelling of the calf muscle. One test that is contraindicated in assessment of this patient is testing for
.
ANS:
Homans‘ sign Homans‘ sign is no longer considered a reliable indicator for the presence or absence of DVT and should not be considered a reliable test. Trauma to the vein or muscle, reduced mobility, and increased blood clotting are reliable risk factors. If the calf is swollen, tender, or red, notify the patient‘s health care provider for further assessment and evaluation. If there is a strong suspicion of DVT, testing for Homans‘ sign is contraindicated. If a clot is present, it may become dislodged from its original site during this test. This could result in a pulmonary embolism.
DIF: CognitiveLevel: Analysis OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Deep Vein Thrombosis
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
6. The patient has been in the ICU following an acute myocardial infarction 3 days earlier. During an initial assessment of the patient, the nurse detects a heart murmur that the patient did not have previously. The nurse should
.
ANS:
notify the physician Impaired blood flow through the heart indicates the need for immediate medical attention. Some murmurs are benign. DIF: CognitiveLevel: Analysis OBJ: Communicate abnormal findings to appropriate personnel. TOP: Murmurs
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
7. The patient is noted to have difficulty swallowing. The nurse realizes that the most probable cause of this difficulty is damage to cranial nerve
.
ANS:
IX Damage to CN IX causes impaired swallowing; damage to CN X causes loss of gag reflex, hoarseness, and nasal voice. When the palate fails to rise and the uvula pulls toward the normal side, this indicates a unilateral paralysis. DIF: CognitiveLevel: Synthesis OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Cranial Nerves MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Assessment
8. When breast self-examination is done, it should be done once a month. For women who menstruate, the best time is
.
ANS:
2 or 3 days after a period ends For women who menstruate, the best time to do BSE is 2 or 3 days after a period ends, when the breasts are least likely to be tender or swollen. Women who no longer menstruate should pick a day, such as the first day of the month, to regularly do a BSE. DIF: CognitiveLevel: Application OBJ: Identify self-screening assessments commonly performed by patients. TOP: Breast Self-Examination
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
9. Increased visibility of oxyhemoglobin caused by dilation or increased blood flow is known as . ANS:
erythema Red skin (erythema) is caused by increased visibility of oxyhemoglobin caused by dilation or increased blood flow. DIF: CognitiveLevel: Application OBJ: Discuss normal physical findings for patients across the life span. TOP: Skin Color Variations
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
10. A late sign of decreased oxygen levels may cause a change in skin color known as . ANS:
cyanosis
Bluish (cyanosis) coloring of the skin is caused by hypoxia (late sign of decreased oxygen levels). DIF: CognitiveLevel: Application OBJ: Discuss normal physical findings for patients across the life span. TOP: Skin Color Variations
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
11.
is a yellow-orange skin color seen with increased deposit of bilirubin in tissues. ANS:
Jaundice Jaundice, a yellow-orange skin color, is seen with increased deposits of bilirubin in tissues. DIF: CognitiveLevel: Knowledge OBJ: Discuss normal physical findings for patients across the life span. TOP: Skin Color Variations
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
Chapter 07: Specimen Collection Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. How should the nurse identify a patient before obtaining a laboratory specimen? a. Use at least two patient identifiers. b. Look at the chart before entering the room. c. Ask the patient his name. d. Check the patient‘s armband twice. ANS: A
Before obtaining a laboratory specimen, use at least two identifiers such as checking the identification number on the admission armband and asking the patient‘s name. Patients who are confused or who have a language barrier may smile and not understand the question. The patient could also have the wrong armband on; checking it twice would not change that. DIF: CognitiveLevel: Application OBJ: Identify measures to minimize anxiety and promote safety for selected techniques. TOP: Positive Patient Identification
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
2. When discussing the collection of a clean-voided urine specimen, it is important for the nurse to instruct the patient to: a. use a clean specimen cup. b. collect 100 to 150 mL of urine for testing. c. void some urine first and then collect the sample. d. wash the perineal area with soap and water immediately before voiding. ANS: C
After the patient has initiated a urine stream, pass the urine specimen container into the stream and collect 90 to 120 mL of urine. A sterile specimen container is used. Pour antiseptic solution over cotton balls. A cotton ball or gauze is used to cleanse the perineum. DIF: CognitiveLevel: Application OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens. TOP: Obtaining Urine Culture and Sensitivity (C&S) Specimen KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
3. The nurse needs to obtain a sterile urine specimen for culture and sensitivity (C&S) from a patient who has an indwelling catheter. The catheter was placed the night before. What must the nurse do to obtain the specimen? a. Obtain the urine from the drainage bag. b. Clamp the drainage tubing for 10 to 15 minutes. c. Draw urine using a 20-mL syringe.
d. Insert the needle into the silicone catheter. ANS: B
Clamp the drainage tubing with a clamp or rubber band for 30 minutes to permit collection of fresh, sterile urine in the catheter tubing rather than draining into the bag. Do not collect a urine specimen for culture tests from a urine drainage bag unless it is the first urine to drain into a new sterile bag. Draw urine into a 3-mL syringe (for culture), or draw urine into a 20-mL syringe (for routine urinalysis). Proper volume is needed to perform the test. Do not puncture Silastic, silicone, or plastic catheters. These are not self-sealing. DIF: CognitiveLevel: Application OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens. TOP: Obtaining Urine C&S Specimen from a Catheter KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
4. What should the nurse do first if a patient is unable to void on demand for a clean-voided specimen? a. Perform Credé‘s procedure for the suprapubic area. b. Catheterize the patient to obtain the specimen. c. Offer fluids, if allowed. d. Notify the physician that the test cannot be completed. ANS: C
If the patient is unable to urinate on demand, offer fluids if permitted. Allow more time for urine to accumulate in the bladder. Try obtaining a specimen after 30 minutes. If the patient has no urine in the bladder, Credé‘s would not be useful. The risk for infection precludes the use of catheterization simply to obtain a specimen. If the patient is unable to void after several hours, the physician may need to be called to obtain an order for catheterization. DIF: CognitiveLevel: Application OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens. TOP: Obtaining Urine C&S Specimen from a Catheter KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. What must the nurse do to collect a midstream urine sample from an infant? a. Apply a sterile plastic collection bag to the perineum. b. Wring out diapers and collect the urine in a specimen container. c. Have the infant sit facing the back of the toilet. d. Catheterize the infant and collect the urine using sterile procedure. ANS: A
Use a sterile plastic urine collecting bag that adheres to the perineum of a non–toilet-trained child. Special considerations for boys: Place the penis and scrotum inside the bag. Diapers may be contaminated. Seating on a toilet generally is not realistic for an infant. Catheterization should be used as a last resort only. DIF: CognitiveLevel: Application OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens. TOP: Obtaining Urine C&S Specimen from an Infant KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
6. What should the nurse do when a patient is required to provide a timed urine specimen? a. Save all urine from the time the test began. b. Leave the collection bottle on the floor near the patient‘s bed. c. Send notices along with the patient when leaving the unit to have all urine saved and returned to the unit. d. Remove contaminants such as toilet paper from the urine before transferring it to the collection bottle. ANS: C
Place signs on the patient‘s door and toileting area, indicating that a timed urine specimen collection is in progress. If the patient leaves the unit for a test or procedure, be sure that personnel in that area collect and save all urine. The nurse discards the first specimen and then collects every successive specimen until the time period has ended. Place a specimen collection container in the bathroom and, if indicated, in a pan of ice. The urine specimen is not to be contaminated with feces or toilet tissue.
DIF: CognitiveLevel: Application OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens. TOP: Obtaining a Timed Urine Specimen KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
7. What instructions does the nurse provide to the patient to obtain a double-voided urine specimen? a. Save two separate specimens from the first voiding in the morning. b. Add two specimens together from the morning voiding and the evening voiding. c. Discard the first sample, then wait a half hour and void again. d. Void first and then self-catheterize to obtain the specimens. ANS: C
A fresh specimen should be used because stagnant urine that has been in the bladder for several hours will not accurately reflect the serum glucose level at the time of testing. Ask the patient to collect a random urine specimen and discard, drink a glass of water, and collect another specimen 30 to 45 minutes later. DIF: CognitiveLevel: Application OBJ: Identify special conditions necessary for collection of each specimen. TOP: Collecting a Double-Voided Specimen KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
8. An appropriate procedure for urine testing with reagent strips for chemical properties of the sample is to: a. obtain the first voided specimen in the morning. b. immerse the test strip in the urine and remove immediately. c. add a chemically active tablet to the urine and then test it with a reagent strip. d. wipe the strip with a sterile gauze after dipping. ANS: B
Immerse the strip briefly in the urine sample, and then remove it and tap it gently on the side of the container; prolonged exposure to excess urine can dilute reagents. Stagnant urine stored in the bladder overnight or for long periods does not reveal quantities of glucose and ketones excreted by the kidney at the time of testing. Kits that contain tablets do not also use strips; the tablet contains the reagent and changes color to indicate chemical properties of the urine. Tap the strip gently against the side of the container to shed excess urine; do not wipe it. DIF: CognitiveLevel: Application OBJ: Discuss nursing responsibilities for processing a specimen after collection. TOP: Testing the Chemical Properties of Urine KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
9. A patient is concerned because her first guaiac test is positive. What information should the nurse share with the patient? a. The patient probably has colorectal cancer. b. The test needs to be repeated after she eats some red meat. c. The test needs to be repeated at least 3 times. d. The patient needs a low-residue diet to reduce intestinal abrasions. ANS: C
A single positive test result does not confirm bleeding or indicate colorectal cancer. For confirmed positive results, the test must be repeated at least 3 times while the patient is on a meat-free, high-residue diet. More in-depth diagnosis is needed with a positive result. DIF: CognitiveLevel: Application OBJ: Explain instructions to encourage patient cooperation for successful collection of each specimen.
TOP: Guaiac Testing
KEY: NursingProcess Step: Diagnosis
MSC: NCLEX: Physiological Integrity
10. When teaching a patient about home testing for occult blood, the nurse instructs the patient that: a. positive results are indicative of bleeding. b. poultry and fish should be eaten before testing.
c. testing should be done carefully during the menstrual cycle. d. two samples should be obtained from the same part of the stool specimen. ANS: C
Specimens will be positive if contaminated by menstrual blood or hemorrhoidal blood or povidone-iodine. A single positive test result does not confirm bleeding or indicate colorectal cancer. Diets rich in meats; green leafy vegetables; poultry; and fish may produce false-positive results. Obtain a second fecal specimen from a different portion of the stool. DIF: CognitiveLevel: Application OBJ: Explain instructions to encourage patient cooperation for successful collection of each specimen.
TOP: Guaiac Testing
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
11. A patient asks what food may be eaten before a stool specimen is obtained for occult blood. What food should the nurse allow the patient to eat? a. Fish b. Apples c. Red meats d. Green leafy vegetables ANS: B
Diets rich in meats; green leafy vegetables; poultry; and fish may produce false-positive results. DIF: CognitiveLevel: Comprehension OBJ: Explain instructions to encourage patient cooperation for successful collection of each specimen.
TOP: Guaiac Testing
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
12. The nurse evaluates that an expected outcome for analysis of gastric secretions is: a. inability of the patient to discuss the rationale for the test. b. negative occult blood. c. the presence of clumps or clots.
d. the presence of brown, ―coffee-ground‖ secretions. ANS: B
An expected outcome after completion of the procedure is the test for occult blood. If frank red blood is observed or coffee-ground materials are seen, report these findings immediately. This is an unexpected finding. DIF: CognitiveLevel: Comprehension OBJ: Explain the rationale for the collection of each specimen. TOP: Guaiac Testing of Gastric Contents KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
13. An appropriate technique for the nurse to implement when obtaining throat cultures is to: a. have the patient lie flat in the bed. b. do the culture before meals or an hour after meals. c. avoid touching the swab to any of the inflamed areas. d. place pressure on the tongue blade along the back of the tongue. ANS: B
Plan to do the culture before mealtime or at least 1 hour after eating. This procedure often induces gagging; timing will decrease the patient‘s chances of vomiting. Ask the patient to sit erect in bed or on a chair facing the nurse. Gently but quickly swab the tonsillar area from side to side, making contact with inflamed or purulent sites. Depress the anterior third of the tongue only; placement of a tongue blade along the back of the tongue is more likely to initiate a gag reflex. DIF: CognitiveLevel: Application OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Obtaining a Throat Culture
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
14. What step should the nurse take to obtain a vaginal specimen for a culture? a. Apply sterile gloves. b. Assist the patient to a side-lying position. c. Collect discharge from the perineum on the same swab.
d. Insert the swab to 1 inch into the orifice and rotate before removal. ANS: D
Gently insert the swab to 1 inch into the vaginal orifice and rotate before removal. Apply clean disposable gloves. The patient should be in dorsal recumbent position. If a discharge near the vagina appears different from the discharge along the perineum, collect separate specimens from each area. DIF: CognitiveLevel: Application OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Obtaining a Vaginal Culture
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
15. When using a commercially prepared tube to collect a culture, the nurse should: a. take the swab and mix it in the reagent to check for color changes. b. place the swab into the culture tube and then add a special reagent to the tube. c. crush the ampule at the end of the tube and put the tip of the swab into the solution. d. place the swab into the tube, close it securely, and keep it warm until it is sent to the laboratory. ANS: C
Immediately squeeze the end of the tube to crush the ampule, and push the tip of the swab into fluid medium. DIF: CognitiveLevel: Application OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Preparing a Culture Tube
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
16. A nurse suspects that the patient may have tuberculosis (TB). She sends a sputum sample to the lab for testing. When the following tests are compared, which will best support the diagnosis of possible tuberculosis? a. Acid-fast bacilli (AFB) b. General cytology c. Chemical analysis
d. Culture and sensitivity ANS: A
Sputum specimens are collected to identify cancer cells, for culture and sensitivity (C&S) to identify pathogens and determine the antibiotics to which they are sensitive, and for acid-fast bacilli to diagnose pulmonary tuberculosis. Cytological or cellular examinations of sputum may identify aberrant cells or cancer. Chemical analysis would indicate chemicals within the blood, not sputum. Sputum collected for culture and sensitivity testing is used to identify specific microorganisms and to determine which antibiotics are most sensitive. A definitive diagnosis of tuberculosis (TB) also requires a sputum culture and sensitivity. DIF: CognitiveLevel: Analysis OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Acid-Fast Bacilli
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
17. The patient has come to the emergency department complaining of coughing up bloody sputum. The patient has a 30-year history of smoking and has lost 15 pounds in the last month. What will the nurse expect the sputum specimen to be evaluated for? a. Culture and sensitivity b. Acid-fast bacilli (AFB) c. Cytology d. Chemical analysis ANS: C
The patient is showing signs of cancer. Sputum specimens are collected to identify cancer cells. Sputum collected for culture and sensitivity testing is used to identify specific microorganisms. The acid-fast bacilli (AFB) is used to support the diagnosis of tuberculosis. Chemical analysis would indicate chemicals within the blood, not sputum. DIF: CognitiveLevel: Analysis OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Cytological Examination of Sputum KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
18. An appropriate technique that the nurse can tell the patient to implement before obtaining a sputum specimen is to: a. use mouthwash before the collection. b. splint the surgical incision before coughing. c. try to obtain a sample immediately after eating. d. take a deep breath, cough hard, and expectorate. ANS: B
If the patient has a surgical incision or localized area of discomfort, have the patient place hands firmly over the affected area, or place a pillow over the area. Splinting of painful areas minimizes muscular stretching and discomfort during coughing and thus makes cough more productive. The patient should not use mouthwash or toothpaste because it may decrease viability of microorganisms and culture results. Have the patient wait 1 to 2 hours after eating. After a series of deep breaths, ask the patient to cough after full inhalation. DIF: CognitiveLevel: Application OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Obtaining Sputum Specimen
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
19. During a sputum collection, the patient becomes hypoxic. What action should the nurse take? a. Suction the patient thoroughly. b. Continue to complete the procedure quickly. c. Stop the procedure and provide oxygen, if ordered. d. Have the patient lie down and take deep breaths before continuing with the specimen collection. ANS: C
If the patient becomes hypoxic, discontinue the procedure until stable and provide oxygen therapy as needed, if ordered. Suctioning can decrease usable oxygen to the patient. DIF: CognitiveLevel: Application OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Hypoxia During Suctioning MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
20. The nurse has delegated activities of daily living (ADL) care of a patient with a large wound that is draining. Which of the following should the nurse instruct the nurse assistant to report back to her? a. The wound has a foul odor. b. Drainage is decreased. c. The patient‘s temperature is slightly below normal. d. The patient does not complain of discomfort. ANS: A
Report a foul odor, increased drainage, and increased temperature or complaints of discomfort. DIF: CognitiveLevel: Application OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Signs of Infection
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
21. An appropriate technique for the nurse to use when culturing wound drainage that is suspected to contain anaerobic bacteria is to: a. use older secretions for the specimen. b. add exudate from the skin to the wound specimen. c. aspirate 5 to 10 mL of exudate from a deep cavity wound. d. swab carefully and slowly in a back-and-forth motion across the wound. ANS: C
Take a swab from a special anaerobic culture tube, swab deeply into the draining body cavity, and rotate gently. Remove the swab and return it to the culture tube. Insert tip of syringe (without needle) into wound and aspirate 5 to 10 mL of exudate. Attach 19-gauge needle, expel all air, and inject drainage into special culture tube. Cleanse the area around the wound edges with an
antiseptic swab. This removes old exudate and skin flora, preventing possible contamination of the specimen. Never collect exudate from the skin unless it is a separate culture and is labeled as such. DIF: CognitiveLevel: Application
OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Obtaining Anaerobic Wound Specimen KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
22. The patient is diagnosed with suspected bacteremia. The physician has ordered blood cultures from two different sites. The patient is complaining of chills and has an elevated temperature. What action should the nurse take in the presence of these symptoms? a. Delay drawing the blood cultures until symptoms subside. b. Draw blood from only one site to prevent further discomfort. c. Draw the blood cultures as ordered. d. Draw blood from the patient‘s intravenous (IV) catheter. ANS: C
Because bacteremia may be accompanied by fever and chills, blood cultures should be drawn when the patient is experiencing these clinical signs. It is important that at least two culture specimens be drawn from two different sites. Bacteremia exists when both cultures grow the infectious agent. Because blood culture specimens obtained from an IV catheter are frequently contaminated, tests that use them should not be performed unless catheter sepsis is suspected. DIF: CognitiveLevel: Application OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Drawing Blood Cultures
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
23. When blood specimens are drawn, which of the following statements is true? a. Draw cryoglobulin levels using test tubes placed on ice. b. To test ammonia and ionized calcium levels, warm the test tubes. c. To draw for lactic acid levels, do not use a tourniquet. d. To draw for vitamin levels, use light to determine density. ANS: C
Some specimens have special collection requirements before or after specimen collection, for example, for lactic acid levels, do not use a tourniquet. For cryoglobulin levels, use pre-warmed test tubes. For ammonia and ionized calcium levels, place the tube in ice for delivery to the laboratory. For vitamin levels, avoid exposure of the test tube to light. DIF: CognitiveLevel: Analysis OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Drawing Blood
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
24. A patient is to have a venipuncture to obtain a blood sample to check ammonia levels. What should the nurse do when given this information? a. Use pre-warmed test tubes. b. Keep the specimen out of the light. c. Avoid use of a tourniquet during the procedure. d. Place the samples on ice before sending them to the lab. ANS: D
Some specimens have special collection requirements before or after specimen collection. For ammonia levels, tubes must be placed on ice for delivery to the laboratory. For cryoglobulin levels, use pre-warmed test tubes. For vitamin levels, avoid exposure of the test tube to light. For lactic acid levels, do not use a tourniquet. DIF: CognitiveLevel: Analysis OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Drawing Blood
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
25. The nurse is preparing to perform a venipuncture on a patient. Which of the following is an appropriate action for the nurse to take? a. Apply the tourniquet until the distal pulse is no longer felt. b. Remove the tourniquet after 1 minute. c. Instruct the patient to vigorously open and close the fist. d. Do not use veins that rebound.
ANS: B
Do not keep a tourniquet on the patient longer than 1 minute. Prolonged tourniquet application causes stasis, localized acidemia, and hemoconcentration. Palpate the distal pulse (e.g., brachial) below the tourniquet. If the pulse is not palpable, reapply the tourniquet more loosely. Ask the patient to open and close the fist several times, finally leaving the fist clenched. Instruct the patient to avoid vigorous opening and closing of the fist. Palpate for a firm vein that rebounds; a patent, healthy vein is elastic and rebounds on palpation. DIF: CognitiveLevel: Application
OBJ: Use correct technique to perform venipuncture.
TOP: Applying Tourniquet
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
26. An appropriate technique for the nurse to implement when preparing for a venipuncture is to: a. tie the tourniquet in a knot. b. tie the tourniquet, so it can be easily removed. c. place the tourniquet 6 to 8 inches above the selected site. d. make the tourniquet tight enough to occlude the distal pulse. ANS: B
Apply the tourniquet by encircling the extremity and pulling one end of the tourniquet tightly over the other, looping one end under the other, so it can be removed by pulling the end with a single motion. Apply the tourniquet 2 to 4 inches above the venipuncture site selected. Palpate the distal pulse below the tourniquet; if the pulse is not palpable, reapply the tourniquet more loosely. DIF: CognitiveLevel: Application
OBJ: Use correct technique to perform venipuncture.
TOP: Applying Tourniquet
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
27. The nurse is drawing blood from a patient to determine the blood alcohol level. Which step is an appropriate action for the nurse to take? a. Swab the area with an antiseptic swab. b. Swab the area with an alcohol swab. c. Do not swab the area at all.
d. Apply the tourniquet for 5 minutes. ANS: A
If drawing a sample for a blood alcohol level or blood culture, use only an antiseptic swab, not an alcohol swab. Do not keep a tourniquet on the patient longer than 1 minute. DIF: CognitiveLevel: Application
OBJ: Use correct technique to perform venipuncture.
TOP: Drawing Blood for Blood Alcohol Level KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
28. When performing a venipuncture, the nurse should: a. inject with the needle at a 45-degree angle. b. select a vein that is rigid and cordlike, and that rolls when palpated. c. perform the needle insertion immediately after cleansing the skin with alcohol. d. place the thumb of the nondominant hand about 1 inch below the site and pull the skin taut. ANS: D
Place the thumb or forefinger of the nondominant hand 1 inch below the site and gently pull the skin taut. Stretch the skin down until the vein is stabilized. Hold a syringe and needle at a 15- to 30-degree angle from the patient‘s arm with the bevel up. Palpate for a firm vein that rebounds. Do not use veins that feel rigid or cordlike; a thrombosed vein is rigid, rolls easily, and is difficult to puncture. Allowing alcohol to dry completes its antimicrobial task and reduces the ―sting‖ of venipuncture. Alcohol left on the skin can cause hemolysis of the sample. DIF: CognitiveLevel: Application
OBJ: Use correct technique to perform venipuncture.
TOP: Venipuncture
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
29. When obtaining a venipuncture sample for a blood culture, the nurse should: a. recap the needles. b. shake the culture bottles well.
c. use two different sites to draw samples. d. inoculate the aerobic culture bottle first. ANS: C
Collect 10 to 15 mL of venous blood by venipuncture in a 20-mL syringe from each venipuncture site. Culture specimens must be obtained from two sites. Dispose of needles, syringe, and soiled equipment in the proper container. Do not cap the needles. Mix gently after inoculation. If both aerobic and anaerobic cultures are needed, inoculate the anaerobic culture first. DIF: CognitiveLevel: Analysis OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Blood Cultures
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
30. When teaching about the procedure for capillary puncture, the nurse instructs a patient to: a. hold the finger upright. b. use the central tip of the finger. c. allow the antiseptic to dry completely. d. vigorously squeeze the end of the finger. ANS: C
Clean the site with an antiseptic swab, and allow it to dry completely. Alcohol left on the skin can cause hemolysis of the sample. Hold the finger to be punctured in a dependent position. Do not milk or massage finger site. Milking may hemolyze specimen and introduce excess tissue fluid. Select the lateral side of the finger; be sure to avoid the central top of the finger, which has a more dense nerve supply. DIF: CognitiveLevel: Application OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Capillary Puncture
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
31. Which of the following is the site of choice for obtaining samples for an arterial blood gas (ABG)?
a. Radial artery b. Brachial artery c. Femoral artery d. Popliteal artery ANS: A
The radial artery is the safest, most accessible site for puncture; it is superficial, is not adjacent to large veins, and usually has adequate collateral circulation by the ulnar artery. Its use is relatively painless if the periosteum is avoided, and it is used when Allen‘s test is positive. The brachial artery has reasonable collateral blood flow but is less superficial, is more difficult to palpate and stabilize, and carries increased risk for venous puncture; its use results in increased discomfort. The femoral artery should not be used by nurses without specialized training. The popliteal artery usually is not used. DIF: CognitiveLevel: Application OBJ: Use correct technique to perform arterial puncture for blood gas measurement. TOP: Arterial Blood Gases
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
32. An appropriate technique for the nurse to implement when obtaining an arterial blood gas (ABG) specimen is to: a. insert the needle at a 45-degree angle. b. use a 19-gauge, 1-inch needle. c. leave 0.5 mL of heparin in the syringe. d. aspirate blood after the puncture. ANS: A
Hold the needle bevel up, and insert the needle at a 45-degree angle into the artery. Use a 23to 25-gauge needle. Aspirate 0.5-mL sodium heparin into a syringe, and then eject all heparin in the barrel out of the syringe. Allow arterial pulsations to pump 2 to 3 mL of blood into the heparinized syringe slowly to reduce the presence of air bubbles. DIF: CognitiveLevel: Application OBJ: Use correct technique to perform arterial puncture for blood gas measurement. TOP: Arterial Blood Gases
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
33. What should the nurse do after obtaining a sample for an arterial blood gas (ABG)? a. Maintain pressure over the site for 3 to 5 minutes. b. Check the artery proximal to or above the puncture site. c. Place the syringe into a plastic bag, and send it to the lab. d. Apply a cool compress to hematoma formation at the puncture site. ANS: A
Maintain continuous pressure on and proximal to the site for 3 to 5 minutes. Palpate the artery below or distal to the puncture site to determine whether pulse quality has changed, indicating alteration in arterial flow. Place a syringe in a cup of crushed ice. Failure to do this may result in decreased pH, arterial oxygen pressure (PaO2), and oxygen saturation. Apply warm compresses to enhance the absorption of blood. DIF: CognitiveLevel: Application OBJ: Use correct technique to perform arterial puncture for blood gas measurement. TOP: Arterial Blood Gases
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. When collecting specimens, the nurse should: (Select all that apply.) a. wear gloves and perform hand hygiene. b. handle excretions discreetly. c. explain the procedure to the patient. d. allow patients to collect their own urine specimens. ANS: A, B, C, D
When collecting specimens, wear gloves, and perform hand hygiene. Also, handle excretions discreetly. Invasive collection procedures and fear of unknown test results often cause patients anxiety. Patients who receive a clear explanation about the purpose of the specimen and how the nurse will obtain it are more cooperative. Give patients proper instruction to collect their own specimens of urine, stool, and sputum, thus avoiding embarrassment.
DIF: CognitiveLevel: Application OBJ: Identify measures to minimize anxiety and promote safety during specimen collection. TOP: Specimen Collection
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
2. When obtaining laboratory specimens, the nurse needs to be aware that: (Select all that apply.) a. specimen collection may cause anxiety and embarrassment. b. sociocultural variations may affect a patient‘s compliance. c. contact isolation precautions are required for collection of blood. d. two identifiers, including room number, must be used. ANS: A, B
The nurse should recognize that specimen collection may cause anxiety, embarrassment, and/or discomfort. Cultural considerations are important when collecting specimens and performing diagnostic procedures. Culture and beliefs may affect a patient‘s response and willingness to participate in specimen collection. Use of a patient‘s room number is not an acceptable identifier, and the nurse should follow standard precautions when collecting specimens of blood or other body fluids. DIF: CognitiveLevel: Application OBJ: Recognize the impact of patient-centered issues on patients‘ cooperation with collection of specimens.
TOP: Obtaining Laboratory Specimens
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
3. A timed urine collection can be used for which of the following? (Select all that apply.) a. Glucose b. Adrenocorticosteroids c. Bacteria count d. Color ANS: A, B
Some tests of renal function and urine composition require urine to be collected over 2 to 72 hours. The 24-hour timed collection is most common. These tests measure for elements such as amino acids, creatinine, hormones, glucose, and adrenocorticosteroids, whose levels fluctuate throughout the day. A timed urine collection also can serve as a means to measure the concentration or dilution of urine. Bacteria count and color can be determined through a routine urinalysis. DIF: CognitiveLevel: Knowledge OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens. TOP: Obtaining a Timed Urine Specimen KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
4. Hemoccult testing helps to reveal blood that is visually undetectable. This test is a useful diagnostic tool for which of the following conditions? (Select all that apply.) a. Colon cancer b. Bleeding GI ulcers c. Localized gastric irritant d. Large polyps ANS: A, B, C
This test is a useful diagnostic tool for conditions such as colon cancer, upper gastrointestinal ulcers, and localized gastric parasitic infection or intestinal irritation. The amount of bleeding increases with the size of the polyp and the stage of cancer. People with small polyps (less than 1 cm in diameter) bleed scarcely more than those without polyps. DIF: CognitiveLevel: Comprehension OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Guaiac Testing
KEY: NursingProcess Step: Diagnosis
MSC: NCLEX: Physiological Integrity
5. The nurse is caring for a patient who has had a craniotomy. The patient appears to need endotracheal suctioning. The nurse is aware that this can be of concern because suctioning can cause which of the following? (Select all that apply.)
a. Violent coughing b. Aspiration of stomach contents c. Increased intracranial pressure d. Bradycardia or tachycardia ANS: A, B, C, D
Sometimes suctioning provokes violent coughing, causes vomiting and aspiration of stomach contents, and induces constriction of pharyngeal, laryngeal, and bronchial muscles. In addition, suctioning may cause hypoxemia or vagal overload, resulting in cardiopulmonary compromise and increased intracranial pressure. DIF: CognitiveLevel: Comprehension OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Suctioning
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
6. In explaining to the patient about obtaining a sputum specimen to diagnose tuberculosis, the nurse explains which of the following? (Select all that apply.) a. Specimens are best obtained in the early morning. b. Acid-fast bacilli (AFB) smears require three consecutive morning samples. c. Bacteria accumulate as secretions pool. d. Specimens should be obtained at bedtime. ANS: A, B, C
Specimens for acid-fast bacilli (AFB) require three consecutive morning samples, and cultures can take up to 8 weeks. The ideal time to collect sputum is early morning because bronchial secretions tend to accumulate during the night. Bacteria also accumulate as secretions pool. DIF: CognitiveLevel: Comprehension OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Cultures for Acid-Fast Bacilli and C&S for Tuberculosis KEY: NursingProcess Step: Planning
COMPLETION
MSC: NCLEX: Physiological Integrity
1. Assessment of the chemical properties of urine is done by immersing a special, chemically prepared strip of paper into a clean urine specimen, or by combining drops of urine with chemically prepared tablets. The
of the strip or tablet indicates the presence
of any of unique chemical properties. ANS:
change in color You assess the chemical properties of urine by immersing a special, chemically prepared strip of paper into a clean urine specimen, or by combining drops of urine with chemically prepared tablets. The change in color of the strip or tablet indicates the presence of glucose, ketones, protein, and blood as well as pH of the urine. DIF: CognitiveLevel: Application OBJ: Discuss nursing responsibilities for processing a specimen after collection. TOP: Testing the Chemical Properties of Urine KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
2. A common test performed on fecal material is the
test for fecal occult blood.
ANS:
guaiac A common test performed on fecal material is the guaiac test for fecal occult blood. DIF: CognitiveLevel: Knowledge OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Guaiac Testing
KEY: NursingProcess Step: Diagnosis
MSC: NCLEX: Physiological Integrity
3.
is often indicated to collect sputum from patients unable to spontaneously produce a sample for laboratory analysis.
ANS:
Suctioning Suctioning is often indicated to collect sputum from patients unable to spontaneously produce a sample for laboratory analysis. DIF: CognitiveLevel: Comprehension OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Suctioning
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
4. Localized inflammation, tenderness, warmth at the wound site, and purulent drainage usually signify
_.
ANS:
wound infection Localized inflammation, tenderness, warmth at the wound site, and purulent drainage usually signify wound infection. DIF: CognitiveLevel: Comprehension OBJ: Properly collect specimens for culture from the nose and throat, urethra and vagina, sputum, and wound.
TOP: Wound Infection
KEY: NursingProcess Step: Assessment
5.
MSC: NCLEX: Physiological Integrity
organisms grow in superficial wounds exposed to the air. ANS:
Aerobic Aerobic organisms grow in superficial wounds exposed to the air. DIF: CognitiveLevel: Knowledge OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.
TOP: Aerobic Organisms
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
6. The least traumatic method of obtaining a blood specimen is known as
.
ANS:
skin puncture capillary puncture Skin puncture, also called capillary puncture, is the least traumatic method of obtaining a blood specimen. DIF: CognitiveLevel: Knowledge OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Skin/Capillary Puncture
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
Chapter 08: Diagnostic Procedures Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. A nurse should contact the physician to postpone intravenous moderate sedation if the patient: a. has had nothing by mouth (NPO) for 1 hour. b. has a history of substance abuse. c. has no history of latex allergy. d. has demonstrated an understanding of the procedure. ANS: A
Verify that the patient has not ingested food or fluids, except for oral medications, for at least 4 hours. Verify specific agency requirements. Because a risk of moderate sedation is loss of airway protection, an empty stomach reduces the risk for aspiration. A history of substance abuse is not a contraindication to the procedure, although it usually requires dose adjustment of the sedative. With no history of latex allergy, allergic reactions are not a concern. An understanding of the procedure implies that consent was informed. DIF: CognitiveLevel: Application OBJ: Demonstrate understanding of nursing responsibilities related to the use of intravenous sedation during diagnostic procedures.
TOP: Moderate Sedation
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. Which action should the nurse take after a procedure requiring intravenous moderate sedation? a. Report to the physician a Ramsay sedation score that is less than 3. b. Monitor airway patency and vital signs every 5 minutes for 30 minutes. c. Take vital signs every 15 minutes for the next 2 hours. d. Take vital signs every 30 minutes until stable. ANS: B
After the procedure, monitor airway patency, vital signs, SpO2, pain score, and level of consciousness every 5 minutes for at least 30 minutes, then every 15 minutes for an hour, and then every 30 minutes until the patient meets the discharge criteria on the agency‘s designated scoring system. Report to the physician only a Ramsay sedation score higher than 3. DIF: CognitiveLevel: Application OBJ: Demonstrate understanding of nursing responsibilities related to the use of intravenous sedation during diagnostic procedures.
TOP: Moderate Sedation
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. Under which circumstances should a nurse contact the physician to postpone an angiography? a. If a patient has had nothing by mouth (NPO) for only 1 hour. b. If a patient‘s femoral site has been shaved and cleansed with an antiseptic. c. If the patient received Benadryl as a preprocedure medication.
d. When test results reveal a blood urea nitrogen (BUN) level of 15 mg/100 mL and a creatinine level of 0.8 mg/mL. ANS: A
A patient needs to be NPO for 6 to 8 hours before the procedure to prevent possible aspiration because the patient is sedated. The site of catheter insertion needs to be shaved and prepped with antiseptic just before the procedure. Benadryl is used prophylactically to block histamine and decrease allergic responses. Elevated BUN or creatinine levels would place patients at risk for renal failure induced by contrast media. DIF: CognitiveLevel: Application OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.
TOP: Postponing Angiography
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
4. What action should the nurse take after an angiography? a. Limit the patient‘s fluid intake. b. Have the patient ambulate as soon as possible. c. Apply a pressure dressing to the vascular site. d. Maintain the patient in a sitting position while he or she is in bed. ANS: C
Five to 15 minutes of manual pressure is often enough to stop active site bleeding. However, a certain amount of bed rest is needed to achieve reliable hemostasis. Check agency policy for postprocedure bed rest requirements. This is often up to 6 hours when no vascular closure device is used. Encourage patient to drink 1 to 2 L of fluid after the procedure. Emphasize the need to lie flat for 6 to 12 hours. DIF: CognitiveLevel: Application OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures.
TOP: Post-Angiography Procedure
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. The nurse is alert to a possible delayed reaction to the dye injected during an angiography. For which response should she monitor the patient? a. Pallor b. Dyspnea c. Thirst d. Numbness and tingling ANS: B
Assess the patient for a possible delayed reaction to iodine dye, seen as dyspnea, hives, tachycardia, and rash. This reaction occurs up to 6 hours after injection of dye. Thirst, by itself, is not a major warning sign of reaction to the dye. Pallor, by itself, is not a major warning sign of reaction to the dye. A patient‘s report of any feelings of pain, dyspnea, numbness or tingling, or other untoward symptoms may indicate cardiac complications or procedure site complications, but not a reaction to the dye. DIF: CognitiveLevel: Application OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures.
TOP: Reaction to IV Dye
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
6. The nurse is preparing to assist with a bone marrow aspiration on a 3-month-old infant. The nurse may expect that the physician will use which site to perform the aspiration? a. Sternum b. Anterior iliac crest c. Proximal tibia d. Posterior iliac crest ANS: C
In children, the anterior or posterior iliac crest is used, and in infants, the proximal tibia is used. DIF: CognitiveLevel: Application OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.
TOP: Bone Marrow Aspiration
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
7. The nurse is discussing the patient‘s upcoming elective lumbar puncture, and explains that the patient will probably need to undergo computed tomography of the brain before the procedure is done. What is the reason for this? a. Diagnose central nervous system (CNS) infection. b. Rule out increased intracranial pressure. c. Visualize cerebrospinal fluid. d. Measure pressure in the subarachnoid space. ANS: B
In elective lumbar puncture (LP), pre-procedure computed tomography results are reviewed for evidence of brain shift to rule out increased intracranial pressure. The purpose of the LP procedure itself is to measure pressure in the subarachnoid space; obtain cerebrospinal fluid (CSF) for visualization and laboratory examination; and inject anesthetic, diagnostic, or therapeutic agents. A computed tomography (CT) scan will not allow adequate visualization of these structures. DIF: CognitiveLevel: Application OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.
TOP: Lumbar Puncture
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
8. The patient is a 56-year-old man who has terminal cirrhosis and severe ascites. He is lethargic but is demonstrating signs of discomfort and respiratory distress. The physician has spoken with the patient‘s wife and has obtained consent to perform an abdominal paracentesis on the patient. After the physician leaves to prepare for the procedure, the wife asks the nurse whether the procedure is really necessary. The nurse should respond by saying this: a. is the first step in the patient‘s recovery. b. may help the patient feel better. c. is needed to detect increased intracranial pressure. d. is needed to analyze pleural fluid. ANS: B
The patient is diagnosed as terminal. Paracentesis is a palliative measure used to provide temporary relief of abdominal and respiratory discomfort caused by severe ascites. Intracranial pressure is assessed with computed tomography. Thoracentesis, not paracentesis, is performed to analyze or remove pleural fluid. DIF: CognitiveLevel: Application OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.
TOP: Abdominal Paracentesis
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
9. Which is the appropriate patient position for a lumbar puncture? a. Prone b. Supine c. Sims‘ d. Lateral recumbent ANS: D
Position the patient in a lateral recumbent (fetal) position with the head and neck flexed. This provides spinal column full curvature. The spinal column is flexed as much as possible to allow maximal space between vertebrae. DIF: CognitiveLevel: Application OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.
TOP: Positioning for Lumbar Puncture
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
10. In which position is the patient usually placed for a thoracentesis? a. Dorsal recumbent position b. Supine with the arms over the head c. Sims‘ position on the affected side d. Sitting and leaning over a bedside table
ANS: D
Place the patient in the orthopneic position (upright position with arms and shoulders raised and supported on a padded over-bed table). If the patient is unable to tolerate this position, assist the patient to a side-lying position with the affected lung positioned upward. This expands the intercostal space for needle insertions. DIF: CognitiveLevel: Application OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.
TOP: Positioning for Thoracentesis
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
11. When explaining about a lumbar puncture, the nurse informs the patient that during the procedure, he or she will be asked to: a. remain very still. b. cough during the fluid aspiration. c. change position. d. breathe deeply during the needle insertion. ANS: A
Emphasize the importance of remaining immobile during the procedure to prevent trauma, especially with the lumbar puncture, because sudden movement is a risk for spinal cord nerve root damage. Also, instruct the patient not to cough, sneeze, or breathe deeply during the procedure because these actions increase the risks for needle displacement and damage to other structures. DIF: CognitiveLevel: Application OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.
TOP: Lumbar Puncture
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
12. When explaining what to expect during a bronchoscopy, the nurse informs the patient that:
a. an anesthetic solution will be swallowed. b. the tube will be passed through the nose. c. nothing will be given by mouth for 2 to 3 hours before. d. no food or fluid will be provided until the gag reflex returns. ANS: D
Do not allow the patient to eat or drink until the tracheobronchial anesthesia has worn off and the gag reflex has returned—usually for 2 hours. Instruct the patient not to swallow the local anesthetic. The bronchoscope is introduced into the mouth, to the pharynx, to pass through the glottis. The patient should have taken nothing by mouth for at least 8 hours before a bronchoscopy. DIF: CognitiveLevel: Application OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.
TOP: Bronchoscopy
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
13. The physician needs to visually examine a patient‘s esophagus, stomach, and duodenum. The nurse anticipates that the physician will order: a. endoscopic retrograde cholangiopancreatography (ERCP). b. esophagoscopy. c. esophagogastroduodenoscopy (EGD). d. proctoscopy. ANS: C
Esophagogastroduodenoscopy (EGD) permits visualization of the esophagus, stomach, and duodenum in a single examination. Endoscopic retrograde cholangiopancreatography (ERCP) is performed for visualization of the hepatobiliary tree and pancreatic ducts. Esophagoscopy is used to examine the esophagus only. Proctoscopy offers a visual examination of the lower gastrointestinal tract. DIF: CognitiveLevel: Application OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and
endoscopy.
TOP: Esophagogastroduodenoscopy (EGD)
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
14. A patient who is a candidate for an upper gastrointestinal endoscopy has: a. been NPO for 8 hours. b. evident respiratory distress. c. active gastrointestinal bleeding. d. an esophageal diverticulum. ANS: A
Verify that the patient has been NPO for at least 8 hours. Evident respiratory distress will increase risk, and the procedure may have to be delayed. This test is contraindicated in patients with severe upper gastrointestinal tract bleed, Zenker‘s diverticulum, or a large aortic aneurysm. DIF: CognitiveLevel: Application OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.
TOP: Esophagogastroduodenoscopy (EGD)
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
15. For an upper gastrointestinal endoscopy, a nurse should: a. remove the patient‘s dentures. b. suction the patient every 5 minutes. c. place the patient in high-Fowler‘s position. d. provide fluids immediately after the test is finished. ANS: A
Remove the patient‘s dentures and other dental appliances to prevent dislodgement of dental structures during the intubation phase. Position the tip of the cannula in the patient‘s mouth for easy access to drain oral secretions; suction as needed. Help the patient to maintain left lateral Sims‘ position. Instruct the patient not to eat or drink after the procedure until the gag reflex returns, which is usually about 2 hours after the procedure.
DIF: CognitiveLevel: Application OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy.
TOP: Gastrointestinal Endoscopy
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
16. The nurse is caring for a patient who underwent a cardiac catheterization. The sheaths have just been removed. You should assess the patient carefully for what potential complication? a. Vasovagal reaction b. Hypertension c. Tachycardia d. Allergic reaction ANS: A
Before removing the catheter sheath, check the health care provider‘s orders for instructions on treating a vasovagal reaction. Manual pressure applied to the groin/femoral area can stimulate the baroreceptors and cause a vasovagal reaction in which the patient becomes bradycardic and hypotensive. Vasovagal reactions are usually brief and self-limited. When applying pressure to the groin after sheath removal, be alert for a vasovagal reaction and be prepared to treat it by lowering the head of the bed to the flat position and giving a bolus of intravenous (IV) fluids. DIF: CognitiveLevel: Application OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures.
TOP: Cardiac Catheterization
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
17. The nurse is caring for a patient who has received moderate sedation for a procedure at the bedside. Which task can be delegated to the nursing assistive personnel (NAP) during this procedure? a. Assessing sedation score b. Obtaining blood pressure
c. Monitoring respiratory rate d. Recording urine output ANS: D
The task of assisting with intravenous (IV) moderate sedation, including the pre-procedure assessment, cannot be delegated to nursing assistive personnel (NAP). In most agencies, an RN or health care provider assesses and monitors a patient‘s level of sedation, airway patency, and level of consciousness. Roles in monitoring depend on scope-of-practice guidelines as determined by state regulations (see agency policy). You could delegate to assistive personnel the task of recording urine output. DIF: CognitiveLevel: Application OBJ: Describe the health care team collaboration and teamwork required before, during, and after procedures, including delegation to nursing assistive personnel.
TOP: Conscious Sedation
KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. The patient will be undergoing moderate intravenous (IV) sedation. The nurse needs to assess which of the following during the procedure? (Select all that apply.) a. Airway compromise b. Hemodynamic instability c. Agitation d. Combativeness ANS: A, B, C, D
Patient risks during IV sedation include hypoventilation, airway compromise, hemodynamic instability, and/or altered levels of consciousness that include an overly depressed level of consciousness or agitation and combativeness. Emergency equipment appropriate for the patient‘s age and size and staff with skill in airway management, oxygen delivery, and use of resuscitation equipment are essential. During and after the procedure, patients need continuous monitoring of vital signs, oxygen saturation, heart rhythm, lung sounds, and level of consciousness.
DIF: CognitiveLevel: Application OBJ: Demonstrate understanding of nursing responsibilities related to the use of intravenous sedation during diagnostic procedures.
TOP: Moderate Sedation
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The patient has undergone a cardiac catheterization. It has been 2 hours since the catheter and sheath have been removed. Which of the following would be a concern for the nurse recovering the patient after the procedure? (Select all that apply.) a. Swelling and hardness at the catheter insertion site b. Complaints of itching and urticaria c. Urine output less than 30 mL/hr d. Low back pain radiating to both sides of the body ANS: A, B, C, D
If hematoma or hemorrhage is present at the catheter insertion site, apply pressure over the insertion site, and notify the health care provider or physician if interventions do not stop the bleeding, or if the patient demonstrates symptoms of acute blood loss (hypotension, tachycardia). If the patient has an allergic reaction to contrast medium manifested by symptoms of flushing, itching, and urticaria, continue monitoring the patient and assess for anaphylaxis. Notify the health care provider. Renal toxicity from contrast can be detected by monitoring intake and output. Urine output of less than 30 mL/hr is a sign of renal toxicity. Low back pain radiating to both sides of the body is a hallmark sign of retroperitoneal bleeding. DIF: CognitiveLevel: Analysis OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures.
TOP: Reaction to IV Dye
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. Both aspiration and biopsy diagnose and differentiate which of the following? (Select all that apply.) a. Leukemia b. Certain malignancies
c. Heart disease d. Thrombocytopenia/anemia ANS: A, B, D
Both aspiration and biopsy diagnose and differentiate leukemia, certain malignancies, anemia, and thrombocytopenia. Heart disease is not diagnosed with these studies. DIF: CognitiveLevel: Comprehension OBJ: Identify physiological indications for diagnostic procedures. TOP: Bone Marrow Biopsy/Aspiration
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. The nurse is caring for a patient who has just undergone a bronchoscopy and has been in recovery for the last 15 minutes. The nurse should be especially watchful for which of the following? (Select all that apply.) a. Return of the gag reflex b. Laryngospasm c. Respiratory status d. Facial or neck crepitus ANS: B, C, D
Laryngospasm with bronchospasm evidenced by sudden, severe shortness of breath is an unexpected and potentially lethal outcome. Call the health care provider or physician immediately, prepare emergency resuscitation equipment, and anticipate a possible cricothyrotomy. Observe respiratory status closely, particularly for facial or neck crepitus. This is an early sign of bronchial perforation. The gag reflex does not normally return until 2 hours after the procedure. DIF: CognitiveLevel: Application OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures.
TOP: Evaluation of Patient Undergoing Bronchoscopy
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
COMPLETION
1.
is often used for diagnostic or surgical procedures that do not require complete anesthesia in acute care, surgical care, and outpatient care settings. ANS:
Intravenous sedation Intravenous sedation is often used for diagnostic or surgical procedures that do not require complete anesthesia in acute care, surgical care, and outpatient care settings. DIF: CognitiveLevel: Knowledge OBJ: Demonstrate understanding of nursing responsibilities related to the use of IV sedation during the diagnostic/surgical procedure.
TOP: Intravenous Sedation
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2.
is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. In addition, no interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. ANS:
Moderate sedation Moderate sedation/analgesia produces a minimally depressed level of consciousness induced by the administration of pharmacological agents in which a patient retains a continuous and independent ability to maintain protective reflexes and a patent airway and is aroused by physical or verbal stimulation. DIF: CognitiveLevel: Knowledge OBJ: Perform appropriate physical and psychological assessments before, during, and after related procedures.
TOP: Moderate Sedation
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. An
permits visualization of the vasculature of an organ and the organ‘s
arterial system. ANS:
arteriogram (angiogram) arteriogram angiogram An arteriogram (angiogram) permits visualization of the vasculature and arterial system of an organ. DIF: CognitiveLevel: Knowledge OBJ: Identify physiological indications for diagnostic procedures. TOP: Arteriogram (Angiogram)
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. A specialized form of angiography in which a catheter is inserted into the left or right side of the heart via a major peripheral vessel to study pressures within the heart, cardiac volumes, valvular function, and patency of coronary arteries is known as
.
ANS:
cardiac catheterization Cardiac catheterization is a specialized form of angiography in which a catheter is inserted into the left or right side of the heart via a major peripheral vessel. This test studies pressures within the heart, cardiac volumes, valvular function, and patency of coronary arteries. DIF: CognitiveLevel: Knowledge OBJ: Identify physiological indications for diagnostic procedures. TOP: Cardiac Catheterization
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
5.
are sterile invasive procedures involving the removal of body fluids or tissue for diagnostic procedures.
ANS:
Aspirations Aspirations are sterile invasive procedures involving the removal of body fluids or tissue for diagnostic procedures. Informed consent is required for these invasive procedures. DIF: CognitiveLevel: Knowledge OBJ: Identify physiological indications for diagnostic procedures. TOP: Aspirations
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
6. The removal of a small amount of the liquid organic material in the medullary canals of selected bones, in particular the sternum and the posterior superior iliac crests in adults, is known as
.
ANS:
bone marrow aspiration Bone marrow aspiration is the removal of a small amount of the liquid organic material in the medullary canals of selected bones, in particular the sternum and the posterior superior iliac crests in adults. DIF: CognitiveLevel: Knowledge OBJ: Identify physiological indications for diagnostic procedures. TOP: Bone Marrow Aspiration
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
7. A
involves the introduction of a needle into the subarachnoid space of the
spinal column. The purpose of this test is to measure pressure in the subarachnoid space; obtain cerebrospinal fluid (CSF) for visualization and laboratory examination; and inject anesthetic, diagnostic, or therapeutic agents. ANS:
lumbar puncture (LP)
lumbar puncture A lumbar puncture (LP), called a spinal puncture or spinal tap, involves the introduction of a needle into the subarachnoid space of the spinal column. The purpose of this test is to measure pressure in the subarachnoid space; obtain CSF for visualization and laboratory examination; and inject anesthetic, diagnostic, or therapeutic agents. DIF: CognitiveLevel: Knowledge OBJ: Identify physiological indications for diagnostic procedures. TOP: Lumbar Puncture
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
Chapter 09: Medical Asepsis Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The nurse understands that the priority nursing action needed when medical asepsis is used includes: a. handwashing. b. surgical procedures. c. autoclaving of instruments. d. sterilization of equipment. ANS: A
Medical asepsis, or clean technique, includes procedures used to reduce the number, and prevent the spread, of microorganisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis. Surgical asepsis, or sterile technique, includes procedures used to eliminate all microorganisms from an area. Sterilization destroys all microorganisms and their spores. The techniques used in maintaining surgical asepsis are more rigid than those performed under medical asepsis. DIF: CognitiveLevel: Application OBJ: Explain the difference between medical and surgical asepsis.
TOP: Medical Asepsis
KEY: NursingProcess Step: Intervention
MSC: NCLEX: Physiological Integrity
2. Handwashing with soap and water is: a. the most effective way to reduce the number of bacteria on the nurse‘s hands. b. more effective than alcohol-based products for washing hands. c. necessary for hand hygiene if hands are visibly soiled. d. not necessary if the nurse wears artificial nails. ANS: C
Soap and water is still necessary for hand hygiene if hands are visibly soiled. Recent research has shown that handwashing with plain soap sometimes results in paradoxical increases in bacterial counts on the skin. Alcohol-based products have been more effective for standard handwashing or hand antisepsis than soap or antiseptic soaps. Studies have shown the efficacy of alcohol-based hand sanitizers in reducing infection in a variety of settings from intensive care to long-term care. Studies have shown that health care workers with chipped nail polish or long or artificial nails have high numbers of bacteria on their fingertips. For this reason, the CDC recommends that health care workers not wear artificial nails and extenders, and that they keep natural nails less than one-quarter of an inch long when caring for high-risk patients. DIF: CognitiveLevel: Analysis OBJ: Describe factors that can influence nursing staff compliance with hand hygiene. TOP: Hand Hygiene
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
3. When caring for patients, the nurse understands that the single most important technique to prevent and control the transmission of infection is: a. hand hygiene. b. the use of disposable gloves. c. the use of isolation precautions. d. sterilization of equipment. ANS: A
The most important and most basic technique in preventing and controlling transmission of infection is hand hygiene. Use of disposable gloves may help reduce the transmission of infection, but it is not the single most important technique to prevent and control the transmission of infection. Neither the use of isolation precautions nor the sterilization of equipment is the single most important technique to prevent and control the transmission of infection. DIF: CognitiveLevel: Application OBJ: Describe factors that can influence nursing staff compliance with hand hygiene. TOP: Hand Hygiene
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. Which of the following measures is appropriate when a nurse is washing his or her hands? a. Use very hot water. b. Leave rings and watches in place. c. Lather for at least 15 to 20 seconds. d. Keep the fingers and hands up and the elbows down. ANS: C
Perform hand hygiene using plenty of lather and friction for at least 15 to 20 seconds. Interlace fingers and rub palms and back of hands with circular motion at least 5 times each. Keep fingertips down to facilitate removal of microorganisms. Hot water can be damaging to the skin. Regulate the flow of water so that the temperature is warm. Warm water removes less of the protective oils on the hands than hot water. Jewelry and watches can be a place for pathogens to hide. Push wristwatch and long uniform sleeves above wrists. Avoid wearing rings. If worn, remove during washing. This provides complete access to fingers, hands, and wrists. Wearing of rings increases the numbers of microorganisms on the hands. The position of hands and arms will aid in washing pathogens away. Wet hands and wrists thoroughly under running water. Keep hands and forearms lower than elbows during washing. Hands are the most contaminated parts to be washed. Water flows from the least to the most contaminated area, rinsing microorganisms into the sink. DIF: CognitiveLevel: Application
OBJ: Perform proper procedures for hand hygiene.
TOP: Hand Hygiene
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
5. The nurse shows an understanding of the psychological implications for a patient on isolation when planning care to control the risk for: a. denial. b. aggression. c. regression. d. isolation. e. depression. ANS: D
A sense of loneliness may develop because normal social relationships become disrupted. The nurse should plan care to control the risk that the patient may feel isolated. Denial and regression are not risks related to isolation. Aggression is not a risk for the patient on isolation precautions. DIF: CognitiveLevel: Application TOP: Isolation
OBJ: Perform correct isolation techniques.
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
6. An appropriate technique for the nurse to implement for the patient on isolation precautions is to: a. double-bag all disposable items and linens. b. put another gown over the one worn if it has become wet. c. place specimen containers in plastic bags for transport. d. hand items to be reused directly to a nurse standing outside the room. ANS: C
Transfer the specimen to a container without soiling the outside of the container. Place the container in a plastic bag and label the outside of the bag or as per agency policy. Specimens of blood and body fluids are placed in well-constructed containers with secure lids to prevent leaks during transport. Use single bags that are impervious to moisture and sturdy to contain soiled articles. Use the double-bagging technique if necessary for heavily soiled linen or heavy wet trash. Linen or refuse should be totally contained to prevent exposure of personnel to infective material. Avoid allowing the isolation gown to become wet; carry the wash basin outward, away from the gown; avoid leaning against wet tabletops. Moisture allows organisms to travel through the gown to the uniform. Remove all reusable pieces of equipment. Clean any contaminated surfaces with hospital-approved disinfectant. All items must be properly cleaned, disinfected, or sterilized for reuse. DIF: CognitiveLevel: Application TOP: Isolation
OBJ: Perform correct isolation techniques.
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
7. Before entering the room of a patient on isolation where all protective barriers are required, the nurse first puts on the: a. gown. b. gloves. c. eyewear. d. mask/respirator. ANS: A
Apply the gown first, making sure that it covers all outer garments. Pull sleeves down to the wrist. Tie securely at the neck and waist. Next, apply either a surgical mask or a fitted respirator around the mouth and nose. Goggles or a face shield is put on after the gown and mask are applied. Gloves are put on last. DIF: CognitiveLevel: Application TOP: Isolation
OBJ: Perform correct isolation techniques.
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
8. The patient is presenting to the hospital with a high fever and a productive cough. He says that he hasn‘t felt right since he returned from visiting Somalia about a month before admission. He also states that he has lost about 20 pounds in the last month and frequently wakes up in the middle of the night sweaty and ―clammy.‖ What should the nurse prepare to do? a. Place the patient on contact isolation. b. Place the patient in a negative-pressure room. c. Place the patient on droplet precautions. d. Use standard precautions only. ANS: B
Suspect tuberculosis (TB) in any patient with respiratory symptoms lasting longer than 3 weeks accompanied by other suspicious symptoms, such as unexplained weight loss, night sweats, fever, and a productive cough often streaked with blood. Isolation for patients with suspected or confirmed TB includes placing the patient on airborne precautions in a single-patient negative-pressure room. In addition to standard precautions, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient‘s environment. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection and colonization with multidrug-resistant bacteria judged by the infection control program as follows: (1) enteric with a low infectious dose or prolonged environmental survival, including Clostridium difficile, Escherichia coli, Shigella, hepatitis A, or rotavirus; (2) skin infections that are highly contagious or that may occur on dry skin, including diphtheria (cutaneous), herpes simplex virus (neonatal or mucocutaneous), impetigo, major (noncontained) abscesses, cellulitis, decubiti, pediculosis, scabies, staphylococcal furunculosis in infants and young children, or zoster; or (3) viral/hemorrhagic conjunctivitis or viral hemorrhagic infection (Ebola, Lassa, or Marburg). In addition to standard precautions, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, epiglottitis, and sepsis; and invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis. Other serious bacterial respiratory infections spread by droplet transmission include diphtheria (pharyngeal), Mycoplasma pneumoniae, pertussis, pneumonic plague, streptococcal pharyngitis, pneumonia, and scarlet fever in infants and young children. Serious viral infections spread by droplet transmission include adenovirus, influenza, mumps, parvovirus B19, and rubella. DIF: CognitiveLevel: Synthesis OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: Airborne Precautions
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
9. For patients with which of the following conditions should the nurse implement airborne precautions? a. Rubella
b. Influenza c. Tuberculosis d. Pediculosis ANS: C
In addition to standard precautions, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include measles, varicella (including disseminated zoster), and TB. Airborne precautions are not appropriate for viral infections spread by droplet transmission, including adenovirus, influenza, mumps, parvovirus B19, and rubella. Contact precautions would be appropriate for a patient with pediculosis. DIF: CognitiveLevel: Comprehension OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: Airborne Precautions
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
10. The patient is admitted to the pediatric unit with severe pertussis. The nurse explains to the parents and the child that the patient will be treated with the use of: a. airborne precautions. b. standard precautions only. c. droplet precautions. d. contact isolation. ANS: C
In addition to standard precautions, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include invasive H. influenzae type b disease, invasive N. meningitidis disease, and other serious bacterial respiratory infections spread by droplet transmission, such as diphtheria (pharyngeal), M. pneumoniae, and pertussis. Pertussis is spread by large particle droplets. For infection spread via airborne routes, use airborne precautions, in addition to standard precautions. Examples of such illnesses include measles, varicella, and TB. Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. People who have infections that are spread by large particle droplets, such as pertussis, need more than just standard precautions. Pertussis is not spread through direct patient contact. For patients known or suspected to have serious illnesses easily transmitted by direct patient contact, or by contact with items in the patient‘s environment, use contact precautions in addition to standard precautions. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection, C. difficile, Escherichia coli, Shigella, hepatitis A, rotavirus, and skin infections that are highly contagious or that may occur on dry skin. DIF: CognitiveLevel: Analysis OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: Droplet Precautions
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
11. Droplet precautions will be instituted for the patient admitted to the infectious disease unit with: a. streptococcal pharyngitis. b. herpes simplex. c. pulmonary TB. d. measles. ANS: A
Droplet precautions are instituted when droplets are larger than 5 m, as in the case of streptococcal pharyngitis. Contact precautions are instituted for herpes simplex. Airborne precautions are instituted for pulmonary TB and measles.
DIF: CognitiveLevel: Analysis OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: Droplet Precautions
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient has been hospitalized for several days and has received multiple intravenous antibiotic medications. This morning, the patient had three episodes of severe, foul-smelling diarrhea. The nurse should institute: a. contact precautions. b. standard precautions only. c. airborne precautions. d. droplet precautions. ANS: A
In addition to standard precautions, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient‘s environment. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection and colonization with multidrug-resistant bacteria judged by the infection control program as follows: (1) enteric with a low infectious dose or prolonged environmental survival, including C. difficile, E. coli, Shigella, hepatitis A, or rotavirus; or (2) skin infections that are highly contagious or that may occur on dry skin. Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. Patients who may be infected by pathogens that can be spread through direct patient contact may need more. The patient is not exhibiting signs of infection/colonization by pathogens that can be spread via the airborne route. In addition to standard precautions, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include measles, varicella, and TB. The patient is not exhibiting signs of infection/colonization by pathogens that can be spread via large particle droplets. In addition to standard precautions, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include invasive H. influenzae type B disease, pertussis, pneumonic plague, streptococcal pharyngitis, pneumonia, and scarlet fever in infants and young children, as well as mumps, parvovirus B19, and rubella.
DIF: CognitiveLevel: Analysis OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: Contact Precautions
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
13. What should the nurse do to break the chain of infection at the reservoir level? a. Change a soiled dressing. b. Keep drainage systems intact. c. Cover the nose and mouth when sneezing. d. Avoid contact of the uniform with soiled items. ANS: A
The reservoir is the site or source of microorganism growth. Control: sources of body fluids and drainage. Perform hand hygiene. Bathe the patient with soap and water. Change soiled dressings. Dispose of soiled tissues, dressings, or linen in moisture-resistant bags. Place syringes, uncapped hypodermic needles, and intravenous needles in designated puncture-proof containers. Keep table surfaces clean and dry. Do not leave bottled solutions open for prolonged periods. Keep solutions tightly capped. Keep surgical wound drainage tubes and collection bags patent. Empty and dispose of drainage suction bottles according to agency policy. The portal of entry is the site through which a microorganism enters a host. Urinary: Keep all drainage systems closed and intact, maintaining downward flow. The portal of exit is the means by which microorganisms leave a site. Respiratory: Avoid talking, sneezing, or coughing directly over a wound or sterile dressing field. Cover nose and mouth when sneezing or coughing. Wear mask if suffering respiratory tract infection. Transmission is the means of spread. Reduce microorganism spread. Perform hand hygiene. Use personal set of care items for each patient. Avoid shaking bed linen or clothes; dust with damp cloth. Avoid contact of soiled item with uniform. DIF: CognitiveLevel: Analysis OBJ: Identify nursing care measures intended to break the chain of infection. TOP: Breaking the Chain of Infection MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
KEY: NursingProcess Step: Implementation
1. The patient is admitted with mumps. The nurse knows that she will have to: a. put the patient in a private room. b. place the patient on standard precautions. c. wear a mask when closer than 3 feet to the patient. d. place the patient on contact precautions. ANS: A, C
For diseases transmitted by large droplets (larger than 5 m), such as streptococcal pharyngitis, pneumonia, scarlet fever in infants or small children, pertussis, mumps, meningococcal pneumonia or sepsis, or pneumonic plague, place the patient in a private room, or cohort the patient and wear a mask when closer than 3 feet from the patient. For diseases transmitted by small droplet nuclei (smaller than 5 m), such as measles, chickenpox, disseminated varicella zoster, and pulmonary or laryngeal TB, place the patient on airborne precautions in a private room with negative airflow of at least six air exchanges per hour, and wear a respirator or mask. Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. For diseases transmitted by direct patient or environmental contact, such as colonization or infection with multidrug-resistant organisms, respiratory syncytial virus, major wound infection, herpes simplex, and scabies, place the patient on contact precautions in a private room, or cohort the patient. Wear gloves and gowns. DIF: CognitiveLevel: Analysis OBJ: Identify nursing care measures intended to break the chain of infection. TOP: Breaking the Chain of Infection
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
2. For an infection to take place, which of the following must be present? (Select all that apply.) a. Pathogen and reservoir b. Portals of exit and entry c. Mode of transmission d. Susceptible host ANS: A, B, C, D
The mere presence of a pathogen does not mean that an infection will begin. Development of an infection occurs in a cyclic process, often referred to as the chain of infection, which depends on the following six elements: an infectious agent or pathogen, a reservoir or source for pathogen growth, a portal of exit from the reservoir, a mode of transmission, a portal of entry to the host, and a susceptible host. DIF: CognitiveLevel: Analysis OBJ:
Explain how each element of the infection chain contributes to infection.
TOP: Chain of Infection
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. If hands are not visibly soiled, the nurse may use an alcohol-based hand rub in which of the following situations? (Select all that apply.) a. Before having direct contact with patients b. After contact with a patient‘s intact skin c. After contact with body fluids or excretions d. After removing gloves ANS: A, B, C, D
If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands before having direct contact with patients, before putting on sterile gloves, and before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices; after contact with a patient‘s intact skin (e.g., when taking a pulse or blood pressure, lifting a patient); after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled; when moving from a contaminated body site to a clean body site during care; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; and after removing gloves. DIF: CognitiveLevel: Application
OBJ: Perform proper procedures for hand hygiene.
TOP: Hand Hygiene
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The nurse is planning to care for a patient diagnosed with possible tuberculosis (TB). Assessment of possible TB may be based on which of the following? (Select all that apply.)
a. A positive AFB smear or culture b. Signs or symptoms of TB c. Cavitation on chest x-ray study d. History of recent exposure e. TB skin test ANS: A, B, C, D
Signs of infectious pulmonary or laryngeal TB include documentation of positive AFB smear or culture, signs or symptoms of TB, cavitation on chest x-ray study, history of recent exposure, and physician progress notes indicating a plan to rule out TB. A TB skin test is not recommended by the CDC. DIF: CognitiveLevel: Comprehension OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: Assessment of Potential TB
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
1. The nurse has a ―scratchy throat‖ and has been sniffling for 2 days. While at work, she wears a protective mask when coming into contact with her patients. She does this in an attempt to protect them from a
.
ANS:
health care–acquired infection (HAI) health care–acquired infection Health care–acquired infections (HAIs) are those that develop as a result of contact with a health care facility/provider; the infection was not present or incubating at the time of admission. DIF: CognitiveLevel: Analysis OBJ: Identify nursing care measures intended to break the chain of infection. TOP: Health Care–Acquired Infection
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
2. The nurse is preparing to provide care for the patient. Before making patient contact, she washes her hands. This practice is known as
.
ANS:
medical asepsis Medical asepsis, or clean technique, includes procedures used to reduce the number, and prevent the spread, of microorganisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis. DIF: CognitiveLevel: Comprehension OBJ: Explain the difference between medical and surgical asepsis. TOP: Medical Asepsis
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3.
, also known as sterile technique, includes procedures used to eliminate all microorganisms from an area. ANS:
Surgical asepsis Surgical asepsis, or sterile technique, includes procedures used to eliminate all microorganisms from an area. Sterilization destroys all microorganisms and their spores. DIF: CognitiveLevel: Knowledge OBJ: Explain the difference between medical and surgical asepsis. TOP: Surgical Asepsis
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. The primary strategies for prevention of infection transmission with regard to contact with blood, body fluids, nonintact skin, and mucous membranes are known as ANS:
.
standard precautions Standard precautions, the primary strategies for prevention of infection transmission, apply to contact with (1) blood, (2) body fluids, (3) nonintact skin, and (4) mucous membranes, as well as with equipment or surfaces contaminated with these potentially infectious materials. DIF: CognitiveLevel: Comprehension
OBJ: Perform correct isolation techniques.
TOP: Standard Precautions
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
5. OSHA and CDC guidelines require health care workers who care for suspected or confirmed TB patients to wear special
.
ANS:
respirators OSHA and CDC guidelines require health care workers who care for suspected or confirmed TB patients to wear special respirators. These respirators are high-efficiency particulate masks that have the ability to filter particles at 95% or better efficiency. Health care workers who use these respirators must be fit-tested in a reliable way to obtain a face-seal leakage of 10% or less. DIF: CognitiveLevel: Application
OBJ: Perform correct isolation techniques.
TOP: OSHA Guidelines—Respirators
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
6. The nurse is applying for a position at a local hospital. As part of the employment criteria, she will be required to be assessed for TB exposure. She should be prepared for the blood test to be scheduled. ANS:
QuantiFERON-TB Gold test (QFT-G) QuantiFERON-TB Gold test
The CDC now recommends use of the QuantiFERON-TB Gold test (QFT-G) (CDC, 2005), a blood test, in place of the traditional TB skin test. The advantages of the QFT-G test are that it does not boost responses measured by subsequent tests, and the results are not subject to reader bias. DIF: CognitiveLevel: Comprehension OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: OSHA Guidelines—TB Testing
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
7. The nurse knows that the basic concept of all patient care that is implemented to prevent the spread of infection from blood, body fluids, secretions, excretions, nonintact skin, and mucus membranes is
.
ANS:
standard precautions Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. DIF: CognitiveLevel: Application OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: Standard Precautions
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
Chapter 10: Sterile Technique Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The nurse is applying for a job at a local hospital. She wants to look her best for the interview and decides to wear artificial nails. She does this knowing that artificial nails: a. are appropriate in the ICU setting as long as the nurse washes her hands frequently. b. can lead to fungal growth under the nail.
c. can actually lower the bacterial count on the hands because they cover the natural nail. d. are banned only in areas where patients are critically ill. ANS: B
Numerous reports identify that fungal growth frequently occurs under artificial nails as a result of moisture becoming trapped between the natural nail and the artificial nail. Because of the risks for infection posed by artificial nail use, health care workers who have direct contact with patients at high risk (e.g., those in intensive care units or operating rooms) should not wear artificial nails. Health care workers who wear artificial nails or nail extenders are more likely to harbor gram-negative pathogens on their fingertips, both before and after handwashing. Many health care institutions have chosen to ban artificial nails and extenders in all clinical areas, with the rationale that all patients are at risk for infection. DIF: CognitiveLevel: Application
OBJ: Identify principles of surgical asepsis.
TOP: Artificial Nails
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. When removing the mask after an aseptic procedure, what should the nurse do first? a. Remove gloves. b. Untie top strings of mask. c. Untie bottom strings of mask. d. Untie top strings and let mask hang. ANS: A
Remove gloves first, if worn. This prevents contamination of hair, neck, and facial area by contaminants on gloves. Untie the top strings of the mask after untying the bottom strings. This prevents the top part of the mask from falling down over the clothing. If the mask falls and touches the clothing, it will be contaminated. DIF: CognitiveLevel: Application OBJ: Apply and remove a cap, mask, and eyewear correctly. KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Removing the Mask
3. An appropriate principle of surgical asepsis is that: a. the entirety of a sterile package is sterile once it is opened. b. all of the draped table, top to bottom, is considered sterile. c. an object held below the waist is considered contaminated. d. if the sterile barrier field becomes wet, the dry areas are still sterile. ANS: C
A sterile object or field out of the range of vision or an object held below a person‘s waist is contaminated. Once a sterile package is opened, a 2.5-cm (1-inch) border around the edges is considered unsterile. Tables draped as part of a sterile field are considered sterile only at table level. A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated. DIF: CognitiveLevel: Application OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly.
TOP: Sterile Field
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
4. A patient requires a sterile dressing change for a mid-abdominal surgical incision. An appropriate intervention for the nurse to implement in maintaining sterile asepsis is to: a. put sterile gloves on before opening sterile packages. b. discard items that may have been in contact with the area below waist level. c. place the povidone-iodine bottle well within the sterile field. d. place sterile items on the very edge of the sterile drape. ANS: B
A sterile object held below a person‘s waist is considered contaminated. To maintain sterile asepsis, discard items that may have been in contact with the area below waist level. Sterile gloves are not put on before opening sterile packages, because the outside of the package is not sterile. The nurse uses hand hygiene and opens sterile packages while being careful to keep the inner contents sterile. Povidone-iodine and chlorhexidine are not considered sterile solutions and require separate work surfaces for prepping. The edges of a sterile field are considered to be contaminated. Sterile items should be placed in the middle of the sterile field to maintain sterile asepsis. DIF: CognitiveLevel: Application OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly.
TOP: Sterile Field
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. Which patient may the nurse suspect will be at risk for a latex allergy? a. Patient with food allergies b. Patient with diabetes c. Patient with arthritis d. Patient with hypertension ANS: A
Individuals at risk for latex allergy include those with a history of food allergies. Patients with diabetes, arthritis, and hypertension are not at increased risk for latex allergies. DIF: CognitiveLevel: Application
OBJ: Identify individuals at risk for latex allergy.
TOP: Latex Allergy
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
6. Which of the following is an appropriate technique for the nurse to use when performing sterile gloving? a. Put the glove on the nondominant hand first. b. Interlock the hands after both gloves are applied. c. Pull the cuffs down on both gloves after gloving.
d. Grasp the outside cuff of the other glove with the gloved hand. ANS: B
After the second glove is on, interlock the hands above waist level. Be sure to touch only sterile sides. Gloving of the dominant hand first improves dexterity. The cuffs usually fall down after application. With a gloved dominant hand, slip fingers underneath the second glove‘s cuff. The cuff protects gloved fingers. Sterile touching sterile prevents glove contamination. DIF: CognitiveLevel: Application OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly.
TOP: Applying Sterile Gloves
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
7. The nurse is preparing to insert a urinary catheter. The package is dry but shows signs of yellowing inside the plastic wrapper, as if the package was wet at one time. What should the nurse do? a. Use the package because it is dry at present. b. Consider the outer package contaminated, but the inner package sterile. c. Discard the entire package as contaminated. d. Open the package and consider the 1-inch border as contaminated. ANS: C
A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated. If there is any question or doubt of an item‘s sterility, the item is considered to be unsterile. Once a sterile package has been opened, a 2.5-cm (1-inch) border around the edges is considered unsterile. DIF: CognitiveLevel: Application OBJ: Explain the importance of organization and caution when using surgical aseptic techniques. TOP: Principles of Surgical Asepsis
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
8. A type I hypersensitivity to latex is evident if the nurse assesses:
a. localized swelling. b. skin redness and itching. c. runny eyes and nose and cough. d. tachycardia, hypotension, and wheezing. ANS: D
Type I allergic reaction is a true latex allergy that can be life threatening. Reactions vary on the basis of the type of latex protein and the degree of individual sensitivity, including local and systemic. Symptoms include hives, generalized edema, itching, rash, wheezing, bronchospasm, difficulty breathing, laryngeal edema, diarrhea, nausea, hypotension, tachycardia, and respiratory or cardiac arrest. Type IV hypersensitivity is a cell-mediated allergic reaction to chemicals used in latex processing. Reaction, including redness, itching, and hives, can be delayed up to 48 hours. Localized swelling, red and itchy or runny eyes and nose, and coughing may develop. Irritant dermatitis is a nonallergic response characterized by skin redness and itching. DIF: CognitiveLevel: Comprehension
OBJ: Identify individuals at risk for latex allergy.
TOP: Levels of Latex Reactions
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
9. A nurse is preparing a sterile field for a dressing change using surgical aseptic technique. The nurse gathers supplies to prepare the sterile field using a packaged drape. Which option correctly describes how the nurse should set up the field? a. Don sterile gloves before opening the packaged drape. b. Clean the bottle of irrigation solution with alcohol before placing the bottle on the field. c. Avoid dropping sterile supplies close to the 1-inch border around the drape. d. Leave the sterile field unattended to obtain needed supplies. ANS: C
The exterior border of the sterile drape is presumed contaminated, so all supplies must be kept within the sterile portion. Dropping supplies too close to the 1-inch border risks having them bounce off the sterile area. Nonsterile supplies are never to be placed on the sterile field. The sterile field is never to be out of the nurse‘s line of sight. Sterile gloves will not be applied until the sterile field is set up, and items needed to deliver care are ready for use. Applying them earlier in the process risks having them become contaminated. DIF: CognitiveLevel: Application OBJ: Prepare a sterile field and use a sterile drape correctly.
TOP: Using Surgical Asepsis
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Nurses commonly use surgical asepsis in which of the following situations? (Select all that apply.) a. In labor and delivery areas b. When inserting an intravenous catheter c. When treating patients with surgical incisions or burns d. When inserting a urinary catheter e. When dressing an MRSA-positive wound ANS: A, B, C, D
Although nurses commonly practice surgical asepsis in operating rooms, labor and delivery areas, and major diagnostic or special procedure areas, they use surgical aseptic techniques at the patient‘s bedside in three primary situations: (1) during procedures that require intentional perforation of a patient‘s skin (e.g., insertion of intravenous [IV] catheters), (2) when the skin‘s integrity is broken as the result of a surgical incision or burns, and (3) during procedures that involve insertion of devices or surgical instruments into normally sterile body cavities (e.g., insertion of a urinary catheter). Dressing an MRSA-positive wound is not one of the three primary situations that impact skin integrity. DIF: CognitiveLevel: Application OBJ: Discuss settings in which you will use surgical aseptic techniques.
TOP: Surgical Asepsis
KEY: NursingProcess Step: Intervention
MSC: NCLEX: Physiological Integrity
2. A sterile field consists of which of the following? (Select all that apply.) a. Sterile tray b. Work surface draped with a sterile towel c. Table covered by a large sterile drape d. Patient‘s bedside table ANS: A, B, C
A sterile field may consist of a sterile kit or tray, a work surface draped with a sterile towel or wrapper, or a table covered with a large sterile drape. A patient‘s bedside table is not sterile but can be a work surface where a sterile field can be applied. DIF: CognitiveLevel: Application OBJ: Perform thefollowing skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly.
TOP: Sterile Field
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
COMPLETION
1.
is one practice designed to make and maintain objects and areas free from pathogenic microorganisms. ANS: Sterile technique OR aseptic practices
Surgical asepsis or aseptic techniques and practices are designed to make and maintain objects and areas free from pathogenic microorganisms. DIF: CognitiveLevel: Comprehension
OBJ: Describe conditions when you use surgical asepsis.
TOP: Surgical Asepsis
KEY: NursingProcess Step: Intervention
MSC: NCLEX: Physiological Integrity
2. When performing sterile aseptic procedures, thenurse must create a
in which
objects can be handled with minimal risk for contamination. ANS:
sterile field When performing sterile aseptic procedures, thenurse must have a work area in which objects can be handled with minimal risk for contamination. A sterile field serves such a purpose. DIF: CognitiveLevel: Application OBJ: Perform thefollowing skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly.
TOP: Sterile Field
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
OTHER
1. Which is theappropriate sequence to use when applying sterile attire? a. Apply sterile gloves. b. Secure hair. c. Don protective eyewear. d. Apply hair cover. e. Wash hands. f. Apply mask. ANS:
E, B, D, F, C, A The correct sequence is wash hands, secure hair, apply hair cover, apply mask, don protective eyewear, and apply sterile gloves. DIF: CognitiveLevel: Application
OBJ: Don sterile attire.
TOP: Sterile Attire
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
Chapter 11: Safe Patient Handling and Mobility (SPHM) Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. A nurse should be aware of safety measures to prevent personal injury when lifting or moving patients. An appropriate principle to follow is: a. bend at thewaist for lifting. b. The lower thecenter of gravity, thegreater thestability of thenurse c. keep theweight to be lifted away from thebody. d. carry or hold theweight 1 to 2 feet above thewaist. ANS: B
Principles of Safe Body Mechanics When Transferring and Positioning Patients Mechanical lifts and lift teams are essential when patient is unable to help. When a patient is able to help, remember these principles: • thelower thecenter of gravity, thegreater thestability of thenurse. • theequilibrium of an object is maintained as long as theline of gravity passes through its base of support. • Facing thedirection of movement prevents abnormal twisting of thespine. • Dividing balanced activity between arms and legs reduces therisk for back injury. • Leverage, rolling, turning, or pivoting requires less work than lifting. • When friction is reduced between theobject to be moved and thesurface on which it is moved, less force is required to move it.
Tighten thestomach muscles and tuck thepelvis; this provides balance and protects theback. Bend at theknees; this helps to maintain thenurse‘s center of gravity and lets thestrong muscles of thelegs do thelifting. Keep theweight to be lifted as close to thebody as possible; this action places theweight in thesame plane as thelifter and close to thecenter of gravity for balance.
DIF: CognitiveLevel: Application OBJ: Describe principles of safe patient transfer and positioning. TOP: Principles of Lifting
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
2. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop. b. pressure ulcers. c. Overexertion injuries d. contractures. ANS: C
The greatest risk factor for overexertion injuries in health care workers is themanual lifting, moving, and repositioning of patients. Such patient care tasks occur repeatedly during a nurse‘s routine shift of care resulting in high rates of nursing injuries DIF: CognitiveLevel: Comprehension OBJ: Describe body mechanics and its importance in caring for patients. TOP: Risks for Nurses
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for severe dehydration. thenurse must turn thepatient frequently to prevent complications of immobility. What does thenurse realize? a. This patient should be turned onto his back for meals. b. This patient requires frequent position at least every 2 hours c. This patient may be allowed to remain in his favorite position as long as he doesn‘t complain of discomfort. d. Skin breakdown is not an issue for this patient. ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed rest benefit from therapeutic positioning. Correct positioning maintains patients‘ body alignment and comfort. Immobilized patients require vigilant nursing care with frequent repositioning to reduce therisk of physical complications, including pressure injuries, reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every 2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At thesame time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90 degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed. Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because thecenter of gravity is not aligned. Cluttered hallways and bedside areas increase thepatient‘s risk for falling. Dehydration or edema may require more frequent position changes because patients are prone to skin breakdown. DIF: CognitiveLevel: Application OBJ: Describe principles of safe patient transfer and positioning. TOP: Repositioning
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a. Fatigue b. Muscle injury c. Sensory disorientation d. Orthostatic hypotension ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop in blood pressure) when transferred.
DIF: CognitiveLevel: Comprehension OBJ: Describe principles of safe patient transfer and positioning. TOP: Orthostatic Hypotension
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
5. A nurse is reviewing thepatient assignment for theday. Of all thepatients, which individual has thegreatest potential for injury during transfers? a. Diabetes mellitus b. Myocardial infarction c. A cerebrovascular accident d. An upper extremity fracture ANS: C
Patients who are at high risk for complications from improper positioning and injury during transfer include those with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient‘s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus, myocardial infarction, or upper extremity fracture does not increase thepatient‘s risk for injury to thesame extent. DIF: CognitiveLevel: Application
OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
6. To assist thepatient to a sitting position on theside of thebed, what should thenurse do first? a. Raise theheight of thebed. b. Raise thehead of thebed 30 degrees. c. Turn thepatient onto theside facing away from thenurse. d. Move thepatient‘s legs over theside of thebed. ANS: B
With thepatient in supine position, raise thehead of thebed 30 degrees; this decreases theamount of work needed by thepatient and thenurse to raise thepatient to a sitting position. thebed should be in thelow position. thepatient is turned to face thenurse after thehead of thebed is raised 30 degrees. thepatient‘s legs are positioned over theedge of thebed after thehead of thebed is raised and thepatient is turned to face thenurse. DIF: CognitiveLevel: Application OBJ: Describe theprocedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and transferring a patient from a bed to a chair. TOP: Assisting Patient to a Sitting Position on Side of Bed KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
7. To transfer thepatient who has normal weight bearing and upper body strength out of bed to a chair, what should thenurse do? a. Grab thepatient under theaxilla to lift. b. Have thepatient move forward with theweak side. c. Have thepatient put on shoes with nonskid soles. d. Place thechair in a position 90 degrees opposite thebed. ANS: C
Assist thepatient to apply stable nonskid shoes. Nonskid soles decrease therisk of slipping during transfer. Patients should never be lifted by or under thearms. If thepatient demonstrates weakness or paralysis of one side of thebody, place a chair on thepatient‘s strong side. thepatient would move forward toward thestrong side. Have thechair in position at a 45-degree angle to thebed. DIF: CognitiveLevel: Application OBJ: Describe theprocedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and transferring a patient from a bed to a chair. TOP: Assisting Patient to a Sitting Position on Side of Bed KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer thepatient from thebed to thestretcher. thepatient is unable to assist. Of thefollowing, which would be thebest technique for transferring thepatient? a. Using three nurses and a slide board b. Using thethree-person lift technique c. Raising thehead 30 degrees d. Having thepatient keep arms to theside ANS: A
Physical stress can be decreased significantly by theuse of a slide board or a friction-reducing board positioned under a drawsheet beneath thepatient. In addition, thepatient is more comfortable using this method. thethree-person lift for horizontal transfer from bed to stretcher is no longer recommended and, in fact, is discouraged. Lower thehead of thebed as much as thepatient can tolerate. This maintains alignment of thespinal column. Cross thepatient‘s arms on thechest to prevent injury to thearms during transfer. DIF: CognitiveLevel: Application OBJ: Describe principles of safe patient transfer and positioning. TOP: Normal Body Alignment for Sitting Position KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
9. An appropriate technique for thenurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a. lower theheight of thebed. b. lower thehead of thebed. c. place thesling from shoulders to knees. d. keep thecheck valve open when thepatient is seated in thechair. ANS: C
The sling should extend from shoulders to knees (hammock) to support thepatient‘s body weight equally. Raise thebed to a high position with themattress flat. This allows thenurse to use proper body mechanics. Elevate thehead of thebed; this places thepatient in sitting position. Close thecheck valve as soon as thepatient is down and thestraps can be released. If thevalve is left open, theboom may continue to lower and injure thepatient.
DIF: CognitiveLevel: Application OBJ: Describe principles of safe patient transfer and positioning. TOP: Normal Body Alignment for Sitting Position KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
10. When preparing to move a patient in bed, thenurse should: a. expect that thepatient‘s comfort level will decrease. b. make sure that all pillows used in theprevious position stay in position. c. raise thebed to a comfortable working height. d. plan on moving thepatient herself because other nurses are busy. ANS: C
Raise thelevel of thebed to a comfortable working height. This raises thelevel of work toward thenurse‘s center of gravity and reduces therisk for back injury. Proper positioning reduces stress on thejoints. thepatient‘s comfort level should increase. thenurse should remove all pillows and devices used in theprevious position. This reduces interference from bedding during thepositioning procedure. thenurse should get extra help as needed. This provides for patient and nurse safety. DIF: CognitiveLevel: Application OBJ: Describe principles of safe patient transfer and positioning. TOP: Planning Patient Move
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
11. An appropriate procedure to use when moving a patient up in bed is for thenurse to: a. raise thehead of thebed. b. start by flexing thepatient‘s knees and hips. c. place a pillow under thepatient‘s shoulders. d. instruct thepatient to inhale and hold still. ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so body moves up in bed.
When possible, ask thepatient to flex his or her knees with thefeet flat on thebed. This decreases friction and enables thepatient to use leg muscles during movement. thenurse should place thepatient on his or her back with thehead of thebed flat. This enables thenurse to assess body alignment and reduces thepull of gravity on thepatient‘s upper body. thenurse should remove thepillow from under thepatient‘s head and shoulders and place thepillow at thehead of thebed. This prevents striking thepatient‘s head against thehead of thebed. thenurse should instruct thepatient to push with theheels and elevate thetrunk while breathing out, thus moving toward thehead of thebed on thecount of three. This prepares thepatient for themove, reinforces assistance in moving up in bed, and increases patient cooperation. Breathing out avoids theValsalva maneuver. DIF: CognitiveLevel: Application OBJ: Describe principles of safe patient transfer and positioning. TOP: Moving Patient Up in Bed
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, thepatient is in a supported Fowler‘s position with thehead of thebed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with pillows. b. place a large pillow behind his head to prevent extension. c. place a pillow behind his upper back. d. avoid using pillows if thepatient does not have use of thehands and arms. ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support theknee in slight flexion (avoids hyper extension) and to allow theheels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support thecalves with pillows. Heels should not be in contact with thebed to prevent prolonged pressure of themattress on theheels. This sometimes is referred to as ―floating‖ heels. Rest thepatient‘s head against themattress or on a small pillow. This prevents flexion contractures of thecervical vertebrae. A pillow behind theupper back would put thetorso out of alignment. Position a pillow at thelower back to support thelumbar vertebrae and decrease flexion of thevertebrae. Use pillows to support thearms and hands if thepatient does not have voluntary control or use of thehands and arms. This prevents shoulder dislocation from theeffect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion contractures of arms and wrists. DIF: CognitiveLevel: Application OBJ: Describe principles of safe patient transfer and positioning. TOP: Moving an Immobile Patient
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
13. In positioning thepatient in theprone position, one way to improve breathing is to: a. support thearms in a flexed position level at theshoulders. b. place a pillow under thelower legs. c. place a small pillow under thepatient‘s abdomen. d. support thepatient‘s head with a small pillow. ANS: C
Placing a small pillow under thepatient‘s abdomen below thelevel of thediaphragm reduces pressure on thebreasts of some female patients and decreases hyperextension of thelumbar vertebrae and strain on thelower back; it also improves breathing by reducing mattress pressure on thediaphragm. Supporting thearms in flexed position level at theshoulders maintains proper body alignment and reduces therisk for joint dislocation, but does not improve breathing. Supporting thelower legs with pillows to elevate thetoes prevents footdrop, reduces external rotation of thelegs, and reduces mattress pressure on thetoes, but does not directly improve breathing. Turning thepatient‘s head to one side and supporting it with a small pillow is designed to reduce flexion or hyperextension of thecervical vertebrae. Although it may help with breathing, this is not theprimary purpose. DIF: CognitiveLevel: Application
OBJ: Describe positioning techniques for thesupported Fowler‘s, supine, prone, 30-degree lateral side-lying, and Sims‘ positions.
TOP: Hand Rolls
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
14. A postoperative patient has been instructed by a nurse about theimportance of moving in bed but is still avoiding movement. thenurse should: a. avoid moving thepatient until he or she is motivated. b. have family members move thepatient around. c. decrease thefrequency of movement to be performed. d. medicate thepatient with a prescribed analgesic before moving. ANS: D
If thepatient avoids moving, medicate with analgesia as ordered by thephysician to ensure thepatient‘s comfort before moving. Allow pain medication to take effect before proceeding. If thepatient does not move, he or she is at risk for developing complications of immobility. Family members are not trained in proper moving techniques and can cause injury to thepatient and/or themselves. Decreasing thefrequency of movement increases therisk of developing complications of immobility. DIF: CognitiveLevel: Application OBJ: Describe principles of safe patient transfer and positioning. TOP: Increasing Patient Mobility
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
15. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. thepatient is nonverbal and does not respond to requests but is able to turn himself in bed. thenurse notices that thepatient likes to lie on his right side, and soon after being turned by thenursing staff, thepatient turns back to his right side. thenurse in this case should: a. allow thepatient to lie on his right side continuously because he seems comfortable. b. prevent thepatient from lying on his right side until he no longer wishes to lie on that side. c. frequently assess thepatient and turn him more frequently.
d. allow thepatient to lie on his right side until a pressure ulcer develops and he can no longer lie on that side. ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important. Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing thepatient to lie on his preferred side limits thenumber of sides available for turning and decreases patient comfort. thepurpose of assessment and turning is to prevent complications of immobility. DIF: CognitiveLevel: Analysis OBJ: Describe principles of safe patient transfer and positioning. TOP: Turning
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
16. The nurse is preparing to reposition thepatient. Which of thefollowing is a principle of safe patient transfer and positioning? a. The wider thebase of support, thegreater thestability of thenurse. b. The higher thecenter of gravity, thegreater thestability of thenurse. c. Facing in theopposite direction of movement prevents twisting. d. Using either thearms or thelegs reduces therisk for back injury. ANS: A
The wider thebase of support, thegreater thestability of thenurse. thelower thecenter of gravity, thegreater thestability of thenurse. Facing thedirection of movement prevents abnormal twisting of thespine. Dividing balanced activity between arms and legs reduces therisk for back injury. DIF: CognitiveLevel: Comprehension OBJ: Describe principles of safe patient transfer and positioning. TOP: Principles of Safe Patient Transfer and Positioning
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
17. The nurse plans to use a trochanter roll when repositioning a patient. Where should thenurse place thetrochanter roll? a. Under thesmall of theback b. Behind theknees when supine c. Parallel to lateral surface of highs d. In thepalm of thehand with fingers flexed ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with patient in supported supine position. Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent thepatient from leaning towards theaffected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for hemipleic pt in Fowler position. DIF: CognitiveLevel: Application
OBJ: Describe theuse of thetrochanter.
TOP: Trochanter Rolls
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Patients at risk for complications and/or injury from improper positioning include patients with which of thefollowing? (Select all that apply.) a. Poor nutrition b. Loss of sensation c. Impaired muscle development d. Poor circulation ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer. Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility, and impaired muscle development. DIF: CognitiveLevel: Comprehension OBJ: Describe body mechanics and its importance in caring for patients. TOP: Risks for Complications
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because thenurse realizes that mobilization: (Select all that apply.) a. improves joint motion. b. decreases circulation. c. increases social activity. d. enhances mental stimulation. ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on theskin, and improves urinary and respiratory functions. It also benefits thepatient psychologically by increasing social activity and mental stimulation and providing a change in environment. As a result, mobilization plays a crucial role in thepatient‘s rehabilitation. DIF: CognitiveLevel: Analysis OBJ: Describe principles of safe patient transfer and positioning. TOP: Mobilization
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. The nurse prevents self-injury by using which of thefollowing when transferring a patient? (Select all that apply.) a. Correct posture b. Maximal muscle strength c. Effective body mechanics
d. Effective lifting techniques ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting techniques. Consider individual patient problems during transfer. DIF: CognitiveLevel: Comprehension OBJ: Describe principles of safe patient transfer and positioning. TOP: Preventing Self-Injury
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. Proper alignment for a patient in sitting position includes which of thefollowing? (Select all that apply.) a. Head erect b. Four-inch space between edge of seat and popliteal space c. Vertebrae straight d. Both feet elevated ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on thefloor, and ankles are comfortably flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between theedge of theseat and thepopliteal space on theposterior surface of theknee. DIF: CognitiveLevel: Application OBJ: Describe normal body alignment for standing, sitting, and lying down. TOP: Normal Body Alignment for Sitting Position KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
5. Which of thefollowing risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis b. Traction
c. Arterial insufficiency d. Incontinence e. Constipation ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require thepatient to be repositioned more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and poor awareness of theinvolved body part, thepatient is unable to protect and position thebody part for self. Traction, bone fractures, surgery, or arthritic changes of theaffected extremity result in decreased ROM. Decreased circulation predisposes thepatient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is not a risk factor for immobility. DIF: CognitiveLevel: Comprehension OBJ: Describe principles of safe patient transfer and positioning. TOP: Risk Factors That Contribute to Complications of Immobility KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of thefollowing complications? (Select all that apply.) a. Thrombus b. Pressure ulcer c. Kyphosis d. Contractures ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates proper body alignment.
DIF: CognitiveLevel: Comprehension OBJ: Describe body mechanics and its importance in caring for patients. TOP: Complications of Poor Alignment
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
1. Plantar flexion contracture, otherwise known as
, is caused when theforce of
gravity pulls an unsupported, weakened foot into a plantar-flexed position. ANS:
Footdrop Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when theforce of gravity pulls an unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at walking. DIF: CognitiveLevel: Comprehension OBJ: Describe body mechanics and its importance in caring for patients. TOP: Footdrop
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal independence is known as
.
ANS:
transferring Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to regain optimal independence as quickly as possible.
DIF: CognitiveLevel: Comprehension OBJ: Describe principles of safe patient transfer and positioning. TOP: Transferring
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. The term
_ refers to theconditions of thejoints, tendons, ligaments, and muscles
in various body positions. ANS:
body alignment The term body alignment refers to theconditions of thejoints, tendons, ligaments, and muscles in various body positions. When thebody is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures. DIF: CognitiveLevel: Knowledge OBJ: Describe principles of safe patient transfer and positioning. TOP: Body Alignment
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. Body balance is achieved when a wide
exists.
ANS:
base of support Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center of gravity to object to be raised. The lower thecenter of gravity, thegreater thestability of thenurse. Body balance is achieved when a wide base of support exists, thecenter of gravity falls within thebase of support, and a vertical line can be drawn from thecenter of gravity through thebase of support. DIF: CognitiveLevel: Comprehension
OBJ: Describe principles of safe patient transfer and positioning. TOP: Base of Support
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in thesupine position. To reduce extension of thefingers and abduction of thethumb, thenurse places
in thepatient‘s
hands. ANS:
hand rolls For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for theuse of hand splints. This is designed to reduce extension of thefingers and abduction of thethumb. This also maintains thethumb slightly adducted and in opposition to thefingers. DIF: CognitiveLevel: Application OBJ: Describe theprocedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and transferring a patient from a bed to a chair. TOP: Hand Rolls
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
Chapter 12: Exercise and Mobility Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The patient has been admitted for hypertension. His blood pressure is normally in the160/90 range. He has been on bed rest for thepast few days, and thedoctor has started him on a new blood pressure medication. thenurse is assisting thepatient to move from thebed to thechair for breakfast, but when thepatient tries to sit up on theside of thebed, he complains of being dizzy and nauseous. thenurse lays thepatient down and takes his vital signs. His pulse is 124. His blood pressure is 130/80. This blood pressure is indicative of what? a. A normal blood pressure for this patient b. Orthostatic hypotension
c. Orthostatic hypertension d. Effective baroreceptor function ANS: B
Orthostatic hypotension is a drop in blood pressure that occurs when thepatient changes from a horizontal to a vertical position. It traditionally is defined as a drop in systolic or diastolic blood pressure of 20 or 10 mm Hg, respectively. Those at higher risk are immobilized patients, those undergoing prolonged bed rest, theolder-adult patient, those receiving antihypertensive medications, and those with chronic illness, such as diabetes mellitus or cardiovascular disease. Signs and symptoms of orthostatic hypotension include dizziness, light-headedness, nausea, tachycardia, pallor, and even fainting. Orthostatic hypertension would be an increase in blood pressure. Physiological changes associated with aging and prolonged bed rest may reduce theeffectiveness of thebaroreceptors. In these patients, moving to thedangling position may cause a gravity-induced drop in blood pressure; thus, it is recommended to raise thehead of thebed and allow a few minutes before dangling. DIF: CognitiveLevel: Analysis OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation. TOP: Orthostatic Hypotension
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The patient is an elderly gentleman who has been on bed rest for thepast several days. When getting thepatient up, thenurse should: a. tell thepatient not to move his legs when dangling. b. tell thepatient to hold his breath while dangling. c. raise thehead of thebed and allow a few minutes before dangling. d. have thepatient stand without dangling. ANS: C
Physiological changes associated with aging and prolonged bed rest may influence theeffectiveness of thebaroreceptors. For these patients, moving to thedangling position may cause a gravity-induced drop in blood pressure; thus, it is recommended to raise thehead of thebed and allow a few minutes before dangling. Interventions to minimize orthostatic hypotension include movement of thelegs and feet in thedangling position to promote venous return via intermittent contraction and relaxation of theskeletal leg muscles, and asking thepatient to take several deep breaths before and during dangling. Dangling a patient before standing is an intermediate step that allows assessment of theindividual before changing positions to maintain safety and prevent injury to thepatient. DIF: CognitiveLevel: Application OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation. TOP: Dangling
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
3. An appropriate technique for thenurse to use when performing range of motion (ROM) exercises is to: a. repeat each action 5 times during theexercise. b. perform theexercises quickly and firmly. c. support theproximal portion of theextremity being exercised. d. continue theexercise slightly beyond thepoint of resistance. ANS: A
Each movement should be repeated 5 times during an exercise period. Be sure that ROM exercises are performed slowly and gently. When performing active-assisted or passive ROM exercises, support thejoint by holding thedistal portion of theextremity, or by using a cupped hand to support thejoint. Discontinue exercise if thepatient complains of discomfort, or if you note resistance or muscle spasm. DIF: CognitiveLevel: Application OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Range of Motion
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. A patient is admitted to themedical unit following a cerebrovascular accident (CVA). Evidence of left-sided hemiparesis is noted, and thenurse will be following up on ROM and other exercises performed in physical therapy. thenurse should correctly teach thepatient and family members which of thefollowing principles of ROM exercises? a. Flex thejoint to thepoint of discomfort. b. Medicate thepatient after theROM exercise session. c. Move thejoints quickly. d. Provide support for distal joints. ANS: D
When performing active-assisted or passive ROM exercises, support thejoint by holding thedistal portion of theextremity, or by using a cupped hand to support thejoint. thejoint should be flexed to thepoint of resistance, not to thepoint of discomfort. Assess thepatient‘s level of comfort (on a scale of 0 to 10, with 10 being theworst pain) before performing exercises. Before beginning ROM exercises, determine whether thepatient would benefit from pain medication. Joints should be moved slowly through theROM. Quick movement could cause injury. DIF: CognitiveLevel: Application OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Range of Motion
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
5. A nurse encourages a patient to prevent venous stasis by: a. crossing thelegs when sitting in a chair. b. wearing thigh-length nylon stockings or garters. c. elevating thelegs on pillows while in bed. d. increasing early ambulation. ANS: D
Prevention is thebest method to reduce therisk for deep vein thrombosis (DVT) secondary to immobility. Early ambulation remains themost effective preventive measure. Discourage patients from activities that promote venous stasis (e.g., crossing legs, wearing garters, and elevating legs on pillows). DIF: CognitiveLevel: Comprehension OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Venous Stasis
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
6. Graduated compression stockings are ordered for thepatient on bed rest after surgery. thenurse explains to thepatient that theprimary purpose for theelastic stockings is to: a. keep theskin warm and dry. b. prevent abnormal joint flexion. c. apply external pressure. d. prevent bleeding. ANS: C
The primary purpose of graduated compression stockings is to maintain external pressure on themuscles of thelower extremities and thus promote venous return. theprimary purpose of graduated compression stockings is not to keep theskin warm and dry, prevent abnormal joint flexion, or prevent bleeding. They are used to prevent clot formation due to venous stasis. DIF: CognitiveLevel: Comprehension OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Antiembolic Stockings
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
7. When assessing thepatient for risk for deep vein thrombosis (DVT), thenurse should consider which of thefollowing an indicator of increased risk?
a. Arthritis in theextremity b. Pallor to thedistal area c. Edema noted in theextremity d. Fever or dehydration ANS: D
Indicators in Virchow‘s triad include clotting disorders, fever, and dehydration. Additionally, a swollen extremity, pain, and warm cyanotic skin indicate an elevated risk. Edema of theextremity may or may not occur. Pallor to thedistal area is a sign of arterial insufficiency, not deep vein thrombosis. DIF: CognitiveLevel: Application OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: DVT
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
8. An appropriate procedure for thenurse to use when applying an elastic stocking is to: a. remove thestockings every 24 hours. b. keep thetops of thestockings rolled down slightly. c. turn thestocking inside out to apply from thetoes up. d. wash stockings daily and dry in a dryer. ANS: C
Turn elastic stocking inside out by placing one hand into thesock, holding thetoe of thesock with theother hand, and pulling. This allows easier application of thestocking. Elastic stockings should be removed and reapplied at least twice a day. Instruct thepatient not to roll thesocks partially down. Rolling thesocks partially down has a constricting effect and can impede venous return. Instruct thepatient to launder elastic stockings every 2 days with mild detergent and lay flat to dry. DIF: CognitiveLevel: Application OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric
exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Applying Elastic Stockings
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
9. When using a sequential compression device (SCD), thenurse should: a. apply powder to thepatient‘s skin if redness and itching are present. b. leave a two-finger space between thepatient‘s leg and thecompression stocking. c. keep thepatient connected to thecompression device when transferring into and out of bed. d. remove theelastic stockings before putting on thesequential pneumatic compression stockings. ANS: B
Check thefit of SCD sleeves by placing two fingers between thepatient‘s leg and thesleeve. Observe for signs, symptoms, and conditions that might contraindicate theuse of elastic stockings or SCD: Elastic stockings and SCD sleeves may aggravate a skin condition or cause it to spread. Remove SCD sleeves when transferring thepatient into and out of bed to prevent injury. If thepatient is wearing elastic stockings, eliminate any wrinkles and folds before applying SCD sleeves. Wrinkles lead to increased pressure and alter circulation. DIF: CognitiveLevel: Comprehension OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Applying SCD Sleeves
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
10. The patient is a paraplegic who possesses good arm and hand strength. When thefollowing devices are compared, which would be most appropriate for this patient? a. Axillary crutch b. Platform crutch c. Lofstrand crutch d. Standard crook cane ANS: C
The Lofstrand crutch has a handgrip and a metal band that fits around thepatient‘s forearm. Both themetal band and thehandgrip are adjusted to fit thepatient‘s height. This type of crutch is useful for patients with a permanent disability such as paraplegia. theaxillary crutch frequently is used by patients of all ages on a short-term basis. theplatform crutch is used by patients who are unable to bear weight on their wrists. It has a horizontal trough on which patients can rest their forearms and wrists and a vertical handle for thepatient to grip. thestandard crook cane provides theleast support and is used by patients who require only minimal assistance to walk. DIF: CognitiveLevel: Analysis OBJ: Develop teaching plans for selected patients for safety precautions to use at home while using an ambulation aid, applying and monitoring effects of elastic stockings and SCDs, using theCPM, and performing ROM and isometric exercises. TOP: Crutches KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
11. An appropriate way for thenurse to measure a patient for crutches is to: a. have a flexion of 45 degrees at both of thepatient‘s elbows. b. have a space of two to three fingers between thetop of thecrutch and theaxilla. c. place thecrutch tips 1 foot to each side of thepatient‘s feet, and observe thepositioning of thecrutches. d. place thecrutch tips 1 foot to thefront of thepatient‘s feet, and observe thepositioning of thecrutches. ANS: B
Following correct crutch adjustment, two to three fingers should fit between thetop of thecrutch and theaxilla. Following correct crutch adjustment, elbows should be flexed 15 to 30 degrees. Elbow flexion is verified with a goniometer. Position thecrutches with thecrutch tips at 6 inches (15 cm) to theside and 6 inches in front of thepatient‘s feet, and thecrutch pads 2 inches (5 cm) below theaxilla. DIF: CognitiveLevel: Comprehension OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.
TOP: Crutches
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
12. The patient has been using crutches for thepast 2 weeks. When she comes for her follow-up examination, she complains of tingling and numbness in her hands and upper torso. Possible causes of these symptoms are: a. the patient‘s elbows are flexed 15 to 30 degrees when using thecrutches. b. crutch pad is approximately 2 inches below thepatient‘s axilla. c. patient holds thecane 4 to 6 inches to theside of her foot. d. handgrip does not allow for elbow flexion. ANS: D
Instruct thepatient to report any tingling or numbness in theupper torso, which may mean that thecrutches are being used incorrectly, or that they are thewrong size. If thehandgrip is too low, radial nerve damage can occur even if overall crutch length is correct, because theextra length between thehandgrip and theaxillary bar can force thebar up into theaxilla as thepatient stretches down to reach thehandgrip. After correct crutch adjustment, two to three fingers must fit between thetop of thecrutch and theaxilla. Adequate space prevents crutch palsy. Proper fit is when thecrutch pad is approximately 2 inches or two to three finger widths under theaxilla, with thecrutch tips positioned 6 inches (15 cm) lateral to thepatient‘s heel. DIF: CognitiveLevel: Analysis OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Crutches
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
13. The patient has a leg injury and is being fitted for a cane. thepatient should be taught to: a. hold thecane on theuninvolved side. b. hold thecane on theweaker side. c. extend thecane 15 inches from thefoot when used. d. maintain approximately 60 degrees of elbow flexion. ANS: A
The patient holds thecane on theuninvolved side, 4 to 6 inches (10 to 15 cm) to theside of thefoot. This offers themost support when thecane is placed on thestronger side of thebody. thecane and theweaker leg work together with each step. thecane extends from thegreater trochanter to thefloor while thecane is held 6 inches (15 cm) from thefoot. Allow approximately 15 to 30 degrees of elbow flexion. As weight is taken on by thehand and theaffected leg is lifted off thefloor, complete extension of theelbow is necessary. DIF: CognitiveLevel: Comprehension OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Cane Measurement
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
14. When thefour gaits listed below are compared, which is themost stable of thecrutch gaits? a. Four-point gait b. Three-point gait c. Two-point gait d. Swing-to gait ANS: A
Four-point gait is themost stable of crutch gaits because it provides at least three points of support at all times. thepatient must be able to bear weight on both legs. Each leg is moved alternately with each opposing crutch, so that three points of support are on thefloor all thetime. This gait is often used when thepatient has some form of paralysis, such as for spastic children with cerebral palsy. This is less stable than four-point gait because it requires thepatient to bear all weight on one foot. Weight is borne on theuninvolved leg and then on both crutches. theaffected leg does not touch theground during theearly phase of three-point gait. This gait may be useful for patients with a broken leg or a sprained ankle. This is less stable than four-point gait because it requires at least partial weight bearing on each foot. It is faster than four-point gait and requires better balance because only two points support thebody at any one time. This is theeasier of thetwo swinging gaits. It is less stable than four-point gait because it requires theability to partially bear body weight on both legs. This gait is frequently used by patients whose lower extremities are paralyzed, or who wear weight-supporting braces on their legs. DIF: CognitiveLevel: Analysis OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Crutch Gaits KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
15. The nurse is caring for a patient who has just been treated for a broken leg. She needs to teach thepatient how to use crutches. Which crutch gait is most appropriate for this patient? a. Four-point gait b. Three-point gait c. Two-point gait d. Swing-to gait ANS: B
The three-point gait requires thepatient to bear all weight on one foot. Weight is borne on theuninvolved leg and then on both crutches. theaffected leg does not touch theground during theearly phase of three-point gait. It is useful for patients with a broken leg or a sprained ankle. thefour-point gait is themost stable of crutch gaits because it provides at least three points of support at all times. thepatient must be able to bear weight on both legs. Each leg is moved alternately with each opposing crutch, so that three points of support are on thefloor all thetime. thetwo-point is used when thepatient has some form of paralysis, such as for spastic children with cerebral palsy. This gait requires at least partial weight bearing on each foot. It requires better balance because only two points support thebody at one time. This is theeasier of thetwo swinging gaits. It requires theability to partially bear body weight on both legs. theswing-to gait is used by patients whose lower extremities are paralyzed, or who wear weight-supporting braces on their legs. DIF: CognitiveLevel: Analysis OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Crutch Gaits KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
16. When teaching theuse of a three-point crutch gait, thenurse should instruct thepatient to move: a. both crutches and theaffected leg first, then thestronger leg. b. the right crutch, left foot, left crutch, and right foot in sequence. c. the left crutch and right foot, then move theright crutch and left foot. d. both crutches, then lift and swing thelegs forward as far as thecrutches. ANS: A
The proper sequence for thethree-point crutch gait is: begin in tripod position, advance both crutches and theaffected leg, and then move thestronger leg forward, stepping on thefloor. This is theproper sequence for thefour-point gait, thetwo-point gait, and theswing-to gait. DIF: CognitiveLevel: Comprehension OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric
exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Crutch Gaits KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
17. A patient with left hemiparesis is using a quad cane for ambulation. Which of thefollowing is thecorrect technique for thenurse to use in teaching thepatient? a. Use thecane on theright side, with thecane moving forward first. b. Use thecane on theleft side, with theleft leg moving forward with thecane. c. Use thecane in either hand, with theright leg moving forward first. d. Use thecane in either hand, with theleft leg moving beyond theforward placement of thecane. ANS: A
To correctly use a quad cane, thepatient places thecane on theside opposite theinvolved leg. This provides added support for theweak or impaired side. Ambulation then begins by moving thecane forward 6 to 10 inches (15 to 25 cm), keeping body weight on both legs. theweak leg is then brought forward even with thecane while thebody weight is supported by thestrong leg and thecane. thestrong leg is then advanced past thecane. Moving a leg and thecane forward at thesame time will compromise balance and increase risk of fall. DIF: CognitiveLevel: Comprehension OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Ambulation with a Cane
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. The patient had a stroke and is currently immobile. thenurse realizes that increasing mobility is critical because immobility can result in alterations in which of thefollowing? (Select all that apply.) a. Cardiovascular function b. Pulmonary function
c. Skin integrity d. Elimination ANS: A, B, C, D
When mobility is altered, many body systems are at risk for impairment. Impaired mobility can result in altered cardiovascular functioning, disruption of normal metabolic functioning, increased risk for pulmonary complications, thedevelopment of pressure ulcers, and urinary elimination alterations. DIF: CognitiveLevel: Comprehension OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation. TOP: Complications of Immobility
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. Factors that contribute to thedevelopment of deep vein thrombosis (DVT) are: (Select all that apply.) a. elevated sodium (Na+) levels. b. hypercoagulability of theblood. c. venous wall damage. d. stasis of blood flow. ANS: B, C, D
Three elements (commonly referred to as Virchow‘s triad) contribute to thedevelopment of DVT: hypercoagulability of theblood, venous wall damage, and stasis of blood flow. DIF: CognitiveLevel: Comprehension OBJ: Understand thepathophysiology of thedevelopment of DVTs. TOP: Deep Vein Thrombosis
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
1.
refers to an ability to move about freely. ANS:
Mobility Mobility refers to an ability to move about freely. DIF: CognitiveLevel: Knowledge OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation. TOP: Mobility
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. A person‘s inability to move about freely is known as
.
ANS:
immobility Immobility refers to a person‘s inability to move about freely. DIF: CognitiveLevel: Knowledge OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation. TOP: Immobility
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. A drop in blood pressure that occurs when thepatient changes position from a horizontal to a vertical position is known as
.
ANS:
orthostatic hypotension Orthostatic hypotension is a drop in blood pressure that occurs when thepatient changes position from a horizontal to a vertical position. DIF: CognitiveLevel: Comprehension OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation. TOP: Orthostatic Hypotension MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Assessment
4. The patient is performing range of motion (ROM) exercises independently. These are known as
exercises.
ANS:
active ROM ROM exercises may be active, passive, or active-assisted. They are active if thepatient is able to perform theexercises independently and passive if theexercises are performed for thepatient by thecaregiver. theexercises are active-assisted if thepatient is able to perform some of theactions independently with support and assistance from thecaregiver. DIF: CognitiveLevel: Knowledge OBJ: Discuss indications for performing ROM and isometric exercises. TOP: Active Range of Motion
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
5. Virchow‘s triad (hypercoagulability of blood, venous wall damage, and stasis of blood flow) has been found to contribute to
.
ANS:
deep vein thrombosis (DVT) deep vein thrombosis Three elements (commonly referred to as Virchow‘s triad) contribute to thedevelopment of DVT: hypercoagulability of theblood, venous wall damage, and stasis of blood flow. DIF: CognitiveLevel: Comprehension OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Deep Vein Thrombosis MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Assessment
6. The nurse is concerned that thepatient may fall while he is ambulating. To help her maintain control while thepatient walks, thenurse may apply a
around thepatient‘s
waist. ANS:
gait belt A gait belt encircles a patient‘s waist and has space for thenurse to hold while thepatient walks. This gives thenurse better control and helps to prevent injury. DIF: CognitiveLevel: Application OBJ: Demonstrate thefollowing skills on selected patients: assisting with ambulation, assisting with ambulation with theuse of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Gait Belt
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
Chapter 13: Support Surfaces and Special Beds Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The patient is admitted to theunit with a stage 3 pressure injury. When thedifferent types of support surfaces are compared, which would be most therapeutic for this patient? a. Foam mattress b. Gel overlay c. Air-fluidized bed d. Air mattress ANS: C
Patients with stage 3 or 4 pressure injuries on multiple turning surfaces often benefit from an air-fluidized bed (Nix and Mackey, 2016).
Air-fluidized beds are recommended for use for patients with stage 3 and stage 4 pressure injuries. Foam support surfaces are recommended to reduce therisk of thepatient developing pressure ulcers. Gel overlay support surfaces are recommended for patients who are wheelchair dependent, as well as those who are at risk for developing pressure ulcers. Nonpowered air-filled mattress is recommended for patients who are able to reposition themselves. DIF: CognitiveLevel: Analysis OBJ: Identify thedifferent types of support surfaces and specialty beds used for pressure redistribution.
TOP: Pressure Ulcers
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. What is themost important factor in preventing and treating pressure injuries? a. Proper use of foam or air mattresses b. Proper utilization of an air-fluidized bed c. Frequent repositioning of thepatient d. Proper use of a low-air-loss bed ANS: C
Frequent repositioning, which temporarily relieves pressure, is thebackbone of preventive protocols. It is thenurse‘s responsibility to use appropriate turning schedules for patients in bed or on a chair. No bed or mattress totally eliminates theneed for competent nursing care. DIF: CognitiveLevel: Comprehension OBJ: Explain why preventive nursing care is still essential when support surfaces and specialty beds are used.
TOP: Repositioning
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. What is theprimary purpose for theuse of a support surface? a. To reduce pressure b. To promote patient comfort c. To increase circulation d. To facilitate patient movement ANS: A
Support surfaces aid in reducing pressure on thepatient‘s skin. Promoting patient comfort may happen, but it is not theprimary purpose of thesupport mattress. A support mattress does not increase patient circulation, nor does it facilitate patient movement. DIF: CognitiveLevel: Comprehension OBJ: Describe guidelines to follow when placing patients on support surfaces and specialty beds. TOP: Patient Assessment
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. When working with a patient who is being placed on an air mattress/overlay, thenurse should: a. apply thepreinflated overlay over thestandard mattress. b. bring any plastic strips or flaps around thecorners of thebed mattress. c. administer an analgesic after thepatient is moved onto themattress. d. keep clamps or pins attached to thesheets to keep them in place over themattress. ANS: B
When preparing an air mattress/overlay, bring any plastic strips or flaps around thecorners of thebed mattress. This secures theair mattress in place. Apply a deflated mattress flat over thesurface of thebed mattress. thedecision to administer analgesic would be based on thepatient‘s condition rather than on theprocedure. Pins and other sharps should not be used, to avoid puncturing an air mattress. DIF: CognitiveLevel: Application OBJ: Describe guidelines to follow when placing patients on support surfaces and specialty beds. TOP: Air Mattress/Overlay
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
5. After comparing thebenefits of thefollowing support surfaces, thenurse realizes that a patient with multiple trauma and/or spinal cord injury is expected to be placed on a(n): a. Lateral Rotation bed b. bariatric bed. c. flotation mattress. d. air-fluidized mattress. ANS: A
The Lateral Rotation bed provides skeletal alignment and constant rotation and is used for patients with multiple trauma and spinal cord injury. Use of thebariatric bed is contraindicated in patients with spinal cord injury. Flotation mattresses and air-fluidized mattresses are contraindicated for patients with an unstable spine. DIF: CognitiveLevel: Analysis OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress.
TOP: Rotokinetic Bed
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
6. The patient is admitted with a large stage 4 pressure injury on his coccyx. After comparing thebenefits of thefollowing support surfaces, thenurse would choose which of thefollowing as most appropriate for this patient? a. Water mattress b. Gel overlay c. Foam overlay d. Air-fluidized bed ANS: D
If a patient has large stage 3 or stage 4 pressure injury on multiple turning surfaces, a low-air-loss bed or air-fluidized bed may be indicated. theuse of water mattresses has been reduced considerably because they harbor organisms in thewater, and leaks in themattress are risky for patients with open wounds. Gel overlays are used for moderate- to high-risk patients, not for patients who have stage 4 ulcers. They are useful for patients who are wheelchair dependent. Foam overlays are used for moderate- to high-risk patients, not for those with stage 4 ulcers. DIF: CognitiveLevel: Analysis OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. KEY: NursingProcess Step: Evaluation
TOP: Air-Fluidized Beds
MSC: NCLEX: Physiological Integrity
7. An air-suspension bed is contraindicated for thepatient with:
a. burns. b. traction. c. osteoporosis. d. respiratory insufficiency. ANS: B
Changes in pressure and position from an air-suspension bed are contraindicated for patients with an unstable spine or traction who must remain in alignment. An air-suspension bed is not contraindicated for patients with burns, osteoporosis, and respiratory insufficiency. DIF: CognitiveLevel: Application OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Air-Suspension Beds KEY: NursingProcess Step: Evaluation MSC: NCLEX: Physiological Integrity
8. Of thefollowing problems that may occur with theuse of an air-fluidized bed, which is of greatest concern to thenurse? a. Nausea b. Anxiety c. Slight disorientation d. Insensible fluid loss ANS: D
Diaphoresis often goes undetected, and thus insensible fluid loss is not always evident until a patient develops fluid and electrolyte imbalances. This individual often is already compromised in relation to hydration, fluids, and electrolytes; therefore, thenurse needs to carefully monitor thepatient‘s fluid balance status. Some nausea, disorientation, and anxiety can occur, but they are not as critical as insensible fluid loss. DIF: CognitiveLevel: Evaluation OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. KEY: NursingProcess Step: Evaluation
TOP: Air-Fluidized Beds
MSC: NCLEX: Physiological Integrity
9. A patient is on bed rest after sustaining injuries in a car accident. Which nursing action helps prevent complications of immobility? a. Decreasing fluid intake to ease dependent edema b. Turning thepatient every 2 hours and providing a low-air-loss mattress c. Raising thehead of thebed to maximize thepatient‘s lung inflation d. Bathing and feeding thepatient to decrease energy expenditure ANS: B
To avoid pressure ulcers in an immobilized patient, thenurse must assess theskin thoroughly and use such preventive measures as regular turning, a low-air-loss mattress, and a trapeze (if thepatient‘s condition allows). thenurse should increase, not decrease, thepatient‘s fluid intake to help prevent renal calculi, which may result from immobility. To prevent atelectasis, another complication of immobility, having thepatient cough, deep-breathe, and use an incentive spirometer would be more effective than raising thehead of thebed. Instead of bathing and feeding thepatient, thenurse should promote independent self-care activities whenever possible to prepare thepatient for a return to theprevious health status. DIF: CognitiveLevel: Analysis OBJ: Explain why preventive nursing care is still essential when support surfaces and specialty beds are used.
TOP: Use of a Low-Air-Loss Mattress
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
10. After comparing thefollowing support surfaces, thenurse realizes that an extremely obese patient should benefit from theuse of a(n): a. bariatric bed. b. foam mattress. c. water mattress. d. air-fluidized bed. ANS: A
A valuable resource in thecare of themorbidly obese patient (a person who weighs more than 100 pounds above ideal weight) is thebariatric bed, which provides a safe, adaptable surface. thefoam or water mattress and theair-fluidized bed are not designed specifically for theobese patient. DIF: CognitiveLevel: Analysis OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress.
TOP: Bariatric Bed
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Factors that contribute to pressure injury formation include which of thefollowing? (Select all that apply.) a. Friction b. Shear c. Turning every 2 hours d. Malnutrition e. Impaired mobility ANS: A, B, D, E
Factors contributing to pressure injury formation are both extrinsic (e.g., pressure, moisture, friction, and shear, medical devices) and intrinsic (e.g., malnutrition, loss of sensation, impaired mobility, aging skin, impaired mental status, infection, incontinence, and low arteriolar pressure) (Padula et al, 2017; Serraes et al, 2018). Factors that contribute to pressure injury formation are both extrinsic (e.g., moisture, friction, and shear) and intrinsic (e.g., malnutrition, loss of sensation, impaired mobility, aging skin, impaired mental status, infection, incontinence, and low arteriolar pressure). Turning every 2 hours is a measure to prevent ulcer formation, not a factor that contributes to it. DIF: CognitiveLevel: Comprehension OBJ: Explain why preventive nursing care is still essential when support surfaces and specialty beds
are used.
TOP: Risk Factors for Pressure Ulcers
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The patient is admitted to thehospital. Part of thepatient assessment will include: (Select all that apply.) a. use of an appropriate pressure ulcer risk scale. b. assessment of thepatient‘s nutritional status. c. assessment of thepatient‘s mobility status. d. assessment of thepatient‘s fluid status. ANS: A, B, C, D
A complete patient assessment includes theuse of appropriate pressure injury risk scales; thepresence of shear and friction; and thepatient‘s nutritional, fluid, mobility, and continence status. DIF: CognitiveLevel: Application OBJ: Describe guidelines to follow when placing patients on support surfaces and specialty beds. TOP: Patient Assessment
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. Air-fluidized beds require thenurse to assess for which of thefollowing? (Select all that apply.) a. The patient‘s fluid and electrolyte status b. The patient‘s financial status c. The structural strength of theroom where thebed will be d. The room temperature ANS: A, B, C, D
Air-fluidized beds provide continuous circulation of warm, dry air, which may increase patient risk for dehydration. thebed also may increase room temperature, making it uncomfortable for thepatient and possibly leading to overheating of theequipment. Another concern is that thebed is heavy and expensive. Unless thepatient has a physician order, third-party payment may not be available. DIF: CognitiveLevel: Application
OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress.
TOP: Air-Fluidized Beds
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
COMPLETION
1.
are defined as localized injury to theskin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. ANS:
Pressure Injuries •
Pressure injuries are localized injuries to theskin and/or underlying tissue, usually over a bony prominence, such as theheel or sacrum. These injuries are a result of pressure or pressure in combination with shear and/or friction (Tomova-Smitchieva et al, 2018; WOCN, 2016).
DIF: CognitiveLevel: Comprehension OBJ: Explain why preventive nursing care is still essential when support surfaces and specialty beds are used.
TOP: Pressure Ulcers
KEY: NursingProcess Step: Assessment
2. The major cause of pressure injury is
MSC: NCLEX: Physiological Integrity
.
ANS:
unrelieved pressure The major cause of pressure injury is unrelieved pressure. thegreater thepressure and thelonger thepressure is applied, thegreater thelikelihood that a pressure ulcer will develop. DIF: CognitiveLevel: Comprehension OBJ: Explain why preventive nursing care is still essential when support surfaces and specialty beds
are used.
TOP: Pressure Ulcers
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. The nurse understands that an
using foam, air, water, or gel can be
placed on top of themattress to provide pressure relief. ANS:
overlay Support surfaces are categorized as mattress (or wheelchair) overlays, mattress replacements, or specialty beds. An overlay rests on top of thehospital mattress and uses foam, air, water, gel, or combinations of these products to provide pressure relief. DIF: CognitiveLevel: Comprehension OBJ: Compare and contrast mattress overlays and mattress replacements. TOP: Overlays
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. A
serves as an artificial layer of fat to protect bony surfaces.
ANS:
flotation pad A flotation pad is made of a silicone or polyvinyl chloride gel enclosed in a vinyl-covered square. thepad serves as an artificial layer of fat to protect bony surfaces such as thesacrum and thegreater trochanters. These flotation pads are available for thebed or for wheelchair patients. DIF: CognitiveLevel: Comprehension OBJ: Compare and contrast mattress overlays and mattress replacements. TOP: Flotation Pads MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Assessment
5.
beds are for patients who are immobile or otherwise are confined to thebed; they support a patient‘s weight on air-filled cushions. ANS:
Air-suspension Air-suspension beds are for patients who are immobile or otherwise are confined to thebed. theair-suspension bed supports a patient‘s weight on air-filled cushions. DIF: CognitiveLevel: Knowledge OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Air-Suspension Beds KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
6. The patient will be going home but still requires an air-fluidized bed. Before discharge, it will be necessary for thecompany that is leasing thebed to inspect thehome for accessibility and . ANS:
structural support Beds weigh between 1700 and 2100 pounds; therefore, thecompany that is leasing thebed needs to inspect thehome for accessibility and structural support. DIF: CognitiveLevel: Application OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress.
TOP: Home Care Considerations
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
7. A ANS:
bariatric bed
can accommodate a patient up to 1000 pounds.
Most bariatric beds are capable of supporting weights up to 454 kg (1000 lbs.). DIF: CognitiveLevel: Comprehension OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress.
TOP: Bariatric Bed
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
8. Use of thelow-air-loss bed is contraindicated in patients with
.
ANS:
spinal cord injury Use of this bed is contraindicated in patients with spinal cord injury. DIF: CognitiveLevel: Comprehension OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress.
TOP: Bariatric Bed
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
9. The
bed rotates and improves skeletal alignment with constant side-to-side
rotation up to 90 degrees. ANS:
Lateral Rotation Bed This bed improves skeletal alignment with constant side-to-side rotation up to 90 degrees. DIF: CognitiveLevel: Comprehension OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Rotokinetic Bed
10. It is recommended that theLateral Rotation bed stay in therotation mode for at least hours a day. ANS:
20 It is recommended that theRotokinetic bed stay in therotation mode for at least 20 hours a day. DIF: CognitiveLevel: Comprehension OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress.
TOP: Rotokinetic Bed
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
Chapter 14: Patient Safety Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The patient is admitted to thehospital with orders for activity as tolerated. He is wheelchair-bound at home and has brought his own electric wheelchair and battery charger to help him maintain mobility. thenurse realizes that: a. patients are not allowed to bring in an electric wheelchair. b. electrical equipment is banned from all hospitals. c. the charger needs to be checked by hospital engineers. d. electrical devices are not a cause for concern. ANS: C
If a patient brings an electrical device to a hospital, an engineer must inspect thedevice for safe wiring and function before use. DIF: CognitiveLevel: Comprehension OBJ: Describe methods used to evaluate interventions designed to maintain or promote a patient‘s safety. TOP:
Fire/Electrical Safety
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
2. Upon entering thepatient‘s room, thenurse sees a fire burning in thetrash can next to thebed. thenurse removes thepatient and reports thefire. What is thenurse‘s next action? a. Extinguish thefire. b. Remove all other patients from theunit. c. Close all doors of patient rooms. d. Move thetrash can into thebathroom. ANS: C
Using the―RACE‖ acronym, thenext action thenurse should take is to confine thefire by closing doors and windows and turning off oxygen and electrical equipment (Rescue, Activate, Contain, and Evacuate). DIF: CognitiveLevel: Application OBJ: Describe nursing interventions taken in theevent of fire and electrical shock. TOP: Fire Safety
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
3. In a long-term care facility, an elderly patient drops his burning cigarette into a trash can and starts a fire. A type
_ fire extinguisher is themost appropriate type of fire extinguisher for
thenurse to use in this situation. a. A b. B c. C d. D ANS: A
Type A fire extinguishers are used for ordinary combustibles such as wood, cloth, paper, and plastic. A trash can fire would require a type A fire extinguisher. Type B fire extinguishers are used for flammable liquids such as gasoline, grease, paint, and anesthetic gas. Type C fire extinguishers are used for electrical fires. There is no type D fire extinguisher. DIF: CognitiveLevel: Comprehension
OBJ: Describe nursing interventions performed in theevent of fire and electrical shock. TOP: Fire Extinguishers
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. Given themost common causes of hospital fires, which of thefollowing choices are most appropriate in preventing patient injury? a. Assure that all electrical devices are checked by engineering. b. Assist patients who smoke to a safe area to smoke. c. Prop fire doors open for easier patient access. d. Educate patients on theimportance of smoking cessation. ANS: A
The leading causes of fires in healthcare facilities involve cooking equipment in cafeterias, electrical distribution and lighting equipment, intentional causes, and smoking materials (NFPA, 2017). Smoking-related fires pose a significant risk because of unauthorized smoking in beds or bathrooms by patients and visitors. Always comply with agency smoking policies, use equipment correctly, and keep combustible materials away from heat sources. Health care agencies routinely check and maintain all electrical devices. Every biomedical device (e.g., suction machine, infusion pump) must have a safety inspection sticker with an expiration date applied to it. Electrical equipment in good working order requires a three-prong electrical plug for proper grounding. Most agencies have fire doors that are held open by magnets and close automatically when a fire alarm sounds. Fire doors should never be blocked. DIF: CognitiveLevel: Analysis OBJ: Describe nursing interventions performed in theevent of fire and electrical shock. TOP: Fire Extinguishers
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
5. After recognizing that a patient has received an electrical shock and removing thesource of theshock, what should thenurse do next? a. Call for assistance. b. Immediately start CPR. c. Obtain emergency equipment. d. Assess for thepresence of a pulse.
ANS: D
If patient receives an electrical shock, immediately turn off power to electrical source and assess for presence of a pulse. If patient is pulseless, institute emergency resuscitation. Notify emergency personnel and patient's health care provider. If patient has a pulse and remains alert and oriented, obtain vital signs and assess theskin for signs of thermal injury. DIF: CognitiveLevel: Application OBJ: Describe nursing interventions performed in theevent of fire and electrical shock. TOP: Electrical Shock
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
6. The patient is an elderly gentleman who is admitted for a medical problem. While doing his admission assessment, thenurse learns that thepatient gets up 2 to 3 times a night to use therestroom. theinstitution has only beds with four side rails. Which of thefollowing is theappropriate rationale for leaving one of thelower side rails down? a. Falls rarely happen in theinpatient setting. b. Having all side rails raised increases theoccurrence of falling. c. Side rails have no bearing on whether or not a patient falls. d. Patient falls rarely result in physical injury. ANS: B
Dependent, less mobile patients: Rails on newer hospital beds allow for room at foot of bed for patient to safely exit bed. In four-side rail bed, only leave two upper rails up. Patient able to get out of bed independently: In four–side rail bed, leave two upper side rails up. Allows for safe exit from bed. theCMS standards note that there is no evidence that theuse of physical restraint, (including, but not limited to, raised side rails) will prevent or reduce falls (CMS, 2018). DIF: CognitiveLevel: Comprehension OBJ: Discuss theimportance of a nursing assessment in providing for patient safety. TOP: Falls Prevention MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Planning
7. What should thenurse do to promote patient understanding and security in thehealth care setting? a. Restrain thepatient as necessary. b. Explain all procedures to thepatient. c. Allow thepatient more time alone. d. Restrict activity as much as possible. ANS: B
Orient patient and family to surroundings, introduce to staff, and explain all treatments and procedures. This promotes patient understanding and cooperation. theuse of restraints is one safety strategy that can protect patients from injury, but restraints must be used with extreme caution. Physical restraints should be thelast resort and should be used only when reasonable alternatives have failed. Isolation may increase anxiety. Encourage family and friends to stay with thepatient. Sitters or companions may be used. In some institutions, volunteers can be effective companions. Patient anxiety is reduced and safety is increased when one person provides care and supervision is constant. Constant activity may irritate thepatient, yet thelack of activity may create anxiety and/or boredom. Meaningful diversional activities provide distraction, help to reduce boredom, and provide tactile stimulation. Minimize occurrences of wandering. DIF: CognitiveLevel: Comprehension OBJ: Describe steps in thedesign of a restraint-free environment. TOP: Alternatives to Physical Restraint
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
8. As part of an attempt to implement a restraint-free environment, thenurse: a. provides constant activity for thepatient. b. covers or camouflages tubes and drains. c. changes caregivers as often as possible. d. reduces visiting hours and times in therapy. ANS: B
Position intravenous (IV) catheters, urinary catheters, and tubes/drains out of patient view, or use camouflage by wrapping theIV site with bandage or stockinette, placing undergarments on patients with a urinary catheter, or covering abdominal feeding tubes/drains with a loose abdominal binder. This helps maintain medical treatment and reduces patient access to tubes/lines. Provide scheduled ambulation, chair activity, and toileting. Organize treatments so thepatient has long uninterrupted periods throughout theday. Provide for sleep and rest periods. Constant activity may irritate thepatient. Provide thesame caregivers to theextent possible. This increases familiarity with individuals in thepatient‘s environment, decreasing anxiety and restlessness. Encourage family and friends to stay with thepatient. Sitters or companions may be used. In some institutions, volunteers can be effective companions. Patient anxiety is reduced and safety is increased when one person provides care and supervision is constant. DIF: CognitiveLevel: Application OBJ: Describe steps in thedesign of a restraint-free environment. TOP: Alternatives to Physical Restraint
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
9. A patient is well known to thehospital staff from previous admissions and is prone to wandering at night. For patient safety, thephysician writes an order for ―belt restraint prn.‖ What should thenurse do upon reviewing this order? a. Apply a belt restraint on thepatient as needed. b. Have thepatient sign an ―informed consent‖ form. c. Inform thephysician that ―prn‖ restraint orders are unacceptable. d. Obtain a signed ―informed consent‖ from a family member. ANS: C
The use of mechanical or physical restraints should be part of a patient‘s prescribed medical treatment. Obtain current health care provider's order for restraint, including purpose, type, location, and time or duration of restraint. Determine if signed consent for use of restraint is necessary (long-term care). DIF: CognitiveLevel: Application OBJ: Discuss precautions used to prevent injury in patients who are restrained.
TOP: Applying Physical Restraints
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
10. To promote patient safety, government standards regarding mechanical and physical restraints state that: a. alternative measures are to be implemented before restraints are used. b. the nurse‘s judgment is all that is required for restraint use. c. restraints should be used immediately for all patients who may need them. d. restraints cannot be used except to prevent others from being harmed. ANS: A
When theuse of a restraint is necessary, theleast restrictive method must be used to ensure a patient‘s safety (CMS, 2018).The Centers for Medicare and Medicaid (CMS) (2018) have a standard citing that all patients have theright to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. In addition CMS (2018) emphasizes that restraint or seclusion may only be used to ensure theimmediate physical safety of a patient, a staff member, or others and must be discontinued at theearliest possible time. DIF: CognitiveLevel: Application OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Applying Physical Restraints
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
11. When applying a belt restraint to a patient, it is important for thenurse to: a. apply thebelt under thehospital gown. b. place therestraint around theabdomen. c. have thepatient in a sitting position. d. apply thebelt as tightly as possible. ANS: C
Have thepatient in a sitting position. Remove wrinkles or creases in clothing. Bring ties through slots in a belt. Apply a belt over clothes, gown, or pajamas to prevent damage to theskin. Make sure to place therestraint at thewaist, not at thechest or abdomen. Avoid applying thebelt too tightly.
DIF: CognitiveLevel: Application OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Belt Restraints
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
12. When caring for a patient who has been restrained, how often will thenurse perform an assessment? a. Every 15 minutes b. Every 30 minutes c. Every hour d. Every 2 hours ANS: A
After restraint application, evaluate patient‘s response to restraints: Non-violent patients – conduct evaluation for signs of injury (e.g. circulation, ROM, vital signs, skin condition), behavior and psychologic status and readiness for discontinuation (frequency based on agency policy) (TJC, 2018b). For violent/self-destructive patients conduct same evaluation every 15 minutes. Evaluate patient's need for toileting, nutrition and fluids, hygiene, and elimination and release restraint at least every 2 hours. DIF: CognitiveLevel: Comprehension OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Evaluation of Patient Condition
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
13. When caring for a patient who has an arm or leg restraint in place, how often will thenurse remove therestraint? a. Every 15 minutes b. Every 30 minutes c. Every hour d. Every 2 hours ANS: D
Remove restraint at least every 2 hours (TJC, 2018b) or more frequently as determined by agency policy. Reposition patient, provide comfort and toileting measures, and evaluate patient condition each time. If patient is agitated, violent or noncompliant, remove one restraint at a time and/or have staff assistance while removing restraints. DIF: CognitiveLevel: Comprehension OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Evaluation of Patient Condition
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
14. When assessing a patient, a nurse notes that theskin distal to a restraint is pale and cool to thetouch. Which of thefollowing interventions will thenurse perform first? a. Remove therestraint. b. Loosen therestraint. c. Obtain a larger restraint. d. Reapply therestraint with more padding. ANS: A
Patient has neurovascular injury (e.g., cyanosis, pallor, and coldness of skin or complains of tingling, pain, or numbness). Remove restraint immediately, stay with patient, and have health care provider notified. Protect extremity from further injury. DIF: CognitiveLevel: Application OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Altered Neurovascular Status of an Extremity KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
15. A nurse enters theroom of a patient who is sitting in a chair and begins to have a seizure. To promote patient safety, which nursing intervention will thenurse initially perform? a. Immediately call for assistance. b. Assist thepatient to thefloor. c. Put thepatient back into thebed. d. Insert a padded tongue blade into thepatient‘s mouth.
ANS: B
Taking immediate action in theevent of a seizure by protecting thepatient from falling or injury, not trying to restrain thepatient, and not placing anything into patient‘s mouth. Guide a patient who is standing or sitting to thefloor and protect head by cradling in your lap or place pillow under head. Position patient so as to keep head tilted to maximize breathing (if able). Try to position patient on side but do not force. Do not lift patient from floor to bed during seizure. If patient is in bed, turn him or her onto side (do not force) and raise side rails. Position protects patient from aspiration and traumatic injury, especially head injury. DIF: CognitiveLevel: Application OBJ: Describe nursing interventions for a patient who experiences generalized seizures. TOP: Seizures
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
16. What should thenurse do to prevent a patient from aspirating during a seizure? a. Insert an oral airway. b. Restrain thepatient securely. c. Sit thepatient upright. d. Turn thepatient onto his/her side. ANS: D
Provide airway protection and gas exchange by positioning head. Position patient so as to keep head tilted to maximize breathing (if able). Try to position patient on side but do not force. If patient is in bed, turn him or her onto side (do not force) and raise side rails. Keep patient in side-lying position (if possible), supporting head and keeping it flexed slightly forward. Position protects patient from aspiration and traumatic injury, especially head injury. Establishing and protecting airway when patient loses consciousness must occur in first 2 minutes Never force any object into patient's mouth such as fingers, medicine, tongue depressor, or airway when teeth are clenched. Do not restrain patient; if patient is flailing limbs, hold them loosely. Loosen restrictive clothing/gown to aid breathing.
DIF: CognitiveLevel: Application OBJ: Describe nursing interventions for a patient who experiences generalized seizures. TOP: Aspiration
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Effective fall prevention programs include which of thefollowing? (Select all that apply.) a. Risk assessment b. Medication reviews c. Use of assistive devices d. Exercise and strength training ANS: A, B, C, D
An individualized patient assessment and multifactorial interventions that include aerobic exercises, strength training, mobility strategies, medication management, consumer and staff education, provision of effective assistive devices and environmental modifications have been shown to reduce falls in hospitals (Slade et al., 2017). DIF: CognitiveLevel: Comprehension OBJ: Discuss current evidence in thearea of fall prevention. KEY: NursingProcess Step: Assessment
TOP: Fall Prevention Programs
MSC: NCLEX: Physiological Integrity
2. Which of thefollowing fall prevention strategies should thenurse perform on all hospitalized patients? (Select all that apply.) a. Conduct hourly rounds. b. Provide thepatient regular toileting. c. Assess thepatient‘s comfort needs. d. Evaluate theeffectiveness of pain medication. ANS: A, B, C, D
Anticipate patient's basic needs (e.g., toileting, relief of pain, relief of hunger) as quickly as possible; conduct hourly rounds
DIF: CognitiveLevel: Comprehension OBJ: Describe nursing interventions specific for reducing therisk for falls. TOP: Fall Prevention Programs
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. Which of thefollowing alternatives to physical restraints should thenurse use to promote patient safety? (Select all that apply.) a. Environmental modifications b. Less frequent patient observation c. Involvement of family during visitation d. Frequent reorientation of thepatient ANS: A, C, D
Many alternatives to theuse of restraints are available, and you should try all of them before using restraints. Modification of theenvironment is an effective alternative to restraints. More frequent observation of patients, involvement of family during visitation, and frequent reorientation are helpful measures. DIF: CognitiveLevel: Application OBJ: Describe steps in thedesign of a restraint-free environment. TOP: Alternatives to Physical Restraint
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The use of restraints has been associated with which of thefollowing complications? (Select all that apply.) a. Pressure injuries b. Pneumonia c. Constipation d. Death ANS: A, B, C, D
The use of restraints is associated with serious complications, including pressure injuries, hypostatic pneumonia, constipation, incontinence, and death. DIF: CognitiveLevel: Comprehension
OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Applying Physical Restraints
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
5. When working with a patient who has a new seizure disorder, thenurse is alerted to theneed for further instruction when thepatient tells thenurse: (Select all that apply.) a. ―I will avoid over-the-counter medications that contain alcohol.‖ b. ―I have themedications that I take listed on this card that I carry with me.‖ c. ―I will be sure to take my medications as prescribed by my provider.‖ d. ―I will visit my physician right after I return home from my next trucking job.‖ ANS: B, D
Patients should wear a medical alert bracelet or carry an identification card noting thepresence of seizure disorder and listing medications taken. Without a medical alert bracelet or identification noting thepresence of seizure disorder and medications taken, just having themedications at work or home will not necessarily mean that theappropriate treatment will be started. A seizure condition usually imposes driving limitations. It is recommended that a waiting period of 1 seizure-free year elapses before thepatient attempts to drive or operate dangerous equipment. DIF: CognitiveLevel: Application OBJ: Describe nursing interventions for a patient who experiences generalized seizures. TOP: Teaching Considerations
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
COMPLETION
1. More than theUnited States. ANS:
300,000
patients are injured in falls in inpatient settings annually in
Falls are themost common adverse events that are reported in hospitalized older adults (Slade et al., 2017). theJoint Commission noted that an estimated 700,000 to 1,000,000 people fall in U.S. hospitals each year and that 30 to 35 percent of those patients sustain an injury as a result of thefall, and approximately 11,000 falls are fatal. DIF: CognitiveLevel: Knowledge OBJ: Describe methods used to evaluate interventions designed to maintain or promote a patient‘s safety. TOP:
Medical Errors
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. Health care facilities must provide employees access to information about theproperties of particular chemicals and information for handling substances in a safe manner. Facilities do this by providing
.
ANS:
Safety data sheets (SDS) Health care agencies provide employees access to a safety data sheet (SDS) (previously called material safety data sheet) for each hazardous chemical in theworkplace (United States Department of Labor, 2015). An SDS form contains information about theproperties of theparticular chemical and how to handle thesubstance safely DIF: CognitiveLevel: Comprehension OBJ: Describe methods used to evaluate interventions designed to maintain or promote a patient‘s safety. TOP:
Material Safety Data Sheets (MSDS)
KEY: NursingProcess Step: Assessment
3.
MSC: NCLEX: Physiological Integrity
are themost common type of inpatient accident. ANS:
Falls
Falls are themost common adverse events that are reported in hospitalized older adults (Slade et al., 2017). theJoint Commission noted that an estimated 700,000 to 1,000,000 people fall in U.S. hospitals each year and that 30 to 35 percent of those patients sustain an injury as a result of thefall, and approximately 11,000 falls are fatal. DIF: CognitiveLevel: Comprehension OBJ: Discuss current evidence in thearea of fall prevention. KEY: NursingProcess Step: Assessment
4. A
TOP: Falls
MSC: NCLEX: Physiological Integrity
maintains immobilization of theextremities to protect thepatient from
accidental removal of a therapeutic device. ANS:
soft extremity restraint Soft Extremity (ankle or wrist) restraint: Restraint made of soft quilted material or sheepskin with foam padding. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly (not tightly) in place by Velcro strap. Appropriate for patients who are becoming increasingly agitated, can‘t be redirected with distraction, and keep trying to remove needed medical devices (Rose, 2015). Restraint designed to immobilize one or all extremities. DIF: CognitiveLevel: Comprehension OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Extremity Restraints
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
5. A thumb-less device used to restrain patients‘ hands to prevent them from dislodging invasive equipment, removing dressings, or scratching is known as a
.
ANS:
mitten restraint Mitten restraint: Thumbless mitten device restrains patient's hands. Prevents patient from dislodging or removing medical device, removing dressings, or scratching.
DIF: CognitiveLevel: Comprehension OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Mitten Restraints
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
6.
are sudden, abnormal, and excessive electrical discharges from thebrain that change motor or autonomic function, consciousness, or sensation. ANS:
Seizures A seizure is a sudden, abnormal, electrical discharge in thebrain causing alterations in behavior, sensation, or consciousness. DIF: CognitiveLevel: Knowledge OBJ: Describe nursing interventions for a patient who experiences generalized seizures. TOP: Seizures
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
7. Continuous seizure activity that lasts longer than 5 minutes is known as ANS:
status epilepticus Status epilepticus is a neurologic and medical emergency defined as 5 or more minutes of either continuous seizure activity or repetitive seizures with no intervening recovery of consciousness (Lesser et al., 2018). It is a medical emergency. DIF: CognitiveLevel: Knowledge OBJ: Describe nursing interventions for a patient who experiences generalized seizures. TOP: Status Epilepticus MSC: NCLEX: Physiological Integrity
Chapter 15: Disaster Preparedness
KEY: NursingProcess Step: Assessment
.
Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. In addition to theDepartment of Homeland Security, which of thefollowing agencies has a mission to ensure that thenation is well prepared to respond to an act of terrorism? a. National Terrorism Advisory System (NTAS) b. American Red Cross c. Centers for Disease Control & Prevention (CDC) d. Salvation Army ANS: C
In theevent of a biological, chemical, or radiation attack, theCDC strategic plan includes preparedness and prevention, detection and surveillance, diagnosis and characterization of agents, response, and communication. The National Terrorism Advisory System (NTAS) facilitates public awareness of disasters. thesystem provides government officials, first responders, and public citizens with information regarding thenature and degree of terrorist threat. The American Red Cross (2019) advocates preparedness and coordination of prompt, effective emergency efforts. This includes outreach to other agencies or groups through mutual aid agreements (e.g., willingness of an agency to provide shelter [school or church]), clothing (e.g., department store, Salvation Army), or care for thedeceased (funeral homes). DIF: CognitiveLevel: Comprehension OBJ: Discuss guidelines for patient care in theevent of mass casualty care. TOP: Centers for Disease Control and Prevention (CDC) KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. Personal protective equipment (PPE) is categorized by thelevel of safety provided. Standard work uniforms or work clothes offer what level of protection? a. Level A b. Level B c. Level C
d. Level D ANS: D
Level D—Standard work uniforms or work clothes are appropriate and used for nuisance contamination only. theusers must wear coveralls and chemical-resistant shoes; and, depending on thecontaminant, gloves, goggles, mask, face shield, and hard hats may also be worn. There is no respiratory protection. It is important to take standard precautions when using level D protection. Level A—Selected when thegreatest level of skin, respiratory, and eye protection is required. It provides maximum protection because it offers a self-contained breathing apparatus, total encapsulating chemical-protective suit, coveralls, undergarments, chemical-resistant boots and gloves, hard hat, and disposable protective suit worn over theencapsulating suit. Level B—Provides thehighest level of respiratory protection but lower level of skin protection. Used by trained responders, this PPE includes a self-contained breathing apparatus; hooded chemical-resistant suit; and face, boot, and glove protection. Level B protection also requires training and fitting. Level D—Standard work uniforms or work clothes are appropriate and used for nuisance contamination only. theusers must wear coveralls and chemical-resistant shoes; and, depending on thecontaminant, gloves, goggles, mask, face shield, and hard hats may also be worn. There is no respiratory protection. It is important to take standard precautions when using level D protection. DIF: CognitiveLevel: Comprehension OBJ: Identify actions to take in theevent of biological, chemical, and radiation exposure. TOP: Levels of Safety
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
3. The most recently labeled level of protection is BioPPE. theuse of BioPPE requires which of thefollowing items? a. Self-contained breathing apparatus b. Respiratory protection but less skin protection c. Chemically resistant boots and gloves d. Standard work clothes, contact and respiratory protective devices
ANS: D
The most recently labeled level of protection is BioPPE. BioPPE requires theuse of standard work clothes, along with contact and respiratory protection. Double gloving and an N95 mask or a better respirator is recommended. Level A protection provides maximum protection in that it offers a self-contained breathing apparatus, fully encapsulates theindividual, and includes chemically resistant boots and gloves. BioPPE protection is not adequate when caring for patients exposed to toxic chemicals; however, it provides adequate protection against radiological and biological agents. DIF: CognitiveLevel: Application OBJ: Identify actions to take in theevent of biological, chemical, and radiation exposure. TOP: BioPPE
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The nurse has arrived at thescene of a natural disaster and is assigned to care for four patients. To which patient should thenurse provide care first? a. Patient with a closed head injury with no changes in level of consciousness b. Patient with a 3-cm laceration to theforearm c. Patient who is breathing 8 times per minute d. Patient with a displaced wrist fracture ANS: C
Nursing care should be prioritized when multiple patients are cared for at once. ABCs (airway, breathing, and circulation) should always take precedence. thepatient who is breathing only 8 times per minute is in need of immediate nursing care. Triage, treat, and evacuate: Triage is theprocess of sorting individuals by theseriousness of their condition and thelikelihood of their survival DIF: CognitiveLevel: Analysis OBJ: Discuss guidelines for patient care in theevent of mass casualty care. TOP: Disaster Nursing MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Assessment
5. The patient is brought into theemergency department as part of a mass casualty incident (MCI). thepatient has white powder on his clothes, and it is suspected that thepatient has been exposed to anthrax. What should thenurse do first? a. Cut off thepatient‘s clothing and place it in a plastic bag. b. Have thepatient remove his sweater by pulling it over his head. c. Avoid using oxygen that could decrease thepatient‘s oxygen drive. d. Provide thepatient with appropriate antibiotics. ANS: A
If you suspect anthrax, have patient remove clothing and place in labeled plastic biohazard bag. CAUTION: Do not pull over patient's head; instead cut garments off. Instruct patient to shower thoroughly with soap and water. Administer oxygen therapy. Various biological agents (e.g., pulmonary anthrax) commonly cause respiratory symptoms that result in altered gas exchange. Administer appropriate antibiotics and/or antitoxins. Various biological agents are commonly treated with ciprofloxacin and/or doxycycline. biological agents are commonly treated with ciprofloxacin and/or doxycycline. DIF: CognitiveLevel: Application OBJ: Identify actions to take in theevent of biological, chemical, and radiation exposure. TOP: Anthrax
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
6. Which of thefollowing biological agent requires theuse of an antitoxin if exposure occurs? a. Anthrax b. Plague c. Botulism d. Typhoid ANS: C
Botulism requires supportive care and use of an antitoxin. Attack with various biological agents (e.g., anthrax, plague, and typhoidal tularemia) is commonly treated with ciprofloxacin and/or doxycycline. DIF: CognitiveLevel: Application OBJ: Identify actions to take in theevent of biological, chemical, and radiation exposure.
TOP: Botulism
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
7. If a patient is receiving radiation using gamma rays, thenurse would be watching for which of thefollowing? a. Severe pain during administration b. Development of an allergy to shellfish c. Severe burns or internal injury d. Confusion and lethargy ANS: C
Gamma rays pose thegreatest health risk because thewaves penetrate deeply, causing severe burns and internal injury. High levels of radiation exposure cause a person to develop acute radiation syndrome (ARS) with symptoms of nausea, vomiting, and diarrhea. Patients with iodine sensitivity need to avoid taking potassium iodide, thetreatment of choice for radioactive iodine exposure. DIF: CognitiveLevel: Analysis OBJ: Identify actions to take in theevent of biological, chemical, and radiation exposure. TOP: Gamma Rays
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
8. After a suspected radiological exposure, theinitial scan of thepatient‘s extremities is positive. What will be thenext step in this patient‘s care? a. Washing theskin with soap and water while taking care not to irritate or abrade theskin b. Removing clothing to eliminate 70% to 90% of thecontamination c. Isolating and covering up any skin that is positive for radiation using a plastic wrap d. Conducting a thorough survey of thepatient‘s entire body with theradiation sensing equipment ANS: D
A specially trained technician conducts a radiation survey of thepatient, initially scanning theface, hands, and feet with a radiation survey instrument. If meter results are positive, a thorough survey (5 to 8 minutes per person) is conducted. DIF: CognitiveLevel: Application OBJ: Identify actions to take in theevent of biological, chemical, and radiation exposure. TOP: Assessment of Patient
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
9. How is a disaster best defined? a. Any event or situation that results in multiple casualties and/or deaths b. A catastrophic and/or destructive event that disrupts normal functioning c. An industrial accident and unplanned release of nuclear waste d. An event that results in human casualties that overwhelm available health care resources ANS: B
A disaster is defined as a catastrophic and/or destructive event that disrupts normal functioning; it may include any anticipated or unexpected event whose effects lead to significant destruction and/or adverse consequences. Any event or situation that results in multiple casualties and/or deaths is called a mass casualty incident (MCI). An industrial accident with unplanned release of nuclear waste is classified as a technological disaster. A medical disaster is a catastrophic event that results in human casualties that overwhelm available health care resources. DIF: CognitiveLevel: Comprehension OBJ: Discuss thecharacteristics of different types of disasters. KEY: NursingProcess Step: Assessment
TOP: Disasters
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Which of thefollowing should make thenurse suspect a biological event? (Select all that apply.) a. Large numbers of ill people with unexplained similar symptoms
b. Unexplained deaths among young and healthy populations c. A patient population with symptoms suggestive of a common agent d. An unusual geographical pattern associated with thesymptoms ANS: A, B, D
You should suspect a biological event when large numbers of ill people present who have unexplained yet similar symptoms; when unexplained deaths occur, particularly among young and healthy populations; when an unusual pattern (e.g., geographical, season, and patient population) is associated with thesymptoms; when thepatient fails to respond to traditional therapy; and when a single patient presents with symptoms suggestive of an uncommon agent (e.g., anthrax, and smallpox). Once you suspect a biological event, notify incident command immediately. DIF: CognitiveLevel: Comprehension OBJ: Identify actions to take in theevent of biological, chemical, and radiation exposure. TOP: Bioterrorism KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. Why are children particularly vulnerable to environmental toxins? (Select all that apply.) a. They have stronger immune systems. b. They take in proportionally larger doses of toxins from food, water, and theair. c. Their organ systems are less able to remove toxins than adult organ systems. d. They have a greater number of years of life expectancy. ANS: B, C, D
Children are very vulnerable to theadverse effects of environmental chemicals and toxins because (1) pound for pound children take in larger doses of toxins through food, water, and air; (2) their organ systems are less mature and unable to remove some of thetoxins; and (3) their life expectancy is longer, and long-term effects of exposure to toxins is unknown (Hockenberry et al, 2019). DIF: CognitiveLevel: Comprehension OBJ: Discuss guidelines for patient care in theevent of mass casualty care. TOP: Psychological Status MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Assessment
3. The patient is admitted with exposure to an unknown chemical. His clothing appears to be grossly contaminated. What should thenurse do? (Select all that apply.) a. Avoid touching contaminated parts of clothing. b. Pull thepatient‘s tee shirt off over his head. c. Cut thepatient‘s clothes off. d. Wash thepatient with large amounts of soap and water. ANS: A, C, D
Remove all of thepatient‘s clothing, but do not pull it over thepatient‘s head; instead, cut garments off. Act quickly, and avoid touching contaminated parts of clothing as much as possible. Decontaminate thepatient using large amounts of soap and water to wash thepatient thoroughly. DIF: CognitiveLevel: Application OBJ: Discuss guidelines for patient care in theevent of mass casualty care. TOP: Decontamination
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
COMPLETION
1. The strategic plan of theCenters for Disease Control and Prevention (CDC) in theevent of a disaster first focuses on _
.
ANS:
preparedness In theevent of a biological, chemical, or radiation attack, theCDC strategic plan includes preparedness and prevention, detection and surveillance, diagnosis and characterization of agents, response, and communication. DIF: CognitiveLevel: Comprehension OBJ: Describe elements of theCDC‘s strategic plan for disasters. TOP: The Centers for Disease Control and Prevention (CDC)
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. In theevent of a mass casualty incident, part of theCenters for Disease Control & Prevention (CDC)‘s disaster preparedness program involves backup plans for maintaining public and intraagency/interagency
.
ANS:
communication Traditional modes of communication will likely be interrupted in theevent of a mass casualty incident (MCI); therefore, part of disaster preparedness involves backup plans for maintaining public and intraagency/interagency communication (e.g., use of two-way radios and satellite phones). DIF: CognitiveLevel: Comprehension OBJ: Describe elements of theCDC‘s strategic plan for disasters. TOP: The Centers for Disease Control and Prevention (CDC) KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. Releasing nuclear energy in an explosive manner as theresult of a nuclear chain reaction is known as a
.
ANS:
nuclear event A nuclear event involves a device that releases nuclear energy in an explosive manner as theresult of a nuclear chain reaction. DIF: CognitiveLevel: Knowledge OBJ: Identify actions to take in theevent of biological, chemical, and radiation exposure. TOP: Nuclear Event
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. It is recommended that every household prepares a
.
ANS:
disaster supply kit Assemble a disaster kit before disaster strikes. Every household should prepare a disaster supply kit that includes basic items (water, can opener, utility knife, food, first-aid kit, identification, etc.) but items unique to members of thehousehold, like hearing aid batteries or an extra pair of glasses. DIF: CognitiveLevel: Comprehension OBJ: Discuss thecharacteristics of different types of disasters. KEY: NursingProcess Step: Planning
5. An
TOP: Disaster Supply Kit
MSC: NCLEX: Physiological Integrity
provides a standard approach to managing emergencies in which
multiple agencies are involved. ANS:
incident command system An incident command system (ICS) is used by all disciplines to help respond to an emergency situation (FEMA, 2018). An incident command system (ICS), also referred to as theincident management system (IMS), provides a standard approach to managing emergencies in which multiple agencies are involved. DIF: CognitiveLevel: Comprehension OBJ: Identify actions to take in theevent of biological, chemical, and radiation exposure. TOP: Incident Command Systems
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
6.
is thesorting of individuals by theseriousness of their condition and thelikelihood of their survival.
ANS:
Triage Triage is thesorting of individuals by theseriousness of their condition and thelikelihood of their survival. DIF: CognitiveLevel: Knowledge OBJ: Discuss guidelines for patient care in theevent of mass casualty care. TOP: Triage
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
7. The terrorist act of releasing a biological agent into a specified environment is known as . ANS:
bioterrorism biological attack In a bioterrorism attack there is a deliberate release of viruses, bacteria, or other germs with theintent to cause illness or death (NIH, 2019). DIF: CognitiveLevel: Comprehension OBJ: Identify actions to take in theevent of biological, chemical, and radiation exposure. TOP: Bioterrorism KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
8. The patient is being treated for biological agent exposure and is resting in theemergency department bay. It is important that thenurse evaluate changes in airway, breathing, and circulation, as well as ANS:
psychological status
.
Observe for improved airway maintenance, breathing, circulation, level of consciousness, and neurological functioning. Evaluate vital signs, thecondition of thepatient‘s skin, and changes that suggest improvement or deterioration of psychological status. Ask thepatient, ―How do you feel right now?‖ Check level of orientation and ability to conduct conversation. This evaluates thepatient‘s response to emotional trauma. DIF: CognitiveLevel: Application OBJ: Describe psychosocial effects of disasters on patients.
TOP: Psychological Status
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
9. For safety reasons, rescue workers should be upwind and uphill from a toxic chemical disaster scene to avoid exposure. theexception is when
has been released, because it is
lighter than air. ANS:
cyanide gas For safety reasons, rescue workers should be upwind and uphill from a toxic chemical disaster scene to avoid exposure. theexception is when cyanide gas has been released. Cyanide is lighter than air and thus will travel uphill. It has theunique smell of bitter almonds. DIF: CognitiveLevel: Comprehension OBJ: Discuss guidelines for patient care in theevent of mass casualty care. TOP: Cyanide Gas KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
10. A patient has been exposed to a toxic chemical. thenurse‘s first priority is _ ANS:
decontamination
.
Suspect a toxic chemical event when large numbers of ill people present who have unexplained yet similar symptoms. theprimary objective for initial care is decontamination, theprocess used to remove harmful contaminants from thesurface of theskin. You achieve this by removing clothing, scrubbing theskin, and performing hydrolysis, a process of chemical dilution in which large volumes of water are used. DIF: CognitiveLevel: Comprehension OBJ: Discuss guidelines for patient care in theevent of mass casualty care. TOP: Decontamination
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
11. The dispersal of radioactive material via a ―dirty bomb‖ or by deliberate contamination of food supplies or water supplies is known as a
.
ANS:
radiological event A radiological event is thedispersal of radioactive material via a ―dirty bomb‖ or by deliberate contamination of food supplies or water supplies or over theterrain. DIF: CognitiveLevel: Knowledge OBJ: Identify actions to take in theevent of biological, chemical, and radiation exposure. TOP: Radiological Event
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
Chapter 16: Pain Management Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The patient is admitted with chronic pain. She states that nothing takes thepain away totally, but that ―Dilaudid works best.‖ thefact that thepatient calls themedication by name should alert thenurse to: a. suspect that thepatient is drug seeking.
b. expect that thepatient may need smaller doses than normal. c. assess thepatient‘s acceptable level of comfort. d. accept thefact that nothing will help this patient‘s pain. ANS: C
Complete a comprehensive pain assessments to understand each patient‘s unique pain experience in order to tailor interventions. Patients currently receiving opioids for chronic pain often require higher doses of analgesics to alleviate new or increased pain. This is tolerance, not an early sign of addiction. It is important to assess thepatient‘s acceptable level of comfort so that both you and thepatient are striving for thesame outcome. Some patients with prior pain conditions can alert thenurse to pain-relieving measures that were successful. Patients with chronic/persistent pain are often familiar with thenames and actions of medications, including opioid medications. This should not cause you to view thepatient negatively or with suspicion. Patients currently receiving opioids for chronic pain often require higher doses of analgesics to alleviate new pain. Do not accept that ―there is nothing that will help this patient‘s pain.‖ Learn theinstitutional policy for how to proceed in this situation. DIF: CognitiveLevel: Application
OBJ: Assess a patient‘s level of comfort.
TOP: Assessment of Comfort Level
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
2. The nurse frequently must assess a patient who is experiencing pain. When assessing theintensity of thepain, thenurse should: a. ask whether there are any precipitating factors. b. question thepatient about thelocation of thepain. c. offer thepatient a pain scale to objectify theinformation. d. use open-ended questions to find out about thesensation. ANS: C
An appropriate pain-assessment tool should be multidimensional to capture thecomplexity of patients‘ pain experience. An approach to pain-intensity assessment can utilize a numerical scale; however, additional questions should assess thepain experience and how it impacts function. Descriptive scales are an objective means of measuring pain intensity. Use a pain intensity scale appropriate to thepatient‘s age, developmental level, and comprehension, and ask thepatient to rate thepain. An appropriate pain rating scale is reliable, easily understood, and easy to use, and it reflects changes in pain intensity. Asking thepatient what precipitates thepain does not assess intensity, but rather assesses thepain pattern. Asking thepatient about thelocation of pain does not assess theintensity of thepatient‘s pain. To determine thequality of thepatient‘s pain, thenurse may ask open-ended questions to find out about thesensation experienced (e.g., ―Tell me what your pain feels like‖). This approach assists in identifying theunderlying pain mechanism (e.g., somatic or neuropathic pain), but it may not reveal intensity or changes in intensity. DIF: CognitiveLevel: Application
OBJ: Assess a patient‘s level of comfort.
TOP: Assessing Pain Intensity
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
3. The nurse who is caring for a patient postoperatively notes that he is expressing discomfort and is diaphoretic. Which of thefollowing interventions is most appropriate? a. Straighten thebed linens. b. Change thesaturated surgical dressing. c. Administer prescribed pain medications. d. Check for displaced equipment underneath thepatient. ANS: C
Prepare and administer appropriate pain-relieving medications (nonopioids, opioids, co-analgesic or multimodal combination) per health care provider‘s order.
Administer pain-relieving medications as ordered. Analgesics are thecornerstone of pain management. Smoothing wrinkles in bed linens may reduce pressure and irritation to theskin; however, pain-relieving medication should be given first. Changing a wet surgical dressing might not be needed if thepatient has received a wet-to-dry dressing as treatment, or if not changing thedressing will reduce irritation to theskin but will not address thediscomfort. Reposition underlying tubes, wires, or equipment that may apply pressure directly to dependent skin surfaces. Removing these stimuli may maximize theresponse to pain-relieving interventions such as medication, but pain-relieving medication should be administered first. DIF: CognitiveLevel: Application OBJ: Identify skills appropriate for relieving a patient‘s reported pain. TOP: Treatment of Pain
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The patient‘s family is concerned that thepatient may get too much pain medication after surgery and become addicted to themedication if he is placed on a patient-controlled analgesia (PCA) pump. They also voice concern about theeffectiveness of thePCA. thenurse should instruct thefamily and thepatient that: a. pain relief with thePCA pump is not as good as when thenurse provides it, but it does save on nursing time. b. pain relief is good when themedication peaks, but less so when thelevels drop, and that is when thepatient will know that he needs more. c. because thedevice provides medication as soon as thepatient needs it, he will probably use less of themedication. d. the patient will be kept in bed for several days after surgery to make sure it is safe to ambulate. ANS: C
Patient-controlled analgesia (PCA) is an interactive method of pain management that gives patients pain control through self-administration of analgesics.
Explain that device is programmed to deliver ordered type and dose of pain medication, lockout interval, and 1- to 4-hour dosage limits. Explain how lockout time prevents overdose. Relieves anxiety in patients who might be concerned about overdosing. Ensures safe, therapeutic drug administration. With appropriate dose intervals (e.g., 10 min), usually an appreciable analgesic effect and/or mild sedation is achieved before patient can access thenext dose; thus there is lower chance for oversedation and respiratory depression. The patient-controlled analgesia (PCA) has several advantages. It allows more constant serum levels of theopioid and, as a result, avoids thepeaks and troughs of a large bolus. An advantage of PCA is that when used postoperatively, fewer complications arise because earlier and easier ambulation occurs as a result of effective pain relief. DIF: CognitiveLevel: Comprehension
OBJ: Teach a patient to use a PCA device.
TOP: Patient-Controlled Analgesia (PCA) KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. The nurse caring for a patient who has a patient-controlled analgesia (PCA) knows that it: a. allows thefamily to participate in pain management for thepatient. b. prevents mistakes in medication administration. c. can be used by all hospitalized patients. d. provides a more constant level of medication. ANS: D
Patient-controlled analgesia (PCA) is an interactive method of pain management that gives patients pain control through self-administration of analgesics. Explain that device is programmed to deliver ordered type and dose of pain medication, lockout interval, and 1- to 4-hour dosage limits. Explain how lockout time prevents overdose. Relieves anxiety in patients who might be concerned about overdosing. Ensures safe, therapeutic drug administration. With appropriate dose intervals (e.g., 10 min), usually an appreciable analgesic effect and/or mild sedation is achieved before patient can access thenext dose; thus there is lower chance for oversedation and respiratory depression.
Potential concerns involving PCA use are pump failure, and operator errors. Patients may misunderstand how PCA therapy works, may mistake thePCA button for thenurse call button, or may have family members who operate thedemand button. Instruct thefamily not to push thetiming device for thepatient unless thepatient is unable to push thebutton himself, and thenurse has instructed thefamily to do so. Use of a PCA pump does not prevent mistakes. thepump may fail to deliver drug on demand, may have a faulty alarm or a low battery, or may lack free-flow protection. Operators may incorrectly program thedose, concentration, or rate. Not all patients are candidates for PCA. Assess thepatient‘s cognitive ability to determine theappropriateness of PCA pain management. DIF: CognitiveLevel: Comprehension
OBJ: Teach a patient to use a PCA device.
TOP: Patient-Controlled Analgesia (PCA) KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
6. When evaluating theeffects of patient-controlled analgesia (PCA), thenurse notes that thepatient is sedated and is difficult to arouse. What step should thenurse take next? a. Insert an airway. b. Turn patient to theside. c. Stop thePCA. d. Expect this as a patient outcome of thetherapy. ANS: C
If thepatient is sedated and is not readily arousable, stop thePCA. As long as thepatient has spontaneous respirations, instruct him or her to take deep breaths. Apply oxygen at 2 L via nasal cannula. Elevate thehead of thebed 30 degrees, unless contraindicated, to facilitate respirations. Heavy sedation is not an expected outcome of PCA therapy. Evaluate for thepresence of analgesic side effects. Maintain a slightly drowsy, easily aroused patient. DIF: CognitiveLevel: Application OBJ: Evaluate theeffectiveness of pain-management techniques. TOP: Patient-Controlled Analgesia (PCA) KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
7. The patient is scheduled for surgery late in theafternoon. His postoperative orders include patient-controlled analgesia (PCA) therapy. Which of thefollowing nursing interventions is appropriate to perform? a. Teach thepatient about PCA after thepatient comes out of recovery. b. Teach thepatient about PCA before surgery and before preoperative medication administration. c. Tell thepatient not to use PCA unless he can no longer tolerate thepain. d. Inform thepatient‘s family to watch him carefully and to depress thePCA administration button whenever they think he needs it. ANS: B
Instruct surgical patients preoperatively. Encourage thepatient to push thebutton on thetiming unit whenever he feels pain. Tell thepatient not to delay if he is experiencing pain. Pain is easier to prevent than to treat. Inform thepatient and family that thepatient cannot overdose with PCA if only thepatient pushes thebutton. thefamily should not push thebutton unless instructed to do so by thenurse. DIF: CognitiveLevel: Application
OBJ: Teach a patient to use a PCA device.
TOP: Patient-Controlled Analgesia (PCA) Teaching Consideration KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
8. While reviewing a patient‘s medication history, thenurse determines that intraspinal analgesia is contraindicated as a result of: a. previous spinal anesthesia. b. recent administration of anticoagulants. c. a history of cardiac problems. d. a diagnosis of advanced cancer. ANS: B
Recent anticoagulation may contraindicate theplacement of epidural catheter because of inability to apply pressure at insertion site and risk for bleeding.
Certain conditions may make epidural analgesia themethod of choice for pain control: following surgery, for patients with trauma or advanced cancer that is not responsive to other pain-management modalities, and those predisposed to cardiopulmonary complications because of a preexisting medical condition or surgery. Previous spinal anesthesia is not a contraindication for receiving subsequent spinal anesthesia. DIF: CognitiveLevel: Analysis OBJ: Monitor and manage thepatient who is receiving epidural analgesia. TOP: Intraspinal Analgesia
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
9. A nurse checks thecontinuous intravenous (IV) infusion for theintraspinal analgesia. theIV setup should be changed if: a. tubing with a Y-port is attached. b. an infusion pump is attached. c. the tubing connections are all taped. d. a diluted, preservative-free medication is used. ANS: A
Epidural infusion system between pump and patient should be considered closed, with no injection or Y ports. Epidural infusions should be labeled ―For Epidural Use Only.‖ Use tubing without Y-ports for continuous infusions. Use of tubing without Y-ports prevents accidental injection or infusion of another medication meant for vascular space into epidural space. Normal equipment used for intraspinal infusion includes an infusion pump and compatible tubing without Y-ports. Catheter and injection cap or infusion pump tubing should be securely taped and labeled. Closed, intact systems prevent entry of pathogens and disruption of theflow of medication. Medication should be prediluted, preservative-free opioid, or local anesthetic as prescribed by thephysician and prepared for use in an IV infusion pump (usually prepared by pharmacy). Preservatives may be toxic to nerve tissue. DIF: CognitiveLevel: Application OBJ: Monitor and manage thepatient who is receiving epidural analgesia. TOP: Intraspinal Analgesia
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
10. A nurse is evaluating theepidural catheter insertion site and suspects that theintraspinal catheter has punctured thedura when
noted.
a. clear drainage is b. bloody drainage is c. purulent drainage is d. redness, warmth, and swelling are ANS: A
Clear drainage may indicate cerebrospinal fluid (CSF) leaking from punctured dura. Bloody drainage may indicate that catheter entered blood vessel. Purulent drainage is sign of infection. Purulent drainage is sign of infection. DIF: CognitiveLevel: Analysis OBJ: Monitor and manage thepatient who is receiving epidural analgesia. TOP: Evaluating Epidural Site
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
11. The patient had knee-replacement surgery and has a local infusion pump to provide a local anesthetic to thesurgical site. thepatient puts on thecall light and complains that pain at thesite is more intense than it has ever been and is getting worse. thenurse checks thesite and finds that thedressing is damp but intact. theinfusion pump is pumping, and there is medication in thebag. themost probable cause of theproblem might be the: a. catheter may be clogged. b. pump may be releasing too much drug into thesite. c. catheter may be displaced. d. patient may be exaggerating thepain. ANS: C
Assess thesurgical dressing and thesite of catheter insertion. thedressing should be dry and intact. Determine whether thecatheter is properly placed. If thecatheter is clogged, infusion of medication will stop. Pain levels will increase but thedressing will be dry, and thepump should alarm. If thepump is releasing too much medication, thenurse should expect to see symptoms of local anesthetic adverse reaction. It is not thepatient‘s responsibility to convince thenurse that he has pain; it is thenurse‘s responsibility to believe thepatient. DIF: CognitiveLevel: Analysis OBJ: Monitor and manage thepatient who is receiving a local anesthetic infusion pump. TOP: Unexpected Outcomes
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
12. A nonpharmacological approach that thenurse may implement for patients who are experiencing pain that focuses on diverting thepatient‘s attention away from thepain sensation by promoting pleasurable and meaningful stimuli is: a. massage. b. heat/cold. c. guided imagery. d. distraction. ANS: D
Direct patient‘s attention away from pain by involving him or her in a distraction technique.
Distraction is a technique that diverts an individual‘s attention away from thepain sensation. By introducing meaningful stimuli, thenurse helps thepatient refocus attention. Distraction directs a patient‘s attention to something else and thus can reduce awareness of pain and even increase tolerance. A proper massage not only blocks theperception of pain impulses but also helps relax muscle tension and spasm that otherwise might increase pain. Massage hastens theelimination of wastes stored in muscles, improves oxygenation of tissues, and stimulates therelaxation response in thenervous system. Heat produces vasodilation, reduced blood viscosity, reduced muscle tension, and increased tissue metabolism. Heat helps relieve muscle spasms and joint stiffness. Cold produces vasoconstriction, reduced cell metabolism, and increased blood viscosity. Cold is effective for inflamed joints and muscles. thegoal of imagery is to have thepatient use one or several of thesenses to create an image of thedesired result. This image creates a positive psychophysiological response. Guided imagery can be used as a distraction technique. DIF: CognitiveLevel: Comprehension OBJ: Monitor and manage thepatient who is receiving nonpharmacological measures to relieve pain. TOP: Distraction
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
13. Offering thepatient a backrub before preparing for sleep can promote relaxation and comfort. An effective backrub takes: a. 1 to 2 minutes. b. 3 minutes c. 7 to 10 minutes. d. 11 to 15 minutes. ANS: C
ontinue massage pattern for 3 minutes. DIF: CognitiveLevel: Comprehension OBJ: Identify and discuss various nonpharmacological pain-relief measures. TOP: Massage: backrub MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
14. The patient is admitted for chronic pain. He states that morphine sulfate has been used to relieve his pain, but recently he has been needing to use more of themedication to relieve pain. This patient‘s plan of care will have to incorporate interventions to deal with which of thefollowing? a. Addiction b. Pseudoaddiction c. Drug tolerance d. Physical dependence ANS: C
Drug tolerance is defined as a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of thedrug‘s effects over time. Addiction: A primary, chronic disease of brain reward, motivation, memory and related neuro circuitry (Federation of State Medical Boards, 2017). Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. Addictive behaviors include one or more of thefollowing: impaired control over drug use, compulsive use, continued use despite harm, diminished recognition of problems related to one‘s behavior, and craving. Physical dependence: A state of adaptation that is manifested by a drug class–specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of an opioid, and/or administration of a drug that can act as an antagonist. DIF: CognitiveLevel: Analysis OBJ: Plan care on thebasis of a patient‘s history, including pain history, and physical assessment findings.
TOP: Terminology Related to Drug Dependency
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
15. Which of thefollowing patient conditions is categorized as a neurobiological disease? a. Physical dependence b. Addiction c. Pseudoaddiction d. Drug tolerance
ANS: B
Addiction: A primary, chronic disease of brain reward, motivation, memory and related neuro circuitry (Federation of State Medical Boards, 2017). Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. Addictive behaviors include one or more of thefollowing: impaired control over drug use, compulsive use, continued use despite harm, diminished recognition of problems related to one‘s behavior, and craving. Physical dependence: A state of adaptation that is manifested by a drug class–specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of an opioid, and/or administration of a drug that can act as an antagonist. Drug tolerance is defined as a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of thedrug‘s effects over time. DIF: CognitiveLevel: Analysis OBJ: Plan care on thebasis of a patient‘s history, including pain history, and physical assessment findings.
TOP: Terminology Related to Drug Dependency
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
16. Which of thefollowing statements about evaluating patients in pain is true? a. The best judge of theexistence of pain is thenurse. b. Visible signs always accompany pain. c. Patients often are hesitant to report pain. d. Nonpharmacological interventions are better than pain medications. ANS: C
Patients often are hesitant to report pain for fear of being labeled as complainers, hypochondriacs, or addicts. thepatient‘s self-report is themost reliable indicator of theexistence and intensity of pain. Even with severe pain, periods of physiological and behavioral adaptation occur, leading to periods of minimal or no observable signs of pain. Lack of pain expression does not necessarily mean lack of pain. Nonpharmacological interventions are synergistic with medications, but are not a substitute for pharmacological management of pain.
DIF: CognitiveLevel: Comprehension
OBJ: Assess a patient‘s level of comfort.
TOP: Misconceptions of Pain
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Which of thefollowing are characteristics of cancer pain? (Select all that apply.) a. It may be acute. b. It may be chronic. c. It usually is related to tumor recurrence or treatment. d. It often is of less intensity than thepatient reports. ANS: A, B, C
Cancer pain may be acute, chronic, or intermittent, and it usually is related to tumor recurrence or treatment. thepatient is theonly one who knows whether pain is present and what theexperience is like. It is not thepatient‘s responsibility to convince thenurse that he has pain; it is thenurse‘s responsibility to believe thepatient. DIF: CognitiveLevel: Comprehension TOP: Cancer Pain
OBJ: Assess a patient‘s level of pain.
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The patient has morphine sulfate ordered for pain every 4 hours ―prn.‖ thepatient complains of severe pain and usually requests more morphine an hour before it is due. thenurse should: (Select all that apply.) a. Request a ―placebo order‖ from thephysician. b. Offer thepatient medication ―around theclock‖ instead of ―prn.‖ c. Offer thepatient massage between medication doses. d. Offer thepatient a nonopioid medication between morphine doses if ordered. ANS: B, C, D
Some patients exhibit drug-seeking behaviors when in fact they are seeking pain relief. Occasionally, a physician will order a placebo to discredit a patient‘s report of pain. This is unethical and should be avoided. Timely administration before a patient‘s pain becomes severe is crucial to ensure optimal relief. Pain is easier to prevent than to treat. In most circumstances, administration of pharmacological agents ―around-the-clock‖ rather than on an ―as-needed‖ (prn) basis is preferable. Often a combination of nonopioids and opioids is effective in managing pain. Using an integrated approach that considers both pharmacological and nonpharmacological therapies in managing pain is recommended. DIF: CognitiveLevel: Application
OBJ: Assess a patient‘s level of pain.
TOP: Pain Treatment Strategies
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. The patient voices concern to thenurse regarding his patient-controlled analgesia (PCA) pump. He states that he is afraid of getting an overdose if he pushes thebutton too many times. thenurse reassures thepatient that: (Select all that apply.) a. there is a time delay (lockout) between patient doses. b. there is a maximum dose thepatient can receive. c. the patient has a right to be concerned and needs to be careful. d. the patient could be put on a continuous infusion instead, because it is safer. ANS: A, B
PCA prevents overdosing by interposing a preprogrammed delay time or ―lockout‖ (usually 6 to 16 minutes) between patient-initiated doses. In addition, theprescriber may limit thetotal amount of opioid that thepatient may receive in 1 to 4 hours (Pasero, 1999). Use basal (continuous) infusions cautiously because studies have not shown superior analgesic benefit. Continuous infusion increases therisk for opioid overdose. DIF: CognitiveLevel: Comprehension TOP: Patient-Controlled Analgesia (PCA) KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
OBJ: Teach a patient to use a PCA device.
4. The patient states that thepatient-controlled analgesia (PCA) is not controlling his pain. thenurse checks theinfusion setup and IV site and then evaluates thepatient‘s ability to use thesystem. All looks in order. thenurse should notify thephysician to: (Select all that apply.) a. report suspected drug-seeking behavior. b. possibly change thedrug being used. c. adjust thedosage of thedrug being used. d. request placebo medication to evaluate true pain. ANS: B, C
Instruct thepatient to check with thenurse or physician with questions and concerns, or if medication is not controlling thepain. thedrug may have to be changed, or thedosage may need to be adjusted. DIF: CognitiveLevel: Application
OBJ: Teach a patient to use a PCA device.
TOP: Patient-Controlled Analgesia (PCA) KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. Drugs administered in theepidural space spread by: (Select all that apply.) a. diffusion through thedura mater. b. transport through blood vessels. c. absorption by fat. d. absorption through muscle. ANS: A, B, C
A drug administered in theepidural space spreads (1) by diffusion through thedura mater into thecerebrospinal fluid (CSF), where it acts directly on receptors in thedorsal horn of thespinal cord; (2) via blood vessels in theepidural space for systemic delivery; and/or (3) by means of absorption by fat in theepidural space, creating a depot where thedrug is released slowly into thesystemic circulation. DIF: CognitiveLevel: Comprehension OBJ: Monitor and manage thepatient who is receiving epidural analgesia. TOP: Epidural Space MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Assessment
6. Pain is experienced differently by different people, because pain perception is based on which of thefollowing? (Select all that apply.) a. Past pain experiences b. Personal values c. Cultural expectations d. Emotions ANS: A, B, C, D
Because higher centers in thebrain influence perception greatly, thepain experience is a product of a person‘s past pain experiences, values, cultural expectations, and emotions. DIF: CognitiveLevel: Comprehension OBJ: Monitor and manage thepatient who is receiving nonpharmacological measures to relieve pain. TOP: Pain Perception
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
1.
has an identifiable cause and rapid onset and generally disappears with healing. ANS:
Acute pain Acute pain or transient pain has an identifiable cause, has a rapid onset, varies in intensity, is of short duration, and generally disappears with healing. DIF: CognitiveLevel: Knowledge TOP: Acute Pain
OBJ: Assess a patient‘s level of pain.
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. Pain that extends beyond theperiod of healing and often lacks an identified pathology is known as
.
ANS:
chronic pain Chronic pain or persistent pain extends beyond theperiod of healing, often lacks identified pathology, rarely has autonomic signs, does not provide a protective function, disrupts sleep and activities of daily living, degrades thehealth and function of an individual, and may be cancer or noncancer/nonmalignant in origin. DIF: CognitiveLevel: Knowledge
OBJ: Assess a patient‘s level of pain.
TOP: Chronic Pain
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3.
is an interactive method of pain management that permits patient control over pain through self-administration of analgesics. ANS:
Patient-controlled analgesia (PCA) Patient-controlled analgesia Patient-controlled analgesia (PCA) is an interactive method of pain management that permits patient control over pain through self-administration of analgesics. DIF: CognitiveLevel: Knowledge OBJ: Describe delivery of medication through a patient-controlled analgesia (PCA) device. TOP: Patient-Controlled Analgesia (PCA) KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
4. The
is a potential space between thevertebral bones and thedura mater,
theoutermost meninges covering thebrain and spinal cord. ANS:
epidural space
The epidural space is a potential space between thevertebral bones and thedura mater, theoutermost meninges covering thebrain and spinal cord. DIF: CognitiveLevel: Knowledge OBJ: Monitor and manage thepatient who is receiving epidural analgesia. TOP: Epidural Space
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
5. Catheter migration into the
can produce dangerously high medication levels.
Only physicians and nurse anesthetists administer drugs in this space. ANS:
subarachnoid space Only physicians and nurse anesthetists administer spinal drugs due to theincreased risk associated with them. DIF: CognitiveLevel: Knowledge OBJ: Monitor and manage thepatient who is receiving epidural analgesia. TOP: Epidural Space
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
6. The application of touch and movement to muscles, tendons, and ligaments without manipulation of thejoints is called
.
ANS:
massage A gentle massage, a form of cutaneous stimulation, is theapplication of touch and movement to muscles, tendons, and ligaments without manipulation of thejoints. DIF: CognitiveLevel: Comprehension OBJ: Monitor and manage thepatient who is receiving nonpharmacological measures to relieve pain. TOP: Massage
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
7.
draws on internal experiences of memories, dreams, fantasies, and visions; explores theinner world of experience; protects theprivacy of thepatient; and fosters theimagination. ANS:
Guided imagery Guided imagery, a form of distraction, is a creative sensory experience that effectively reduces pain perception and minimizes reaction to pain. It draws on internal experiences of memories, dreams, fantasies, and visions; explores theinner world of experience; protects theprivacy of thepatient; and fosters theimagination. thegoal of imagery is to have thepatient use one or several of thesenses to create an image of a desired result. DIF: CognitiveLevel: Comprehension OBJ: Monitor and manage thepatient who is receiving nonpharmacological measures to relieve pain. TOP: Guided Imagery
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
8. Massaging upward and outward from thevertebral column and back again is known as . ANS:
effleurage Effleurage is massaging upward and outward from thevertebral column and back again. Gliding strokes, used without manipulation of deep muscles, smooth and extend muscles, increase nutrient absorption, and improve lymphatic and venous circulation. DIF: CognitiveLevel: Comprehension OBJ: Identify and discuss various nonpharmacological pain-relief measures. TOP: Effleurage
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
9.
is a massage technique used on tense muscles to ―knead‖ muscles, promote relaxation, and stimulate local circulation. ANS:
Pétrissage Pétrissage is used on tense muscle groups to ―knead‖ muscles, promote relaxation, and stimulate local circulation. DIF: CognitiveLevel: Comprehension OBJ: Identify and discuss various nonpharmacological pain-relief measures. TOP: Pétrissage
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
Chapter 17: End-of-Life Care Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The patient has a history of terminal cancer but is being admitted for treatment of a pressure injury. thepatient‘s wife has been caring for him at home and refuses to discuss admission to a nursing home. thewife looks extremely tired and is near thepoint of exhaustion. What could thenurse suggest? a. A consult for hospice care b. Continuing with theplan of care as is c. That thedoctor orders thepatient into a nursing home d. That thewife stays away while thepatient is hospitalized ANS: A
Hospice benefits include respite for family caregivers. Palliative and hospice care place a primary focus on thepatient‘s values, quality of life, and care preferences. DIF: CognitiveLevel: Application
OBJ: Describe hospice care.
TOP: Respite Care KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
2. Grief that occurs before an actual loss or death and involves gradual disengagement from what is being lost is known as which type of grief? a. Anticipatory b. Complicated c. Uncomplicated d. Normal ANS: A
Grief that occurs before an actual loss or death and involved gradual disengagement from what is being lost is anticipatory grief. Normal or uncomplicated grief is evidenced by feelings, behaviors, and reactions associated with loss such as sadness, anger, crying, resentment, and loneliness. Complicated grief occurs when a person experiences distress related to theloss. DIF: CognitiveLevel: Comprehension TOP: Loss
OBJ: Discuss principles of palliative care.
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
3. The nurse recognizes that anticipatory grieving can be most beneficial for a patient or family because it can: a. be done in a private setting. b. be discussed with other individuals. c. promote separation of theill patient from thefamily. d. allow time for theprocess of grief. ANS: D
Anticipatory grief allows for a gradual disengagement from loss. For example, if a dying process is lengthy, thepatient and family caregiver prepare for death before it occurs and sometimes, but not always, display fewer common grief responses at thetime of death.
The benefit of anticipatory grief is that it allows for a gradual disengagement from theloss. Anticipatory grief may help people move through thestages of grief, allowing time to grieve in private, to discuss theanticipated loss with others, and then to ―let go‖ of theloved one. DIF: CognitiveLevel: Comprehension OBJ: Identify thenurse‘s role in assisting patients and families in grief and at theend of life. TOP: Grief
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. The nurse is preparing to assist thepatient at theend stage of her life. To provide comfort for thepatient in response to anticipated symptom development, thenurse plans to: a. decrease thepatient‘s fluid intake. b. limit theuse of pain medication. c. provide larger meals with more seasoning. d. determine patient wishes and select appropriate therapies. ANS: D
Help patient achieve short-term goals (e.g., symptom relief, task completion, resolution of relational problems). Helping patients identify and meet their personal goals contributes to their quality of life. Use basic knowledge of grief responses to support patients and their families and to address other common psychosocial and spiritual symptoms at theend of life. Have thepatient identify what she wants to accomplish, and use strategies to conserve energy for meeting those goals. This provides thepatient with a sense of well-being and purpose to meet important personal goals. Decreasing thepatient‘s fluid intake may make theterminally ill patient more prone to dehydration and constipation. thenurse should take measures to help maintain oral intake, such as administering antiemetics, applying topical analgesics to oral lesions, and offering ice chips. theuse of analgesics should not be limited. Controlling theterminally ill patient‘s level of pain is a primary concern in promoting comfort. Nausea, vomiting, and anorexia may increase theterminally ill patient‘s likelihood of inadequate nutrition. thenurse should serve smaller portions and bland foods, which may be more palatable. DIF: CognitiveLevel: Analysis
OBJ: Identify thenurse‘s role in assisting patients and families in grief and at theend of life. TOP: Caring for theDying Patient
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
5. A nurse-initiated or independent activity for promotion of respiratory function in a terminally ill patient is to: a. limit PO fluid intake. b. position thepatient in semi-Fowler‘s or Fowler‘s position. c. reduce narcotic analgesic use. d. administer bronchodilators. ANS: B
Position thepatient in semi-Fowler‘s or Fowler‘s position. This promotes maximal ventilation, lung expansion, and drainage of secretions. Limiting fluids may not promote respiratory function, and unless a patient is on a fluid-restricted diet, thenurse should not do so. Reducing narcotic analgesic use is not a nurse-initiated activity to promote respiratory function. Respiratory rate should be assessed before narcotics are administered, to prevent further respiratory depression. Management of air hunger involves judicious administration of morphine and anxiolytics for relief of respiratory distress. theadministration of bronchodilators would require a physician‘s order. It is not an independent nursing activity. DIF: CognitiveLevel: Application OBJ: Identify thenurse‘s role in assisting patients and families in grief and at theend of life. TOP: Caring for theDying Patient
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
6. When caring for a patient who is an appropriate candidate for organ or tissue donation, thenurse knows that requests for donation are: a. required by state law. b. the total responsibility of thesurvivors. c. a possible inclusion in theadvance directive. d. made only by thephysician. ANS: C
Two legal considerations arise at thetime of death. First, the1986 Omnibus Budget Reconciliation Act (OBRA) legally requires that a patient's survivors be made aware of theoption of organ and tissue donation. In most states citizens can sign theback of their driver's license if they wish to be an organ or tissue donor. However, a family member still usually gives consent for donation at thetime of death. Patients may indicate their wish to donate organs and tissue in an advance directive. A patient‘s choice regarding organ and tissue donation can be included in an advance directive. the1986 Omnibus Budget Reconciliation Act (OBRA) requires that a patient‘s significant others be offered theoption of organ and tissue donation; however, organ donation is voluntary. It is important for people to keep family members informed of their wishes regarding organ donation. Because of thesensitive nature of making requests for organ donation, professionals educated in organ procurement often assume that responsibility. They inform family members of their options for donation, provide information about costs (no cost to thefamily), and inform thefamily that donation does not delay funeral arrangements. DIF: CognitiveLevel: Application OBJ: Discuss thenurse‘s role in facilitating autopsy and organ and tissue donation requests. TOP: Organ Donation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
7. The patient is on a ventilator and has a heartbeat but has been declared ―brain dead.‖ thefamily has agreed to organ donation. thenurse realizes that which of thefollowing organ donations would require that thepatient be left on life support? a. Eyes b. Bone c. Kidney d. Skin ANS: C
In thecase of vital organ donation (e.g., heart, lungs, liver, pancreas, and kidneys), thepatient must remain on life support until theorgans are removed surgically. Tissues such as eyes, bone, and skin are commonly retrieved from deceased patients who are not on life support.
DIF: CognitiveLevel: Application OBJ: Discuss thenurse‘s role in facilitating autopsy and organ and tissue donation requests. TOP: Organ Donation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
8. An appropriate technique for thenurse to implement when caring for a patient‘s body after death is to: a. remove thepatient‘s identification band and put a new gown on thepatient. b. cover thepatient with a sheet and transfer him or her to themorgue. c. inquire about particular cultural or spiritual practices. d. remove tubes and lines if thepatient is to be autopsied. ANS: C
At thetime of death nurses provide postmortem care (e.g., care of thebody after death) in a dignified manner, consistent with a patient's religious and cultural beliefs. Respect theindividuality of thepatient and family and support their right to have cultural or religious values and beliefs upheld. Identify and tag thebody, leaving identification on thebody as directed by agency policy to ensure proper identification of thebody for delivery to themorgue or mortuary. After viewing, remove linens and gown, per agency policy. Place thebody in a shroud provided by theagency. theshroud protects from injury to theskin, avoids exposure of thebody, and provides a barrier against potentially contaminated body fluids. Removal of tubes and lines is contraindicated if an autopsy is planned. DIF: CognitiveLevel: Application
OBJ: Describe postmortem care.
TOP: Postmortem Care
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
9. After thedeath of a patient and before other nursing interventions are implemented, thenurse should: a. place thepatient in a supine position and elevate thehead of thebed 30 degrees. b. wait an hour to prepare thepatient for viewing. c. place thepatient in a side-lying position to allow drainage. d. exclude thefamily while thebody is being prepared.
ANS: A
Position thepatient on their back using theappropriate equipment, as per agency policy. It is important to straighten thelimbs before rigor mortis begins. Position patient supine in bed, arms at side, in a private room if possible. Immediately after death and before other activities are begun, place thebody in supine position, and elevate thehead of thebed 30 degrees to decrease rigor mortis. Ask family members if they have requests for preparation or viewing of thebody (such as position of thebody, special clothing, and shaving). Determine whether they wish to be present or assist with care of thebody. This provides closure for those who wish to assist with body preparation. DIF: CognitiveLevel: Application
OBJ: Describe postmortem care.
TOP: Postmortem Care
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
10. Before allowing thefamily of a deceased patient to view thebody, thenurse should: a. insert thepatient‘s dentures. b. lower thehead of thebed. c. fold thearms and hands over thechest. d. leave all of theold dressings and tape in place. ANS: A
If theperson wore dentures, reinsert them. If themouth fails to close, and if it is culturally appropriate to close themouth, place a rolled-up towel under thechin. Dentures maintain thepatient‘s natural facial expression. Place a small pillow or a folded towel under thehead. This prevents pooling of blood in theface and subsequent discoloration. Avoid placing one hand on top of theother. Placing one hand on top of theother can lead to discoloration of theskin. Remove soiled dressings and replace with clean gauze dressings. Use paper tape. Paper tape minimizes skin trauma. Changing dressings helps to control odors caused by microorganisms and creates a more acceptable appearance. DIF: CognitiveLevel: Application
OBJ: Describe postmortem care.
TOP: Postmortem Care
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
11. A new staff member is working with a patient who is dying. A nurse evaluates that this new employee requires additional teaching when he or she is observed: a. limiting thefamily‘s visiting hours. b. staying with thepatient and family as much as possible. c. finding a quiet place for family members to gather. d. asking thefamily if they would like to help with preparing thebody. ANS: A
Allow family time alone with body and encourage them to say goodbye with religious rituals and in a culturally appropriate manner. Some families want time to sit quietly with thebody, console each other, and share memories (NIA, 2017). Some cultural practices include maintaining silence at thetime of death; whereas others express grief with intense emotional displays, loud wailing, or ―falling out.‖ Do not rush any grieving process. Compassionate care provides family members with meaningful experience during early phase of grief. Ensure privacy and a safe environment. Provide chair at bedside for family member who might collapse. Some cultures require silence at thetime of death; others express grief with loud wailing, ―falling out,‖ or hysteria. Do not rush any grieving process. Give family members and friends a private place to gather. Allow them time to ask questions. This creates a safe environment for thegrieving family. Questions provide information about how they are coping with loss and their needs. Ask family members if they have requests for preparation or viewing of thebody (such as position of thebody, special clothing, or shaving). Determine whether they wish to be present or assist with care of thebody. This may provide closure for those who wish to assist with body preparation. DIF: CognitiveLevel: Application
OBJ: Describe postmortem care.
TOP: Postmortem Care
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient was a practicing Hindu when he died. Knowing this, thenurse realizes that: a. the body should be covered with a cotton sheet.
b. anointing of thesick is performed even after death. c. family members often prefer to wash thebody after death. d. the body should be buried within 24 hours. ANS: C
With Hinduism, family members prefer to wash thebody after death and are present to chant, pray, and use incense. In Buddhism, when theperson has died, thebody should be covered with a cotton sheet. Others should not touch thebody, and themouth and eyes of thedeceased are left open. Christians in theRoman Catholic tradition often request sacraments of penance and anointing of theSick and Holy Communion at theend of life. In Orthodox Judaism, a family member remains with thebody until burial, which takes place within 24 hours, not on theSabbath. DIF: CognitiveLevel: Application
OBJ: Describe postmortem care.
TOP: Postmortem Care
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
13. For a patient in thefinal stages of dying, a nurse expects to: a. keep thepatient‘s room cool. b. avoid catheterizing thepatient. c. elevate thehead of thebed as tolerated. d. encourage thepatient to eat and drink more. ANS: C
Elevate head to facilitate postural drainage. Turn from side to side to mobilize and drain secretions. Suction only if necessary. Elevate head to facilitate postural drainage. Turn from side to side to mobilize and drain secretions. Suction only if necessary. Coolness, color, and temperature change in hands, arms, feet, and legs; mottling of legs; perspiration Place socks on feet. Cover with light blanket. Incontinence of urine and/or bowel Change bedding as appropriate. Use bed pads; try not to use indwelling catheters.
Decreased intake of food and fluids, nausea. Blood shunted away from gastrointestinal (GI) tract, causing decreased GI motility and anorexia; ketosis. Do not force patient to eat or drink; give ice chips or popsicles if desired. Provide mouth care.
Poor circulation of body fluids, immobilization, and inability to expectorate secretions cause rattles and bubbling. Elevate thehead with a pillow or raise thehead of thebed; gently turn thehead to theside to drain secretions. Coolness, color, and temperature change in thehands, arms, legs, and feet. Place socks on thefeet. Cover with a light cotton blanket. Keep warm blankets on thepatient. Decreased muscle tone and consciousness may lead to incontinence of urine and/or bowel. Change bedding as appropriate. Use an indwelling catheter for patient comfort. Do not force thepatient to eat or drink; give ice chips, soft drinks, or juice, as possible. Provide mouth care. DIF: CognitiveLevel: Application OBJ: Identify thenurse‘s role in assisting patients and families in grief and at theend of life. TOP: Physical Signs and Symptoms in theFinal Stages of Dying KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Hospice care can be provided in which of thefollowing settings? (Select all that apply.) a. Home b. Freestanding hospice facilities c. Extended care facilities d. Acute care facilities ANS: A, B, C, D
Because hospice is a philosophy of care, not necessarily a place, theservices are sometimes provided at home, in freestanding hospice facilities, or in nursing home, extended care, or acute care settings. DIF: CognitiveLevel: Knowledge
OBJ: Describe hospice care.
TOP: Hospice
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. Hospice benefits include which of thefollowing? (Select all that apply.) a. Respite for family caregivers b. Hospitalization for acute symptom management c. Emotional and psychological support d. Financial assistance and funeral arrangement ANS: A, B, C
Hospice benefits include respite for family caregivers, limited hospitalization for acute symptom management, and bereavement care after death. Hospice does not provide financial assistance or funeral arrangements. DIF: CognitiveLevel: Knowledge TOP: Hospice
OBJ: Describe hospice care.
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
1. The World Health Organization (2002) defines
as an ―approach that improves
thequality of life of individuals and their families facing life-threatening illness, through theprevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other physical, psychological, and spiritual problems.‖ ANS:
palliative care The World Health Organization (2002) defines palliative care as an ―approach that improves thequality of life of individuals and their families facing life-threatening illness, through theprevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other physical, psychological, and spiritual problems.‖ DIF: CognitiveLevel: Knowledge
OBJ: Discuss principles of palliative care.
TOP: Palliative Care
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2.
helps people live as well as possible through thedying process. ANS:
Hospice Hospice, an interdisciplinary, patient- and family-centered program of total palliative care, helps people live as well as possible through thedying process. DIF: CognitiveLevel: Knowledge TOP: Hospice
OBJ: Describe hospice care.
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3.
specify medical interventions that thepatient does not want in certain situations, such as mechanical ventilation, and are used to communicate thecare a patient wants, for example, pain relief to thefullest extent possible. ANS:
Advance directives Advance directives are legal document that explains how patients want medical decisions about them to be made if they cannot make thedecisions themselves. An advance directive lets thehealth care team and family caregivers know what kind of health care patients want, or who patients want to make decisions when they cannot. An advance directive also helps patients think ahead of time about thekind of care they want. Adults in consultation with thehealth care team may consent to a ―do not resuscitate‖ (DNR) status verbally or in writing. Proper patient identification, especially in communicating a patient‘s DNR or CPR status, ensures that caregivers will not initiate unwanted and unhelpful medical interventions. Know themethods of your agency for designating a patient‘s resuscitation status. DIF: CognitiveLevel: Comprehension
OBJ: Describe hospice care.
TOP: Advance Directives
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
4. Nurses provide
that is defined as care of thebody after death in a manner
consistent with thepatient‘s religious and cultural beliefs. ANS:
postmortem care Nurses provide postmortem care that is defined as care of thebody after death in a manner consistent with thepatient‘s religious and cultural beliefs. DIF: CognitiveLevel: Comprehension
OBJ: Describe postmortem care.
TOP: Postmortem Care
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
5.
grief (symptoms lasting longer than 6 months) occurs when a person experiences significant distress related to theloss. ANS:
Complicated Criteria for a person experiencing complicated grief may include inability to accept thedeath of a loved one, anger, depression, or inability to maintain social relationships and intense longing for thedeceased. DIF: CognitiveLevel: Comprehension TOP: Loss
OBJ: Discuss principles of palliative care.
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
6. The irreversible absence of all brain function is termed ANS:
brain death
.
Family members often need help understanding what ―brain death,‖ theirreversible absence of all brain function (including thebrainstem), means for theperson who has died. DIF: CognitiveLevel: Comprehension OBJ: Discuss thenurse‘s role in facilitating autopsy and organ and tissue donation requests. TOP: Brain Death
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
7. An
is thesurgical dissection of a body after death.
ANS:
autopsy An autopsy, thesurgical dissection of a body after death, helps determine theexact cause and circumstances of a death, discovers thepathway of a disease, or provides data for research purposes. DIF: CognitiveLevel: Comprehension OBJ: Discuss thenurse‘s role in facilitating autopsy and organ and tissue donation requests. TOP: Autopsy
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
8. The patient was brought into theemergency department with a cardiac arrest after suffering multiple gunshot wounds. thepatient did not survive even after multiple attempts at resuscitation. thenurse is preparing thebody for transport to themorgue by completing hospital procedures for ANS:
autopsy
.
An autopsy is not performed in every death. State laws determine when autopsies are required, but they usually are performed in circumstances of unusual death (e.g., violent trauma, unexpected death in thehome) and when death occurs within 24 hours of hospital admission. DIF: CognitiveLevel: Application OBJ: Discuss thenurse‘s role in facilitating autopsy and organ and tissue donation requests. TOP: Autopsy
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
Chapter 18: Personal Hygiene and Bed Making Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The nurse is aware that normal flora that does not cause disease but does prevent disease-causing microorganisms from reproducing is known as: a. sebum. b. the epidermis. c. resident bacteria. d. the dermis. ANS: C
Bacteria reside on theskin‘s outer surface. Resident bacteria constitute normal flora that does not cause disease but does prevent disease-causing microorganisms from reproducing. Sebum, secreted from hair follicles from sebaceous glands, provides an acidic coating. This acid coating protects theepidermis against penetration from chemicals and microorganisms. It also minimizes loss of water and plasma proteins. It is not alive, however, and is not considered flora. theepidermis, or outer skin layer, is thefirst line of defense from external injury and infection. It contains several thin layers of cells undergoing different stages of maturation. Resident bacteria live on its surface and protect it. Three primary layers make up theskin: theepidermis, thedermis, and subcutaneous tissue. thedermis lies underneath theepidermis and is not considered ―flora.‖
DIF: CognitiveLevel: Comprehension OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Resident Bacteria
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. In relation to hygiene and theacute care setting, thenurse knows that which of thefollowing statements is true? a. The disposable bath is a less desirable form of bathing than thetraditional basin bath. b. The disposable bath is a more desirable form of bathing than thetraditional basin bath. c. The disposable bath is more desirable for patients who can bathe independently. d. The disposable bath is not an acceptable form of bathing in theacute care setting. ANS: B
The use of disposable washcloths impregnated with an antiseptic solution such as chlorhexidine gluconate (CHG) is more common now in acute care hospitals, especially critical care settings. CHG replaces soap and water baths. CHG cloths clean and remove bacteria, and theantiseptic binds to theskin for persistent antibacterial activity lasting 24 hours. DIF: CognitiveLevel: Analysis OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: The Disposable Bath
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
3. The nurse is caring for a ventilated patient in theICU who has just undergone coronary artery bypass. thenurse is concerned that thepatient may be at risk for ventilator-acquired pneumonia (VAP). What step will she take to minimize this risk? a. Not provide oral hygiene because this may cause bacterial contamination of theairway. b. Be careful not to use chlorhexidine in oral care because it provides a medium for bacterial growth. c. Not use chlorhexidine in oral care because it enhances therate at which VAP develops.
d. Include theuse of a chlorhexidine rinse as part of oral hygiene to delay thedevelopment of VAP. ANS: D
The use of a chlorhexidine gluconate (CHG) oral hygiene protocol as part of daily oral care reduces theincidence of VAP Special oral care is needed for theunconscious or debilitated patient because they are more susceptible to infection due to thechange in thenormal flora of theoral cavity, increased plaque formation from thedryness of themouth, and decreased salivation. The critically ill patient with an artificial airway and who is on mechanical ventilation is at risk for ventilator-associated pneumonia (VAP). Once intubated, theartificial airway causes a bypass of normal airway defenses, which also causes a rapid change in thenormal oral flora.). Some patients require mouth care as often as every 1 to 2 hours until themucosa returns to normal. Guidelines for oral care in ventilator patients and those who need assistance with oral hygiene often include theuse of a chlorhexidine rinse as a part of oral hygiene. Chlorhexidine early in thepostintubation period may help delay theonset or development of VAP. Presently, chlorhexidine is recommended during thepostoperative period for patients undergoing cardiac surgery. Ventilator-associated pneumonia results from thecolonization of bacteria in theoral pharynx. These microorganisms then migrate from themouth into thelungs. Dental plaque is also a reservoir for microorganisms causing VAP. Because of this evidence, guidelines for oral care in ventilator patients and those who need assistance with oral hygiene often include theuse of a chlorhexidine rinse as a part of oral hygiene. DIF: CognitiveLevel: Application OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Chlorhexidine
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The nurse plans to give thepatient a therapeutic bath. Which of thefollowing is considered therapeutic? a. Bed bath b. Sponge bath at thesink
c. Sitz bath d. Bag bath ANS: C
The sitz bath cleanses and reduces pain and inflammation in perineal and anal areas. It is used for a patient who has undergone rectal or perineal surgery or childbirth or has local irritation from hemorrhoids or fissures. There are two categories of baths: cleansing and therapeutic. Cleansing baths include thebed bath, tub bath, sponge bath at thesink, shower, and bag bath. DIF: CognitiveLevel: Analysis OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Therapeutic Baths
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
5. What should thenurse do before starting a patient‘s bed bath? a. Lower thebed. b. Offer thebedpan or urinal. c. Partially undress thepatient. d. Place thehead of thebed in high-Fowler‘s position. ANS: B
The patient will feel more comfortable after voiding, and this will prevent interruption of thebath. thebed should be raised to a comfortable working height to aid thenurse‘s access to thepatient and to minimize strain on thenurse‘s back muscles. thepatient‘s gown or pajamas are removed and thebath blanket is used to cover thepatient. This provides full exposure of body parts during bathing. thehead of thebed is raised 30 to 45 degrees if thepatient‘s condition allows. DIF: CognitiveLevel: Application
OBJ: Administer a complete bed bath.
TOP: Providing Comfort During theBed Bath KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
6. The nurse is preparing to provide a complete bed bath to a patient who has a running IV. She places a bath blanket over thepatient and:
a. removes thegown from thearm with theIV first. b. removes thegown from thearm without theIV first. c. removes thegown after thebath to keep thepatient warm. d. readjusts theIV rate before removing thegown. ANS: B
If thepatient has an IV line, remove thegown from thearm without theIV first. Then remove thegown from thearm with theIV. Remove theIV from thepole, and slide theIV container and tubing through thearm of thepatient‘s gown. Rehang theIV container; check theflow rate and regulate if necessary. Removing thepatient‘s gown or pajamas before thebath provides full exposure of body parts during bathing. Rehang theIV container after changing thegown. Check theflow rate. It may have changed with all themanipulation of thegown change. Regulate if necessary. DIF: CognitiveLevel: Application
OBJ: Administer a complete bed bath.
TOP: Changing theHospital Gown
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
7. While washing thepatient‘s face, thenurse should: a. wash theeyes using soap and warm water. b. wash theeyes from outer canthus to inner canthus. c. wash theeyes with plain warm water. d. use thesame portion of thewashcloth. ANS: C
Wash thepatient‘s eyes with plain warm water, using a clean area of cloth for each eye, bathing from inner to outer canthus. Soap irritates eyes. Use of separate sections of themitt reduces infection transmission. Bathing theeye gently from inner to outer canthus prevents secretions from entering thenasolacrimal duct. DIF: CognitiveLevel: Application
OBJ: Administer a complete bed bath.
TOP: Washing theEyes
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
8. When bathing a patient, which sequence is thecorrect approach to use?
a. Wash thefeet after thelegs. b. Wash theeyes after theface. c. Wash thelegs before theabdomen. d. Wash theback area before theextremities. ANS: A
When washing thepatient, thenurse will try to work from themost soiled area to theleast soiled area. Therefore, thelegs are washed before thefeet, theeyes are washed before theface, theabdomen is washed before thelegs, and theback is washed after theextremities. DIF: CognitiveLevel: Application
OBJ: Administer a complete bed bath.
TOP: Sequence of theBed Bath
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
9. What should hygienic care of thepatient with dry skin include? a. Use of moisturizers b. Use of ultraviolet light c. Application of antiseptic lotion d. Lowering of bath water temperature ANS: A
Apply body lotion to theskin as needed and topical moisturizing agents to dry, flaky, reddened, or scaling areas. Dry skin results in reduced pliability and cracking. Moisturizers help to prevent skin breakdown. Ultraviolet light and antiseptic lotion are not used to treat dry skin. Decreased bath water temperature causes chilling. DIF: CognitiveLevel: Application TOP: Dry Skin
OBJ: Administer a complete bed bath.
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
10. While giving thepatient a bed bath, thenurse notices a reddened area on thepatient‘s coccyx. thenurse should: a. decrease thetemperature of thebath water. b. massage thereddened area to decrease theredness.
c. apply topical moisturizing agents to thearea. d. ignore theredness because it will return to normal soon. ANS: C
Apply body lotion to theskin as needed and topical moisturizing agents to dry, flaky, reddened, or scaling areas. Decreased bath water temperature causes chilling. Do not massage any reddened area on thepatient‘s skin. Reddened areas, especially over bony prominences, indicate localized injury to theskin and/or underlying tissue and cannot be ignored. DIF: CognitiveLevel: Application
OBJ: Administer a complete bed bath.
TOP: Reddened Areas
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
11. The optimal position for a female patient for theprovision of perineal care is: a. prone. b. side-lying. c. high-Fowler‘s. d. dorsal recumbent. ANS: D
Perineal care for a female: Help patient assume dorsal recumbent position. DIF: CognitiveLevel: Comprehension
OBJ: Administer a complete bed bath.
TOP: Perineal Care for theFemale
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
12. While evaluating thehygienic care practices of a female patient, thenurse recognizes that additional instruction is necessary if thepatient: a. washes theperineal area from back to front. b. washes thelabia majora before thelabia minora. c. avoids tension on theindwelling catheter. d. uses separate sections of thewashcloth for each cleansing stroke. ANS: A
The patient should wash downward from thepubic area toward therectum in one smooth stroke. She should use a separate section of thecloth for each stroke. DIF: CognitiveLevel: Application OBJ: Identify principles of aseptic technique applied while administering a bed bath. TOP: Perineal Care for theFemale
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
13. In providing perineal care for a male patient, thenurse realizes that thepatient has not been circumcised. thenurse should: a. retract theforeskin aftercare has been completed. b. place thepatient in prone position. c. replace theforeskin to its natural position aftercare has been provided. d. have thepatient adduct his legs. ANS: C
After administering male perineal care for uncircumcised males, make sure that theforeskin is in its natural position. This is extremely important for those patients with decreased sensation in thelower extremities. Tightening of theforeskin around theshaft of thepenis causes local edema, discomfort, and, if not corrected, permanent urethral damage. Assist thepatient to a supine position and have him abduct his legs. DIF: CognitiveLevel: Application
OBJ: Administer a complete bed bath.
TOP: Perineal Care for theMale Patient
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
14. The home care nurse is getting ready to help thepatient prepare a tub bath. What should thenurse be sure to do? a. Instruct thepatient to use safety bars. b. Use thepatient‘s favorite bath oil for aroma therapy. c. Instruct thepatient to stay in thetub no longer than 30 minutes. d. Check on thepatient every 20 minutes. ANS: A
Instruct thepatient to use safety bars when getting into and out of thetub or shower. Caution thepatient against theuse of bath oil in tub water. This could lead to falls. Instruct thepatient not to remain in thetub longer than 20 minutes. Check on thepatient every 5 minutes. DIF: CognitiveLevel: Application OBJ: Explain precautions to take when assisting patients with a tub bath or shower. TOP: Preparing for a Tub Bath
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
15. When teaching parents how to provide oral care to their child, thenurse instructs them to: a. give bottles with juice at bedtime. b. begin dental visits after thechild is 8 years old. c. allow thepreschool child to floss his teeth without parental supervision. d. Choose drinks and foods that do not contain a lot of sugar. ANS: D
Choose drinks and foods that do not contain a lot of sugar. Teach parents that theinfant should not be put to bed with a bottle; this causes tooth decay as well as ear infection. Children should have their first dental examination at 1 year or sooner if needed. Then children need to have a dental examination every 6 months. Young children will need parenteral assistance and supervision to learn to floss correctly. DIF: CognitiveLevel: Application OBJ: Identify guidelines to follow when administering oral hygiene. TOP: Pediatric Considerations
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
16. The nurse is about to provide oral hygiene to an unconscious patient. To do so, she places thepatient in which position? a. Fowler‘s b. Semi-Fowler‘s c. Sims‘ d. Supine ANS: C
Unless contraindicated (e.g., head injury, neck trauma), position patient in Sims‘ or side-lying position. Turn patient‘s head toward mattress in dependent position with HOB elevated at least 30 degrees. DIF: CognitiveLevel: Application OBJ: Explain differences in providing oral hygiene to dependent versus unconscious patients. TOP: Oral Hygiene for an Unconscious Patient KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
17. A nurse recognizes that a shampoo may be contraindicated for a bed-bound patient with: a. heart disease. b. diabetes mellitus. c. a neck injury. d. a bleeding disorder. ANS: C
Certain medical conditions such as head and neck injuries, spinal cord injuries, and arthritis place patient at risk for injury during shampooing because of positioning and manipulation of patient's head and neck. In addition, patients with positional vertigo are not able to tolerate neck hyperextension as it might increase dizziness. DIF: CognitiveLevel: Comprehension OBJ: Identify guidelines for administering hair, nail, and foot care. TOP: Washing theHair of Patients with Neck Injuries KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
18. Shaving with a disposable razor is contraindicated for a patient with: a. heart disease. b. diabetes mellitus. c. a head injury. d. a bleeding disorder. ANS: D
Before shaving, assess whether thepatient has a bleeding tendency. Review medical history or laboratory values (e.g., platelet counts and prothrombin time). Determine theneed to use an electric razor for thepatient‘s safety because of thepotential for bleeding. Shaving with a disposable razor is not contraindicated for patients with heart disease, diabetes mellitus, or a head injury. DIF: CognitiveLevel: Analysis
OBJ: Shave a male or female patient.
TOP: Shaving a Male Patient
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
19. When evaluating theshaving of a patient done by a family member, thenurse determines that thetechnique is done appropriately when: a. long strokes are used. b. the razor is held at a 45-degree angle to theskin. c. shaving is done against thedirection of hair growth. d. a cool cloth is used on theskin before theshave. ANS: B
The razor should be held in thedominant hand at a 45-degree angle to thepatient‘s skin. Begin by shaving across one side of thepatient‘s face using short, firm strokes in thedirection thehair grows. Use thenondominant hand to gently pull theskin taut while shaving. Check with thepatient, and ask whether he feels comfortable. Use a warm cloth. A warm cloth helps soften theskin and beard, and thesensation of warmth can be relaxing. DIF: CognitiveLevel: Application
OBJ: Shave a male or female patient.
TOP: Shaving a Male Patient
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
20. The nurse is providing nail care for thepatient who wants his fingernails ―done.‖ thenurse should: a. clip thefingernails gently to prevent injury. b. clean under thenails using an orange stick. c. soak thefingernails no longer than 10 minutes. d. clean under thenails using theend of a cotton swab.
ANS: C
Unless thepatient has diabetes, allow thepatient‘s feet and fingernails to soak no longer than 10 minutes. thegoal is to soften theskin and debris beneath thenails, without causing excessive dryness. Obtain a physician‘s order for cutting thenails (required by most agencies). thepatient‘s skin may be cut accidentally. Certain patients are more at risk for infection, depending on their medical condition. Check agency policy for appropriate process for cleaning beneath thenails. Do not use an orange stick or theend of a cotton swab; both of these splinter and can cause injury. DIF: CognitiveLevel: Application TOP: Nail Care
OBJ: Safely administer nail care.
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
21. The nurse assesses thepatient‘s skin and notices an abrasion. Which of thefollowing best describes this type of skin abnormality? a. A papulopustular skin eruption b. Rough texture on theskin surface c. Erythema and scaly, oozing areas d. A scraping away of theepidermis ANS: D
An abrasion is a scraping or rubbing away of theepidermis; it may result in localized bleeding and later weeping of serous fluid. Acne is defined as a papulopustular skin eruption. Rough texture may indicate dry skin, not an abrasion. Scaly, oozing erythematous areas may indicate contact dermatitis. DIF: CognitiveLevel: Comprehension OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Skin Problems
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
22. The nurse is caring for a gentleman who has dry skin. When thefollowing interventions are compared, which would be most appropriate for this patient? a. Limiting thefrequency of bathing
b. Using a fat-free soap for washing c. Using warm water and moisturizers d. Bathing with hot water to increase blood flow ANS: C
Effective treatment for dry skin does not include limiting thefrequency of bathing but lies in bathing with warm, not hot, water and using moisturizers. Super-fatted soap (e.g., Dove) should be used for cleansing. thebody should be rinsed well of all soap, because residue left can cause irritation and breakdown. Moisture should be added to theair through theuse of a humidifier. Fluid intake should be increased when theskin is dry. DIF: CognitiveLevel: Application OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Treatment for Dry Skin
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
23. The patient confides in thenurse that she is bothered by thefact that she has alopecia. How should thenurse respond to this information? a. Shave hair off of theaffected area. b. Use permethrin. c. Offer thepatient access to scarves or wigs. d. Place a drop of oil on thearea. ANS: C
Alopecia is balding patches in theperiphery of thehairline. Offer patients access to scarves, hairpieces, or wigs. Stop hair-care practices that damage hair. Shaving hair off of theaffected area is thetreatment for pediculosis pubis (crab lice). Permethrin is thetreatment for pediculosis capitis (head lice). Ticks are removed by placing a drop of oil or ether on thetick, causing it to suffocate. DIF: CognitiveLevel: Application OBJ: Identify guidelines for administering hair, nail, and foot care. TOP: Alopecia
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
24. The patient requires postural drainage 3 times a day. Which of thefollowing bed positions would be most appropriate for this task? a. Fowler‘s position b. Trendelenburg‘s position c. Reverse Trendelenburg‘s position d. Semi-Fowler‘s position ANS: B
With Trendelenburg‘s position, theentire bed frame is tilted, with thehead of thebed down. This position facilitates postural drainage and venous return in patients with poor peripheral perfusion. In Fowler‘s position, thehead of thebed is raised to an angle of 45 to 90 degrees or more. This position is preferred while thepatient eats, is used during nasogastric tube insertion and nasotracheal suction, and promotes lung expansion. In reverse Trendelenburg‘s position, theentire bed frame is tilted, with thefoot of thebed down. It is used infrequently, promotes gastric emptying, and prevents esophageal reflux. In semi-Fowler‘s position, thehead of thebed is raised approximately 30 to 45 degrees. This promotes lung expansion and relieves strain on abdominal muscles. DIF: CognitiveLevel: Application OBJ: Identify guidelines for administering hair, nail, and foot care. TOP: Bed Positions
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. The skin, thelargest human body organ, protects us from heat, light, injury, and infection and does which of thefollowing? (Select all that apply.) a. Helps regulate body temperature. b. Stores water, vitamin D, and fat. c. Helps to sense pain. d. Prevents theentry of bacteria. ANS: A, B, C, D
Skin, thelargest human body organ, protects us from heat, light, injury, and infection and serves to (1) help regulate body temperature; (2) store water, vitamin D, and fat; (3) help sense pain and other stimuli; and (4) prevent theentry of bacteria. DIF: CognitiveLevel: Comprehension OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Skin
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. Critically ill patients on a ventilator are at risk for ventilator-associated pneumonia (VAP). Sources of VAP include: (Select all that apply.) a. bacteria in theoral pharynx. b. dental plaque. c. chlorhexidine rinses. d. frequent oral hygiene. ANS: A, B
Special oral care is needed for theunconscious or debilitated patient because they are more susceptible to infection due to thechange in thenormal flora of theoral cavity, increased plaque formation from thedryness of themouth, and decreased salivation. The critically ill patient with an artificial airway and who is on mechanical ventilation is at risk for ventilator-associated pneumonia (VAP). Once intubated, theartificial airway causes a bypass of normal airway defenses, which also causes a rapid change in thenormal oral flora. ). Some patients require mouth care as often as every 1 to 2 hours until themucosa returns to normal. theuse of a chlorhexidine gluconate (CHG) oral hygiene protocol as part of daily oral care reduces theincidence of VAP. VAP results from thecolonization of bacteria in theoral pharynx. These microorganisms then translocate from themouth into thelungs. Dental plaque is also a reservoir for microorganisms causing VAP. Because of this, guidelines for oral care in ventilator patients and in those who need assistance with oral hygiene often include theuse of a chlorhexidine rinse as part of oral hygiene. Chlorhexidine early in thepost intubation period may help delay theonset or development of VAP.
DIF: CognitiveLevel: Comprehension OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Oral Hygiene
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. When taking a shower in thehome setting, thepatient at risk for falls may benefit from: (Select all that apply.) a. installation of grab bars. b. adhesive strips applied to thetub floor. c. addition of a shower chair or stool. d. a hydraulic lift. ANS: A, B, C
Patients at risk for falls may benefit from theinstallation of grab bars in theshower, theapplication of adhesive strips to theshower or tub floor, and theaddition of a shower chair or placement of a chair or stool. Hydraulic lifts are useful in bathtubs. DIF: CognitiveLevel: Application OBJ: Explain precautions to take when assisting patients with a tub bath or shower. TOP: Preparing for a Shower
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. Patients at greatest risk for developing serious foot problems include those with: (Select all that apply.) a. peripheral neuropathy. b. peripheral vascular disease. c. pancreatitis. d. diabetes. ANS: A, B, D
Patients at greatest risk for developing serious foot problems are those with peripheral neuropathy and peripheral vascular disease. These two disorders, commonly found in patients with diabetes, cause reduction in blood flow to theextremities and loss of sensory, motor, and autonomic nerve function. As a result, thepatient is unable to feel heat and cold, pain, pressure, and theposition of thefoot. This reduction in blood flow impairs healing and promotes risk for infection. DIF: CognitiveLevel: Analysis
OBJ: Identify risk factors for foot and nail problems.
TOP: Foot Problems
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The development of diabetic foot ulcers is dependent on which of thefollowing? (Select all that apply.) a. Peripheral neuropathy b. Tissue ischemia c. Trauma to thefoot d. Pain in theaffected extremity ANS: A, B, C
The development of diabetic foot ulcers is multifactorial; three contributing factors are (1) peripheral neuropathy (changes in thefunction and efficiency of thenerves), (2) ischemia (decrease in blood flow related to plaque formation in thearteries), and (3) a pivotal event (e.g., trauma caused by banging thetoe or stepping on a foreign object). DIF: CognitiveLevel: Comprehension
OBJ: Identify risk factors for foot and nail problems.
TOP: Diabetic Foot Ulcers
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
6. A patient is admitted with thediagnosis of pediculosis capitis (head lice). Proper treatment for this condition would include which of thefollowing? (Select all that apply.) a. Use of medicated shampoo or permethrin b. Use of products containing lindane c. Combing thehair with a nit comb for 2 to 3 days after treatment d. Washing linens in cold water for 30 minutes
ANS: A, C
Use medicated shampoo available as a crème rinse for eliminating lice, or permethrin. Caution against theuse of products containing lindane, because this ingredient is toxic and is known to cause adverse reactions. Remove thepatient‘s clothing before treatment, and apply new clothing after treatment. Repeat treatment according to product directions. Check thehair for nits, and comb with a nit comb for 2 to 3 days until you are sure all lice and nits have been removed. Manual removal of lice is thebest option when treatment has failed. Vacuum infested areas of thehome. Wash linens in hot water, and dry for at least 30 minutes. DIF: CognitiveLevel: Analysis OBJ: Identify guidelines for administering hair, nail, and foot care. TOP: Lice
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
COMPLETION
1. The
is thelargest human organ.
ANS:
skin Skin, thelargest human body organ, protects us from heat, light, injury, and infection, and serves to (1) help regulate body temperature; (2) store water, vitamin D, and fat; (3) help sense pain and other stimuli; and (4) prevent theentry of bacteria. DIF: CognitiveLevel: Knowledge OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Skin
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The first line of defense against external injury and infection contains several thin layers of cells undergoing different stages of maturation. This first line of defense is known as the
.
ANS:
epidermis The epidermis, or outer skin layer, is thefirst line of defense against external injury and infection. DIF: CognitiveLevel: Comprehension OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: The Epidermis
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3.
provides an acidic coating to protect theepidermis against penetration from chemicals and microorganisms; it also minimizes loss of water and plasma proteins. ANS:
Sebum Sebum, secreted from hair follicles from sebaceous glands, provides an acidic coating. This acidic coating protects theepidermis against penetration from chemicals and microorganisms. It also minimizes loss of water and plasma proteins. DIF: CognitiveLevel: Comprehension OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Sebum
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4.
removes sweat, oil, dirt, and bacteria and helps maintain skin integrity. ANS:
Bathing Bathing removes sweat, oil, dirt, and microorganisms from theskin. DIF: CognitiveLevel: Comprehension OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Bathing
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The act of chewing is also known as
.
ANS:
mastication The teeth are organs of chewing, or mastication. DIF: CognitiveLevel: Comprehension OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Mastication
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
6.
are mucous membranes with underlying supportive tissue that encircle theneck of erupted teeth to hold them in place. ANS:
Gingivae The gums, or gingival tissue, are mucous membranes with underlying supportive fibrous tissue. They encircle theneck of erupted teeth to hold them firmly in place. thegums normally are pink, moist, firm, and relatively inelastic. DIF: CognitiveLevel: Comprehension OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Gingivae
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
7. Regular oral hygiene is necessary to maintain theintegrity of tooth surfaces and to prevent gum inflammation known as ANS:
gingivitis
.
Regular oral hygiene is necessary to maintain theintegrity of tooth surfaces and to prevent gingivitis, or gum inflammation. DIF: CognitiveLevel: Comprehension OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Gingivitis
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
8. Tissue that surrounds thefingernail, slowly grows over thenail, and must be regularly pushed back with a soft nailbrush is known as the
.
ANS:
cuticle The nail is surrounded by a cuticle, which slowly grows over thenail and must be regularly pushed back with a soft nailbrush. Take care to avoid breaking theskin around thenail. Breaks in theskin allow theentry of bacteria. DIF: CognitiveLevel: Comprehension OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: The Cuticle
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
9. Many foot ulcers are due to repeat trauma over time, often caused by
.
ANS:
poorly fitting shoes Some types of shoes predispose thepatient to foot problems. Heel, soles and sides of feet are prone to irritation from ill-fitting shoes. Pay close attention to areas of dryness, inflammation, or cracking. Inspect areas between toes, heels, and soles of thefeet. Inspect socks for stains. DIF: CognitiveLevel: Comprehension TOP: Foot Ulcers
OBJ: Identify risk factors for foot and nail problems.
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
10.
is defined as excessive growth of body and facial hair. ANS:
Hirsutism Hirsutism is defined as excessive growth of body and facial hair, especially in women. DIF: CognitiveLevel: Knowledge OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Hirsutism
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
11.
is balding patches in theperiphery of thehairline. ANS:
Alopecia Alopecia is balding patches in theperiphery of thehairline. Hair becomes brittle and broken. Alopecia can be caused by diseases, as a medication side effect, or after improper use of hair-care products and hair-styling devices. DIF: CognitiveLevel: Knowledge OBJ: Identify guidelines for administering hair, nail, and foot care. TOP: Alopecia
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
Chapter 19: Care of theEye and Ear Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. When providing eye care for thecomatose patient, thenurse should: a. place thepatient in a prone position for easier access.
b. use a different corner of thewashcloth for each eye. c. wipe each eye from outer to inner canthus. d. use a sterile medicine cup to instill lubricant. ANS: B
Use clean washcloth or cotton balls moistened with warm water or sterile saline and gently wipe each eye from inner to outer canthus. Use a separate, clean cotton ball or corner of thewashcloth for each eye. Position patient in supine position. Use eyedropper to instill theprescribed lubricant. DIF: CognitiveLevel: Application OBJ: Identify guidelines used in caring for eye and ear prostheses. TOP: Eye Care for a Comatose Patient
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
2. In caring for a patient with contact lenses, thenurse should be aware that: a. rigid gas-permeable (RGP) lenses are no longer used. b. soft contact lenses are smaller than thecornea. c. all lenses must be removed periodically. d. extended wear lenses can be used for only 6 nights. ANS: C
It is important to remember that all lenses must be removed periodically to prevent infection and corneal damage and that proper cleaning and safe handling are necessary before reinserting a lens. RGP lens are removed at theend of each day. Most disposable soft contact lenses are made of a flexible hydrogel plastic and cover theentire cornea and a small rim of thesclera. Extended wear contact lenses, usually soft lenses, are available for overnight or continuous wear ranging from one to six nights or up to 30 days. DIF: CognitiveLevel: Application OBJ: Identify guidelines used in caring for eye and ear prostheses. TOP: Contact Lenses
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
3. Which of thefollowing nursing interventions would thenurse perform first after a patient sustained a chemical splash injury to theeye? a. Assess visual acuity. b. Flush theeye with large amounts of irrigation fluid. c. Assess level of pain. d. Determine whether thepupils are equal, round, reactive to light and accommodation (PERRLA). ANS: B
A chemical injury to theeye is an emergency and requires flushing theeye with copious amounts of irrigation fluid. Although irrigating solutions are usually normal saline, cool tap water is recommended during theemergent phase because it is effective, immediately available for first aid, and initially helps to dilute theconcentration of thechemical. Assessing visual acuity, pain, and PERRLA will be performed after theeye has been irrigated appropriately. DIF: CognitiveLevel: Application OBJ: Identify nursing care for a patient with a chemical splash to theeye. TOP: Splash to Eye
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The nurse caring for a comatose patient determines that he is wearing contact lenses. Which of thefollowing nursing interventions will thenurse use when removing thecontact lenses? a. Put on snug, powdered, clean gloves. b. Ask thepatient to look down to expose thelower eyeball. c. Use thefingernail to slide thelens off of thecornea. d. Inspect theeye after thelenses have been removed. ANS: D
For patients unable to open eye or blink on command, nurse will remove lens using a lens suction cup to remove lens from eye. Gently apply suction cup to lens surface and lift out.
After thelenses have been removed, inspect theeye for redness, pain, swelling of theeyelids or conjunctivae, discharge, or excess tearing. Perform hand hygiene. Don snug, powder-free, clean gloves, and place a towel just below thepatient‘s face. With thepad of theindex finger of thesame hand, slide thelens off thecornea down onto thelower sclera. Use of thepad rather than thefingernail prevents injury to thecornea and damage to thelens. DIF: CognitiveLevel: Application OBJ: Correctly remove, store, clean, and insert a contact lens.
TOP: Removal of Contact Lenses
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. When removing a soft contact lens, thenurse finds that it is sticking together. What should thenurse do next? a. Rub thelens briskly. b. Soak thelens in saline. c. Place cleansing solution on thelens. d. Pry thelens apart with thefingertips. ANS: B
If lens edges stick together, place lens in palm and soak thoroughly with sterile saline solution. Gently roll lens with index finger in back-and-forth motion. If necessary, soak lens in storage solution, which may return lens to normal shape. DIF: CognitiveLevel: Application OBJ: Correctly remove, store, clean, and insert a contact lens.
TOP: Removal of Contact Lenses
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
6. When providing care to a patient who has splashed bleach into his eye, thenurse will: a. remove thepatient‘s contacts immediately. b. flush theeye from theouter to theinner canthus. c. reinsert contacts as soon as irrigation is done. d. irrigate toward thelower conjunctival sac. ANS: D
Gently irrigate with steady stream toward lower conjunctival sac, moving from inner to outer canthus. In an emergency such as first aid for a chemical burn, irrigation is theimmediate treatment. Flush eye from theinner to outer canthus with cool tap water (Marsden, 2016). Do not delay treatment by removing a patient's contact lenses unless rapid swelling is occurring. Ask thepatient to look toward thebrow. Gently irrigate with a steady stream toward thelower conjunctival sac. This will minimize theforce of thestream on thecornea and will flush irritant out of theeye and away from theother eye and nasolacrimal duct. In an emergency such as first aid for a chemical burn, do not delay flushing by removing thepatient‘s contact lens before irrigation. Do not remove thecontact unless rapid swelling is occurring. Flush theeye from theinner to theouter canthus. Advise thepatient to consult theprescriber before reusing thecontact lens. DIF: CognitiveLevel: Application OBJ: Explain differences in irrigation procedures for removing exudates and chemicals from theeyes. TOP:
Eye Irrigation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
7. The patient is found to have impacted cerumen in his ear canal. thenurse most likely will: a. instill 1 to 2 drops of mineral oil. b. instill theirrigation under pressure. c. occlude theear canal when irrigating. d. straighten theear canal. ANS: A
If thepatient is found to have impacted cerumen, instill 1 to 2 drops of mineral oil or over-the-counter softener into theear twice a day for 2 to 3 days before irrigation, to loosen cerumen and ensure easier removal during irrigation. thegreatest danger during administration of ear irrigation is rupture of thetympanic membrane. Fluids must not be instilled under pressure or with theirrigating device occluding theear canal. Always attempt to remove foreign objects in theear by first simply straightening theear canal. Cerumen, however, is wax buildup and is not a foreign object.
DIF: CognitiveLevel: Application
OBJ: Correctly perform eye and ear irrigations.
TOP: Ear Irrigation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
8. How should thenurse position theear when performing ear irrigation for a 2-year-old patient? a. Instill theirrigating solution quickly and forcefully. b. Pull thepinna up and back. c. Direct thefluid toward theanterior aspect of theear canal. d. Pull thepinna down and back. ANS: D
In children age 3 or younger, pull thepinna down and back. Slowly instill irrigating solution by holding thetip of thesyringe 1 cm (0.39 inch) above theopening to theear canal. Allow fluid to drain out during instillation into thebasin. Continue until thecanal is cleansed or thesolution is used. Slow instillation prevents buildup of pressure in theear canal and ensures contact of thesolution with all canal surfaces. For adults and children older than age 3, gently pull thepinna up and back. Direct thefluid toward thesuperior aspect of theear canal. DIF: CognitiveLevel: Application
OBJ: Correctly perform eye and ear irrigations.
TOP: Ear Irrigation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
9. How does thenurse assess that a hearing aid is operating correctly? a. Speaking very softly behind thepatient b. Covering thepatient‘s unaffected ear and speaking c. Determining thepatient‘s response to a normal tone of voice d. Removing thehearing aid and sending it to be checked by an audiologist ANS: C
Determine whether patient can hear clearly with hearing aid by talking slowly and clearly in normal tone of voice. Inability to hear may indicate a problem with thehearing aid or battery or that particular model is no longer effective for patient.
To determine whether thepatient can hear clearly using thehearing aid, turn your back to thepatient and ask a question slowly and clearly in a normal tone of voice. Depending on your position, thepatient may be able to read your lips. theprostheses are limited by thefunction of theear structures. thehearing aid may not be theproblem in this case. DIF: CognitiveLevel: Comprehension OBJ: Describe techniques that determine whether a hearing aid functions properly. TOP: Assessing theFunction of theHearing Aid KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
10. The nurse is preparing to clean thepatient‘s hearing aid. thenurse realizes that she must: a. make sure thehearing aid volume is turned on before removing thehearing aid. b. hold thehearing aid over thesink when cleansing. c. insert a paper clip into thereceiver port to cleanse cerumen buildup. d. make sure thepressure equalization channel is clear. ANS: D
The pressure equalization channel is a tiny hole through theentire length of theear mold; it should be clear for theentire length. Before removing thehearing aid, turn thevolume off to prevent feedback (whistling) during removal. Hold thehearing aid over a towel and wipe theexterior with tissue to remove thecerumen. This prevents breakage if dropped. thereceiver port is easily damaged. Never insert anything into thereceiver port. DIF: CognitiveLevel: Application
OBJ: Correctly remove, clean, and reinsert a hearing aid.
TOP: Cleaning theHearing Aid
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
11. When instructing a patient on correct technique for inserting a hearing aid into theear, thenurse will include which of thefollowing instructions? a. Pull theouter ear up and out. b. Hold theaid with thelong portion upright. c. Insert pointed end of ear mold into ear canal. d. Turn theaid to thedesired sound level before insertion. ANS: C
Hold hearing aid with thumb and index finger of dominant hand so canal (long part with holes) is at bottom. Insert pointed end of ear mold into ear canal. Follow natural ear contours to guide aid into place. Hold thehearing aid in thedominant hand and insert thepointed end of theear mold into theear canal while following thenatural contours of thecanal. Pulling up and out on theouter ear has little effect on hearing aid insertion. Instead, hold thehearing aid in thedominant hand and insert thepointed end of theear mold into theear canal while following thenatural contours of thecanal. Turn thevolume slowly to high to prevent damage to thehearing aid. DIF: CognitiveLevel: Application
OBJ: Correctly remove, clean, and reinsert a hearing aid.
TOP: Inserting theHearing Aid
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The elderly patient is instructed to store his hearing aid in a(n): a. cold place. b. container that keeps out moisture. c. easy to reach place. d. a cup of water. ANS: B
Hearing aids and batteries should be stored in a dry container with desiccant or in an electronic dryer to prolong life, minimize repairs, and preserve batteries. Advise thepatient to avoid exposing thehearing aid to extremes of temperature. Batteries are toxic if swallowed; keep them away from pets and children. Advise thepatient to protect thehearing aid from water, alcohol, hair spray or cologne, perspiration, rain, and snow. DIF: CognitiveLevel: Application
OBJ: Correctly remove, clean, and reinsert a hearing aid.
TOP: Storage of Hearing Aid
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. The nurse is preparing to provide eye care for a comatose patient. thenurse realizes that comatose patients do not have natural protective mechanisms to protect thecornea. These protective mechanisms include: (Select all that apply.) a. blinking. b. squinting. c. lubrication. d. dilation. ANS: A, C
Comatose patients do not have thenatural protective mechanisms to protect thecornea. These protective mechanisms include blinking and lubrication of theeye. When patients are in a coma, thenurse is responsible for providing this care. DIF: CognitiveLevel: Comprehension OBJ: Identify guidelines used in caring for eye and ear prostheses. TOP: Protective Mechanisms
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
2. The patient is brought to theemergency department after receiving a chemical burn to his eyes. thedoctor orders immediate eye irrigations. Of thefollowing solutions, which would be themost beneficial for this patient? (Select all that apply.) a. Lactated Ringer‘s solution b. Albumin c. Tap water d. Dextrose and water ANS: A, C
For chemical flushing, use normal saline or lactated Ringer‘s solution in large volume to provide continuous irrigation over 15 to 30 minutes. A chemical injury to theeye is an emergency and requires flushing theeye with copious amounts of irrigation fluid. Although irrigating solutions are usually normal saline, cool tap water is recommended during theemergent phase because it is effective, immediately available for first aid, and initially helps to dilute theconcentration of thechemical.
Use copious amounts of clear, cool water (normal saline or lactated Ringer‘s if quickly available). DIF: CognitiveLevel: Analysis OBJ: Explain differences in irrigation procedures for removing exudates and chemicals from theeyes. TOP:
Eye Irrigation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
COMPLETION
1. The patient is brought into theemergency department after a motor vehicle accident. thepatient is unresponsive. thenurse is concerned about whether or not thepatient wears contact lenses because contact lenses that are not removed can cause
.
ANS:
corneal injury It is extremely important to determine whether patients wear contact lenses, particularly when patients are admitted to hospitals or agencies in an unresponsive or confused state. If a seriously ill patient is wearing contact lenses, and this fact goes undetected, severe corneal injury can result. DIF: CognitiveLevel: Application OBJ: Identify guidelines used in caring for eye and ear prostheses. TOP: Contact Lenses
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
2. The substance found in theear canal that has an antibacterial effect and maintains an acid pH is called
.
ANS:
cerumen Cerumen has an antibacterial effect and maintains an acid pH in theauditory canal.
DIF: CognitiveLevel: Comprehension
OBJ: Correctly perform eye and ear irrigations.
TOP: Ear Irrigation
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. A
is a small, battery-powered, electronic device that amplifies sound.
ANS:
hearing aid Hearing aids amplify sound, so it is heard at a more effective level. thetwo main types of electronic hearing aids are analog and digital. power source (batteries). A hearing aid is a small, battery-powered, electronic device that amplifies sound. DIF: CognitiveLevel: Comprehension OBJ: Describe techniques that determine whether a hearing aid functions properly. TOP: Hearing Aid
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
Chapter 20: Safe Medication Preparation Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The prescribed dose of Tylenol is given to a patient. thenurse recognizes thename Tylenol as which of thefollowing? a. Chemical name b. Trade name c. Generic name d. United States Pharmacopeia ANS: B
The trade name, brand name, or proprietary name is thename under which a manufacturer markets a medication. thetrade name has thesymbol (™) at theupper right of thename, indicating that themanufacturer has trademarked thename of themedication. Acetaminophen is an example of thegeneric name for Tylenol. thegeneric name becomes theofficial name listed in official publications such as theUnited States Pharmacopeia (USP). DIF: CognitiveLevel: Remembering OBJ: Discuss factors that contribute to medication errors. KEY: NursingProcess Step: Assessment
TOP: Medication Names
MSC: NCLEX: Physiological Integrity
2. The nurse is aware that a patient with liver disease and a decreased albumin level may develop which of thefollowing effects? a. Toxicity on normal doses of medication b. Less active medication available in thebody c. Reduction in therapeutic effect d. Accelerated biotransformation of themedication ANS: A
Most medications bind to albumin to some extent. When medications bind to albumin, they are unable to exert pharmacological activity. Only theunbound or ―free‖ medication is active. Older adults and patients with liver disease or malnutrition have reduced albumin, which increases their risk for medication toxicity. With less albumin to bind with themedication, more ―free‖ or active medication is present in thebody. This would result in an increase in therapeutic effect and possibly in toxicity. Most biotransformation occurs in theliver, although thelungs, kidneys, blood, and intestines also play a role. Patients (e.g., elderly, those with chronic disease) are at risk for medication toxicity if their organs that metabolize medications do not function correctly. DIF: CognitiveLevel: Application
OBJ: Discuss thetypes of medication actions.
TOP: Protein Binding
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
3. During theadmission process, thepatient states that he stopped taking daily aspirin because of nausea. thenurse documents thenausea as which of thefollowing?
a. Noncompliance b. Toxic effects of themedication c. Side effects of themedication d. Allergic reaction to themedication ANS: C
Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. They are either harmless or cause injury. theintensity of side effects is often dose dependent. If theside effects are serious enough to outweigh thebenefits of thetherapeutic action of a medication, thehealth care provider will likely discontinue themedication. Patients commonly stop taking medications because of side effects such as anorexia, nausea, vomiting, dizziness, drowsiness, dry mouth, constipation, and diarrhea. Report any side effect to thehealth care provider to ensure that it is not incorrectly interpreted as a more serious adverse medication reaction. DIF: CognitiveLevel: Application TOP: Side Effects
OBJ: Discuss thetypes of medication actions.
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. An 80-year-old patient who complains of feeling ―anxious‖ is given lorazepam. thepatient becomes agitated and delirious. thenurse documents this reaction to Ativan as which of thefollowing? a. Toxicity b. Side effect c. Idiosyncratic reaction d. Allergic reaction ANS: C
Medications often cause unpredictable effects such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction different from normal. Predicting which patients will have an idiosyncratic response is impossible. For example, Ativan, an antianxiety medication, when given to an older adult, may cause agitation and delirium. Toxic effects develop after prolonged intake of a medication, when a medication accumulates in theblood because of impaired metabolism or excretion, or when too high a dose is given. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. Allergic reactions are unpredictable responses to a medication. themedication acts as an antigen, and this causes antibodies to be produced. With repeated administration, thepatient develops an allergic response. Sudden constriction of bronchiolar muscles, edema of thepharynx and larynx, severe wheezing, and shortness of breath are characteristic of severe or anaphylactic reactions. Some patients become severely hypotensive, necessitating emergency resuscitation measures. Anaphylaxis is potentially fatal. DIF: CognitiveLevel: Application
OBJ: Discuss thetypes of medication actions.
TOP: Idiosyncratic Reactions
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
5. A patient admitted to thehospital with pneumonia has IV antibiotics ordered. He receives thefirst dose with no problem, but during thesecond dose, he begins to complain of shortness of breath and difficulty breathing. thenurse notes wheezes throughout thelung fields. thenurse documents these symptoms as which of thefollowing? a. Idiosyncratic reaction b. Toxic effect of theantibiotic c. Side effect of themedication d. Anaphylactic reaction ANS: D
An allergic reaction ranges from mild to severe, depending on thepatient and themedication. Among thedifferent classes of medications, antibiotics cause a high incidence of allergic reactions. Sudden constriction of bronchiolar muscles, edema of thepharynx and larynx, severe wheezing, and shortness of breath are characteristic of severe or anaphylactic reactions. Some patients become severely hypotensive, necessitating emergency resuscitation measures. Anaphylaxis is potentially fatal. Medications often cause unpredictable effects, such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction that is different from normal. However, thesymptoms displayed by this patient are classic anaphylactic symptoms. Toxic effects develop after prolonged intake of a medication, when a medication accumulates in theblood because of impaired metabolism or excretion, or when too high a dose is given. Two doses of a medication usually are not enough to develop toxic effects. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. Anaphylaxis is usually unpredictable initially and is avoided after thefirst reaction by listing thecause of theanaphylaxis in theallergy alert section of thepatient record. DIF: CognitiveLevel: Application
OBJ: Discuss thetypes of medication actions.
TOP: Allergic Reactions
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
6. A patient with chronic back pain has been taking oral morphine sulfate for thepast 2 years. Upon admission to thehospital, thepatient receives morphine sulfate for back pain but reports no pain relief. thenurse notifies thehealth care provider, recognizing that thereason for thelack of pain relief is which of thefollowing? a. Side effect of themorphine b. Drug dependence c. Idiosyncratic response to themorphine d. Medication tolerance ANS: D
Medication tolerance is thediminished response to a medication with repeated use and occurs over time. A patient receives thesame medication for long periods of time and then requires higher doses to produce thesame desired effect. Patients taking various pain medications may develop tolerance over time. It may take a month or longer for tolerance to occur.
DIF: CognitiveLevel: Analysis
OBJ: Discuss thetypes of medication actions.
TOP: Medication Tolerance
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
7. A patient is receiving vancomycin IV every 8 hours at 0800, 1600, and 2400. A serum peak and trough level is ordered after thethird dose, which will be given at 1600. When should thenurse order thetrough level? a. 1630 b. 1800 c. 2330 d. 2400 ANS: C
The point at which thelowest amount of drug is in theserum is thetrough concentration. Some medication doses (e.g., vancomycin and gentamicin) are based on peak and trough serum levels. A patient‘s trough level is drawn as a blood sample 30 minutes before thedrug is administered, and thepeak level is drawn whenever thedrug is expected to reach its peak concentration. thethird dose will be given at 1600, which means that thelowest level of drug will be present 30 minutes before thefourth dose at midnight. A patient‘s trough level is drawn as a blood sample 30 minutes before thedrug is administered. 1630 is 30 minutes after thedrug is administered. 1800 is 2 hours after thedrug is administered. If themedication reaches its peak concentration in 2 hours, this could be a peak concentration, because thepeak level is drawn whenever thedrug is expected to reach its peak concentration. 2400 is thetime that thenext dose is due. A patient‘s trough level is drawn as a blood sample 30 minutes before thedrug is administered. DIF: CognitiveLevel: Application
OBJ: Discuss thetypes of medication actions.
TOP: Trough ConcentrationKEY:
NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The hospital uses a unit-dose system for medication distribution. thenurse recognizes that this system includes which safety feature? a. All medications are kept in thepatient‘s drawer.
b. Liquids are kept in multi-dose containers to prevent spillage. c. Narcotics are kept in an area separate from thepatient‘s regular medications. d. The nurse is responsible for restocking themedication drawers daily. ANS: C
A cart also contains limited amounts of prn and stock medications for special situations. Controlled substances are not kept in theindividual patient drawer; they are kept in a larger locked drawer to keep them secure. theunit dose is theordered dose of medication that thepatient receives at one time. Each tablet or capsule is wrapped in a foil or paper container. Liquid doses come in prepackaged foil or paper cups. At a designated time each day, thepharmacist or a pharmacy technician refills thedrawers in thecart with a fresh supply. DIF: CognitiveLevel: Understanding OBJ: Discuss factors that contribute to medication errors.
TOP: Unit Dose
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
9. The nurse is calculating a medication dosage using themetric system. A vial contains 1 mL of fluid, and thenurse calculates thecorrect dosage to be half of themedication in thevial. How should thenurse document thecorrect dosage? a. 1/2 mL b. .5 mL c. 0.5 mL d. 0.50 mL ANS: C
Many actual or potential medication errors happen with theuse of fractions or decimal points. Use practice standards when medications are ordered in fractions to prevent errors. For example, never use a trailing zero (e.g., 1.0 mg), use 1 mg, and always include a zero before a decimal point (e.g., 0.1 mL). DIF: CognitiveLevel: Application OBJ: Identify thesystem of measurement for a given prescribed medication. TOP: The Metric System
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
10. The nurse receives an order to give a drug parenterally. thenurse will administer this medication by which route? a. Oral b. Topical c. Sublingual d. Intramuscular ANS: D
Parenteral medications can be intramuscular, subcutaneous, intradermal, epidural, or intravenous. Medications given orally are given by mouth. Topical medications are applied on theskin (as a cream or patch) and as eye/eardrops. Sublingual medications are given under thetongue. DIF: CognitiveLevel: Application OBJ: Identify guidelines for safe administration of medications. TOP: Routes of Medication Administration KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
11. The patient is complaining of severe leg pain. No pain medication is ordered, so thenurse calls thehealth care provider. An order for Tylenol with Codeine prn is given, in addition to a one-time order for morphine sulfate to be given stat. Which action by thenurse is most appropriate? a. Give themorphine sulfate and Tylenol with Codeine immediately. b. Give theTylenol with Codeine now. c. Give themorphine sulfate immediately. d. Ask thepatient which medication he would like first. ANS: C
Single (one-time) orders are common for preoperative medications or medications given before diagnostic procedures. themedication is ordered to be given only once at a specified time. A stat order means that you give a single dose of medication immediately and only once. Stat orders are used for emergencies when a patient's condition changes suddenly. A now order is more specific than a one-time order and is used when a patient needs a medication quickly but not as soon as a stat order. When you receive a now order, you have up to 90 minutes to give thedrug (see agency policy). A medication can be ordered to be given only when a patient requires or requests it. This is a prn (as needed) order. DIF: CognitiveLevel: Application OBJ: List and discuss thesix rights of medication administration. TOP: Medication Orders
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The nurse is preparing to administer medication to a patient who is alert and oriented. When medications are reviewed with thepatient, thepatient states that he does not take metoprolol. Which action by thenurse is most appropriate? a. Ignore thepatient‘s statement and give themedication. b. Withhold themedication. c. Convince thepatient that thedoctor ordered it, and he should take it. d. Give themedication and check theorder afterward. ANS: B
If a patient questions a medication, stop and recheck to be certain that there is no mistake. An alert patient or family caregiver will know whether a medication is different from those received before. In most cases themedication order has been changed, or thedrug is manufactured by a different company than thepatient has been using at home. However, attention to a patient's question is how errors are identified and prevented. DIF: CognitiveLevel: Application OBJ: List and discuss thesix rights of medication administration. TOP: Medication Orders MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
13. The nurse enters thepatient‘s room to give medications. Which action is most appropriate to identify the―right patient‖? a. Ask thepatient to state his name. b. Ask thepatient to state his name and birth date. c. Ask theprimary nurse to identify thepatient. d. Say thepatient‘s name and date of birth and request patient validation. ANS: B
Before giving a medication to a patient, always use at least two patient identifiers (TJC, 20121a). Acceptable patient identifiers include thepatient‘s name, an identification number assigned by thehealth care agency, and thedate of birth. DIF: CognitiveLevel: Application OBJ: List and discuss thesix rights of medication administration. TOP: Right Patient
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
14. When medications are administered, which action by thenurse is appropriate? a. Administering medications prepared by another nurse b. Using sterile technique for nonparenteral medications c. Leaving medication at thebedside when thepatient is in thebathroom d. Documenting thereason for medication refusal in thenurse‘s notes ANS: D
When a patient refuses a medication, determine thereason for it, and take action. Document refusal of medications, and notify theprescriber. Never administer a medication prepared by another nurse. Use good medical aseptic technique and perform hand hygiene before preparing a dose of medication. Avoid touching tablets and capsules. Use sterile technique for parenteral medications. Remain with thepatient as thepatient takes themedication. Provide assistance if necessary (e.g., for thepatient who is weak and unable to administer eyedrops). Do not leave medications at a patient‘s bedside without a prescriber‘s order to do so. DIF: CognitiveLevel: Application OBJ: Identify guidelines for safe administration of medications.
TOP: Medication Preparation/Medication Administration KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
15. When controlled substances are administered, which action is required by thenurse? a. Discard and sign for unused quantities. b. Count theamount of medication daily. c. Keep narcotics to be given with other patient medications. d. Have a second nurse witness disposal of unused portions and sign therecord. ANS: D
If you give only part of a premeasured dose of a controlled substance, a second nurse must witness disposal of theunused portion. Both nurses sign their names on therequired form. Store all narcotics in a locked, secure cabinet separate from thepatient‘s routine medications. (Computerized, locked cabinets are preferred.) thecomputerized dispensing system should maintain theinventory of medications. DIF: CognitiveLevel: Application OBJ: Identify guidelines for safe administration of medications. TOP: Controlled Substances
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
16. To prevent medication errors, which action should be taken by thenurse? a. Clarify illegible orders with theprescriber. b. Document themedication before administration. c. Read medication labels 2 times when preparing. d. Prepare all of thepatient‘s medications for theshift at thesame time. ANS: A
Do not interpret illegible handwriting; clarify illegible orders with theprescriber. Document all medications as soon as they are given. Be sure to read labels at least 3 times (comparing MAR with label): before, during, and after administering themedication. Prepare medications at thetime ordered, and document all medications as soon as they are given. DIF: CognitiveLevel: Application
OBJ: Identify guidelines for safe administration of medications. TOP: Medication Orders/Right Documentation KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
17. The patient is to receive a medication via thesublingual route. Which action by thenurse is appropriate? a. Placing themedication under thetongue b. Crushing themedication before administration c. Offering thepatient a glass of orange juice after administration d. Using sterile technique to administer themedication ANS: A
Administering a medication by thesublingual route involves placing thesolid medication in themouth under thetongue until themedication dissolves. Crushing themedication is not necessary because it is designed to dissolve under thetongue. Patients are not to take any liquids with medications given by sublingual administration or immediately afterward. themouth is not sterile. Sterile technique is not necessary for sublingual administration. DIF: CognitiveLevel: Application OBJ: Identify guidelines for safe administration of medications. TOP: Routes of Medication Administration KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
18. The nurse is caring for several patients. thepatient in which situation can safely receive oral medications? a. Nausea with frequent episodes of vomiting b. Taking a daily dose of vitamins c. Nasogastric tube connected to suction d. Diagnosed with an esophageal stricture ANS: B
Avoid giving oral medications to patients with alterations in gastrointestinal function (e.g., nausea and vomiting), reduced motility (after general anesthesia or inflammation of thebowel), or surgical resection of a portion of thegastrointestinal tract. Oral medications cannot be given when thepatient has gastric suctioning and are contraindicated in patients before some tests or surgery. Oral administration is contraindicated in patients who are NPO and unable to swallow (e.g., patients with neuromuscular disorders, esophageal strictures, or lesions of themouth). DIF: CognitiveLevel: Application OBJ: Identify guidelines for safe administration of medications. TOP: Factors Influencing Choice of Administration Routes KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. A patient with a history of renal failure and liver disease has been receiving morphine sulfate every 4 hours for thepast 2 weeks. thenurse finds thepatient lethargic with a respiratory rate of 6 breaths per minute. thehealth care provider orders naloxone. thenurse anticipates which effects when naloxone is given? (Select all that apply.) a. Increase in alertness b. Decrease in urine output c. Complaints of pain d. Increase in respiratory rate ANS: A, C, D
Toxic effects develop after prolonged intake of a medication, when a medication accumulates in theblood as theresult of decreased clearance by theliver and/or kidneys (because of impaired metabolism or excretion), or when too high a dose is given. For example, toxic levels of morphine, an opioid, cause severe respiratory depression and death. Antidotes are available to treat specific types of medication toxicity. For example, naloxone, an opioid antagonist, reverses theeffects of opioid toxicity.
DIF: CognitiveLevel: Application
OBJ: Discuss thetypes of medication actions.
TOP: Toxic Effects
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The nurse recognizes that patients with which conditions will have a reduction in thedistribution of drugs? (Select all that apply.) a. Peripheral vascular disease b. Heart failure c. Liver disease d. Obesity ANS: A, B
The rate and extent of distribution depends on circulation, cell membrane permeability, and protein binding. Poor perfusion (e.g., heart failure) alters medication distribution. DIF: CognitiveLevel: Application
OBJ: Discuss thetypes of medication actions.
TOP: Pharmacokinetics
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
3. The hospital has implemented a computerized physician order entry system (CPOE) to eliminate theneed for written orders. thebenefits of this system include which of thefollowing? (Select all that apply.) a. Automatic drug allergy checks b. Automatic dosage indications c. Identification of potential drug interactions d. Reduced number of medical errors ANS: A, B, C, D
Decision support software, integrated into a CPOE system, allows for automatic drug allergy checks, dosage indications, and identification of potential drug interactions. Use of CPOE systems may significantly reduce medication errors by as much as 55% to 83%. DIF: CognitiveLevel: Understanding OBJ: Describe thesafety features of medication delivery systems. TOP: Computerized Provider Order Entry
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. The nurse reviews a medication administration record for an anticoagulant that is ordered at 0900 daily. themedication record indicates that thedrug was given at thefollowing times over thepast 4 days. Which times follow the―right time‖ of medication administration? (Select all that apply.) a. 0800 b. 0830 c. 0930 d. 1000 ANS: B, C
Time-critical medications such as anticoagulants must be administered within 30 minutes of thescheduled time. Non–time-critical medications can be given 1 to 2 hours before or after thescheduled time. DIF: CognitiveLevel: Application OBJ: List and discuss thesix rights of medication administration. TOP: Right Time
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
5. Medication errors include which of thefollowing? (Select all that apply.) a. Administration of thewrong medication b. Administration via thewrong route c. Inaccurate prescribing d. Failing to administer a medication ANS: A, B, C, D
Medication errors include inaccurate prescribing and administering thewrong medication, by thewrong route, and in thewrong time interval, as well as administering extra doses or failing to administer a medication. DIF: CognitiveLevel: Understanding OBJ: Identify guidelines for safe administration of medications. TOP: Reporting Medication Errors
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
6. The nurse administers a medication to thewrong patient but thepatient suffers no harm from themedication error. What actions should thenurse take? (Select all that apply.) a. Prepare a written incident report. b. Document in thenurses‘ notes that an incident report was completed. c. Report theincident to a manager only if thepatient is harmed. d. Notify theprescriber. ANS: A, D
When a medication error occurs, thenurse assesses thepatient and notifies theprescriber as soon as possible. When thepatient is stable, thenurse notifies theappropriate person in theinstitution (e.g., manager and supervisor). thenurse is responsible for preparing a written incident report usually within 24 hours of theincident. To legally protect thenurse and theinstitution, theincident report is not referred to in thenurses‘ notes. All medication errors, including those that do not cause obvious or immediate harm, should be reported. DIF: CognitiveLevel: Application OBJ: Identify steps to take in reporting medication errors.
TOP: Reporting Medication Errors
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
COMPLETION
1. A patient receives theusual dose of a medication for thefirst time and develops severe hypotension and bradycardia. thenurse reports this event as an
type of medication
action. ANS:
adverse drug effect (ADE) adverse drug effect Adverse drug effects are unintended, undesirable, and often unpredictable. They occur at doses normally used.
DIF: CognitiveLevel: Application
OBJ: Discuss thetypes of medication actions.
TOP: Adverse Drug Effect
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. Medication safety is always one of the
set by theJoint Commission.
ANS:
National Patient Safety Goals Medication safety has consistently been one of theNational Patient Safety Goals. DIF: CognitiveLevel: Remembering OBJ: Discuss National Patient Safety Goals for medication administration. TOP: National Patient Safety Goals
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. The intended or desired physiological response to a medication is known as its . ANS:
therapeutic effect Each medication has a therapeutic effect—the intended or desired physiological response to a medication. For example, thenurse administers morphine sulfate, an analgesic, to relieve a patient‘s pain. DIF: CognitiveLevel: Remembering
OBJ: Discuss thetypes of medication actions.
TOP: Therapeutic Effects
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4.
are predictable and often unavoidable secondary effects of a medication produced at a usual therapeutic drug dose. ANS:
Side effects Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. For example, some antihypertensive medications cause impotence in male patients. DIF: CognitiveLevel: Remembering
OBJ: Discuss thetypes of medication actions.
TOP: Side Effects/Adverse Effects
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient reports taking an opioid medication in large dosages for thepast several years. While in thehospital, thepatient is not prescribed themedication and develops tachycardia, hypertension, sweating, and tremors. He becomes confused and experiences visual hallucinations. thenurse recognizes these signs as indicative of
_.
ANS:
physical dependence Drug dependence can be physical or psychological. Physical dependence is manifested by intense physical disturbance when themedication is withdrawn. DIF: CognitiveLevel: Application
OBJ: Discuss thetypes of medication actions.
TOP: Medication Tolerance and Dependence KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
6. A drug interaction in which thecombined effect of drugs is greater than thesum of theeffects of each individual agent acting independently is known as a ANS:
synergistic effect
.
A synergistic effect is a drug interaction in which thecombined effect of two drugs is greater than thesum of theeffects of each individual agent acting independently. In other words, 1+1 = 3 or more. theuse of a combination of drugs to treat hypertension is an example of synergism. Each drug lowers blood pressure but in a different way; thesummed effect produces a greater reduction in hypertension than is produced by theeffects of each medication. DIF: CognitiveLevel: Remembering
OBJ: Discuss thetypes of medication actions.
TOP: Medication Interactions
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
7. The prescriber orders an IV antibiotic every 8 hours. thenurse administers themedication at 0900. themedication‘s onset of action is 5 minutes, peak action is 30 minutes, and duration is 6 to 24 hours. An order for peak and trough levels is written. thenurse will have thepeak level drawn at
.
ANS:
0930 The highest level is called thepeak concentration. thepeak level is drawn whenever thedrug is expected to reach its peak concentration. DIF: CognitiveLevel: Application
OBJ: Discuss thetypes of medication actions.
TOP: Medication Dose Responses
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
8. The nurse administers 100 mg of a drug at 0800. thedrug‘s biological half-life is 4 hours. A serum drug level is drawn at 1600. thenurse should anticipate be left in thebody at 1600? ANS:
25 mg
_ milligrams will
Biological half-life is thetime it takes for excretion processes to lower theserum medication concentration by half. After thefirst half-life (1200), 50 mg will be left in thebody. After thesecond half-life (1600), 25 mg will be left in thebody. Each half-life lowers theamount of drug in thebody by half. DIF: CognitiveLevel: Application
OBJ: Discuss thetypes of medication actions.
TOP: Medication Dose Responses
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
9. A patient reports a pain level of 7 out of 10 and receives 10 mg of morphine IV. thenurse knows that IV morphine has an onset of 1 to 2 minutes, a peak of 20 minutes, and a duration of 4 to 5 hours. thepatient asks when he will start to feel some pain relief. thenurse should respond that relief should begin in
_.
ANS:
1 to 2 minutes The period of time it takes after a medication is administered for it to produce a therapeutic effect is known as theonset of medication action. DIF: CognitiveLevel: Application
OBJ: Discuss thetypes of medication actions.
TOP: Onset of Medication Action
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
10. The nurse administers 650 mg of acetaminophen orally to a patient with a pain level of 4 out of 10. thenurse is aware that theonset of action is 30 minutes to 1 hour, thepeak action is 1 to 3 hours, and theduration of action is 3 to 8 hours. After
hours, thenurse should assess
thepatient to determine themaximum effectiveness of thedrug. ANS:
1 to 3 Peak action is thetime it takes for a medication to reach its highest effective peak concentration.
DIF: CognitiveLevel: Application TOP: Peak Action
OBJ: Discuss thetypes of medication actions.
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
11. A patient is prescribed diltiazem tablets, which have an onset of 30 minutes, a peak of 2 to 3 hours, and a duration of 6 to 8 hours. thenurse anticipates that themedication will be prescribed
_ per day.
ANS:
3 to 4 times Duration of action is thelength of time during which themedication is present in a concentration great enough to produce a therapeutic effect. A medication with a duration of action of 6 to 8 hours will usually be given 3 to 4 times daily to maintain therapeutic effects. DIF: CognitiveLevel: Application
OBJ: Discuss thetypes of medication actions.
TOP: Duration of Action
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
12. The
_ of a drug is theblood serum concentration reached and maintained
after repeated, fixed doses. ANS:
plateau The plateau of a drug is theblood serum concentration reached and maintained after repeated, fixed doses. DIF: CognitiveLevel: Remembering TOP: Plateau
OBJ: Discuss thetypes of medication actions.
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
13. A medication distribution system that uses individual patient drawers and whereby medication is packaged according to what thepatient would receive at one time is known as the system. ANS:
unit-dose The standard for medication distribution is theunit-dose system. thesystem uses automated medication dispensing systems or carts containing a drawer with a 24-hour supply of medications for each patient. Each drawer has a label with thename of thepatient in thedesignated room. theunit dose is theordered dose of medication thepatient receives at one time. DIF: CognitiveLevel: Remembering OBJ: Describe thesafety features of medication delivery systems. TOP: Unit Dose
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
14. The patient is to receive 200 mg of a medication. There are 100-mg scored tablets available. thenurse prepares
tablets.
ANS:
2 The dose ordered is theamount of medication prescribed (e.g., 200 mg). thedose on hand is thedose (e.g., mg, mL, units) of medication supplied by thepharmacy (in this case, 100-mg tablets). theamount on hand is theweight or volume of medication available and supplied by thepharmacy. It appears on themedication label as thecontents of a tablet or capsule, or as theamount of medication dissolved per unit volume of liquid. theamount on hand is thebasic quantity of themedication that contains thedose on hand. For solid medications, theamount on hand is often one capsule; theamount of liquid on hand is often 1 mL or 1 L (in this case, it is 1 tablet). theamount to be administered (e.g., mL, mg) is always expressed in thesame measure as theamount on hand.
DIF: CognitiveLevel: Application
OBJ: Accurately calculate medication doses.
TOP: Dosage Calculations
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
15. The dose ordered for a patient is 75 mg IM. themedication is available in a 50-mg/mL solution. thenurse prepares
mL.
ANS:
1.5 The dose ordered is theamount of medication prescribed (e.g., 75 mg). thedose on hand is thedose (e.g., mg, mL, units) of medication supplied by thepharmacy (in this case, a 50-mg solution). theamount on hand is theweight or volume of medication available and supplied by thepharmacy. It appears on themedication label as thecontents of a tablet or capsule, or as theamount of medication dissolved per unit volume of liquid. theamount on hand is thebasic quantity of themedication that contains thedose on hand. theamount of liquid on hand is often 1 mL or 1 L (in this case, it is 1 mL). theamount to administer (e.g., mL, mg) is always expressed in thesame measure as theamount on hand.
DIF: CognitiveLevel: Application
OBJ: Accurately calculate medication doses.
TOP: Dosage Calculations
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
16. The prescriber orders 3 mg/kg/d of a medication to be given in 3 equal doses. thepatient weighs 44 pounds. thenurse calculates that theproper amount per dose is ANS:
20 mg Convert pounds to kilograms. 44 pounds 1 kg/2.2 pounds = 20 kg Solve theequation for how many mg/dose. 20 kg 3 mg/kg = 60 mg/dose Solve theequation for how many mg/dose. 60 mg divided by 3 equal doses = 20 mg/dose DIF: CognitiveLevel: Application
OBJ: Accurately calculate medication doses.
TOP: Pediatric Doses
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
17. The nurse calculates that theproper dosage of a medication is 2 tsp. thenurse prepares mL to administer to thepatient. ANS:
10 Conversion: 1 tsp = 5 mL; 2 tsp = 10 mL. DIF: CognitiveLevel: Application
OBJ: Accurately calculate medication doses.
TOP: Equivalents of Measurement
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
Chapter 21: Nonparenteral Medications Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
.
MULTIPLE CHOICE
1. The nurse is administering a buccal medication. Which instruction should be given to thepatient? a. Hold themedication under thetongue. b. Swallow themedication after 30 seconds. c. Chew themedication before swallowing. d. Hold themedication against thecheek membranes. ANS: D
For buccal administered medications: Have patient place medication in mouth against mucous membranes of cheek and gums until it dissolves. Buccal medications act locally or systemically as they are swallowed in saliva. DIF: CognitiveLevel: Application OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Buccal Medication
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
2. The nurse is preparing to administer a medication. Which of thefollowing is themost critical to assess before medication administration? a. Diet history b. Allergy history c. Surgical history d. Drug tolerance ANS: B
Drug allergies should be listed on each page of themedication administration record (MAR), prominently displayed on thepatient‘s medical record, and thepatient should be wearing theagency‘s allergy bracelet. Assessment for drug allergies is necessary before medication is administered. A patient‘s diet, surgical, and drug histories are important to assess, but they are not as critical as allergy history, which can reveal life-threatening conditions. DIF: CognitiveLevel: Application OBJ: Identify guidelines for administering oral, enteral, and topical medications.
TOP: Allergy History
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
3. The nurse is preparing oral medications for administration. Which action by thenurse is appropriate? a. Using a cutting device to cut scored tablets b. Unwrapping all of themedications to be given and placing them together in a cup c. Crushing capsules and enteric-coated medication for easier swallowing d. Holding themedication cup at eye level to pour a liquid dosage ANS: A
If it is necessary to give half thedose of medication, pharmacy should split, label, package, and send medication to unit. In health care agencies, only pharmacy should split tablets to ensure patient safety (ISMP, 2017). Reduces contamination of tablet. If you have to break a medication to administer half thedosage, use a clean, gloved hand to break thetablet or cut it with a cutting device. Tablets that are to be broken in half must be prescored by a manufactured line that transverses thecenter of thetablet. Tablets that are not prescored cannot be broken into equal halves, and theresult will be an inaccurate dose. Using a cutting device results in a more even split of thetablet. Wrappers maintain thecleanliness of medications and identify drug name and dose. Not all drugs can be crushed (e.g., capsules, enteric-coated, and long-acting/slow-release drugs). thecoating of these drugs protects thestomach from irritation or protects thedrug from destruction by stomach acids. Liquid medications poured from a stock bottle should be poured into a medication cup that is placed at eye level on a flat surface. DIF: CognitiveLevel: Application OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Cutting Tablets
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The nurse is caring for four patients who require medications at 0900. Which action by thenurse adheres to theseven rights of medication administration? a. Prepare medications for all of thepatients at once and keep thecups separate.
b. Ask thesupervisor to clarify an unclear medication order. c. Give theprescribed anticonvulsant between 0830 and 0930. d. Leave each patient‘s medications at thebedside and return within 30 minutes to make sure they have been taken. ANS: C
Time-critical medications such as anticonvulsants must be given within 30 minutes of theprescribed time. Prepare medications for one patient at a time. Keep all pages of theMAR for one patient together. This prevents preparation errors. Unclear orders should be clarified with theprescriber before administration. Stay with each patient until themedication is swallowed completely or is taken by theprescribed route. DIF: CognitiveLevel: Application OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Administering Oral Medication
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
5. What should thenurse do to assist a patient who is having difficulty swallowing tablets? a. Administer themedication with less fluid. b. Insert a nasogastric tube and instill themedication. c. Crush themedications and administer with a small amount of food. d. Administer thetablets one at a time with plenty of water. ANS: C
If thepatient has difficulty swallowing, use a pill-crushing device to crush thetablets. Mix theground tablet in a small amount of soft food (custard or applesauce). Large tablets are often difficult to swallow. A ground tablet mixed with palatable soft food is usually easier to swallow. Not all drugs can be crushed (e.g., capsules, enteric-coated, and long-acting/slow-release drugs). thecoating of these drugs protects thestomach from irritation or protects thedrug from destruction by stomach acids. Administration of medication with less fluid could make it more difficult for thepatient to swallow. Insertion of a nasogastric tube requires an order from thehealth care provider. A patient who is having difficulty swallowing may not be safe when swallowing large capsules or tablets even one at a time. Thin liquids such as water are more readily aspirated than thickened liquids.
DIF: CognitiveLevel: Application OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Crushing MedicationsKEY:
NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
6. The nurse is preparing to administer a pediatric dose of liquid medication to an infant. Which action by thenurse is appropriate? a. Empty theunit-dose container into a plastic cup. b. Gently shake themulti-dose bottle before pouring themedication. c. Draw themedication into a syringe with a needle. d. Use an oral syringe to measure liquid dosages greater than 25 mL. ANS: B
Use unit-dose container with correct amount of medication. Gently shake container. Administer medication packaged in a single-dose cup directly from thesingle-dose cup. Do not pour medicine into another cup. Using unit-dose container with correct dosage of medication provides most accurate dose of medication (ISMP, 2017). Shaking container ensures that medication is mixed before administration. DIF: CognitiveLevel: Application OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Pediatric Liquid Medications
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
7. The patient is unable to sit upright for medication administration. thenurse should assist thepatient to which position to decrease therisk for aspiration? a. Prone b. Supine c. Side-lying d. Dorsal recumbent ANS: C
Assist thepatient to a side-lying position if sitting is contraindicated by thepatient‘s condition. This decreases therisk for aspiration during swallowing. Swallowing is difficult or impossible in theprone position. therisk for aspiration is increased when thepatient is swallowing in thesupine position or in thedorsal recumbent position. DIF: CognitiveLevel: Application OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Positioning of Patient
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse is preparing to give sublingual nitroglycerin to a patient complaining of chest pain. thenurse instructs thepatient not to swallow themedication. Why is this instruction important? a. The effects of themedication will be nullified if swallowed. b. Sublingual drugs begin to dissolve when placed on thetongue. c. The medication needs to be held against thecheek membranes until dissolved. d. The patient may aspirate on thewater used for these medications. ANS: A
If swallowed, thedrug is destroyed by gastric juices or is detoxified so rapidly by theliver that therapeutic blood levels are not attained. Orally disintegrating formulations begin to dissolve when placed on thetongue. Sublingually administered medications are placed under thetongue and are allowed to dissolve completely. Water is not needed with these medications. DIF: CognitiveLevel: Application OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Sublingual Medications
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
9. The nurse is preparing a medication for a small child. themedication comes in pill or liquid form, but theliquid preparation has a bitter taste. Which action by thenurse is most appropriate? a. Give thepill form. b. Mix theliquid with honey. c. Mix theliquid in milk.
d. Mix theliquid in applesauce. ANS: D
Children will refuse bitter or distasteful oral preparations. Mix thedrug with a small amount (about 1 tsp) of a sweet-tasting substance such as jam, applesauce, sherbet, ice cream, or fruit puree. Offer thechild juice or a flavored ice pop after medication administration. Liquid forms of medication are safer to swallow to avoid aspiration of small pills. Do not use honey in infants because of therisk for botulism. Do not place medication in an essential food item such as milk or formula; thechild may refuse thefood at a later time. DIF: CognitiveLevel: Application OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Pediatric Considerations
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
10. The nurse is preparing to administer aspirin to a patient via an enteral feeding tube. Which form is appropriate for thenurse to administer? a. Crushed chewable aspirin b. Liquid aspirin c. Enteric-coated aspirin d. Sustained-release aspirin capsule ANS: B
Preferably, medications administered by enteral tubes should be given in liquid form. If liquid form is not available, you will have to modify theform of themedication tablet by crushing or dissolving it. However, you cannot crush sustained-release, chewable, long-acting, or enteric-coated tablets and capsules. Therefore, do not administer these medications by enteral tubes. Consult with thehospital pharmacy when in doubt. DIF: CognitiveLevel: Understanding OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Enteral Feeding Tubes MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
11. The nurse is preparing to administer a medication via a jejunostomy tube to a patient who is receiving continuous tube feedings. themedication needs to be given on an empty stomach and comes only in tablet form. What action should thenurse take first? a. Add themedications directly to thetube feeding. b. Flush thetubing before themedication is given. c. Stop thefeeding 30 minutes before medication administration. d. Dissolve themedication in cold water. ANS: C
Determines if medication interacts with enteral feedings. If there is a risk of interaction, stop feeding for at least 20 minutes before administering medication (check agency policy). Never add crushed medications directly to thetube feeding. Whenever possible, use liquid medications instead of crushed tablets, but if you have to crush tablets, thetubing must be flushed before and after themedication is given to prevent thedrug from adhering to theinside of thetube. Dissolve in at least 30 mL of warm water. Cold water causes gastric cramping. DIF: CognitiveLevel: Application OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Instilling Crushed Medications
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The nurse is to administer several medications to a patient via a nasogastric (NG) tube. What should thenurse do first? a. Add themedications to thetube feeding being given. b. Crush all tablets and capsules before administration. c. Administer all of themedications mixed together. d. Check for placement of theNG tube. ANS: D
Check theplacement of thefeeding tube by observing gastric contents and checking thepH of aspirated contents. Gastric pH should be 5 or less. This ensures proper tube placement and reduces therisk of introducing fluids into therespiratory tract. Never add medications directly to thetube feeding. Not all tablets can be crushed, such as sustained-release tablets, nor should all capsules be opened. Medications should be reviewed carefully before a tablet is crushed or a capsule is opened. To administer more than one medication, give each separately, and flush between medications with 10 mL of water. Keeping themedications separate allows for accurate identification of medication if a dose is spilled. In addition, some medications are not compatible with each other, and this may cause clogging of thetube. DIF: CognitiveLevel: Application OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Administering Several Medications via NG Tube KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
13. When preparing to administer medication via a nasogastric tube, thenurse aspirates 275 mL of gastric residual. What is thefirst action thenurse should take? a. Wait 1 hour and recheck theresidual. b. Administer themedication with more fluid. c. Return theaspirate and withhold themedication. d. Attach thenasogastric tube to suction to remove additional volume. ANS: C
Return aspirated contents to stomach unless a single GRV exceeds 250 mL (see agency policy). When GRV is excessive, hold medication and contact health care provider. GRV categories have been identified in studies as significant when patients have two or more GRVs exceeding 500 mL (Boullata and others, 2017). Large residuals indicate delayed gastric emptying and put patient at increased risk for aspiration. DIF: CognitiveLevel: Application OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Gastric Residual MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
14. The patient is to receive three different medications via a nasogastric tube. What is thetotal amount of water thenurse should prepare to administer? a. 30 mL of water b. 60 mL of water c. 90 mL of water d. 250 mL of water ANS: C
30 mL of water is administered before themedications, 15 to 30 mL of water is administered after each of thefirst two medications, and 30 to 60 mL is administered after thethird medication, so 90 to 150 mL of water is needed. DIF: CognitiveLevel: Analysis OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Flushing theNG Tube KEY:
NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
15. The nurse is applying a new nitroglycerin transdermal patch. Which action by thenurse is appropriate? a. Instructing thepatient to wear thepatch 24 hours a day every day b. Applying thenew patch to thesame site as theprevious patch c. Cutting thepatch in half when a change of dose is ordered d. Instructing thepatient to avoid heat sources over thepatch ANS: D
Heat sources over a transdermal patch can increase therate of absorption, leading to potentially serious adverse effects. It is recommended to have a daily ―patch-free‖ interval of 10 to 12 hours because tolerance develops if patches are used 24 hours a day every day. thepatch should not be applied to previously used sites for at least 1 week. Transdermal patches are never to be cut in half. A change in dosage requires a new prescription. DIF: CognitiveLevel: Application OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Applying Topical Medications
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
16. The nurse is teaching a patient how to use a topical medication. Which statement indicates an understanding of theprocedure? a. ―If thepatch starts to come off, I can secure it with tape.‖ b. ―If thepatch falls off, I will put a new one on in thesame place.‖ c. ―If my skin is irritated, I will cleanse it using water only.‖ d. ―I can dispose of used materials in thehousehold trash as usual.‖ ANS: C
If skin is inflamed, instruct patients to use only warm water rinse without soap for cleansing. Instruct thepatient on how to manage a transdermal patch that begins to peel off before thenext dose is due. Rather than tape thepatch or cover it, instruct thepatient to remove thepatch, clean theskin, and apply a new patch to a different area. Instruct thepatient to wrap applicators, used patches, and similar materials and dispose of them into cardboard or plastic disposable containers. Careful disposal is necessary to ensure thesafety of thepatient, other adults, pets, and children. DIF: CognitiveLevel: Application OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Applying Topical Medications
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
17. The patient is prescribed an ophthalmic medication via an intraocular disc. Which action by thenurse is appropriate when administering themedication? a. Place thedisc in theconjunctival sac. b. Apply sterile gloves before placing thedisc. c. Pull on thepatient‘s upper eyelid and ask thepatient to look up. d. Instruct thepatient that thedisc will be changed daily. ANS: A
Medications delivered by disc resemble a contact lens, but thedisc is placed in theconjunctival sac, not on thecornea. Clean gloves are used to place and remove thedisc. thelower eyelid is pulled down and thepatient is asked to look up. thedisc remains in place for up to 1 week.
DIF: CognitiveLevel: Application OBJ: Correctly administer medications for irrigation and instillation. Differentiate types of topical administration that require sterile technique from those that require medical aseptic technique. TOP: Instilling Eye and Ear Medications
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
18. The patient has eyedrops ordered daily to both eyes. Which action by thenurse is appropriate when administering themedication? a. Carefully place thedrop on thecornea. b. Wipe theeye with a tissue after placing theeyedrop. c. Hold theeyedropper about 1 to 2 cm above theeye. d. Instruct thepatient to squeeze theeye shut after instillation. ANS: C
Holding theeyedropper approximately 1 to 2 cm (1/2 to 3/4 inch) above theconjunctival sac of theeye prevents accidental contact of theeyedropper with theeye and reduces risk for injury and transfer of microorganisms to thedropper. thecornea is very sensitive. If drops were instilled onto thecornea, this would stimulate theblink reflex. thetissue should be placed just below thelower eyelid so medication that escapes theeye is absorbed. Wiping theeye removes too much of themedication. Squinting or squeezing theeyelids after instillation forces themedication from theconjunctival sac. DIF: CognitiveLevel: Application OBJ: Correctly administer medications for irrigation and instillation. TOP: Instilling Eye and Ear Medications
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
19. The nurse is preparing to administer an eye ointment to thepatient. Which action by thenurse is appropriate? a. Clean away drainage or crusts by wiping from theouter to theinner canthus. b. Instruct thepatient to keep theeye open for 2 minutes after instillation. c. Apply a thin ribbon evenly along theinner edge of thelower eyelid. d. Instruct thepatient to avoid wiping theeye after instillation. ANS: C
While holding theointment applicator above thelower lid margin, apply a thin ribbon of ointment evenly along theinner edge of thelower eyelid on theconjunctiva from theinner canthus to theouter canthus. This distributes medication evenly across theeye and lid margin. Eyes are cleansed from theinner to theouter canthus to avoid entry of microorganisms into thelacrimal duct. After instillation, thepatient is instructed to close theeye and rub thelid lightly in a circular motion, if not contraindicated, to distribute themedication. If excess medication is on theeyelid, it can be gently wiped from theinner to theouter canthus. DIF: CognitiveLevel: Application OBJ: Correctly administer medications for irrigation and instillation. TOP: Instilling Eye and Ear Medications
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
20. A patient is experiencing a systemic effect from eyedrops. Which assessment finding by thenurse is indicative of this? a. Headache b. Reddened eyes c. Darkened conjunctiva d. Elevated pulse and blood pressure ANS: D
An unexpected outcome is noted when thepatient experiences systemic effects from drops (e.g., increased heart rate and blood pressure from epinephrine, decreased heart rate and blood pressure from timolol). Local side effects include headache, bloodshot eyes, and local eye irritation. DIF: CognitiveLevel: Analysis OBJ: Correctly administer medications for irrigation and instillation. TOP: Unexpected Outcomes of an Eye Medication KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
21. A nurse is preparing to administer eardrops to an adult patient. Which action should be taken by thenurse? a. Warm themedication to room temperature using warm water.
b. Pull thepinna down and back to straighten theear canal. c. Apply gentle pressure or massage to thepinna of theear. d. Remove cerumen from theinner ear canal with a cotton-tipped applicator. ANS: A
Internal ear structures are very sensitive to temperature extremes. Failure to instill a solution at room temperature can cause vertigo (severe dizziness) or nausea and can debilitate a patient for several minutes. Pulling thepinna down and back is theprocedure for children aged 3 and younger. Do not massage thepinna of theear; instead massage thetragus. Gentle pressure or massage to thetragus of theear moves medication inward. Cerumen is removed from theouter canal only. DIF: CognitiveLevel: Application OBJ: Correctly administer medications for irrigation and instillation. TOP: Instilling Eye and Ear Medications
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
22. The nurse administers eardrops in thepatient‘s left ear. Which of thefollowing positions is appropriate after instillation of thedrops? a. Prone b. Upright c. Right lateral d. Dorsal recumbent with hyperextension of theneck ANS: C
The patient should remain in theside-lying position, with thetreated ear upward for a few minutes. Upright, prone, and dorsal recumbent positions are not recommended after administration of eardrops. theeardrops would run out of theear canal. DIF: CognitiveLevel: Application OBJ: Correctly administer medications for irrigation and instillation. TOP: Administering Eye and Ear Medications KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
23. How should thenurse position thepatient to administer nose drops to themaxillary sinus? a. Sitting upright with thehead tilted backward toward theside to be treated b. Supine with a small pillow under theshoulders and thehead tilted backward c. Supine with thehead tilted backward and turned to theunaffected side d. Head tilted back over theedge of thebed and turned toward theside to be treated ANS: D
For access to thefrontal and maxillary sinus, tilt thehead back over theedge of thebed or pillow with thehead turned toward theside to be treated. This position allows medication to drain into theaffected sinus. For access to theposterior pharynx, tilt thepatient‘s head backward. For access to theethmoid or sphenoid sinus, tilt thehead back over theedge of thebed or place a small pillow under thepatient‘s shoulder and tilt thehead back. DIF: CognitiveLevel: Application OBJ: Correctly administer medications for irrigation and instillation. TOP: Positioning to Administer Nose Drops to Maxillary Sinus KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
24. The nurse is teaching a mother how to administer nasal drops to her infant. What should be included in theteaching plan? a. Over-the-counter nasal drops can be saved and used later. b. Nasal decongestants are safe and have no serious side effects. c. Infants should receive nose drops 20 to 30 minutes before feedings. d. Infants are mouth breathers, so nasal medications are well tolerated. ANS: C
Infants are nose breathers, and thepossible congestion caused by nasal medications may inhibit their sucking. Administer nose drops 20 to 30 minutes before feedings. Over-the-counter nasal sprays or nose drops should be used for only one illness; bottles become easily contaminated with bacteria. Nasal decongestants can enter thesystemic circulation by way of thenasal mucosa or thegastrointestinal tract if swallowed, causing restlessness, nervousness, tremors, or insomnia in some patients. Long-term use can worsen nasal congestion through a rebound effect.
DIF: CognitiveLevel: Application OBJ: Prepare a teaching plan regarding medication use for a selected patient. TOP: Teaching and Pediatric Considerations Relative to Nasal Medication KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
25. Several patients have been prescribed inhalation medications. thenurse is aware that a spacer will be beneficial for which patient? a. A young child using a dry powder inhaler b. An elderly patient who uses a metered-dose inhaler c. A teenager who has just started using a nebulizer d. A young child who needs medication several times per day ANS: B
Because use of a metered-dose inhaler (MDI) requires coordination during thebreathing cycle, many patients spray only theback of their throat and fail to receive a full dose. theinhaler must be depressed to expel medication just as thepatient inhales. This ensures that themedication reaches thelower airways. Poor coordination can be solved by theuse of spacer devices. Coordination is not necessary with dry powder inhalers or nebulizers. theuse of a spacer is not dependent on theschedule of administration. DIF: CognitiveLevel: Application OBJ: Instruct patients in theproper use of a metered-dose inhaler (MDI), a dry powder inhaler (DPI), and a small-volume nebulizer.
TOP: Using Metered-Dose Inhalers
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
26. The nurse is teaching a patient how to use a metered-dose inhaler without a spacer. Which action by thepatient demonstrates correct use of thedevice? a. Being careful not to shake thecanister b. Positioning themouthpiece in front of themouth while not touching thelips c. Depressing thecanister fully, waiting 3 to 5 seconds, then inhaling slowly and deeply d. Taking another puff of themedication within 10 seconds ANS: B
The best way to deliver medication without a spacer is to position themouthpiece 2 to 4 cm in front of a widely opened mouth with theopening of theinhaler toward theback of thethroat. thelips should not touch theinhaler. Shaking theinhaler before administration is thecorrect procedure; it mixes themedication within thecanister. thecorrect procedure is to depress thecanister fully while inhaling slowly and deeply through themouth for 3 to 5 seconds. A wait of 20 to 30 seconds is advised between doses of thesame medication; 2 to 5 minutes is thestandard time between doses of different medications. DIF: CognitiveLevel: Application OBJ: Instruct patients in theproper use of a metered-dose inhaler (MDI), a dry powder inhaler (DPI), and a small-volume nebulizer.
TOP: Metered-Dose Inhalers
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
27. The patient has a bronchodilator and an inhaled steroid scheduled for thesame time. What teaching should thenurse provide to thepatient about administering these medications? a. Inhale thebronchodilator, wait 20 to 30 seconds, then inhale thesteroid. b. Inhale thebronchodilator, wait 2 to 5 minutes, then inhale thesteroid. c. Inhale thesteroid, wait 20 to 30 seconds, then inhale thebronchodilator. d. Inhale thesteroid, wait 2 to 5 minutes, then inhale thebronchodilator. ANS: B
Drugs must be inhaled sequentially. If bronchodilators are administered with inhaled steroids, thebronchodilators should be given first to dilate theairway passages for thesecond medication. thepatient is instructed to wait 2 to 5 minutes between inhalations when different medications are being given. thepatient is instructed to wait 20 to 30 seconds between inhalations if thesame medication is being taken. DIF: CognitiveLevel: Application OBJ: Prepare a teaching plan regarding medication use for a selected patient. TOP: Bronchodilators and Steroids
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
28. The nurse is administering a beta-adrenergic medication via a small-volume nebulizer. Which assessment finding requires thenurse to withhold themedication immediately?
a. Episodes of coughing b. Rapid and shallow respirations c. Wheezing noted on auscultation of thelungs d. Irregular pulse with light-headedness ANS: D
If thepatient experiences cardiac dysrhythmias (light-headedness, syncope), especially if receiving beta-adrenergics, withhold all additional doses of medication, assess vital signs, and notify theprescriber regarding reassessment of thetype of medication and delivery method. Coughing, rapid and shallow respirations, and wheezing would be assessed and recorded, but this would not necessarily require discontinuation of treatment. theprescriber would be notified to reassess thetype of medication and/or delivery system. DIF: CognitiveLevel: Application OBJ: Identify conditions contraindicating theadministration of medications by various oral and topical routes.
TOP: Dysrhythmias
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
29. The nurse is preparing to administer a rectal suppository to a patient. thepatient should be assisted to which position for insertion of therectal suppository? a. Prone b. Supine c. Dorsal recumbent d. Left Sims‘ position ANS: D Help patient assume left side-lying Sims' position with upper leg flexed upward
Left side-lying Sims‘ position exposes theanus and helps thepatient to relax theexternal anal sphincter, while lessening thelikelihood that thesuppository or feces will be expelled. Supine and dorsal recumbent positions would make access to theanus difficult and would allow thesuppository to slip out. theprone position would make inserting thesuppository difficult. DIF: CognitiveLevel: Application OBJ: Correctly administer medications for irrigation and instillation.
TOP: Inserting a Suppository
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
30. The nurse is preparing to administer a rectal suppository to an adult patient. Which action should be taken by thenurse? a. Apply sterile gloves before handling thesuppository. b. Apply extra lubricant to thesuppository if there is active rectal bleeding. c. Insert thesuppository past theinternal sphincter, against therectal wall, about 6 to 10 inches. d. Instruct thepatient to remain lying flat or on theside for 5 minutes after insertion of thesuppository. ANS: D
Lying flat or on theside for 5 minutes after thesuppository is inserted prevents it from being expelled. Administering a suppository is not a sterile procedure; clean examination gloves are used. A suppository is contraindicated in thepresence of active bleeding. thesuppository is inserted 10 cm (4 inches). DIF: CognitiveLevel: Application OBJ: Correctly administer medications for irrigation or instillation. Differentiate types of topical administration that require sterile technique from those that require medical aseptic technique. TOP: Inserting a Suppository
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. The nurse receives orders on several patients for oral medications. thenurse will question theorder on patients with which conditions? (Select all that apply.) a. History of asthma and difficulty breathing b. Inability to swallow food c. Decreased level of consciousness d. Use of gastric suction ANS: B, C, D
Certain situations contraindicate receiving medications by mouth, such as nausea/vomiting, inability to swallow, bowel inflammation, reduced peristalsis, recent gastrointestinal surgery, gastric suction, and decreased level of consciousness. Alterations in GI function can interfere with absorption, distribution, and excretion of thedrug. Impaired swallowing and decreased level of consciousness increase therisk for aspiration. A history of asthma and difficulty breathing is not a contraindication to oral medications. DIF: CognitiveLevel: Application OBJ: Describe factors to assess before administering medications. TOP: Oral Route of Drug Administration KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The nurse is preparing several topical medications for a patient. thenurse identifies which of thefollowing as ways to administer a topical medication? (Select all that apply.) a. Administering through an enteral tube placed in thejejunum b. Inhaling an aerosol spray into thelungs c. Spraying a mist into thenose d. Dissolving a medication under thetongue ANS: B, C, D
Topical medications can be applied by direct application of liquid (eyedrops, gargling, and swabbing thethroat), insertion of a drug into a body cavity (rectal or vaginal suppositories, vaginal creams or foams), instillation of fluid into a body cavity (fluid is retained) (eardrops, nose drops, bladder, and rectal instillation), irrigation of a body cavity (fluid is not retained) (flushing eye, ear, vagina, bladder, or rectum with medicated fluid), spraying (instillation into nose or throat or under thetongue), and inhalation of medicated aerosol spray or dry powder medication (distributes medication throughout thenasal passages and thetracheobronchial airway). Medication may be directly applied to theskin or mucosa (lotion, ointment, cream, powder, foam, spray, patch, and disc), or it may be given by thesublingual (medication placed under thetongue and allowed to dissolve) or buccal (medication placed between theupper or lower molar teeth and cheek area and allowed to dissolve) route. Medications placed in thegastrointestinal tract via an enteral tube are not topical medications. DIF: CognitiveLevel: Understanding
OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Topical Medications
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. The nurse is preparing to administer medications to a patient with an enteral tube. thenurse can safely give themedications through which types of enteral tube? (Select all that apply.) a. Nasogastric feeding tube b. Percutaneous endoscopic gastrostomy tube c. Jejunostomy tube d. Nasogastric decompression tube ANS: A, B, C
A nasogastric feeding tube, a percutaneous endoscopic gastrostomy (PEG) tube, and a jejunostomy tube are used to administer enteral feedings and can also be used to administer medications. Do not administer medications into nasogastric tubes that are inserted for decompression. DIF: CognitiveLevel: Application OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Enteral Feeding Tubes
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
4. The nurse is teaching a patient with asthma about using a metered-dose inhaler to administer albuterol. Which statements should thenurse include in theteaching plan? (Select all that apply.) a. This medication can produce systemic effects such as tachycardia and tremors. b. After inhaling themedication, hold your breath for about 10 seconds. c. After inhaling themedication and holding your breath, exhale slowly through an open mouth. d. After thelast dose, do not rinse your mouth or drink any water for at least 1 hour. ANS: A, B
Inhaled medications are designed to produce local effects; for example, bronchodilators open narrowed bronchioles. However, because these medications are absorbed rapidly through thepulmonary circulation, some have thepotential for producing systemic side effects. Holding thebreath for 10 seconds after inhalation allows theaerosol to penetrate deeper areas of thelung. Exhalation should occur slowly through thenose or pursed lips to keep thesmall airways open during exhalation. About 2 minutes after thelast dose, themouth should be rinsed with warm water because inhaled bronchodilators may cause dry mouth and taste alterations. DIF: CognitiveLevel: Application OBJ: Prepare a teaching plan regarding medication use for a selected patient. TOP: Metered-Dose Inhalers
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
COMPLETION
1. The easiest and most desirable way to administer medications is via the
route.
ANS:
oral The oral route is theeasiest and most desirable way to administer medications. Patients usually ingest or self-administer oral medication with few problems. DIF: CognitiveLevel: Knowledge OBJ: Describe factors to assess before administering medications. TOP: Oral Route of Drug Administration KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. Medications in theform of drops or ointments will have theword thecontainer to identify them as eye medications. ANS:
ophthalmic
on
Common eye (ophthalmic) medications used by patients are drops and ointments, including over-the-counter preparations such as artificial tears and vasoconstrictors (e.g., Visine and Murine). DIF: CognitiveLevel: Knowledge OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Applying Ophthalmic Medications
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
3. Handheld devices that disperse medications through an aerosol spray or mist to penetrate lung airways are known as
.
ANS:
metered-dose inhalers (MDIs) metered-dose inhalers MDIs are handheld devices that disperse medications through an aerosol spray or mist to penetrate lung airways. DIF: CognitiveLevel: Knowledge OBJ: Instruct patients in theproper use of a metered-dose inhaler (MDI), a dry powder inhaler (DPI), and a small-volume nebulizer.
TOP: Using Metered-Dose Inhalers
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. Handheld devices that deliver inhaled medication in a fine powder to penetrate lung airways are known as
.
ANS:
dry powder inhalers (DPIs) dry powder inhalers DPIs are handheld devices that deliver inhaled medication in a fine powder formulation to therespiratory tract.
DIF: CognitiveLevel: Knowledge OBJ: Instruct patients in theproper use of a metered-dose inhaler (MDI), a dry powder inhaler (DPI), and a small-volume nebulizer.
TOP: Using Dry Powdered Inhaled Medications
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
Chapter 22: Parenteral Medications Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The nurse is preparing an injection of 0.45 mL of medication for a pediatric patient. Which syringe is most appropriate? a. Tuberculin syringe b. Insulin syringe c. 3-mL syringe d. 10-mL syringe ANS: A
The tuberculin syringe (see Fig. 22.5, C) is calibrated in sixteenths of a minim and hundredths of a milliliter and has a capacity of 1 mL. Use a tuberculin syringe to prepare small amounts of medications (e.g., ID or subcutaneous injections). A tuberculin syringe is also useful when preparing small, precise doses for infants or young children. A 3-mL syringe and a 10-mL syringe are calibrated in 0.2 of a milliliter and are not accurate for small volumes. DIF: CognitiveLevel: Application OBJ: Explain theimportance of selecting theproper size syringe and needle for an injection. TOP: Syringes
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
2. The nurse is preparing to administer an intramuscular (IM) injection to a 6-month-old infant. Which injection site is themost appropriate for this patient? a. Deltoid muscle
b. Dorsogluteal injection site c. Vastus lateralis d. Abdomen 2 inches away from theumbilicus ANS: C The vastus lateralis muscle is another injection site used in adults and is an alternate site for administration of biologics (e.g., immunizations) to infants, toddlers, and children. DIF: CognitiveLevel: Application OBJ: Discuss factors to consider when selecting injection sites. TOP: Intramuscular Injection Sites in Children KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
3. The nurse is administering a parenteral medication to thepatient. Which action by thenurse demonstrates proper technique? a. Using strict aseptic technique b. Using work-arounds to administer medications in a timely manner c. Injecting themedication smoothly but rapidly d. Inserting theneedle into thepatient‘s skin smoothly and slowly ANS: A
Strict aseptic technique is used during all steps of preparation and administration of parenteral medications. Work-arounds bypass a procedure, policy, or protocol and should not be used. Medication should be injected slowly and smoothly. theneedle should be inserted smoothly and quickly. DIF: CognitiveLevel: Application OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP:
Aseptic Technique in Injections
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
4. The nurse is preparing a medication that comes in an ampule. Which action by thenurse is appropriate? a. Tapping theampule so fluid moves from thebottom of theampule to theneck
b. Avoiding inversion of theampule after opening to prevent spillage of themedication c. Using a filter needle long enough to reach thebottom of theampule d. Guiding theneedle against therim of theampule to access themedication ANS: C
Filter needles filter out any fragments of glass, and reaching thebottom of theampule allows themedication to be completely withdrawn. thetop of theampule is tapped to move thefluid from theneck into thebottom of theampule, where it is withdrawn. theampule is held upside down or is set on a flat surface for withdrawal of themedication. themedication will not spill from theampule after opening unless theneedle tip or shaft touches therim. therim is considered contaminated and should not be touched by theneedle. DIF: CognitiveLevel: Application OBJ: Correctly prepare injectable medications from a vial and an ampule. TOP: Preparing Injections: Ampules and Vials KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. The nurse is teaching a patient how to mix 5 units of regular insulin and 15 units of NPH insulin in thesame syringe. thenurse determines that further instruction is needed if thepatient does which of thefollowing? a. Injects 5 units of air into theregular insulin vial first and withdraws 5 units of regular insulin. b. Injects 15 units of air into theNPH insulin vial but does not withdraw themedication. c. Withdraws 5 units of regular insulin before withdrawing 15 units of NPH insulin. d. Calculates thecombined total insulin dose as 20 units after withdrawing theregular insulin from thevial. ANS: A
When rapid- or short-acting insulin is mixed with intermediate- or long-acting insulin, air should be injected into theintermediate- or long-acting insulin vial first without withdrawal of themedication. Regular insulin is withdrawn first, and then thecombined total insulin dose is calculated before theNPH insulin is withdrawn from thevial. DIF: CognitiveLevel: Application OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Mixing Insulin
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
6. A patient has orders for 10 units of glargine insulin and 5 units of regular insulin to be given at thesame time. Which action by thenurse is appropriate? a. Injecting 10 units of air into theglargine insulin vial first and not withdrawing themedication b. Injecting 5 units of air into theregular insulin vial first and then 10 units of air into theglargine insulin vial c. Giving two separate injections using different needles and syringes d. Withdrawing 5 units of regular insulin first and then calculating thetotal dose of regular and glargine insulin combined ANS: C
If long-acting insulin glargine is ordered, it should not be mixed with other insulin preparations, so two separate injections are prepared. Air is injected into one vial, and this is followed by withdrawal of themedication. It does not matter which one is drawn up first because they are in separate syringes. DIF: CognitiveLevel: Application OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Mixing Insulin
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
7. The nurse is preparing several medications that are administered parenterally. thepatient receiving which medication will have an intradermal injection? a. Opioid
b. Medication for allergy testing c. Low-molecular-weight heparin d. Glargine insulin ANS: B
The nurse typically gives intradermal injections for skin testing, for example, in tuberculin screening and allergy tests. Opioid pain medications, low-molecular-weight heparin, and insulin are administered subcutaneously, not intradermally. DIF: CognitiveLevel: Application OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Intradermal Injections
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse is preparing to administer an intradermal injection to an adult patient. Which action should be taken by thenurse? a. Use a tuberculin syringe with a 1-inch 25-gauge needle. b. Inject no more than 1 mL of solution at one site. c. Insert theneedle at a 5- to 15-degree angle 3 finger widths below theantecubital space. d. Expect a bleb and a small amount of bleeding after injection. ANS: C
The angle of insertion for an intradermal injection is 5 to 15 degrees. If possible, thesite should be 3 to 4 finger widths below theantecubital space and one hand width above thewrist. To administer an injection intradermally, use a tuberculin or small syringe with a short (3/8 to 5/8 inch), fine-gauge (25 to 27) needle. Inject only small amounts of medication (0.01 to 0.1 mL) intradermally. If a bleb does not appear, or if thesite bleeds after needle withdrawal, themedication may have entered subcutaneous tissue. In this situation, skin test results will not be valid. DIF: CognitiveLevel: Application OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Intradermal Injections MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
9. The nurse administers a tuberculin screening test to a patient who has no known risk factors for tuberculosis (TB). When thetest site is read 48 hours later, which result is considered positive? a. Induration of 2 mm or more b. Induration of 5 mm or more c. Induration of 10 mm or more d. Induration of 15 mm or more ANS: D
A raised, reddened, or hard zone around thetest site indicates a positive tuberculin skin test. An induration of 15 mm or more indicates a positive reaction in patients with no known risk factors for tuberculosis (TB). An induration that measures 5 mm or more in diameter indicates a positive TB reaction in patients who are human immunodeficiency virus (HIV) positive, have fibrotic changes on chest radiograph consistent with previous TB infection, have had organ transplants, or are immunosuppressed. An induration of 10 mm or more indicates a positive TB reaction in patients who are recent immigrants; injection drug users; residents and employees in high-risk settings; patients with certain chronic illnesses; children younger than 4 years of age; and infants, children, and adolescents exposed to high-risk adults. DIF: CognitiveLevel: Application OBJ: Evaluate theeffectiveness and outcomes of administering medications by each injection route. TOP: Positive TB Test Results
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
10. The nurse is teaching a family member of an obese patient how to administer a subcutaneous U-100 insulin injection to thepatient. Which instruction should be included in theteaching plan? a. Carefully massage thesite after theinjection to aid absorption. b. Draw themedication into a tuberculin syringe with a 27-gauge needle. c. Insert theneedle quickly and firmly at a 90-degree angle. d. Rotate injection sites between theabdomen, thighs, and upper arms. ANS: C
For an obese patient, theskin is pinched and theneedle is inserted quickly and firmly at a 90-degree angle. Massage can damage underlying tissue. Subcutaneous U-100 insulin is given using an insulin syringe with a preattached needle of 28 to 31 gauge. Injection site rotation is no longer necessary because newer human insulins carry a lower risk for hypertrophy. Patients choose one anatomical area (e.g., theabdomen) and systematically rotate sites within that region—a practice that maintains consistent insulin absorption from day to day. DIF: CognitiveLevel: Application OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Insulin Injection
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
11. The nurse is teaching a patient how to inject low-molecular-weight heparin. What instruction should be included in theteaching plan? a. The injection can be given in theabdomen or theupper thighs. b. Before injecting themedication, be sure to expel theair bubble in thesyringe. c. After inserting theneedle, pull back on theplunger of thesyringe before injecting themedication. d. After injecting themedication, apply gentle pressure to theinjection site for 30 to 60 seconds. ANS: D
Gentle pressure for 30 to 60 seconds prevents bleeding at thesite. To minimize thepain and bruising associated with low-molecular-weight heparin (LMWH), it is given subcutaneously on theright or left side of theabdomen, at least 2 inches away from theumbilicus; this area is commonly referred to as a patient‘s ―love handles.‖ LMWH comes in a prefilled syringe, and theair bubble should not be expelled before administration. Aspiration after a subcutaneous injection is not necessary. Aspiration after an LMWH injection is not recommended. DIF: CognitiveLevel: Application OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Low-Molecular-Weight Heparin Injections KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
12. The nurse is preparing an intramuscular injection for a thin elderly patient. thenurse is aware that themaximum volume most likely tolerated by this patient is which amount? a. 1 mL b. 2 mL c. 3 mL d. 5 mL ANS: B
Children, older adults, and thin patients tolerate only 2 mL of an IM injection, depending on thesite. A normal, well-developed adult patient tolerates 3 mL of medication into a larger muscle without severe muscle discomfort (Lilley et al., 2017). However, larger volumes of medication (4 to 5 mL) are unlikely to be absorbed properly. Do not give more than 1 mL to small children and older infants, and do not give more than 0.5 mL to smaller infants. DIF: CognitiveLevel: Application OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Volume of Medication That Can Be Given Safely IM KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
13. The nurse is preparing to administer an intramuscular injection via theZ-track method. Which action should be taken by thenurse? a. Pinch theskin between thethumb and thefirst finger. b. Insert theneedle at a 90-degree angle. c. Immediately remove theneedle after injecting themedication. d. Release theskin before removing theneedle from thesite. ANS: B
For an intramuscular injection, theneedle is inserted perpendicular to thepatient‘s body as close to 90 degrees as possible. In using theZ-track method, theoverlying skin and subcutaneous tissues are pulled approximately 2.5 to 3.5 cm (1 to 1 1/2 inches) laterally to theside with theulnar side of thenondominant hand. Keep theneedle inserted for 10 seconds after injection to allow themedication to disperse evenly. Release theskin after withdrawing theneedle.
DIF: CognitiveLevel: Application OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Z-Track Method
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
14. A student nurse is preparing to administer an intramuscular injection into theventrogluteal muscle. thenursing instructor should question which action by thestudent? a. Asking thepatient to assume a sitting position b. Placing theheel of thehand over thepatient‘s greater trochanter c. Asking thepatient to flex theknee and hip d. Using theright hand to locate theinjection site on thepatient‘s left side ANS: A
The patient should lie in either thesupine or thelateral position while theventrogluteal muscle is located. To locate theventrogluteal site, theheel of thehand is placed over thegreater trochanter of thepatient‘s hip with thewrist almost perpendicular to thefemur. theright hand is used for theleft hip, and theleft hand is used for theright hip. To relax themuscle, thepatient lies on theside or back with theknee and hip flexed. DIF: CognitiveLevel: Application OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Ventrogluteal Injection Site
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
15. The nurse is preparing to administer an immunization to a toddler. Which action by thenurse is appropriate? a. Grasp thebody of themuscle during injection. b. Place one hand above theknee and one below theknee to find thesite. c. Have thepatient‘s knee flexed with thefoot internally rotated. d. Ask themother to hold thetoddler on his side. ANS: A
The vastus lateralis is thepreferred injection site for administration of immunizations to infants, toddlers, and children. With young children, it helps to grasp thebody of themuscle during injection to be sure themedication is deposited in muscle tissue. themuscle is located on theanterior lateral aspect of thethigh. In an adult, one hand is placed above theknee and one below thegreater trochanter to locate themuscle. To relax themuscle, thepatient lies flat with theknee slightly flexed and thefoot externally rotated or assumes a sitting position. A side-lying position would not be appropriate for this immunization. DIF: CognitiveLevel: Application OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Vastus Lateralis Injection Site
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
16. After insertion of theneedle into thepatient‘s ventrogluteal muscle, thenurse aspirates and notices a very small amount of blood in thesyringe. What action should thenurse take? a. Inject themedication slowly but smoothly. b. Withdraw theneedle, expel theblood from thesyringe, reinsert theneedle, and inject themedication. c. Withdraw theneedle, change theneedle, insert theneedle, and inject themedication. d. Withdraw theneedle, dispose of themedication and syringe, and prepare another dose of medication. ANS: D
Aspiration of blood into thesyringe indicates possible placement into a vein. If blood appears in thesyringe, remove theneedle, dispose of themedication and syringe properly, and prepare another dose of medication for injection. DIF: CognitiveLevel: Application OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Aspiration of Blood MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
17. The nurse is preparing to give a medication by intravenous (IV) bolus. When assessing thepatient‘s IV insertion site, thenurse notes that it is warm, reddened, and tender. What action should thenurse take first? a. Slow theinfusion rate and slowly inject themedication. b. Discontinue theIV infusion. c. Inject a local anesthetic to relieve thetenderness. d. Apply warm compresses over theinsertion site. ANS: B
Swelling, warmth, redness, and tenderness indicate infiltration or phlebitis. Stop theIV infusion, remove theIV catheter, treat theIV site as indicated by institutional policy, and insert a new IV catheter if therapy continues. DIF: CognitiveLevel: Application OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. KEY: NursingProcess Step: Assessment
TOP: Phlebitis
MSC: NCLEX: Physiological Integrity
18. A patient with a continuous IV infusion has an order for ciprofloxacin to be given IV piggyback. Which action by thenurse is appropriate for administering themedication? a. Hang thebag with ciprofloxacin higher than thecontinuous infusion bag. b. Stop thecontinuous infusion while running theciprofloxacin. c. Connect thepiggyback tubing into theY-port on thetubing of thecontinuous infusion that is closest to thepatient. d. Occlude thetubing of thecontinuous infusion just above theinjection port while injecting themedication. ANS: A
The set is called a ―piggyback‖ because thesmall bag or bottle is set higher than theprimary infusion bag or bottle. In thepiggyback setup, themain line does not infuse when a compatible piggybacked medication is infusing. theport of theprimary IV line contains a back-check valve that automatically stops theflow of theprimary infusion once thepiggyback infusion flows. After thepiggyback solution infuses and thesolution within thetubing falls below thelevel of theprimary infusion drip chamber, theback-check valve opens, and theprimary infusion starts to flow again. thepiggyback is connected to a short tubing line that connects to theupper Y-port of a primary infusion line or to an intermittent venous access. thetubing is occluded to check for blood return or to give an IV bolus, but not for a piggyback medication. DIF: CognitiveLevel: Application OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock.
TOP: Piggyback Infusion
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
19. The nurse is preparing to administer an intravenous (IV) antibiotic using a mini-infusion pump. Which action should thenurse do first? a. Place thesyringe into themini-infusion pump. b. Hang thepump on an IV pole. c. Connect theend of themini-infusion tubing to themain IV line. d. Apply pressure to thesyringe plunger to fill thetubing with medication. ANS: D
After connecting theprefilled syringe to themini-tubing, thenurse carefully applies pressure to thesyringe plunger to fill thetubing with fluid and to ensure that thetubing is free of air bubbles to prevent air embolus. After thetubing is filled with fluid, thesyringe is placed into themini-infusion pump and is hung on an IV pole. Then themini-infusion tubing is connected to themain IV line. DIF: CognitiveLevel: Application OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. KEY: NursingProcess Step: Implementation
TOP: Mini-infusion Pump
MSC: NCLEX: Physiological Integrity
20. The nurse is preparing to administer a medication using a volume-controlled administration set or Volutrol. Which action should thenurse do first? a. Open theclamp between theVolutrol and themain intravenous (IV) bag. b. Open theair vent on theVolutrol. c. Inject themedication into theVolutrol. d. Clean theinjection port on top of theVolutrol. ANS: A
The Volutrol is filled with thedesired amount of intravenous (IV) fluid (50 to 100 mL) by opening theclamp between theVolutrol and themain IV bag. After theVolutrol is filled with thedesired amount of fluid, theclamp is closed and theclamp on theair vent of theVolutrol is checked and opened if necessary. theinjection port on theVolutrol is cleaned, and themedication is injected through theport. DIF: CognitiveLevel: Application OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. TOP: Volume-Control Administration Sets KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
21. The nurse is teaching a patient about continuous subcutaneous infusion with an insulin pump. What should thenurse include in theteaching plan? a. Rotate thesite every 1 to 2 days. b. Place a gauze dressing over theinsertion site. c. Select an insertion site in theabdomen away from thewaistline. d. Pull theskin laterally before inserting theneedle. ANS: C
Insulin is absorbed most consistently in theabdomen, so a site should be chosen in theabdomen away from thewaistline. thesite is changed every 2 to 7 days unless erythema or leaking occurs. An occlusive transparent dressing is used over thesite. theskin should be gently pinched or lifted up to ensure that theneedle will enter subcutaneous tissue.
DIF: CognitiveLevel: Application OBJ: Initiate, maintain, and discontinue a continuous subcutaneous infusion. TOP: Continuous Subcutaneous Infusion (CSQI) KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
22. A patient has medication ordered to be given by intravenous (IV) bolus. thenurse recognizes which advantage of this type of administration? a. There is a slower onset of medication effects. b. Medications are given over a longer time frame. c. Medications given by IV bolus are less irritating to theveins. d. Small volumes are used, so fluid overload can be avoided. ANS: D
An intravenous (IV) bolus usually requires small volumes of fluid, which is an advantage for patients who are at risk for fluid overload. With IV bolus medications, rapid onset of medication effects occurs, which is useful for patients who are experiencing critical or emergent health problems. Medications can be prepared quickly and given over a shorter time frame rather than by IV piggyback. Medications given by IV bolus may cause direct irritation to thelining of theblood vessel. DIF: CognitiveLevel: Analysis OBJ: Compare therisks of three different intravenous routes. TOP: Intravenous Bolus Administration
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. The nurse follows practice guidelines when administering injections to a patient to avoid which possible complications? (Select all that apply.) a. Drug response that is too rapid or too slow b. Nerve injury with possible pain or paralysis c. Death of tissue surrounding theinjection site
d. Death of thepatient ANS: A, B, C, D
Failure to inject a medication correctly will result in complications such as an inappropriate drug response (e.g., too rapid and too slow), nerve injury with associated pain or paralysis, localized bleeding, tissue necrosis, and sterile abscess. Administration of an IV push medication too quickly can cause death. DIF: CognitiveLevel: Understanding OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP:
Choosing Correct Injection Method
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
2. The nurse is preparing to administer an intramuscular medication. In determining which size needle and syringe to use to administer themedication, thenurse must consider which of thefollowing? (Select all that apply.) a. The volume of medication b. The viscosity of themedication c. The size and weight of thepatient d. Whether or not thesyringe has a safety needle ANS: A, B, C
Determine theappropriate size of thesyringe, and length and gauge of theneedle based on thevolume of solution ordered, medication route, type of medication prescribed, and patient body size. These decisions are based on thequantity and type of medication prescribed and thebody size of a patient. Choose theneedle length according to a patient's size and weight and thetype of tissue into which themedication is to be injected. theselection of a gauge depends on theviscosity of fluid to be injected or infused. DIF: CognitiveLevel: Application OBJ: Explain theimportance of selecting theproper size syringe and needle for an injection. TOP: Choosing Correct Syringe and Needle Size KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
3. The nurse is preparing a subcutaneous injection for a patient. thenurse is careful not to touch which part of thesyringe or needle? (Select all that apply.) a. The needle hub b. The needle shaft c. The syringe outer barrel d. The needle bevel ANS: A, B, D
The needle hub, shaft, and bevel must remain sterile at all times. DIF: CognitiveLevel: Application OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Maintaining Needle Sterility
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The nurse is teaching a patient how to give a subcutaneous injection. thenurse includes which sites as acceptable for this route of administration? (Select all that apply.) a. Ventrogluteal area between thegreater trochanter and theiliac crest b. Outer aspect of theupper arms c. Abdomen from below thecostal margins to theiliac crests d. Anterior thighs ANS: B, C, D
The best subcutaneous injection sites include theouter aspect of theupper arms, theabdomen from below thecostal margins to theiliac crests, and theanterior aspects of thethighs. These areas are easily accessible and are large enough that you can rotate multiple injections within each anatomical location. theventrogluteal area is used for intramuscular injections. DIF: CognitiveLevel: Application OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Subcutaneous Injection Sites MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
5. The nurse administers an injection of iron to a patient using theZ-track method. thenurse recognizes which of thefollowing as advantages of this method? (Select all that apply.) a. Provides faster absorption of themedication. b. Reduces discomfort from theneedle. c. Prevents leakage of themedication into subcutaneous tissue. d. Prevents thedrug from irritating sensitive tissue. ANS: C, D
The Z-track method is recommended for IM injections. theZ-track technique, which pulls theskin laterally before injection, prevents leakage of medication into subcutaneous tissue, seals medication in themuscle, and minimizes irritation. DIF: CognitiveLevel: Understanding OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Z-Track Method
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
6. The nurse is preparing to administer an intravenous (IV) medication that must be diluted in 60 mL of fluid and then given over 45 minutes. Which of thefollowing methods can thenurse use to give this medication? (Select all that apply.) a. Piggyback infusion b. Volume-control device c. Mini-infusion pump d. IV bolus injection ANS: A, B, C
Piggyback infusions contain 25 to 250 mL, volume-control devices contain 50 to 150 mL, and mini-infusion pumps contain 5 to 60 mL. All three can be set to deliver themedication over a specific time frame. IV bolus injections are smaller volumes that are delivered quickly, usually over a few minutes. DIF: CognitiveLevel: Application OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. TOP: Administration of IV Medication
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
COMPLETION
1. The health care provider orders 4 units of regular insulin and 10 units of NPH insulin subcutaneous before breakfast. thenurse draws theregular insulin into thesyringe and is preparing to draw theNPH insulin into thesame syringe. When finished, thesyringe should contain
units.
ANS:
14 The combined units of insulin are determined by adding thenumber of units of both insulins together (4 units of regular + 10 units of NPH = 14 units). DIF: CognitiveLevel: Application OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Subcutaneous Insulin Injection
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
2. The nurse injects themedication into theloose connective tissue just under thedermis when giving a
injection.
ANS:
subcutaneous A subcutaneous injection involves depositing medication into theloose connective tissue underlying thedermis. DIF: CognitiveLevel: Remembering OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Subcutaneous Injection MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
3. The nurse informs thepatient that themedication will be absorbed rapidly because it was injected into tissue with a rich blood supply. thepatient has just received a _ injection. ANS:
intramuscular (IM) intramuscular The intramuscular (IM) injection route deposits medication into deep muscle tissue, which has a rich blood supply, allowing themedication to be absorbed faster than by thesubcutaneous or intradermal route. DIF: CognitiveLevel: Application OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP:
Intramuscular (IM) Injection
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. The patient is receiving allergy testing. thenurse is using theinner forearm to inject theallergen into the
.
ANS:
dermis Intradermal (ID) injections are used for allergy testing. They are injected into thedermis, usually in theinner forearm or upper back. DIF: CognitiveLevel: Application OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Intradermal (ID) Injection MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
5. A patient with multiple intravenous lines has blood infusing in theright antecubital space, parenteral nutrition infusing through a right subclavian line, and normal saline with potassium infusing in theleft forearm. An intravenous medication is ordered stat. thenurse will use theline in the
to administer themedication.
ANS:
left forearm Never administer IV medications through tubing that is infusing blood, blood products, or parenteral nutrition solutions. DIF: CognitiveLevel: Application OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. TOP: Intravenous (IV) Injection or Infusion KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
6. The nurse is preparing to give an intramuscular injection to a toddler. To decrease pain, a eutectic mixture of local anesthetics (EMLA) cream is applied to theinjection site at least hour(s) before administration of theinjection. ANS:
1 Eutectic mixture of local anesthetics (EMLA) cream should be applied to theinjection site at least 1 hour before IM injection to decrease pain. DIF: CognitiveLevel: Application OBJ: Discuss ways to promote patient comfort while administering an injection. TOP: Pediatric Considerations for Intramuscular Injections KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
7. The most frequent route of exposure to bloodborne disease for health care workers is needlestick injury. thenurse recognizes that implementation of
can
prevent needlestick injury. ANS:
safe needle devices The Needlestick Safety and Prevention Act is a federal law that mandates health care facilities to use safe needle devices to reduce thefrequency of needlestick injury. DIF: CognitiveLevel: Understanding OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP:
Needlestick Injuries KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
8. An experienced nurse recognizes that thedorsogluteal injection site is no longer used for intramuscular injections because of therisk of damaging the
.
ANS:
sciatic nerve Because of thesciatic nerve location, thedorsogluteal muscle is not recommended as an injection site. Recent evidence supports avoiding thetraditional dorsogluteal route in favor of theventrogluteal site. Therefore, thedorsogluteal site should not be used as a site for IM injection. Studies have demonstrated that theexact location of thesciatic nerve varies from one person to another. If a needle hits thesciatic nerve, thepatient may experience permanent or partial paralysis of theinvolved leg. DIF: CognitiveLevel: Understanding OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP:
Complications of IM Injections
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
9. The nurse is preparing to draw up a medication using a filter needle and a syringe. This equipment is necessary when themedication is being withdrawn from an _
.
ANS:
ampule Filter needles must be used when medication is withdrawn from a glass ampule. Filter needles prevent glass particles from being drawn into thesyringe. DIF: CognitiveLevel: Understanding OBJ: Correctly prepare injectable medications from a vial and an ampule. TOP: Filter Needle
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
Chapter 23: Oxygen Therapy Perry et al.: Clinical Nursing Skills & Techniques, 9th Edition
MULTIPLE CHOICE
1. A patient with chronic obstructive pulmonary disease (COPD) has carbon dioxide retention and is ordered oxygen therapy. thenurse anticipates theuse of which oxygen delivery system? a. Face tent b. Face mask c. Nasal cannula d. Nonrebreathing mask ANS: C
Oxygen can be delivered via thenasal cannula at flow rates of 1 to 2 L per minute, which deliver 24% to 28% FiO2 and are useful for patients with chronic lung disease. theface tent is used primarily for humidification and for oxygen only when thepatient cannot or will not tolerate a tight-fitting mask. theFiO2 cannot be controlled, and there is no way to estimate how much oxygen is delivered. thesimple face mask is used for short-term oxygen therapy. It fits loosely and delivers oxygen concentrations from 40% to 60%. themask is contraindicated for patients with carbon dioxide retention because it will make theretention worse. When used as a nonrebreather, theplastic face mask with a reservoir bag delivers 60% to 100% oxygen at appropriate flow rates. This oxygen mask maintains a high-concentration oxygen supply in thereservoir bag. If thebag deflates, thepatient breathes in large amounts of exhaled carbon dioxide. DIF: CognitiveLevel: Analysis OBJ: Demonstrate applying a nasal cannula and an oxygen mask. TOP: Nasal Cannulas
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
2. The nurse is caring for several patients receiving oxygen by various delivery systems. Which assessment finding by thenurse indicates proper use of theoxygen device? a. No mist is noted in a face tent. b. The reservoir of therebreathing mask collapses on inhalation. c. The flow rate is between 1 and 6 L/min for a nasal cannula. d. The flow rate for an oxygen hood is set at 3 L/min. ANS: C
The nasal cannula is used with an oxygen flow rate of 1 to 6 L/min. theface tent provides high humidity, and mist is expected. thereservoir of therebreathing mask remains partially inflated when operating effectively to avoid rebreathing of carbon dioxide. theflow rate for an oxygen hood may be 5 L/min or more to prevent carbon dioxide (CO2) narcosis. DIF: CognitiveLevel: Knowledge OBJ: Demonstrate applying a nasal cannula and an oxygen mask. TOP: Nasal Cannulas MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Assessment
3. A patient in respiratory distress enters theemergency department. thepatient denies a history of chronic obstructive pulmonary disease (COPD). thenurse anticipates an order for oxygen delivered by which method to achieve thehighest possible concentration of oxygen? a. Simple face mask at 15 L/min b. Nonrebreathing face mask at 15 L/min c. Venturi mask at 15 L/min d. Oxygen tent at 15 L/min ANS: B
When used as a nonrebreather, theface mask with a reservoir bag delivers 60% to 90% oxygen at 15 L/min. thesimple face mask delivers oxygen concentrations from 40% to 60% when set at 5 to 8 L/min. It is not used at 15 L/min. A Venturi mask delivers oxygen concentrations from 24% to 60% when set at 4 to 12 L/min. It is not used at 15 L/min. An oxygen tent is usually for pediatric use and delivers up to 50% oxygen concentration at 10 to 15 L/min. DIF: CognitiveLevel: Analysis OBJ: Discuss methods for administering oxygen therapy. KEY: NursingProcess Step: Planning
TOP: Oxygen Mask
MSC: NCLEX: Physiological Integrity
4. A patient with a nasal cannula at 5 L/min has skin irritation around thenares and complains of a dry mouth and nose. Which action by thestudent nurse should be questioned by thenursing instructor? a. Using humidification b. Applying petroleum-based gel to thenares c. Providing frequent oral care d. Asking thephysician for an order for sterile nasal saline ANS: B
Petroleum-based gel should not be used around oxygen because it is flammable. If theoxygen flow rate is greater than 4 L/min, humidification should be used. Frequent oral care and sterile nasal saline will help when there is drying of thenasal and oral mucosa. DIF: CognitiveLevel: Application OBJ: Discuss methods for administering oxygen therapy.
TOP: Unexpected Outcomes
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. A patient with a tracheostomy tube has an order for oxygen. Which action by thenurse is appropriate? a. Apply sterile gloves to connect theoxygen to thetracheostomy tube. b. Check theoxygen tubing frequently to make sure water is present in thetubing. c. Attach theT tube to a humidified oxygen source. d. Monitor theresponse to oxygen with hourly arterial blood gas levels. ANS: C
The T tube connects an oxygen source to an artificial airway such as a tracheostomy tube. Humidification is necessary because theartificial airway bypasses thenormal humidification process of thenose and mouth. Clean gloves, not sterile gloves, are used to connect oxygen to theartificial airway. Fluid should be drained from thetubing so that it does not provide a medium for bacterial growth. Hourly arterial blood gases (ABGs) are not thestandard for monitoring patients with artificial airways and oxygen. DIF: CognitiveLevel: Application OBJ: Demonstrate administering oxygen therapy to a patient with an artificial airway. TOP: Attaching a T Tube
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
6. The nurse is caring for several patients postoperatively following abdominal surgery. Which patient will benefit theleast from theuse of incentive spirometry? a. Middle-aged male with a history of smoking since high school b. Elderly female with type 2 diabetes c. Middle-aged female with a history of chronic respiratory disease d. Adolescent female with atelectasis ANS: B
Incentive spirometry helps a patient deep breathe, thereby helping them achieve maximum inspiration. It works by providing visual feedback that helps encourage thepatient to take long, deep, slow breaths. theuse of an incentive spirometer (IS) alone is not recommended to prevent postoperative pulmonary complications. It is beneficial in patients who will benefit from its use (e.g., patients who have undergone thoracic or abdominal surgery; surgical patients with a history of COPD, patients with sickle cell disease with acute chest syndrome). DIF: CognitiveLevel: Application
OBJ: Demonstrate proper use of incentive spirometry.
TOP: Incentive Spirometry
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
7. The nurse is teaching a patient how to use a flow-oriented incentive spirometer (IS) thenight before abdominal surgery. Which statement by thepatient indicates an understanding of theprocedure? a. ―I need to get theballs to thetop as quickly as possible.‖ b. ‖Quick rapid breaths are themost effective when theincentive spirometer is used.‖ c. ―I need to keep theballs elevated as long as possible.‖ d. ―The balls must be elevated to be effective.‖ ANS: C
A patient‘s goal is to keep theballs elevated for as long as possible to ensure maximal sustained inhalation. Even if a very slow inspiration does not elevate theballs, this pattern helps a patient improve lung expansion. DIF: CognitiveLevel: Application
OBJ: Demonstrate proper use of incentive spirometry.
TOP: Incentive Spirometry
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
8. A patient is planning to perform incentive spirometry after abdominal surgery. thenurse should encourage thepatient to do which of thefollowing? a. Get comfortable in a semi-reclined position. b. Inhale as deeply as possible and then exhale into theincentive spirometry device. c. Hold thebreath for at least 3 seconds before exhaling. d. Exhale as quickly as possible.
ANS: C
The patient should hold his breath for at least 3 seconds after inhalation. thepatient should be positioned in themost erect position (e.g., high-Fowler‘s position), if tolerated. This promotes optimal lung expansion during respiratory maneuvers. thepatient should exhale completely through themouth and place thelips around themouthpiece, and then he should take a slow, deep breath, hold it for at least 3 seconds, and exhale normally. DIF: CognitiveLevel: Application
OBJ: Demonstrate proper use of incentive spirometry.
TOP: Incentive Spirometry
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
9. A patient has been using continuous positive airway pressure (CPAP), and now thehealth care provider is recommending bi-level positive airway pressure (BiPAP). thepatient is asking thenurse to explain thedifference again. Which response is appropriate? a. ―CPAP maintains a set positive airway pressure during inspiration only.‖ b. ―CPAP opens theairways during inspiration and allows them to close during expiration.‖ c. ―BiPAP maintains a set pressure that is thesame for inspiration and expiration.‖ d. ―BiPAP delivers sufficient expiratory pressure to keep theairways open.‖ ANS: D
BiPAP supplies pressure at both inhalation and exhalation. theinhalation pressure (sometimes referred to as pressure support) is set according to health care provider's order and helps prevent airway closure. Expiratory pressure (sometimes referred to as positive end-expiratory pressure) is set according to health care provider's order and keeps alveoli open at end-expiration. CPAP provides single positive pressure throughout breathing cycle, which helps to keep alveoli open at end-expiration. DIF: CognitiveLevel: Application OBJ: Demonstrate use of noninvasive positive-pressure ventilation using continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: CPAP/BiPAP
10. A patient is admitted to theemergency department following a motor vehicle accident. thepatient is unconscious and has a broken jaw, a broken nose, and facial lacerations. thepatient‘s breath sounds are diminished, and thehealth care provider suspects atelectasis. Frequent suctioning is required to clear theairway. Oxygen saturation levels range from 70% to 75%. thenurse recognizes that this patient most likely will have which type of ventilatory device ordered? a. Continuous positive airway pressure (CPAP) b. Bi-level positive airway pressure (BiPAP) c. Nasal cannula d. Mechanical ventilation ANS: D
Noninvasive ventilation, including CPAP and BiPAP, is contraindicated in cardiac or respiratory arrest, nonrespiratory organ failure, facial surgery or trauma, inability to protect theairway and/or high risk for aspiration, and inability to clear secretions. A nasal cannula cannot be used with nasal obstruction from a broken nose. DIF: CognitiveLevel: Analysis OBJ: Demonstrate use of noninvasive positive-pressure ventilation using continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). TOP: CPAP/BiPAP, Noninvasive Positive-Pressure Ventilation KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
11. The nurse is caring for a patient on a mechanical ventilator and thelow-pressure alarm sounds. Which action by thenurse is most appropriate? a. Assess for secretions in theairway and suction thepatient. b. Administer a sedative to thepatient to prevent coughing. c. Assess theendotracheal tube cuff to make sure it is deflated. d. Check theventilator tubing and reconnect if disconnected. ANS: D
The low-pressure alarm sounds when theventilator has no resistance to inflating thelung. thepatient may be disconnected from theventilator, or a leak may have developed in theventilator circuit. thehigh-pressure alarm sounds when theventilator has met resistance to delivery of thetidal volume. This may result from coughing, increased secretions, or biting on theendotracheal tube. thecuff of theendotracheal tube is inflated to create a seal for positive-pressure ventilation. A cuff that is leaking could cause thelow-pressure alarm to sound. DIF: CognitiveLevel: Application OBJ: Demonstrate care of a patient receiving mechanical ventilation. TOP: Ventilator Alarms
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
12. The nurse is caring for a patient on mechanical ventilation. thenurse determines that theendotracheal tube is properly placed by which assessment? a. Auscultating both lungs and watching therise and fall of both sides of thechest b. Monitoring and comparing theblood pressure in both arms c. Observing and measuring inspiratory and expiratory rates d. Checking thesettings on theventilator and thelow-pressure and high-pressure alarm settings ANS: A
Verify that ET or tracheostomy tube is still properly positioned during an inspiratory and expiratory cycle by listening to both lungs and assessing chest wall symmetry. Capnography can also be used to verify proper placement (Wiegand, 2017). When chest x-ray film is available, observe tube placement. DIF: CognitiveLevel: Application OBJ: Demonstrate care of a patient receiving mechanical ventilation. TOP: Artificial Airway Placement MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Assessment
13. A patient on mechanical ventilation has an FiO2 setting of 38%. thenurse is reviewing arterial blood gas results and pulse oximetry readings. thenurse is aware that thedesired level of oxygen is which of thefollowing? a. PaO2 greater than 90 mm Hg b. SpO2 greater than 60% c. PaO2 greater than 60 mm Hg d. SpO2 greater than 95% ANS: C
A patient on mechanical ventilation ideally has an FiO2 setting less than 40% to maintain PaO2 levels greater than 60 mm Hg and SpO2 levels greater than 90%. DIF: CognitiveLevel: Analysis OBJ: Demonstrate care of a patient receiving mechanical ventilation. TOP: Care of thePatient on a Ventilator
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. A patient will be using a nasal cannula continuously to deliver oxygen at home, and thenurse is instructing thepatient and family about important safety guidelines. Which of thefollowing should be included in theteaching plan? (Select all that apply.) a. Smoking is allowed if it is not done in thesame room in which theoxygen device is placed. b. If you feel short of breath, increase your oxygen by 2 to 3 L per minute. c. Avoid using an electric razor. d. Keep theoxygen tank at least 5 feet away from thestove. ANS: C, D
Items that create a spark such as an electric razor should not be used while a nasal cannula is in use. Oxygen delivery systems should be at least 5 feet from any heat source. No smoking is allowed on thepremises. Oxygen is a medication. Increasing theoxygen liter flow for shortness of breath is similar to doubling heart, asthma, or other medications.
DIF: CognitiveLevel: Application
OBJ: Discuss indications for oxygen therapy.
TOP: Oxygen Therapy Safety Guidelines KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The nurse is caring for several patients who require oxygen therapy. thenurse anticipates an order for noninvasive positive-pressure ventilation (NIPPV) for thepatients with which diagnoses? (Select all that apply.) a. Pulmonary edema b. Obstructive sleep apnea c. Stroke with dysphagia d. Congestive heart failure ANS: A, B, D
NIPPV is used both in acute care settings and increasingly more in home care settings to treat a variety of conditions, including obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), cardiogenic pulmonary edema, hypoxic and/or hypercapnic respiratory failure, and neuromuscular disorders. It is commonly used in these conditions to avoid thecomplications of invasive ventilation strategies, including pneumonia and aspiration. DIF: CognitiveLevel: Application OBJ: Demonstrate use of noninvasive positive-pressure ventilation using continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). KEY: NursingProcess Step: Assessment
TOP: Noninvasive Ventilation
MSC: NCLEX: Physiological Integrity
3. The nurse is teaching a patient with asthma how to measure peak expiratory flow rate (PEFR). What should be included in theteaching plan? (Select all that apply.) a. Assume a recumbent position before measuring PEFR. b. Take a deep breath in, exhale, then place themouthpiece in themouth and form a firm seal with thelips. c. After placing themouthpiece in themouth, blow out as hard and as fast as possible through themouth in only one single breath. d. Measure PEFR 3 times and record thehighest number. ANS: C, D
To measure PEFR, thepatient should be standing. If thepatient is unable to stand, high-Fowler‘s position or any other position that promotes optimum lung expansion should be used. thepatient should take in a deep breath, place themouthpiece in themouth, and form a tight seal. Then thepatient should blow out as hard and as fast as possible through themouth in only one single breath. Two additional measurements are taken, and thehighest number is recorded. DIF: CognitiveLevel: Application OBJ: Demonstrate proper peak expiratory flow rate (PEFR) measurements. TOP: Use of a Peak Flowmeter
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The patient is placed on mechanical ventilation. After theinitial settings have been applied, thenurse should watch for which of thefollowing complications? (Select all that apply.) a. Signs of decreased cardiac output b. Tension pneumothorax c. Pneumonia d. Failure to wean ANS: A, C
Multiple complications are associated with positive-pressure ventilation, including decreased cardiac output, aspiration, barotrauma, and ventilator-associated events (VAEs) such as ventilator-associated pneumonia (VAP). It is important that patients remain on mechanical ventilation only as long as necessary because there is an increased mortality risk associated with positive-pressure ventilation. In addition, as thelength of time needed for mechanical ventilation increases, there is an increased risk of failure to wean from theventilator. DIF: CognitiveLevel: Analysis OBJ: Demonstrate care of a patient receiving mechanical ventilation. TOP: Initiation of Mechanical Ventilation KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is on mechanical ventilation. Which actions by thenurse are appropriate? (Select all that apply.)
a. Keep thepatient in a supine position. b. Note and mark thelevel of theendotracheal (ET) tube at thelips or nares. c. Have suction equipment available for immediate use. d. Perform mouth care at least twice daily. ANS: B, C
Reassess and mark level of ET tube at lips or nares (see Chapter 25). Ensure that ET tube is secured. Ensure that suction equipment is set up and functioning, including oral suctioning. The patient should be positioned with thehead of bed elevated 30 to 45 degrees to reduce gastric reflux, thereby decreasing therisk for aspiration and ventilator-associated pneumonia. Note and mark thelevel of theendotracheal (ET) tube at thelips or nares. This provides a baseline for depth of tube placement and ensures that thetube is not too close to thecarina or in theright main-stem bronchus. Set up suction equipment, including oral suctioning, to provide airway care and suctioning as needed of theET or tracheostomy tube, to prevent plugging of theairway, and to reduce therisk for infection. Perform mouth care at least 4 times per 24 hours. Use a toothbrush and a solution such as chlorhexidine, which is effective in reducing oral bacteria and therisk for ventilator-associated pneumonia. DIF: CognitiveLevel: Application OBJ: Demonstrate care of a patient receiving mechanical ventilation. TOP: Care of thePatient on a Ventilator
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
COMPLETION
1. A condition in which oxygen is insufficient to meet themetabolic demands of thetissues and cells is known as
.
ANS:
hypoxia Hypoxia is a condition in which oxygen is insufficient to meet themetabolic demands of thetissues and cells.
DIF: CognitiveLevel: Remembering TOP: Hypoxia
OBJ: Discuss indications for oxygen therapy.
KEY: NursingProcess Step: Diagnosis
MSC: NCLEX: Physiological Integrity
2. The
, also called a Briggs adaptor, connects an oxygen source to an artificial airway
such as an endotracheal tube. ANS:
T tube The T tube, also called a Briggs adaptor, is a T-shaped device with a 15-mm (3/5-inch) connection that connects an oxygen source to an artificial airway such as an endotracheal (ET) tube or tracheostomy. DIF: CognitiveLevel: Remembering OBJ: Demonstrate administering oxygen therapy to a patient with an artificial airway. TOP: The T Piece
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
3. A curved oxygen-delivery device with an adjustable strap that fits around thepatient‘s neck is known as a
.
ANS:
tracheostomy mask A tracheostomy mask is a curved device with an adjustable strap that fits around a patient's neck DIF: CognitiveLevel: Remembering OBJ: Demonstrate administering oxygen therapy to a patient with an artificial airway. TOP: The Tracheostomy Collar MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
4. In noninvasive ventilation,
keeps theterminal airways (alveoli) partially
inflated, reducing therisk for atelectasis. ANS:
positive airway pressure Continuous positive airway pressure keeps thealveoli partially inflated, reducing therisk for atelectasis; if atelectasis has occurred, positive pressure assists in reinflation. Noninvasive positive-pressure ventilation (NIPPV or NPPV), or noninvasive ventilation (NIV), maintains positive airway pressure and improves alveolar ventilation without theneed for an artificial airway. DIF: CognitiveLevel: Remembering OBJ: Demonstrate use of noninvasive positive-pressure ventilation using continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP).
TOP: Positive Airway Pressure
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. The amount of air inspired and expired with each breath while a patient is on mechanical ventilation is known as the
.
ANS:
tidal volume (TV) tidal volume The tidal volume, theamount of air per breath, is usually set by thepatient‘s ideal body weight (5 to 8 mL/kg). DIF: CognitiveLevel: Remembering OBJ: Demonstrate care of a patient receiving mechanical ventilation. TOP: Tidal Volume
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
Chapter 24: Performing Chest Physiotherapy Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The nurse receives orders on several patients for chest percussion, and vibration. thenurse is aware that chest physiotherapy maneuvers are indicated for which patient? a. 18-year-old who sustained thoracic trauma from a motor vehicle accident b. 75-year-old with osteoporosis who is underweight c. 15-year-old with cystic fibrosis d. 20-year-old with a fractured clavicle ANS: C
Chest physiotherapy (CPT) and coughing maneuvers assist with airway clearance of mucus in patients with retained tracheobronchial secretions. Secretions accumulate in theairways of patients with bronchitis, asthma, cystic fibrosis (CF), pneumonia, and bronchiectasis. Thoracic trauma, osteoporosis, and fracture of rib cage structures such as theclavicle contraindicate percussion, vibration, and shaking. DIF: CognitiveLevel: Comprehension OBJ: Determine theneed to modify or discontinue CPT maneuvers, including contraindications and individual variations.
TOP: Indications for CPT
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The nurse auscultates thepatients‘ lung fields and notes congestion in several patients. thenurse anticipates that postural drainage may be used for thepatient with which condition? a. Congestive heart failure (CHF) with pulmonary edema b. History of cigarette smoking with recent hemoptysis c. Chronic bronchitis with frequent coughing d. Pulmonary embolism after a long international flight ANS: C
Secretions accumulate in patients with bronchitis, asthma, cystic fibrosis (CF), pneumonia, and bronchiectasis. Contraindications for postural drainage include pulmonary edema associated with congestive heart failure, active hemoptysis, and pulmonary embolism.
DIF: CognitiveLevel: Analysis OBJ: Determine theneed to modify or discontinue CPT maneuvers, including contraindications and individual variations. TOP: Contraindications and Indications for Postural Drainage KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. The nurse is teaching family members how to perform postural drainage at home for a patient with chronic bronchitis. What instruction should thenurse provide? a. Plan to perform postural drainage 3 times a day about 1 hour after meals. b. Don‘t give any pain medication within 2 hours of performing postural drainage. c. Perform postural drainage 20 minutes after thepatient uses theinhaler. d. Encourage thepatient to remain in each position for 30 minutes to adequately drain thearea. ANS: C
Patients receiving inhaled bronchodilators, nebulizers, or aerosol treatments should have postural drainage performed 20 minutes after such therapy. If a patient‘s pain is 4 or greater, analgesics should be administered 20 minutes before chest physiotherapy (CPT) maneuvers. Pain control is essential for thepatient to actively participate and cough forcefully to clear theairways. Treatments should not overlap with meals. Avoid postural drainage 1 to 2 hours before and after meals. thepatient should maintain each position for 10 to 15 minutes. DIF: CognitiveLevel: Application OBJ: Explain how to prepare thepatient and thefamily for theperformance of each CPT maneuver. TOP: Teaching Considerations
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The nurse receives orders for an Acapella device on several patients. thenurse should question theorder on thepatient with which condition? a. Chronic bronchitis b. Asthma c. Cystic fibrosis (CF) d. Pleural effusion ANS: D
The Acapella device is a respiratory rehabilitation device designed to aid sputum clearance. Patients with chronic conditions such as cystic fibrosis, chronic bronchitis, and asthma appear to receive thegreatest benefit from this type of treatment. Chest physiotherapy (CPT) is contraindicated in patients with pleural effusion. DIF: CognitiveLevel: Application OBJ: Perform theoutlined CPT maneuvers, including standard and modified versions. TOP: Acapella Device
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The nurse is teaching a patient how to use an Acapella device. What instruction should thenurse give to thepatient? a. Take a full deep breath in and fill your lungs. b. Hold your breath for 5 to 10 seconds after placing themouthpiece in your mouth. c. Cough forcefully to clear your lungs while maintaining a tight seal on themouthpiece. d. Exhale slowly for 3 to 4 seconds through thedevice while it vibrates. ANS: D
Instruct thepatient to try not to cough and to exhale slowly for 3 to 4 seconds through thedevice while it vibrates. thepatient should be instructed to take in a breath that is larger than normal, but not to fill thelungs completely—about 75% of inspiratory capacity. Hold thebreath for 2 to 3 seconds, and try not to cough. DIF: CognitiveLevel: Application OBJ: Describe discharge teaching and planning related to theuse of each CPT maneuver in thehome setting.
TOP: Acapella Device
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
6. A patient has received instructions on theuse of an Acapella device. Which action by thepatient indicates an understanding of theteaching? a. Complains of not being able to use an aerosol drug with thedevice. b. Turns thefrequency adjustment dial to medium resistance.
c. After completing one cycle, repeats for 2 more breaths. d. After removing themouthpiece, performs 1 to 2 forceful exhalations and ―huff‖ coughs. ANS: D
When thecycles are completed, themouthpiece is removed and 1 to 2 forceful exhalations and ―huff‖ coughs are performed. If aerosol drug therapy is ordered, a nebulizer is attached to theend of theAcapella device. For theinitial setting, thefrequency adjustment dial should be set at thelowest resistance setting. thecycle should be repeated for 5 to 10 breaths as tolerated. DIF: CognitiveLevel: Application OBJ: Describe discharge teaching and planning related to theuse of each CPT maneuver in thehome setting.
TOP: Acapella Device
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
7. The health care provider orders percussion on a patient to help clear airway secretions. Which action by thenurse is appropriate? a. Performing percussion over theribs, while avoiding theclavicles and sternum b. Administering pain medication before performing thepercussion because thevibrations will be painful c. Performing percussion during exhalation only with theflat part of thepalm d. Creating a rocking motion by slightly leaning on thepatient‘s chest ANS: A
Percussion is performed by clapping thechest wall with cupped hands over theribs only. theclavicles, breast tissue, sternum, spine, waist, and abdomen should not be used. If done correctly, percussion painlessly sets up vibrations in thechest to dislodge retained secretions. Vibration is done during exhalation only with theflat part of thepalm. DIF: CognitiveLevel: Application OBJ: Perform theoutlined CPT maneuvers, including standard and modified versions. TOP: Percussion
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
8. A patient who is very frail and thin with osteoporosis has just undergone abdominal surgery. thenurse anticipates that which technique will be used to control respiratory secretions in this patient? a. Forceful coughing b. Percussion c. Vibration d. Shaking ANS: A
Thin, frail patients with osteoporosis are most susceptible to injury and are taught other secretion control measures (e.g., forceful coughing and humidification). Percussion, vibration, and shaking are contraindicated with rib fracture; fracture of other rib cage structures such as clavicle or sternum; pain; severe dyspnea; and severe osteoporosis. DIF: CognitiveLevel: Analysis OBJ: Describe expected and unexpected outcomes of each CPT maneuver. TOP: Percussion, Shaking, and Vibration KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
9. Percussion and vibration is ordered on a patient with retained pulmonary secretions. Which action by thestudent nurse should thenursing instructor question? a. Performs percussion for 3 to 5 minutes in each position as tolerated. b. Uses thewrist and elbow to create movement when performing percussion. c. While thepatient inhales, gently pushes down and vibrates thechest wall with theflat part of thehand. d. Repeats thevibration 3 times and then instructs thepatient to take a deep breath and cough while exhaling. ANS: C
Vibration is performed while thepatient is exhaling, not inhaling. Percussion is performed for 3 to 5 minutes in each position. When clapping, most arm movement comes from theelbow and wrist joints. Vibration is repeated 3 times and then thepatient cascade coughs by taking a deep breath and doing a series of small coughs until theend of thebreath. DIF: CognitiveLevel: Application
OBJ: Perform theoutlined CPT maneuvers, including standard and modified versions. TOP: Percussion
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
10. A patient has retained secretions in theright and left lower lobe superior bronchi. A nurse is demonstrating to family members how to perform percussion and vibration. Which action by thenurse is appropriate? a. Positioning thepatient in a chair leaning forward on a table b. Asking thepatient to lie flat on thestomach with a pillow under thestomach c. Assisting thepatient to theright side with thearm overhead and thefeet elevated d. Asking thepatient to lie on theleft side with thehead elevated ANS: B
Have thepatient lie flat on thestomach with a pillow under thestomach. Percuss and vibrate below thescapula on either side of thespine. Sitting up and leaning forward is theposition for drainage of theleft and right upper lobe posterior apical branch. Having thepatient lying on theright side in Trendelenburg‘s position with thearm overhead facilitates drainage of theleft upper lobe lingular bronchi. On theleft side with thehead elevated is not a correct position for any drainage procedure. DIF: CognitiveLevel: Application OBJ: Explain how to prepare thepatient and thefamily for theperformance of each CPT maneuver. TOP: Patient Positioning
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. The nurse is teaching thefamily of a patient with cystic fibrosis how to use a high-frequency chest wall oscillation (HFCWO) vest. thenurse informs thefamily that this device will do which of thefollowing? (Select all that apply.) a. Allow patient to perform other tasks while receiving therapy. b. Improve patient adherence to chest physiotherapy. c. Assist in theremoval of secretions from thelungs.
d. Decrease theviscosity of mucus so coughing it up will be easier. ANS: A, B, C, D
The use of high-frequency chest wall oscillation (HFCWO) such as theVest airway clearance system often improves patient attitude toward chest physiotherapy because thepatient is able to perform other tasks while receiving therapy. theHFCWO therapy assists with theremoval of secretions from thelungs and decreases theviscosity of mucus, making it easier to cough productively. DIF: CognitiveLevel: Application OBJ: Assess theneed to perform chest physiotherapy (CPT) maneuvers. TOP: Mechanical Devices
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
2. The nurse is planning to perform postural drainage on a patient who is receiving continuous tube feedings. What should thenurse do before performing thetreatment? (Select all that apply.) a. Stop thetube feedings for 1 to 2 hours before and after postural drainage. b. Check for residual feeding in thepatient‘s stomach and hold treatment if greater than 100 mL. c. Give theprescribed inhaled bronchodilator 20 minutes before theprocedure. d. Auscultate all lung fields, assess vital signs, and draw arterial blood gas levels (ABG). ANS: B, C
Stop all continuous gastric tube feedings for 30 to 45 minutes before postural drainage. Check for residual feeding in thepatient‘s stomach; if greater than 100 mL, hold treatment. If thepatient is receiving inhaled bronchodilator, nebulizer, or aerosol treatment, postural drainage is performed 20 minutes after such therapy is provided. Assessing lung sounds and vital signs, but not blood gas levels, is routinely done. Instead, pulse oximetry readings can be assessed. DIF: CognitiveLevel: Application OBJ: Determine theneed to modify or discontinue CPT maneuvers, including contraindications and individual variations.
TOP: Preparation for CPT
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
3. The nurse is reviewing medical records on several patients. Which findings reported in thechart indicate theneed for postural drainage? (Select all that apply.) a. Atelectasis reported on chest x-ray b. Thick, sticky, tenacious, green secretions noted in thenurse‘s notes c. Multiple rib fractures noted on chest x-ray d. Chest x-ray report indicating pneumonia with collapse of right lower lobe ANS: A, B, D
Chest x-ray film changes consistent with atelectasis, lobar collapse pneumonia, or bronchiectasis indicate a need for postural drainage. Other signs are ineffective coughing and thick, sticky, tenacious, discolored secretions that are difficult to cough up. Rib fractures are a contraindication for postural drainage. DIF: CognitiveLevel: Application OBJ: Assess theneed to perform chest physiotherapy (CPT) maneuvers. TOP: Indications for Postural Drainage
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. The nurse receives orders for postural drainage using Trendelenburg‘s position. On which patients should thenurse question theorder? (Select all that apply.) a. Patient with a history of gastroesophageal reflux disease (GERD) b. Postsurgical patient with a distended abdomen c. Patient with blood pressure of 180/100 d. Patient with bronchiectasis on chest x-ray ANS: A, B, C
Trendelenburg‘s position is contraindicated for uncontrolled hypertension, distended abdomen, esophageal surgery, recent gross hemoptysis, and uncontrolled airway at risk for aspiration. When patients have a risk for or history of GERD, thehead-down position should not be used. Bronchiectasis is an indication for postural drainage. DIF: CognitiveLevel: Application
OBJ: Determine theneed to modify or discontinue CPT maneuvers, including contraindications and individual variations.
TOP: Contraindications to Trendelenburg‘s Position
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
1. The nurse positions thepatient flat on theback with a small pillow under theknees to drain theright and left
.
ANS:
anterior upper lobe bronchi The patient is positioned flat on theback with a small pillow under theknees for theright and left anterior upper lobe bronchi. DIF: CognitiveLevel: Application OBJ: Explain how to prepare thepatient and thefamily for theperformance of each CPT maneuver. TOP: Positions for CPT
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
2. The patient is complaining of feeling congested. After assessing thepatient, thenurse places thepatient in theproper position and claps her cupped hands against thepatient‘s thorax. She does this because she is aware that
assists in loosening retained secretions
from theairway. ANS:
percussion Percussion involves clapping thechest wall with cupped hands. It sets up vibrations in thechest to dislodge retained secretions from theairway. DIF: CognitiveLevel: Comprehension OBJ: Assess theneed to perform chest physiotherapy (CPT) maneuvers. TOP: Percussion
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3.
is positioning thepatient so that theposition of thelung segment to be drained allows gravity to have its greatest effect. ANS:
Postural drainage (PD) Postural drainage Postural drainage (PD) is theuse of positioning techniques to drain secretions from specific segments of thelungs and bronchi into thetrachea. DIF: CognitiveLevel: Comprehension OBJ: Describe expected and unexpected outcomes of each CPT maneuver. TOP: Postural Drainage (PD)
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The system that lines theinternal lumen of thetracheobronchial tree and consists of a thin layer of mucus that constantly is propelled toward thelarynx by cilia is called the
.
ANS:
mucociliary transport system In thenormal lung, themucociliary transport system clears theairways of excessive mucus and inhaled particles. This system lines theinternal lumen of theentire tracheobronchial tree and consists of a thin layer of mucus that is constantly being propelled toward thelarynx by cells that have hairlike projections called cilia. DIF: CognitiveLevel: Comprehension OBJ: Assess theneed to perform chest physiotherapy (CPT) maneuvers. TOP: Mucociliary Transport System MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Assessment
5. The
provides positive expiratory pressure (PEP) with oral airway
oscillations. ANS:
Acapella device The Acapella is a handheld airway clearance device. It provides positive expiratory pressure (PEP) with oral airway oscillations. Positive expiratory pressure stabilizes airways and improves aeration of thedistal lung areas. During exhalation, pressure from theairways is transmitted to theAcapella device, which helps mucus dislodge from theairway walls and as a result prevents airway collapse, accelerates expiratory flow, and moves mucus toward thetrachea. DIF: CognitiveLevel: Comprehension OBJ: Perform theoutlined CPT maneuvers, including standard and modified versions. TOP: Acapella Device
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
Chapter 25: Airway Management Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE 1. A patient with a tracheostomy tube has thick, tenacious mucus that is difficult to remove. thenurse should choose which technique to suction theairway? a. Normal saline instillation (NSI) before suctioning b. Dry suctioning 1 time followed by NSI with suctioning 2 more times c. Dry suctioning as long as theheart rate is above 60 beats/min d. Dry suctioning ANS: D In thepast, thepractice of instilling normal saline into theartificial airway was performed to try and thin thesecretions, making them easier to suction out of theairway. Evidence indicates that this practice should no longer be performed and actually causes more damage to thelungs.
DIF:
CognitiveLevel: Application
OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care.
TOP: Normal Saline Instillation
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 2. A patient using a nasal cannula has gurgling on inspiration. thenurse notes a productive cough but theinability to clear thesecretions from themouth. Which action should thenurse take first to prepare for oropharyngeal suctioning? a. Apply clean gloves and a mask. b. Insert thesuction device to theback of thethroat. c. Remove thepatient‘s nasal cannula. d. Connect thetubing to a standard suction catheter. ANS: A Perform hand hygiene and apply clean gloves. Apply a mask or face shield if splashing is likely. Insert thedevice into themouth along thegum line to thepharynx. Remove thepatient‘s oxygen mask, if present. A nasal cannula may remain in place. Connect one end of theconnecting tubing to thesuction machine and theother to a Yankauer suction catheter. DIF:
CognitiveLevel: Application
OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care.
TOP: Oropharyngeal Suctioning
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 3. After oropharyngeal suctioning of a patient, thenurse notes bloody secretions in thesuction catheter and tubing. What should thenurse do next? a. Increase thesuction pressure. b. Provide additional oxygen. c. Reduce thefrequency of oral hygiene. d. Check thesuction catheter for nicks.
ANS: D Observe thecatheter tip for nicks, which can cause mucosal trauma. thenurse should assess theoral cavity for trauma or lesions, reduce theamount of suction pressure used, provide supplemental oxygen only if respiratory distress occurs, and increase thefrequency of oral hygiene. DIF:
CognitiveLevel: Application
OBJ: Describe thenursing interventions for airway management. TOP: Oropharyngeal Suctioning
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity 4. The nurse is caring for an infant who has been vomiting and is having difficulty breathing. What actions by thenurse are appropriate for suctioning theinfant? a. Place theinfant in side-lying position b. Suction only when a large amount of mucus is present. c. Suction for only 30 seconds. d. Compress thebulb syringe after it is placed in thenostril. ANS: A Position infants with breathing problems or excessive vomitus in side-lying position to decrease risk of aspiration. However, NEVER place an infant on a pillow (Hockenberry et al., 2019). Airways of infants and children are smaller than those of an adult. Even small amounts of mucus cause airway obstruction. Smaller suction catheters may need to be used (Hockenberry et al., 2019). Bulb syringes may be used to suction theoral cavity in newborns and infants. To properly use a bulb syringe, compress thebulb before inserting into mouth to decrease therisk of forcing thesecretions into lower airways. If thebulb syringe cannot remove thesecretions, use appropriate-size mechanical suction equipment (Hockenberry et al., 2019). Use lower suction pressures with infants and children than with adults (Hockenberry et al., 2019). DIF:
CognitiveLevel: Application
OBJ: Describe thenursing interventions for airway management.
TOP: Pediatric Considerations
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 5. A patient on mechanical ventilation with an endotracheal tube requires suctioning. A closed in-line catheter is in place. Which action by thenurse is appropriate? a. Use manual ventilation to hyperoxygenate thepatient with 100% oxygen via Ambu bag. b. Push thecatheter and slide theplastic sleeve back when thepatient exhales. c. Push thecatheter in until resistance is felt or thepatient coughs. d. Apply suction for no longer than 30 seconds as you remove thecatheter. ANS: C The catheter is pushed in while theplastic sleeve is slid back between thethumb and forefinger until resistance is felt or thepatient coughs. Hyperoxygenation is done by adjusting theFiO2 setting on theventilator. Manual ventilation is not recommended. thecatheter is pushed in when thepatient inhales. Suction is applied for no longer than 15 seconds. DIF:
CognitiveLevel: Application
OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care.
TOP: Closed (In-line) Suction
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is assessing several patients who have returned from surgery. Which finding most likely indicates a need for suctioning? a. Complaint of pain when breathing b. Cough producing thick yellow mucus c. Oxygen saturation level of 88% d. Drowsiness and respiratory rate of 8 ANS: C
When a patient‘s oxygen saturation falls below 90%, this is a good indicator of theneed for suctioning. Pain with breathing is probably related to thesurgery. If a cough is productive, suctioning is not necessary. Drowsiness and a decreased respiratory rate may be due to administration of pain medications such as opioids. DIF:
CognitiveLevel: Application
OBJ: Discuss theindications for airway suctioning. TOP: Indications for Suctioning
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 7. A patient with head trauma following a motor vehicle accident is on mechanical ventilation with an endotracheal tube. Which action by thenurse will reduce therisk for elevations in intracranial pressure during suctioning? a. Avoid hyperoxygenating thepatient before suctioning. b. Insert thesuction catheter just to theend of theendotracheal tube. c. Apply suction while inserting thecatheter. d. Limit suctioning to 2 times with each suctioning procedure. ANS: D Suctioning can cause elevations in intracranial pressure (ICP) in patients with head injuries. Reduce this risk by presuction hyperoxygenation, which results in hypocarbia, which in turn induces vasoconstriction. Vasoconstriction reduces thepotential for an increase in ICP. The number of suction passes should be based on patient assessment and presence of secretions. If secretions persist after two passes, allow patient more time to rest and recover before suctioning again. thecatheter is inserted past theend of theendotracheal tube until resistance is met to adequately remove secretions from theairway. Suction should be applied while thecatheter is removed. DIF:
CognitiveLevel: Application
OBJ: Describe thenursing interventions for airway management. TOP: Increased Intracranial Pressure with Suctioning KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
8. The student nurse is preparing to perform nasotracheal suctioning on an adult patient wearing a face mask. Which action by thestudent should thenursing instructor question? a. Increasing theoxygen flow rate for theface mask and asking thepatient to deep-breathe slowly before suctioning b. Inserting thecatheter into thenares slanting slightly downward c. Asking thepatient to swallow while thecatheter is being inserted d. Inserting thecatheter about 8 inches without applying suction ANS: C The suction catheter should not be inserted during swallowing because it will most likely enter theesophagus. Insert during inhalation because theepiglottis is open. thepatient should be hyperoxygenated before suctioning. theoxygen flow rate can be increased on theface mask, and thepatient can deep-breathe slowly to accomplish this. thecatheter should be inserted along thenatural course of thenares—slightly slanted downward. In adults, thecatheter is inserted about 20 cm (8 inches). DIF:
CognitiveLevel: Application
OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care.
TOP: Nasotracheal Suctioning
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse is providing nasotracheal suctioning for a 13-year-old patient with secretions in thethroat and trachea. Which action by thenurse demonstrates proper technique? a. Applying sterile petroleum jelly to thedistal tip of thesuction catheter b. Applying clean gloves to both hands c. Inserting thesuction catheter 3-5 inches during inspiration d. Suctioning thepharynx first and then thetrachea ANS: C
In older children, thesuction catheter is inserted about 8–12 cm (3 to 5 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible. thecatheter is always inserted during inspiration. thecatheter should be lubricated with water-soluble lubricant to avoid lipid aspiration pneumonia from a petroleum-based gel. theprocedure requires sterile gloves, at least on one hand. thetrachea should be suctioned before thepharynx because themouth and thepharynx contain more bacteria than thetrachea. DIF:
CognitiveLevel: Application
OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care.
TOP: Nasotracheal Suctioning
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse is performing nasotracheal suctioning for a patient. Which action by thenurse is appropriate? a. Applying intermittent suctioning while slowly withdrawing thesuction catheter b. Carefully pushing thesuction catheter in and out while applying suction c. Applying suction for 15 seconds or less d. Asking thepatient to deep-breathe for 15 seconds before passing thecatheter a second time ANS: C Apply intermittent suction for no more than 10–15 seconds by placing and releasing nondominant thumb over catheter vent. Slowly withdraw catheter while rotating it back and forth between thumb and forefinger. Suction time greater than 15 seconds increases risk for suction-induced hypoxemia (AARC, 2010; Urden et al., 2020). Intermittent suction and rotation of catheter prevents injury to tracheal mucosa. If catheter ―grabs‖ mucosa, remove thumb to release suction. DIF:
CognitiveLevel: Application
OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care.
TOP: Nasotracheal Suctioning
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 11. The nurse is performing nasotracheal suctioning on a patient. thenurse should discontinue thesuctioning if which of thefollowing occurs? a. The patient coughs as thecatheter is inserted. b. The heart rate decreases from 84 beats per minute to 60 beats per minute. c. An increase in pulse occurs from 74 beats per minute to 94 beats per minute. d. Oxygen saturation levels decrease from 97% to 94%. ANS: B Monitor patient's vital signs and oxygen saturation throughout suctioning process. Stop suctioning if thepatient becomes hemodynamically unstable, e.g. a 20 beats/min change (increase or decrease) in pulse rate or if SpO2 falls below 90% or 5% from baseline. DIF:
CognitiveLevel: Analysis
OBJ: Identify guidelines for managing a patient‘s airway. TOP: Discontinuation of Suction
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity 12. The nurse is suctioning a patient with an endotracheal tube. Which action should thenurse take when thepatient develops respiratory distress? a. Quickly remove thecatheter and carefully reinsert it. b. Continue to apply intermittent suction to remove thick secretions. c. Administer oxygen directly through thesuction catheter. d. Withdraw thecatheter and encourage thepatient to cough and deep-breathe. ANS: C If patient develops respiratory distress during thesuction procedure, immediately withdraw catheter and supply additional oxygen and breaths as needed. In an emergency administer oxygen directly through thecatheter. Disconnect suction and attach oxygen at prescribed flow rate through thecatheter. DIF:
CognitiveLevel: Application
OBJ: Describe thenursing interventions for airway management.
TOP: Respiratory Distress While Suctioning KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 13. The nurse has completed suctioning a patient‘s airway. Which action should thenurse take first? a. Reduce thesuction level to medium. b. Remove theface shield and save for future suctioning. c. Reposition thepatient and assist with oral hygiene using sterile gloves. d. Pull thegloves off over therolled catheter and discard. ANS: D When suctioning is completed, disconnect thecatheter from theconnecting tubing. Roll thecatheter around thefingers of thedominant hand. Pull theglove off inside out so that thecatheter remains coiled in theglove. Pull off theother glove over thefirst glove in thesame way. Discard in an appropriate receptacle. thesuction device should be turned off when suctioning is complete. There is no further need for suction. Remove theface shield and discard into an appropriate receptacle. Apply clean gloves to give personal care. DIF:
CognitiveLevel: Application
OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care.
TOP: Completing Airway Suctioning
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse is preparing to suction an infant with a tracheostomy tube. Which action by thenurse follows appropriate procedure? a. Using a suction catheter that is half thediameter of thetracheostomy tube b. Suctioning 0.2 to 0.5 inches beyond thetip of thetracheostomy tube c. Hyperoxygenating with 90% oxygen to avoid oxygen toxicity d. Using less than 150 mm Hg negative pressure ANS: A
Suction catheters for pediatrics should be half thediameter of thechild‘s tracheostomy tube. thedistance suctioned should be no greater than 0.5 cm (0.2 inches) beyond thetip of theartificial airway. To determine distance, thecatheter is placed near a sample artificial airway. Hyperoxygenate with 100% oxygen in pediatric patients. Negative pressure for suctioning should not exceed 100 mm Hg. DIF: CognitiveLevel: Application OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care.
TOP: Pediatric Considerations for Suctioning
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 15. A patient has been on mechanical ventilation with an endotracheal tube for 1 week. Which intervention by thenurse will help prevent ventilator-associated pneumonia (VAP)? a. Providing oral care with a toothbrush at least twice daily b. Changing theventilator circuits at least every 72 hours c. Removing subglottal secretions before every position change d. Maintaining endotracheal cuff pressures at 10 cm H2O ANS: C Provide subglottic secretion drainage, although it is not clear whether it should be continuous or intermittent manual suction. SSD allows for thesuction of secretions above thecuff of theET. Maintain airway cuff pressure between 20-30 mm Hg Change ventilator circuits only when dirty or contaminated and not on a routine basis Perform oral hygiene with chlorhexidine at least twice a day. DIF:
CognitiveLevel: Application
OBJ: Describe thenursing interventions for airway management. TOP: Ventilator-Associated Pneumonia (VAP) KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
16. The nurse is caring for a patient with an oral endotracheal tube in place. Which intervention by thenurse demonstrates proper procedure when providing endotracheal tube care?
a. Determining proper endotracheal tube depth by noting thelength of tube beyond thegum line b. Instructing theassistant to hold thetube away from thelips while changing thetape c. Removing theoral airway if thepatient is actively biting down after thetape is removed from theendotracheal tube d. Repositioning thetube on theopposite side or at thecenter of themouth at least every 24 to 48 hours ANS: D The ET should be repositioned at least daily. Changing sides of ET removes pressure and decreases risk of tissue injury at corners of mouth and oral mucosa. Note level of ET by looking at mark or noting centimeter value on tube itself. Move oral ET to other side of mouth and ensure that tube marking at lip is unchanged. Perform oral care as needed on side where tube was initially positioned. The endotracheal tube should be repositioned to theopposite side or at thecenter of themouth every 24 to 48 hours to prevent formation of pressure sores at thesides of themouth. theproper depth of theendotracheal tube is determined by noting thecentimeter mark at thelip or gum line. This line is marked on thetube and is recorded in thepatient‘s record at thetime of intubation. thetube should not be held away from thelips because this allows too much ―play‖ in thetube and increases therisk for tube movement and accidental extubation. theoral airway should not be removed if thepatient is actively biting down until tape partially or completely secures thetube. DIF:
CognitiveLevel: Application
OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care.
TOP: Endotracheal Tube Care
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 17. The student nurse is providing tracheostomy care to a patient who has intratracheal secretions and a damp tracheostomy dressing and ties. Which action by thestudent should thenursing instructor question?
a. Suctioning thetracheostomy tube before removing thesoiled tracheostomy dressing b. Assisting thepatient to semi-Fowler‘s position c. Placing new tracheostomy ties before cutting theold ties d. Cutting gauze pads to place around thetracheostomy tube ANS: D Do not use scissors to cut gauze pads as they may shed fibers that could be inhaled by thepatient and lead to pulmonary damage or infection. Use a manufactured pad with a slit. Suctioning thetube removes secretions to avoid occluding theouter cannula while theinner cannula is removed. Usually a supine or semi-Fowler‘s position is used to promote patient comfort and prevent muscle strain for thenurse. If changing ties without an assistant, theold ties are not cut until thenew ties are securely in place. DIF:
CognitiveLevel: Application
OBJ: Discuss theindications for tracheostomy care. TOP: Tracheostomy Tube Care
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 18. The nurse is providing care to a patient with a tracheostomy tube that has an inner cannula. Which intervention by thenurse follows proper procedure for tracheostomy tube care? a. Carefully removes theinner cannula and places it in a basin of 1:10 bleach solution b. Scrubs theinner cannula on theinside and outside with a 1:10 bleach solution c. After scrubbing theinner cannula, rinses it with normal saline d. Uses a wet 4 4 gauze and cleans theinside of theouter cannula ANS: C After theinner cannula is thoroughly cleaned, it is rinsed with normal saline. theinner cannula is removed and is placed in a basin of normal saline to loosen secretions. It is scrubbed and then rinsed with normal saline. theouter cannula is not cleaned on theinside. theexposed outer cannula surfaces at thestoma are dried with a 4 4 gauze to prevent a moist environment and prohibit microorganism growth and skin excoriation. DIF:
CognitiveLevel: Application
OBJ: Change a tracheostomy tube or inner cannula.
TOP: Tracheostomy Tube Care
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 19. A patient with a tracheostomy tube is accidentally extubated. What should thenurse do immediately? a. Call thehealth care provider. b. Mechanically ventilate thepatient. c. Insert a new tracheostomy tube. d. Hold thestoma open with thefingertips. ANS: C Replace theold tracheostomy tube with a new tube. Some experienced nurses or respiratory therapists may be able to quickly reinsert thetracheostomy tube. A spare tracheostomy tube of thesame size and kind should be kept at thebedside in theevent of emergency replacement. Notify thehealth care provider after reestablishing theairway. Be prepared to manually ventilate thepatient with an Ambu bag if respiratory distress develops until thetracheostomy is replaced. An endotracheal tube of thesame size can be inserted in thestoma in an emergency. DIF:
CognitiveLevel: Application
OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care.
TOP: Accidental Decannulation
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 20. When assessing a patient‘s tracheostomy site, thenurse notes redness and inflammation around thestoma. Which intervention can thenurse provide to address this problem? a. Decrease thefrequency of tracheostomy care. b. Apply a dry gauze dressing just under thestoma. c. Remove theties at frequent intervals. d. Apply a topical antibacterial solution and allow it to dry. ANS: D
Apply a topical antibacterial solution and allow it to dry. Increase thefrequency of tracheostomy care. Apply a hydrocolloid or transparent dressing just under thestoma to protect theskin from breakdown. Consult with a skin-care specialist. Adjust theties or apply new ones when theties are loose or tight. Never remove theties. DIF:
CognitiveLevel: Application
OBJ: Describe thenursing interventions for airway management. TOP: Stomal Inflammation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 21. The nurse is assessing a patient with an endotracheal tube on mechanical ventilation. Which assessment finding indicates a partially deflated cuff? a. Increased exhaled tidal volume b. Spasmodic coughing c. Tense test balloon on theendotracheal tube d. Vocalizations by thepatient ANS: D A partially deflated cuff allows secretions to enter thetrachea and permits vocalization. Other signs of an underinflated cuff are decreased exhaled tidal volume, a flaccid test balloon on thetube, and gurgling on expiration. An overinflated cuff can cause spasmodic coughing and a tense test balloon on thetube. DIF:
CognitiveLevel: Analysis
OBJ: Correctly inflate a cuff on an endotracheal or tracheostomy tube. TOP: Underinflated Cuff
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE 1. The nurse is assessing therisk for aspiration of gastric contents into thelungs resulting in airway obstruction. thenurse identifies patients with which conditions as having increased risk? (Select all that apply.)
a. Presence of a gastrostomy feeding tube b. History of smoking 2 packs per day for 30 years c. Head injury with a decreased level of consciousness d. Stroke with dysphagia ANS: A, C, D Conditions that increase thepatient‘s risk for aspiration include enteral feeding tubes or other nasal or oral gastric tubes, a decreased level of consciousness, and a decreased swallowing ability. DIF:
CognitiveLevel: Application
OBJ: Identify guidelines for managing a patient‘s airway. TOP: Risk for Aspiration
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 2. A patient with increased secretions may develop airway obstruction. thenurse can promote a patent airway by using which of thefollowing techniques? (Select all that apply.) a. Limiting fluid intake b. Positioning c. Deep breathing d. Humidity ANS: B, C, D Hydration, positioning, deep breathing, and humidity are techniques that are helpful in maintaining a patent airway. DIF:
CognitiveLevel: Application
OBJ: Describe thenursing interventions for airway management. TOP: Airway Management
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 3. The nurse performing nasotracheal suctioning should be assessing thepatient for which possible unexpected outcomes? (Select all that apply.)
a. Severe reduction in heart rate b. Wheezing and inability to breathe c. Reduction in oxygen saturation d. Nasal bleeding ANS: A, B, C, D Tracheal suctioning has many complications, including hypoxemia, cardiac dysrhythmias, changes in blood pressure (can be either hypertensive or hypotensive), laryngeal or bronchospasm, pain, infection, or bradycardia. Bradycardia is associated with stimulation of thevagus nerve. Respiratory or cardiac arrest can even occur as a result of tracheal suctioning. Nasal trauma and bleeding can develop from a suction catheter being introduced through thenares. DIF:
CognitiveLevel: Application
OBJ: Describe thenursing interventions for airway management. TOP: Risks of Nasotracheal Suctioning
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 4. The nurse is providing care to a patient on mechanical ventilation with an endotracheal tube. thenurse carefully inflates thecuff of theendotracheal tube using theminimal leak method, knowing that a properly inflated cuff provides which benefits to thepatient? (Select all that apply.) a. Prevents aspiration of gastric contents. b. Promotes accumulation of secretions below theepiglottis. c. Prevents air from escaping between thetube and thetracheal wall. d. Promotes lung inflation for mechanical ventilation. ANS: A, C, D A cuff on an endotracheal tube prevents theescape of air between thetube and thewalls of thetrachea and reduces aspiration when a patient is receiving mechanical ventilation. thegoals of correctly inflating thecuff on an artificial airway are to promote lung inflation for mechanical ventilation, prevent aspiration of gastric contents, and at thesame time allow drainage of secretions that accumulate between theepiglottis and thecuff.
DIF:
CognitiveLevel: Understanding
OBJ: Correctly inflate a cuff on an endotracheal or tracheostomy tube. TOP: Endotracheal (ET) Tube Cuffs
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a patient who has a tracheostomy. To prevent thepatient from developing an airway obstruction, thenurse assesses which of thefollowing? (Select all that apply.) a. Patient‘s nutritional status b. Environmental humidity c. Existing respiratory infection d. Patient‘s ability to cough ANS: A, B, C, D The patient‘s hydration and nutritional status, humidity delivered to thetracheostomy tube, thestatus of an existing infection, and theability to cough are all factors that affect theamount and consistency of secretions in thetracheostomy tube and thepatient‘s ability to clear theairway. DIF:
CognitiveLevel: Understanding
OBJ: Discuss theindications for tracheostomy care. TOP: Preventing Airway Obstruction
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 6. A nurse is preparing to suction a patient via thenasotracheal route. Which conditions should thenurse recognize as contraindications to nasotracheal suctioning? (Select all that apply.) a. Motor vehicle accident with acute head injuries b. History of hemophilia c. Epiglottitis or croup d. Environmental allergies with sinus drainage ANS: A, B, C
Contraindications to nasotracheal suctioning: occluded nasal passages; nasal bleeding; epiglottis or croup; acute head, facial, or neck injury or surgery; coagulopathy or bleeding disorder; irritable airway; laryngospasm or bronchospasm; gastric surgery with high anastomosis; myocardial infarction (American Association of Respiratory Care [AARC], 2004; Hockenberry et al, 2019; Wiegand, 2017). These conditions are contraindicated because passage of suction catheter through nasal route causes trauma to existing facial trauma/surgery, increases nasal bleeding, or causes severe bleeding in presence of coagulopathy or bleeding disorders. In presence of epiglottitis or croup, laryngospasm, or irritable airway, passage of suction catheter through nose causes intractable coughing, hypoxemia, and severe bronchospasm, necessitating emergency intubation or tracheostomy. Hypoxemia could worsen cardiac damage in myocardial infarction (AARC, 2004). DIF:
CognitiveLevel: Application
OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care. TOP: Contraindications to Nasotracheal Suctioning KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
7. The nurse is caring for a patient on mechanical ventilation with an endotracheal tube. Which nursing interventions will help prevent ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Maintain airway cuff pressure between 20-30 mm Hg b. Keeping thehead of thebed elevated 30 to 45 degrees c. Providing oral care with a toothette every 8 hours d. Keeping thehead flat during and for 30 minutes after enteral feedings ANS: A, B Elevate thehead of thebed to at least 30 degrees, unless contraindicated Perform oral hygiene with chlorhexidine at least twice a day Provide subglottic secretion drainage, although it is not clear whether it should be continuous or intermittent manual suction. SSD allows for thesuction of secretions above thecuff of theET. Maintain airway cuff pressure between 20-30 mm Hg Change ventilator circuits only when dirty or contaminated and not on a routine basis
DIF:
CognitiveLevel: Application
OBJ: Describe thenursing interventions for airway management. TOP: Ventilator-Associated Pneumonia (VAP) Prevention KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse is evaluating a patient to determine whether theendotracheal tube cuff is properly inflated. Which findings indicate proper inflation? (Select all that apply.) a. Cuff pressure is between 20-25 mm Hg b. Clear breaths sounds (no gurgling) on expiration c. The patient is able to vocalize. d. Gastric contents are noted in airway secretions. ANS: A, B The amount of cuff inflation is based on two factors: thesize of thepatient's trachea and theexternal diameter of theartificial airway. Cuff pressure should be between 20- and 25-mm Hg. Signs and symptoms of an underinflated cuff—gurgling on expiration, decreased exhaled tidal volume (mechanically ventilated patient), signs and symptoms of inadequate ventilation (rising end-tidal carbon dioxide concentration [ETCO2], patient-ventilator dyssynchrony, or dyspnea), or spasmodic coughing. DIF:
CognitiveLevel: Application
OBJ: Correctly inflate a cuff on an endotracheal or tracheostomy tube. TOP: Inflating theCuff on an Artificial Airway KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
COMPLETION 1. Too much oxygen reduces thedrive to breathe in patients with chronic ANS:
.
hypercapnia Too much oxygen reduces thedrive to breathe in patients with chronic hypercapnia (elevated arterial carbon dioxide tension). DIF:
CognitiveLevel: Understanding
OBJ: Identify guidelines for managing a patient‘s airway. KEY: NursingProcess Step: Assessment
TOP: Hypercapnia
MSC: NCLEX: Physiological Integrity
2. A patient has extremely copious and thick oral secretions. thenurse provides oropharyngeal suctioning using a
suction device.
ANS: Yankauer or tonsillar tip Yankauer tonsillar tip A Yankauer, or tonsillar tip, suction device is used for oropharyngeal suctioning (i.e., theremoval of pharyngeal secretions through themouth). A Yankauer suction catheter is made of rigid, minimally flexible plastic. thetip of this suction catheter usually has one large and several small openings through which themucus enters with application of negative pressure. theYankauer suction catheter is angled to facilitate removal of secretions through a patient's mouth. DIF:
CognitiveLevel: Application
OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care.
TOP: Yankauer Suction
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. A plastic or rubber tube that is inserted through thenares or mouth past theepiglottis and vocal cords to maintain an airway is known as an ANS:
.
endotracheal (ET) tube endotracheal tube An ET tube is inserted through thenares (nasal ET tube) or themouth (oral ET tube) past theepiglottis and vocal cords, into thetrachea. ET tubes usually are made of plastic or rubber. DIF:
CognitiveLevel: Understanding
OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care.
TOP: Endotracheal (ET) Tubes
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. A
is inserted directly into thetrachea through a small incision made in
thepatient‘s neck. ANS: tracheostomy (trach) tube tracheostomy tube trach tube A tracheostomy tube is inserted directly into thetrachea through a small incision made in thepatient‘s neck. DIF:
CognitiveLevel: Knowledge
OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care.
TOP: Tracheostomy Tube
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
Chapter 26: Cardiac Care Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE 1. Proper placement of theECG electrodes is essential for which reason?
a. To ensure real-time detection of arrhythmias b. To prevent painful removal of theelectrodes c. To facilitate capture of all leads d. To reduce ventricular arrhythmias ANS: A Proper placement of theECG electrodes is essential to ensure real-time detection of arrhythmias. Proper placement is not related to a less painful removal procedure. One primary lead is chosen to view theelectrical activity of theheart and this determines where theelectrodes are placed. Ventricular arrhythmias are not reduced by ECG electrode placement. DIF:
CognitiveLevel: Application
OBJ: Determine correct electrode placement to obtain an accurate ECG tracing. TOP: ECG Electrode Placement
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 2. When applying ECG electrodes to a woman, it is important to give special consideration to which of thefollowing objectives? a. Place theelectrode as close to thechest wall as possible, close to thebreast tissue. b. Place theelectrode away from thechest wall, close to thebreast tissue. c. Place theelectrode as close to thechest wall as possible, avoiding thebreast tissue. d. Place theelectrode away from thechest way, avoiding thebreast tissue. ANS: C When applying ECG electrodes to a woman, take special consideration to place theelectrode as close to thechest wall as possible, avoiding thebreast tissue. DIF:
CognitiveLevel: Application
OBJ: Determine correct electrode placement to obtain an accurate ECG tracing. TOP: ECG Electrode Placement MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
3. The nurse has explained to thepatient that a 12-lead ECG is indicated. thepatient refused to have theprocedure done citing that she fears that theelectrodes will cause harm to her heart. thenurse recognizes that which of thefollowing patient rationales are contraindications for a 12-lead ECG? a. Patient refusal b. The patient is receiving chemotherapy. c. The patient is ordered to have nothing by mouth (NPO). d. The patient has just been medicated for a pain level of 8 on a scale of 1 to 10. ANS: A No absolute contraindications to performing an electrocardiogram exist other than patient refusal. DIF:
CognitiveLevel: Application
OBJ: Identify indications to perform a 12-lead ECG and cardiac monitor application. TOP: Evidence-Based Practice Contraindications KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. The nurse understands that it is a priority to obtain the12-lead ECG on thepatient newly admitted with chest pain because theECG must be obtained within how many minutes of theonset of pain? a. 3 minutes b. 5 minutes c. 8 minutes d. 10 minutes ANS: D Patients suffering from chest pain need to have their 12-lead ECG within 10 minutes of theassessment and onset of pain. DIF:
CognitiveLevel: Comprehension
OBJ: Identify theindications to perform a 12-lead ECG and cardiac monitor application. TOP: Safety Guidelines MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
5. The nurse is assessing several patients who have returned from surgery when a 12-lead ECG is ordered for a newly admitted patient. Prioritizing patient needs, thenurse determines that obtaining the12-lead ECG can be most appropriately delegated to which member of thehealth care team? a. Administrative secretary b. Registered nurse who is covering for lunch breaks c. Nursing assistive personnel (NAP) who has been specifically trained to obtain themeasurement d. ECG technician from thevascular lab ANS: C The skill of obtaining a 12-lead ECG can be delegated to nursing assistive personnel (NAP) who are specifically trained in obtaining themeasurement. theRN who is covering breaks and theECG technician are not appropriate choices as this is a skill that a NAP can perform. theadministrative secretary is typically not trained to perform this skill. The skill of applying a cardiac monitor can be delegated to assistive personnel (AP) who are specifically trained. In some healthcare agencies theresponsible party for monitoring ECG rhythms and alarms may also be that of a specifically trained AP such as a telemetry technician. DIF:
CognitiveLevel: Application
OBJ: Identify theindications to perform a 12-lead ECG and cardiac monitor application. TOP: Delegation and Collaboration
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity 6. The nurse determines theneeds to obtainment of a 12-lead ECG on a patient. thenurse assesses two identifiers to ensure patient safety. This practice is in compliance with which safety organization? a. American Nurses Association b. The Joint Commission c. The National Hospital Association for Patient Safety
d. Magnet Credentialing ANS: B Identifying a patient using two identifiers such as name and date of birth and medical record ensures patient safety and complies with theJoint Commission standards. DIF:
CognitiveLevel: Understanding
OBJ: Determine correct electrode placement to obtain an accurate ECG tracing. TOP: 12-Lead ECG Skill Assessment
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 7. The student nurse is preparing to perform a 12-lead ECG on an adult patient. Which action by thestudent should thenursing instructor question? a. Cleansing and preparing theisolated electrode area with soap and water b. Wiping thearea with a rough cloth or gauze to gently scrape thearea c. Clipping theexcessive hair from theelectrode area d. Using alcohol to cleanse theelectrode area ANS: D Cleanse and prepare theisolated electrode area with soap and water. Wipe thearea with a rough washcloth or gauze or use theedge of theelectrode to gently scrape thearea. Clip excessive hair from theelectrode area. Do not use alcohol to cleanse thearea as it will dry out theskin. DIF: CognitiveLevel: Understanding OBJ: Identify theindications to perform a 12-lead ECG and cardiac monitor application. TOP: 12-Lead ECG Implementation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 8. The nurse is observing a nursing assistive personnel (NAP) perform a 12-lead ECG tracing on a newly admitted patient. thenurse recognizes that theNAP requires additional training on this skill when she observes which of thefollowing erroneous lead placements? a. V1—Fourth intercostal space at theright sternal angle
b. V2—Fourth intercostal space at theright sternal border c. V4—Fifth intercostal space at themidclavicular line d. V6—Left midaxillary line at thelevel of V4 horizontally ANS: B The V2 electrode is placed at thefourth intercostal space at theleft sternal border. DIF:
CognitiveLevel: Application
OBJ: Determine correct electrode placement to obtain an accurate ECG tracing. TOP: ECG Tracing Implementation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 9. While thenurse is performing a 12-lead ECG tracing, thepatient complains of crushing chest pain. thenurse recognizes that thetiming of thechest pain is important to note for which of thefollowing reasons? a. The 12-lead ECG must be held until thepain is relieved and continued as soon as it passes. b. The physician will order a follow-up ECG exactly 5 minutes post thelast episode of chest pain. c. It helps to correlate theECG changes to symptoms of chest pain. d. The ECG tracing must be stopped immediately. ANS: C The nurse should note and document if thepatient experiences any chest discomfort during theprocedure as this helps to correlate ECG changes to symptoms of chest pain. DIF:
CognitiveLevel: Application
OBJ: Determine correct electrode placement to obtain an accurate ECG tracing. TOP: 12-Lead ECG Implementation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 10. In order to determine thepatient and family caregiver‘s level of understanding of therationale for obtaining the12-lead ECG, thenurse most effectively utilizes which of thefollowing statements?
a. Can you tell me why you need this test? b. Did you experience pain during thetest? c. Can you tell me when thetest results will be shared with you? d. Can you give me your name and date of birth? ANS: A Use teach-back statement: I want to be sure that I explained why you need this ECG. Can you tell me about why you need thetest? This determines thepatient and family caregiver‘s level of understanding of thetopic. Pain is assessed during thetest and helps to correlate changes in theECG tracing. thetiming of theresults does not assess rationale for thetest. Patient identifiers are required to ensure patient safety. DIF:
CognitiveLevel: Application
OBJ: Determine thecorrect electrode placement to obtain an accurate ECG tracing. TOP: 12-Lead ECG Implementation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 11. The nurse is obtaining a 12-lead ECG on a patient with chest discomfort and interprets theresults as a very thick-lined waveform tracing. thenurse troubleshoots this tracing by performing which appropriate intervention? a. Unplugs thebattery-operated equipment in theroom one item at a time. b. Reapplies theelectrodes to ensure proper connection with theskin. c. Adjusts theextremity electrodes on thewrists and ankles. d. Asks thepatient to hold his breath to see if thetracing improves. ANS: A Artifact that looks like a very thick-lined waveform is 60-cycle interference. thenurse should unplug battery-operated equipment in theroom one item at a time to see if theinterference disappears. 60-cycle interference is rare. thetracing needs to be repeated. theelectrode placement and thepatient‘s breathing pattern do not cause 60-cycle interference. DIF:
CognitiveLevel: Analysis
OBJ: Determine correct electrode placement to obtain an accurate ECG tracing. TOP:
12-Lead ECG Unexpected Outcomes
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
12. The nurse changes theECG electrodes on a patient who is on a continuous cardiac monitor. thepatient tells thenurse that theelectrodes were just changed theprevious day. Which of thefollowing rationales is thecorrect explanation for thenurse to share with thepatient? a. Changing theelectrodes more often than 24 hours can result in skin breakdown. b. It is not necessary to change theelectrodes daily. c. It was not documented that theelectrodes were changed. d. Changing theelectrodes daily will decrease thenumber of false alarms. ANS: D The nurse recognizes that theECG electrodes should be changed daily or more often if electrode contact to theskin is loose. Changing theECG electrodes will decrease thenumber of false alarms. If there is poor skin contact, it may be necessary to change theelectrodes more frequently; this will not cause skin breakdown. DIF:
CognitiveLevel: Application
OBJ: Describe measures to reduce false alarms. TOP: Continuous Cardiac Monitoring
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 13. The nurse is preparing to apply electrodes for continuous cardiac monitoring to a newly admitted adult with syncope. Which action by thenurse follows appropriate procedure? a. Cleanse and prepare thechest area for electrode placement with chlorhexidine. b. Use a blanket to cover thepatient‘s abdomen while thelimb electrodes are being placed. c. Scrape thearea to roughen thedermis layer of skin to allow electrical signals to travel more easily. d. Place thepatient in a supine position. ANS: D
The chest area is prepared for electrode placement with soap and water. There are no limb electrodes for continuous cardiac monitoring. Ensure thepatient‘s abdomen and thighs are covered. Roughening theskin helps to remove theepidermis outer layer to allow electrical signals to travel. Do not roughen thedermis layer of skin. Electrodes should be applied when thepatient is in thesupine position. DIF:
CognitiveLevel: Application
OBJ: Determine correct electrode placement to obtain an accurate ECG tracing. TOP:
Continuous Cardiac Monitoring Implementation
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse is supervising a nursing assistive personnel (NAP) while applying electrodes for continuous cardiac monitoring to an elderly patient. thenurse recognizes theneed for further education when theNAP attaches which monitor lead to theelectrode? a. White is negative. b. Black is neutral. c. Red is theground lead. d. Brown is positive. ANS: B Colors of theleads represent their polarity. theblack lead is positive. DIF:
CognitiveLevel: Application
OBJ: Determine correct electrode placement to obtain an accurate ECG tracing. TOP: Continuous Cardiac Monitoring Implementation KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is caring for a patient on continuous cardiac monitoring. thenurse assesses therhythm as regular with a normal PQRST complex and a rate of 62 beats per minute. Which analysis is thecorrect interpretation of this cardiac rhythm? a. Sinus bradycardia
b. Sinus tachycardia c. Premature bradycardia d. Normal sinus rhythm ANS: D Characteristics of normal sinus rhythm include regular rhythm, rate 60 to 99 beats per minute, and a normal PQRST complex. Sinus bradycardia is a heart rate less than 60 beats per minute. Sinus tachycardia is a heart rate 100 to 180 beats per minute. There is no rhythm known as premature bradycardia. DIF:
CognitiveLevel: Application
OBJ: Determine correct electrode placement to obtain an accurate ECG tracing. TOP: Common Basic Cardiac Rhythms
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity 16. The nurse is caring for a 6-year-old child after open-heart surgery. When assessing thepatient, thenurse notes that theposition of theleads may be different in thepediatric population. Which lead placement explains this special consideration? a. The position of thegreen lead can be changed to mirror one of theprecordial lead positions. b. The standard placement for V1 is at thefifth intercostal space, right sternal border. c. The standard placement for V1 is at thefourth intercostal space, left sternal border. d. In general, mechanisms of dysrhythmias are thesame in children as they are in adults. ANS: D The position of thebrown lead can be changed to mirror one of theprecordial (chest) lead positions, V1 to V6. thestandard placement is for V1 at thefourth intercostal space, right sternal border. In general, themechanisms of dysrhythmias are thesame in children as they are in adults; however, theappearance of thearrhythmias on theECG may differ because of developmental issues such as heart size, baseline heart rate, sinus and AV node function, and autonomic innervation. DIF:
CognitiveLevel: Application
OBJ: Determine correct electrode placement to obtain an accurate ECG tracing. TOP:
Continuous Cardiac Monitoring Special Considerations
Pediatrics KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 17. Reduction of alarm fatigue is an important nursing practice. thenurse addresses this concern when which of thefollowing actions is implemented? a. Change theelectrodes once per shift. b. Provide initial and ongoing education about theintravenous pumps. c. Monitor all patients diagnosed with cancer on continuous cardiac monitoring. d. Set theparameters for thepulse oximetry machine within thestandard normal range. ANS: B Electrodes should be changed daily. Monitor only those patients with clinical indications for monitoring. Patient with cancer is not an indication for continuous cardiac monitoring. Provide initial and ongoing education about devices with alarms (intravenous pumps). Customize delay and threshold settings on oxygen saturation via pulse oximetry monitors. DIF:
CognitiveLevel: Application
OBJ: Determine measures to reduce false alarms. TOP: Expected Practice and Nursing Actions for theReductions of Alarm Fatigue KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse analyzes thepatient‘s cardiac rhythm as follows: regular rhythm, rate 108 beats per minute, normal PQRS complex. thenurse interprets that theclinical significance of this cardiac rhythm is most likely related to which indication? a. Decreased cardiac output b. Dizziness c. Pain d. Syncope ANS: C
The rhythm is identified as sinus tachycardia: regular rhythm, rate 100 to 180 beats per minute, normal PQRS complex. This rhythm is common as a normal response to exercise, pain, fever, hyperthyroidism, and certain drugs. Decreased cardiac output, dizziness, and syncope are indicators of sinus bradycardia. DIF:
CognitiveLevel: Analysis
OBJ: Identify theindications to perform a 12-lead ECG and cardiac monitor application. TOP: Common Basic Rhythms
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity 19. The nurse is reviewing thepatient‘s Do Not Resuscitate orders when thecardiac alarm sounds. therhythm is chaotic with no identifiable waves and therate cannot be determined. Based on these clinical findings, thenurse determines that thepatient is in which of thefollowing cardiac rhythms? a. Asystole b. Ventricular fibrillation c. Ventricular tachycardia d. Sinus bradycardia ANS: B Ventricular fibrillation is a chaotic rhythm with no identifiable waves and therefore a rate cannot be identified. Asystole is a flat line with no waves. Ventricular tachycardia is a rate of 100 to 200 beats per minute. Sinus bradycardia is a rate of less than 60 beats per minute. DIF:
CognitiveLevel: Analysis
OBJ: Identify theindications to perform a 12-lead ECG and cardiac monitor application. TOP: Common Basic Dysrhythmias
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity 20. When describing therationale for connecting electrodes to each limb and around theheart, thenurse shares with thepatient which appropriate explanation? a. The leads view a specific portion of theheart‘s surface to help determine which part has sustained damage.
b. Multiple leads are necessary to provide a three-dimensional view of theheart. c. The electrodes are necessary to provide a shock to theheart if needed during cardiac conversion. d. The limb electrodes are required to provide a backup study in theevent of artifact. ANS: D A 12-lead ECG does not construct a three-dimensional view of theheart. A 12-lead ECG does not cardiovert theheart. Limb electrodes do not eliminate artifact. theleads view a specific portion of theheart‘s surface to help determine which part has sustained damage, origin, and flow of theimpulse. DIF:
CognitiveLevel: Analysis
OBJ: Determine correct electrode placement to obtain an accurate ECG tracing. TOP: Obtaining a 12-Lead Electrocardiogram KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse is obtaining a 12-lead ECG on a patient with syncope. Which of thefollowing actions, if taken by thenurse, are effective at reducing thepresence of artifact in theECG tracing? a. Instruct thepatient to stop talking. b. Turn theECG machine on after all theelectrodes are applied. c. Position thepatient in semi-Fowler‘s position. d. Maintain thegown on thepatient to provide privacy. ANS: A Talking produces artifact that may necessitate repeating the12-lead ECG. theECG machine should be turned on first in order to help identification of electrodes and lead issues upon application. Position thepatient in thesupine position. Remove thepatient‘s gown to expose thepatient‘s chest and arms. DIF:
CognitiveLevel: Application
OBJ: Determine correct electrode placement to obtain an accurate ECG tracing. TOP:
Obtaining a 12-Lead ECG Implementation
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 22. After obtaining a 12-lead ECG, thenurse records thedate and time theECG was obtained, thereason for obtaining theECG, and who theECG was given to for interpretation in thepatient‘s chart. After this documentation, what is theappropriate action of thenurse? a. Immediately report any unexpected outcomes. b. Reposition thepatient to a position of comfort. c. Report to thenursing assistive personnel that the12-lead ECG is completed. d. Invite thefamily caregivers to visit at thebedside. ANS: A After documentation of thedetails related to the12-lead ECG, thenurse should report any unexpected outcomes immediately. Repositioning thepatient and inviting family caregivers to thebedside are not related to thecompletion of the12-lead ECG. While it assists with communication between team members, thenursing assistive personnel (NAP) does not need to immediately know that thetest was completed. DIF:
CognitiveLevel: Implementation
OBJ: Determine correct electrode placement to obtain an accurate ECG tracing. TOP:
Air Leak KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE 1. The nurse is assessing if thepatient needs a 12-lead ECG. Which of thefollowing indications, if identified, indicates that a 12-lead ECG should be obtained? (Select all that apply.) a. Suspected acute coronary syndromes including myocardial infarction b. History of smoking 2 packs per day for 30 years c. Evaluation of syncope d. Disorders of thecardiac rhythm ANS: A, C, D
Indications for 12-lead ECG include suspected acute cardiac syndromes including myocardial infarction, evaluation of implanted defibrillators and pacemakers, disorders of thecardiac rhythm, evaluation of syncope, evaluation of metabolic disorders, effects and side effects of pharmacotherapy. DIF:
CognitiveLevel: Application
OBJ: Identify indications to perform a 12-lead ECG and cardiac monitor application. TOP: Evidence-Based Practice Indications KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The nurse identifies theappropriate equipment necessary to obtain a 12-lead ECG and gathers thefollowing supplies. (Select all that apply.) a. 12-Lead ECG machine b. Clean, dry towel c. Hair clippers d. Betadine cleanser ANS: A, B, C Equipment necessary to obtain a 12-lead ECG includes 12-lead ECG machine; 10 ECG leads; 10 ECG electrodes; clean, dry towel or sponge wipes; and hair clippers. Betadine cleanser is not necessary. DIF:
CognitiveLevel: Understanding
OBJ: Determine correct electrode placement to obtain an accurate ECG tracing. TOP:
Equipment
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity 3. The nurse is obtaining a 12-lead ECG on a patient and notices that theECG cannot be interpreted. Which of thefollowing interventions are appropriate for thenurse to take? (Select all that apply.) a. Inspect theelectrodes for secure placement. b. Reposition any wires that move as a result of patient breathing or movement. c. Reposition electrodes that are in thecorrect position.
d. Remind thepatient to remain still in order to obtain a good tracing. ANS: A, B, D When theECG cannot be interpreted, thenurse should inspect electrodes for secure placement, reposition any wires that move as a result of patient breathing or movement, and remind thepatient to lie still. Do not reposition electrodes if in thecorrect position. DIF:
CognitiveLevel: Analysis
OBJ: Describe measures to reduce false alarms. TOP: 12-Lead ECG Evaluation
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity 4. The nurse is caring for a patient who has chest discomfort. While obtaining the12-lead ECG, thepatient complains of feeling very anxious. Which of thefollowing interventions should thenurse take in caring for thepatient‘s anxiety? (Select all that apply.) a. Continue to monitor thepatient. b. Reassess factors contributing to anxiety or distress. c. Ask thefamily caregiver to leave theroom. d. Notify thehealth care provider. ANS: A, B, D If thepatient experiences chest pain or anxiety during theobtainment of a 12-lead ECG, thenurses should continue to monitor thepatient, reassess factors contributing theanxiety or distress, notify thehealth care provider, and follow specific orders related to findings. Asking thefamily caregiver to leave theroom may increase thepatient‘s anxiety. DIF:
CognitiveLevel: Application
OBJ: Describe measures to reduce false alarms. TOP:
12-Lead ECG Unexpected
Outcomes KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
5. A patient is being monitored on a continuous cardiac monitor. thenurse directs thenursing assistive personnel (NAP) to immediately report which of thefollowing patient findings? (Select all that apply.)
a. Patient complaints of pain b. Shortness of breath c. Hypotension d. Patient‘s request to use thebedside commode ANS: A, B, C The skill of applying a cardiac monitor can be delegated to nursing assistive personnel (NAP) who are specifically trained. thenurse directs theNAP to immediately report to thenurse alarms or patient complaints of pain, shortness of breath or hypotension. theNAP also ensures that theparameters for alarms are set as per thehealth care provider‘s orders. DIF:
CognitiveLevel: Application
OBJ: Describe measures to reduce false alarms. TOP: Applying a Cardiac Monitor Delegation and Collaboration KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
6. The nurse is caring for a patient on continuous cardiac monitoring who is experiencing occasional premature ventricular contractions. Which of thefollowing actions demonstrate appropriate protocol? (Select all that apply.) a. Review alarm trends and waveforms at least once per shift. b. Review alarm trends and waveforms upon report of an alarm. c. Record at least one rhythm strip per shift to thepatient‘s medical record. d. Report any unexpected outcomes to thehealth care provider at theend of theshift. ANS: A, B, C Review alarm trends and waveforms at least once per shift and upon report of an alarm. Record at least one rhythm strip per shift per agency policy. Report any unexpected outcomes immediately to thehealth care provider; do not wait until theend of theshift. DIF:
CognitiveLevel: Application
OBJ: Describe measures to reduce false alarms. TOP: Continuous Cardiac Monitoring Recording and Reporting KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
7. The nurse recognizes thefollowing indications as appropriate for continuous cardiac monitoring. (Select all that apply.) a. Postresuscitation patients b. Patients with heart failure c. Patients over theage of 75 years d. Diagnosis of dysrhythmias in children ANS: A, B, D Patients‘ age 75 years or older is not an indication for continuous cardiac monitoring. Indications include postresuscitation, heart failure, and children with dysrhythmias. DIF:
CognitiveLevel: Application
OBJ: Identify indications to perform a 12-lead ECG and cardiac monitor application. TOP: Class 1 Indications for Continuous Cardiac Monitoring KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
COMPLETION 1. Some patients may have allergies, or more commonly, sensitivities to theadhesive used to affix theleads. In these cases,
are available from various manufacturers.
ANS: hypoallergenic alternatives Nurses should use hypoallergenic alternatives for patients who are allergic to theadhesive of theelectrodes. DIF:
CognitiveLevel: Application
OBJ: Identify theindications to perform a 12-lead ECG and cardiac monitor application. TOP: Evidence-Based Practice Contraindications KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. When preparing theskin before ECG electrode placement, clipping thehair in theelectrode area is preferred over shaving due to risk of
.
ANS: infection Clipping thehair in theelectrode area is preferred over shaving due to therisk of infection. DIF:
CognitiveLevel: Application
OBJ: Determine correct electrode placement to obtain an accurate ECG tracing. TOP: 12-Lead ECG Implementation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 3. ECG tracings that cannot be interpreted are known as
.
ANS: artifact When an ECG tracing cannot be interpreted, this is known as artifact. thenurse interprets for thepresence of artifact in theECG tracings and troubleshoots related interventions to correct this unexpected outcome. DIF:
CognitiveLevel: Analysis
OBJ: Describe measures to reduce false alarms. TOP:
12-Lead ECG Unexpected
Outcomes KEY: NursingProcess Step: Evaluation 4.
MSC: NCLEX: Physiological Integrity
develops when a person is exposed to an excessive number of alarms. ANS: Alarm fatigue
This situation can result in sensory overload, which may cause theperson to become desensitized to thealarms. Consequently, theresponse to alarms may be delayed, or alarms may be missed altogether. DIF:
CognitiveLevel: Knowledge
OBJ: Describe measures to reduce false alarms. TOP: Applying a Cardiac Monitor
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
Chapter 27: Closed Chest Drainage Systems Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE 1. The nurse is caring for a patient who is comatose and on a ventilator. When she enters theroom, she notices that thepatient‘s trachea has shifted toward theleft side of thepatient‘s neck, and he has become tachycardic. She assesses thepatient‘s blood pressure and notes that it is 84/38. thenurse calls for help, having recognized that thepatient has developed which of thefollowing conditions? a. Hemothorax b. Pneumothorax on theleft side c. Pneumothorax on theright side d. Myocardial infarction ANS: C
A tension pneumothorax occurs from rupture in thepleura when air accumulates in thepleural space more rapidly than it is removed. If left untreated, thelung on theaffected side collapses, and themediastinum and thetrachea shift to theopposite (unaffected) side. thepatient has sudden chest pain, a fall in blood pressure, and tachycardia, and cardiopulmonary arrest can occur. Patients with chest trauma, fractured ribs, and invasive thoracic bedside procedures (such as insertion of central lines) and those on high-pressure mechanical ventilation are at risk for tension pneumothorax. A hemothorax is a collapse of thelung caused by an accumulation of blood and fluid in thepleural cavity between thechest wall and thelung, usually as a result of trauma. Nothing in this scenario would suggest myocardial infarction. DIF:
CognitiveLevel: Synthesis
OBJ: List three conditions requiring chest tube insertion. KEY: NursingProcess Step: Assessment
TOP: Pneumothorax
MSC: NCLEX: Physiological Integrity
2. For a patient with a pneumothorax, where does thenurse anticipate that thechest tube will be located? a. Second to third intercostal space (apical), anterior b. Fifth to sixth intercostal space, posterior c. Fifth to sixth intercostal space, lateral d. Mediastinal area ANS: A Apical (second or third intercostal space) and anterior chest tube placement promotes removal of air, which is necessary in thecase of a pneumothorax. Chest tubes are placed low (usually in thefifth or sixth intercostal space) and posterior or lateral to drain fluid. A mediastinal chest tube is placed in themediastinum, just below thesternum. This tube drains blood or fluid, preventing its accumulation around theheart. A mediastinal tube commonly is used after open-heart surgery. DIF:
CognitiveLevel: Analysis
OBJ: List three common sites for chest tube placement. TOP: Chest Tube Position MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Assessment
3. The patient‘s chest tube is attached to a one-way flutter valve that allows air to escape thechest cavity and prevents air from reentering. How does thenurse document this finding? a. Heimlich chest drain valve b. Pneumovax c. Water seal d. Pleurovac ANS: A The device described is a Heimlich chest drain valve. Pneumovax is a pneumococcal vaccine that is effective against 23 common strains of Pneumococcus. A Pleurovac is thebrand name of a water-seal set. DIF: CognitiveLevel: Knowledge OBJ: Define thekey terms used in thecare of patients with chest tubes. TOP: Type of Chest Tube
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 4. The nurse is caring for a patient who has a chest tube connected to a water seal. thepatient is not on a ventilator. Which of thefollowing would thenurse consider normal? a. The fluid level in thewater seal rises with inspiration. b. The fluid level in thewater seal falls with inspiration. c. Constant bubbling occurs in thewater seal. d. The fluid level in thewater seal falls with expiration 3 days after insertion. ANS: A Observe thewater seal for intermittent bubbling and a rise and fall of thefluid in thewater seal chamber (tidaling) that is synchronous with respirations, which is expected. For example, in a spontaneously breathing patient thefluid level normally rises during inspiration and falls during expiration. When a patient is on a mechanical ventilator, theopposite occurs. Constant bubbling in thewater seal or a sudden, unexpected stoppage of water-seal activity is considered abnormal and requires immediate attention. After 2 to 3 days, tidaling or bubbling on expiration is expected to stop, indicating that thelung has reexpanded.
DIF: CognitiveLevel: Analysis OBJ: Discuss thenursing principles involved in caring for patients with chest tubes. TOP: Water-Seal Tidaling
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a patient with a chest tube that was inserted 4 days earlier. She notices that thedrainage contains a large amount of pus. What does thepresence of thepus indicate? a. Malignancy b. Pulmonary infarction c. Empyema d. Hemothorax ANS: C Pus indicates an empyema, which is a collection of pus in thepleural cavity, and thedrainage is pus colored. Blood-tinged fluid usually indicates malignancy, pulmonary infarction, or severe inflammation. Frank blood indicates a hemothorax. DIF:
CognitiveLevel: Knowledge
OBJ: Discuss thenursing principles involved in caring for patients with chest tubes. TOP: Pleural Drainage
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 6. What is indicated by continuous bubbling in thewater-seal chamber with no bubbles noted in thesuction-control chamber of thedrainage system? a. A leak in thesystem b. Normal functioning c. A drainage obstruction d. Insufficient suction pressure ANS: A
Continuous bubbling in thewater-seal chamber with an absence of bubbles in thesuction-control chamber indicates that there is a leak in thesystem. Normal functioning is indicated by gentle, continuous bubbling in thesuction chamber and occasional bubbling in thewater seal, with fluctuations on inspiration and expiration. Constant bubbling in thewater seal or a sudden, unexpected stoppage of water-seal activity is considered abnormal and requires immediate attention. Insufficient suction pressure has little to no bubbling in thesuction chamber. DIF:
CognitiveLevel: Analysis
OBJ: Describe methods of troubleshooting chest tube systems. TOP: Bubbling in Suction-control Chamber KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
7. What condition is indicated when a patient with a chest tube experiences sharp, stabbing chest pain without a change in pulse or blood pressure? a. Pneumonitis b. Tube displacement c. A myocardial infarction d. A tension pneumothorax ANS: D Sharp, stabbing chest pain with or without decreased blood pressure and increased heart rate may indicate a tension pneumothorax. A chest tube is not an expected treatment for pneumonitis. Tube displacement is an unexpected outcome and can lead to increased pneumothorax. Immediately apply pressure over thechest tube insertion site. Myocardial infarction pain is expressed as ―crushing‖ or ―pressure‖ over thesternal area. DIF:
CognitiveLevel: Analysis
OBJ: Describe methods of troubleshooting chest tube systems. TOP: Tension Pneumothorax
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity 8. Which of thefollowing is an expected outcome of chest tube insertion?
a. Mild chest pain is maintained. b. Breath sounds are auscultated in all lobes. c. Drainage from thepleural cavity increases over time. d. Lung expansion is increased beyond theunaffected side. ANS: B When breath sounds are auscultated in all lobes, lung expansion is symmetrical, oxygen saturation (SaO2) is stable or improved, and respirations are nonlabored. Chest pain is not an expected outcome. Treatment is effective when thepatient reports no chest pain. Drainage from thepleural cavity decreases over time with reexpansion of thelung. Lung expansion would be equal to preinjury status. DIF:
CognitiveLevel: Knowledge
OBJ: Describe methods of troubleshooting chest tube systems. TOP: Expected Outcomes of Chest Tube Insertion KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
9. What should thenurse do to establish a two-chamber waterless chest tube system? a. Add sterile water to thesuction chamber. b. Add sterile solution to thewater seal. c. Set thefloat ball to thecorrect drainage pressure. d. Connect directly to thechest tube and add nothing. ANS: D The waterless two-chamber system is ready for connecting to thepatient‘s chest tube after thewrappers have been opened. thewaterless system‘s principles are similar to those of thewater-seal system, except that fluid is not required for setup. Because water is not used, accidentally tipping over thesystem does not compromise thepatient‘s condition. thesuction chamber does not depend on water. Instead, it contains a float ball, which is set by a suction control dial after thesuction source is turned on. DIF:
CognitiveLevel: Application
OBJ: Describe closed chest drainage systems: water-seal and waterless systems. TOP: Two-Chamber Waterless Chest Tube System
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 10. Which of thefollowing represents appropriate technique when providing care for a patient with chest tubes? a. Applying an occlusive dressing over thesite b. ―Stripping‖ thetube on a regular basis c. Assessing thepatient hourly after insertion d. Keeping excess loops of tubing from hanging over theside of thebed ANS: D Lay excess tubing horizontally on themattress next to thepatient. Secure with a rubber band and safety pin or with thesystem‘s clamp. This prevents excess tubing from hanging over theedge of themattress in a dependent loop. Drainage could collect in theloop and occlude thedrainage system. Physician responsibility in chest tube placement includes covering theinsertion site with sterile petroleum gauze, 4 4-inch gauze, and a large dressing to form an occlusive dressing supported with an elastic bandage. Strip or milk thechest tube only if indicated (this means compressing thetube to encourage clots to press through thetube). Stripping may cause complications because it creates excessive negative intrapleural pressure. Check agency policy. Monitor vital signs, SaO2, and theinsertion site every 15 minutes for thefirst 2 hours. DIF:
CognitiveLevel: Application
OBJ: Discuss thenursing principles involved in caring for patients with chest tubes. TOP: Providing Care to thePatient Who Has a Chest Tube KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 11. Which of thefollowing is thecorrect positioning for a patient after a chest tube has been inserted for a pneumothorax? a. Supine b. Side-lying c. Semi-Fowler‘s
d. High-Fowler‘s ANS: D After thetube is placed, assist thepatient to a comfortable position. Supine does not facilitate drainage or removal of air or fluid, and side-lying does not facilitate lung expansion. thehigh-Fowler‘s position is used to evacuate air (pneumothorax). DIF:
CognitiveLevel: Application
OBJ: Discuss thenursing principles involved in caring for patients with chest tubes. TOP: Positioning thePatient Who Has a Chest Tube KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 12. What is theexpected amount of drainage for an adult patient with a mediastinal chest tube? a. Less than 100 mL/hr during theimmediate postoperative period b. Less than 10 mL/hr during theimmediate postoperative period c. 1000 mL/hr during thefirst 24-hour period d. 200 mL/hr during thefirst 24-hour period ANS: A From mediastinal tube, expect less than 100 mL/hr immediately after surgery and no more than 500 mL in first 24 hours. DIF:
CognitiveLevel: Comprehension
OBJ: Discuss thenursing principles involved in caring for patients with chest tubes. TOP: Postoperative Drainage from a Mediastinal Chest Tube KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
13. What is theexpected amount of drainage for an adult patient with a posterior chest tube? a. 100 to 300 mL during thefirst 3 hours b. 10 to 50 mL during thefirst 2 hours c. 200 mL during thefirst 24 hours d. 400 to 500 mL during thefirst 24 hours
ANS: A From posterior chest tube, drainage is grossly bloody during first several hours after surgery and changes to serous. Acute bleeding indicates hemorrhage. Health care provider should be notified if there is more than 200 mL of bloody drainage in an hour. DIF:
CognitiveLevel: Comprehension
OBJ: Discuss thenursing principles involved in caring for patients with chest tubes. TOP: Drainage from a Pleural Chest Tube KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
14. A nurse determines that there may be a leak in thechest tube system. Clamps are applied near thepatient‘s chest, and thenurse finds that thebubbling stops. What should thenurse do next? a. Change thetubing. b. Change thedrainage container. c. Move theclamps farther down thechest tube. d. Reinforce thedressing and notify thephysician. ANS: D Assess for thelocation of theair leak by clamping thechest tube close to thechest wall with two shodded hemostats. If thebubbling stops, theleak is inside thethorax or insertion site. Unclamp thetube, reinforce thedressing, and notify thephysician immediately. If bubbling continues with theclamps near thechest wall, gradually move one clamp at a time down thetubing toward thepatient. If bubbling stops, replace thetubing or secure theconnections. If bubbling continues, replace thedrainage system. DIF:
CognitiveLevel: Application
OBJ: Discuss thenursing principles involved in caring for patients with chest tubes. TOP: Detecting Air Leak in a Chest Tube System KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 15. During assessment of a patient, thechest tube becomes dislodged. What should thenurse do first?
a. Have an assistant apply an occlusive gauze dressing and tape on all four sides. b. Clamp thechest tube. c. Attempt to gently reinsert thetube. d. Apply pressure over theinsertion site. ANS: D If thechest tube becomes dislodged, immediately apply pressure over chest tube insertion site. Have assistant obtain sterile petroleum gauze dressing. Apply as patient exhales. Secure dressing with tight seal. Dressing with tape over three of four sides may allow for escape of air if there is residual pneumothorax. Notify health care provider. DIF:
CognitiveLevel: Application
OBJ: Discuss thenursing principles involved in caring for patients with chest tubes. TOP: Dislodged Chest Tube
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 16. What does theexpected role of thenurse include during chest tube removal? a. Prepares an occlusive dressing. b. Performs clipping of thesutures. c. Provides support and assessment of thepatient. d. Removes thechest tube firmly and quickly. ANS: C The nurse supports thepatient physically and emotionally while thephysician or an advanced practice nurse (APN) removes thedressing and clips thesutures. A physician or an APN prepares an occlusive dressing of petroleum gauze on a pressure dressing, sets it aside on a sterile field, and applies sterile gloves; removes thedressing and clips thesutures; and pulls out thechest tube. DIF:
CognitiveLevel: Application
OBJ: Discuss thenursing principles involved in caring for patients with chest tubes. TOP: Chest Tube Removal MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
17. Appropriate intervention for thepatient who is having a reinfusion of chest tube drainage is noted when thenurse: a. hangs thereinfusion lower than theusual intravenous (IV) bag. b. uses a microaggregate filter on thereinfusion bag. c. maintains 500 mm Hg pressure in thegravity blood cuff. d. keeps theclamps open on thedrainage tubing during bag transfer. ANS: B Use a new microaggregate filter to reinfuse each autotransfusion bag. Hang thebag on an IV pole and continue to prime thetubing until all air is gone. Clamp thetubing, attach it to thepatient‘s IV access, and adjust theclamp to deliver thereinfusion at theappropriate rate. Reinfusion is delivered by gravity or by application of a blood cuff (not to exceed 150 mm Hg pressure) or a blood-compatible IV pump. Connect thered and blue connectors on top of theinitial collection bag, and remove it by lifting it from theside hook and then from thefoot hook. This maintains a closed system within thebag and removes it for use in autotransfusion. DIF:
CognitiveLevel: Application
TOP: Autotransfusion
OBJ: Describe autotransfusion. KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 18. Of thefollowing nursing assessments, which should be reported to theprimary care provider immediately by thenurse? a. Bloody drainage from a patient with a hemothorax b. Subcutaneous emphysema is noted on assessment. c. Bubbling in thewater seal stops on a patient with a pneumothorax. d. Over 300 mL of drainage has been collected in thesystem in thepast hour. ANS: D Drainage exceeding 100 mL/hr should be reported immediately because this would be considered abnormal. Drainage would be expected to be bloody if thepatient has a hemothorax. Cessation of bubbling in thewater seal indicates that theair has been evacuated in thepatient with a pneumothorax. Although thefinding of subcutaneous emphysema should be reported, documented, and monitored, it is not an emergency.
DIF:
CognitiveLevel: Analysis
OBJ: Demonstrate appropriate documentation and reporting of chest tube care. TOP: Chest Tube Assessment
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment 19. The nurse is providing care for a patient with a pneumothorax. She anticipated removal of thechest tube because of theabsence of an air leak for thepast
hours.
a. 6 to 8 b. 12 to 16 c. 18 to 24 d. 48 to 72 ANS: C Note trend in water-seal fluctuation over last 24 hours. Determine if bubbling is present. Pleura of expanded lung seals holes on internal tip of chest tube, halting fluctuation in water seal. Halt in fluctuation for 24 hours indicates that lung is expanded. When bubbling is present, it usually indicates that lung has not fully expanded. . Other findings that indicate that thechest tube may be removed include a chest x-ray showing lung reexpansion, minimal tube drainage, and lack of water-seal tidaling. DIF:
CognitiveLevel: Analysis
OBJ: Verbalize thesteps used in assisting with chest tube removal. TOP: Chest Tube Removal
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity 20. The nurse is caring for a patient with blood collecting in thepleural space. thenurse documents this as: a. pleural effusion. b. hemothorax. c. pulmonary hemorrhage. d. pneumothorax. ANS: B
A hemothorax is a collection of blood in thepleural space. A pneumothorax is thecollection of air in thepleural space. A pulmonary hemorrhage is bleeding inside thelung. A pleural effusion is thecollection of fluid within thepleura. DIF:
CognitiveLevel: Knowledge
OBJ: Define thekey terms used in thecare of patients with chest tubes. TOP: Chest Tubes Drainage
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 21. The nurse knows that
is theproper term to describe that thepatient‘s water
seal is fluctuating up and down with each breath. a. bubbling b. tidaling c. fluttering d. alternating ANS: B The term for thefluctuation of thewater-seal chamber when thepatient breathes is tidaling. Bubbling is different from tidaling, because bubbling is thepresence of gas moving through thechamber, whereas tidaling is an up and down movement that correlates with thepatient‘s breathing. Fluttering and alternating reflect incorrect terminology. DIF:
CognitiveLevel: Knowledge
OBJ: Define thekey terms used in thecare of patients with chest tubes. TOP: Chest Tube Functioning
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 22. The nurse is caring for a patient with a chest tube connected to water-seal drainage. thenurse may delegate which of thefollowing tasks to nursing assistive personnel (NAP)? a. Changing thechest tube drainage system b. Milking thechest tube c. Measuring chest tube output d. Turning and positioning thepatient
ANS: D The NAP may turn and position thepatient as long as thenurse ensures that theNAP understands how to manipulate thetubing safely and what signs and symptoms should be reported immediately. Care of thechest tube, including milking thetube if ordered, measuring chest tube output, and changing thechest tube drainage system, should never be delegated to unlicensed assistive personnel. DIF:
CognitiveLevel: Application
OBJ: Recognize when it is appropriate to delegate aspects of thecare of patients with chest tubes to unlicensed assistive personnel.
TOP: Chest Tube Assessment
KEY: NursingProcess Step: Planning MSC: NCLEX: Safe and Effective Care Environment 23. The patient has a chest tube for a pneumothorax. Assessment revealed continuous bubbling in thewater-seal chamber. thenurse finds no loose connections. After thechest tube near thepatient is clamped, thebubbling stops. thenurse‘s first action should be to: a. apply pressure to thedressing around thechest tube insertion site. b. move theclamp farther down thetube and note whether bubbling resumes. c. replace theentire collection tubing and system. d. increase suction control until bubbling does not resume when theclamp is removed. ANS: A If bubbling stops when thechest tube is clamped between thecollecting system and thebody, theleak is at theinsertion site or inside thepatient. Applying pressure to thedressing will determine which of thesites is leaking. If bubbling continues after thechest tube is clamped, theleak is below theclamp, and thenext step would be to move theclamp farther away from thepatient and reassess. Only if thebubbling never stops after theclamp is moved all theway down thetubing should thecollection system be replaced. Turning thesuction device higher will increase bubbling in thesuction chamber and will not affect bubbling in thewater-seal chamber. DIF:
CognitiveLevel: Application
OBJ: Verbalize thesteps used in maintaining chest tube drainage. TOP: Chest Tube Assessment
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE 1. A pneumothorax can be caused by which of thefollowing? (Select all that apply.) a. Trauma b. Rupture of a blister c. Emphysema d. Dyspnea ANS: A, B, C A variety of mechanisms can cause a pneumothorax. A traumatic pneumothorax develops as a result of penetrating chest trauma, such as a stabbing or a case of thechest striking thesteering wheel in an automobile accident. A spontaneous or primary pneumothorax sometimes occurs from therupture of a small bleb (blister) on thesurface of thelung or from an invasive procedure, such as insertion of a subclavian intravenous (IV) line. Secondary pneumothorax occurs because of underlying disease, such as emphysema. A patient with a pneumothorax usually feels pain as atmospheric air irritates theparietal pleura. Dyspnea is a symptom of pneumothorax, not a cause. DIF: CognitiveLevel: Comprehension OBJ: TOP: Pneumothorax
Describe causes of pneumothorax.
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 2. The nurse is caring for a patient with a chest tube connected to wall suction. To keep thetube patent, thenurse should implement which of thefollowing? (Select all that apply.) a. Routinely ―milk‖ thedrainage tubing. b. Avoid dependent loops of thedrainage tubing. c. Lift and clear thetube every 15 minutes. d. Coil thedrainage tubing to prevent dependent loops.
ANS: B, C Chest tube milking or stripping usually is contraindicated because it does not improve catheter patency. Careful management of chest tube drainage prevents theneed to milk thechest tube. Institute nursing interventions to maintain tube patency. These interventions include avoiding dependent loops of thedrainage tube, or, when these loops cannot be avoided, such as when thepatient is sitting, lifting, and clearing thetube every 15 minutes. If thetubing is coiled, looped, or clotted, drainage is impeded, and this can result in a tension pneumothorax. DIF:
CognitiveLevel: Application
OBJ: Discuss thenursing principles involved in caring for patients with chest tubes. TOP: Chest Tube Patency
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient with a chest tube that was inserted 4 days earlier. She notices that thedrainage is blood-tinged. What might this indicate to thenurse? (Select all that apply.) a. Malignancy b. Pulmonary infarction c. Empyema d. Hemothorax ANS: A, B Blood-tinged fluid usually indicates malignancy, pulmonary infarction, or severe inflammation. Pus indicates an empyema, which is a collection of pus in thepleural cavity, and thedrainage is pus colored. Frank blood indicates a hemothorax. DIF:
CognitiveLevel: Analysis
OBJ: Discuss thenursing principles involved in caring for patients with chest tubes. TOP: Pleural Drainage
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 4. The nurse is preparing to assist thephysician in removal of a chest tube. What should thenurse do to prepare thepatient? (Select all that apply.) a. Assess thepatient‘s need for pain medication.
b. Instruct thepatient about theprocess. c. Teach thepatient to take a deep breath and hold it. d. Clamp thechest tubes. ANS: A, B, C The nurse should prepare thepatient for chest tube removal by (1) assessing theneed for pre-removal analgesia and obtaining therequired medication orders, and (2) instructing thepatient about theprocess and what will be requested of thepatient. During removal of thechest tube, it is important to instruct thepatient to take a deep breath and hold it until thetube is removed. This maneuver prevents air from being sucked into thechest as thetube is pulled out and an occlusive dressing is applied. Although clamping of thechest tubes is done to determine whether thechest tube can be eliminated, this is not part of theimmediate chest tube removal procedure. DIF:
CognitiveLevel: Application
OBJ: Discuss thenursing principles involved in caring for patients with chest tubes. TOP: Chest Tube Removal
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a patient who has a chest tube. Attached to thetop of thepatient‘s bed are two shodded hemostats. In which situations would these be used? (Select all that apply.) a. To assess an air leak b. To quickly empty or change disposable systems c. To quickly seal off thelungs if thesystem becomes disconnected d. To assess whether thepatient is ready to have thechest tube removed ANS: A, B, D Chest tubes are clamped only under thefollowing specific circumstances, per health care provider order or nursing policy and procedure to assess air leak, to quickly empty or change disposable systems, or to assess whether thepatient is ready to have thechest tube removed (which is done by a health care provider‘s order). Clamping an open system could lead to a tension pneumothorax. DIF:
CognitiveLevel: Application
OBJ: Describe methods of troubleshooting chest tube systems. TOP: Two-Chamber Waterless Chest Tube System KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is performing an initial assessment of a patient with a chest tube placed in theeighth intercostal space. Which of thefollowing findings would thenurse need to assess further? (Select all that apply.) a. Respiratory rate of 18 breaths per minute b. Continuous bubbling in thewater-seal chamber c. The presence of subcutaneous emphysema d. Complaints of pain at theinsertion site e. Serous drainage on thechest tube dressing thesize of a bean ANS: B, C, D Continuous bubbling in thewater-seal chamber could indicate a leak in thesystem and should be assessed further. thepresence of subcutaneous emphysema must be assessed further because it can be caused by a poor seal at thechest tube insertion site. Complaints of pain at theinsertion site can be expected but should be fully assessed before analgesics are administered. A respiratory rate of 18 breaths per minute falls within thenormal range and does not, by itself, indicate a need for further assessment. A small amount of drainage on thechest tube dressing can be expected and serous drainage would be normal; however, it should be monitored for any change in appearance. DIF:
CognitiveLevel: Analysis
OBJ: Demonstrate appropriate documentation and reporting of chest tube care. TOP: Chest Tube Assessment
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 7. The nurse is caring for a patient who has had a chest tube in place for 2 days. As thenurse begins her shift assessment, she should ensure that what equipment is at thebedside? (Select all that apply.) a. Two rubber-tipped clamps
b. Plain gauze 4 4 c. Sterile petroleum gauze d. Extra drainage system e. A sterile chest tube of thesame size as theone inserted in thepatient ANS: A, B, C, D The nurse should ensure that two rubber-tipped clamps are at thebedside to clamp thetubing in case of emergency, as well as a plain gauze 4 4 and sterile petroleum gauze to make an occlusive dressing should thechest tube become dislodged, and an extra drainage system, should thecurrent system become full. There is no need to keep a spare chest tube in most instances because it could be obtained while waiting for theprimary care provider to arrive and reinsert. DIF:
CognitiveLevel: Application
OBJ: Demonstrate appropriate documentation and reporting of chest tube care. TOP: Chest Tube Assessment
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity Chapter 28: Emergency Measures for Life Support Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE 1. The nurse is working in theemergency department when an 8-year-old patient is brought in with respiratory distress. thenurse is preparing to insert an oral airway. Which of thefollowing is theappropriate size for this patient? a. Size 1 b. Size 2 c. Size 3 d. Size 7 ANS: C The correct size of an oropharyngeal airway is based on width and length of themouth for thepatient‘s age.
Size
Age
30 mm or size 000
Premature neonates
45 mm or size 00
Newborn
55 mm or size 0
Newborn to 1 year
60 mm or size 1
1–2 years
70 mm or size 2
2–6 years
80 mm or size 3
6–18 years
90 mm or size 4
Adult medium
100 mm or size 5
Adult large
110 mm or size 6
Adult extra large
DIF:
CognitiveLevel: Application
OBJ: Demonstrate thefollowing in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR). TOP: Oral Airway KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 2. While measuring an oral airway for proper fit, thenurse places theairway so that theflange is held parallel to thefront teeth with theairway against thepatient‘s cheek. Where is theend of thecurve? a. At theangle of thejaw b. Above theear c. To thelevel of thenose d. Upside down ANS: A Size is correct if, when theflange is held parallel to thefront teeth with theairway against thepatient‘s cheek, theend of thecurve reaches theangle of thejaw. DIF:
CognitiveLevel: Application
OBJ: Demonstrate thefollowing in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR).
TOP: Oral Airway KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 3. Which sign or symptom of airway compromise may require insertion of an oral airway? a. Ability of thepatient to speak b. Ability of thepatient to cough forcefully c. Presence of wheezing between coughs d. Presence of gurgling with therespiratory cycle ANS: D Identify need to insert an oropharyngeal airway. Signs and symptoms include thefollowing in an unconscious patient: upper airway gurgling with breathing, absent cough or gag reflex, increased oral secretions, excessive drooling, absent or labored respirations. DIF:
CognitiveLevel: Application
OBJ: Demonstrate thefollowing in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR). TOP: Oral Airway KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is preparing to insert an oral airway in a patient who is exhibiting signs of potential respiratory distress. thenurse knows that candidates for oral airway placement are those: a. with oral trauma. b. with loose teeth. c. who are unconscious. d. who have had recent oral surgery. ANS: C Never insert an oral airway in a conscious patient or a patient with recent oral trauma, oral surgery, or loose teeth. Use oral airways only in unconscious patients. Oral airways may stimulate vomiting or laryngospasm if inserted in thesemiconscious or conscious patient. DIF:
CognitiveLevel: Application
OBJ: Demonstrate thefollowing in a laboratory or clinical situation: insertion of an oral
airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR). TOP: Oral Airway KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity 5. Which of thefollowing is theappropriate technique for a nurse to implement when inserting an oral airway? a. Insert theairway with thecurved end up, then rotate it 180 degrees at theback of thethroat. b. Insert theairway with thecurved end down along thecurve of thetongue. c. Use a tongue blade to insert and push theairway into position. d. Insert theairway sideways, then rotate it with thecurved end up. ANS: A Hold theoral airway with thecurved end up, insert thedistal end until theairway reaches theback of thethroat, then turn theairway more than 180 degrees, and follow thenatural curve of thetongue. Never push theairway into position. thenurse may also hold theairway sideways, insert it halfway, and then rotate it 90 degrees while gliding it over thenatural curvature of thetongue (curved end down). DIF:
CognitiveLevel: Application
OBJ: Demonstrate thefollowing in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR). TOP: Oral Airway Insertion
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 6. The nurse is providing an educational seminar to a group of nursing students on theadvantages of using an automated external defibrillator (AED). She knows that her teaching has been effective when thestudents reply: a. ―Health care providers do not need to learn CPR to use theAED.‖ b. ―The health care provider is given a printout of therhythm change.‖ c. ―The health care provider can safely use both CPR skills and AED skills.‖ d. ―The health care provider can adjust thelevel of shock administered.‖ ANS: C
The advantage of theAED is that laypeople or health care providers trained in basic life support, who have less training than ACLS personnel, can defibrillate. AEDs eliminate theneed for training in rhythm interpretation and make early defibrillation practical and achievable. theAED is an automated external defibrillator that incorporates a rhythm analysis system. Upon rhythm identification, some AEDs will automatically provide theelectrical shock after a verbal warning (fully automated). Other AEDs will recommend a shock, if needed, and then will prompt theresponder to press theshock button. theprovider does not need to adjust anything. DIF:
CognitiveLevel: Application
OBJ: Identify theneed for automated external defibrillator (AED) application and indications for use.TOP:
Advantages of an Automated External Defibrillator (AED)
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 7. The nurse finds a patient lying on thebathroom floor. thepatient is unresponsive and has a pulse but is not breathing. What is thenurse‘s first action? a. Give two breaths using mouth-to-mouth without a barrier device. b. Give two breaths using mouth-to-mouth without a barrier device and watch for chest movement. c. Give two breaths using a bag-mask device. d. Start chest compressions until an automated external defibrillator (AED) is available. ANS: C Give two breaths using mouth-to-mouth with a barrier device or a mouth-to-mask device or a bag-mask device. Watch for chest rise and fall. In a hospital setting where protected methods of artificial ventilation are available, mouth-to-mouth without a barrier device is not recommended because of therisk for microbial contamination. Watch for chest rise and fall. Motion, by itself, could be caused by fasciculation and is not indicative of air moving into and out of thechest. DIF:
CognitiveLevel: Application
OBJ: State theend points for CPR.
TOP: Mouth-to-Mouth with a Barrier Device KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 8. The patient is brought to theemergency department after a motor vehicle accident. thepatient has head and neck trauma and has stopped breathing. What should thenurse do? a. Open theairway using thehead tilt–chin lift method. b. Open theairway using thejaw-thrust method. c. Give two breaths using mouth-to-mouth and a barrier device. d. Give two breaths using a bag-mask device. ANS: B First determine whether thepatient has spontaneous respirations by opening theairway. Consider spinal cord injury in patients with trauma. In these situations, a rescuer must use thejaw-thrust maneuver. Prevention of head extension and neck movement is very important to prevent paralysis or spinal cord injury. Apply a rigid cervical collar as soon as possible to reduce cervical spine motion. DIF:
CognitiveLevel: Analysis
TOP: Jaw-Thrust Maneuver
OBJ: State theend points for CPR. KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 9. During thesecondary survey of thecode event, thenurse realizes that thepatient is not breathing on his own. What should thenurse do next? a. Immediately intubate thepatient. b. Have a laryngoscope handle and curved blades available. c. Ensure that thelight source on thelaryngoscope is functional. d. Have a laryngoscope handle and straight blades available. ANS: C
Ensure that thelight source on thelaryngoscope is functional. Light is necessary on thelaryngoscope to visualize thevocal cords and intubate thetrachea. Batteries may have to be changed. If respirations are absent, assist thecode team with endotracheal intubation. Have available a laryngoscope handle, curved and straight blades, endotracheal (ET) tubes, a stylet, suction and tape, or an ET tube holder. DIF:
CognitiveLevel: Application
TOP: Intubation
OBJ: Discuss code management.
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 10. The nurse is performing cardiopulmonary resuscitation (CPR) on an adult patient who has an endotracheal tube in place. At what rate does thenurse, who is alone, administer breaths? a. 8 per minute b. 12 per minute c. 20 per minute d. 24 per minute ANS: A Rescue breaths for cardiopulmonary resuscitation (CPR) with an advanced airway (endotracheal tube/tracheotomy) are given at 8 to 10 breaths per min. DIF:
CognitiveLevel: Application
TOP: Rescue Breathing
OBJ: Discuss code management. KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 11. The nurse enters her patient‘s room to find him unresponsive. She begins cardiopulmonary resuscitation (CPR) according to protocol. How deep should thenurse do chest compressions in this pulseless adult? a. 1 to
inches in depth
b.
to 3 inches in depth
c.
to 1 inch in depth
d. 2 to 2.4 inches in depth
ANS: D Begin compressions if no pulse Lower half of sternum, Heel of one hand, other hand on top. Depth of 5–6 cm (2–2.4 inches)
For children and infants, therecommendation is
to
thedepth of thechest.
to 3
inches is too deep for theaverage adult. DIF:
CognitiveLevel: Application
TOP: Chest Compressions
OBJ: Discuss code management. KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 12. The nurse observes a person collapse and stop breathing. thenurse would establish an airway by: a. inserting an endotracheal tube. b. inserting a finger to pull thetongue forward. c. using thehead tilt–chin lift maneuver. d. using a modified jaw-thrust maneuver. ANS: C The nurse would establish an airway by tilting thehead back and lifting thechin. An endotracheal tube should not be inserted by thenurse. It is not necessary to put tension on thetongue because proper head tilt with chin thrust will remove thetongue from obstructing theairway. A modified jaw thrust would be used if a neck injury was suspected, but because this patient collapsed in front of thenurse, that would not be a concern in this scenario. DIF:
CognitiveLevel: Application
OBJ: State theend points for CPR.
TOP: Steps Used in Performing Rescue Breathing KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
13. The nurse is performing cardiac compressions on a 4-year-old child with theassistance of another nurse. thenurses would deliver breaths and compressions at a ratio of compressions for
breaths.
a. 30; 2 b. 5; 1 c. 15; 2 d. 5; 2 ANS: C The correct ratio of compressions to breaths is 15 chest compressions followed by 2 breaths if there are two rescuers for a child. A ratio of 30:2 would be used in adult CPR; if there are two rescuers, 1 breath is interspersed after 15 compressions but theratio remains 30:2. Ratios of 5:1 and 5:2 are always incorrect when CPR is performed on a child. DIF:
CognitiveLevel: Application
OBJ: State theend points for CPR.
TOP: Steps Used in Administering External Cardiac Compressions KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 14. When applying an automated external defibrillator, thenurse would: a. connect thecable to themachine, apply thepads, and turn on thepower. b. turn on thepower, apply thepads, and connect thecable. c. turn on thepower, connect thecable, and apply thepads. d. connect thecable, turn on thepower, and apply thepads. ANS: B As soon as thecable is connected, themachine begins to attempt to analyze therhythm, so thepower should be turned on and thepads should be applied to thechest wall before thecable is connected to themachine. Connecting thecable, applying thepads, and then turning on thepower would cause themachine to malfunction or would delay analysis while it cycles on. Connecting thecable before applying thepads could result in therescuer being shocked. DIF:
CognitiveLevel: Application
OBJ: State theend points for CPR.
TOP: Steps Used in Administering Automated External Defibrillation
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 15. When using an automated external defibrillator, it is important for thenurse to ensure that no one is touching thepatient: a. after connecting thecable to themachine. b. when themachine is plugged in. c. while thepads are applied. d. while themachine analyzes therhythm. ANS: A The nurse needs to ensure that no one is touching thepatient while themachine is analyzing because this may interfere with correct interpretation of thepatient‘s rhythm and could put anyone touching thepatient at risk of being shocked. Cardiopulmonary resuscitation (CPR) may be continued up until themachine is ready to analyze, although CPR may need to be momentarily stopped for placement of thechest pad, and when theAED instructs theuser to resume CPR. There is no risk in touching thepatient while themachine is plugged in, and it is not possible to apply thepads without touching thepatient. CPR should be performed until an automated external defibrillator (AED) is brought to thepatient and thecable is ready to be inserted into themachine with thepads already in place. DIF:
CognitiveLevel: Application
OBJ: State theend points for CPR.
TOP: Steps Used in Administering Automated External Defibrillation KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse sees on thecardiorespiratory monitor that thepatient‘s cardiac rhythm has changed from normal sinus rhythm to ventricular fibrillation. thenurse knows that themost effective means of converting this rhythm is: a. cardiopulmonary resuscitation (CPR). b. defibrillation. c. oxygen. d. precordial thump.
ANS: B Two of thelethal dysrhythmias include ventricular tachycardia (VT) and ventricular fibrillation (VF) require a medically-delivered electrical shock for treatment. Early defibrillation or shock may quickly return theheart to normal without further deterioration of a patient's status Cardiopulmonary resuscitation (CPR) should be performed until thedefibrillator patches are applied, but it is not themost effective means of converting theelectrical rhythm; rather it supports life until defibrillation can be performed. Oxygen should be administered during CPR, but it is not themeans of converting therhythm. Precordial thumps are controversial at best and would not be themost effective means of converting therhythm. DIF:
CognitiveLevel: Application
OBJ: State theend points for CPR.
TOP: Key Terms Used in theSkills of Hospital Emergency Measures and Cardiopulmonary Resuscitation
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 17. The nurse would call thecode team for which of thefollowing patients? a. A patient with blood pressure of 60/28 mm Hg b. A patient experiencing severe dyspnea secondary to asthma c. A patient in atrial fibrillation d. An unconscious patient in ventricular tachycardia ANS: D A patient who becomes unconscious while in ventricular tachycardia requires therapid intervention of thecardiac/respiratory arrest team. A hypotensive patient or a patient experiencing dyspnea requires theintervention of therapid response team. A patient in atrial fibrillation requires notification of theprimary care provider. DIF:
CognitiveLevel: Application
OBJ: Identify indications for requesting a rapid response or cardiac/respiratory arrest team. TOP:
Oral Airway
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
18. The nurse enters thepatient‘s room and finds that thepatient is not breathing and has no pulse. thepatient does not have a do-not-resuscitate order. What would thenurse‘s most immediate action be? a. Call thecardiac/respiratory arrest team. b. Begin cardiopulmonary resuscitation (CPR). c. Call a co-worker for help. d. Get thecrash cart. ANS: A The nurse‘s first action should be to summon thecardiac/respiratory arrest team because it will take them a few minutes to arrive, and thepatient‘s best outcome depends on their rapid arrival. As soon as theteam has been called, thenurse should begin cardiopulmonary resuscitation (CPR). If thearrest is not called over thepublic address system, thenurse should call a co-worker for help while performing CPR or after initiating CPR. If thecode is called over thepublic address system, co-workers will hear thecall and will come to theroom without being summoned. Once co-workers have been alerted, they can obtain thecrash cart and summon additional support. DIF:
CognitiveLevel: Application
OBJ: Describe therole of thenurse in initiating and participating in a cardiopulmonary arrest situation in a hospital.
TOP:
Oral Airway
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 19. For which of thefollowing patients would thenurse request therapid response team‘s immediate intervention? a. A patient complaining of severe postoperative incisional pain b. A patient with no pulse who is not breathing c. A patient complaining of chest pain, hypotension, and shortness of breath d. A patient with blood pressure of 164/96 mm Hg ANS: C
Frequently, cardiac arrest is preceded with signs and symptoms of deterioration which may include tachycardia, hypotension, tachypnea, decreasing oxygen saturation below 90% despite provision of supplemental oxygen, and a decreasing urine output of less than 50 mL in 4 hours. The nurse would request therapid response team‘s immediate intervention for thepatient with chest pain, hypotension, and shortness of breath to prevent a potentially life-threatening situation. A patient with postoperative pain can be successfully treated by thenurse on theunit and does not require therapid response team. If thepatient has no pulse and no respirations, thenurse should call thearrest team, not therapid response team. thenurse should call theprimary care provider for thepatient who is hypertensive. DIF:
CognitiveLevel: Application
OBJ: Identify indications for requesting a rapid response or cardiac/respiratory arrest team. TOP:
Oral Airway
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity 20. A patient has been found with no pulse or respirations. thecardiopulmonary arrest team has been called. What should thenurse do while awaiting theteam‘s arrival? a. Gather thepatient‘s medical record and medication administration record. b. Obtain thecrash cart. c. Notify thepatient‘s primary care provider. d. Perform cardiopulmonary resuscitation (CPR). ANS: D The nurse‘s responsibility while awaiting thearrest team is to perform cardiopulmonary resuscitation (CPR), with or without assistance as available. Other team members can collect thepatient‘s records, obtain thecrash cart, and notify theprimary care provider. thenurse assigned to thepatient should stay with thepatient to provide thehistory when theteam arrives. DIF:
CognitiveLevel: Application
OBJ: State theend points for CPR.
TOP: The Nurse‘s Role in Initiating and Participating in a Cardiopulmonary Arrest Situation in a Hospital
KEY:
NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE 1. The nurse in theintensive care unit (ICU) is caring for a newly admitted patient with chest pain. She is aware that dysrhythmia may be caused by which of thefollowing? (Select all that apply.) a. Electrolyte disturbances b. Heart damage c. Medications d. Respiratory arrest ANS: A, B, C, D The cause of thedysrhythmia may include acute coronary syndrome, electrolyte disturbances and certain prescribed or recreational medications. DIF:
CognitiveLevel: Knowledge
OBJ: State indications for cardiopulmonary resuscitation (CPR). TOP: Cardiac Arrest
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 2. The nurse walks into her patient‘s room to find him unresponsive. She begins cardiopulmonary resuscitation (CPR), knowing that during a ―code‖ situation, chest compressions should be interrupted for which of thefollowing situations? (Select all that apply.) a. Ventilation b. Pulse checks c. Intubation d. Defibrillation ANS: A, B, C, D
Interruptions in chest compressions should be minimized and should never exceed 10 seconds (Kleinman et al., 2018). CPR can be continued through thefollowing actions: endotracheal intubation, defibrillator pad placement, brief interruption during chest compressors rotation, only checking for pulse every 2 minutes during chest compressor rotation. The 2010 AHA resuscitation guidelines recommend performing chest compressions at a rate of 100 per minute with few and very brief interruptions for ventilation, pulse checks, intubation, and defibrillation. DIF:
CognitiveLevel: Application
TOP: Chest Compressions
OBJ: Discuss code management. KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 3. The nurse is caring for an unconscious patient who has an oral airway in place, and who has copious amounts of oral secretions. What may thenurse have to do while caring for this patient? (Select all that apply.) a. Cleanse themouth frequently using lemon glycerin swabs. b. Replace or clean theoral airway. c. Suction theoral cavity frequently. d. Keep theairway in place for extended periods. ANS: B, C The oral airway will have to be removed, cleaned or discarded, and replaced in patients with excessive oral secretions. Frequent suctioning of theoral cavity may be required. Oral airways are not a long-term solution. They can cause significant lip and tongue erosion. DIF:
CognitiveLevel: Application
OBJ: Demonstrate thefollowing in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR). TOP: Oral Airway Maintenance MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
4. What is thenurse‘s responsibility for thepatient after he has been intubated during a code event? (Select all that apply.) a. Ventilate using a bag-mask device at a rate of 22 breaths per minute. b. Monitoring thecarbon dioxide (CO2) c. Auscultate both lungs. d. Call for a chest radiograph. ANS: B, C Help in confirmation of ET tube placement or advanced airway support by auscultating lungs for bilateral breath sounds and monitoring thecarbon dioxide (CO2) detector to confirm correct airway placement. Ventilate using bag device on intubation. Avoid hyperventilation. Increased intrathoracic pressure caused by incomplete exhalation results in reduced cardiac output. Chest x-ray film is usually obtained after patient has been stabilized to confirm placement of ET tube and central venous catheters. DIF:
CognitiveLevel: Application
TOP: Intubation
OBJ: Discuss code management.
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
COMPLETION 1. Many cardiac arrests are caused by irregular heart rhythms known as
.
ANS: Dysrhythmias In some cardiac arrests, circulating blood flow is lost due to an erratic heart rhythm known as a dysrhythmia Many cardiac arrests are caused by irregular heart rhythms known as dysrhythmias. DIF:
CognitiveLevel: Knowledge
OBJ: State indications for cardiopulmonary resuscitation (CPR). TOP: Cardiac Arrest
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 2. In theevent of cardiopulmonary arrest, all patients receive cardiopulmonary resuscitation (CPR) unless otherwise indicated in thepatient‘s _
.
ANS: advance directive Advance directives offer valuable information concerning a patient's resuscitation status and individual patient decisions regarding resuscitation efforts. Although advance directives are often addressed before or during a patient's hospitalization, nurses play an important role in encouraging patients to complete their plan of care. DIF:
CognitiveLevel: Knowledge
OBJ: State indications for cardiopulmonary resuscitation (CPR). TOP: Advance Directives
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 3. A semicircular, minimally flexible, curved piece of hard plastic that is inserted into themouth so it extends from just outside thelips to thepharynx is known as an
.
ANS: oral airway An oral airway is a semicircular, minimally flexible, curved piece of hard plastic. When inserted, it extends from just outside thelips, over thetongue, and to thepharynx. Oral airways enable thenurse to suction through a central core or along theside of theairway and to maintain airway patency in theunconscious patient. DIF:
CognitiveLevel: Knowledge
OBJ: Discuss indications for oral airway insertion.
TOP: Oral Airway
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. The most common cause of airway obstruction in an unresponsive patient is the
.
ANS: tongue The tongue is themost common cause of blocked airway in an unresponsive patient. DIF:
CognitiveLevel: Knowledge
TOP: Airway Obstruction
OBJ: State theend points for CPR. KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity Chapter 29: Intravenous and Vascular Access Therapy Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE 1. The nurse is caring for a patient receiving antineoplastic medications intravenously. thenurse discovers that theintravenous site is red, edematous, and painful. thenurse knows that antineoplastic medications are vesicant medications and documents that thepatient has experienced which of thefollowing events? a. Occlusion b. Extravasation c. Phlebitis d. Thrombophlebitis ANS: B When a vesicant medication infiltrates thetissue, this is called an extravasation. Occlusion refers to a thrombus or fibrin sheath that impedes theflow of intravenous (IV) fluids. Phlebitis occurs with redness surrounding thevein, and extravasation leads to trauma within thevein. Thrombophlebitis occurs when trauma occurs within a vein due to a thrombus.
DIF:
CognitiveLevel: Application
OBJ: Define thekey terms used in theskills of intravenous therapy. TOP: Assessment of IV Site
KEY:
NursingProcess Step:
Diagnosis MSC: NCLEX: Physiological Integrity 2. Established standards for routine replacement of peripheral IV catheters and intravenous administration sets have recommended a maximum of
hours to reduce intravenous (IV)
fluid contamination and prevent catheter site complications. a. 24 b. 48 c. 72 d. 96 ANS: D Established standards for routine replacement of peripheral intravenous (IV) catheters and intravenous administration sets have recommended a maximum of 96 hours to reduce IV fluid contamination and prevent catheter site complications. DIF:
CognitiveLevel: Comprehension
OBJ: Discuss complications of IV therapy.
TOP: Replacement of IV Catheters and Administration Sets KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 3. While assessing thepatient, thenurse recognizes that special caution should be taken with theintravenous (IV) infusion because of fluid volume excess when thenurse notes thepresence of which condition? a. Poor skin turgor b. Crackles in thelungs c. Decreased blood pressure d. Dry skin and mucous membranes ANS: B
Auscultation of crackles or rhonchi in thelungs may signal fluid buildup in thelungs caused by fluid volume excess. Poor skin turgor is common with fluid volume deficit. thepinched skin stays elevated for several seconds (tenting). This may be an indication of theneed for IV therapy. Decreased blood pressure may indicate fluid volume deficit caused by a decrease in stroke volume. This may indicate theneed for intravenous (IV) therapy. Dry skin and mucous membranes may indicate dehydration. DIF:
CognitiveLevel: Comprehension
TOP: Fluid Volume Excess
OBJ: Discuss complications of IV therapy. KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 4. The nurse needs to specifically prevent air emboli that may result from intravenous (IV) therapy. What should thenurse make sure to do to prevent air emboli? a. Use a needleless system. b. Prime thetubing completely. c. Check for medication compatibility. d. Select a larger-gauge needle or catheter. ANS: B Prime theinfusion tubing by filling it with intravenous (IV) solution. Be certain that thetubing is clear of air and air bubbles. Large air bubbles can act as emboli. A needleless system does not specifically prevent theintroduction of air emboli. Medication incompatibility may lead to crystallization of themedication and may cause emboli to form from precipitate. It will not lead, however, to air embolism. Catheter size does not contribute to emboli formation. DIF:
CognitiveLevel: Application
TOP: Air Embolism
OBJ: Discuss complications of IV therapy. KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 5. Which of thefollowing steps is necessary when a patient is prepared for intravenous (IV) catheter insertion? a. Shaving thehair from thesite b. Selecting a proximal site in an extremity
c. Applying a tourniquet 4 to 6 inches above theselected site d. Vigorously taping and massaging theselected vein ANS: C Apply a flat tourniquet around thearm, above theantecubital fossa or 10 to 15 cm (4 to 6 inches) above theproposed insertion site. Do not shave thearea. Shaving may cause microabrasions and may predispose to infection. Use themost distal site in thenondominant arm, if possible. Vigorous friction and multiple taping of theveins, especially in older adults, may cause hematoma and/or venous constriction. DIF:
CognitiveLevel: Application
OBJ: Explain how to prepare thepatient and thefamily for IV therapy. TOP: Applying a Tourniquet
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 6. What should be thenext action by thenurse once an over-the-needle catheter (ONC) has been inserted through theskin and into thevein? a. Loosen thestylet for removal. b. Check for blood return in theflashback chamber. c. Stabilize thecatheter and release thetourniquet. d. Advance thecatheter until thehub rests at theinsertion site. ANS: B Observe for blood return in catheter or flashback chamber of catheter, indicating that bevel of needle has entered vein (see illustration. Advance VAD approximately 1/4 inch (0.6 cm) into vein and loosen stylet (needle) of ONC. Continue to hold skin taut while stabilizing VAD and, with index finger on push-off tab of VAD, advance catheter off needle into vein until hub rests at venipuncture site. Do not reinsert stylet into catheter once catheter has been advanced into vein. Advance catheter while safety device automatically retracts stylet (techniques for retracting stylet vary with different VADs). Place stylet directly into sharps container. DIF:
CognitiveLevel: Application
OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a
peripheral IV.
TOP: Inserting theOver-the-Needle Catheter
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 7. What should thenurse do once she recognizes that thepatient has phlebitis at his intravenous (IV) catheter site? a. Reduce theIV flow rate. b. Elevate theaffected extremity. c. Place a moist warm compress over thesite. d. Adjust theadditive in thecurrent IV. ANS: C Phlebitis is indicated by pain, increased skin temperature, and erythema along thepath of thevein. Stop theinfusion and discontinue theintravenous (IV) catheter. Start a new IV if continued therapy is necessary. Place a moist warm compress over thearea of phlebitis. Document thedegree of phlebitis and nursing interventions per agency policy and procedure. theextremity is elevated for an infiltration to reduce edema. DIF:
CognitiveLevel: Application
TOP: Phlebitis
OBJ: Discuss complications of IV therapy.
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 8. What should thenurse do upon noting bleeding around a dressing at an intravenous (IV) catheter insertion site? a. Discontinue theIV. b. Assess theinsertion site. c. Leave thedressing intact, but reinforce it. d. Elevate and apply warm compresses to theextremity. ANS: B
When blood appears on thedressing, verify that thesystem is intact, and change thedressing. theintravenous (IV) catheter should be discontinued in theevent of infiltration or phlebitis. If bleeding occurs around thevenipuncture site and thecatheter is within thevein, gauze dressing may be applied over thesite. Be aware that if gauze dressing is used, it must be removed to accurately assess theinsertion site. Elevation is used in cases of infiltration to reduce edema. Warm compresses are used in cases of phlebitis. DIF:
CognitiveLevel: Application
OBJ: Discuss complications of IV therapy.
TOP: Bleeding at Venipuncture Site
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 9. Which patient would a nurse anticipate would be a candidate for a peripherally inserted central catheter (PICC)? a. An older adult who is having cataracts removed b. A perinatal patient who is having prolonged labor c. A neonate requiring blood therapy d. An adolescent who is having surgery for reduction of a fracture ANS: C When a child is critically ill or when long-term intravenous (IV) access is anticipated, a PICC catheter, a Broviac catheter, or an implanted port may be used to access a larger vein. PICCs can be used to infuse IV fluids, parenteral nutrition, blood and blood products, and medications such as antibiotics. Gerontological veins are very fragile, with less subcutaneous support tissue and with thinning of theskin. In older patients, use thesmallest gauge possible. For example, a 22-gauge needle is adequate for fluid and medication therapy. PICC lines are not inserted routinely. PICCs are used when long-term IV therapy is needed. DIF:
CognitiveLevel: Comprehension
OBJ: Explain how to prepare thepatient and thefamily for IV therapy. TOP: Pediatric Considerations MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Planning
10. The nurse is caring for a patient receiving intravenous therapy. thenurse should report which of thefollowing to theprimary care provider? a. Completion of each liter of fluid b. Initiation of intravenous (IV) fluids c. Small infiltration d. Extravasation ANS: D Immediately stop vesicant administration. Administer antidote or therapeutic medications to maintain tissue integrity according to protocol. Apply cold/warm compresses according to specific vesicant protocol. Provide emotional support. Obtain x-ray film if ordered. Use antidotes per protocol. Discontinue IV solution. DIF:
CognitiveLevel: Application
OBJ: Demonstrate appropriate documentation and reporting of intravenous therapy. TOP: Assessment of IV Therapy Access Devices KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
11. The patient has intravenous (IV) therapy ordered to infuse at 1000 mL over 10 hours. theinfusion set has a calibration of 15 gtt/mL. At which rate does thenurse regulate theinfusion? a. 20 gtt/min b. 25 gtt/min c. 30 gtt/min d. 32 gtt/min ANS: B Select one of thefollowing formulas to calculate drop rate based on drops per minute: mL/hr/60 min = mL/min followed by Drop factor mL/min = Drops/min, or mL/hr Drop factor/60 min = Drops/min.
DIF:
CognitiveLevel: Analysis
OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV
solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.
TOP: IV Rate Calculation
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 12. The order is for thepatient to receive 500 mL over 4 hours. thenurse has an electronic infusion device (EID) in place that provides for theregulation of hourly infusion. theintravenous (IV) tubing available is 10 gtt/mL. What is thesetting for theinfusion device? a. 125 mL/hr b. 500 mL/hr c. 21 gtt/min d. 32 gtt/min ANS: A For use of electronic infusion device (EID) for infusion, turn on thepower button, select therequired drops per minute or volume per hour, close thedoor to thecontrol chamber, and press thestart button. In this case, 500 mL/4 hr = 125 mL/hr. DIF:
CognitiveLevel: Analysis
OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.
TOP: IV Rate Regulation via EID
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 13. A pediatric patient has an intravenous (IV) catheter with microdrip tubing. theorder is for 40 mL/hr to infuse. At what rate does thenurse set themicrodrip? a. 10 gtt/min b. 20 gtt/min c. 40 gtt/min d. 80 gtt/min ANS: C
Select one of thefollowing formulas to calculate drop rate based on drops per minute: mL/hr/60 min = mL/min followed by Drop factor mL/min = drops/min, or mL/hr Drop factor/60 min = Drops/min. In this case, 40 mL/hr 60 gtt/mL = 240 gtt/hr 1 hr/60 min = 40 gtt/min. When microdrip is used, mL/hr always equals gtt/min.
DIF:
CognitiveLevel: Analysis
OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.
TOP: IV Rate Regulation via Microdrip
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 14. While assessing thepatient‘s intravenous (IV) infusion, thenurse notes that it is infusing more slowly than it should be. What should thenurse do first? a. Discontinue theIV. b. Increase therate of infusion. c. Observe for fluid overload. d. Check theposition of theIV fluid and extremity. ANS: D Check thepatient for positional changes that might affect infusion rate, height of theintravenous (IV) container, and tubing obstruction. Check thecondition of thesite. themost likely cause of a slow-running IV is positioning. If IV is positional, fluid will run slowly or stop, depending on position of patient's arm; if this continues, you may have to restart IV line. An infiltrated or clotted IV line probably will not be running at all. Discontinue theIV if it is determined that it is infiltrated or clotted off. Position will affect flow even if rate is increased. Fluid overload is not associated with slowing of theinfusion rate. Often it occurs when an IV is running too quickly. DIF:
CognitiveLevel: Application
OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.
TOP: Slow-Running IV
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse caring for a patient receiving intravenous (IV) fluids knows that thecurrent recommendation for changing thetubing on a continuously running IV is: a. at least every 48 hours. b. every 24 hours. c. no more often than every 96 hours. d. with each IV solution bag change. ANS: C Intravenous tubing administration sets remain sterile for 96 hours. Thus, theInfusion Nurses Society (INS) recommends changing tubing no more frequently than every 96 hours. When possible, schedule tubing changes when it is time to hang a new IV container. DIF:
CognitiveLevel: Application
OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.
TOP: IV Tubing Change for Continuous Infusions
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is caring for a patient diagnosed with pneumonia who receives intravenous (IV) antibiotics every 8 hours. How often should thenurse change theprimary intermittent IV sets? a. No more often than every 72 hours b. At least every 72 hours c. With each IV bag change d. Every 24 hours ANS: D The nurse should change primary intermittent sets every 24 hours because theintravenous (IV) system becomes interrupted, which increases therisk for contamination. DIF:
CognitiveLevel: Application
OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.
TOP: IV Tubing Change for Intermittent Infusions
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 17. What is an appropriate technique for thenurse to implement when changing thedressing at a peripheral intravenous (IV) catheter site? a. Wear sterile gloves to remove theold dressing. b. Keep one finger over theIV catheter until thetape is replaced. c. Cleanse with an antiseptic solution in a circular manner toward thesite. d. Tape theconnection between theIV catheter port and thetubing. ANS: B Always keep one finger over catheter until dressing secures catheter hub. If patient is restless or uncooperative, it is helpful to have another staff member help with procedure. DIF:
CognitiveLevel: Application
OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.
TOP: IV Dressing Change
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 18. What should thenurse do when discontinuing a peripheral intravenous (IV) catheter? a. Withdraw thecatheter quickly. b. Keep thehub perpendicular to theskin. c. Apply pressure to thesite for 1 minute. d. Inspect thecatheter for intactness after removal. ANS: D
Inspect thecatheter for intactness after removal, noting tip integrity and length. Place clean sterile gauze above thesite, and withdraw thecatheter, using a slow, steady motion. Keep thehub parallel to theskin. Do not raise or lift thecatheter before it is completely out of thevein, to avoid trauma or hematoma formation. Apply pressure to thesite for 2 to 3 minutes, using a dry, sterile gauze pad. Secure with tape. Note: Apply pressure for 5 to 10 minutes if thepatient is taking anticoagulants. DIF:
CognitiveLevel: Application
OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV.
TOP: Discontinuing a Peripheral IV
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 19. The patient is expected to require intravenous therapy for several years as treatment for a chronic disease process. Which of thefollowing would be thebest choice for venous access in this patient? a. Peripherally inserted central catheter (PICC) b. Nontunneled percutaneous central venous catheter c. Subcutaneous implanted port d. Peripheral IV ANS: C Implanted infusion ports are used for long-term and complex intravenous (IV) infusion therapy. A port may not be used for extended periods (i.e., weeks) between infusions, and it is not necessary that theport remain accessed during these periods. To maintain thepatency of a port, it is necessary to flush monthly with heparin solution or 0.9% sodium chloride in accordance with agency policies and procedures and manufacturer directions for use. PICCs provide alternative IV access when thepatient requires intermediate-length venous access (greater than 7 days to several months). These catheters are used for shorter placements (e.g., 5 to 10 days). Use of peripheral IV therapy increases therisk for patients to develop infection, vein sclerosis, phlebitis, and infiltration.
DIF:
CognitiveLevel: Synthesis
OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance.
TOP: Subcutaneous Implanted Ports
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
20. The nurse is assisting thephysician during theinsertion of a central line into thesubclavian vein. How should thenurse cleanse thearea? a. With chlorhexidine in a back and forth scrubbing motion b. With chlorhexidine followed by alcohol in a back and forth scrubbing motion c. With alcohol in a circular motion for 5 minutes d. With antimicrobial solution that must be dabbed dry with a sterile towel ANS: A Antiseptics such as chlorhexidine remove resident and transient bacteria. Alcohol should not be applied after theapplication of iodophor solution. Chlorhexidine is scrubbed in a back and forth motion for 30 seconds. Allow theantimicrobial solution to air-dry completely. This ensures maximum antimicrobial effect. DIF:
CognitiveLevel: Application
OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Inserting a Central Venous Access Device KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse is preparing to draw blood from a central venous access device for blood cultures. Which of thefollowing steps is part of that process? a. Apply sterile gloves. b. Flush theport with 5 to 10 mL of 0.9% sodium chloride. c. Slowly aspirate 5 mL of blood and discard thesyringe. d. Use thedistal lumen to draw blood. ANS: D
When drawing through staggered multilumen catheters, draw from distal lumen (or one recommended by manufacturer). Distal lumen typically is largest-gauge lumen. Apply clean gloves to prevent transfer of body fluids. Do not flush before drawing blood for blood cultures. If blood cultures have been ordered, do not discard any blood. Use theinitial specimen for blood cultures. DIF:
CognitiveLevel: Application
OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance.
TOP: Blood Sampling
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 22. What should thenurse do to decrease thepotential for infection related to intravenous (IV) infusion therapy? a. Use theclean technique for dressing changes. b. Change theIV tubing every 12 hours. c. Palpate theinsertion site daily through theintact dressing. d. After cleansing theskin, dab it dry with a sterile gauze pad. ANS: C Palpate thecatheter insertion site for tenderness daily through theintact dressing. Perform hand hygiene before and after palpating, inserting, replacing, or dressing any intravascular device. Maintain use of sterile dressings. Replace intravenous (IV) tubing no more frequently than at 72-hour intervals unless clinically indicated. Allow thesite to air-dry before proceeding with theprocedure. DIF:
CognitiveLevel: Application
OBJ: Explain techniques for preventing transmission of infection for a patient receiving IV therapy. TOP: Standards to Decrease Intravascular Infection Related to IV Therapy KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
23. The nurse is caring for a patient with a continuous intravenous infusion of 0.9% normal saline with 40 mEq of potassium chloride added to each liter. During a routine hourly check of theinfusion, thenurse discovers that 4 hours of fluid has infused in thepast 1 hour. thenurse‘s first action should be to: a. notify theprimary care provider. b. assess thepatient. c. reduce theinfusion rate. d. notify thecharge nurse. ANS: C If theintravenous fluid is infusing 4 times faster than ordered, thefirst intervention should be to reduce theinfusion rate. Notification of theprimary care provider and thecharge nurse would occur after theflow rate is reduced and an assessment of thepatient is performed. Although assessing thepatient is vitally important, you do not want to allow thefluid to continue infusing at a rapid rate while you are performing theassessment. DIF:
CognitiveLevel: Analysis
OBJ: Identify interventions required to prevent complications associated with IV therapy TOP: IV Administration Rates
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 24. Which of thefollowing patients would thenurse anticipate requiring theplacement of a central venous catheter? a. A patient in same-day surgery who might require blood transfusions b. A patient in theintensive care unit requiring multiple simultaneous intravenous medications c. A patient in thecardiac care unit diagnosed with possible myocardial infarction d. A patient on thesurgical unit recovering from hernia repair ANS: B
CVADs have single or multiple lumens. thechoice of thenumber of lumens depends on a patient's condition and prescribed therapy. Patients requiring numerous infusions and blood samplings may have a device placed with more than one lumen, allowing simultaneous administration of solutions and medications. In addition, multiple lumens allow for administration of incompatible solutions or medications at thesame time. You access a CVAD through thehub of thedevice located on theend of each external lumen. DIF:
CognitiveLevel: Application
OBJ: Identify indications and contraindications for intravenous therapy and central venous lines.
TOP:
Tunneled Central Venous Catheters
KEY: NursingProcess Step: Planning
MSC: NCLEX: Physiological Integrity
25. The nurse assigns nursing assistive personnel (NAP) to care for several patients with continuous IV infusions. Which of thefollowing can NAP assist with? a. Changing empty IV solution containers b. Confirming thecorrect IV drip rate c. Assessing thepatient for response to IV therapy d. Informing thenurse if they notice anything abnormal ANS: D If nursing assistive personnel (NAP) notice anything they consider abnormal, they should notify thenurse. It is thenurse‘s responsibility to inform theNAP of specific things to look for. Changing empty intravenous (IV) solution containers cannot be delegated to NAP because theprocedure requires knowledge of sterile technique. Confirming thecorrect IV drip rate is thenurse‘s responsibility. Assessment is not theresponsibility of NAP; it is theresponsibility of thenurse. DIF:
CognitiveLevel: Application
OBJ: Recognize when it is appropriate to delegate aspects of intravenous therapy to unlicensed assistive personnel.
TOP: Intravenous Devices
KEY: NursingProcess Step: Planning MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE 1. The patient is on daily weights and is receiving intravenous therapy. thenurse notices that thepatient has gained 2 kg since theprevious morning. What else would thenurse expect to observe? (Select all that apply.) a. Dry skin and mucous membranes b. Distended neck veins c. Tenting of theskin d. Crackles or rhonchi in thelungs ANS: B, D A change in body weight of 1 kg corresponds to 1 L of fluid retention or loss. Dry skin and mucous membranes suggest fluid volume deficit (FVD). Distended neck veins suggest fluid volume excess (FVE). Poor skin turgor is seen when after pinching, theskin fails to return to normal position within 3 seconds. With FVD, thepinched skin stays elevated for several seconds. This is called tenting. Auscultation of crackles or rhonchi in thelungs may signal fluid buildup in thelungs caused by FVE. DIF:
CognitiveLevel: Analysis
TOP: Fluid Volume Excess
OBJ: Discuss complications of IV therapy. KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 2. What should thenurse do upon noting that thepatient‘s intravenous (IV) catheter site is pale, cool, and edematous? (Select all that apply.) a. Stop theinfusion. b. Elevate theextremity. c. Start a new IV. d. Flush theIV site. ANS: A, B, C Infiltration: pain, swelling, coolness to touch, or presence of blanching (white, shiny appearance at or above IV site) or redness. Stop infusion and remove IV catheter at first sign of infiltration. Elevate affected extremity. Avoid applying pressure, which can force solution into contact with more tissue, causing tissue damage.
DIF:
CognitiveLevel: Application
TOP: Infiltration
OBJ: Discuss complications of IV therapy.
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 3. The nurse is preparing to start an intravenous (IV) infusion on a 92-year-old patient. thenurse realizes that she may need to take which of thefollowing actions? (Select all that apply.) a. Avoid using veins in thehand. b. Avoid using veins in thedominant arm. c. Use thelargest-gauge catheter possible for maximum flow. d. Avoid using a tourniquet. ANS: A, B, D Veins of theolder population are very fragile; perform venipuncture gently and evaluate theneed for a tourniquet (Gorski, 2018). Avoid sites that are easily moved or bumped, and thedorsal metacarpal veins where hematoma formation may occur. Use a commercial protective device to protect thesite and reduce manipulation. In older patients theuse of a 22or 24-gauge catheter is appropriate for most therapies. Smaller-gauge catheters are less traumatizing to thevein but still allow blood flow to provide increased hemodilution of theIV solutions or medications. As older adults lose subcutaneous tissue, theveins lose stability and roll away from theneedle. To stabilize thevein, pull theskin taut and toward you with your nondominant hand and anchor thevein with your thumb. If patient has fragile veins or bruises easily, tourniquet should be applied loosely or not at all to prevent damage to veins and bruising. DIF:
CognitiveLevel: Application
OBJ: Explain how to prepare thepatient and thefamily for IV therapy. TOP: Starting IVs in Older Patients
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 4. For which patients are electronic infusion devices (EIDs) used? (Select all that apply.) a. Those who require low hourly rates b. Those who are at risk for volume overload
c. Those who have impaired renal clearance d. Those who are receiving fluids that require a specific hourly volume ANS: A, B, C, D Infusion pumps are necessary for patients requiring low hourly rates, at risk for volume overload, with impaired renal clearance, or receiving medications or fluids that require a specific hourly volume. DIF:
CognitiveLevel: Knowledge
OBJ: Explain how to prepare thepatient and thefamily for IV therapy. TOP: Electronic Infusion Device (EID)
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 5. Central venous access devices (CVADs) can be used in thehome, in thehospital, and in long-term care facilities for patients who require which of thefollowing? (Select all that apply.) a. Supplemental nutrition b. Blood and blood products c. Hemodynamic monitoring d. Blood sampling ANS: A, B, C, D Central venous access devices (CVADs) can be used in thehome, in thehospital, and in long-term care facilities for patients who require supplemental nutrition, blood and blood products, continuous fluids, medications, hemodynamic monitoring, and blood sampling. DIF:
CognitiveLevel: Comprehension
OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Central Venous Access Devices (CVADs) KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 6. Which of thefollowing are central venous access devices (CVADs)? (Select all that apply.)
a. Implanted subcutaneous ports b. Peripherally inserted central catheter (PICC) lines c. Saline locks d. Heparin locks ANS: A, B Four types of CVADs are available: nontunneled percutaneous central venous catheters, tunneled central venous catheters, peripherally inserted central catheters (PICCs), and implanted subcutaneous ports. DIF:
CognitiveLevel: Comprehension
OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Central Venous Access Devices (CVADs) KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
COMPLETION 1. Fluids that have thesame osmolality as body fluids are used most often to replace extracellular volume and are known as
fluids.
ANS: isotonic Isotonic fluids have thesame osmolality as body fluids and are used most often to replace extracellular volume (e.g., prolonged vomiting). Isotonic fluids effectively mimic thebody‘s fluid loss in theabsence of an electrolyte imbalance. DIF:
CognitiveLevel: Knowledge
OBJ: Discuss patient conditions requiring intravenous (IV) therapy. TOP: Isotonic Fluids MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Assessment
2.
pull fluid into thevascular space by osmosis, resulting in an increased vascular volume that possibly will result in pulmonary edema. ANS: Hypertonic solutions Hypertonic solutions are irritating to thevein and can cause increased risk of heart failure and pulmonary edema. DIF:
CognitiveLevel: Knowledge
TOP: Hypertonic Fluids
OBJ: Discuss complications of IV therapy. KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient who will be on long-term antibiotic therapy. thepatient has had numerous intravenous (IV) catheters in thepast, but because theupcoming therapy will be given on a long-term basis, thenurse suggests that a
be inserted.
ANS: central venous access device (CVAD) Factors considered when determining placement of a CVAD include type and duration of infusion therapy (greater than 7 days), vascular characteristics, patient's age, co-morbidities, history of infusion therapy, and preference for VAD location. DIF:
CognitiveLevel: Comprehension
OBJ: Discuss patient conditions requiring intravenous (IV) therapy. TOP: Central Venous Access Devices (CVADs) KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. The nurse is caring for a patient who has a peripheral intravenous (IV) catheter. While performing her routine assessment, she notes that theinsertion site is pale, cool, and edematous. thepatient indicates that thesite is also painful to thetouch. thenurse recognizes these symptoms as revealing a possible
.
ANS: infiltration Infiltration: pain, swelling, coolness to touch, or presence of blanching (white, shiny appearance at or above IV site) or redness DIF:
CognitiveLevel: Analysis
TOP: Infiltration
OBJ: Discuss complications of IV therapy.
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity 5.
is manifested by decreased urine output, dry mucous membranes, decreased capillary refill, a disparity in central and peripheral pulses, tachycardia, hypotension, and shock. ANS: Fluid volume deficit (FVD) FVD is manifested by decreased urine output, dry mucous membranes, decreased capillary refill, a disparity in central and peripheral pulses, tachycardia, hypotension, and shock. DIF:
CognitiveLevel: Knowledge
TOP: Fluid Volume Deficit MSC: NCLEX: Physiological Integrity
OBJ: Discuss complications of IV therapy. KEY: NursingProcess Step: Evaluation
6. The nurse is caring for a patient who is receiving intravenous (IV) fluids at a rate of 150 mL per hour. During her assessment, thenurse notes that thepatient is having more labored respirations, and that crackles have developed in thepatient‘s lungs. thenurse reduces theIV rate and notifies thephysician. She does this while recognizing that thepatient is experiencing signs of
.
ANS: fluid volume excess (FVE) FVE is manifested by crackles in thelungs, shortness of breath, and edema. DIF:
CognitiveLevel: Analysis
TOP: Fluid Volume Excess
OBJ: Discuss complications of IV therapy. KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity 7. While assessing thepatient‘s intravenous (IV) catheter site, thenurse notes that thesite is reddened and warm. thepatient states that it is ―sore.‖ thenurse recognizes these as signs of . ANS: phlebitis Phlebitis (i.e., vein inflammation): pain, redness, warmth, swelling, induration, or presence of palpable cord along course of vein DIF:
CognitiveLevel: Application
TOP: Phlebitis
OBJ: Discuss complications of IV therapy.
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 8. An electronic device that delivers a measured amount of intravenous fluid over a specified period (e.g., 100 mL/hr) using positive pressure is called an ANS:
.
electronic infusion device (EID) An EID delivers a measured amount of fluid over a specified period (e.g., 100 mL/hr) using positive pressure. EIDs use an electronic sensor and an alarm that signals if thepressure in thesystem changes and thedesired flow rate is altered. DIF:
CognitiveLevel: Knowledge
OBJ: Explain how to prepare thepatient and thefamily for IV therapy. TOP: Electronic Infusion Device (EID)
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity 9. Intravenous pumps that have built-in software programmed from health care pharmacy databases with unit-specific profiles are known as
.
ANS: smart pumps Multifunctional EIDs or ―smart pumps‖ have an embedded computer system with a drug library and are associated with reduced risk for infusion-related medication errors. thebuilt-in software is programmed from health care pharmacy databases with unit-specific profiles. thepump has an audible and visual alert when its setting does not match thepreselected dose or volume limits, helping to prevent infusion errors. theuse of ―smart pump‖ with thepotential reduction in serious medication errors and improved patient outcomes is becoming thestandard of care across all settings. DIF:
CognitiveLevel: Knowledge
OBJ: Explain how to prepare thepatient and thefamily for IV therapy. TOP: Smart Pumps
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity 10. An intravenous catheter that is inserted through a large arm vein and is advanced until thetip enters thecentral venous system is known as a
.
ANS: peripherally inserted central catheter (PICC) Peripherally inserted central catheter [PICC] Insertion sites: Antecubital fossa or upper arm (basilic or cephalic vein) and advanced until catheter tip reaches superior vena cava (SVC) DIF:
CognitiveLevel: Knowledge
OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Peripherally Inserted Central Catheter (PICC) KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity 11. Intravenous catheters that are inserted directly through theskin and into theinternal or external jugular, subclavian, or femoral vein for up to several weeks are known as _
.
ANS: nontunneled percutaneous venous access devices Nontunneled percutaneous venous access devices are inserted directly through theskin and into theinternal or external jugular, subclavian, or femoral vein. thetip of thecatheter rests in thesuperior vena cava. These catheters may be left for anywhere from several days up to several weeks. DIF:
CognitiveLevel: Knowledge
OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Nontunneled Percutaneous Central Venous Catheters KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
12.
are surgically inserted through a tunnel into subcutaneous tissue, usually between theclavicle and thenipple, into theinternal jugular or subclavian vein, with thecatheter tip resting in thedistal end of thesuperior vena cava. thesubcutaneous tunnel allows thecatheter to remain in place for months to years. ANS: Tunneled central venous catheters External Tunneled (Hickman, Broviac, Groshong) •Length of dwell: Considered permanent •Insertion sites: Chest region through subclavian or jugular vein •Insertion technique: Surgery required; tunneling of proximal end subcutaneously from insertion site and bringing it out through skin at an exit site •Held in place by a Dacron cuff coated in antimicrobial solution; in approximately 2–3 weeks scar tissue forms around cuff, fixing catheter in place. DIF:
CognitiveLevel: Knowledge
OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance.
TOP: Tunneled Central Venous Catheters
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
Chapter 30: Blood Therapy Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The nurse is caring for a patient who needs a blood transfusion. thepatient has been tested and was found to have blood type O. thenurse knows this means that which antigen is present on thesurface of thered blood cells? a. The type A antigen is present. b. The type B antigen is present. c. Neither type A nor type B antigens are present.
d. Both type A and type B antigens are present. ANS: C
When neither A nor B antigens are present, theblood group is type O. When thetype A antigen is present, theblood group is type A. When thetype B antigen is present, theblood group is type B. When both A and B antigens are present, theblood group is type AB. DIF: CognitiveLevel: Application TOP: Blood Type
OBJ: Describe various transfusion reactions.
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
2. A nurse is concerned about thetype of blood that a patient is to receive. A patient with an O blood type may safely receive which type of blood? a. Type A blood b. Type B blood c. Type AB blood d. Type O blood ANS: D
People with type O blood have both A and B antibodies and therefore can receive only type O blood. People with type A blood have anti-B antibodies and therefore can receive only type A blood. People with type B blood have anti-A antibodies and therefore can receive only type B blood. People with type AB blood have neither antibodies and therefore can receive all blood types. DIF: CognitiveLevel: Comprehension OBJ: Demonstrate thefollowing skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Type O Blood
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
3. The patient is brought to theemergency department after a motor vehicle accident and has lost a large volume of blood. thepatient‘s blood type is AB. Which blood type may this patient safely receive in transfusion? a. Only type AB blood
b. Only type O blood c. All blood types d. Only type A blood ANS: C
People with type AB blood have neither antibodies and therefore can receive all blood types. DIF: CognitiveLevel: Application OBJ: Demonstrate thefollowing skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Type AB Blood
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4. The patient is scheduled to receive a blood transfusion. Preadministration laboratory tests are run to assess thelevel of which component in thepatient‘s blood? a. Sodium (Na) b. Calcium (Ca) c. Potassium (K) d. Iron (Fe) ANS: C
When blood is stored, there is continual destruction of red blood cells (RBCs), which releases potassium from thecells into theplasma. If blood is transfused rapidly, transient elevated potassium levels may occur before thepotassium is reabsorbed and put thepatient at risk. DIF: CognitiveLevel: Application
OBJ: Describe various transfusion reactions.
TOP: Hypocalcemia
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
5. The patient has received a total of 7 units of blood over thepast 8 hours. thenurse assesses thepatient‘s laboratory test results. Which of thefollowing would be an expected complication? a. Hypokalemia b. Hyperkalemia c. Hypercalcemia
d. Iron deficiency ANS: B
When blood is stored, there is continual destruction of red blood cells (RBCs), which releases potassium from thecells into theplasma. If blood is transfused rapidly, transient hyperkalemia may occur before thepotassium is reabsorbed. Blood that is preserved with citrate phosphate dextrose (CPD) contains a high concentration of citrate ions. theexcess citrate may combine with theionized calcium in therecipient‘s blood, resulting in transient low ionized calcium levels. Patients receiving multiple transfusions should be assessed for iron overload. DIF: CognitiveLevel: Application
OBJ: Describe various transfusion reactions.
TOP: Hyperkalemia
KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
6. The patient is to receive 2 units of packed red blood cells (RBCs). theunits are cold, and thenurse is concerned that this could lead to dysrhythmias and/or a reduction in core temperature. What action may thenurse take to prevent this? a. Warm theblood in a microwave. b. Warm theblood using hot water. c. Warm theblood using a blood warmer. d. Allow theblood to warm to room temperature before administering. ANS: C
In emergency situations, rapid transfusion of cold blood may lead to dysrhythmias and a reduction in core temperature. Sometimes a blood warmer machine is used for large transfusions of greater than 50 mL/kg/hr or in patients with cold agglutinins. Heating blood products in a microwave or with hot water is dangerous and may destroy blood cells. Blood must be given within a prescribed time frame. Allowing theblood to come to room temperature before administration would decrease thetime available for administration. DIF: CognitiveLevel: Application TOP: Blood Warmer MSC: NCLEX: Physiological Integrity
OBJ: Describe various transfusion reactions. KEY: NursingProcess Step: Implementation
7. The patient is scheduled to receive 1 unit of packed red blood cells (RBCs). She has small, fragile veins, and a 22-gauge intravenous (IV) patent catheter is in place. What should thenurse do? a. Cancel theblood transfusion. b. Insert a 16-gauge IV catheter into theantecubital fossa. c. Use theIV catheter that is in place. d. Transfuse theblood over 6 hours. ANS: C
In emergency situations that require rapid transfusions, a large-gauge cannula is preferred; however, transfusions for therapeutic indications may be infused with cannulas ranging from 20 to 24 gauge. Large-gauge cannulas (18 or 20 gauge) promote rapid flow of blood components. 16-Gauge catheters are used frequently in surgery, but not usually on acute care units. Blood must be transfused within 4 hours. Use of smaller-gauge cannulas, such as 24 gauge, often requires theblood bank to divide theunit so that each half can be infused within theallotted time or requires theuse of pressure-assisted devices. DIF: CognitiveLevel: Application TOP: IV Catheter Size MSC: NCLEX: Physiological Integrity
OBJ: Describe various transfusion reactions. KEY: NursingProcess Step: Implementation
8. What primary intervention should a nurse who is preparing a blood transfusion perform? a. Set up theY tubing. b. Obtain 0.9% saline. c. Verify theblood product and thepatient. d. Have thepatient void or empty theurine drainage container. ANS: C
Correctly verify theproduct and identify thepatient with a person considered qualified by your agency. Strict adherence to verification procedures before administration of blood or blood components reduces therisk of administering thewrong blood to thepatient. Clerical errors are thecause of most hemolytic transfusion reactions. Y tubing is used to facilitate maintenance of intravenous (IV) access in case a patient will need more than 1 unit of blood. However, thefocus here is on prevention of possible blood reactions. Use of Y tubing will not prevent a blood reaction. Normal saline is compatible with blood products, unlike solutions that contain dextrose, which causes coagulation of donor blood. However, strict adherence to verification procedures before administration of blood or blood components reduces therisk of administering thewrong blood to thepatient. Empty theurine drainage collection container or have thepatient void. If a transfusion reaction occurs, a urine specimen containing urine produced after initiation of thetransfusion will be sent to thelaboratory. DIF: CognitiveLevel: Application OBJ: Demonstrate thefollowing skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Pretransfusion Procedure KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
9. The patient is to receive 1 unit of packed red blood cells (RBCs). thenurse obtains theblood from theblood bank and returns to theunit to find that thepatient has been taken to radiology for a computed tomography (CT) scan and is expected to return in about an hour. What should thenurse do? a. Go to radiology and administer theblood. b. Keep theblood refrigerated until thepatient returns. c. Return theblood to theblood bank. d. Hang theblood in thepatient‘s room and start it when thepatient returns. ANS: C
Initiate theblood transfusion within 30 minutes of thetime of release from theblood bank. If theblood cannot be started because thepatient is in thebathroom or thephysician has to be notified of an elevated temperature, immediately return theblood to theblood bank, and retrieve it when it can be administered. DIF: CognitiveLevel: Application OBJ: Demonstrate thefollowing skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Delayed Start of Transfusion KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
10. The nurse is preparing to administer a unit of blood to a patient using blood tubing. On theblood product side of theY tubing, thenurse will hang blood. What will be hung on theother side of theY tubing? a. Dextrose 5% b. Normal saline c. Dextrose 10% d. Dextrose 5%/normal saline ANS: B
Normal saline is compatible with blood products, unlike solutions that contain dextrose, which causes coagulation of donor blood. DIF: CognitiveLevel: Application OBJ: Demonstrate thefollowing skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Normal Saline and Blood Products KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
11. The nurse is administering blood. What should thenurse do to detect a blood reaction as quickly as possible? a. Remain with thepatient during thefirst 15 minutes. b. Transfuse theblood at 10 mL/min. c. Monitor vital signs q 1 hour. d. Transfuse blood at 50 gtt/min. ANS: A
Remain with thepatient during thefirst 15 minutes of a transfusion. Most transfusion reactions occur within thefirst 15 minutes of a transfusion. theinitial flow rate during this time should be 2 mL/min, or 20 gtt/min. Initially infusing a small amount of blood component minimizes thevolume of blood to which thepatient is exposed, thereby minimizing theseverity of a reaction. Monitor thepatient‘s vital signs at 5 minutes, at 15 minutes, and every 30 minutes until 1 hour after transfusion or per agency policy. Frequent monitoring of vital signs will help to quickly alert thenurse to a transfusion reaction. DIF: CognitiveLevel: Application OBJ: Demonstrate thefollowing skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Early Detection of Blood Reaction KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
12. An appropriate technique for thenurse to implement for a blood transfusion is to:
a. b. c. d.
provide medication through theintravenous (IV) tubing with theblood. regulate theflow of blood so that it infuses over 8 hours. clear theIV tubing with normal saline after theblood infuses. administer a blood product with clots through a filter line.
ANS: C
After theblood has infused, clear theIV line with 0.9% normal saline and discard theblood bag according to agency policy. Medication should never be injected into thesame IV line as a blood component because of therisk of contaminating theblood product with pathogens and thepossibility of incompatibility. A separate IV line must be maintained if thepatient requires IV infusion (total parenteral nutrition, pain control) during thetransfusion. A unit of blood should not hang for longer than 4 hours because of thedanger of bacterial growth. Check theappearance of blood product for leaks, bubbles, clots, or a purplish color. Do not transfuse blood if its integrity is compromised. Blood serves as a medium for bacteria. DIF: CognitiveLevel: Application OBJ: Demonstrate thefollowing skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Blood Product Administration KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
13. When a patient‘s adverse reaction to a blood transfusion is differentiated, which of thefollowing signs/symptoms indicates thepresence of an anaphylactic response? a. Wheezing and chest pain b. Headache and muscle pain c. Hypotension and tingling of theextremities d. Crackles in thelungs and increased central venous pressure ANS: A
Observe thepatient for wheezing, chest pain, and possible cardiac arrest. All of these are indications of an anaphylactic reaction. Be alert to patient complaints of headache or muscle pain in thepresence of a fever. Both may be indicative of a febrile nonhemolytic reaction. Observe patients receiving massive transfusions for mild hypothermia, cardiac dysrhythmias, hypotension, and hypocalcemia. Cold blood products can affect thecardiac conduction system, resulting in ventricular dysrhythmias. Other cardiac dysrhythmias, hypotension, and tingling may indicate hypocalcemia, which occurs when citrate (used as a preservative for some blood products) combines with thepatient‘s calcium. Crackles in thebases of lungs and rising central venous pressure (CVP) are indications of circulatory overload. DIF: CognitiveLevel: Analysis TOP: Anaphylactic Response MSC: NCLEX: Physiological Integrity
OBJ: Describe various transfusion reactions. KEY: NursingProcess Step: Evaluation
14. The patient is receiving a unit of packed red blood cells (RBCs). Fifteen minutes into theprocedure, he complains of severe kidney pain, and his temperature increases by 3°F. thenurse stops thetransfusion immediately, suspecting that which of thefollowing reactions is occurring? a. Delayed hemolytic transfusion reaction b. Nonhemolytic febrile reaction c. Acute hemolytic transfusion reaction d. Severe allergic reaction
ANS: C
Symptoms of an acute hemolytic reaction usually begin within 15 minutes of transfusion initiation and include severe pain in thekidney area and chest, increased temperature (up to 105°F), increased heart rate, and a sensation of heat and pain along thevein receiving blood, as well as chills, low back pain, headache, nausea, chest or back pain, chest tightness, dyspnea, bronchospasm, anxiety, hypotension, vascular collapse, disseminated intravascular coagulation, and possibly death. Symptoms of a delayed hemolytic reaction usually begin 2 to 14 days after thetransfusion and include unexplained fever, an unexplained decrease in hemoglobin/hematocrit (Hgb/Hct), increased bilirubin levels, and jaundice. Symptoms of a nonhemolytic febrile reaction begin between 30 minutes after initiation and 6 hours after completion of transfusion and include fever greater than 1°C above baseline, flushing, chills, headache, and muscle pain; they occur most frequently in immunosuppressed patients. Symptoms of an acute severe allergic reaction usually begin within 5 to 15 minutes of initiation of transfusion and include coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of consciousness, and possible cardiac arrest. DIF: CognitiveLevel: Analysis TOP: Acute Hemolytic Reaction MSC: NCLEX: Physiological Integrity
OBJ: Describe various transfusion reactions. KEY: NursingProcess Step: Evaluation
15. The patient has been home from thehospital for 10 days. On thelast day of his hospitalization, he received 2 units of packed red blood cells (RBCs). This morning, he noticed that his skin had a yellow tint to it and his temperature was elevated. Which reaction might this patient be experiencing? a. Delayed hemolytic transfusion reaction b. Acute hemolytic transfusion reaction c. Nonhemolytic febrile reaction d. Severe allergic transfusion reaction ANS: A
Symptoms of a delayed hemolytic reaction usually begin 2 to 14 days after thetransfusion and include unexplained fever, unexplained decrease in Hgb/Hct, increased bilirubin levels, and jaundice. Symptoms of an acute hemolytic reaction usually begin within 15 minutes of transfusion initiation and include severe pain in thekidney area and chest, increased temperature (up to 105°F), increased heart rate, and increased sensation of heat and pain along thevein receiving blood, as well as chills, low back pain, headache, nausea, chest or back pain, chest tightness, dyspnea, bronchospasm, anxiety, hypotension, vascular collapse, disseminated intravascular coagulation, and possibly death. Symptoms of a nonhemolytic febrile reaction begin between 30 minutes after initiation and 6 hours after completion of transfusion and include fever greater than 1°C above baseline, flushing, chills, headache, and muscle pain; they occur most frequently in immunosuppressed patients. Symptoms of an acute severe allergic reaction usually begin within 5 to 15 minutes of initiation of transfusion and include coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of consciousness, and possible cardiac arrest. DIF: CognitiveLevel: Analysis TOP: Delayed Hemolytic Reaction MSC: NCLEX: Physiological Integrity
OBJ: Describe various transfusion reactions. KEY: NursingProcess Step: Evaluation
16. The specific blood product used for replacement of clotting factors and fibrinogen is:
a. b. c. d.
whole blood. packed RBCs. cryoprecipitate. albumin, 25% pooled.
ANS: C
Cryoprecipitate replaces factors VIII and XIII, von Willebrand‘s factor, and fibrinogen. It also replaces red cell mass and plasma volume and is expected to raise hemoglobin by 1 g/100 mL and hematocrit by 3% in a non-hemorrhaging adult. Using cryoprecipitate is thepreferred method of replacing red blood cell mass. DIF: CognitiveLevel: Knowledge TOP: Cryoprecipitate MSC: NCLEX: Physiological Integrity
OBJ: Discuss indications for blood therapy. KEY: NursingProcess Step: Evaluation
17. The nurse is administering 1 unit of packed red blood cells as ordered by theprimary care provider. While thenurse is measuring vital signs 15 minutes after starting thetransfusion, thepatient complains of chills and back pain. What is thenurse‘s first action? a. Stop theblood transfusion and keep thevein patent by administering saline to infuse from theother side of theY tubing. b. Slow theblood transfusion and notify thecharge nurse. c. Disconnect theblood tubing from thecatheter and replace it with an infusion of normal saline. d. Stop theblood transfusion and notify theprimary care provider. ANS: C
The nurse‘s first priority is to stop theblood transfusion. To keep theintravenous site patent, normal saline can be infused at a keep-open rate, but thetubing must be changed to avoid administering more blood as thesaline flushes theblood from thetubing. If thetubing is not changed, additional blood will be administered, and thepossible transfusion reaction will increase. thecharge nurse or theprimary care provider should be notified only after thepatient has been assessed. DIF: CognitiveLevel: Application OBJ: Verbalize theskills used in administering blood transfusions. TOP: Transfusion Reaction KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE
1. Transfusion therapy is theintravenous (IV) administration of which of thefollowing? (Select all that apply.) a. Whole blood b. Plasma products c. Red blood cells (RBCs) d. Platelets ANS: A, B, C, D
Transfusion therapy or blood replacement is theintravenous (IV) administration of whole blood, its components, or plasma-derived product for therapeutic purposes.
DIF: CognitiveLevel: Comprehension TOP: Transfusion Therapy MSC: NCLEX: Physiological Integrity
OBJ: Discuss indications for blood therapy. KEY: NursingProcess Step: Assessment
2. What is thepurpose of administering a transfusion? (Select all that apply.) a. Restore intravascular volume. b. Restore theoxygen-carrying capacity of blood. c. Provide clotting factors. d. Improve blood pressure. ANS: A, B, C
Transfusions are used to restore intravascular volume with whole blood or albumin, to restore theoxygen-carrying capacity of blood with red blood cells (RBCs), and to provide clotting factors and/or platelets. Although increasing blood volume may increase blood pressure, increasing blood pressure is not a primary objective of transfusion. DIF: CognitiveLevel: Comprehension TOP: Transfusion Therapy MSC: NCLEX: Physiological Integrity
OBJ: Discuss indications for blood therapy. KEY: NursingProcess Step: Planning
3. The patient is to receive 2 units of packed red blood cells (RBCs). Before administering theblood, what does thenurse need to do? (Select all that apply.) a. Insert an 18-gauge intravenous (IV) cannula. b. Have thepatient complete a consent form. c. Obtain pretransfusion vital signs. d. Notify thephysician for a temperature of 37°C. ANS: B, C
In emergency situations that require rapid transfusions, a large-gauge cannula is preferred; however, transfusions for therapeutic indications may be infused with cannulas ranging from 20 to 24 gauge. Check that thepatient has properly completed and signed transfusion consent before retrieving blood. Most agencies require patients to sign consent forms before receiving blood component therapy because of theinherent risks. Obtain and record pretransfusion vital signs, including temperature, immediately before initiation of thetransfusion. If thepatient is febrile (temperature greater than 100°F [37.8°C]), notify thephysician or thehealth care provider before initiating thetransfusion. Change from baseline vital signs during infusion will alert thenurse to a potential transfusion reaction or adverse effect of therapy. DIF: CognitiveLevel: Application OBJ: Demonstrate thefollowing skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Pretransfusion Procedure KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
4. The patient is receiving blood when he suddenly complains of low back pain and develops diaphoresis and chills. thenurse should: (Select all that apply.) a. stop thetransfusion. b. start normal saline connected to theY tubing. c. notify thephysician. d. start normal saline using new intravenous (IV) tubing. ANS: A, C, D
If signs of a transfusion reaction occur, stop thetransfusion, start normal saline with new primed tubing directly to theventricular assist device (VAD) at thekeep-vein-open rate (KVO), and notify thephysician immediately. DIF: CognitiveLevel: Application OBJ: Demonstrate thefollowing skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Blood Reaction KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. Symptoms that indicate an adverse reaction to blood products include which of thefollowing? (Select all that apply.) a. Fever b. Skin rash c. Hypotension d. Cardiac arrest ANS: A, B, C, D
Symptoms that indicate an adverse reaction range from fever, chills, and skin rash to hypotension and cardiac arrest. DIF: CognitiveLevel: Knowledge OBJ: Describe various transfusion reactions. TOP: Symptoms of a Blood Product Reaction KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION
1. A transfusion in which thedonor is thepatient is known as an autotransfusion.
transfusion or
ANS:
autologous In autologous transfusion, or autotransfusion, thedonor is thepatient. DIF: CognitiveLevel: Knowledge TOP: Autologous Transfusion MSC: NCLEX: Physiological Integrity
OBJ: Discuss indications for blood therapy. KEY: NursingProcess Step: Assessment
2. The presence or absence of specific antigens on thesurface of red blood cells determines in theABO system. ANS:
blood type The presence or absence of specific antigens on thesurface of red blood cells determines blood type in theABO system. DIF: CognitiveLevel: Knowledge OBJ: Describe various transfusion reactions. TOP: Blood Type KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
3. Antibodies that react against theA and B antigens are naturally present in theplasma of people whose red blood cells do not carry theantigen. These antibodies react against theforeign antigens. Incompatible red blood cells clump together or , which results in a life-threatening hemolytic transfusion reaction. ANS:
agglutinate Antibodies that react against theA and B antigens are naturally present in theplasma of people whose red blood cells do not carry theantigen. These antibodies (agglutinins) react against theforeign antigens (agglutinogens). Incompatible red blood cells agglutinate (clump together), which results in a life-threatening hemolytic transfusion reaction. DIF: CognitiveLevel: Knowledge TOP: Agglutination MSC: NCLEX: Physiological Integrity
OBJ: Describe various transfusion reactions. KEY: NursingProcess Step: Assessment
4. The nurse is caring for a patient who is receiving blood while monitoring thepatient for potential complications. thenurse knows that a systemic response to administration of a blood product that is incompatible with theblood of therecipient, contains allergens to which therecipient is sensitive or allergic, or is contaminated with pathogens is known as a . ANS:
hemolytic reaction A hemolytic reaction is a systemic response to theadministration of a blood product that is incompatible with theblood of therecipient, contains allergens to which therecipient is sensitive or allergic, or is contaminated with pathogens. DIF: CognitiveLevel: Knowledge TOP: Hemolytic Reaction MSC: NCLEX: Physiological Integrity
OBJ: Describe various transfusion reactions. KEY: NursingProcess Step: Assessment
5. The patient has received blood within thepast 6 hours. thepatient begins to feel short of breath and calls for thenurse. thenurse finds that thepatient is dusky in color with crackles throughout his lungs and is coughing up pink frothy sputum. thenurse calls thephysician immediately, knowing that thepatient is showing signs of . ANS:
transfusion-related acute lung injury (TRALI) transfusion-related acute lung injury Possible adverse outcomes that result from transfusion therapy include transmission of diseases, circulatory overload, and TRALI characterized by noncardiogenic pulmonary edema with onset within 6 hours of transfusion. DIF: CognitiveLevel: Analysis OBJ: Describe various transfusion reactions. TOP: Transfusion-Related Acute Lung Injury (TRALI) KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
6. Under theABO system, theblood type known as the―Universal Donor.‖
_ can be given to any individual and is
ANS:
O negative O negative can be given to people of any blood type and is known as the―Universal Donor.‖ DIF: CognitiveLevel: Knowledge OBJ: Demonstrate thefollowing skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Universal Donor KEY: NursingProcess Step: Evaluation MSC: NCLEX: Physiological Integrity
Chapter 31: Oral Nutrition Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition MULTIPLE CHOICE
1. The nurse is admitting a person to theunit and is assessing thepatient‘s nutritional status. In assessing thepatient‘s nutritional status, thenurse realizes that: a. body mass index (BMI) is themain indicator of obesity. b. ideal body is thestandard gauge for nutritional status. c. clinical judgment is required, along with other indicators. d. the amount of weight change is themain nutritional indicator. ANS: C
Use clinical judgment when evaluating muscular patients or patients with large amounts of edema or ascites, because these physiological states will lead to false overestimation of thedegree of fatness. BMI alone is not a perfect predictor of overweight or obesity. You gather weight information in several ways, including usual body weight (UBW), ideal body weight (IBW), actual body weight (ABW), and BMI. A thorough nutritional assessment usually requires thecollection of all of these weight measures. themagnitude and direction of weight change are more meaningful than standardized weight references when one is dealing with sick or debilitated patients. DIF: CognitiveLevel: Application TOP: Anthropometrics/Body Weight MSC: NCLEX: Physiological Integrity
OBJ: Perform accurate nutritional screening. KEY: NursingProcess Step: Assessment
2. The nurse is caring for a patient who requires assistance with eating. thepatient repeatedly apologizes to thenurse, saying, ―I‘m so sorry. I‘m like a baby. I‘m such a burden since I can‘t even feed myself.‖ What is themost appropriate strategy for thenurse to use? a. Feed all of thesolid foods first, and then offer liquids. b. Feed thepatient quickly so as not to make thepatient feel like it is taking a great deal of time out of thenurse‘s day. c. Minimize conversation so that thepatient can eat faster. d. Appear unhurried, sit at thebedside, and encourage thepatient to feed himself/herself as much as possible.
ANS: D
Meals should be a pleasant event for thepatient. Conversation promotes socialization. Adults who need help to eat need compassion and understanding. Given theimportance of nutrition in thehealing process, thenurse should use common sense to provide a socially meaningful mealtime. Feeding thepatient quickly is likely to accentuate his belief that he is a burden. DIF: CognitiveLevel: Application OBJ: Verbalize thesteps used in assisting an adult to eat. TOP: Assisting thePatient with Oral Nutrition KEY: NursingProcess Step: Implementation MSC: NCLEX: Psychosocial Integrity
3. What must thenurse do before assisting thepatient with feeding? a. Assess thepatient‘s gag reflex. b. Make sure that theconsistency of thefood is thin. c. Remove thepatient‘s dentures to prevent gagging. d. Prepare thepatient to be fed by a staff member. ANS: A
Assess thepatient‘s ability to swallow and thepatient‘s gag reflex. Some patients (those who have neurological diseases or who are handicapped) have a reduced gag reflex and/or dysphagia, increasing therisk for aspiration. Changes in theconsistency of thediet (thickened liquids, pureed, soft), swallow training, or alternative means of nutrition are often necessary and require a speech therapist or a registered dietitian. If thepatient wears dentures, check to ensure that they fit well and are clean. This ensures that thepatient is able to chew food and swallow more normally. Patients with any level of independence should not be totally fed by hospital staff. A thorough understanding of thepatient‘s physical and cognitive limitations alerts thenurse to thetype of assistance thepatient needs. DIF: CognitiveLevel: Application OBJ: Perform accurate nutritional screening. TOP: Assisting thePatient with Oral Nutrition KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
4. The nurse is caring for an infant who is 3 months old and is being bottle-fed human milk. Will thenurse need to provide theinfant with any additional sources of nutrition or fluids? a. The infant will need extra water in between feedings. b. The infant will need juice in between feedings. c. No additional fluids will be needed between meals. d. The child will need to start on infant cereal. ANS: C
Human milk is themost desirable complete diet for infants during thefirst 6 months. Infants who are breast- or bottle-fed human milk do not require additional fluids, especially water or juice, during thefirst 4 months of life. Excessive intake of water causes water intoxication, failure to thrive, and hyponatremia. Typically, infants do not consume solid foods until 4 to 6 months of age. Iron-fortified infant cereal is usually thefirst solid food to be offered. DIF: CognitiveLevel: Application OBJ: Perform accurate nutritional screening. TOP: Pediatric Considerations with Oral Feedings KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. What is an appropriate technique for thenurse to use to prevent aspiration when assisting a patient with meals? a. Keep thepatient‘s head back and straight. b. Offer thin-consistency foods. c. Provide large amounts of fluids. d. Have thepatient sit up for 30 minutes after eating. ANS: D
Ask thepatient to remain sitting upright for at least 30 minutes after themeal to reduce therisk for gastroesophageal reflux, which can cause aspiration. thepatient must be sitting upright for passage of food through thepharynx and esophagus. Observe thepatient‘s ability to ingest foods of various textures and thicknesses to indicate whether aspiration risk is increased with thin liquids. Observe thepatient with various consistencies of liquids. Difficulty managing certain foods may indicate dysphagia, and referral to a dietitian is appropriate if a patient has difficulty with a particular consistency. DIF: CognitiveLevel: Application OBJ: Identify risk factors for aspiration related to dysphagia. TOP: Preventing Aspiration KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
6. The patient is admitted with a diagnosis of stroke. thenurse attempts to feed thepatient, but thepatient coughs and gags when food is placed in his mouth. What should thenurse do to assist this patient? a. Feed thepatient more slowly. b. Feed thepatient more quickly. c. Contact thespeech pathology department. d. Ignore thecough and try again later. ANS: C
If thepatient coughs, gags, complains of food ―stuck in thethroat,‖ or has pockets of food in themouth, thepatient may require a swallowing evaluation by a licensed speech pathologist or by videofluoroscopy. Consider consultation with a speech therapist for swallowing exercises and techniques to improve swallowing and reduce risk for aspiration. Notify thephysician of any symptoms that occurred during themeal and which foods caused thesymptoms. DIF: CognitiveLevel: Application OBJ: Identify risk factors for aspiration related to dysphagia. TOP: Suspected Dysphagia KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
7. The nurse is caring for a patient who is 6 feet 2 inches tall and weighs 250 pounds. What is thepatient‘s body mass index (BMI)? a. 18.5 kg/m2 b. 30.2 kg/m2 c. 32.13 kg/m2 d. 40.11 kg/m2 ANS: C
BMI = Weight (pounds)/Height (inches) Height (inches) 703. In this case, 250/(74 74) 703 250/5476 703 0.0457 703 = 32.13 kg/m2. DIF: CognitiveLevel: Analysis
OBJ: Perform accurate nutritional screening.
TOP: BMI KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
8. The nurse is caring for a patient who is believed to be suffering from malnutrition. thenurse calculates that thepatient‘s body mass index (BMI) is 16.4 kg/m2. What does this indicate about thepatient‘s weight? a. The patient is underweight. b. The patient‘s weight is normal. c. The patient is overweight. d. The patient is obese (class 1). ANS: A
Underweight is defined as a BMI less than 18.5 kg/m2. Normal weight is classified as a BMI between 18.5 and 24.9 kg/m2. Overweight is defined as a BMI between 25 and 29.9 kg/m2. Obesity (class 1) is defined as a BMI between 30 and 34.9 kg/m2. DIF: CognitiveLevel: Analysis TOP: Underweight MSC: NCLEX: Physiological Integrity
OBJ: Perform accurate nutritional screening. KEY: NursingProcess Step: Assessment
9. A patient is admitted to thehospital for evaluation for sleep apnea. thenurse calculates his body mass index (BMI) at 42 kg/m2. What does this indicate about thepatient‘s weight? a. The patient is overweight. b. The patient falls into theclass 1 range of obesity. c. The patient falls into theclass 2 range of obesity. d. The patient falls into theclass 3 range of extreme obesity. ANS: D
Extreme obesity (class 3) is defined as a BMI equal to or greater than 40 kg/m 2. Overweight is defined as a BMI between 25 and 29.9 kg/m 2. Class 1 obesity is defined as a BMI between 30 and 34.9 kg/m2. Class 2 obesity is defined as a BMI between 35 and 39.9 kg/m2. DIF: CognitiveLevel: Analysis TOP: Extreme Obesity MSC: NCLEX: Physiological Integrity
OBJ: Perform accurate nutritional screening. KEY: NursingProcess Step: Assessment
10. The nurse is caring for a patient 2 days after surgery. theordered diet is a mechanical soft diet. Which of thefollowing foods may thepatient choose to eat? a. Salad b. Baked potato without skin c. Cooked cereal d. Soft peeled apples ANS: C
Mechanically altered diets consist of chopped, ground, mashed, or pureed foods for patients who have problems with chewing or swallowing. Consistency can be varied according to thepatient‘s own ability to chew or swallow. Small amounts of liquids added to foods contribute to an appropriate consistency. Liquids that are added should complement thefood and should not conceal thefood‘s original flavor. Butter, margarine, and honey can be added to increase caloric density. A regular diet with no restrictions could include a salad. A baked potato without theskin or soft peeled apples would be allowed on a dysphagia advanced diet that uses regular food, with theexception of very hard, sticky, or crunchy foods.
DIF: CognitiveLevel: Application TOP: Types of Therapeutic Diets MSC: NCLEX: Physiological Integrity
OBJ: Perform accurate nutritional screening. KEY: NursingProcess Step: Assessment
11. The patient is placed on a clear liquid diet after surgery. Which of thefollowing foods may thepatient select? a. Coffee with milk and sugar b. Gelatin, popsicles, apple juice c. Water, orange juice, Jell-O d. Black coffee, popsicles, ice cream ANS: B
A clear liquid diet consists of foods that are clear and liquid at room or body temperature (e.g., water, clear fruit juice, gelatin, popsicles). Coffee with milk, orange juice, and ice cream are not clear liquids. DIF: CognitiveLevel: Application TOP: Clear Liquid Diet MSC: NCLEX: Physiological Integrity
OBJ: Perform accurate nutritional screening. KEY: NursingProcess Step: Assessment
12. The patient is on thedysphagia puree stage of theinternational dysphagia diet. Which of thefollowing foods may thepatient select? a. Mashed potatoes b. Dry cereals moistened with milk c. Well-cooked noodles in gravy d. Well-moistened cereals ANS: A The dysphagia puree stage notes that patient cannot drink from cup, usually eaten with a spoon, cannot suck through a straw, does not require chewing, can be molded, no lumps, not sticky. Rationale: If tongue control is significantly reduced, requires less propulsion, no biting or chewing is required, missing teeth or poorly fitting dentures. DIF: CognitiveLevel: Analysis TOP: National Dysphagia Diet MSC: NCLEX: Physiological Integrity
OBJ: Perform accurate nutritional screening. KEY: NursingProcess Step: Assessment
13. The nurse is preparing to assess thenutritional status of an 80-year-old patient in a long-term care agency. What screening tool would best suit this purpose? a. The Malnutrition Universal Screening Tool (MUST) b. Mini Nutritional Assessment (MNA) c. Anthropometric measurements d. A daily nutrition intake log ANS: A The Malnutrition Universal Screening Tool (MUST) was designed to detect both undernutrition and obesity in adults. It can be used in multiple settings, including hospitals and nursing homes. Body mass index (BMI), unplanned weight loss, and thepresence or absence of serious disease allows a score to be derived to indicate whether nutrition intervention is necessary. Not valid for children or renal failure patients.
Including anthropomorphic measurements might be part of an assessment as might information from thenutrition intake log, but neither would provide a complete picture in this case. DIF: CognitiveLevel: Application OBJ: Discuss thecomponents and purposes of nutritional assessments and screenings. TOP: Nutritional Screening Tools KEY: NursingProcess Step: Planning MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE
1. The nurse is admitting a patient to themedical unit. Which of thefollowing are reasons thenurse may perform a nutritional screening on this patient? (Select all that apply.) a. To assess risk for malnutrition b. To assist with feeding c. To identify risk for aspiration d. To determine body weight ANS: A, B, C
A nurse‘s role includes performing nutritional screening to assess a patient‘s risk status for malnutrition, assessing and assisting an adult patient with feeding, and identifying patients at risk for aspiration during oral feeding. Although determining body weight is one aspect of assessing nutritional status, it is not thefocus of a nutritional screening. DIF: CognitiveLevel: Application OBJ: Identify and refer patients appropriate for nutritional assessment. TOP: Nutritional Screening KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION
1. A nurse‘s role includes performing to assess a patient‘s risk status for malnutrition, assessing and assisting an adult patient with feeding, and identifying patients at risk for aspiration during oral feeding. ANS:
nutritional screening A nurse‘s role includes performing nutritional screening to assess a patient‘s risk status for malnutrition, assessing and assisting an adult patient with feeding, and identifying patients at risk for aspiration during oral feeding. DIF: CognitiveLevel: Knowledge OBJ: Identify and refer patients appropriate for nutritional assessment. TOP: Nutritional Screening KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. Patients who have a cancer diagnosis, infected or draining wounds, burns, or an elevated temperature for more than 2 days are at elevated risk. ANS:
nutritional Risk factors for potential nutritional problems include cancer diagnoses, infected or draining wounds, burns, and elevated body temperature for more than 2 days. Patients exhibiting these conditions should be assessed for their nutritional status. DIF: CognitiveLevel: Knowledge OBJ: Identify and refer patients appropriate for nutritional assessment. TOP: Nutritional Risk KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse will collaborate with a identified as being at nutritional risk.
to develop a nutritional plan for a patient
ANS:
registered dietitian A registered dietitian is a vital member of thehealth care team. An RD will assess thepatient‘s nutritional status and recommend theintervention that will best address thepatient‘s unique nutrition diagnosis. DIF: CognitiveLevel: Knowledge OBJ: Identify and refer to a registered dietitian patients appropriate for nutritional assessment. TOP: Registered Dietitian KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
4.
are measures of height; weight; head, arm, and muscle circumferences. ANS:
Anthropometrics Anthropometrics are measures of height; weight; head, arm, and muscle circumferences. DIF: CognitiveLevel: Knowledge TOP: Anthropometrics MSC: NCLEX: Physiological Integrity
5.
OBJ: Perform accurate nutritional screening. KEY: NursingProcess Step: Assessment
is useful for monitoring short-term changes in visceral protein. ANS:
Prealbumin Review results of relevant laboratory tests (e.g., albumin, prealbumin, hemoglobin, immune factors [zinc, vitamin A], Vitamin D). Compare with known standards. Test data provide clues about nutritional status. No single test is available for evaluating short-term response to nutrition therapy. Serial testing will give more accurate information but usually not practical in acute care setting (Grodner et al., 2019). Biochemical markers such as albumin and prealbumin help to identify changes in nutritional status over time.
DIF: CognitiveLevel: Knowledge OBJ: Perform accurate nutritional screening. TOP: Prealbumin KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
6. The nurse recognizes that thepatient is exhibiting signs of when she notices that he has difficulty holding food and fluid in his mouth and experiences difficulty moving it to his esophagus. ANS:
dysphagia Classic signs of dysphagia include inability to hold food and fluid in themouth or difficulty moving food into theesophagus. Any condition that produces muscle weakness may result in impairment of theswallowing mechanism. Early recognition of thepatient‘s difficulty will allow thenurse to implement aspiration precautions to protect thepatient from complications of dysphagia. DIF: CognitiveLevel: Knowledge OBJ: Define aspiration. TOP: Aspiration KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity OTHER
1. The nurse is caring for a patient who is 48 hours post bowel resection with creation of a colostomy. This morning, thenurse assessed thereturn of bowel sounds. In what order would this patient‘s diet progress? a. Full liquid diet b. Regular diet c. Clear liquid diet d. NPO e. Soft diet ANS:
D, C, A, E, B The patient has most likely been kept NPO until bowel sounds returned. Once bowel sounds resume, theinitial diet will be clear liquids. If clear liquids are tolerated, thepatient will advance to a full liquid diet, then to a soft diet, and finally to a regular diet. DIF: CognitiveLevel: Analysis OBJ: State types of and reasons for special or modified diets. TOP: Types of Diets KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
Chapter 32: Enteral Nutrition Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition MULTIPLE CHOICE
1. Of thepatients listed below, which would be a candidate for nasoenteric feeding tube placement?
a. b. c. d.
Post–motor vehicle accident victim with a broken nose and jaw Patient with a bleeding ulcer and possible esophageal varices Elderly patient with a diagnosis of failure to thrive and an inability to chew Patient with an esophageal tumor
ANS: C
Enteral nutrition, commonly called tube feeding, is theadministration of nutrients through thegastrointestinal tract when a patient cannot ingest, chew, or swallow, but can digest and absorb nutrients. Nasoenteric tubes are contraindicated in patients with facial trauma, prolonged bleeding, and upper gastrointestinal (GI) blockage (as is seen in cases of solid cancer). DIF: CognitiveLevel: Analysis OBJ: Assess thepatient who is to receive enteral tube feedings. TOP: Indications/Contraindications for Nasoenteric Tube Insertion KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse has just inserted a nasogastric (NG) feeding tube into a patient. What should thenurse do to definitely ascertain that thetube is in thestomach or in theintestine? a. Test thepH of thecontents. b. Use a carbon dioxide sensor. c. Lower thehead of thebed to 15 degrees. d. Obtain an order for a chest radiograph. ANS: D
The most reliable method of feeding tube verification is a chest radiograph (chest x-ray). Gastric and intestinal pH measurements have been shown to differentiate tube placement, with thestomach having a lower pH than theintestines. This helps to ensure that thetube is beyond thepylorus, theoretically reducing therisk for aspiration. This method is helpful before and after radiological confirmation. Carbon dioxide sensors are helpful in determining tube placement between thestomach and thelung. A small plastic piece with an embedded yellow sensor is attached to theend of thefeeding tube; thesensor changes color when carbon dioxide is present. Investigators have shown that this reduces theincidence of inadvertent pulmonary placement. This method is helpful before and after radiological confirmation. Elevation of thehead of thebed to a minimum of 30 degrees is a simple method used to keep therisk for aspiration at a minimum. thenurse is instrumental in achieving this goal. This method does not ascertain placement but may be useful in preventing aspiration. DIF: CognitiveLevel: Application OBJ: Demonstrate ability to correctly insert a small-bore feeding tube. TOP: Determining Position of NG Tubes KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
3. The nurse is checking gastric residual on a patient who has a continuously running tube feeding and finds that thepatient has a 600-mL gastric residual volume (GRV). How should thenurse respond? a. Stop thetube feeding. b. Slow thetube feeding. c. Continue thetube feeding at thesame rate. d. Increase therate of thetube feeding.
ANS: A
Tube feedings are stopped if thepatient has a gastric residual volume (GRV) greater than 500 mL. DIF: CognitiveLevel: Application OBJ: Assess thepatient who is to receive enteral tube feedings. TOP: Residual Volume KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
4. Before insertion of a nasogastric (NG) tube, of which finding should thephysician be notified? a. Patent nares b. Absent bowel sounds c. Evident gag reflex d. Impaired swallowing ANS: B
Absent bowel sounds may indicate decreased or absent peristalsis. A finding of patent nares rules out obstruction or irritated nares, septal defect, or facial fracture and does not need to be reported to thephysician because it is a ―normal‖ finding. thenurse should assess thepatient for a gag reflex to determine thepatient‘s ability to swallow and to discern whether a greater risk for aspiration exists. An evident gag reflex is a normal finding and does not need to be reported to thephysician. Impaired swallowing is theprobable reason for insertion of thenasogastric (NG) tube. DIF: CognitiveLevel: Application OBJ: Demonstrate ability to correctly insert a small-bore feeding tube. TOP: Absent Bowel SoundsKEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
5. An appropriate technique for nasogastric (NG) tube insertion is for thenurse to: a. position thepatient supine. b. apply oil-based lubricant to theplastic tube. c. advance thetube while thepatient swallows. d. measure thetube length from thenose to thesternum. ANS: C
Encourage thepatient to swallow by giving small sips of water or ice chips. Advance thetube as thepatient swallows. Rotate thetube 180 degrees while inserting. Swallowing facilitates passage of thetube past theoropharynx. Position thepatient sitting with thehead of thebed elevated at least 30 degrees. If thepatient is comatose, place him in semi-Fowler‘s position with thehead propped forward using a pillow. If thepatient is forced to lie supine, place him in reverse Trendelenburg‘s position. This reduces therisk for pulmonary aspiration in theevent that thepatient should vomit. Apply water-soluble lubricant. thetip of thetube must reach thestomach. Measure thedistance from thetip of thenose to theearlobe to thexiphoid process of thesternum. Add 20 to 30 cm (8 to 12 inches) for a nasoenteric tube. DIF: CognitiveLevel: Application OBJ: Demonstrate ability to correctly insert a small-bore feeding tube. TOP: NG Tube Insertion KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
6. Which technique is appropriate for thenurse to implement during nasogastric (NG) tube insertion? a. Use sterile gloves. b. Have thepatient mouth-breathe. c. Advance thetube quickly when thepatient coughs. d. Bend thepatient‘s head backward after thetube is through thenasopharynx. ANS: B
Emphasize theneed to mouth-breathe and swallow during theprocedure. This facilitates passage of thetube and alleviates thepatient‘s fears during theprocedure. Put on clean gloves. Do not force thetube. If resistance is met, or if thepatient starts to cough or choke, or becomes cyanotic, stop advancing thetube, pull thetube back, and start over. Have thepatient flex his head toward his chest after thetube has passed through thenasopharynx. This closes off theglottis and reduces therisk that thetube may enter thetrachea. DIF: CognitiveLevel: Application OBJ: Demonstrate ability to correctly insert a small-bore feeding tube. TOP: NG Tube Insertion KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
7. The nurse has inserted a nasogastric (NG) feeding tube. thefeeding tube has a stylet in place to aid insertion. What should thenurse do once thetube is in place? a. Remove thestylet immediately. b. Reinsert thestylet if theradiograph determines incorrect placement. c. Fasten theend of theNG tube to thepatient‘s gown using tape and a safety pin. d. Leave thestylet in place and obtain a chest/abdomen radiograph. ANS: D
Leave thestylet in place (if used) until correct position has been verified by x-ray film. Never attempt to reinsert a partially or fully removed stylet while thefeeding tube is in place. This can cause perforation of thetube and can injure thepatient. Do not use safety pins to pin thetube to thepatient‘s gown. Safety pins become unfastened and can cause injury to thepatient. DIF: CognitiveLevel: Application OBJ: Demonstrate ability to correctly insert a small-bore feeding tube. TOP: NG Tube Insertion KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
8. The nurse is caring for a patient who is receiving continuous tube feedings. What must thenurse do to care for this patient? a. Verify tube position every 4 to 6 hours. b. Obtain a radiograph every 4 to 12 hours. c. Instill air into thestomach via thetube and listen for bubbles. d. Do not worry about tube placement because thetube has already been determined to be in theright place. ANS: A
After initial radiographic verification that a tube is positioned in thedesired site (either thestomach or thesmall-intestine), thenurse is responsible for ensuring that thetube has remained in theintended position before administering formula or medications through thetube. Therefore, thenurse must verify tube position every 4 to 6 hours and as needed. Because it is not practical to do radiographic checks at this frequency, other methods of determining placement have been investigated. Insufflation of air into thetube while theabdomen is auscultated is not a reliable means of determining theposition of thefeeding tube tip. It is possible for thetip of a feeding tube to move into a different location (from thestomach to theintestine, or from theintestine into thestomach) without any external evidence that thetube has moved. therisk for aspiration of regurgitated gastric contents into therespiratory tract increases when thetip of thetube accidentally dislocates upward into theesophagus. DIF: CognitiveLevel: Application OBJ: Discuss therationale for methods used to determine nasogastric or nasoenteric feeding tube placement. TOP: NG Tube Placement KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
9. The home health nurse evaluates theprovision of intermittent tube feedings by thepatient‘s family member. thenurse notes that additional teaching is required when she notices that thefamily member: a. keeps theformula refrigerated between feedings. b. keeps thefeeding tube capped between feedings. c. begins thefeeding before checking tube placement. d. irrigates thetube with 30 to 60 mL of water before and after feedings. ANS: C
For intermittent tube-fed patients, test placement immediately before each feeding and before each administration of medication. Each administration of feeding/medication can lead to aspiration if thetube is displaced. For intermittent feeding, have a syringe ready and be sure that theformula is at room temperature. When tube feedings are not being administered, cap or clamp theproximal end of thefeeding tube. Draw up in thesyringe 30 mL of normal saline or tap water. This amount of solution will flush thelength of thetube. DIF: CognitiveLevel: Application OBJ: Demonstrate three appropriate techniques for administering enteral formulas. TOP: Beginning Tube Feedings KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
10. Which evaluation indicates that placement of a nasogastric or enteric tube is correct? a. Nasointestinal aspirate with a pH of less than 6 b. Pleural fluid pH of less than 6 c. Gastric aspirate with a pH of 5 or less after patient fasting d. Gastric aspirate with a pH of 4 and continuous tube feedings ANS: C
Gastric fluid from a patient who has fasted for at least 4 hours usually has a pH of 5 or less. Fluid from an enteric tube of a fasting patient usually has a pH greater than 6. thepH of pleural fluid from thetracheobronchial tree is generally greater than 6. Patients with continuous tube feeding may have a pH of 5 or greater.
DIF: CognitiveLevel: Analysis OBJ: Discuss therationale for methods used to determine nasogastric or nasoenteric feeding tube placement. TOP: NG Tube Placement KEY: NursingProcess Step: Evaluation MSC: NCLEX: Physiological Integrity
11. The nurse is checking theresidual volume on a patient who is getting intermittent tube feedings via his NG tube. Which of thefollowing may indicate that thepatient has started to bleed again? a. The nurse obtains brown aspirate. b. The nurse notices that theabdomen is distended. c. The nurse obtains red aspirate. d. The nurse notices severe respiratory distress. ANS: C
Red or brown coloring (coffee-grounds appearance) of fluid aspirated from a feeding tube indicates new blood or old blood, respectively, in thegastrointestinal tract. If thecolor is not related to medications recently administered, notify thephysician. Abdominal distention usually indicates that thetube feeding is not progressing through theGI tract. This could be a sign of paralytic ileus. Stop thetube feeding and notify thephysician. If thepatient develops severe respiratory distress (e.g., dyspnea, decreased oxygen saturation, increased pulse rate), this may be a result of aspiration or tube displacement into thelung. Stop any enteral feedings. Notify thephysician. Obtain chest radiographs as ordered. DIF: CognitiveLevel: Analysis OBJ: Discuss therisk for pulmonary complications during insertion and maintenance of a feeding tube. TOP: NG Tube Placement KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
12. The nurse determines that a nasogastric (NG) tube needs irrigation when she: a. obtains more than 200 mL of residual volume. b. obtains a small amount of thin watery residual. c. does not encounter resistance when aspirating theresidual. d. obtains an unusually thick secretions. ANS: D
Secretions indicate theneed to irrigate thetube. Note theease with which tube feeding infuses through thetubing. Excess volume of secretions (more than 200 mL) indicates delayed gastric emptying. Irrigating theNG tube will not help. Failure of theformula to infuse as desired may indicate a developing obstruction. DIF: CognitiveLevel: Analysis OBJ: Demonstrate theappropriate technique for irrigating a feeding tube. TOP: NG Tube Irrigation KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
13. What is an appropriate amount of nasogastric irrigant for an adult patient? a. 1 to 2 mL b. 30 mL c. 5 to 15 mL d. 250 mL
ANS: B
Draw up 30 mL of water in a syringe. This amount of solution will flush thelength of thetube. Irrigation of a tube requires a smaller volume of solution in children: 1 to 2 mL for small tubes to 5 to 15 mL or more for large ones. DIF: CognitiveLevel: Knowledge OBJ: Demonstrate theappropriate technique for irrigating a feeding tube. TOP: NG Tube Irrigation KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
14. Which technique is appropriate for providing intermittent tube feeding once placement of thetube has been checked? a. Cooling theformula b. Lowering thehead of thebed c. Allowing thebag to empty gradually over 30 to 45 minutes d. Adding food coloring to detect aspiration ANS: C
Allow thebag to empty gradually over 30 to 45 minutes. Gradual emptying of tube feeding by gravity from thefeeding bag reduces therisk for abdominal discomfort, vomiting, or diarrhea induced by bolus or too-rapid infusion of tube feedings. Cold formula causes gastric cramping. Place thepatient in high-Fowler‘s position, or elevate thehead of thebed at least 30 degrees to prevent aspiration. Do not add food coloring or dye to formula to assist in detecting aspiration, presumably by staining tracheobronchial secretions. This is associated with increased risk for contamination and may cause patient deaths. DIF: CognitiveLevel: Application OBJ: Demonstrate three appropriate techniques for administering enteral formulas. TOP: Administering Tube Feedings KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
15. The nurse is preparing to administer an enteral feeding for thepatient. thepatient has been on enteral feedings for 2 days. thenurse knows that themost appropriate technique for implementing enteral feeding is: a. weighing thepatient weekly. b. measuring thegastric residual every hour. c. changing theformula every 12 hours in an open system. d. leaving theformula in place in an open system for up to 24 hours. ANS: C
Maximum hang time for formula is 12 hours in an open system, and 24 to 48 hours in a closed, ready-to-hang system (if it remains closed). Weigh thepatient daily until themaximum administration rate is reached and maintained for 24 hours, and then weigh thepatient 3 times per week. Check thegastric residual volume. Residual volume should be assessed before each feeding for intermittent feedings. DIF: CognitiveLevel: Comprehension OBJ: Demonstrate three appropriate techniques for administering enteral formulas. TOP: Administering Tube Feedings KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
16. The nurse is initiating a continuous tube feeding for a patient who has a gastrostomy tube. Which of thefollowing procedures indicates proper practice? a. Allow thecontainer to empty gradually over 60 minutes. b. Change thebag every 24 hours. c. Do not use water to flush thetube. d. Quickly increase therate of administration. ANS: B
Rinse thebag and tubing with warm water whenever feedings are interrupted. Use a new administration set every 24 hours. Allowing thecontainer to empty over 30 to 45 minutes is themethod used for intermittent administration of tube feedings. Administer water via a feeding tube as ordered or between feedings. This provides thepatient with a source of water to help maintain fluid and electrolyte balance and clears thetubing of formula. Gradually advancing therate of concentration of thetube feeding helps to prevent diarrhea and gastric intolerance to formula. DIF: CognitiveLevel: Comprehension OBJ: Demonstrate three appropriate techniques for administering enteral formulas. TOP: Gastrostomy Tube Feedings KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
17. The nurse would anticipate theneed for an enteral access device in which of thefollowing patients? a. Patient whose bowel sounds have not yet returned after abdominal surgery b. Patient recently diagnosed with a cerebrovascular accident (CVA) c. Patient who dislikes thetaste of agency meals d. Patient who suffers from severe acute dysphagia ANS: D
A patient who is unable to swallow because of severe acute dysphagia will require an enteral access device to provide adequate nutrition. thepatient recently diagnosed with a CVA may require an enteral access device if theability to swallow is affected, but more information would be needed before this option is chosen. A patient whose bowel sounds have not yet returned will remain NPO and may have no need for an enteral access device. Less invasive strategies can be used for thepatient who does not like thetaste of food provided by theagency. DIF: CognitiveLevel: Evaluation TOP: Enteral Access Devices MSC: NCLEX: Physiological Integrity
OBJ: Identify indications for enteral access devices. KEY: NursingProcess Step: Planning
MULTIPLE RESPONSE
1. The nurse is caring for a patient with an enteral feeding tube in place. thenurse assesses for pulmonary aspiration as themain complication related to feeding tubes. Other complications include which of thefollowing? (Select all that apply.) a. Infection b. Diarrhea c. Tube clogging d. Tube dislodgment ANS: A, B, C, D
The main complication related to feeding tubes is pulmonary aspiration with possible lung compromise. Other complications include misplaced tubes, infection, diarrhea, tube clogging, and tube dislodgment. DIF: CognitiveLevel: Comprehension OBJ: Discuss therationale for methods used to determine nasogastric or nasoenteric feeding tube placement. TOP: Complications Related to Feeding Tubes KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse, physician, and dietitian collaborate to select an enteral feeding formula for thepatient. Their decision should be based on which of thefollowing? (Select all that apply.) a. Protein requirements of thepatient b. Digestive ability of thepatient c. Amount of lactose required d. The patient‘s disease process ANS: A, B
The nurse, dietitian, and physician collaborate to select an enteral feeding formula based on thepatient‘s protein and calorie requirements and digestive ability. Formulas in theUnited States are sterile and lactose free. Disease-specific formulas are available, but research has not always supported their efficacy. DIF: CognitiveLevel: Comprehension OBJ: Assess thepatient who is to receive enteral tube feedings. TOP: Enteral Feeding Formulas KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
3. Conditions that increase therisk for spontaneous tube dislocation include which of thefollowing? (Select all that apply.) a. Retching/vomiting b. Nasotracheal suction c. Coughing d. Cyanosis ANS: A, B, C
Conditions that increase therisk for spontaneous tube dislocation include retching/vomiting, nasotracheal suction, and severe bouts of coughing. Cyanosis may be an indicator of displacement but is not a cause. DIF: CognitiveLevel: Comprehension OBJ: Discuss therationale for methods used to determine nasogastric or nasoenteric (NG) feeding tube placement. TOP: Dislocation of NG Tube KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
4. The nurse is caring for a patient with a nasogastric tube in place. What interventions would thenurse perform to reduce therisk of clogging thefeeding tube? (Select all that apply.) a. Use thesmallest barrel syringe possible to reduce thepressure in thetube. b. Mix medication with feedings to thoroughly dilute themedication. c. Flush thetube liberally with water before, between, and after each medication instillation. d. Use thelargest barrel syringe possible to reduce thepressure in thetube.
e. Crush solid medications thoroughly and mix them in water before administration. ANS: C, D, E
Flushing thetube liberally with water before, between, and after each medication instillation will reduce therisk of clogging, as will crushing solid medications thoroughly and mixing them in water before administration. thelargest barrel, not thesmallest barrel, syringe exerts less pressure and reduces therisk of clogging. Mixing medications with formula is contraindicated because it increases therisk of clogging. DIF: CognitiveLevel: Application OBJ: List strategies to help prevent clogged feeding tubes. KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: NG Tube Clogging
COMPLETION
1. A tube passed through thenose or mouth with theend terminating in thestomach or thesmall bowel, and used in feeding thepatient for short periods is known as a . ANS:
nasogastric (NG) feeding tube NG feeding tube A nurse passes a nasogastric (NG) tube through thenose or mouth with theend terminating in thestomach or thesmall bowel for use in delivering supplemental nutrition or facilitating gastric decompression. DIF: CognitiveLevel: Knowledge TOP: Nasogastric Feeding Tube MSC: NCLEX: Physiological Integrity
OBJ: Assess thepatient who is to receive tube feedings. KEY: NursingProcess Step: Assessment
2. The nurse is caring for a patient in a chronic vegetative state with inadequate gastric emptying. thenurse would anticipate finding in a tube placed to assist with this patient‘s nutritional needs. ANS:
jejunostomy A jejunostomy tube would be appropriate for this patient. A nasally inserted tube would be inappropriate for long-term use; this fact rules out nasogastric and nasoenteric tubes. A tube placed into thestomach would be inappropriate for a patient with inadequate gastric emptying; this fact rules out gastrostomy and nasogastric tubes. DIF: CognitiveLevel: Analysis OBJ: Compare and contrast use of thenasogastric tube, nasoenteric tube, gastrostomy tube, and jejunostomy tube for nutritional support. TOP: Types of Access Devices KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
Chapter 33: Parenteral Nutrition Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. A 72-year-old patient is admitted to thehospital with a medical diagnosis of intestinal failure. Which intervention should thenurse include in theplan of care to deliver nutritional needs? a. Enteral nutrition (EN) b. Parenteral nutrition (PN) c. A combination of enteral and parenteral nutrition d. Oral nutrition ANS: B Parenteral nutrition (PN) is a specialized form of nutritional support that is given intravenously by an infusion pump to patients who have significant gastrointestinal (GI) dysfunction If thepatient was healthy before a critical illness, with no evidence of protein calorie malnutrition, use of PN should be reserved and initiated only after thefirst 7 to 10 days of hospitalization, when enteral nutrition is not available. DIF: CognitiveLevel: Analysis OBJ: Identify patients who are candidates for parenteral nutrition. TOP: Parenteral Nutrition KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. The patient has been ordered to receive parenteral nutrition (PN) but will require thenutritional therapy to continue for several months. Which route is most important for thenurse to consider? a. Second intravenous line b. Enteral feeding tube c. Central venous access device (CVAD) d. Parenteral feeding tube ANS: C The type of catheter to use for administration of PN depends on patient factors and theexpected length of PN therapy. thelocation of thecatheter is defined on thebasis of where thedistal tip of thecatheter lies. Concentrated PN solutions are diluted quickly when infused into a large-diameter central vein. Patients who self-administer their PN solutions at home will require a central catheter, which may be an implanted subcutaneous port, a peripherally inserted central catheter (PICC) or a tunneled central access device. DIF: CognitiveLevel: Analysis OBJ: Describe factors influencing theselection of appropriate sites for administering parenteral nutrition. TOP: Central Lines KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
3. The nurse is caring for a patient who is receiving PN. As part of therapy, thepatient undergoes routine bedside glucose monitoring that reveals which expected outcome? a. Lower than normal blood glucose to determine adequate tolerance for PN b. Slightly higher than normal blood glucose to meet increased cellular needs c. Slightly higher than normal blood glucose to prevent infection or systemic sepsis d. Normal blood glucose to prevent associated complications ANS: D Because hyperglycemia has been linked to increased infection rates, monitoring blood glucose levels during a PN infusion is an important procedure.
Maintain blood glucose in range ordered by health care provider. Glucose levels differ based on thedegree of illness so a specific health care provider order is needed. DIF: CognitiveLevel: Analysis TOP: Blood Sugar Control MSC: NCLEX: Physiological Integrity
OBJ: Discuss risks associated with parenteral nutrition. KEY: NursingProcess Step: Evaluation
4. A patient had surgery 1 week ago, has not been eating his meals, and states that he has no appetite. thenurse assesses that thepatient has been progressively losing weight. Which intervention has thehighest priority? a. Encourage thepatient to eat. b. Force-feed thepatient. c. Consult with thenutritional support team. d. Be aware that thepatient will come around when hungry. ANS: C Assess indications of and risks for protein/calorie malnutrition: weight loss from baseline or ideal, muscle atrophy/weakness, edema, lethargy, failure to wean from ventilatory support, chronic illness, and nothing by mouth for more than 7 days. Confer with nutritional support team.
The first sign of a developing problem is a pattern of a decline in oral food intake and reduced appetite. Assessment provides information for consulting with thenutritional support team and thephysician in an effort to initiate appropriate PN. Force-feeding thepatient may only lead to worse issues, especially if thepatient has a nonfunctioning intestinal system. DIF: CognitiveLevel: Analysis OBJ: Identify patients who are candidates for parenteral nutrition. TOP: Nutritional Support Team KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
5. During intravenous (IV) administration of fat (lipid) emulsions, thepatient voices complaints. Which complaint indicates to thenurse that thepatient is experiencing a complication associated with theadministration? a. Fever, chills, and malaise b. Low temperature, chills, and headache c. Fever, flushing, and muscle relaxation d. Low temperature, muscle aches, and dyspnea ANS: A
Patient develops fever, malaise, and chills, indicating systemic infection. DIF: CognitiveLevel: Analysis OBJ: Identify complications r/t intolerance to fat emulsion. KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Lipid Infusion
6. Which assessment should a nurse expect to see for a patient receiving parenteral nutrition (PN)? a. Weight gain of 1 to 3 pounds per week b. Serum calcium level of 10 mEq/L c. Serum potassium level of 2.8 mEq/L d. Serum glucose level of more than 200 mg/100 mL
ANS: A
Patient‘s ideal weight gain is between 1 and 3 lbs (0.5 to 1.5 kg) per week. Serum electrolytes are out of normal range. This may indicate movement of electrolytes in response to infusion of fluids and glucose. theelectrolyte levels in thesolution may need to be adjusted. Serum glucose levels should be less than 200 mg/100 mL. DIF: CognitiveLevel: Analysis OBJ: Demonstrate appropriate nursing care for thepatient receiving parenteral nutrition. TOP: Weight Gain KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
7. A patient receiving parenteral nutrition (PN) has gained 4 pounds over a 24-hour period. Given this weight gain, which interpretation by thenurse is most accurate? a. Increased nutrition from thepatient‘s parenteral infusions b. Decreased linoleic acid intake c. Increased fluid loss d. Fluid retention ANS: D Weight is indicator of patient‘s nutritional status and determines fluid volume. Weight gain greater than 1 lb (0.5 kg)/day indicates fluid retention. Weight gain in excess of 1 lb (0.5 kg)/day, dependent edema, lung crackles, and intake greater than output per each 24-hour period indicate fluid retention.
A nutritional regimen without adequate fatty acids leads to essential fatty acid deficiency (EFAD), characterized by dry, scaly skin, sparse hair growth, impaired wound healing, decreased resistance to stress, increased susceptibility to respiratory tract infection, anemia, thrombocytopenia, and liver function abnormalities. DIF: CognitiveLevel: Analysis OBJ: Demonstrate appropriate nursing care for thepatient receiving parenteral nutrition. TOP: Fluid Retention KEY: NursingProcess Step: Evaluation MSC: NCLEX: Physiological Integrity
8. To detect a common untoward effect of interrupting a parenteral nutrition (PN) infusion, thenurse should assess thepatient for development of which symptom? a. Fever b. Chest pain c. Erythema and induration d. Shaking and dizziness ANS: D
Symptoms of hypoglycemia include patient feeling shaky, dizzy, nervous, anxious, hungry, blood glucose level <80 mg/100 dL. Fever could be caused by systemic infection. Chest pain could be caused by air embolism. Localized infection can occur at theexit site or tunnel. DIF: CognitiveLevel: Application OBJ: Demonstrate appropriate nursing care for thepatient receiving parenteral nutrition. TOP: Complications of Parenteral Nutrition
KEY: NursingProcess Step: Evaluation
MSC: NCLEX: Physiological Integrity
9. The nurse is managing thecare of a patient receiving parenteral nutrition (PN). Which assessment finding indicates potential systemic infection? a. Shakiness and dizziness b. Chest pain/hypotension c. Increased thirst d. Increased temperature ANS: D Signs of systemic infection. Monitor for temperature, elevated white blood cell count, and malaise.
Know thepatient‘s recent temperature range. Patients with peripheral or central intravenous (IV) lines are susceptible to septicemia; elevated temperature can be an early indicator of a bacterial process. Hypoglycemia causes thepatient to be shaky, dizzy, nervous, and anxious; thepatient senses hunger and has a blood sugar level less than 80 mg/100 mL. Air embolism results in sudden respiratory distress, shortness of breath, coughing, chest pain, and decreased blood pressure. Hyperglycemia leads to excessive thirst. DIF: CognitiveLevel: Analysis OBJ: Demonstrate appropriate nursing care and use of safety precautions when caring for a patient receiving PN. TOP: Complications of Parenteral Nutrition KEY: NursingProcess Step: Evaluation MSC: NCLEX: Physiological Integrity
10. The nurse has been caring for a patient who has had a central venous access device (CVAD) in place. thepatient complains of sudden chest pain and difficulty breathing. These assessment findings are symptoms of which severe complication? a. Exit site infection b. Catheter-related sepsis c. Pneumothorax d. Hyperglycemia ANS: C
Symptoms of pneumothorax include sudden chest pain, difficulty breathing, decreased breath sounds, cessation of normal chest movement on theaffected side, and tachycardia. Symptoms of exit site infection include erythema, tenderness, induration, or purulence within 2 cm of theskin at theexit site. Symptoms of catheter-related sepsis include isolation of thesame microorganism from a blood culture and catheter segment, with thepatient showing fever, chills, malaise, and elevated white blood cell count. Symptoms of hyperglycemia include excessive thirst, urination, blood glucose greater than 160 mg/100 mL, and confusion. DIF: CognitiveLevel: Application OBJ: Discuss risks associated with parenteral nutrition. TOP: Complications of Central Parenteral Nutrition KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
11. The nurse is caring for a patient receiving parenteral nutrition (PN). In planning thepatient‘s care for theday, which nursing assessment is most essential? a. Electrolyte levels b. Weight c. Temperature
d. Condition of catheter insertion site ANS: A Patients who require PN infusions usually have medical or surgical conditions that are often associated with GI fluid losses (e.g., obstruction, diarrhea, fistula) and organ dysfunction; therefore, electrolyte monitoring is paramount. Thus, a routine laboratory panel relative to PN infusions would include a baseline assessment of electrolytes, serum proteins, complete blood count, triglyceride level, and liver function tests. DIF: CognitiveLevel: Application TOP: Assessment/Planning MSC: NCLEX: Physiological Integrity
OBJ: Discuss risks associated with parenteral nutrition. KEY: NursingProcess Step: Implementation
MULTIPLE RESPONSE
1. The nurse is caring for a patient who is receiving parenteral nutrition (PN). thenurse realizes that PN is associated with which of thefollowing risks? (Select all that apply.) a. Decreased mortality b. Bloodstream infection c. Pneumothorax d. Decreased length of stay e. Liver disease ANS: B, C, E
PN creates risks. It has been associated with catheter-related bloodstream infection, noninfective complications such as pneumothorax, increased hospital length of stay, and liver disease. Thus, a routine laboratory panel relative to PN infusions would include a baseline assessment of electrolytes, serum proteins, complete blood count, triglyceride level, and liver function tests. DIF: CognitiveLevel: Comprehension TOP: Parenteral Nutrition Complications KEY: NursingProcess Step: Assessment
OBJ: Discuss risks associated with parenteral nutrition. MSC: NCLEX: Physiological Integrity
2. The patient will be discharged to home on parenteral nutrition (PN). thepatient and his family education will need to perform which of thefollowing care steps? (Select all that apply.) a. Monitor thepatient‘s weight. b. Monitor thepatient‘s serum glucose levels. c. Measure thepatient‘s intake and output. d. Perform catheter care. e. Limit thepatient‘s activity. ANS: A, B, C, D Teach patient and family caregiver to monitor patient's temperature, weight, I&O, and serum glucose level and recognize signs and symptoms of PN-related complications. Patients receiving home CPN may have a peripherally inserted central catheter (PICC) line or a tunneled or implanted catheter to reduce thepossibility of infection. Patients or family caregivers need to learn to perform catheter site care, dressing changes, techniques for connecting and disconnecting PN solutions, and infusion pump management. DIF: CognitiveLevel: Comprehension TOP: Quality of Life KEY:
OBJ: Discuss risks associated with parenteral nutrition. NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity COMPLETION 1. If parenteral nutrition (PN) must be discontinued suddenly, hang
in water at
thesame infusion rate to prevent hypoglycemia. ANS: 10% dextrose
Call health care provider; if PN discontinued abruptly, may need to restart D10W at previous PN rate. If patient has oral intake, give cup fruit juice. Perform blood glucose monitoring; retest in 15 to 30 min. DIF: CognitiveLevel: Knowledge OBJ: Identify measures used to prevent complications of central parenteral nutrition. TOP: Lipids KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
Chapter 34: Urinary Elimination Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition MULTIPLE CHOICE
1. The nurse is assessing a patient whose 24-hour output is 2400 mL. Which finding reflects thenurse‘s understanding of urine output? a. Increased output b. Decreased output c. Normal output d. Balanced output ANS: C
The average output range for adult urinary output averages between 2200 and 2700 mL in 24 hours. DIF: CognitiveLevel: Comprehension TOP: Normal Urinary Output MSC: NCLEX: Physiological Integrity
OBJ: Identify factors that alter normal voiding. KEY: NursingProcess Step: Evaluation
2. On thebasis of thenurse‘s assessment of kidney function for an adult patient, which finding is normal? a. 10 mL/hr b. 20 mL/hr c. 30 mL/hr d. 100 mL/hr ANS: C
Minimum average hourly output is 30 mL. DIF: CognitiveLevel: Knowledge
OBJ: Identify factors that alter normal voiding.
TOP: Normal Urinary Output MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Evaluation
3. Which activities related to urinary elimination may be delegated to a nursing assistive personnel (NAP)? a. Catheterization b. Positioning thepatient c. Evaluating alternatives to catheter use d. Assessing urinary drainage ANS: B
Nursing assistive personnel (NAP) may position thepatient, focus lighting for theprocedure. thenurse uses sterile asepsis when inserting an indwelling or straight catheter to reduce therisk for bladder infection. thenurse evaluates possible alternatives to catheter use, and assessment is theresponsibility of thenurse. DIF: CognitiveLevel: Application OBJ: Describe devices used to promote urinary elimination. TOP: Delegation Considerations for Inserting a Urinary Catheter KEY: NursingProcess Step: Intervention MSC: NCLEX: Physiological Integrity
4. The nurse is planning care for a 12-year-old female patient who needs a Foley catheter inserted. It is most important for thenurse to use a catheter of which size French (Fr)? a. 5 to 6 Fr b. 8 to 10 Fr c. 12 Fr d. 14 to 16 Fr ANS: C
Gender and age determine catheter size. A 12-Fr catheter may be considered for use in young girls. theprescriber may order a larger size. 14 to 16 Fr is indicated for adult women. DIF: CognitiveLevel: Analysis OBJ: Perform thefollowing skills: insert a urinary catheter, and provide care for an indwelling urinary catheter. TOP: Size of Urinary Catheter KEY: NursingProcess Step: Intervention MSC: NCLEX: Physiological Integrity
5. The nurse notes that urine does not flow after a female patient is catheterized. thenurse believes that thecatheter has been placed into thevagina. Which action should thenurse take? a. Remove thecatheter and reinsert it. b. Irrigate thecatheter with saline. c. Leave thecatheter in place and insert another one. d. Insert thecatheter 9 to 10 inches farther into thepatient to verify that it is in thevagina. ANS: C
If no urine appears, check whether thecatheter is in thevagina. If misplaced, leave thecatheter in thevagina and insert another catheter into themeatus. Reinserting a catheter that has already been contaminated by vaginal exposure could lead to urinary tract infection. DIF: CognitiveLevel: Application OBJ: Perform thefollowing skills: place and remove a urinal, insert a urinary catheter, and provide
care for an indwelling urinary catheter. KEY: NursingProcess Step: Intervention
TOP: Inserting Catheter into a Female Patient MSC: NCLEX: Physiological Integrity
6. When theballoon on an indwelling urinary catheter is inflated and thepatient expresses discomfort, it is essential for thenurse to take which action? a. Remove thecatheter. b. Continue to blow up theballoon because discomfort is expected. c. Aspirate thefluid from theballoon and advance thecatheter. d. Pull back on thecatheter slightly to determine tension. ANS: C
If resistance to inflation is noted, or if thepatient complains of pain, theballoon may not be entirely within thebladder. Stop inflation, aspirate any fluid injected into theballoon, and advance thecatheter a little farther before attempting again to inflate. DIF: CognitiveLevel: Application OBJ: Perform thefollowing skills: place and remove a urinal, insert a urinary catheter, and provide care for an indwelling urinary catheter. TOP: Inflating theBalloon KEY: NursingProcess Step: Intervention MSC: NCLEX: Physiological Integrity
7. The nurse is caring for a patient who has an indwelling urinary catheter. Which intervention is most important to include in this patient‘s plan of care? a. Maintaining tension on thetubing b. Emptying theurinary collection bag every 24 hours c. Cleaning in a circular motion from themeatus down thecatheter d. Keeping thedrainage bag on thebed or attached to theside rails ANS: C
Using a clean washcloth, wipe in a circular motion along thelength of thecatheter for about 10 cm (4 inches). Allow slack in thecatheter so movement does not create tension on it. Empty thedrainage bag, and record amounts. thedrainage bag must be below thelevel of thebladder; do not place thebag on theside rails of thebed. DIF: CognitiveLevel: Application OBJ: Perform thefollowing skills: place and remove a urinal, insert a urinary catheter, and provide care for an indwelling urinary catheter. TOP: Catheter Care KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
8. The nurse has been ordered to perform closed intermittent irrigation of a patient‘s indwelling urinary catheter. Which intervention is indicative of safe practice? a. Applies sterile gloves. b. Instills 100 mL of irrigant. c. Leaves thedrainage tubing unclamped irrigation. d. Determines theamount of urinary drainage by subtracting theamount of irrigant from thetotal output. ANS: D
Calculate thefluid used to irrigate thebladder and catheter, and subtract from thevolume drained to determine accurate urinary output. Closed intermittent irrigation does not require theuse of sterile gloves. thetypical amount of irrigant used is 30 to 50 mL and thetubing is clamped during theprocess.
DIF: CognitiveLevel: Application TOP: Catheter Irrigation MSC: NCLEX: Physiological Integrity
OBJ: Perform thefollowing skill: irrigate a catheter. KEY: NursingProcess Step: Evaluation
9. When evaluating thehealth care team member‘s ability to apply a condom catheter, it is most important for thenurse to provide further instruction for which intervention? a. Clipping of hair at thebase of thepenis b. Applying skin preparation to thepenis before catheter placement c. Using regular adhesive tape to hold thecatheter in place d. Leaving 1 to 2 inches of space between thetip of thepenis and theend of thecatheter ANS: C
Use of an adhesive strip not designed for sheath application may be inflexible and may impede circulation to thepenis. Clip hair at thebase of thepenis. Hair adheres to thecondom and is pulled during condom removal or may get caught in rubber as thecondom catheter is applied. Apply skin preparation to thepenis and allow it to dry. Leave 1 to 2 inches of space between thetip of theglans penis and theend of thecondom. DIF: CognitiveLevel: Application OBJ: Perform thefollowing skills: apply a condom catheter. TOP: Condom Catheter KEY: NursingProcess Step: Evaluation MSC: NCLEX: Physiological Integrity
10. When providing care for a patient with a suprapubic catheter who has acquired a urinary tract infection (UTI), which intervention is most important for thenurse to implement? a. Using clean technique b. Securing thetube to theinner thigh c. Cleansing theinsertion site in a direction toward thedrain d. Promoting intake of 2200 mL of fluid per day ANS: D
Encourage thepatient with a UTI to drink at least 2200 mL of fluid per day. theinsertion site is cleansed in a circular swabbing pattern so as not to disturb thetubing. Standard care requires theuse of clean gloves and securing thecatheter to theabdomen. DIF: CognitiveLevel: Application OBJ: Perform thefollowing skills: care for a patient with a suprapubic catheter. TOP: Suprapubic Catheterization KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
11. When providing care for a patient in need of an indwelling catheter, thenurse understands that which of thefollowing is an indication for this need? a. Presence of stage III and IV pressure ulcers b. Presence of a yeast infection c. Need for an accurate measurement of urinary output d. Need to manage urinary elimination ANS: C
An indication for an indwelling catheter includes theneed for accurate measurement of urinary output in critically ill patients. theincidence of catheter-associated UTI significantly decreases when thenurse gives theprescriber daily reminders to remove unnecessary catheters and suggests theuse of alternative noninvasive treatments to manage urinary elimination.
DIF: CognitiveLevel: Comprehension OBJ: Describe devices used to promote urinary elimination. TOP: Foley Catheter KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
12. The nurse receives an order to insert a Foley catheter. In obtaining a catheter of theright size, thenurse is aware that large catheters can lead to which complication? a. Urethral damage b. Bladder relaxation c. Obstruction of urinary flow d. Decreased risk for infection ANS: A
Large catheters (larger than 16 Fr) can distend theurethra and permanently damage theurethra and bladder neck, as well as cause bladder spasms and leaking around thecatheter. Use a catheter of thesmallest size possible to minimize trauma and promote adequate drainage of theperiurethral glands. This will decrease therisk for infection. DIF: CognitiveLevel: Analysis OBJ: Perform thefollowing skills: place and remove a urinal, insert a urinary catheter, and provide care for an indwelling urinary catheter. TOP: Size of Urinary Catheter KEY: NursingProcess Step: Intervention MSC: NCLEX: Physiological Integrity
13. The nurse is caring for a patient who has an indwelling catheter attached to a drainage bag. To achieve thedesired outcome of this procedure, which nursing action should be taken? a. Make sure thetubing has dependent loops to gather urine. b. Make sure thetubing is coiled and secured to thebed. c. Make sure thetubing is kinked. d. Make sure thecollection bag is higher than thebladder. ANS: B
Check thedrainage tubing and thebag to make sure that thetubing does not have dependent loops and thebag is not positioned above thelevel of thebladder. Check to make sure that thetubing is coiled and is secured to thebed linen, is free of kinks, and is not clamped, and that thepatient is not lying on it. DIF: CognitiveLevel: Application OBJ: Perform thefollowing skills: place and remove a urinal, insert a urinary catheter, and provide care for an indwelling urinary catheter. TOP: Catheter Care KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
14. The nurse is caring for a patient who is experiencing inadequate bladder emptying. To determine postvoid residual, which technique is most important for thenurse to implement? a. Bladder scanner b. Indwelling catheterization c. Straight/intermittent catheterization d. Foley catheterization ANS: A
The bladder scan is most commonly used to measure postvoid residual (PVR); it is theleast invasive method of making this determination.
DIF: CognitiveLevel: Analysis OBJ: Perform thefollowing skills: obtain a residual urine. KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Residual Urine
15. The nurse is preparing thepatient for a bladder scan to determine postvoid residual (PVR). Which of thefollowing is part of thepreparation? a. Limit food intake for 2 hours before thescan. b. Begin scan 10 minutes after thepatient has voided. c. Limit liquid intake for 30 minutes before thescan. d. Administer an analgesic 30 minutes before thescan. ANS: B
The nurse will assist thepatient to void, then wait 10 minutes before administering thebladder scan. There is no need to limit either food or fluids before thetest. Since thetest is completely noninvasive, there is no need to administer an analgesic beforehand. DIF: CognitiveLevel: Knowledge TOP: Residual Urine MSC: NCLEX: Physiological Integrity
OBJ: Perform thefollowing skills: determine PVR. KEY: NursingProcess Step: Implementation
MULTIPLE RESPONSE
1. In assisting a male patient in using a urinal, which of thefollowing actions should thenurse take? (Select all that apply.) a. Assess for orthostatic hypotension. b. Assess thepatient‘s normal elimination habits. c. Assess for periods of incontinence. d. Prop theurinal in place if thepatient is unable to hold it. e. Always stay with thepatient during urinal use. ANS: A, B, C
To assist thepatient in using a urinal, thenurse should assess thepatient‘s normal urinary elimination habits and look for periods of incontinence. Always determine mobility status before having a patient stand to void, and assess for orthostatic hypotension if thepatient has been on prolonged bed rest. If thepatient is able to handle theurinal himself, allow him privacy. If thepatient is unable to handle theurinal, thenurse will assist by holding it. DIF: CognitiveLevel: Knowledge OBJ: Perform thefollowing skills: place and remove a urinal. TOP: Assisting theMale Patient in Using a Urinal KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
2. The nurse has inserted an indwelling catheter and secured thecatheter to thepatient‘s thigh, making sure that there is enough slack that movement will not create tension on thecatheter. thenurse understands that thechief purpose of properly securing Foley catheters is to obtain which outcome? (Select all that apply.) a. Minimized risk for bleeding b. Reduced risk for bladder spasm
c. Reduced risk for meatal necrosis d. Reduced risk for trauma e. Increased bladder relaxation ANS: A, B, C, D
Securing thecatheter will minimize accidental dislodgment. It also will minimize risks for bleeding, trauma, meatal necrosis, and bladder spasms from pressure and traction. DIF: CognitiveLevel: Analysis OBJ: Perform thefollowing skills: place and remove a urinal, insert a urinary catheter, and provide care for an indwelling urinary catheter. TOP: Securing theCatheter KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION
1. Antimicrobial catheters coated with silver or antibiotics have been shown to reduce theincidence of . ANS:
catheter-associated urinary tract infection (CAUTI) Antimicrobial catheters have been effective in reducing incidences of CAUTI in short-term catheter use. DIF: CognitiveLevel: Knowledge OBJ: Identify factors that increase risk for urinary infection. TOP: Urinary Tract Infection KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. The risk for catheter-associated urinary tract infection can be reduced by using when inserting thecatheter. ANS:
aseptic technique Numerous studies have confirmed theeffect of theuse of aseptic technique in theinsertion of urinary catheters in reducing therate of catheter-associated infections. DIF: CognitiveLevel: Knowledge OBJ: Identify factors that decrease risk for urinary infection. TOP: Aseptic Technique During Catheter Insertion KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
3. A single-lumen catheter that is inserted into thebladder through theurethra only to empty thebladder and then is removed is known as a catheter. ANS:
straight or intermittent straight intermittent
A straight or intermittent catheter is a single-lumen catheter that is inserted into thebladder through theurethra only to empty thebladder, and then is removed. Use this type of catheter on a one-time basis, for example, to determine theamount of residual urine in thebladder, or intermittently, when thepatient cannot urinate because of a urinary obstruction or a neurological disorder such as spinal cord injury. DIF: CognitiveLevel: Knowledge OBJ: Describe devices used to promote urinary elimination. TOP: Straight or Intermittent Catheters KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
4. An has a separate lumen that is used to inflate a balloon so thecatheter remains in thebladder for short- or long-term use. ANS:
indwelling catheter An indwelling catheter has a separate lumen that is used to inflate a balloon so thecatheter remains in thebladder for short- or long-term use. DIF: CognitiveLevel: Knowledge OBJ: Describe devices used to promote urinary elimination. TOP: Indwelling Catheter KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
5.
is thevolume of urine in thebladder after a normal voiding. ANS:
Residual urine Residual urine, also referred to as postvoid residual (PVR), is thevolume of urine in thebladder after a normal voiding. DIF: CognitiveLevel: Knowledge OBJ: Perform thefollowing skills: obtain a residual urine. TOP: Residual Urine KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
6. A noninvasive device that is used to provide accurate determination of a patient‘s bladder volume by first creating an ultrasound image of thepatient‘s bladder and then calculating theurine volume in thebladder is known as a . ANS:
bladder scanner The bladder scanner is noninvasive, so there is no risk for nosocomial urinary tract infection (UTI) and possible trauma associated with urinary catheterization. It provides accurate determination of a patient‘s bladder volume by first creating an ultrasound image of thepatient‘s bladder and then calculating theurine volume in thebladder. DIF: CognitiveLevel: Knowledge OBJ: Perform thefollowing skills: obtain a residual urine, and measure a bladder scan. TOP: Bladder Scanner KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
7. A is a noninvasive alternative for management of male urinary incontinence. Because it is noninvasive, therisk for urinary tract infection (UTI) is decreased. thedevice fits over thepenis and connects to a small collection bag that attaches to theleg with a strap, or to a standard urinary collection bag that hangs on thebedframe below thelevel of thebladder. ANS:
condom catheter A condom catheter, also referred to as an external catheter or a penile sheath, is a noninvasive alternative for management of male urinary incontinence. Because it is noninvasive, therisk for UTI is decreased. thedevice is a soft, flexible, condom-like sheath that fits over thepenis and connects to a small collection bag that attaches to theleg with a strap, or to a standard urinary collection bag that hangs on thebedframe below thelevel of thebladder. DIF: CognitiveLevel: Knowledge OBJ: Perform thefollowing skills: apply a condom catheter. KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
8.
TOP: Condom Catheter
involves theinsertion of a urinary catheter directly into thebladder through thelower abdominal wall. Urine drains from thecatheter into a urinary drainage bag. ANS:
Suprapubic catheterization Suprapubic catheterization involves theinsertion of a urinary catheter directly into thebladder through thelower abdominal wall. Urine drains from thecatheter into a urinary drainage bag. Suprapubic catheters are inserted with local or general anesthetic for short- or long-term use. DIF: CognitiveLevel: Knowledge OBJ: Perform thefollowing skills: care for a patient with a suprapubic catheter. TOP: Suprapubic Catheterization KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
Chapter 35: Bowel Elimination and Gastric Intubation Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition MULTIPLE CHOICE
1. The nurse is caring for a patient who has been on bed rest for several weeks. thenurse notes that thepatient is continually seeping liquid stool rectally. thenurse should take which action? a. Hold thepatient‘s antibiotics. b. Put thepatient on a bran diet. c. Perform a digital rectal examination. d. Increase thedosage of thepatient‘s antibiotics. ANS: C
Symptoms of fecal impaction include constipation, rectal discomfort, anorexia, nausea, vomiting, abdominal pain, abdominal bloating, small liquid stools (leaking around theimpacted stool), and urinary frequency; once impaction occurs, digital removal of stool is theonly alternative. DIF: CognitiveLevel: Application OBJ: Discuss methods used to relieve constipation or impaction. TOP: Digital Rectal Examination KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. The patient is a 74-year-old man who has been in thehospital for 4 days following an orthopedic surgical procedure. He is concerned because he has not moved his bowels every day as he did before surgery, but every other day. Which response made by thenurse is appropriate? a. Advise thepatient to put himself on over-the-counter laxatives. b. Instruct thepatient that daily bowel movements are not always necessary. c. Educate thepatient that with increasing age, his bowel movements should increase in frequency. d. Inform thepatient that he will call to get a laxative to get him back on track. ANS: B
Reinforce with older-adult patients that as long as theconsistency of thestool remains normal, bowel movements occur with regularity. As long as he is able to move his bowels at least 3 times a week, he should not worry about not having a daily movement. Since there is no indication of constipation, thepatient should not place himself on laxatives. However, since thepatient is most likely less mobile and receiving strong pain medication following his orthopedic surgery (both likely to cause constipation), thenurse should monitor thesituation. DIF: CognitiveLevel: Application OBJ: Discuss methods used to relieve constipation or impaction. TOP: Gerontological Considerations KEY: NursingProcess Step: Intervention MSC: NCLEX: Physiological Integrity
3. The nurse assesses that a patient has a severe fecal impaction. Which action taken by thenurse addresses this problem? a. Administering laxatives b. Providing a high-fiber diet c. Performing a digital removal d. Administering an enema ANS: C
Prevention is thekey to fecal impaction. However, once it occurs, digital removal of stool is theonly alternative. Once theimpaction is cleared, a high-fiber diet, increased activity, and adequate hydration may all reduce thelikelihood of recurrence. DIF: CognitiveLevel: Application OBJ: Describe factors that promote and impede normal bowel elimination. TOP: Digital Removal of Fecal Impaction KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
4. The nurse prepares to exercise a digital removal of feces. To detect an untoward effect of this procedure, thenurse should assess thepatient history for which condition?
a. b. c. d.
Heart disease Abdominal pain Urinary infection Diabetes mellitus
ANS: A
When digital removal of impacted fecal material is ordered, obtain patient baseline vital signs and periodically monitor heart rate during theprocedure. Digital removal of fecal impaction stimulates thevagus nerve, which can cause a decrease in heart rate. DIF: CognitiveLevel: Analysis OBJ: Describe factors that promote and impede normal bowel elimination. TOP: Digital Removal of Fecal Impaction KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
5. The nurse is preparing to administer an enema to a patient. Which type of enema is most likely to lead to circulatory overload? a. Hypertonic solution b. Soapsuds c. Tap water d. Harris flush ANS: C
A tap-water (hypotonic) enema should not be repeated after first instillation because water toxicity or circulatory overload can develop. Hypertonic solution is useful for patients who cannot tolerate large volumes of fluid. A soapsuds enema (SSE) consists of pure castile soap added to tap water or normal saline, depending on thepatient‘s condition and thefrequency of administration. Use only castile pure soap. therecommended ratio of pure soap to solution is 5 mL (1 teaspoon) to 1000 mL (1 quart) warm water or saline. Add soap to theenema bag after water is in place to reduce excessive suds. theHarris flush enema is a return-flow enema that helps to expel intestinal gas. Fluid alternately flows into and out of thelarge intestine. This stimulates peristalsis in thelarge intestine and assists in expelling gas. DIF: CognitiveLevel: Analysis OBJ: Implement thefollowing skills: enema administration. TOP: Tap-water Enema KEY: NursingProcess Step: Evaluation MSC: NCLEX: Physiological Integrity
6. When preparing an infant for an enema, thenurse understands that which solution is thesafest? a. Tap-water enema solution b. Hypertonic enema solution c. Oil retention d. Physiological normal saline ANS: D
Physiological normal saline is thesafest solution. Infants and children can only tolerate this type of solution because of their predisposition to fluid imbalance. If solution is prepared at home, mix 500 mL (1 pt) of tap water with 1 teaspoon of table salt. Tap water, hypertonic, and oil retention enemas are not safe to use for infants and children. DIF: CognitiveLevel: Analysis OBJ: Implement thefollowing skills: enema administration. TOP: Saline Enema KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
7. The patient is being prepped for surgery and has an order for ―enemas until clear.‖ thenurse realizes that she will be giving a maximum of how many enemas? a. One b. Two c. Three d. Four ANS: C
The ―enemas until clear‖ order means that you repeat enemas until thepatient passes fluid that is clear of fecal matter. Check agency policy, but usually a patient should receive a maximum of three consecutive enemas to avoid disruption of fluid and electrolyte balance. If more are required, notify thephysician before administering. DIF: CognitiveLevel: Application OBJ: Implement thefollowing skills: enema administration. KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Enemas Until Clear
8. The nurse is preparing to administer an enema to an adult patient who has normal sphincter control. For administration of theenema, thepatient is placed in which position? a. Right side-lying b. Dorsal recumbent c. Sims‘ d. Prone ANS: C
Assist thepatient into left side-lying (Sims‘) position with theright knee flexed. Additionally, place a child in dorsal recumbent position. This allows enema solution to flow downward by gravity along thenatural curve of thesigmoid colon and rectum, thus improving retention of solution. DIF: CognitiveLevel: Application OBJ: Implement thefollowing skills: enema administration. KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Enema Process: Positioning
9. The nurse has been directed to provide an enema for an elderly female patient who has very poor rectal sphincter control. Which position is most appropriate for this patient? a. Sims‘ position b. Dorsal recumbent position on thebedpan c. Sitting on thetoilet d. Right lateral position ANS: B
If thepatient has poor sphincter control, position thepatient on thebedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control cannot retain all of theenema solution. Administering an enema with thepatient sitting on thetoilet is unsafe because curved rectal tubing can abrade therectal wall. DIF: CognitiveLevel: Application OBJ: Implement thefollowing skills: enema administration.
TOP: Dorsal Recumbent Position on theBedpan KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
10. When preparing an adult patient for an enema, thenurse understands that thetube or nozzle should be inserted how far? a. b. c. d.
1 to inches 2 to 3 inches 3 to 4 inches 4 to 5 inches
ANS: C
Insert thenozzle of thecontainer gently into theanal canal—for adults, 7.5 to 10 cm (3 to 4 inches). If administering to an infant, insert thetip of thetube 2.5 to 3.75 cm (1 to inches). If administering to a child, insert thetip of thetube 5 to 7.5 cm (2 to 3 inches). However, children and infants usually do not receive prepackaged hypertonic enemas because hypertonic solutions cause rapid fluid shift. Inserting thetip of thetube more than 4 inches is not appropriate at any age. DIF: CognitiveLevel: Application OBJ: Implement thefollowing skills: enema administration. KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Insertion of Tubing
11. While thenurse is administering an enema with a standard enema bag, which intervention is important to implement? a. Keeping thesolution at room temperature b. Positioning thepatient on theright side c. Raising theenema bag to 12 inches above thepatient d. Instructing thepatient to release theenema solution as soon as possible ANS: A
If thesolution is too hot it will burn theintestinal mucosa. Cold water can cause abdominal cramping. Solution dripped on inner wrist should be comfortable. Unless patient condition requires a different position, thepatient will lay on his/her left side with thetop leg flexed (left lateral Sims‘) and thebag of solution will be hung 18 inches above therectum. thepatient will be instructed to retain thesolution as long as possible for maximum therapeutic effect. DIF: CognitiveLevel: Application OBJ: Implement thefollowing skills: enema administration. KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Temperature of Solution
12. While thenurse is administering an enema, thepatient complains of some cramping. Which action should thenurse take next? a. Discontinue theprocedure completely. b. Increase theheight of thesolution. c. Slow therate of infusion. d. Have thepatient roll into a supine position. ANS: C
Temporary cessation of infusion minimizes cramping and promotes ability to retain solution. Lower container or clamp tubing if patient complains of cramping or if fluid escapes around rectal tube. DIF: CognitiveLevel: Application OBJ: Implement thefollowing skills: enema administration. KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Abdominal Cramping
13. When providing care for a patient who is disoriented during a nasogastric (NG) tube placement, which intervention is important for thenurse to implement? a. Halt theprocedure. b. Request assistance with insertion. c. Administer a hypnotic medication. d. Continue theprocedure as with any other patient. ANS: B
If thepatient is confused, disoriented, or unable to follow commands, obtain assistance from another staff member to insert thetube. DIF: CognitiveLevel: Application OBJ: Implement thefollowing skills: insertion of an NG tube. KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Disoriented Patient
14. When developing a plan of care for a patient requiring a nasogastric (NG) tube, thenurse recognizes that it is essential to implement which technique in measuring thelength of thetube? a. Measure from thenose to theear to thepatient‘s navel. b. Measure from thenose to themiddle of thesternum. c. Measure and mark a point 30 inches from theend. d. Measure distance from xyphoid process to earlobe to nose (XEN) + 10 cm. ANS: D
Measure distance from xyphoid process to earlobe to nose (XEN) + 10 cm. Shown to be more accurate than NEX. Tip of NG tube must reach stomach to avoid therisk for pulmonary aspiration, which occurs when tubes terminate in theesophagus. DIF: CognitiveLevel: Application OBJ: Implement thefollowing skills: insertion of an NG tube. TOP: Measuring Tube for Placement KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
15. In advancing thenasogastric (NG) tube, which technique provides thesafest outcome? a. Rotate thetube 180 degrees while inserting b. Advance thetube in between swallows. c. Start with thepatient‘s head flexed. d. Check thetube placement by instilling air and auscultating over thestomach. ANS: A
Rotate tube gently 180 degrees while inserting.
Do not force NG tube. If patient starts to cough or has a drop in O2 saturation or an increased CO2, withdraw tube into theposterior nasopharynx until normal breathing resumes. Advance tube each time patient swallows until you reach desired length. Do not advance tube during inspiration or coughing because it will likely enter respiratory tract. Have patient relax and flex head toward chest after tube is passed through nasopharynx. Verify tube placement. Check agency policy for preferred methods. DIF: CognitiveLevel: Application OBJ: Implement thefollowing skills: insertion of an NG tube. KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Insertion of NG Tube
16. When care is provided for a patient with an NG tube in place, which intervention is safest for thenurse to implement? a. Tape thetube up and around theear on theside of insertion. b. Secure thetubing to thebed by thepatient‘s head. c. Mark thetube where it exits thenose. d. Change thetubing daily. ANS: C
Once placement is confirmed, a red mark should be made or place tape on thetube to indicate where thetube exits thenose. themark or thetube length is to be used as a guide to indicate whether displacement may have occurred. thetube should be taped to thenose, not to theear. thetubing should be secured to thepatient‘s gown, not to thebed, and should not be changed daily, but it may be irrigated daily. DIF: CognitiveLevel: Application OBJ: Implement thefollowing skills: insertion of an NG tube. TOP: Marking NG Tube Placement KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE
1. A patient is admitted for constipation. When planning care for this patient, thenurse recognizes that which interventions would help control constipation? (Select all that apply.) a. Increases in activity level b. Elimination of laxative use c. Decreased dietary fiber d. Increased fluids e. Timely response to urge to move bowels ANS: A, B, D, E
Changes in lifestyle that will be helpful to eliminate constipation cycles include increased dietary fiber, increased fluids, moderate exercise, and elimination of laxative use. It is also important to encourage patients to respond to theurge to move bowels when theurge first occurs, since delay may promote constipation. DIF: CognitiveLevel: Analysis OBJ: Describe factors that promote and impede normal bowel elimination. TOP: Interventions to Control Constipation
KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
2. The patient is receiving a soapsuds enema but is having a difficult time retaining thefluid. What action should thenurse take? (Select all that apply.) a. Give theenema slowly. b. Place thepatient in thedorsal recumbent position on a bedpan. c. Give theenema with thepatient on thetoilet. d. Give theenema in theright lateral position. e. Give theenema faster. ANS: A, B
Give theenema slowly to aid absorption. If thepatient is full of stool, retention is difficult. As stool is evacuated, there is more room in thecolon for additional fluid. If thepatient has poor sphincter control, position thepatient on thebedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control cannot retain all of theenema solution. Administering an enema with thepatient sitting on a toilet is unsafe because curved rectal tubing can abrade therectal wall. Enemas are not given to patients in theright lateral position. DIF: CognitiveLevel: Application OBJ: Implement thefollowing skills: enema administration. TOP: Inability to Retain Enema Fluid KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
3. The Levin tube and theSalem sump tube are used most commonly for stomach decompression. Which of thefollowing statements about these tubes is true? (Select all that apply.) a. Levin tubes have a blue ―pigtail‖ that functions as an air vent. b. These tubes are inserted as a sterile procedure. c. The blue air vent should not be used for irrigation. d. The Salem sump tube has a blue ―pigtail‖ that functions as an air vent. e. The Salem sump is preferred for stomach decompression. ANS: C, D, E
The Levin tube is a single-lumen tube with holes near thetip. You connect thetube to a drainage bag or to an intermittent suction device to drain stomach secretions. theSalem sump tube has two lumina: one for removal of gastric contents and one to provide an air vent, which prevents suctioning of gastric mucosa into eyelets at thedistal tip of thetube. A blue ―pigtail‖ is theair vent that connects with thesecond lumen. Never clamp off theair vent, connect it to suction, or use it for irrigation. NG tube insertion does not require sterile technique. Clean technique is adequate. theSalem sump is preferred for gastric decompression. DIF: CognitiveLevel: Comprehension OBJ: Implement thefollowing skills: insertion of an NG tube. KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Nasogastric (NG) Tube
4. What should thenurse do to verify nasogastric (NG) tube placement? (Select all that apply.) a. Ask thepatient to speak. b. Inspect theposterior pharynx. c. Aspirate back on thesyringe.
d. Obtain an x-ray of theplacement. e. Auscultate thelung fields. ANS: B, C, D
While a radiographic examination is thegold standard to verify NG tube placement, there are several steps thenurse can take to gauge correct placement. Inspect theposterior pharynx for thepresence of a coiled tube. thetube is pliable and will coil up behind thepharynx instead of advancing into theesophagus. Aspirate gently back on thesyringe to obtain gastric contents, observing color. Gastric contents are usually cloudy and green but sometimes are off-white, tan, bloody, or brown. Aspiration of contents provides themeans to measure fluid pH and thus determine tube tip placement in theGI tract. DIF: CognitiveLevel: Application OBJ: Implement thefollowing skills: insertion of an NG tube. TOP: Verifying Position of NG Tube KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION
1. Infrequent bowel movements (less often than every 3 days), difficulty in evacuating feces, inability to defecate, and hard feces are signs of . ANS:
constipation Constipation is a functional GI symptom and not a disease. It is defined as infrequent or less than 3 bowel movements per week of hard lumpy stool. DIF: CognitiveLevel: Knowledge OBJ: Describe factors that promote and impede normal bowel elimination. TOP: Constipation KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. A bedpan that is designed for patients with body or leg casts or for patients restricted from raising their hips (e.g., following total joint replacement) is known as a . ANS:
fracture pan A fracture pan, designed for patients with body or leg casts or for those restricted from raising their hips (e.g., following total joint replacement), has a shallow end approximately 1.3 cm ( inch) deep that slips easily under a patient. theopen end of theregular pan fits just under theupper thighs, and theback of thepan fits under thepatient‘s buttocks toward thesacrum. For thefracture pan, thehandle is just under thethighs, and thesmaller portion is toward thebuttocks. DIF: CognitiveLevel: Knowledge OBJ: Implement thefollowing skills: assisting thepatient in using a bedpan. TOP: Fracture Pan KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
3.
is defined by a number of signs including infrequent bowel movements, difficulty evacuating, hard stools, and inability to defecate. ANS:
Constipation Functional constipation includes a group of disorders associated with persistent, difficult, infrequent, or seemingly incomplete defecation without evidence of a structural or biochemical explanation (Sood, 2020). DIF: CognitiveLevel: Knowledge OBJ: Describe factors that promote and impede normal bowel elimination. TOP: Obstipation KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
4. The inability to pass a hard collection of stool is known as
_.
ANS:
fecal impaction Fecal impaction, theinability to pass a hard collection of stool, occurs in all age groups. DIF: CognitiveLevel: Knowledge OBJ: Describe factors that promote and impede normal bowel elimination. TOP: Fecal Impaction KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
5. An is theinstillation of a solution into therectum and sigmoid colon to promote defecation by stimulating peristalsis. ANS:
enema An enema is theinstillation of a solution into therectum and sigmoid colon. Enemas promote defecation by stimulating peristalsis. DIF: CognitiveLevel: Knowledge OBJ: Describe precautions that should be followed in administering an enema. TOP: Enema KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
Chapter 36: Ostomy Care Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition MULTIPLE CHOICE
1. The nurse is caring for a patient with an ostomy. thenurse notes that theostomy is putting out watery effluent. thenurse recognizes that this is indicative of which location? a. Descending colon b. Sigmoid colon c. Ileal portion of thesmall-intestine
d. Transverse colon ANS: C
An opening in theileal portion of thesmall-intestine is an ileostomy, and thefecal effluent will be watery to thick liquid that will contain some digestive enzymes. A colostomy in thedescending or sigmoid colon generally results in a stool similar to that normally passed through therectum. If theopening is in thetransverse or ascending colon, theeffluent will vary from thick liquid to semi-formed stool. DIF: CognitiveLevel: Analysis OBJ: Explain differences in thecolor and consistency of effluent based on thetype of ostomy. TOP: Position of theOstomy KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse is caring for a patient who had a colostomy placed 5 days earlier. thenurse notes that thestoma is red and moist. Which action should thenurse take? a. Notify thephysician immediately. b. Apply pressure. c. Document thecondition of thestoma. d. Change theappliance pouch. ANS: C
The stoma should be red or pink and moist. After assessment thenurse will note theappearance of thestoma in thepatient HER. If it is gray, purple, or black, report this to thecharge nurse or physician immediately. Pressure is applied to control active bleeding. theinformation given in thequestion does not indicate that there is a need to change theappliance at this time. DIF: CognitiveLevel: Application OBJ: Describe methods used to maintain theintegrity of theperistomal skin. TOP: Condition of Ostomy KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
3. In caring for a patient who had a fecal surgical diversion, which nursing intervention is essential? a. Place a pouch over thenewly created stoma. b. Place a dressing over thestoma. c. Wait several days before placing a pouch. d. Prepare several pouches in advance. ANS: A
Immediately after a fecal surgical diversion, it is necessary to place a pouch over thenewly created stoma to contain effluent when thestoma begins to function. thepouch will keep thepatient clean and dry, will protect theskin from drainage, and will provide a barrier against odor. Dressings would obstruct theopening and would become saturated with fecal material. Preparing multiple pouches in advance would be counterproductive; in theimmediate postoperative period, thestoma may be edematous and theabdomen distended. These symptoms eventually resolve, but during this time, it will be necessary to revise thepouching system to meet thechanging size of thestoma and thechanges in body contours. DIF: CognitiveLevel: Application OBJ: Describe methods used to maintain theintegrity of theperistomal skin. TOP: Immediate Postsurgical Care KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
4. When planning care for a patient who has a colostomy, which intervention is important for thenurse to perform when pouching thecolostomy? a. Leave an intact skin barrier in place for 3 to 7 days. b. Use soap and water to cleanse theperistomal skin. c. Empty thepouch when it is two-thirds full. d. Use tape to secure pouches that have minor leaks. ANS: A
Observe theexisting skin barrier and pouch for leakage and length of time in place. thepouch should be changed every 3 to 7 days, not daily. To minimize skin irritation, avoid unnecessary changing of theentire pouching system, but if theeffluent is leaking under thewafer, change it, because skin damage from theeffluent will cause more skin trauma than will be caused by early removal of thewafer. Cleanse theperistomal skin gently with warm tap water using a washcloth; do not scrub theskin. Pat theskin dry. Avoid soap; it leaves residue on theskin, which interferes with pouch adhesion. Pouches must be emptied when they are one-third to one-half full, because theweight of thepouch may disrupt theseal of theadhesive on theskin. If theostomy pouch is leaking, change it. Taping or patching it to contain effluent leaves theskin exposed to chemical or enzymatic irritation. DIF: CognitiveLevel: Application OBJ: Pouch a fecal or urinary diversion. TOP: Pouching a Colostomy or Ileostomy KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. When providing care for a patient with a colostomy or an ileostomy, thenurse recognizes that which is an expected assessment finding? a. A moist, reddish-pink stoma b. A dry, purplish stoma c. Erythema on theskin around thestoma d. No drainage noted from thestoma when washed ANS: A
Normal findings in a patient with a postoperative ostomy that is healing include a stoma that is moist and reddish-pink, skin that is intact and free of irritation, and sutures that are intact. thestoma is edematous initially and shrinks over thenext 4 to 6 weeks. A necrotic stoma is manifested by a purple or black color and a dry instead of moist texture. thestoma is functioning normally when thestoma drains a moderate amount of liquid or soft stool and flatus in thepouch. Flatus indicates thereturn of peristalsis after surgery. Flatus is noted by bulging of thepouch. (Flatus may not be observable if thepouch has a gas filter.) DIF: CognitiveLevel: Application OBJ: Pouch a fecal or urinary diversion. TOP: Pouching a Colostomy or Ileostomy KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
6. The nurse is caring for a preterm infant in theneonatal intensive care unit who has multiple stomas. Given theuniqueness of infants, which action is essential for thenurse to take? a. Apply an ostomy pouch using standard sealants. b. Use a pouch that can accommodate increased amounts of flatus. c. Use multiple pouches (one for each stoma).
d. Be aware that thestoma size will remain thesame as thebaby grows. ANS: B
Because babies swallow large amounts of air while sucking, it is normal to expect flatus. Make sure that thepouch can accommodate increased amounts of flatus after feeding, or be prepared to release flatus frequently. theskin of a preterm infant is not fully developed and is more absorbent than theskin of a full-term infant. Do not use skin sealants and adhesive removers unless they are approved for preterm infant use. Neonates may have multiple stomas on their tiny abdomens that are theresult of corrective bowel surgeries. Select a cut-to-fit pouch that allows multiple stoma openings in theskin barrier yet still fits on theneonate‘s abdomen. Usually, a baby triples its birth weight in thefirst year. As a baby grows in size, so does thestoma. DIF: CognitiveLevel: Application TOP: Pediatric Considerations MSC: NCLEX: Physiological Integrity
OBJ: Pouch a fecal or urinary diversion. KEY: NursingProcess Step: Implementation
7. In caring for a patient who has a pouch for a noncontinent urinary diversion, which nursing intervention is essential? a. Empty thepouch when it is one-third to one-half full. b. Remove theureteral stents after 2 days. c. Pouch thestoma with thepatient sitting up. d. Dispose of used pouches in thetoilet. ANS: A
Empty pouches when they are one-third to one-half full so that theweight of thepouch does not disrupt theseal. A surgeon places thestents; these will be removed during thehospital stay or at thefirst postoperative visit with thesurgeon. Place thepatient in a semi-reclining position. If possible, provide thepatient a mirror for observation. Properly dispose of used pouches and soiled equipment according to agency policy. DIF: CognitiveLevel: Application TOP: Pouching a Urostomy MSC: NCLEX: Physiological Integrity
OBJ: Pouch a fecal or urinary diversion. KEY: NursingProcess Step: Implementation
8. When assessing thepatient with a noncontinent urinary diversion, thenurse finds that theurine has mucus shreds. Which action should thenurse take? a. Culture any drainage. b. Instruct thepatient to consume less water. c. Document thecharacteristics of theurine. d. Cleanse thestoma with soap and water. ANS: C
Mucus shreds are normal when urine flows through an intestinal segment. Obtain a urine specimen for culture and sensitivity to test for possible infection when ordered by thephysician if urine output is less than 30 mL/hr, or if theurine has a foul odor. Teach patients thesignificance and importance of drinking 1.5 to 2 quarts of fluid daily to prevent urinary tract infection. Avoid soap; it leaves residue on theskin, which interferes with pouch adhesion. DIF: CognitiveLevel: Analysis TOP: Mucous Shreds
OBJ: Pouch a fecal or urinary diversion. KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
9. The nurse has removed thepatient‘s old urostomy pouch and is attempting to measure thestoma opening for placement of a new pouch. Which action should thenurse take next? a. Place thepatient in a prone position. b. Cleanse theperistomal skin with warm soap and water. c. Remove any stents that are in place. d. Place rolled gauze at thestoma opening. ANS: D
Wick thestoma continuously during pouch measurement and change. Place a rolled gauze wick at thestomal opening. Using a wick at thestoma opening prevents theperistomal skin from becoming wet with urine during a pouching-change procedure. Position thepatient in a semi-reclining position. Avoid soap when cleansing thearea. In theimmediate postoperative period, urinary stents extend out from thestoma. A surgeon places thestents to prevent stenosis of theureters at thesite where theureters are attached to theconduit. thestents will be removed during thehospital stay or at thefirst postoperative visit with thesurgeon. DIF: CognitiveLevel: Application TOP: Wicking theStoma MSC: NCLEX: Physiological Integrity
OBJ: Pouch a fecal or urinary diversion. KEY: NursingProcess Step: Implementation
10. A patient who has a urostomy is being discharged to home. Which instruction will thenurse to provide to thepatient? a. Restrict fluid intake to reduce urine output. b. Report any mucus in his urine. c. Keep unused pouches in therefrigerator. d. Shower without covering thepouch. ANS: D
The patient may shower without covering thepouch. Teach patients thesignificance and importance of drinking 1.5 to 2 quarts of fluid daily to prevent urinary tract infection. Patients should avoid storing pouches in extremely hot or cold locations like therefrigerator. Teach patients that some mucus in theurine is expected, but that they should report to their physician any blood in theurine, excessively cloudy urine, chills, fever (101° F or higher), or back (flank) pain. DIF: CognitiveLevel: Application OBJ: Describe methods used to maintain theintegrity of theperistomal skin. TOP: Patient Education KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
11. The nurse is caring for a patient who has a urinary diversion. thenurse notices that thepatient has a temperature of 102° F and foul-smelling urine. What action should thenurse take? a. Obtain a urine culture from thepatient‘s pouch. b. Catheterize thepatient to obtain a sterile urine specimen. c. Notify thephysician. d. Realize that these are normal findings. ANS: C
Common symptoms of a urinary tract infection (UTI) include fever and foul-smelling odor. thenurse will need to contact thephysician immediately. thephysician will order a catheterization so that a urine sample may be obtained. Although thenurse realizes theneed for catheterization, it is an invasive procedure, and an invasive procedure requires a physician‘s order. Obtaining a specimen of urine in a pouch does not result in an accurate finding because of thelikely risk of contamination by microorganisms. Some mucus in theurine is expected. DIF: CognitiveLevel: Analysis TOP: Urinary Infection MSC: NCLEX: Physiological Integrity
OBJ: Catheterize a urinary diversion. KEY: NursingProcess Step: Assessment
12. The nurse is preparing to catheterize a patient who has a urostomy and uses a two-piece pouch system. thenurse should take which action? a. Place thepatient in a semi-recumbent position. b. Remove both pieces of thepouch system. c. Remove thepouch and leave thebarrier attached. d. Use sterile gloves to remove thesystem. ANS: C
Remove thepouch. If thepatient uses a two-piece system, remove thepouch but leave thebarrier attached to theskin. Position thepatient sitting, if possible; gravity facilitates theflow of urine. Sterile gloves are used for theactual catheterization. Clean gloves are donned when removing thepouch. DIF: CognitiveLevel: Application TOP: Removing thePouch MSC: NCLEX: Physiological Integrity
OBJ: Catheterize a urinary diversion. KEY: NursingProcess Step: Implementation
MULTIPLE RESPONSE
1. The nurse is caring for a patient who will have surgery in themorning to have a colostomy placed. thenurse is aware of thephysical and emotional stresses that thepatient will experience. These include which of thefollowing? (Select all that apply.) a. Body image changes b. Fear of social rejection c. Sexual function and intimacy issues d. Loss of independence e. Heightened immunity ANS: A, B, C, D
In addition to thestresses of illness and surgical recovery, patients with ostomies face body image changes, fear of social rejection, concern about sexual function and intimacy, and theneed for help with personal care. DIF: CognitiveLevel: Analysis OBJ: Identify types of fecal and urinary diversions. TOP: Physical and Emotional Stressors Related to Ostomy Placement KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION
1. The opening created into theabdominal wall for fecal or urinary elimination is known as a . ANS:
stoma Certain diseases or conditions require surgical intervention to create an opening into theabdominal wall for fecal or urinary elimination. This opening is called a stoma and is constructed from a section of colon or small-intestine. DIF: CognitiveLevel: Knowledge OBJ: Identify types of fecal and urinary diversions. TOP: Stoma KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. The output from a urinary or fecal stoma is called the
.
ANS:
effluent The output from thestoma is called theeffluent. DIF: CognitiveLevel: Knowledge OBJ: Identify types of fecal and urinary diversions. TOP: Effluent KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
3. A material.
is an opening in thelarge intestine or colon for elimination of fecal
ANS:
colostomy An opening in thelarge intestine or colon is a colostomy, and thefecal effluent will vary in consistency depending on where theopening in thecolon is surgically created. DIF: CognitiveLevel: Knowledge OBJ: Identify types of fecal and urinary diversions. TOP: Colostomy KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
4. An opening that is in theileal portion of thesmall-intestine is an
.
ANS:
ileostomy An opening in theileal portion of thesmall-intestine is an ileostomy, and thefecal effluent will be watery to thick liquid that will contain some digestive enzymes. DIF: CognitiveLevel: Knowledge OBJ: Identify types of fecal and urinary diversions. TOP: Ileostomy KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
5. An ostomy that is created from a portion of theileum to form a stoma through which urine can exit thebody is called a(n) . ANS:
urostomy ileal conduit If removal of theurinary bladder is necessary, a section of theileum or small intestine is resected and theureters are inserted into it, creating an ileal conduit or a urostomy from which urine exits thebody through thestoma. DIF: CognitiveLevel: Knowledge TOP: Urostomy or Ileal Conduit MSC: NCLEX: Physiological Integrity
OBJ: Identify types of fecal and urinary diversions. KEY: NursingProcess Step: Assessment
Chapter 37: Preoperative and Postoperative Care Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition MULTIPLE CHOICE
1. Surgical site infections (SSIs) are themost prevalent hospital associated infection. Which of thefollowing evidence-based practice guidelines is effective at reducing surgical site infections? a. Remove all hair at thesurgical site so it does not interfere with thesurgical incision. b. Maintain thepatient‘s core temperature slightly hypothermic to reduce therisk of fever post-operatively. c. Insert urinary catheter devices only when necessary and leave in only as long as necessary. d. Administer prophylactic antibiotics 24 to 48 hours prior to thetime of theincision. ANS: C
Administer prophylactic antibiotics as close to incision time as possible (within 60 minutes preferred), but never greater than 24 hours prior to surgery. Hair should not be clipped unless absolutely necessary and if it must be clipped, an electric razor should be used. Patient‘s temperature should be kept normothermic at 36° C to 38° C. To prevent surgical site infections (SSIs), urinary catheter devices should be inserted only when necessary and left in only as long as necessary. DIF: CognitiveLevel: Application TOP: Hospital-Acquired Infections MSC: NCLEX: Physiological Integrity
OBJ: Explain therationale for preoperative procedures. KEY: NursingProcess Step: Assessment
2. The goal of prophylactic antibiotic therapy is to protect thepatient from infection with as little risk as possible. To achieve this goal, thenurse recognizes that antibiotics should be administered when they will be most beneficial. When would that be? a. Twenty-four hours before surgery b. For 2 weeks after surgery c. Within 30-60 minutes to time of incision d. When signs of infection first appear ANS: C
Overall, it is recommended that prophylactic antibiotics be given as close to thetime of incision as possible (within 30 to 60 minutes). However, vancomycin and fluoroquinolones may be given up to 2 hours before incision because of their longer infusion times. thegoal of prophylactic antibiotic therapy is to protect thepatient from infection with as little risk as possible. To achieve this goal, antibiotics must be administered when they will be most beneficial. DIF: CognitiveLevel: Application OBJ: Describe theactivities needed to prepare a patient for surgery. TOP: Hospital-Acquired Infections KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
3. The nurse is to obtain an informed consent for a patient before surgery is performed. thenurse recognizes that which of thefollowing statements is true? a. Informed consent is required by law to protect thesurgeon in case of an adverse outcome. b. Only thepatient can sign a surgical consent. c. The nurse‘s legal responsibility is to ensure that thepatient understands theinformation presented. d. The surgeon should give thepatient information about thesurgery. ANS: D
The surgeon should give thepatient information about theextent and type of surgery, alternative therapies, usual risks and benefits, and consequences of not having surgery in a nonthreatening manner, as outlined in thePatient Care Partnership developed by theAmerican Hospital Association (AHA). Informed consent is required by law to help protect patients‘ rights, their autonomy, and their privacy. thepatient or thepatient‘s legal guardian must sign a surgical consent form that includes this information. If thepatient‘s cultural practices include male dominance, thehusband, father, or oldest brother of a female patient also may need to sign theconsent form. It is thenurse‘s ethical (not legal) responsibility, acting as thepatient‘s advocate, to ensure that thepatient understands theinformation. See institutional policy regarding consent. DIF: CognitiveLevel: Application TOP: Informed Consent MSC: NCLEX: Physiological Integrity
OBJ: Explain therationale for preoperative procedures. KEY: NursingProcess Step: Implementation
4. The nurse is planning care for a preoperative patient. Which intervention is implemented to ensure safe nursing care? a. Allowing thepatient to have ice chips b. Always keeping thepatient NPO for 12 to 14 hours before c. Allowing thepatient to brush teeth and swallow water d. Allowing thepatient to take specifically ordered oral medications with small amounts of water ANS: D
Patients may take oral medications with sips of water (30 mL) if they are specially ordered to be taken preoperatively (e.g., antiarrhythmic or seizure medications). All other oral medications are withheld. thenurse must later check postoperative orders to ensure that scheduled medications unrelated to surgery are not forgotten. In general, food and fluids are withheld for 4 to 8 hours before surgery requiring general anesthesia, to minimize therisk for aspiration. Patients may brush their teeth but should not swallow water. DIF: CognitiveLevel: Application OBJ: Adequately prepare a patient for surgery. TOP: Preoperative Medication Administration KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. The nurse is providing thepatient with preoperative education. When thenurse informs thepatient that she will not be able to wear makeup, thepatient states, ―But I never go anywhere without my makeup.‖ thenurse‘s response is based on what rationale? a. She will speak with thesurgeon to see if he will make an exception. b. The patient may wear makeup if she insists. c. Makeup makes it difficult for thesurgeon to assess thepatient. d. Makeup impedes circulation. ANS: C
Instruct thepatient to remove hairpins, clips, wigs, hairpieces, jewelry, including rings used in body piercings, and makeup (including nail polish and acrylic nails). Makeup, nail polish, and false nails impede theassessment of skin and oxygenation. In addition, acrylic nails harbor pathogenic organisms. Makeup does not impede circulation. DIF: CognitiveLevel: Application OBJ: Adequately prepare a patient for surgery. TOP: Makeup KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
6. The patient is in thehospital awaiting surgery. When asked to remove her jewelry, thepatient asks why she needs to remove her navel ring. What explanation should thenurse provide? a. The navel ring may impede assessment of theskin. b. The navel ring may decrease circulation. c. She may leave it in place if she chooses. d. The navel ring may cause injury. ANS: D
Hair appliances and jewelry anywhere on thebody may become dislodged and cause injury during positioning and intubation. Navel rings probably would not impede assessment or decrease circulation. Due to therisk of injury if left in place, allowing thepatient to leave thering in place is not an option. DIF: CognitiveLevel: Analysis OBJ: Adequately prepare a patient for surgery. TOP: Jewelry KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
7. The nurse is helping thepatient prepare for surgery. thepatient has removed her jewelry and glasses. Which action should thenurse take to keep thejewelry safe? a. Put these items in thepatient‘s bedside stand. b. Inventory theitems and give them to thefamily.
c. Place theitems in a plastic bag and send them to theOR with thepatient. d. Keep these items with her until thepatient returns. ANS: B
Inventory theitems and give them to family members, or have security lock them up. Document a list of items and their locations in a preoperative checklist and/or in thenurses‘ notes per agency policy. Valuables left in thepatient‘s room may be lost or stolen. Items not secured could be misplaced or lost. Keeping theitems with thenurse creates a liability for thenurse. DIF: CognitiveLevel: Application OBJ: Adequately prepare a patient for surgery. TOP: Jewelry KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
8. In planning surgical care for an older-adult patient, thenurse recognizes which of thefollowing as causing thegreatest risk for surgery? a. Increased tactile sense b. Decreased glomerular filtration rate c. Increased numbers of red blood cells d. Decreased rigidity of arterial walls ANS: B
Reduced glomerular filtration rate and excretory times limit theability to remove drugs or toxic substances. Assess for adverse effects of medications. Older adults usually will have sensory losses, reduced numbers of red blood cells, and increased rigidity of thearterial walls. DIF: CognitiveLevel: Application TOP: Gerontological Consideration MSC: NCLEX: Physiological Integrity
OBJ: Adequately prepare a patient for surgery. KEY: NursingProcess Step: Planning
9. When providing care for an ambulatory surgical patient, thenurse recognizes that which assessment indicates that thepatient meets discharge criteria? a. The patient is able to drive home alone. b. Some respiratory depression is evident. c. The oxygen saturation level is at 85%. d. No intravenous (IV) narcotics have been given in thepast 30 minutes. ANS: D
An ambulatory surgical patient meets discharge criteria when no IV narcotics have been administered for thepast 30 minutes, a responsible adult is present to accompany thepatient home, respiratory depression is not present, and oxygen saturation is greater than 90%. DIF: CognitiveLevel: Application OBJ: Discuss thedifferences in nursing assessment during theimmediate postoperative period and theconvalescent phase of recovery. TOP: Discharge from Ambulatory Care Surgery KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
10. When teaching thepatient about positive expiratory pressure therapy (PEP) and ―huff‖ coughing, thenurse incorporates which of thefollowing in theplan of care? a. Instruct thepatient to remain flat in bed. b. Place a nose clip on thepatient‘s nose. c. Instruct thepatient to breathe through his nose.
d. Instruct thepatient to exhale with long slow breaths. ANS: B
Instruct thepatient to assume semi-Fowler‘s or high-Fowler‘s position, and place a nose clip on thepatient‘s nose. Have thepatient place his lips around themouthpiece. Instruct thepatient to exhale in quick, short, forced ―huffs.‖ ―Huff‖ coughing, or forced expiratory technique, promotes bronchial hygiene by increasing expectoration of secretions. DIF: CognitiveLevel: Application OBJ: Successfully instruct a patient in performing postoperative exercises. TOP: Teaching Positive Expiratory Pressure Therapy (PEP) and ―Huff‖ Coughing KEY: NursingProcess Step: Intervention MSC: NCLEX: Physiological Integrity
11. When providing teaching to a patient, which action is important to help thepatient in performing controlled coughing? a. Repeat thebreathing exercises twice. b. Cough 2 to 3 times and inhale between coughs. c. Place a pillow over theincisional site for splinting. d. Use thechest and shoulder muscles while inhaling during diaphragmatic breathing. ANS: C
If thesurgical incision is to be thoracic or abdominal, teach thepatient to place a pillow over theincisional area and to place his hands over thepillow to splint theincision. thepatient should begin by taking two or three slow, deep breaths inhaling through thenose and exhaling through themouth. On thethird inhale he should hold thebreath to a count of 3. thepatient will then cough fully for two to three consecutive coughs without inhaling between coughs. Teach thepatient to avoid using chest and shoulder muscles while inhaling. thepatient will do this 2 to 3 times every hour he is awake. DIF: CognitiveLevel: Application OBJ: Successfully instruct a patient in performing postoperative exercises. TOP: Teaching Controlled Coughing and Splinting KEY: NursingProcess Step: Intervention MSC: NCLEX: Physiological Integrity
12. When providing care for a postoperative patient, it is important for thenurse to include which postoperative exercise? a. Turning every 4 hours b. Completing leg exercises once daily c. Repeating individual leg exercises 20 times d. Performing exercises with theunaffected extremities ANS: D
A leg unaffected by surgery can be exercised safely unless thepatient has preexisting phlebothrombosis (blood clot formation) or thrombophlebitis (inflammation of thevein wall). Instruct thepatient to turn every 2 hours from side to back to theother side while awake. Have thepatient continue to practice exercises at least every 2 hours while awake and repeat exercises 5 times. Instruct thepatient to coordinate turning and leg exercises with diaphragmatic breathing, incentive spirometry, and coughing exercises. DIF: CognitiveLevel: Application OBJ: Successfully instruct a patient in performing postoperative exercises. TOP: Teaching Postoperative Exercises KEY: NursingProcess Step: Intervention
MSC: NCLEX: Physiological Integrity
13. When planning care for a post anesthesia care unit (PACU) or recovery room patient, how often should thenurse plan to assess thepatient? a. Every 5 minutes b. Every 15 minutes c. Every 30 minutes d. Hourly ANS: B
Conduct complete assessment of all vital signs. Compare findings with thepatient‘s normal baseline. Continue assessing vital signs at least every 15 minutes until thepatient‘s condition stabilizes. DIF: CognitiveLevel: Application OBJ: Discuss thedifferences in nursing assessment during theimmediate postoperative period and theconvalescent phase of recovery. TOP: Assessment of Patient in PACU KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
14. When providing care for a patient who has received spinal anesthesia, thenurse recognizes that which position prevents spinal headaches? a. Prone b. Lying on theside c. Supine, with thehead slightly elevated d. Trendelenburg‘s position ANS: C
Keep patient supine or with head slightly elevated and maintain position. Minimizes risk of postspinal anesthesia headache from leakage of spinal fluid at injection site, with increased pressures caused by elevation of upper body. Headache is more common with spinal than epidural anesthesia (Glick, 2019). DIF: CognitiveLevel: Application OBJ: Discuss thedifferences in nursing assessment during theimmediate postoperative period and theconvalescent phase of recovery. TOP: Positioning of Patient in PACU KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
15. While providing care for a postsurgical patient who has not received spinal anesthesia, thenurse recognizes that which position is required to maintain a patent airway in therecovery phase? a. On his side with head facing down and neck slightly extended b. On his side with head facing down and neck slightly flexed c. On his back with hands over thechest d. On his side with head facing up and neck slightly extended ANS: A
Position thepatient on his side with head facing down and neck slightly extended. Extension prevents occlusion of theairway at thepharynx. A downward position of thehead moves thetongue forward, and mucus or vomitus can drain out of themouth, preventing aspiration. Never position thepatient with hands over thechest (reduces chest expansion).
DIF: CognitiveLevel: Application OBJ: Discuss thedifferences in nursing assessment during theimmediate postoperative period and theconvalescent phase of recovery. TOP: Positioning of Patient in PACU KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
16. The nurse is providing care for a patient who is recovering in thepostanesthesia care unit (PACU). Given that thepatient is restricted to thesupine position, which intervention provides thepatient with adequate chest expansion? a. Keeping thebed flat during recovery b. Positioning thepatient‘s hands over his chest c. Flexing theneck and turning thehead to theside d. Extending theneck and turning thehead to theside ANS: D
If thepatient is restricted to a supine position, elevate thehead of thebed approximately 10 to 15 degrees, extend theneck, and turn thehead to theside. Never position thepatient with his hands over his chest (reduces chest expansion). DIF: CognitiveLevel: Application OBJ: Discuss thedifferences in nursing assessment during theimmediate postoperative period and theconvalescent phase of recovery. TOP: Positioning of Patient in PACU KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
17. A patient is being transferred to a room from thepostanesthesia care unit (PACU). What should thenurse do upon transfer? a. Remove theindwelling urinary catheter. b. Turn off thenasogastric tube suction. c. Use a black pen to note drainage on thedressing. d. Change thedressing immediately when thepatient reaches theroom. ANS: C
Mark thedressing with a circle around thedrainage using a black pen. Never use a felt tip marker to mark thedressing because ink can bleed into thegauze, contaminating theincision site. Once thepatient is transferred to thebed, immediately attach any existing oxygen tubing, hang IV fluids, check theIV flow rate, attach a nasogastric (NG) tube to suction, and place an indwelling catheter in drainage position. Reinforce thepressure dressing, or change a simple dressing as ordered and needed. First dressing changes most often occur 24 hours postoperatively and usually are done by thephysician. DIF: CognitiveLevel: Application TOP: Assessing Dressing MSC: NCLEX: Physiological Integrity
OBJ: Conduct an assessment of a postoperative patient. KEY: NursingProcess Step: Implementation
18. The nurse explains to thepatient that theincentive spirometer is used to promote which of thefollowing outcomes? a. Lung expansion b. Reduced likelihood of vascular complications c. Incisional healing d. Expectoration of mucus
ANS: A
The use of theincentive spirometer promotes lung expansion. thevisual incentive provided by thedevice encourages thepatient to breathe as deeply as possible. Huff coughing is used to promote expectoration of mucus. Repositioning thepatient regularly reduces therisk for vascular complications. While adequate oxygenation is needed for wound healing, theuse of theincentive spirometer is not recommended for that outcome. DIF: CognitiveLevel: Application TOP: Incentive Spirometry MSC: NCLEX: Physiological Integrity
OBJ: Conduct an assessment of a postoperative patient. KEY: NursingProcess Step: Implementation
19. When assessing a postoperative patient, thenurse notes tenderness, redness, and swelling in theleft calf. What should thenurse do next? a. Massage thelower leg. b. Contact thesurgeon and prepare for heparin therapy. c. Keep theleg in a dependent position. d. Have thepatient exercise that extremity. ANS: B
Calf tenderness, redness, and edema in thelower extremity are signs and symptoms of venous thrombosis or thrombophlebitis. Notify thesurgeon and anticipate orders for bed rest, leg elevation, and initiation of anticoagulation (e.g., heparin intravenous drip). Do not massage theaffected leg. Continue to have thepatient do leg exercises with theunaffected leg, not theaffected leg. DIF: CognitiveLevel: Analysis OBJ: Conduct an assessment of a postoperative patient. TOP: DVT KEY: NursingProcess Step: Evaluation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE
1. Which of thefollowing have been identified as evidence-based guidelines to reduce surgical site infections (SSIs)? (Select all that apply.) a. Prepping thesurgical site with a razor followed by an antiseptic scrub b. Giving antibiotics immediately after theprocedure c. Maintaining blood glucose levels d. Maintaining normal body temperatures e. Maintaining proper positioning ANS: C, D
Four evidence-based guidelines have been identified to reduce SSIs: Do not remove hair unless it will interfere with theoperation, and remove it with electrical clippers if possible; give thecorrect antibiotic preoperatively and at theappropriate time; maintain blood glucose postoperatively, especially for patients undergoing cardiac surgery; and maintain normothermia. DIF: CognitiveLevel: Comprehension TOP: Hospital-Acquired Infections MSC: NCLEX: Physiological Integrity
Chapter 38: Intraoperative Care
OBJ: Explain therationale for preoperative procedures. KEY: NursingProcess Step: Assessment
Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition MULTIPLE CHOICE
1. The charge nurse is assigning duties in thesurgical arena. Which member of thesurgical team should be assigned to therole of circulating nurse? a. Registered nurse (RN) b. Licensed practical nurse (LPN) c. Certified surgical technologist (CST) d. Certified Registered Nurse Anesthetist (CRNA) ANS: A A circulating nurse is an RN who both manages and collaborates closely with theinterdisciplinary team while using theNursingProcess to guide thepatient through theintraoperative phase. DIF: CognitiveLevel: Application OBJ: Describe theroles of a registered nurse in theoperating room. TOP: The Circulating Nurse KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
2. Which of thefollowing is true about thecirculating nurse‘s primary responsibility? a. The nurse is a ―sterile‖ member of thesurgical team. b. The nurse provides thesurgeon with instruments. c. The nurse is a ―nonsterile‖ member of thesurgical team. d. The nurse performs delegated medical functions or skills. ANS: C He or she is a ―nonsterile‖ member of thesurgical team who assumes responsibility and accountability for maintaining patient safety and continuity of quality care. This includes supervising theconduct of thescrub technician and delegating tasks to licensed assistive personnel (AP) as appropriate. thecirculating nurse also assists thefirst assistant, scrub nurse/technician, and surgeon. DIF: CognitiveLevel: Application OBJ: Describe theroles of a registered nurse in theoperating room. TOP: The Circulating Nurse KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
3. When planning care for a surgical patient, thenurse implements which technique to maintain sterility in theoperating room? a. Keeps thehands below thewaist. b. Tucks thehands under theaxilla. c. Uses sterile gloved hands to move a sterile drape under a table. d. Has anyone who is unscrubbed stay at least 1 foot away from thesterile field. ANS: D
Unscrubbed persons should always stay at least 1 foot away from thesterile field while keeping it in constant view and should contact only unsterile areas. Sterile persons must keep their hands in view, above waist level and below theneckline, to avoid contamination. When wearing a sterile gown, do not fold thearms with hands tucked in theaxillary region. This area is not considered sterile once operating room personnel have donned gowns. Sterile-draped tables are sterile only at table level. thesides of thedrape extending below table level are unsterile. DIF: CognitiveLevel: Application OBJ: Identify guidelines for theuse of sterile technique in theoperating room. TOP: Principles of Sterile Technique KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
4. When one prepares to enter theoperating room, which technique demonstrates thesafest outcome? a. Keeping thehands below theelbows b. Applying surgical gloves before thescrub c. Scrub for thelength of time recommended by themanufacturer d. Drying thehands and arms, starting at theelbow and moving toward thefingers ANS: C The AORN (2019) recommends a scrub for thelength of time recommended by themanufacturer to allow adequate product contact with theskin. Rinse hands and arms thoroughly under running water. Grasp one end of thesterile towel to dry one hand thoroughly, moving from fingers to elbow in a rotating motion. Use theopposite end of thetowel to dry theother hand. DIF: CognitiveLevel: Application TOP: The Surgical Hand Scrub MSC: NCLEX: Physiological Integrity
OBJ: Correctly perform surgical hand antisepsis. KEY: NursingProcess Step: Implementation
5. When evaluating a health care team member‘s ability to put on a sterile gown and perform closed gloving, it is most important for thenurse to assess for which outcome? a. Opening thesterile gown pack on a sterile surface b. Holding thegown close to thebody before applying c. Having thecirculating nurse tie thegown at thehip d. Keeping thehands inside thesleeves of thegown until thegloves are applied ANS: D
Apply gloves using theclosed-glove method, with hands covered by gown cuffs and sleeves. Open thesterile gown and glove package on a clean, dry, flat surface. This can be done by thescrub nurse (before scrubbing hands) or thecirculating nurse. While keeping it at arm‘s length away from thebody, allow thegown to unfold with theinside of thegown toward thebody. Do not touch theoutside of thegown, and do not allow it to touch thefloor. Have thecirculating nurse tie thegown at theneck and waist. If thegown is wraparound style, thesterile front flap is not touched until thescrub nurse has gloved. DIF: CognitiveLevel: Application OBJ: Correctly apply sterile gloves using theclosed technique. TOP: Applying Gloves via Closed Technique KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
6. The charge nurse is assigning members of thesurgical team; thenurse recognizes that which member is responsible for an expanded role in ensuring preoperative and postoperative patient management in collaboration with other health care providers? a. Registered nurse (RN) b. Licensed practical nurse (LPN) c. Circulating RN d. Registered nurse first assistant (RNFA) ANS: D The registered nurse first assistant (RNFA) has acquired the necessary knowledge, judgment, and skills to perform in the expanded role of RNFA clinical practice. Responsibilities specific to the practice of first assisting include: • Participating in ―time-out‖ procedure with other surgical team members (safety measure taken to ensure correct patient, correct procedure, correct site and side, correct patient position, and correct implants/equipment present) (TJC, 2020). • Providing surgical exposure (assisting in retracting tissues and suctioning surgical field). • Providing hemostasis (control of bleeding). • Handling and/or cutting tissue. • Using surgical instruments/medical devices and suturing. DIF: CognitiveLevel: Application OBJ: Describe the roles of a registered nurse in the operating room. TOP: Role of the Registered Nurse First Assistant KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
7. While supervising the surgical team, the charge nurse notices that a team member‘s nails are long and chipped. Which action should the nurse take next? a. Allow the team member to complete the task. b. Remove the team member to have the nails cut. c. Turn the team member in to the RNFA. d. Ask the team member why the nails are long and chipped. ANS: B
Long nails increase the risk of harboring potential pathogens, limit the effectiveness of hand hygiene, and can injure patients during patient handling (AORN, 2019). Long fingernails can also puncture gloves, causing contamination. Artificial nails harbor gram-negative microorganisms and fungus (AORN, 2019). • Fingernails should be no longer than inch in length, and nail polish should not be chipped. Avoid use of any nail enhancements (artificial nails, acrylics, tips, and gels) DIF: CognitiveLevel: Application TOP: Surgical Hand Antisepsis MSC: NCLEX: Physiological Integrity
OBJ: Describe the meaning of a sterile conscience. KEY: NursingProcess Step: Implementation
MULTIPLE RESPONSE
1. Who of the following can assume the role of the scrub nurse/assistant? (Select all that apply.) a. Registered nurse (RN) b. Licensed practical nurse (LPN)
c. Certified surgical technician (CST) d. Nursing assistive personnel (NAP) e. Medical transcriptionist ANS: A, B, C
RNs, LPNs, and CSTs may assume the scrub nurse role. DIF: CognitiveLevel: Comprehension OBJ: Describe the roles of a registered nurse in the operating room. TOP: The Scrub Nurse KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. The consequences of double gloving during surgery include which of the following? (Select all that apply.) a. Decreased need for handwashing b. Decreased risk for exposure to bloodborne pathogens c. Increased perforations to the innermost glove d. Decreased risk for surgical wound infection e. Increased patient cost ANS: B, D
Benefits of double gloving during surgery include decreased glove perforation results in decreased surgical site infection and protects the health care provider from exposure to bloodborne pathogens. DIF: CognitiveLevel: Comprehension OBJ: Identify guidelines for the use of sterile technique in the operating room. TOP: Double Gloving KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
3. Which of the following are principles of sterile procedure? (Select all that apply.) a. Gowns are sterile from the chest and shoulder to table level. b. Sterile persons must keep hands in view and above the waist and below the neck. c. Sterile persons must fold arms across chest with hands tucked into the axillary region. d. Unscrubbed persons must stay at least 6 inches away from the sterile field. e. Sterile persons may position themselves with their back to the sterile field. ANS: A, B
Once in place, gowns are sterile from the front chest and shoulders to table level and on the sleeves to 2 inches (5 cm) above the elbow. Sterile persons must keep their hands in view, above waist level and below the neckline, and must not turn their back to the sterile field to avoid contamination. When wearing a sterile gown, do not fold arms with hands tucked into the axillary region. This area is not considered sterile once operating room personnel have donned gowns. Perspiration can lead to strike-through, or contamination that occurs when moisture permeates a sterile barrier. Unscrubbed persons always stay at least 1 foot away from the sterile field while keeping it in constant view; they touch only unsterile areas. DIF: CognitiveLevel: Application OBJ: Identify guidelines for the use of sterile technique in the operating room. TOP: Principles of Sterile Technique KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
4. Through the use of an antimicrobial agent and sterile brushes or sponges, which of the following occurs? (Select all that apply.) a. Debris and transient microorganisms are removed from the nails, hands, and forearms. b. The resident microbial count is reduced to a minimum. c. The skin is sterilized. d. Rapid/rebound growth of microorganisms is inhibited. e. The need to wash between patients is reduced. ANS: A, B, D
Although the skin cannot be sterilized, operating room personnel can greatly reduce the number of microorganisms by chemical, physical, and mechanical means. Through the use of an antimicrobial agent and sterile brushes or sponges, the surgical hand scrub removes debris and transient microorganisms from the nails, hands, and forearms, and inhibits rapid/rebound growth of microorganisms. DIF: CognitiveLevel: Comprehension TOP: The Surgical Hand Scrub MSC: NCLEX: Physiological Integrity
OBJ: Correctly perform surgical hand antisepsis. KEY: NursingProcess Step: Planning
5. Which of the following are sources of contamination in the operating room? (Select all that apply.) a. A wristwatch b. Chipped nail polish c. Artificial fingernails d. Abrasions on the hands e. Tattoos to the arms ANS: A, B, C, D Jewelry harbors and protects microorganisms from removal. Skin under rings has been shown to harbor more pathogens and should not be worn (AORN, 2019).
Long nails and chipped or old polish harbor great numbers of bacteria. Long fingernails can puncture gloves, causing contamination. Artificial nails harbor gram-negative microorganisms and fungus. Cuts, abrasions, exudative lesions, and hangnails tend to ooze serum, which may contain pathogens. Broken skin permits microorganisms to enter various layers of the skin, providing deeper microbial breeding. DIF: CognitiveLevel: Comprehension OBJ: Identify guidelines for the use of sterile technique in the operating room. TOP: Sources of Contamination KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
6. The surgeon is about to finish surgery and requests a sponge count. Who would normally perform this task? (Select all that apply.) a. Scrub nurse b. Registered nurse first assistant c. Circulating nurse d. Certified registered nurse anesthetist e. Surgical technician
ANS: A, C
Part of the role of the scrub nurse is to perform sponge, sharps, and instrument counts with the circulating nurse before an incision is made, at the beginning of wound closure, and at the end of the surgical procedure. DIF: CognitiveLevel: Comprehension OBJ: Describe the roles of a registered nurse in the operating room. TOP: Role of the Scrub Nurse and Circulating Nurse KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
7. While the patient is in the operating room (OR) and the OR team is gowned and gloved, the nurse recommends completion of a safety checklist. The nurse understands that the checklist verifies which of the following? (Select all that apply.) a. Patient identity b. Patient allergies c. Accurate marking of surgical site d. Patient cultural preferences e. Questions posed by the patient ANS: A, B, C
While the patient is in the operating room (OR) and the OR team is gowned and gloved, it is recommended that a surgical safety checklist or the World Health Organization (WHO) checklist be conducted. The WHO checklist verifies the patient‘s identity, ascertains whether the patient has any allergies, checks if the surgical site is marked and re-verifies the site marking, and asks the patient if he or she has any questions. DIF: CognitiveLevel: Application OBJ: Describe the roles of a registered nurse in the operating room. TOP: Role of the Checklist Coordinator KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION
1. The phase begins when the patient enters the operating room suite and ends with admission to the postanesthesia care unit (PACU). ANS:
intraoperative The intraoperative phase begins when the patient enters the operating room suite and ends with admission to the PACU. DIF: CognitiveLevel: Knowledge OBJ: Describe the roles of a registered nurse in the operating room. TOP: The Intraoperative Phase KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. The _ is a nurse with advanced education who assists the surgeon with the surgical procedure, performing a combination of nursing and delegated medical functions and/or skills.
ANS:
registered nurse first assistant (RNFA) registered nurse first assistant The registered nurse first assistant (RNFA) has acquired the necessary knowledge, judgment, and skills to perform in the expanded role of RNFA clinical practice. Responsibilities specific to the practice of first assisting include: • Participating in ―time-out‖ procedure with other surgical team members (safety measure taken to ensure correct patient, correct procedure, correct site and side, correct patient position, and correct implants/equipment present) (TJC, 2020). • Providing surgical exposure (assisting in retracting tissues and suctioning surgical field). • Providing hemostasis (control of bleeding). • Handling and/or cutting tissue. • Using surgical instruments/medical devices and suturing. • Performing wound closure. • Applying human anatomical and physiological considerations in practice; recognizing structure, function, and location of tissues and organs; manipulating tissues accordingly to avoid injury. • Ensuring preoperative and postoperative patient management in collaboration with other health care providers. DIF: CognitiveLevel: Knowledge OBJ: Describe the roles of a registered nurse in the operating room. TOP: The Registered Nurse First Assistant KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
3. The is a ―sterile‖ team member who provides the surgeon with instruments and supplies, disposes of soiled sponges, and accounts for sponges, sharps, and instruments in the surgical field. ANS:
scrub nurse/technician scrub nurse technician The scrub nurse/technician is a ―sterile‖ team member who provides the surgeon with instruments and supplies, disposes of soiled sponges, and accounts for sponges, sharps, and instruments in the surgical field. DIF: CognitiveLevel: Knowledge OBJ: Describe the roles of a registered nurse in the operating room. TOP: The Scrub Nurse KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
Chapter 39: Wound Care and Irrigations Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition MULTIPLE CHOICE
1. Healing by primary intention is expected to occur with which of the following situations? a. The wound is left open and is allowed to heal. b. A surgical wound is left open for 3 to 5 days. c. Connective tissue development is evident. d. The edges of a clean incision remain close together. ANS: D
Healing by primary intention occurs when the edges of a clean surgical incision remain close together. The wound heals quickly, and tissue loss is minimal or absent. The skin cells quickly regenerate, and the capillary walls stretch across under the suture line to form a smooth surface as they join. Wounds that are left open and are allowed to heal by scar formation are classified as healing by secondary intention. Connective tissue development is evident during healing by secondary intention. Healing by tertiary intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish. DIF: CognitiveLevel: Comprehension OBJ: Differentiate between primary and secondary intention wound healing. TOP: Primary Intention KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse is caring for a patient who has a dressing over a surgical wound created the night before. The dressing has never been changed. How should the nurse proceed? a. Change the dressing so she can assess the wound. b. Administer an analgesic 30 to 45 minutes before a dressing change. c. Culture the wound if wound exudate is present. d. Administer an analgesic 30 minutes after a dressing change. ANS: B
To promote patient comfort, administer an analgesic as ordered, usually 30 to 45 minutes before changing the dressing. However, you will need to assess to determine the best time for analgesic administration before providing wound care. Do not remove an initial surgical dressing for direct wound inspection until a physician writes a medical order for removal. The presence of wound exudate is an expected stage of epithelial cell growth. DIF: CognitiveLevel: Application OBJ: Perform a wound assessment. TOP: Medicating the Patient Before Dressing Changes KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
3. The nurse is in the process of irrigating the wound for a patient who has a large pressure ulcer on his buttock. How should the nurse proceed? a. Use irrigation pressures of less than 4 psi. b. Cleanse in a direction from most contaminated to least contaminated. c. Irrigate so that the solution flows from least contaminated to most contaminated. d. Irrigate with clean irrigation solution only. ANS: C
When one is irrigating, all the solution flows from the least contaminated to the most contaminated area. The pressure needed to irrigate wounds is between 4 and 15 psi. Irrigating solutions are sterile.
DIF: CognitiveLevel: Application OBJ: Perform wound irrigation. TOP: Irrigation KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
4. The nurse is changing a surgical dressing and is cleansing the wound. She knows that: a. the incision line should be cleansed last. b. she should start at one end of the incision line and swab the entire length. c. she should start at the center of the incision line and swab toward one end. d. she should work in a circular motion around the incision line. ANS: C
The center is the most important part of the suture line; therefore, using a sterile swab or gauze, clean the suture line by starting at the center of the suture line and working toward one end. With another sterile swab or gauze, start at the center of the incision and work toward the other end. All other cleansing involves moving from one end to the other on each side of the incision. Work in straight lines, moving away from the suture line with each successive stroke. DIF: CognitiveLevel: Application OBJ: Explain factors that impair or promote normal wound healing. TOP: Cleansing an Incision KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
5. The nurse prepares to irrigate the patient‘s wound. What is the primary reason for this procedure? a. Decrease scar formation. b. Remove debris from the wound. c. Improve circulation from the wound. d. Decrease irritation from wound drainage. ANS: B
Irrigation is a common method of delivering a wound-cleansing solution to the wound. Wound irrigation cleans and debrides necrotic tissue with pressure that can remove debris from the wound bed without damaging healthy tissue The primary purposes of wound irrigation do not include decreasing scar formation, improving circulation, or decreasing irritation. Irrigation is a common method of delivering a wound-cleansing solution to the wound. Wound irrigation cleans and debrides necrotic tissue with pressure that can remove debris from the wound bed without damaging healthy tissue. DIF: CognitiveLevel: Application OBJ: Explain factors that impair or promote normal wound healing. TOP: Irrigation KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
6. Which of the following approaches is correct technique when wound irrigation is performed? a. Placing the patient in supine position b. Placing the syringe directly into the wound c. Using sterile technique for a chronic wound d. Selecting a soft catheter for deep wounds with small openings
ANS: D
If the patient has a deep wound with a narrow opening, attach a soft catheter to the syringe to permit the fluid to enter the wound. Position the patient comfortably to permit gravitational flow of irrigating solution through the wound and into the collection receptacle. Hold the syringe tip 2.5 cm (1 inch) above the upper end of the wound and over the area being cleansed; this prevents syringe contamination. Wound cleansing and irrigation are accomplished using sterile technique (surgical wounds) or clean technique (some chronic wounds). DIF: CognitiveLevel: Application OBJ: Perform wound irrigation. TOP: Irrigation KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
7. On which types of wounds may the nurse use a pulsatile high-pressure lavage for irrigation? a. Graft sites b. Wounds with exposed blood vessels c. Necrotic tissue d. Wounds with exposed muscle or tendons ANS: C
Pulsatile high-pressure lavage is often the irrigation of choice for necrotic wounds. The amount of irrigant is wound size dependent. Pressure settings on the device need to remain between 4 and 15 psi. Do not use this type of irrigation with graft sites or exposed blood vessels, muscle, tendon, or bone. DIF: CognitiveLevel: Application TOP: Pulsatile High-Pressure Lavage MSC: NCLEX: Physiological Integrity
OBJ: Perform wound irrigation. KEY: NursingProcess Step: Implementation
8. The nurse should consider culturing a wound when which one of the following situations occurs? a. The tissue is clean and dry. b. Exudate is not present. c. The patient is afebrile. d. The surrounding area shows inflammation. ANS: D
Obtain a wound culture if indicated by the presence of inflammation around the wound, purulent odor or drainage, new drainage, or a febrile patient. DIF: CognitiveLevel: Application OBJ: Explain factors that impair or promote normal wound healing. TOP: Wound Culture KEY: NursingProcess Step: Evaluation MSC: NCLEX: Physiological Integrity
9. When teaching about wound care in the home environment, the nurse instructs the patient and caregiver to: a. make normal saline with 8 teaspoons of salt and 1 gallon of distilled water. b. use normal saline for 1 week and then discard it. c. not apply topical anesthetics before wound care. d. call the physician‘s office to have someone come to the home and complete the
wound care. ANS: A
Teach the patient and caregiver how to make normal saline, especially if cost is an issue. They can make normal saline by using 8 teaspoons of salt in 1 gallon of distilled water and keeping it refrigerated for 1 month. The saline solution should be allowed to reach room temperature before use. Commonly used topical anesthetic solutions include 2% and 4% lidocaine jelly, which inactivates exposed wound pain receptors. Some patients need to receive wound care management in an outpatient wound care clinic. Be sure the patient has directions to the clinic and knows where to park and where to obtain dressing supplies. DIF: CognitiveLevel: Application OBJ: Explain factors that impair or promote normal wound healing. TOP: Teaching Considerations KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
10. Which situation noticed during evaluation would determine that the staples or sutures should remain in place? a. The wound edges are separated. b. No drainage or erythema is present. c. The patient is anxious about their removal. d. A cosmetically aesthetic result would not be achieved. ANS: A
Assess healing ridge and skin integrity of the suture line for uniform closure of wound edges, normal color, and absence of drainage and inflammation that indicates adequate wound healing for support of internal structures without continued need for sutures or staples. If wound edges are separated or signs of infection are present, the wound has not healed properly. Notify the health care provider because sutures or staples may need to remain in place. Absence of drainage and erythema would indicate that sutures are ready for removal. Steps could be taken to relieve the patient‘s anxiety, but suture removal is based on the condition of the wound. Timing of suture removal is based on adequate wound healing. DIF: CognitiveLevel: Application TOP: Wound Assessment MSC: NCLEX: Physiological Integrity
OBJ: Remove sutures or staples. KEY: NursingProcess Step: Implementation
11. What should the nurse do when removing intermittent sutures? a. Snip both sides of the suture before removing. b. Snip the suture as close to the knot as possible. c. Snip the suture as close to the skin as possible. d. Pull up the knot to apply as much tension as possible. ANS: C
Snip the suture as close to the skin as possible at the end distal to the knot. Never snip both ends of the suture; there will be no way to remove the part of the suture situated below the surface. Grasp the knot of the suture with forceps, and gently pull up the knot while slipping the tip of the scissors under the suture near the skin. DIF: CognitiveLevel: Application TOP: Removing Sutures MSC: NCLEX: Physiological Integrity
OBJ: Remove sutures or staples. KEY: NursingProcess Step: Implementation
12. What should the nurse do when performing suture or staple removal? a. Snip both ends of the sutures. b. Apply tension to the suture line to remove the sutures. c. Pull the exposed surface of the suture through the tissue below the epidermis. d. Apply Steri-Strip if any separation greater than the width of two stitches is present. ANS: D
Apply Steri-Strip if any separation greater than two stitches or two staples in width is apparent, to maintain contact between wound edges. This supports the wound by distributing tension across the wound and eliminates closure technique scarring. Never snip both ends of the suture; there will be no way to remove the part of the suture situated below the surface. Grasp the knotted end with forceps, and in one continuous smooth action, pull the suture through from the other side; this smoothly removes the suture without additional tension to the suture line. Tension on the suture line is not required. Never pull the exposed surface of any suture into tissue below the epidermis. The exposed surface of any suture is considered contaminated. DIF: CognitiveLevel: Application TOP: Removing Sutures MSC: NCLEX: Physiological Integrity
OBJ: Remove sutures or staples. KEY: NursingProcess Step: Implementation
13. The physician expects that the patient‘s wound will have an output of close to 500 mL/day. The nurse anticipates placement of which of the following? a. Dry sterile dressing b. Jackson-Pratt (JP) drain c. Hemovac drain d. No drain ANS: C
If drainage accumulates in the wound bed, wound healing is delayed. Drainage is removed by using a closed or an open drain system, even if the amount of drainage is small. A JP drain collects fluid that is in the 100 to 200 mL per 24-hour range; the Hemovac drain accommodates more drainage, usually up to 500 mL in 24 hours. DIF: CognitiveLevel: Application TOP: Drainage Systems MSC: NCLEX: Physiological Integrity
OBJ: Demonstrate care of a wound drainage system. KEY: NursingProcess Step: Planning
14. What is an appropriate technique for the nurse to implement for drainage evacuation? a. Replace the Hemovac drain fully expanded. b. Attach the drainage tubing to the patient‘s gown. c. Tilt the evacuator of the Hemovac away from the plug. d. Complete the dressing change before the drainage evacuation. ANS: B
Pinning drainage tubing to the patient‘s gown will prevent tension or pulling on the tubing and the insertion site. Check the evacuator for reestablishment of the vacuum, patency of drainage tubing, and absence of stress on the tubing. The Hemovac needs to be flattened (compressed) to create a vacuum. Tilt the evacuator in the direction of the plug. Drainage evacuation may be done at times other than dressing change times.
DIF: CognitiveLevel: Application TOP: Drainage Systems MSC: NCLEX: Physiological Integrity
OBJ: Demonstrate care of a wound drainage system. KEY: NursingProcess Step: Implementation
15. What should the nurse do to reestablish the vacuum of the Hemovac system after emptying? a. Place a safety pin on the part of the drain outside the body. b. Replace the cap immediately after emptying. c. Pin the drainage tubing to the patient‘s gown. d. Place the Hemovac on a flat surface. ANS: D
Place the evacuator on a flat surface with the open outlet facing upward; continue pressing downward until the bottom and the top are in contact; hold the surfaces together with one hand, quickly cleanse the opening and the plug with the other hand, and immediately replace the plug; and then secure the evacuator to the patient‘s bed. Compression of the surface of the Hemovac creates a vacuum. Cleansing of the plug reduces transmission of microorganisms into the drainage evacuation. Be sure the Penrose drain has a sterile safety pin in place. This pin prevents the drain from being pulled below the skin‘s surface. Compress the bulb of a JP drain over the drainage container. Cleanse the ends of the emptying port with an alcohol sponge while continuing to compress the container. Replacing the cap immediately prevents tension on the drainage tubing, but does not help to reestablish the vacuum. DIF: CognitiveLevel: Application OBJ: Demonstrate care of a wound drainage system. TOP: Reestablishing Vacuum of Drainage Systems KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
16. The nurse is explaining wound healing to a patient. Which of the following statements explains the healing that occurs during the inflammatory stage of wound healing in a full-thickness wound? a. A reduction in the size of the wound is noted. b. The epithelial cells duplicate. c. Synthesis of collagen occurs at the site. d. Blood flow to the wound and arrival of white blood cells are increased. ANS: D
Vasodilatation occurs, allowing plasma and blood cells to leak into the wound, noted as edema, erythema, and exudate. Leukocytes (white blood cells) arrive in the wound to begin wound cleanup. Macrophages, a type of white blood cell, appear and begin to regulate wound repair. The result of the inflammatory phase is a clean wound bed in the patient with an uncomplicated wound. It is during the proliferative stage, not the inflammatory stage, that contraction causes a reduction in the size of the wound, duplication of epithelial cells occurs, and collagen is synthesized. DIF: CognitiveLevel: Application OBJ: Discuss the body‘s response during each stage of the wound-healing process. TOP: Phases of Wound Healing KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
17. The nurse is educating a patient about his role in wound healing. Which of the following factors, if modified by the patient, can support adequate oxygenation at the tissue level?
a. b. c. d.
Age Smoking Underlying cardiopulmonary conditions Hemoglobin
ANS: B
Factors that decrease oxygenation include decreased hemoglobin level, smoking, and underlying cardiopulmonary conditions. Smoking is the only one of these factors that can be modified by the patient alone. Age causes vascular changes. DIF: CognitiveLevel: Application OBJ: Explain factors that impair or promote normal wound healing. TOP: Skin KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
18. The nurse is caring for a patient with a postsurgical wound dehiscence who is being treated with a wet-to-dry dressing. Which of the following can be appropriately delegated to the nurse assistant? a. Performing a sterile dressing change b. Observing for any drainage on the dressing c. Performing wound assessment during the dressing change d. Notifying the physician of drainage present on the dressing ANS: B
Wound assessment and sterile dressing changes cannot be delegated to nursing assistive personnel (NAP). The nurse can direct the NAP to report any drainage from the wound that is present on the sheets or as strike through from the dressing. The NAP should not be reporting this to a physician. DIF: CognitiveLevel: Application OBJ: Perform a wound assessment. TOP: Delegation KEY: NursingProcess Step: Implementation MSC: NCLEX: Management of Care MULTIPLE RESPONSE
1. How does the skin defend the body? (Select all that apply.) a. Skin serves as a sensory organ for pain. b. Skin serves as a sensory organ for touch. c. Skin serves as a sensory organ for temperature. d. Skin has an acid pH. ANS: A, B, C, D
The skin defends the body by serving as a sensory organ for pain, touch, and temperature, and it has an acid pH, which is often called the ―acid mantle.‖ DIF: CognitiveLevel: Comprehension OBJ: Explain factors that impair or promote normal wound healing. TOP: Skin KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse is explaining healing of a full-thickness wound to a patient. Which of the following phases should the nurse include in the explanation? (Select all that apply.)
a. b. c. d.
Hemostasis Inflammation Proliferation Maturation
ANS: A, B, C, D
In a full-thickness wound, the phases include hemostasis, inflammation, proliferation, and maturation (remodeling). DIF: CognitiveLevel: Application OBJ: Discuss the body‘s response during each stage of the wound-healing process. TOP: Phases of Wound Healing KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
3. You are explaining negative-pressure wound therapy (NPWT) to a patient. Which of the following statements will help reassure the patient that this type of therapy will support wound healing? (Select all that apply.) a. NPWT optimizes blood flow. b. NPWT will remove wound fluid. c. NPWT will maintain a moist environment. d. NPWT will apply positive pressure to the wound. ANS: A, B, C NPWT enhances wound healing by the following: elimination of chronic wound exudate; maintenance of a moist wound surface; reduction in edema with resultant improvement in perfusion. DIF: CognitiveLevel: Application OBJ: Perform a wound assessment. TOP: Negative-Pressure Wound Therapy (NPWT) KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
4. Wounds that have been approved for treatment using negative-pressure wound therapy (NPWT) include which of the following? (Select all that apply.) a. Pressure ulcers b. Diabetic ulcers c. Traumatic wounds d. Venous stasis ulcers ANS: A, B, C, D Indications for NPWT include chronic, acute, traumatic, subacute, and dehisced wounds; partial-thickness burns; injuries (e.g. diabetic and pressure); flaps and grafts once nonviable tissue is removed; and select high-risk postoperative surgical incisions (e.g., orthopedic, sternal). DIF: CognitiveLevel: Application OBJ: Perform a wound assessment. TOP: Negative-Pressure Wound Therapy (NPWT) KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
5. The nurse is caring for a patient who has had major abdominal surgery and is concerned about the possibility of dehiscence. During the assessment, the nurse assesses for which of the following contributing factors? (Select all that apply.) a. Age b. Malnutrition/obesity c. Gender
d. Use of steroids ANS: A, B, D
Factors that contribute to surgical wound dehiscence include anemia, malnutrition, obesity, and use of steroids. During assessment, determine history of conditions that may pose risk for impaired wound healing: advanced age, cardiovascular disease, diabetes, immunosuppression, radiation, obesity, smoking, poor nutrition, and infection. Preexisting health disorders affect speed of healing and sometimes result in dehiscence. DIF: CognitiveLevel: Application OBJ: Explain factors that impair or promote normal wound healing. TOP: Dehiscence KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION
1. The is composed of newly formed collagen, and the nurse can usually feel it along a healing wound. It is usually present directly under the suture line between days 5 and 9. ANS:
healing ridge The healing ridge is composed of newly formed collagen, and you can usually feel it along a healing wound. It is usually present directly under the suture line between days 5 and 9. Lack of a ridge is cause for concern, and you will need to begin interventions promptly to reduce mechanical strain on the wound. DIF: CognitiveLevel: Knowledge OBJ: Discuss the body‘s response during each stage of the wound-healing process. TOP: The Healing Ridge KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. Healing by intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish. ANS:
tertiary Healing by tertiary intention is sometimes called delayed primary intention or closure. It occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish. Then the wound edges are sutured or stapled closed. Scarring is usually minimal. DIF: CognitiveLevel: Knowledge TOP: Tertiary Intention MSC: NCLEX: Physiological Integrity
OBJ: Perform a wound assessment. KEY: NursingProcess Step: Assessment
3.
is black, brown, or tan tissue in the wound that should be removed before wound healing can begin. ANS:
Eschar Black, brown, or tan tissue in the wound is eschar that should be removed before wound healing can begin. DIF: CognitiveLevel: Knowledge OBJ: Perform a wound assessment. TOP: Eschar KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
4.
uses the mechanical force (high or low) of a stream of solution to remove debris, bacteria, and necrotic tissue from a wound. ANS:
Irrigation Irrigating wound uses mechanical force, which helps with separation and removal of necrotic debris and surface bacteria (Jaszarowski and Murphree, 2016). Flushing wound helps remove debris and facilitates healing by secondary intention. DIF: CognitiveLevel: Knowledge OBJ: Perform wound irrigation. TOP: Irrigation KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
5.
are threads of wire or other materials used to sew body tissues together. ANS:
Sutures Sutures are threads of wire or other materials used to sew body tissues together. DIF: CognitiveLevel: Knowledge OBJ: Remove sutures or staples. TOP: Sutures KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
6. The Jackson-Pratt (JP) drain relies on the presence of a vacuum to withdraw drainage and is considered a _ drainage system. ANS:
closed A closed drainage system such as the JP drain (Figure 38-8) or Hemovac drain relies on the presence of a vacuum to withdraw accumulated drainage from around the wound bed into the collection device. DIF: CognitiveLevel: Comprehension TOP: Closed Drain SystemsKEY: MSC: NCLEX: Physiological Integrity
OBJ: Demonstrate care of a wound drainage system. NursingProcess Step: Implementation
Chapter 40: Impaired Skin Integrity Prevention and Care
Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition MULTIPLE CHOICE
1. The nurse is turning a patient when she notices an area with nonblanchable redness over the patient‘s coccyx. The patient complains of pain at the site, and the site feels cooler than the areas immediately around the site. The nurse recognizes that this patient has developed: a. a stage I pressure ulcer. b. a stage II pressure ulcer. c. an unstageable pressure ulcer. d. deep tissue injury. ANS: A Stage 1 Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat) and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive–related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Unstageable Pressure Injury Obscured Full-Thickness Skin and Tissue Loss: full-thickness skin and tissue loss in which the extent of tissue damage within the injury cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Suspected Deep Tissue Injury Purple or maroon localized area of discolored, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, much, boggy, or warmer or cooler than adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bad. The wound may further evolve and become covered by thin eschar. Evaluation may be rapid exposing additional layers of tissue even with treatment (EPUAP, NPIAP, PPIA, 2019a) DIF: CognitiveLevel: Analysis OBJ: Describe patient characteristics, as well as characteristics of the pressure ulcer itself, that should be included in an assessment. TOP: Stage I Pressure Ulcer KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. In a patient with a stage II pressure ulcer, the nurse describes the wound as: a. superficial blistering. b. nonblanchable redness. c. loss of skin without bone exposure. d. loss of skin with exposed muscle.
ANS: A Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat) and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive–related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Unstageable Pressure Injury Stage 1 Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the injury and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the injury. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury. DIF: CognitiveLevel: Analysis OBJ: Describe patient characteristics, as well as characteristics of the pressure ulcer itself, that should be included in an assessment. TOP: Stage II Pressure Ulcer KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse is caring for four patients during a shift. Which of the following patients is at greatest risk for developing a pressure ulcer? a. The patient who is bedridden, but who turns himself randomly b. The patient whose Braden Scale score is 8 c. The patient who can ambulate to the bathroom independently d. The patient whose Braden Scale score is 18 ANS: B Score patient in each of the six subscales. Maximum score is 23, indicating little or no risk. A score of 16 indicates ―at risk‖; 9 indicates very high risk.
Use these risk scores to plan care by looking at the individual risk factors that place the patient at risk and developing a care plan to decrease or eliminate the identified risk factors. Immobility often restricts the patient‘s ability to change and control body position, thus increasing pressure over bony prominences. Patients who can turn themselves are at less risk than those who cannot. DIF: CognitiveLevel: Analysis OBJ: Discuss the risk assessment tools commonly used in assessment of pressure ulcer risk. TOP: Braden Scale KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
4. A patient with anemia is at risk for developing pressure ulcers as a result of which of the following? a. Increased sedation b. Edematous tissues c. Reduced tensile strength d. Diminished oxygen to the tissues ANS: D
Decreased hemoglobin reduces the oxygen-carrying capacity of the blood and the amount of oxygen available to the tissues, thus increasing the risk for pressure ulcers. Anemia does not cause increased sedation, edematous tissue, or reduced tensile strength. DIF: CognitiveLevel: Comprehension OBJ: Identify risk factors for the development of pressure ulcers. TOP: Anemia KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
5. In a long-term care agency, how often should the nurse reassess a patient for risk of a pressure ulcer? a. Every 1 to 2 days b. Every time the nurse sees the patient c. Weekly for the first few weeks of stay d. Monthly for the first 4 months of stay ANS: C
In a long-term care agency, the patient is assessed every week for 4 weeks and then quarterly, or whenever the patient‘s condition changes. An assessment schedule of every 1 to 2 days would be more appropriate for acute care than in the long-term care setting. The patient is not reassessed for risk in the long-term setting every time the nurse sees the patient. The new patient in long-term care is reassessed weekly rather than monthly after he is admitted. DIF: CognitiveLevel: Knowledge OBJ: Describe guidelines for the prevention of pressure ulcers. TOP: Reassessment of Pressure Ulcer Risk KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
6. The patient with a nasogastric (NG) tube in place may experience skin breakdown: a. in the nose. b. on the tongue. c. behind the ears. d. around the lips.
ANS: A
NG and oxygen cannulas can cause pressure on the nares, leading to pressure ulcers. Skin breakdown around the lips and tongue may result from oral airways or endotracheal (ET) tubes. Skin breakdown behind the ears may result from pressure from the oxygen cannula or the patient‘s pillow. DIF: CognitiveLevel: Knowledge OBJ: Describe guidelines for the prevention of pressure ulcers. TOP: Reassessment of Pressure Ulcer Factors KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
7. The nurse is caring for a darkly pigmented patient who is immobile and needs turning every 2 hours. While turning the patient, to what should the nurse who is performing the assessment pay particular attention? a. Edema in the sacrum b. Skin texture c. Skin temperature d. Pallor or mottling of the skin ANS: C There is evidence that Stage 1 pressure injuries are under-detected in individuals with darkly pigmented skin. Areas of redness are more difficult to assess on darker skin tones (EPUAP< NPIAP, PPPIA, 2019A) Patients with darkly pigmented skin cannot be assessed for pressure injury risk by examining only skin color. Darkly pigmented skin may not blanch. A change in color may occur at the site of pressure; this change in color differs from patient's usual skin color. Assessment of skin temperature changes: Circumscribed area of intact skin may be warm to touch. As tissue changes color, intact skin will feel cool to touch.
Edema is not an initial indication of a pressure ulcer. Do not massage any reddened or discolored pressure points. Areas of nonblanchable erythema or discolored areas may indicate that deeper tissue damage is present. Massage in this area may worsen the inflammation by further damaging underlying damaged blood vessels. Pallor or mottling will be difficult or impossible to see in a patient with darkly pigmented skin. DIF: CognitiveLevel: Application OBJ: Describe guidelines for the prevention of pressure ulcers. TOP: Reassessment of Pressure Ulcer Factors KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
8. The patient is admitted with an open pressure ulcer with necrotic tissue around the base of the wound. How would the nurse classify this ulcer? a. Stage III pressure ulcer b. Stage IV pressure ulcer c. Wound that cannot be staged d. Stage II pressure ulcer ANS: C Staging is way of assessing a pressure injury based on depth of tissue destruction. Wounds are documented as unstageable if wound base is not visible. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury
To correctly stage a pressure ulcer, the nurse must be able to see the base of the wound. Therefore, pressure ulcers that are covered with necrotic tissue cannot be staged until the eschar has been debrided and the base of the wound is visible. Until debridement occurs, the ulcer should be documented as unstageable. DIF: CognitiveLevel: Application OBJ: Describe patient characteristics, as well as characteristics of the pressure ulcer itself, that should be included in an assessment. TOP: Staging Pressure Ulcers KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
9. A nurse classifies a pressure ulcer according to the type of tissue in the wound bed. What does it indicate if the wound bed has granulation in it? a. Wound needs debridement b. The presence of significant infection c. Colonization by bacteria d. Movement toward healing ANS: D
The presence of granulation tissue signifies a movement toward wound healing. Black tissue is necrotic tissue. A wound with a high percentage of black tissue will require debridement. Yellow tissue or slough tissue indicates the presence of infection or colonization. DIF: CognitiveLevel: Comprehension OBJ: Describe patient characteristics, as well as characteristics of the pressure ulcer itself, that should be included in an assessment. TOP: Color Typing of Tissue KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
10. When evaluating a patient, the nurse observes an unexpected outcome of treatment when the surrounding skin of an ulcer becomes macerated. The nurse should: a. obtain a wound culture. b. apply pressure-reducing devices. c. use dressings with increased moisture absorption. d. monitor the patient for systemic signs and symptoms. ANS: C
Select appropriate dressing based on pressure injury characteristics, principles of wound management, and patient care setting. Dressing should maintain moist environment for wound while keeping surrounding skin dry. Excessive moisture macerates skin, which can lead to pressure injuries. Consider shielding underlying at-risk skin with protective dressing (silicone, hydrocolloid). These dressings absorb moisture from body and reduce pressure to underlying skin. A wound culture is not indicated for macerated skin unless an increase in drainage or development of necrotic tissue occurs. Pressure-reducing devices are not indicated for macerated skin. Macerated skin is a local reaction; the patient would not need systemic monitoring unless the pressure ulcer extended beyond the original margins. DIF: CognitiveLevel: Comprehension OBJ: Discuss indications for the use of topical agents in the treatment of pressure ulcers.
TOP: Unexpected Outcomes MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
11. After teaching a home caregiver how to manage a pressure ulcer, the nurse realizes that further education is needed when the caregiver says: a. ―I will be sure to reposition her frequently and keep her off of the pressure ulcer.‖ b. ―I will wash the pressure ulcer with saline and report any changes in the drainage.‖ c. ―I know that a thick, black covering will protect the pressure ulcer from getting worse.‖ d. ―I will let you know if the pressure ulcer starts to smell rotten.‖ ANS: C
Sometimes eschar looks like a scab to a patient, and he or she needs to understand the difference. A scab is caused by exudate, and an eschar is dead tissue that the patient should not remove. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury. Black tissue in a pressure ulcer is eschar, a necrotic tissue that covers a section of the ulcer and prevents effective assessment. If the caregiver makes this statement additional education is needed. The other statements indicate that the caregiver understands how to care for pressure ulcers. DIF: CognitiveLevel: Analysis OBJ: Discuss teaching needs of the patient and family regarding pressure ulcers. TOP: Teaching Considerations KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE
1. The nurse is aware that pressure ulcers can occur: (Select all that apply.) a. from any position that causes soft tissue compression. b. because of lack of blood flow (ischemia). c. only in bed bound patients. ANS: A, B
Pressure ulcers occur from any position that causes soft tissue compression. Compression of soft tissue interferes with blood flow to the tissue; if this compression continues for a prolonged time, the tissue dies from lack of blood flow, also known as ischemia. This pressure, if not relieved, can cause irreversible tissue damage. It is quite possible for an individual to develop a pressure ulcer even if not confined to bed. DIF: CognitiveLevel: Knowledge OBJ: Identify risk factors for the development of pressure ulcers. TOP: Pressure Ulcer Etiology KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. Patients are at risk for developing pressure ulcers on which areas of the body? (Select all that apply.) a. Coccyx b. Nares c. Ears
d. Genitalia ANS: A, B, C, D
The most common sites of pressure ulcers are the sacrum, coccyx, ischial tuberosities, greater trochanters, elbows, heels, scapulas, iliac crests, and lateral and medial malleoli (Pieper, 2007). Pressure ulcers can occur on any area of skin subjected to pressure. Nonbony locations in which pressure ulcers can occur include the nares, usually related to pressure caused by nasogastric (NG) tubes or oxygen cannulas; the ears, resulting from an oxygen cannula; and the genitalia, with ulcers resulting from Foley catheter tension. DIF: CognitiveLevel: Comprehension OBJ: Identify risk factors for the development of pressure ulcers. TOP: Pressure Ulcer Sites KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse knows that which of the following factors contribute to the development of pressure ulcers? (Select all that apply.) a. Friction and shear b. Immobility c. Poor nutrition d. Moisture and ammonia e. Uncontrolled pain ANS: A, B, C, D
Factors such as incontinence, friction and shear, immobility, loss of sensory perception, reduced level of activity, and poor nutrition contribute to pressure ulcer formation. Moisture and ammonia from incontinence soften the skin, allowing the skin to become susceptible to breakdown. Uncontrolled pain does not contribute to the development of pressure ulcers. DIF: CognitiveLevel: Comprehension OBJ: Identify risk factors for the development of pressure ulcers. TOP: Pressure Ulcer Sites KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
4. The nurse is planning care for her patient who has a stage II pressure ulcer. Care should include which of the following? (Select all that apply.) a. A heat lamp to dry the wound b. Application of topical antibiotics c. Nutritional assessment d. Maintaining moisture in the wound ANS: B, C, D
The treatment plan for a patient with a pressure ulcer must include elimination or reduction of the factors that have caused the pressure ulcer. A moist wound environment supports the growth of new tissue. If the wound is not free of necrotic tissue, you need to choose topical wound care that will cleanse the wound bed of devitalized tissue. Treat infection both systematically and topically. Wound healing in a patient with a pressure ulcer progresses if the patient has adequate nutritional status as well as control over preexisting conditions such as diabetes and cardiovascular and pulmonary disease. DIF: CognitiveLevel: Application OBJ: Identify outcome criteria for patients at risk for pressure ulcers or impaired skin integrity.
TOP: Treatment for Pressure Ulcer MSC: NCLEX: Physiological Integrity
KEY: NursingProcess Step: Implementation
COMPLETION
1. A is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. ANS: pressure injury
A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to placement of a medical device. DIF: CognitiveLevel: Knowledge OBJ: Describe patient characteristics, as well as characteristics of the pressure ulcer itself, that should be included in an assessment. TOP: Pressure Ulcers KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. When skin layers adhere to the linens and deeper tissue layer move downward, damage occurs. ANS:
shear Shear strain occurs when the subcutaneous tissue shears against the dermal layer, distorting the blood vessels (e.g., when the patient slides down in bed causing deep tissue injury. DIF: CognitiveLevel: Comprehension OBJ: Identify risk factors for the development of pressure ulcers. TOP: Shear KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
3. The removal of devitalized tissue in a wound is known as
_.
ANS:
debridement If the tissue in the wound is devitalized, consider debridement, which is the removal of devitalized tissue. Debridement is accomplished by selecting a dressing and using enzyme preparations or surgical or laser techniques. DIF: CognitiveLevel: Comprehension OBJ: Discuss indications for the use of topical agents in the treatment of pressure ulcers. TOP: Debridement KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
Chapter 41: Dressings, Bandages, and Binders Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. The nurse is caring for a patient who is bleeding. To control bleeding, apply a a. pressure b. alginate c. foam d. hydrocolloid
dressing.
ANS: A
Apply a pressure dressing to control bleeding, but when wound drainage is present, use a highly absorbent dressing. Use an alginate, foam, or hydrocolloid dressing in a noninfected wound that is draining a moderate to large amount of exudate. DIF: CognitiveLevel: Application TOP: Pressure Dressings MSC: NCLEX: Physiological Integrity
OBJ: Choose the correct dressing for a wound. KEY: NursingProcess Step: Implementation
2. The nurse is changing a dry, woven gauze dressing when it is observed that the gauze has inadvertently stuck to the wound. What should the nurse do? a. Pull the dressing off to aid in debridement. b. Recover the dressing and leave in place. c. Moisten the gauze to minimize trauma. d. Ensure that the shiny side of the dry gauze dressing does not stick. ANS: C
When a dry dressing inadvertently adheres to the wound, moisten the dressing with sterile normal saline or sterile water before removing the gauze to minimize wound trauma. Moistening the gauze applies only to dry dressings and is not applicable for moist-to-dry dressings. A dry dressing is not used for debriding wounds. Telfa gauze dressings (not dry woven gauze dressings) contain a shiny, nonadherent surface on one side that does not stick to the wound. DIF: CognitiveLevel: Application OBJ: Understand the technique of a dressing, bandage, or binder application. TOP: Dry Woven Gauze Dressings KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
3. The nurse is caring for a patient who has a wound healing by primary intention that has little to no drainage. Which dressing is most appropriate for this type of wound? a. Moist-to-dry dressing b. Hydrocolloid dressing c. Dry dressing d. Hydrogel dressing ANS: C
Dry dressings are used for wound healing by primary intention with little drainage. These dressings protect the wound from injury, prevent the introduction of bacteria, reduce discomfort, and speed healing. The primary purpose of moist-to-dry dressings is to mechanically debride a wound. Hydrocolloid dressings provide a moist environment for wound healing while facilitating softening and subsequent removal of wound debris. Hydrogel dressings (e.g., hydrogel wound dressings, primary wound dressings, etc.) have a high moisture content (95%), causing them to swell and retain fluid. They are useful over clean, moist, or macerated tissues. DIF: CognitiveLevel: Analysis TOP: Dry Dressings MSC: NCLEX: Physiological Integrity
OBJ: Choose the correct dressing for a wound. KEY: NursingProcess Step: Assessment
4. The nurse would consider a dry dressing appropriate for a wound that requires which of the following? a. Protection b. Debridement c. Absorption of heavy exudate d. Healing by second intention ANS: A
A dry dressing may be chosen for management of a wound healing by primary intention with little drainage. The dressing protects the wound from injury, reduces discomfort, and speeds healing. The dry dressing does not interact with wound tissues and causes little wound irritation. A dry dressing is not appropriate for an open wound that is healing by secondary intention. DIF: CognitiveLevel: Application TOP: Dry Dressings MSC: NCLEX: Physiological Integrity
OBJ: Choose the correct dressing for a wound. KEY: NursingProcess Step: Planning
5. The patient has a large, deep wound on the sacral region. The nurse correctly packs the wound by: a. filling two-thirds of the wound cavity. b. leaving saline-soaked folded gauze squares in place. c. putting the dressing in very tightly. d. extending only to the upper edge of the wound. ANS: D
Apply moist, fine-mesh, open-weave gauze as a single layer directly onto the wound surface. If the wound is deep, gently pack the gauze into the wound with a sterile gloved hand or forceps until all wound surfaces are in contact with the moist gauze. Be sure that the gauze does not touch periwound skin. Moisture that escapes the dressing often macerates the periwound area. The gauze should be saturated with the prescribed solution, wrung out, unfolded, and lightly packed into the wound. Overpacking the wound may cause pressure on tissue in the wound bed. DIF: CognitiveLevel: Application OBJ: Apply dry, moist-to-dry, pressure, transparent, and synthetic dressings correctly. TOP: Packing the Wound KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
6. What should the nurse do for a patient with a sudden severe hemorrhage? a. Go for help. b. Drape the patient. c. Apply direct pressure. d. Put on clean or sterile gloves. ANS: C
Apply direct pressure immediately. Seek assistance after pressure is applied. Once the dressing has been applied, notify the surgical team immediately of these findings. Given the emergent nature of an acute bleeding episode, the aseptic techniques considered essential in most dressing applications are secondary to the goal of halting the bleeding. Maintaining asepsis and privacy is considered only if time and severity of blood loss permit inclusion of these activities. DIF: CognitiveLevel: Application OBJ: Choose the correct dressing for a wound. TOP: Hemostasis KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
7. What should the nurse anticipate might happen to a patient if bleeding cannot be controlled? a. Skin dryness b. Bradycardia c. Hypovolemic shock d. Hypertension ANS: C If there is continued bleeding, fluid and electrolyte imbalance, tissue hypoxia, confusion, hypovolemic shock, and cardiac arrest develop.
Findings of tachycardia, hypotension, diaphoresis, restlessness, and diminished urinary output indicate impending hypovolemic shock. Bradycardia is a decreased pulse rate. Dry skin is not an indicator of hypovolemic shock. Hypertension is an increase in blood pressure. DIF: CognitiveLevel: Application TOP: Hypovolemic Shock MSC: NCLEX: Physiological Integrity
OBJ: Assess a wound correctly. KEY: NursingProcess Step: Assessment
8. How should the nurse proceed when applying a pressure bandage? a. Elevate the extremity or area of bleeding. b. Wrap pressure-bandage gauze in a proximal-to-distal direction. c. Apply pressure to diminish the pulse to the distal body part. d. Wrap tape around the circumference of the site to secure the gauze padding. ANS: A
As soon as possible, elevate the extremity or area of bleeding. Elevation assists in decreasing the rate of blood loss. Start the pressure bandage from distal to proximal, working toward the heart. Secure tape on the distal end, pull tape across the dressing, and maintain firm pressure as the proximate end of the tape is secured. To ensure blood flow to distal tissues and to prevent a tourniquet effect, adhesive tape must not be continued around the entire extremity.
DIF: CognitiveLevel: Application OBJ: Understand the technique of a dressing, bandage, or binder application. TOP: Pressure Bandage KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
9. Serious hemorrhaging has resulted in the patient experiencing a fluid and electrolyte imbalance. How should the nurse respond? a. Initiate intravenous (IV) therapy. b. Order blood for transfusions. c. Remove and reapply any dressings. d. Monitor vital signs every 15 minutes. ANS: D
Monitor vital signs every 5 to 15 minutes (apical, distal rate, blood pressure). Intravenous (IV) therapy and blood transfusions require a provider‘s order. Reinforce the dressing with tape as needed to prevent seepage. If the dressing is saturated, replace only the top layers so as not to disturb any clot formation at the wound site. DIF: CognitiveLevel: Application OBJ: Understand the technique of a dressing, bandage, or binder application. TOP: Hemorrhage KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
10. The patient is being sent home from the hospital after a cardiac catheterization. What should the nurse instruct the patient to do first if bleeding should occur at the femoral artery puncture site? a. Call the physician. b. Call 9-1-1. c. Apply pressure to the site. d. Apply a new bandage. ANS: C
Wounds to the groin area can result in a large amount of blood loss, which is not always visible. If bleeding should occur at the femoral artery puncture site, the patient should apply direct pressure immediately. At home, the patient may apply pressure with clean towels or linen. The patient should call the physician as soon as possible after homeostasis is established. The patient should call 9-1-1 as soon as possible after applying pressure to the site. DIF: CognitiveLevel: Application OBJ: Assess a wound correctly. TOP: Hemorrhage KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
11. The patient is brought from a construction site to the emergency department with a pipe puncturing his abdomen. The pipe is still in place. The patient is triaged and is scheduled for the operating room. What should the nurse do while waiting for the surgeon? a. Pull the pipe out in the direction of entry. b. Push the pipe through to the other side, then out. c. Leave the pipe in place. d. Apply direct pressure to the insertion site of the pipe.
ANS: C
If a puncture wound occurs from a penetrating object (e.g., knife, toy, building materials), do not remove the object. Removal of the object will cause more rapid blood loss and may damage underlying structures. Do not push or apply direct pressure to the insertion site, as this may cause more damage to internal organs. DIF: CognitiveLevel: Application TOP: Penetrating Objects MSC: NCLEX: Physiological Integrity
OBJ: Assess a wound correctly. KEY: NursingProcess Step: Implementation
12. For a patient with a transparent film dressing, the nurse assesses that there is white, opaque fluid accumulation and the surrounding tissue is inflamed. How should the nurse respond? a. Culture the wound. b. Leave the current dressing in place. c. Apply gauze over the top of the dressing. d. Remove and stretch the film more tightly over the wound. ANS: A
Accumulation of fluid with a white, opaque appearance and erythema of the surrounding tissue usually indicate an infectious process; the dressing should be removed and a wound culture obtained. DIF: CognitiveLevel: Application TOP: Film Dressings MSC: NCLEX: Physiological Integrity
OBJ: Assess a wound correctly. KEY: NursingProcess Step: Implementation
13. The nurse is changing a film dressing over a wound that is showing a large amount of drainage. How should the nurse proceed? a. Apply a film dressing after culturing the wound. b. Apply a film dressing after cleansing the area. c. Choose another type of dressing for this wound. d. Keep the wound open to air. ANS: C
If the wound has a large amount of drainage, choose another dressing that can absorb this amount of wound drainage, rather than transparent film dressing, which can absorb only light to moderate amounts of drainage. Explain to the patient and family that collection of wound fluid under the dressing is not ―pus,‖ but rather is a result of normal interaction of body fluids with the dressing. DIF: CognitiveLevel: Application TOP: Film Dressings MSC: NCLEX: Physiological Integrity
OBJ: Choose the correct dressing for a wound. KEY: NursingProcess Step: Implementation
14. When assessing a patient with a hydrocolloid dressing, the nurse finds the formation of a soft, white-yellow gel that is adherent to the wound and has a very slight odor. The nurse evaluates this outcome as: a. an expected occurrence. b. a wound infection requiring a culture. c. an adverse reaction to the hydrocolloid components. d. excessive exudate requiring a different type of dressing.
ANS: A
Hydrocolloid dressings interact with wound fluids and form a soft whitish-yellowish gel that is hard to remove and may have a faint odor. These are normal occurrences and should not be confused with pus or purulent exudate, wound infection, or deterioration of the wound. DIF: CognitiveLevel: Application OBJ: Apply dry, moist-to-dry, pressure, transparent, and synthetic dressings correctly. TOP: Hydrocolloid Dressings KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
15. What should the nurse remember to do when applying a hydrocolloid dressing? a. Apply granules after applying the wafer. b. Never use a secondary dressing. c. Hold the dressing in place. d. Use silk tape to hold the dressing in place. ANS: C
Hold the dressing in place for 30 to 60 seconds after application. Hydrocolloid dressings are most effective at body temperature. Holding the dressing in place for a short time facilitates dressing action. In the case of a deep wound, hydrocolloid granules or paste is applied before the wafer. Hydrocolloid granules/paste assists in absorbing drainage to increase the wearing time of the dressing. Apply a secondary dressing (e.g., ABD pad) if needed. When a secondary dressing is not used, apply nonallergic, paper tape around the edges of the hydrocolloid dressing. DIF: CognitiveLevel: Application OBJ: Apply dry, moist-to-dry, pressure, transparent, and synthetic dressings correctly. TOP: Hydrocolloid Dressings KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
16. Which of the following is an appropriate procedure for the nurse to implement during the application of an absorption or alginate dressing? a. Never cut the dressing to fit the wound. b. Irrigate the wound gently to remove residual gel. c. Fill the wound cavity entirely with the dressing material. d. Never use a secondary dressing. ANS: B
Use 4 4–inch gauze cotton ball moistened in saline or an antiseptic swab (per health care provider order) for each cleaning stroke. Option: Spray wound surface with wound cleaner. Cleaning and irrigating effectively remove residual dressing gel without injuring newly formed delicate granulation tissue in healing wound bed. With some brands, dressings can be trimmed to fit wound size, whereas other brands of dressings cannot be cut. Fill the wound cavity only one-half to two-thirds full to allow for expansion with absorption. Apply a secondary dressing, such as transparent film, hydrogen, foam, or hydrocolloid. DIF: CognitiveLevel: Application OBJ: Apply dry, moist-to-dry, pressure, transparent, and synthetic dressings correctly. TOP: Alginate Dressings KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
17. The nurse is preparing to apply a gauze bandage to a dressing on the patient‘s wrist. How should the nurse proceed? a. Use a 3-inch bandage. b. Use a 2-inch bandage. c. Apply from the elbow toward the wrist. d. Secure the bandage with a safety pin. ANS: B
When applying a gauze or elastic bandage, select a type of bandage and bandage width dependent on the size and shape of the body part to be bandaged. For example, 3-inch bandages are used most commonly for the adult leg. A roller gauze or elastic bandage on a wrist or ankle would be smaller than a bandage for the upper leg or thigh. When applying an elastic bandage to an extremity, start the bandage at the site farthest from the heart (distal) and proceed toward the heart (proximal). Use adhesive tape or special clips rather than safety pins to fasten the bandage. DIF: CognitiveLevel: Application OBJ: Demonstrate the technique for applying turned bandages correctly. TOP: Applying a Bandage KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
18. Which of the following tasks might be delegated to nursing assistive personnel (NAP)? a. Pressure dressing to an actively bleeding wound b. Chronic wound that needs a nonsterile moist-to-dry dressing change c. Hydrogel dressing change d. Wound assessment during the dressing change ANS: B
The task of applying dry and moist-to-dry dressings may sometimes be delegated to nursing assistive personnel (NAP) if the wound is chronic (see agency policy and Nurse Practice Act). Wound assessments, care of acute new wounds, and wound care requiring sterile technique cannot be delegated. The application of hydrogel dressings or pressure dressings cannot be delegated. DIF: CognitiveLevel: Application OBJ: Assess a wound correctly. TOP: Delegation KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE
1. Dressings serve several functions. Which of the following is a function of a dressing? (Select all that apply.) a. Maintains a moist environment. b. Prevents the spread of microorganisms. c. Increases patient comfort. d. Controls bleeding. ANS: A, B, C, D
Dressings serve several functions such as maintaining a moist environment, protecting from outside contaminants, protecting from further injury, preventing the spread of microorganisms, increasing patient comfort, and controlling bleeding. DIF: CognitiveLevel: Comprehension OBJ: Discuss the purposes of dressings, bandages, and abdominal binders. TOP: Functions of Dressings KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. Hydrocolloid dressings are used for which of the following? (Select all that apply.) a. Maintaining a moist wound environment b. Autolytic debriding of necrotic wounds c. Absorption of moderately draining wounds d. Protecting from friction ANS: A, B, C
Hydrocolloid dressings comprise elastomeric, adhesive, and gelling agents. They facilitate autolytic debridement of wounds through rehydration. They absorb exudate and encourage healing by maintaining a moist wound healing environment. Transparent dressings are more suitable for preventing friction. DIF: CognitiveLevel: Comprehension TOP: Hydrocolloid Dressings MSC: NCLEX: Physiological Integrity
OBJ: Choose the correct dressing for a wound. KEY: NursingProcess Step: Implementation
3. In caring for a patient who has an abdominal binder, it is expected that the nurse will do which of the following? (Select all that apply.) a. Remove the binder and assess the skin and wound every 8 hours. b. Evaluate the patient‘s ability to breathe deeply and cough effectively every 4 hours. c. Evaluate the patient‘s pulmonary function every 8 hours. d. Remove the binder at least daily. ANS: A, B
Remove the binder and surgical dressing to assess the skin and wound characteristics every 8 hours. Evaluate the patient‘s ability to ventilate properly, including deep breathing and coughing, every 4 hours to help identify any impaired ventilation. A properly applied binder will have no impact on pulmonary function. DIF: CognitiveLevel: Knowledge TOP: Abdominal Binder MSC: NCLEX: Physiological Integrity
OBJ: Apply an abdominal binder correctly. KEY: NursingProcess Step: Implementation
4. The nurse is demonstrating a dressing change to a nursing student. What key safety features should be emphasized during the process? (Select all that apply.) a. Knowing the type of wound b. Knowing the expected amount of drainage c. Knowing the patient‘s blood type d. Knowing whether drainage tubes are present ANS: A, B, D
It is important to:
Know the cause or type of wound. Wounds caused by vascular insufficiency, diabetes mellitus, pressure, trauma, and surgery are all very different and must have an individualized treatment plan. Not knowing the cause of a wound can have serious negative effects if treatments that are contraindicated for certain types of wounds are used. Know the expected amount and type of wound exudate or drainage. Wounds with large amounts of drainage require more frequent dressing changes or need an absorptive dressing. Determine whether wound drainage tubes are present to prevent their accidental dislocation when you remove the old dressing. Knowing the patient‘s blood type is not necessary for the purposes of changing the dressing unless you are expecting a bleeding complication, and then it would be important for the patient to have a blood type and screen done. DIF: CognitiveLevel: Application OBJ: Assess a wound correctly. TOP: Safety KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment COMPLETION
1. A
dressing comes in direct contact with the wound bed.
ANS:
primary A primary dressing comes in direct contact with the wound bed. DIF: CognitiveLevel: Knowledge OBJ: Discuss the purposes of dressings, bandages, and abdominal binders. TOP: Primary Dressing KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2.
dressings cover or hold primary dressings in place. ANS:
Secondary Secondary dressings cover or hold primary dressings in place. DIF: CognitiveLevel: Knowledge OBJ: Discuss the purposes of dressings, bandages, and abdominal binders. TOP: Secondary Dressing KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
3.
healing takes place when tissue is cleanly cut and the margins are reapproximated. ANS:
Primary Primary healing takes place when tissue is cleanly cut and the margins are reapproximated. DIF: CognitiveLevel: Knowledge TOP: Primary Healing
OBJ: Properly assess a wound. KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
4.
dressings are used for wounds that require debridement. ANS:
Moist-to-dry Moist-to-dry dressings are used for wounds that require debridement. DIF: CognitiveLevel: Knowledge TOP: Moist-to-Dry Dressing MSC: NCLEX: Physiological Integrity
OBJ: Choose the correct dressing for a wound. KEY: NursingProcess Step: Assessment
5. A is a clear, adherent, nonabsorptive, polyurethane moisture- and vapor-permeable dressing that often is used for protection over high-friction areas and over intravenous (IV) catheters. ANS:
transparent dressing A transparent dressing is a clear, adherent, nonabsorptive, polyurethane moisture- and vapor-permeable dressing. These dressings manage superficial, minimally draining wounds and often are used for protection over high-friction areas and over IV catheters. DIF: CognitiveLevel: Knowledge TOP: Film Dressings MSC: NCLEX: Physiological Integrity
OBJ: Choose the correct dressing for a wound. KEY: NursingProcess Step: Assessment
Chapter 42: Home Care Safety Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition MULTIPLE CHOICE
1. Patients who require home care often experience physical alterations that require changes in their home environment. In the case of older adults, what is the best way to implement these changes? a. Quickly in order to prevent problems. b. Limit the patient‘s need to move around. c. Complement the patient‘s strengths. d. Without consideration of the patient‘s previous sense of personal space. ANS: C
In the case of older adults, the progressive physical changes of aging create the same type of need. Changes made should complement the patient‘s remaining strengths. Making changes too rapidly without the patient‘s consent will cause more problems than benefits. Appreciate the arrangement of the patient‘s space within the home, and do not move things or suggest modifications without permission. Respect the concept of personal space. DIF: CognitiveLevel: Comprehension OBJ: Identify interventions that modify the home environment for physical safety. TOP: Modifying Safety Risks KEY: NursingProcess Step: Assessment
MSC: NCLEX: Safe and Effective Care Environment
2. When teaching an elderly patient about safety in the bathroom, which of the following recommendations should the nurse make? a. Use bath oils to maintain skin integrity and suppleness. b. Hang towels on grab bars for easy access. c. Make sure the bathroom door can be locked from the inside only for privacy. d. Shower using a shower stool and a handheld sprayer. ANS: D
A shower stool allows the patient to sit while showering. Use of bath oils makes the tub surface slippery and increases the risk for falls. Do not hang towels on grab bars. Some patients accidentally grab the towel instead of the bar when needing support. Be sure that bathroom doors can be unlocked from both sides of the door. Functional locks prevent the person from becoming trapped in the bathroom. DIF: CognitiveLevel: Analysis OBJ: Perform a home safety risk assessment. TOP: Home Safety KEY: NursingProcess Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
3. Which of the following is a safety measure that the patient should implement in the home environment? a. Using fluorescent lighting b. Wearing extra clothing for padding c. Obtaining a large fire extinguisher d. Installing additional towel bars for support in the shower ANS: B
Have the patient use padding or types of clothing that will cushion bony prominences, especially high-risk bony prominences (e.g., hips). Specially designed hip protectors are available; they help to absorb the impact of a falling body. Provide a direct light source in areas where the patient reads, cooks, uses tools, or conducts hobby work. Avoid fluorescent lighting because it creates excessive glare. Have the patient select a fire extinguisher that is easy to handle and manipulate. Have a grab bar installed into wall studs at the tub, toilet, and/or shower. Towel bars are not designed to support the weight of the patient. DIF: CognitiveLevel: Application OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Padded Clothing KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. When discussing safety measures for the home environment, the nurse should remind the patient of which key element? a. Set the hot water heater to only 160° F. b. Turn on the cold water faucet first. c. Use small throw rugs on slippery wood floors. d. Put high-wattage bulbs into all lamps. ANS: B
Instruct the patient to always turn cold water on first to prevent direct exposure to hot water. Have the setting on the hot water heater adjusted to 120° F or lower. Secure all carpeting, mats, and tile; place nonskid backing under small rugs and door mats. Have the patient check light bulb wattage in all fixtures; this ensures that proper wattage is being used. DIF: CognitiveLevel: Application OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Preventing Scalding KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
5. The patient has been brought to the emergency department by a family member, who states that she just ―doesn‘t know what to do.‖ The patient often forgets where he is and refuses to bathe or change clothes. He will put things on the stove and forget that he has something cooking. She is obviously concerned for her loved one‘s safety. The nurse is likely to interpret these symptoms as signs of: a. depression. b. amnesia. c. aphasia. d. Alzheimer‘s disease. ANS: D
Alzheimer‘s disease is a form of dementia that causes problems with memory, thinking, or behavior. There is also a risk for wandering, where patients repeatedly try to carry out tasks or leave the place of residence. Depression is a chronic, insidious emotional disorder characterized by feelings of sadness, melancholy, dejection, and worthlessness that are inappropriate and out of proportion to reality. Amnesia is loss of memory. This is only one symptom of Alzheimer‘s disease. The patient has several symptoms. Aphasia is the loss of language skills. This is only one symptom of Alzheimer‘s disease, and it is not one that the patient‘s family member has identified. DIF: CognitiveLevel: Analysis OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Alzheimer‘s Disease KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
6. While performing a home visit with an elderly patient, the nurse notices that the patient‘s dress is less tidy than in previous visits, finds an open orange juice container in the pantry cabinet instead of the refrigerator and a roll of paper towels in the refrigerator. How should the nurse respond? a. Begin rearranging the patient‘s storage, and show her how it needs to be done. b. Tell the patient that this is not acceptable. c. Complete a Mini-Mental State Examination (MMSE) or short Geriatric Depression Scale (GDS). d. Realize that elderly patients do things differently. ANS: C
Behavioral changes associated with cognitive dysfunction are evident in a disorderly home and inappropriate placement of objects (e.g., carton of orange juice placed inside kitchen cabinet instead of in refrigerator). If the nurse suspects a cognitive or mental status change, complete an MMSE (e.g., Folstein‘s examination) for dementia and/or complete a short GDS for depression. Speak clearly and in a normal tone of voice. DIF: CognitiveLevel: Application OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Cognitive Assessment KEY: NursingProcess Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
7. A patient with a cognitive deficit becomes agitated and upset about not being able to remember daily activities. How should the nurse respond to this agitation? a. Tell the patient not to worry about it. b. Provide an easy-to-follow calendar and reinforce the information. c. Explain that becoming upset is not going to help the situation. d. Remind the patient that now is the time to rest and relax. ANS: B
If the patient has difficulty remembering when to perform tasks (e.g., paying bills, taking medicines), help the patient to create a list, or post reminder notes in a conspicuous location (e.g., bulletin board, front of refrigerator), provide a medication container organized by days of the week, and recommend a wristwatch with alarm to signal medication administration times. Memory function in older adults tends to be preserved for relevant, well-learned material. Lists and organizers will help the patient cope with memory loss and safely perform activities. Telling the patient not to worry negates the patient‘s feelings. Reminding the patient that it is his or her ―time to rest and relax‖ may be seen as a dismissal. False reassurance is not helpful to the patient. Focus on the patient‘s abilities, and modify approaches used to perform daily activities. DIF: CognitiveLevel: Application OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Cognitive Assessment KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
8. When communicating with a patient with a cognitive deficit, what is the best way for the nurse to respond? a. ―You managed all of your medications very well today.‖ b. ―Your family should really take over the cooking. It‘s too hard for you to do.‖ c. ―I don‘t see how you will be able to shop for yourself anymore. Someone will have to do it for you.‖ d. ―This schedule will be too difficult for you to remember. I better write it all down.‖ ANS: A
Focus on the patient‘s abilities rather than disabilities; this retains the patient‘s autonomy and sense of self-worth. DIF: CognitiveLevel: Application OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Patient Autonomy KEY: NursingProcess Step: Implementation
MSC: NCLEX: Physiological Integrity
9. The nurse is visiting an elderly patient who lives with his wife and daughter. He takes several daily medications, including antihypertensives, antiarrhythmics, diuretics, and pain medication. The patient‘s wife states that he takes all of the pills in the morning and some at night. The nurse should examine the pills and suggest which of the following? a. Take the antiarrhythmics and antihypertensives together in the morning to prevent hypotension during sleep. b. Take the diuretics at bedtime. c. Increase the different types of pain medication to prevent addiction to one. d. Administer at bedtime medications that are likely to cause confusion. ANS: D
Administer at bedtime medications that are likely to cause confusion to reduce the risk for confusion during waking hours, which contributes to disorientation and the risk for falling. However, do not recommend this if the patient has nocturia. Space antihypertensives and antiarrhythmics at different times to minimize side effects. Have diuretics taken early in the day and not at night, so that the diuretic effect occurs during the day, while the patient is awake. Reduce the number of pain medications used when possible. Drugs create sedative effects, increasing the risk for falls. DIF: CognitiveLevel: Application OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Medication Changes KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
10. Which assistive device would most benefit a patient with a neuromuscular weakness? a. Large-print labels b. A syringe with a magnifier c. Screw-top medication containers d. Color-coded tops for medications ANS: C
For patients with a weakened grasp or pain in the hands and fingers, have the local pharmacist place medications in a screw-top container. Larger labels and syringe magnifiers are used for patients with visual alterations. Color-coding systems are designed for patients taking multiple medications. DIF: CognitiveLevel: Application OBJ: Recommend strategies to ensure safe drug administration within the home. TOP: Medication Safety KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
11. The patient is on neutral protamine Hagedorn (NPH) insulin and regular insulin at home. How should the nurse teach the patient and the patient‘s caregiver to store the insulin? a. In the refrigerator and removed only for administration b. In a warm place such as in a cabinet above the stove c. In the dairy bin of the refrigerator with the cheese and eggs d. At room temperature for up to 30 days ANS: D
Insulin may be stored in the refrigerator, but this is not necessary. Patients can store insulin at room temperature for up to 30 days without losing potency as per the manufacturer‘s guidelines. Insulin should be kept in a cool place and away from very warm temperatures. If insulin is stored in the refrigerator, be sure that the drug is in a bin or container away from food. DIF: CognitiveLevel: Application OBJ: Recommend strategies to ensure safe drug administration within the home. TOP: Insulin Storage KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
12. When teaching about medication use in the home, what instructions should the nurse provide to the patient? a. Always keep insulin in the refrigerator. b. Put used needles in double paper bags. c. Put all of the medication to be taken in one bottle. d. Discard unused or expired medication in a bag containing coffee grounds. ANS: D
Discard unused portions of drugs or outdated drugs in a bag containing coffee grounds or kitty litter. This makes the medicine less appealing to children and pets and unrecognizable to someone who might intentionally go through the trash looking for drugs. Insulin may be stored in the refrigerator, but this is not necessary. Discard sharps in puncture-resistant sharps containers or in a 2-L soda bottle with a cap. Do not place different medicines in the same container. DIF: CognitiveLevel: Application OBJ: Recommend strategies to ensure safe drug administration within the home. TOP: Disposal of Outdated Medication KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE
1. Common causes of falls in older patients include which of the following? (Select all that apply.) a. Gait disturbances b. Muscle weakness c. Visual impairments d. Environmental hazards ANS: A, B, C, D
Environmental hazards, gait disturbances, muscle weakness, and visual impairments are some of the causes of falls in older patients. Polypharmacy adds to the risk. DIF: CognitiveLevel: Comprehension OBJ: Describe factors within a home environment that create risks for patient injury. TOP: Causes of Falls KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. In determining the causes of falls or other injuries within the home, the nurse should assess for which of the following? (Select all that apply.)
a. b. c. d.
Symptoms at time of fall and history of previous falls Location of fall and activity at the time of the fall Time of fall Trauma post fall
ANS: A, B, C, D
Key symptoms are helpful in identifying causes of falls. Onset, location, and activity associated with falls provide additional details on causative factors and how to prevent future falls. Determine whether the patient has had a history of falls or other injuries within the home. Be specific in your assessment. Use the mnemonic SPLATT: Symptoms at time of fall, Previous fall, Location of fall, Activity at time of fall, Time of fall, and Trauma post fall. DIF: CognitiveLevel: Analysis OBJ: Identify interventions that modify the home environment for physical safety. TOP: SPLATT Mnemonic KEY: NursingProcess Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
3. The nurse is assessing the home of an elderly patient for safety issues. Which of the following actions would reassure the nurse? (Select all that apply.) a. Cleaning the stove top b. Putting a shower chair in the bathroom c. Installing adequate lighting in all living areas d. Placing emergency numbers close to the telephone ANS: A, B, C, D
The kitchen is one of the most hazard-oriented rooms in a home and poses serious hazards for fire. Grease is highly flammable. Stove tops and ovens should be kept clean and grease free. A shower stool allows patients to sit while showering. Adequate lighting helps persons to see any barriers or uneven walking surfaces. Emergency numbers near the phone are important for all home care patients. DIF: CognitiveLevel: Analysis OBJ: Perform a home safety risk assessment. TOP: Home Safety KEY: NursingProcess Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
4. When a caregiver is communicating with a patient, which of the following actions may facilitate communication? (Select all that apply.) a. Face the patient who has a hearing impairment. b. Avoid eye contact. c. Use simple words. d. Be aware of nonverbal gestures. ANS: A, C, D
Instruct the caregiver on how to use simple and direct communication: Sit or stand in front of the patient in full view. This promotes reception of verbal and nonverbal messages. Face the patient who has a hearing impairment while speaking so that the patient can see the speaker‘s lips. Use a calm and relaxed approach. Use eye contact and touch to help reinforce messages. Speak slowly, in simple words and short sentences, to enhance understanding of messages. Use nonverbal gestures that complement verbal messages. DIF: CognitiveLevel: Application OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and
mental status alterations. TOP: Communication KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION
1.
is a generalized impairment of intellectual functioning, with the most common form being Alzheimer‘s disease. ANS:
Dementia Dementia is a generalized impairment of intellectual functioning, with the most common form being Alzheimer‘s disease. DIF: CognitiveLevel: Knowledge OBJ: Identify patients at risk for safety problems and possible accidents in the home. TOP: Dementia KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
2. Activities of daily living (ADLs) include the patient‘s ability to bathe, dress, go to the toilet, transfer, maintain continence, and feed himself; include the ability to use a telephone, prepare meals, travel, do housework, take medication, and shop. ANS:
independent activities of daily living (IADLs) independent activities of daily living ADLs include the patient‘s ability to bathe, dress, go to the toilet, transfer, maintain continence, and feed himself; IADLs include the ability to use a telephone, prepare meals, travel, do housework, take medication, and shop. DIF: CognitiveLevel: Knowledge OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: ADLs/IADLs KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
3. Dementia is characterized by a gradual, progressive, irreversible
dysfunction.
ANS:
cerebral Dementia is characterized by a gradual, progressive, irreversible cerebral dysfunction. DIF: CognitiveLevel: Knowledge OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Dementia KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
Chapter 43: Home Care Teaching Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. Of the following types of thermometers available, which is not recommended for home use? a. Digital b. Tympanic c. Mercury d. Disposable single-use ANS: C
If a mercury thermometer breaks, and it is not disposed of properly, the mercury gets into the air, posing a major health risk in the home (Environmental Protection Agency, 2007). Educate patients about the environmental hazards associated with mercury in the home, and encourage patients to purchase mercury-free thermometers. DIF: CognitiveLevel: Analysis OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Mercury Thermometers KEY: NursingProcess Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
2. Which of the following is essential in teaching the patient how to use a thermometer? a. Reading a digital thermometer b. Shaking down the thermometer before use c. Using the axillary thermometer d. Selecting the most appropriate thermometer ANS: D
Help a patient choose the most appropriate thermometer to use in the home based on the patient‘s dexterity, vision, and financial resources. For example, a patient with visual changes from glaucoma or retinopathy is able to read more easily a thermometer with a large digital display. The need for an oral, rectal, or axillary temperature depends on the patient‘s age and health status. DIF: CognitiveLevel: Analysis OBJ: Identify factors that influence patients‘ abilities to learn and care for themselves at home. TOP: Choosing the Right Thermometer KEY: NursingProcess Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
3. What should the nurse first assess when preparing to teach a patient and/or family member how to read a thermometer? a. Patient‘s actual temperature b. Patient‘s ability to manipulate the thermometer c. Family member‘s temperature d. Patient‘s ability to take a pulse and respiratory rate as well ANS: B
Assess the patient‘s ability to manipulate and read the thermometer. Physical restrictions in handling or reading the thermometer prevent patients from being able to read the thermometer and often require instruction of a family member or significant other instead of the patient. DIF: CognitiveLevel: Analysis
OBJ: Identify factors that influence patients‘ abilities to learn and care for themselves at home. TOP: Choosing the Right Thermometer KEY: NursingProcess Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
4. Which of the following is an appropriate step when teaching temperature monitoring in the home? a. Suggest aspirin to decrease fevers. b. Recommend using only tympanic membrane sensors. c. Encourage the use of alcohol rubs to reduce fevers. d. Demonstrate the technique and have the patient/caregiver perform it. ANS: D
Demonstration is the best technique for teaching psychomotor skills. It allows for correction of errors in technique as they occur and for discussion of potential consequences of errors. Provide rationale for steps to the patient or caregiver. Use caution in recommending aspirin or any other over-the-counter drug or antipyretic medicine for patients whose conditions contraindicate their use. The type of thermometer needed is determined on the basis of the patient‘s age and health status. Instruct the patient or caregiver to never use sponging with isopropyl alcohol to lower fever because of the neurotoxic effects that have been reported. DIF: CognitiveLevel: Application OBJ: Implement and evaluate appropriate learning strategies that support clients‘ ability to care for themselves in the home. TOP: Teaching How to Use the Thermometer KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
5. What should the nurse instruct the patient to do when teaching the patient how to take a temperature? a. Wait at least 20 minutes after smoking or ingesting hot or cold foods. b. Take the temperature immediately upon seeing chills or shivering. c. Wear sterile rubber gloves when taking a rectal temperature. d. Lubricate an oral thermometer with water-soluble lubricant only. ANS: A
Instruct the patient to take the temperature at least 20-30 minutes after smoking or ingesting hot or cold liquids or foods. Waiting at least 20 minutes after drinking hot or cold liquids or foods improves accuracy of temperature reading. To ensure accuracy, teach the patient to take the temperature after chills or shivering subsides. If taking rectal temperature, instruct the patient to lubricate the thermometer tip with water-soluble lubricant, to wear clean, disposable gloves, and to use only a rectal thermometer. Lubrication normally is not needed when one is taking an oral temperature. DIF: CognitiveLevel: Application OBJ: Implement and evaluate appropriate learning strategies that support clients‘ ability to care for themselves in the home. TOP: Teaching How to Use the Thermometer KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
6. What should the nurse instruct the parents to do when teaching them about temperature monitoring for a child? a. Use only a glass mercury thermometer. b. Take the temperature after shivering subsides.
c. Avoid the use of tepid water sponging for fever. d. Take the temperature, but adjust the reading if the child has eaten a popsicle. ANS: B
Teach the patient to take the temperature after chills or shivering subsides to obtain an accurate temperature. Nurses in home care need to encourage their patients to purchase mercury-free thermometers. Applying cool, moist compresses to the skin is a common therapy for temperature reduction that is safe to perform at home. Wait 30 minutes to take the temperature after the patient has ingested a popsicle. DIF: CognitiveLevel: Application OBJ: Implement and evaluate appropriate learning strategies that support clients‘ ability to care for themselves in the home. TOP: Utilizing the Thermometer KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
7. In teaching the patient how to take his own blood pressure, which of the following is true? a. Blood pressure cuffs that are too small will give a falsely low reading. b. Blood pressure cuffs that are too large will give a falsely high reading. c. Electronic blood pressure cuffs are just as accurate as other methods. d. The cuff should be placed directly over the skin and not over clothing. ANS: D
Have clients place the cuff directly on the skin, not over clothing. Blood pressure cuffs that are too small tend to overestimate blood pressure, and cuffs that are too large tend to underestimate blood pressure. Although electronic monitors are easier to use, their accuracy is still a focus of debate. DIF: CognitiveLevel: Application OBJ: Choose appropriate teaching strategies to use in the home setting. TOP: Blood Pressure Devices KEY: NursingProcess Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
8. The patient is taking levothyroxine (a thyroid medication) for hypothyroidism. What should the nurse instruct the patient to do when teaching the patient how to assess her own blood pressure and pulse? a. Withhold the medication if her blood pressure is above the normal range or if her pulse is over 100 beats per minute. b. Withhold the medication if her blood pressure is below the normal range or if her pulse is less than 60 beats per minute. c. Never withhold her medication. Have the patient take it and notify the physician at the next office visit. d. Withhold her medication only if both her blood pressure and pulse rate are too high. ANS: A
Instruct patients taking thyroid medications to withhold medications when blood pressure is above the normal range or when pulse is above 100 beats per minute. Confirm with the prescriber specific guidelines for blood pressure and pulse, document information in the home care record, and provide clear, written instructions for the patient. Beta blockers (e.g., propranolol), calcium channel blockers (e.g., verapamil hydrochloride), or cardiac glycosides (e.g., digoxin) often are withheld if blood pressure is below normal range and/or pulse is below 60 beats per minute. DIF: CognitiveLevel: Analysis OBJ: Choose appropriate teaching strategies to use in the home setting. TOP: Teaching Considerations KEY: NursingProcess Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
9. In teaching the patient how to perform intermittent self-catheterization, the nurse instructs which of the following? a. Only strict aseptic technique should be used. b. All hospitals use strict aseptic technique. c. Clean intermittent self-catheterization increases the chance for infection. d. Clean intermittent self-catheterization is a safe and effective method. ANS: D
Clean intermittent self-catheterization (CISC) is a safe and effective way to empty the bladder. Current practice supports CISC for use in the home to provide a means to completely empty the bladder, prevent urinary tract infection, and prevent further bladder and kidney damage. Today, some hospital policies recommend sterile technique; others recommend clean technique. DIF: CognitiveLevel: Application OBJ: Choose appropriate teaching strategies to use in the home setting. TOP: Clean Intermittent Catheterization KEY: NursingProcess Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
10. What is the principal difference in tracheostomy care between care given in the acute care setting and care given in the home care environment? a. In the acute care setting, the inner cannula is cleaned. b. In the home care setting, dressings are not necessary. c. In the acute care setting, hydrogen peroxide is used for cleaning. d. In the home care setting, the procedure may be done with clean technique. ANS: D
The indications for performing tracheostomy care and suctioning in the home are similar to those for tracheostomy care and suctioning in the hospital, except for one key variable: the use of medical asepsis or clean technique. In the hospital, principles of surgical asepsis are used because the patient is more susceptible to infection, and because the hospital contains more virulent or pathogenic microorganisms than are usually present in the home setting. In the home setting, most patients use clean technique. Inner cannula care is performed both at home and in the acute care setting. The inner cannula is available in both disposable and nondisposable forms. Fresh trach dressings protect the skin around the stoma from pressure breakdown and collect secretions; they are necessary in both acute care and home care settings. Hydrogen peroxide may be used in both home care and acute care settings.
DIF: CognitiveLevel: Comprehension OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Differences in Trach Care Between Home Care and Acute Care Settings KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
11. What is an expected outcome after tracheostomy care is successfully performed? a. A stoma site that is hard to the touch b. An inner cannula that is free of secretions c. Copious secretions obtained from suctioning d. Bloody secretions that have been suctioned ANS: B
A stoma site that is clean and free of infection and transesophageal fistula and an inner cannula that is free of secretions indicate that tracheostomy care is successful. If the stoma site is reddened or hard, with or without drainage, evaluate the cleaning regimen for continued use of clean technique, and increase tracheostomy care frequency. This is an unexpected outcome. Copious colored secretions present around the stoma or when the patient is suctioned are an unexpected outcome. Bloody secretions are an unexpected outcome and require evaluation of suctioning technique and frequency and size of the catheter. DIF: CognitiveLevel: Application OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Unexpected and Expected Outcomes KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
12. The nurse is teaching the patient and family how to perform tracheal suctioning. What does proper technique include? a. Teaching how to instill normal saline before suctioning b. Suctioning the nasal and oral pharynx before the trachea c. Encouraging daily brushing of the teeth and oral hygiene d. Having the patient take two to three deep breaths after the procedure ANS: D
At the conclusion of the procedure, have the patient take two to three deep breaths, and determine whether symptoms that necessitated suctioning are no longer present. Deep breathing reduces oxygen loss and prevents hypoxia. Expect the patient‘s respiratory status to improve after suctioning. Use of normal saline adversely affects arterial and global tissue oxygenation and dislodges bacterial colonies; therefore, this can contribute to lower airway contamination. After suctioning the patient, teach him to suction the nasal and oral pharynx, and give mouth care. Encourage the patient or family member to brush the teeth with a small, soft toothbrush 2 times a day, and to use mouth moisturizer and moisturize the lips every 2 to 4 hours. DIF: CognitiveLevel: Application OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Suctioning KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
13. When teaching the patient about performing trach care, which of the following actions is an acceptable technique? a. Remove the old ties before applying the new. b. Keep two trach tubes of the same size at the bedside. c. Place the new trach tie, then remove the old tie. d. Dispose of all old supplies and replace with new. ANS: C
During tracheostomy care, the patient is at risk for the trach tube coming out. Never remove the old tracheostomy tube ties until the new ties have been secured properly. Keep two tracheostomy tubes, one the same size as the patient‘s and one a size smaller, at the patient‘s bedside, so you can insert a new tube if the tube comes out. Clean reusable supplies in warm, soapy water. Rinse thoroughly, and dry between two layers of clean paper towels. Store supplies in a loosely closed clear plastic bag. DIF: CognitiveLevel: Application OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Trach Care KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
14. What is an appropriate technique to use when teaching an older patient about self-medication in the home? a. Speak very loudly. b. Teach the family separately. c. Provide frequent pauses. d. Provide fewer but longer teaching sessions. ANS: C
Provide frequent pauses so the patient can ask questions and express understanding of content. Use short sentences and speak in a slow, low-pitched voice. Effective teaching strategies for older adults may include involvement of a family member or caregiver. Provide frequent, short teaching sessions. DIF: CognitiveLevel: Application OBJ: Implement and evaluate appropriate learning strategies that support clients‘ ability to care for themselves in the home. TOP: Teaching Older Patients KEY: NursingProcess Step: Planning MSC: NCLEX: Physiological Integrity
15. The patient‘s caregiver is checking the patient‘s nasogastric (NG) tube for gastric residual before proceeding with the patient‘s next feeding. The patient aspirates 250 mL of residual for the second hour in a row. The caregiver held the tube feeding within the last hour. What should the caregiver do now? a. Hold the feeding again. b. Contact the health care provider. c. Proceed with the feeding. d. Give half of the feeding and see how the patient tolerates it. ANS: B
Instruct the patient or caregiver to contact the home care nurse or health care provider. Automatic cessation of feeding should not occur for GRV less than 500 mL in the absence of other signs of intolerance such as nausea or abdominal distention
DIF: CognitiveLevel: Application OBJ: Implement and evaluate appropriate learning strategies that support positive patient outcomes. TOP: Gastric Residual KEY: NursingProcess Step: Implementation MSC: NCLEX: Physiological Integrity
16. What does the nurse teach the patient and caregiver to do when setting up and changing administration sets for continuous tube feedings to preserve medical asepsis? a. Add formula to formula already hung to prevent waste. b. Store unused formula at room temperature to prevent spasm. c. Hang only enough formula that will be infused in a 4- to 6-hour period. d. Change the administration set every 48 hours. ANS: C
Limit the amount of formula ―hung‖ at one time to an amount that can be infused in a 4to 6-hour period (less time in warmer weather to minimize risk for microorganism contamination). Do not add formula to a hanging bag. Using refrigeration and limiting ―hang‖ time reduce microorganisms. Changing administration sets every 24 hours reduces microorganism growth. DIF: CognitiveLevel: Application OBJ: Implement and evaluate appropriate learning strategies that support clients‘ ability to care for themselves in the home. TOP: Asepsis with Tube Feedings KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
17. Information that should be provided to the caregiver of a patient with a nasogastric (NG) tube includes: a. keeping the head of the bed lowered for feedings. b. keeping unused formula at room temperature. c. aspirating every 4 hours when receiving continuous drip feedings. d. providing half of the feeding if the residual exceeds 250 mL. ANS: C
Patients and caregivers need to document intake and output (I&O), daily weights, amount of gastric fluid aspirated before each feeding (or every 4 hours if receiving continuous feeding), date and time of feedings, amount and type of formula, any additives, and date and time administration sets are changed. Instruct the patient or caregiver that the patient should sit up in a chair or have the head of the bed elevated at least 30 to 45 degrees while receiving feedings or medications, or when the tube is flushed. Refrigerate unused formula. If gastric aspirates are greater than or equal to 200 mL, instruct the patient or caregiver to return gastric contents and delay tube feeding for 1 hour. If aspirates remain greater than or equal to 200 mL after an hour, instruct the patient or caregiver to contact the home health nurse or health care provider. DIF: CognitiveLevel: Application OBJ: Implement and evaluate appropriate learning strategies that support clients‘ ability to care for themselves in the home. TOP: Management of Tube Feedings KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
18. A patient is discharged and is sent home with enteral feedings. What instructions should the nurse give to the caregiver? a. Flush the tube out after administering medications. b. Keep the tube loose to allow for patient movement. c. Use sterile technique when preparing and administering feedings. d. Hang enough formula each time to cover 8 to 12 hours of feeding. ANS: A
Discuss flushing of the tube after administration of feedings or medications to prevent clogging. Discuss measures to stabilize the feeding tube in patients with abdominal tubes and to protect skin integrity. Perform hand hygiene to reduce the transfer of microorganisms. Sterile technique is not needed. Limiting the amount of formula ―hung‖ at one time to an amount that can be infused in a 4- to 6-hour period will help limit bacterial growth. DIF: CognitiveLevel: Application OBJ: Implement and evaluate appropriate learning strategies that support clients‘ ability to care for themselves in the home. TOP: Management of Tube Feedings KEY: NursingProcess Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
19. What instructions should the nurse provide when teaching the patient and the patient‘s caregiver how to administer parenteral nutrition (PN)? a. PN solution should be kept refrigerated until time of administration. b. Remixing separated mixture components by shaking the bag is common. c. PN is compatible with most intravenous (IV) medications. d. Blood glucose monitoring will be necessary. ANS: D
Parenteral nutrition (PN) increases blood glucose levels, which negatively affects patient outcomes. Frequent monitoring of glucose helps the caregiver to detect problems early. Expect testing frequency to decrease as the patient‘s condition and response to PN stabilize. Suggest taking PN solution out of the refrigerator for 30 to 60 minutes before scheduled infusion time. Chilled solution often causes discomfort; allowing the solution to warm enhances comfort during infusion. If a precipitate appears, if components of the mixture are separated, or if the color changes, explain that the solution needs to be discarded. Explain that PN is incompatible with most medications; do not add medications to the PN that are not ordered to be added. DIF: CognitiveLevel: Application OBJ: Implement and evaluate appropriate learning strategies that support clients‘ ability to care for themselves in the home. TOP: Glucose Monitoring With PN KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE
1. Expected outcomes for patients who are being taught how to use a thermometer include which of the following outcomes? (Select all that apply.) a. Ability to correctly measure temperature b. Ability to properly clean and store the thermometer c. Knowledge of normal temperature ranges
d. Knowledge of signs and symptoms of fever ANS: A, B, C, D
Expected outcomes after completion of the procedure include that the patient is able to correctly measure temperature, demonstrate proper cleaning and storage of equipment, and state normal temperature range and factors that affect temperature, signs and symptoms of fever and hypothermia, and measures to take with abnormal temperatures. DIF: CognitiveLevel: Analysis OBJ: Implement and evaluate appropriate learning strategies that support clients‘ ability to care for themselves in the home. TOP: Expected Outcomes of Teaching How to Use the Thermometer KEY: NursingProcess Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
2. Which of the following clinical findings are signs of hyperthermia? (Select all that apply.) a. Dry, warm, flushed skin b. Chills and piloerection c. Uncontrolled shivering d. Loss of memory ANS: A, B
Symptoms of fever: warm, dry, flushed skin; feeling warm; chills; piloerection; malaise; and restlessness. The patient needs to recognize the onset of fever in self or family member for early detection and intervention. Symptoms of hypothermia: cool skin, uncontrolled shivering, loss of memory, and signs of poor judgment. DIF: CognitiveLevel: Analysis OBJ: Implement and evaluate appropriate learning strategies that support clients‘ ability to care for themselves in the home. TOP: Signs of Hyperthermia KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse is teaching the patient about the signs of hypothermia. She teaches that signs of hypothermia include which of the following clinical manifestations? (Select all that apply.) a. Piloerection b. Restlessness c. Cool skin d. Uncontrolled shivering ANS: C, D
Symptoms of hypothermia: cool skin, uncontrolled shivering, loss of memory, and signs of poor judgment. Symptoms of fever: warm, dry, flushed skin; feeling warm; chills; piloerection; malaise; and restlessness. The patient needs to recognize onset of fever in self or family member for early detection and intervention. DIF: CognitiveLevel: Analysis OBJ: Implement and evaluate appropriate learning strategies that support clients‘ ability to care for themselves in the home. TOP: Signs of Hypothermia KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
4. In teaching the patient how to take his own blood pressure, the nurse instructs the patient to avoid which of the following actions 30 minutes before taking blood pressure (BP)? (Select all that apply.)
a. b. c. d.
Exercise Caffeine Smoking Resting
ANS: A, B, C
Encourage the patient to avoid exercise, caffeine, and smoking for 30 minutes before assessment to avoid an inaccurate reading. These factors cause elevations in BP and pulse. Have the patient rest at least 5 minutes before measurement to reduce anxiety that can falsely elevate readings. DIF: CognitiveLevel: Comprehension OBJ: Choose appropriate teaching strategies to use in the home setting. TOP: Factors That Affect Blood Pressure KEY: NursingProcess Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
5. In teaching the patient the best sites for assessing blood pressure (BP), which of the following actions should the patient be taught to avoid? (Select all that apply.) a. Sites with intravenous catheters b. Arms with arteriovenous shunts c. Arms on the side of mastectomy d. The left arm after a heart attack ANS: A, B, C
The patient should be taught to avoid applying the cuff to an arm with an IV catheter with or without fluids infusing, an arteriovenous shunt, breast or axillary surgery, trauma, inflammation, disease, or a cast or bulky bandage. Application of pressure from an inflated bladder temporarily impairs blood flow and compromises circulation in the extremity that already has impaired circulation. There is no restriction on the BP cuff site in a heart attack patient unless he or she has one of the above conditions. DIF: CognitiveLevel: Analysis OBJ: Choose appropriate teaching strategies to use in the home setting. TOP: Factors That Affect Blood Pressure Site Selection KEY: NursingProcess Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
6. The patient needs to be taught the signs of hypoxia. Which of the following outcomes are causes of hypoxia? (Select all that apply.) a. Incorrect flow rate b. Poor tubing connection c. Use of long oxygen tubing d. Airway plugging ANS: A, B, C, D
Hypoxia sometimes occurs at home when a patient uses oxygen. Possible causes of hypoxia include poor tubing connections, use of long oxygen tubing, and worsening of the patient‘s physical problem with changes in respiratory status. Assess the patient for changes in respiratory status, such as airway plugging, respiratory tract infection, or bronchospasm. DIF: CognitiveLevel: Comprehension OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Causes of Hypoxia.
KEY: NursingProcess Step: Assessment
MSC: NCLEX: Physiological Integrity
7. The nurse will train the tracheostomy patient and caregiver that reusable supplies need to be disinfected at least weekly. Which of the following methods is recommended for cleaning tracheostomy supplies at home? (Select all that apply.) a. Boil reusable (boilable) supplies for 5 minutes. Allow to cool and dry. b. Soak reusable supplies that touch membranes in prepared solution of 3% hydrogen peroxide for 30 minutes. Rinse reusable supplies in saline or sterile saltwater c. Soak reusable supplies that touch membranes in prepared solution of 70% isopropyl for 5 minutes. Rinse usable supplies in saline or sterile saltwater d. Soak reusable supplies that touch membranes in prepared solution of 5.25% 6.15% sodium hypochlorite (household bleach) for 5 minutes. Rinse reusable supplies in saline or sterile saltwater ANS: B, C, D
Method 1: Soak reusable supplies that touch membranes in prepared solution of 3% hydrogen peroxide for 30 minutes (CDC, 2019c). Rinse reusable supplies in saline or sterile saltwater (John Hopkins Medicine, 2020). Method 2: Soak reusable supplies that touch membranes in prepared solution of 70% isopropyl for 5 minutes (CDC, 2019c). Rinse usable supplies in saline or sterile saltwater (John Hopkins Medicine, 2020). Method 3: Soak reusable supplies that touch membranes in prepared solution of 5.25% 6.15% sodium hypochlorite (household bleach) for 5 minutes (CDC, 2019c). Rinse reusable supplies in saline or sterile saltwater (John Hopkins Medicine, 2020). DIF: CognitiveLevel: Application OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Tracheostomy Care KEY: NursingProcess Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
8. In preparing to teach a patient how to self-administer mediation, the nurse realizes that 80% of patients who are instructed to self-medicate for preventative care fail to do so. Reasons for this include which of the following rationales? (Select all that apply.) a. Fear of adverse events b. Inconvenient medication regimens c. Costly prescriptions d. Forgetfulness ANS: A, B, C, D
Some barriers to medication adherence include fear of adverse reactions from medications, belief that a medication does not help, inconvenience of taking medication, cost of medication, inadequate knowledge, forgetfulness, and lack of social support. DIF: CognitiveLevel: Comprehension OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Failure to Self-Medicate KEY: NursingProcess Step: Planning MSC: NCLEX: Safe and Effective Care Environment COMPLETION
1. Temperatures in the older adult are different from those in the younger adult. The mean oral temperature for older adults often ranges from . ANS:
35° C to 36.1° C (95° F to 97° F) 35° C to 36.1° C 95° F to 97° F Mean oral temperature for older adults often ranges from 35° C to 36.1° C (95° F to 97° F); therefore, temperatures considered within the normal range sometimes reflect a fever in the older adult. DIF: CognitiveLevel: Knowledge OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Temperature of Older Adults KEY: NursingProcess Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
2. Oxygen-conserving devices (OCDs) reduce the amount of oxygen the patient uses, resulting in an overall cost reduction to the patient. The type of OCD that stores oxygen in a chamber during the expiratory phase of respirations is known as the _. ANS:
reservoir nasal cannula The reservoir nasal cannula stores oxygen in a chamber during the expiratory phase of respirations. DIF: CognitiveLevel: Knowledge OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Reservoir Nasal Cannula KEY: NursingProcess Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
3. Oxygen-conserving devices (OCDs) reduce the amount of oxygen the patient uses, resulting in an overall cost reduction to the patient. The type of OCD that delivers oxygen only during inspiration is called a . ANS:
demand oxygen delivery system Demand oxygen delivery systems deliver a burst of oxygen only during inspiration. DIF: CognitiveLevel: Knowledge OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Reservoir Nasal Cannula KEY: NursingProcess Step: Assessment MSC: NCLEX: Physiological Integrity
4. While teaching how to check for gastric residual volume (GRV), the nurse instructs the caregiver to delay the tube feeding if he or she obtains more than mL of gastric aspirate. ANS:
500 Instruct the patient or caregiver to contact the home care nurse or health care provider. Automatic cessation of feeding should not occur for GRV less than 500 mL in the absence of other signs of intolerance such as nausea or abdominal distention If gastric aspirates are greater than 250 mL, instruct the patient or caregiver to return gastric contents and delay tube feeding for 1 hour. If aspirates remain greater than 250 mL after an hour, instruct the patient or caregiver to contact the home care nurse or health care provider. DIF: CognitiveLevel: Knowledge OBJ: Implement and evaluate appropriate learning strategies that support patients‘ ability to care for themselves in the home. TOP: Gastric Residual KEY: NursingProcess Step: Planning MSC: NCLEX: Health Promotion and Maintenance