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TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER

Chapter 01: Using Evidence in Nursing Practice Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. A nursing educator is explaining how the best clinical practices are determined. Which

statement best explains the purpose of evidence-based practice? a. It ensures that all patients receive holistic care. b. It provides a definite reason for providing care in a specific manner. c. It prevents errors when care is being delivered. d. It guarantees that care delivered is based on research.

ANS: B

Evidence-based practice is the use of the current best evidence in making patient care decisions. It applies to all types of health care professionals. Currently there is no method that can ensure that all patients receive holistic care, that all errors can be prevented, or that a guarantee exists that care given is based on research.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

2. Which question is a problem-focused trigger for initiating the evidence-based practice method

in nursing care? a. What is known about reduction of urinary tract infections in the older adult with diabetes? b. How can chronic pain best be described when the patient is nonverbal?

N c. How long can an IV catheter remain in place in a patient with obesity? d. What measures can the nurse take to reduce the rising incidence of urinary tract infections on the older adult care unit?

ANS: D

Evidence-based practice (EBP) questions tend to arise from two sources: recurrent problems or new knowledge. In the correct option, the increase in urinary tract infections indicates a trend or recurring problem in a specific group of patients. The other questions are general information questions, not based on what is happening in a specific area or to a group of specific patients in an area or relating to an observed trend.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

3. What does the “I” indicate in a “PICO” question? a. Intervention of interest b. Incorporation of concepts c. Implementation by nursing d. Interest of personnel ANS: A

The “I” stands for intervention of interest, meaning what the nurse hopes to use in practice and believes is worthwhile or valuable. This could be a treatment for a specific type of wound or an approach on how to teach food preparation for a patient with impaired sight.

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DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

4. Who will the clinical research nurse contact to search relevant databases in preparation for an

upcoming study? a. The physician whose patients may be involved in the study b. The medical librarian c. The nurse manager of the unit where the study will be conducted d. The director of nursing of the facility ANS: B

The medical librarian is most knowledgeable regarding databases relevant to a study. The other individuals do not have the knowledge regarding relevant databases.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

5. Which database contains summaries of clinical guidelines and their development? a. MEDLINE b. CINAHL c. Cochrane Database of Systematic Reviews d. The National Guideline Clearinghouse ANS: D

The National Guideline Clearinghouse is a database supported by the Agency for Healthcare Research and Quality. It contains summaries of clinical guidelines for practice. MEDLINE is a database for studies in medicine, N nursing, dentistry, psychiatry, veterinary medicine, and allied health. CINAHL (Cumulative Index of Nursing and Allied Health Literature) includes studies in nursing, allied health, and biomedicine. The Cochrane Database Full text of regularly updated systematic reviews prepared by the Cochrane Collaboration includes completed reviews and protocols.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

6. Which does the nurse researcher identify as the strongest type of research? a. Randomized controlled trials b. A qualitative study c. A descriptive study d. A case controlled study ANS: A

Individual randomized controlled trials are close to the top of the research pyramid. Only systematic reviews and meta-analyses are higher. This type of study tests an intervention against the usual standard of care. The other types of studies are useful but do not give the same type of information as a randomized controlled trial provides.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

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7. What is the nurse attempting to determine when critiquing the evidence related to a PICOT

question? a. The ethical conduct of the research the nurse read b. The strength of the evidence found in the literature c. If there are any experts in the clinical question needing to be researched d. If the study demonstrates cost-effectiveness if a change in practice occurs ANS: B

Once a literature search is complete and data are gathered about the question, it is time to critique the evidence. Critiquing the evidence involves a systematic approach to looking at the strength of the work reviewed and its relevance. The other questions are not applicable to critiquing the evidence.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

8. A nurse finds a cohort study comparing one group taking hormone treatment with another

group not taking hormone treatment to determine the incidence of changes in bone density of the lower spine. What can the nurse imply from this study? a. Low level of strength makes the study limited in value. b. Moderate level of strength makes the study probably useful. c. Opinions of the individuals in the cohort are not research. d. This could be the basis for a Quality Improvement project.

ANS: B

A cohort study is Level 4 evidence as it is a single, non-experimental study. This moderate level of evidence makes the study probably useful but the nurse should strive to find stronger N evidence.

DIF: Cognitive Level: Applying TOP: Nursing Process: Evaluation

OBJ: NCLEX: Safe and Effective Care Environment

9. Which question would be the best example of a knowledge-focused trigger for conducting an

evidence-based practice project? a. What is the best method for treatment of leg swelling when a patient is taking gabapentin (Neurontin)? b. How can we decrease the incidence of skin cancer in adults over the age of 65? c. What is the current evidence for improving oral intake for cancer patients with stomatitis? d. What is the maximal length of time our hospital allows irrigation kits to be used?

ANS: C

Evidence-based practice (EBP) questions tend to arise from two sources: recurrent problems or new knowledge. In this example, the new knowledge that drives the question is the one looking at current evidence. The other questions do not look at the newest knowledge to form a question to research.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

MULTIPLE RESPONSE

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1. When planning to implement an evidence-based practice strategy, what factors are most

important for the nurse to consider and include? (Select all that apply.) a. Time required to perform the strategy b. Patient preferences and values c. Clinical expertise d. Scientific knowledge e. Historical practices ANS: B, C, D

When implementing evidence-based practice, the nurse considers and includes clinical expertise and patient preferences and values in addition to the scientific knowledge. Time required to perform the new strategy and customary practices are not vital to this approach. In fact, EBP seeks to ensure practices are based on evidence and not just historical practice.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

2. A new nurse wants to ensure practice is based on the best knowledge available. What actions

are best for this nurse to be involved in evidence-based practice? (Select all that apply.) a. Design and conduct a study based on interest. b. Join the hospital’s policy review committee. c. Remain vigilant for recurring problems. d. Maintain a spirit of inquiry. e. Read current literature appropriate to practice area.

ANS: B, C, D, E

N This novice nurse would best maintain an evidence-based nursing practice by joining policy review committees, watching for and taking note of recurring problems in the practice area, maintaining a spirit of inquiry, and staying current in the literature. The nurse would not need to design and conduct a study.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

3. When explaining the value of evidence-based practice, what benefits does the nurse include?

(Select all that apply.) a. Improves quality of care. b. Improves patient outcomes. c. Improves stakeholder satisfaction. d. Incorporates near real-time data in practice. e. Helps nurses remain current in practice.

ANS: A, B, D, E

There are five ways that EBP adds value to the health care system: helps clinicians remain current on standardized, evidence-based protocols; uses near real-time scientific data to make care decisions; improves transparency, accountability, and value (e.g. safe care); improves quality of care; and improves outcomes. One would hope all stakeholders would be more satisfied with this method of determining care but that is not one of the specific benefits.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

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Chapter 02: Communication and Collaboration Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse interviews a patient during admission. Which observation by the nurse identifies

consistency between the patient’s verbal and nonverbal communication? a. Asserts she is eager to answer questions while reading a magazine. b. States that he wants information while frequently changing the subject. c. Asks the nurse to explain a surgical procedure while she listens intently. d. Explains that he is relaxed while continuously shifting in his chair.

ANS: C

The patient demonstrates congruency, or consistency, between her verbal statement asking for an explanation and her nonverbal cue of listening intently. The verbal and nonverbal messages match; each indicates that the nurse’s response is important to her. If she is eager to answer questions, the patient should focus on the nurse’s questions or note taking; reading a magazine is a distraction and indicates a lack of interest. Changing the subject may indicate discomfort or reluctance to address the issue. Continually shifting position may be an indication of anxiety.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

2. The nurse is interviewing a newly admitted patient. Which statement by the nurse is most

likely to result in effective patient communication?

N a. “I’m not sure why you’re here. Can you explain it to me?” b. “Tell me about things and people that are important to you.” c. “Tell me more about your pain. Where does it start?” d. “If you think it’s important, I’ll try to notify the provider.”

ANS: C

The nurse communicates effectively by using focused questions. This encourages the patient to give more information about the specific topic of concern. The remaining options are ineffective communication techniques because each potentially impairs the exchange of information between the nurse and the patient regarding care needs. The patient may be unwilling to express concerns openly after the nurse expresses lack of understanding and empathy. The patient will also likely lose confidence in the nurse if the nurse expresses confusion about suitability of the patient’s presence. By asking what is important to the patient, the nurse loses focus of the objective of the communication and is likely to confuse the patient.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 3. After receiving a diagnosis of a fatal disease, the patient expresses sadness and states “I don’t

know what to do next”. Which action by the nurse best facilitates communication at this time? a. Sit quietly with the patient and observe nonverbal communication. b. Reassure the patient that his family will take care of him. c. Refer the patient to a church for spiritual counseling.

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d. Tell the patient that hospice care is available immediately.

ANS: A

Because of the grim diagnosis, the patient expresses confusion and lacks a clear direction. The patient is not able to process information at this time and is overwhelmed. Sitting quietly with the patient shows acceptance, empathy, and allows the nurse to observe nonverbal communication. The patient can benefit from a calming atmosphere and time to process the new information. Assuring the patient of family involvement requires consultation with the family first. Spiritual counseling may not be indicated for this patient if the patient does not wish to participate. Discussing hospice at this early stage is premature; the patient needs time to process the news and gather information but is not able to do so right now.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 4. The nurse is preparing to begin the patient hand-off procedure for five patients. Who should

the nurse include in this process? a. Only the licensed nurses b. The nursing personnel caring for the patients c. The entire interdisciplinary team d. The nurses and health care provider ANS: B

All the nursing personnel on the unit who will be interacting with this group of patients should actively participate in the patient hand-off. This would include nursing assistive personnel (NAP) and the nurses. An interdisciplinary team usually meets when there is a problem with a patient and all the team members need to discuss approaches and plans with and for a patient N care provider does not participate in the patient hand-off or as a routine meeting. The health procedure.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 5. The nurse brings the patient’s medications into the room, and the patient shouts, “You don’t

care if I take these, so get out of my room!” Which response by the nurse is most appropriate? a. “Who misinformed you about my feelings?” b. “You seem very angry about the medications.” c. “We know each other; why are you saying this?” d. “I cannot leave until you take these medications.”

ANS: B

Stating observations encourages the patient to be aware of his or her behavior. This neutral response would allow the patient time to explain the meaning behind the anger. Asking who misinformed the patient is confrontational. “Why” questions tend to put people on the defensive. Stating that the nurse cannot leave until the medications are taken is also confrontational and would set up a possible power struggle between the two.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 6. The patient shouts at the nurse, “No one answered my nurse call system all night!” Which

response would the nurse use with this patient to restore therapeutic communication?

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a. b. c. d.

“Shouting is going to disturb other patients.”

“I see how that would make you very angry.”

“Are you sure the nurses were avoiding you?”

“The unit has many very sick patients right now.”

ANS: B

Regardless of whether the nurses answered the patient’s nurse call system during the night, the patient felt ignored. By empathizing with the patient’s distress and reflecting feelings, the nurse displays respect and understanding of his or her experience. Reprimanding the patient is humiliating and conveys the nurse’s lack of regard for the patient’s feelings. Quieting the patient is achievable by displaying empathy, caring, respect, and willingness to hear his or her complaints. Questioning the patient’s perception is demeaning and forces the patient to justify feelings, similar to asking a “why” question. Stating that the unit has very sick patients implies that the patient is not as important as the others are.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 7. A patient with a history of violence directed toward others becomes very excited and agitated

during the nurse’s interview. Which intervention does the nurse implement to foster therapeutic communication? a. Call the security staff for assistance. b. Ask the patient to use self-control. c. Lean forward and touch the patient’s arm. d. Assume an open, nonthreatening posture.

ANS: D

N skills and assume an open, nonthreatening posture that The nurse should use neutralizing conveys respect and acceptance, creating an atmosphere in which the patient can communicate without feeling threatened or defensive. Calling security in the patient’s presence is likely to aggravate the patient and escalate the potential for violence because it is humiliating, conveys the nurse’s rejection of the patient, and threatens to take all control away. Asking the patient to use self-control is reprimanding, humiliating, and conveys rejection and lack of respect by the nurse. The patient can perceive leaning in and touching as threatening.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 8. The nurse admits a patient who is nonverbal and agitated. What can the nurse do to

communicate effectively with the patient? a. Use a communication aid. b. Wait for family to arrive. c. Call interpreter services. d. Treat the patient for pain.

ANS: A

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Patients with sensory losses require communication techniques that maximize existing sensory and motor functions. Some patients are unable to speak because of physical or neurological alterations such as paralysis; a tube in the trachea to facilitate breathing; or a stroke resulting in aphasia, difficulty understanding, or verbalizing. Many types of communication aids are available for use, including writing boards, flash cards, and picture boards. The nurse needs to determine what will work for the patient. Waiting for family is unacceptable because the patient needs care and the family may be delayed or not come at all.

Interpreter services are for patients who do not speak the language. The nurse should not assume the patient has pain before completing an assessment.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

9. A patient’s mother died several days ago. The patient begins to cry and states, “The pain of

her death is impossible to bear.” Which statement by the nurse is the most effective response? a. “I was depressed last year when my mother died, too.” b. “I know things seem bleak, but you are doing so well.” c. “I can see this is a very difficult time for you right now.” d. “Should I cancel your appointment with the cardiologist?”

ANS: C

The nurse conveys empathy and respect by acknowledging the patient’s grief. This is an effective response and is likely to enhance the nurse–patient relationship because it is patient centered, displays caring and respect, and helps to make the patient feel accepted. Relating personal details about the nurse’s life redirects the focus of the communication to the nurse and fails to support the objectives of the nurse–patient relationship. Responding with a comment about the patient’s progress and asking about the cardiologist’s appointment ignores N the patient’s grief and conveys a lack of respect and consideration.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 10. A patient who says that both parents died of heart disease early in life is waiting for diagnostic

testing results. The patient is biting fingernails and pacing around the room. Which statement should the nurse use to clarify patient information? a. “I can see that you are anxious about dying.” b. “Tell me more about your family’s history.” c. “Do you have your parents’ medical records?” d. “I’m not sure that I understand what you mean.”

ANS: B

Asking for more information about the family’s history directs the patient to expand on a specific, pertinent topic and relate key details before moving to another topic. “Early in life” and “heart disease” need to be defined by the patient; “early in life” can indicate a wide range of ages, depending on the definition of “early,” and “heart disease” can mean conditions such as heart failure, coronary artery disease, valve disease, and arrhythmias. Until the patient discusses his particular concerns, the nurse cannot be sure about the source of his anxiety.

Asking for the records can display a lack of respect by implying that the patient is an unreliable source for information. Stating that the nurse is not sure what the patient means is vague, leaving the patient to guess what the nurse wants to know.

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DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 11. The patient tells the nurse, “I must be very sick because so many tests are being performed.”

Which statement does the nurse use to clarify the patient’s message? a. “I sense that you are very worried.” b. “Why do you mention this so frequently?” c. “We should talk about this more.” d. “Are you saying you think you are seriously ill?”

ANS: D

The nurse clarifies the patient’s message. This encourages the patient to expand on a thought or feeling that seems vague to the nurse. Pointing out that the patient has stated this before can be misinterpreted to mean that the patient is forgetful or annoying, and “why” questions tend to put people on the defensive. Stating that the nurse feels that the patient is worried is a suitable response but does not clarify what the patient actually said. Telling the patient he or she “should” talk about this topic is confrontational.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 12. The patient tells the nurse, “I want to die.” Which is the best response by the nurse to facilitate

therapeutic communication? a. “Now why would you say a thing like that?” b. “Tell me more about how you’re feeling.” c. “We need to tell the provider how you feel.” d. “You have too much to live for to say that.”

N

ANS: B

The patient’s statement warrants further investigation to determine how serious the patient is about dying and whether he or she has a plan. To elicit more information from the patient in a respectful and caring manner, the nurse allows the patient to expand on the statement, “I want to die” by stating, “Tell me more.” The statement displays concern for and value of the patient by acknowledging the patient’s message and encouraging him or her to continue. Safety is a major concern when a patient wants to die, and the remaining options are likely to be perceived as patronizing and/or dismissive.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 13. The nurse is explaining a procedure to a 3-year-old patient. Which strategy would the nurse

use for patient teaching? a. Ask the patient to draw her feelings. b. Show needles, syringes, and bandages. c. Tell the patient about postoperative pain. d. Use dolls and stories to explain surgery.

ANS: D

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Using dolls, stuffed animals, or puppets with stories is a suitable way to explain surgery to the 3-year-old patient because storytelling is a familiar communication method for the toddler’s developmental stage. A 3-year-old child is unlikely to understand an explanation about the surgery suited for an adult, and the discussion can frighten the child and upset the family or guardian. A 3-year-old child lacks the fine motor and cognitive skills to draw an abstract concept. A toddler is unlikely to understand and probably would be frightened by a discussion about postoperative pain.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 14. The nurse is caring for a patient who states, “I don’t feel well today.” Which is the best

response by the nurse? a. Ask the patient to continue to describe the feeling. b. Measure the blood pressure and temperature. c. State that the patient’s diagnostic testing had normal results. d. Compare recent laboratory results with the prior results.

ANS: A

Because the patient’s statement is too vague, the nurse asks him or her to continue describing, “I don’t feel well today,” because many disorders begin with nonspecific complaints.

Depending on the details the patient shares, the nurse plans and implements nursing care individualized to his or her description. This may include taking vital signs, and reviewing lab data, but before taking action the nurse needs more information. Telling the patient that test results are normal is dismissive of the concern.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment N TOP: Integrated Process: Communication and Documentation 15. The nurse is caring for a patient who refuses to participate in physical therapy (PT) and states,

“I really don’t like to exercise.” Which response by the nurse is most likely to help engage the patient in PT? a. “It makes the pain worse, doesn’t it?” b. “What don’t you like about exercise?” c. “You really should do these exercises.” d. “Do you like to do any other activities?”

ANS: B

The nurse asks an open-ended question using the patient’s words to uncover information about the patient’s refusal to participate in PT by asking what the patient dislikes about exercise. Using the patient’s words conveys acceptance and value because the nurse listened closely enough to repeat what the patient said. Asking the patient a yes-or-no question such as, “It makes the pain worse, doesn’t it?” is unlikely to promote further discussion because it is a closed, yes/no question. Telling the patient to do the exercises is giving advice; rather the nurse can tell the patient the reason for the therapy and the benefits of doing it or the risks of not doing it. Asking about other activities moves the focus away from the patient’s need for physical therapy. This is also a yes/no question.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation

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16. The nursing staff are using the SBAR communication technique during patient hand-off

communication. The circumstances leading up to the current status would be explained by the nurses during which step of the technique? a. Situation b. Background c. Assessment d. Recommendations ANS: B

The background explains circumstances leading up to the situation. The situation explains what is happening at the present time. The assessment phase identifies what the problem is thought to be. The recommendations explain how to correct the problem.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 17. The nursing staff are working with a postoperative patient from another culture who does not

understand or speak the English language well. Which approach by the nurse would be best? a. Act out what the patient needs to do. b. Obtain a medical interpreter. c. Assess if the patient can read or write. d. Talk slowly when instructions are given.

ANS: B

A medical interpreter would be most helpful for effective communication. Acting out what the patient needs to do is ineffective and may be embarrassing to both the patient and the nurse.

Since the patient and nurse do not speak a common language, defining the patient’s ability to N does not solve the communication problem. Talking read or write in his native language slowly will not improve the patient’s ability to understand an unfamiliar language.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 18. The nurse is working toward discharging a patient. Which of following demonstrates patient

engagement during the discharge process? a. Teaching the patient how to use his equipment b. Having the patient establish daily goals c. Reviewing the discharge instructions with the patient d. Including the family in the discharge planning ANS: B

All of the answers are important to the discharge process but having the patient set his or her own daily goals establishes true patient engagement. The other interventions are performed by the nurse and do not really engage the patient. Patient engagement requires that the patient’s preferences be incorporated.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation

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19. The registered nurse is orienting a new nurse to the unit. They are completing paperwork on a

newly admitted patient. When the experienced nurse asks what the new nurse thinks the patient will need to learn for self-care at home, the new nurse expresses surprise. What statement by the registered nurse is most appropriate? a. “You should always at least start thinking about discharge planning.” b. “We don’t want to wait too long because unexpected things happen.” c. “The admitting nurse has to fill in all sections of this document.” d. “Best practice is to begin discharge planning on admission.”

ANS: D

Discharge planning should begin on admission to be accurate, thorough, and to allow the patient and/or family enough time to learn information or to master skills they will need at home. The other options may be at least partially true, but the only comprehensive answer is that it is best practice.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 20. A student is watching a nurse perform a medication reconciliation prior to transferring the

patient to a skilled nursing facility. What explanation of this process to the student is best? a. “It is required by the Joint Commission before discharge or transfer.” b. “It creates an accurate list of medications so errors do not occur later.” c. “It helps us recognize lapses in patients’ ability to remember their medications.” d. “Receiving facilities won’t accept patients without a reconciliation.”

ANS: B

Medication reconciliation is the process of creating the most accurate list of medications a patient is taking and comparingNit to provider admission, transfer, and discharge orders. This is done in order to prevent medication errors at each transition.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 21. A nurse is reviewing medications and treatments one final time before the patient goes home.

The patient becomes agitated and says “I just can’t do this! I’m too upset to ever be able to learn this!” What action by the nurse is best? a. Provide immediate remediation on the knowledge and skills. b. Ask the patient if home health care might be acceptable. c. Request the provider re-examine all the discharge orders. d. Tell the patient you would like to understand what is most difficult.

ANS: D

Just prior to discharge, the nurse reviews the discharge orders and plans with the patient.

When the patient cannot recall information or perform needed skills, the nurse can provide immediate re-teaching and skills practice. However, this patient is upset, so the nurse must first determine the most bothersome aspect of the situation, which may or may not include the instructions. The nurse must first assess this before deciding if home health care is acceptable or before asking the provider to review the orders to see if they are all necessary.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation

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MULTIPLE RESPONSE 1. During a home care visit, the patient experiences an angry outburst and hits the nurse on the

thigh and yells at her. The patient continues to be threatening. What are the most appropriate initial actions by the nurse? (Select all that apply.) a. Increase the personal space between the nurse and patient. b. Call law enforcement to take the patient to the hospital. c. Restrain the patient’s hands to the chair. d. Be empathetic to the patient’s feelings and concerns. e. Call the nursing agency to ask for advice in working with this patient. f. Use a calm, quiet voice when talking with the patient.

ANS: A, D, F

The priority in this situation is the safety of both nurse and patient. The nurse should ensure there is adequate personal space between the two of them so the patient cannot strike the nurse. Being empathetic displays respect; even if the nurse disagrees with the patient’s perception, it is real to that person. Using a calm, quiet voice is a de-escalation technique. The patient may or may not need hospitalization, but calling the police would not be the first action. The patient’s hands should not be restrained as this could cause the patient to escalate and perhaps feel assaulted. The nursing agency should be consulted, but not as an initial action. The nurse needs to create an environment that is safe for both parties.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 2. Which of the following pieces N of information should be included in a hand-off to ensure

patient safety? (Select all that apply.) a. Code status b. Recent changes in condition c. Age d. Family visitation e. Use of oxygen ANS: A, B, E

It is important to include information on a patient’s background, assessment, nursing diagnosis, interventions (including the patient’s response), family information, discharge plans, and current priorities when handing off your patient to another unit or area. However, only code status, recent changes in patient’s condition, and use of oxygen directly impact patient safety.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 3. A faculty member is explaining personal factors that influence communication. What factors

does the faculty member include? (Select all that apply.) a. Perceptions b. Values c. Emotions d. Relationships

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e. Pain ANS: A, B, C, D

Although a patient’s pain may affect communication, it is not a personal factor as are perceptions, values, emotions, and relationships.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation

N

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Chapter 03: Documentation and Informatics Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse discovers a medication error on another nurse’s documentation, so the nurse

completes an incident report. Which statement should the nurse include in the report? a. “Nurse mistakenly gave the wrong dose of medication for pain.” b. “Nurse gave incorrect dose of pain medication, but patient is all right.” c. “Morphine 10 mg IM given rather than morphine 5 mg IM as ordered.” d. “Physician will be notified of error when he makes rounds tomorrow.”

ANS: C

Stating that the patient received morphine 10 mg instead of 5 mg is a factual statement to include on an incident report because it is objective and provides no interpretation or conjecture from the nurse. The remaining choices are incorrect statements that do not accurately reflect what occurred. The physician needs to be notified as soon as the patient has been assessed, not the following day.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 2. The nurse is documenting the care of a patient. Which entry would be characteristic of

charting by exception (CBE) as a documentation method? a. The patient needed to be turned every hour because of increasing pain. b. The patient’s vital signs are stable.

N c. The patient’s gait was steady with assistance from physical therapy. d. There was no odor when the dressing was removed.

ANS: A

CBE allows the nurse to specify exceptions to normal nursing assessments efficiently without documenting the normal assessment data and reducing the amount of narrative writing in patient documentation. The emphasis is on recording abnormal findings and trends in clinical care. It is a shorthand method for documenting based on defined standards for normal nursing assessments and interventions. CBE simply involves completing a flow sheet that incorporates these standards, thus minimizing the need for lengthy narrative notes. Increasing pain would not be expected and would be outside the “normal” or “expected.”

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 3. The nurse is documenting on a patient with a respiratory problem. Which patient datum

documented by the nurse is the least objective? a. Cool and dusky skin b. Low flow rate oxygen c. 30 breaths per minute d. Very restless and drowsy ANS: B

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Low flow rate oxygen is the least objective datum and the datum most subject to interpretation because the quantity of oxygen is not as precise as “liters/minute” or the “percentage” of oxygen. The remaining options provide more verifiable data.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 4. The nurse runs into a co-worker whose family friend is a patient on the unit. The co-worker

asks about the friend’s health problems. Which is the correct response by the nurse? a. “Your friend told us to say nothing.” b. “Why don’t you ask your friend now?” c. “You know I can’t talk about the patients.” d. “Well, it was really a very difficult surgery.”

ANS: C

The nurse can’t talk about the co-worker’s friend or acknowledge the friend’s presence in the agency without breaching the friend’s right to privacy, so the nurse reminds the co-worker about confidentiality.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 5. The nurse is providing home care for a patient with an infection that is not improving. The

patient refuses to see an infectious disease specialist. What should the nurse include in the documentation of the patient teaching provided? a. The discussion about the consequences of refusing to see a specialist and the patient’s response.

N the specialist will most likely lead to a worse b. The explanation that avoiding outcome. c. A hopeful explanation that this will most likely be the last medical specialist that the patient will need to see. d. The recommendation that the patient should discuss the decision with the family.

ANS: A

The nurse documents the discussion about the consequences of refusing to see a specialist and the patient’s response. Documenting the factual information presented about the risks of refusing treatment and the patient’s specific response to it (continued refusal to seek a specialist) are key pieces of information to include. The nurse should neither try to scare the patient into seeing the specialist nor provide false hope that only one consultation will be required. As long as the patient is competent to make a decision, the nurse must accept his or her choice. It is a requirement to document the facts surrounding that choice.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 6. At 0915 the nurse repeatedly instructs the patient to remain in bed. At 0930 the nurse enters

the patient’s room, finds the patient on the floor, and hears the patient say, “I need pain medicine.” Which should the nurse do to document this event? a. Label the late entry using the time of 9:15 AM. b. Enclose the patient statement within quotations. c. Document completion of an incident report.

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d. Record plan to administer pain medication.

ANS: B

The nurse documents patient statements in quotations to indicate the patient’s precise statement. The nurse should document instructions given at 0915 and verify any indications of patient comprehension. A second entry noted at 0930 documents finding patient on floor.

Completion of an incidence report is not documented in the patient record since it is an internal evaluation report. Administration of medication is only documented after it occurs to make sure that the documentation is accurate in terms of time and patient response.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 7. A nurse passes by a computer screen that has patient information that can be seen by visitors.

What is the appropriate action for the nurse to take at this time? a. Leave the computer screen alone. b. Try to find the nurse caring for this patient. c. Document this situation on an incident report. d. Close the computer screen.

ANS: D

All agency staff have a responsibility to maintain patient confidentiality and should not leave a computer displaying patient information open. The nurse should minimize or close the computer screen so patient information cannot be seen by visitors. He or she should talk with the nurse caring for this patient about what happened. Incident reports are only filed when a patient experiences an adverse event. This situation does not require an incident report.

DIF: Cognitive Level: ApplyingN OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 8. Nursing assistive personnel (NAP) finds a patient on the floor 30 minutes after the patient

ambulated with physical therapy. What information should be charted by the NAP on the incident report? a. “Patient fell out of bed and landed on the floor.” b. “Patient found on floor. Upper side rails up. Bed in low position.” c. “Patient got dizzy and fell although ambulated with physical therapy earlier.” d. “Patient unfortunately slipped and fell.”

ANS: B

Documentation should state facts: “Patient found on floor. Upper side rails up. Bed in low position.” Only objective data with no interpretation can be documented by the NAP. The NAP does not evaluate the situation. Words such as “unfortunately” are never used in documentation. The NAP found the patient on the floor and did not see the patient slip and fall.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 9. An incident report is completed as a result of the pharmacy sending the wrong medication to

the unit, even though the medication wasn’t administered. A student asks the nurse why this was needed. What response by the nurse is best? a. To make sure that the pharmacy was blamed for the error and not the nurse

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b. To help the pharmacy identify risks and prevent this situation from occurring again c. To prevent the hospital from a medical malpractice suit d. To get the health care provider’s attention about ordering medications ANS: B

The incident report is a risk-management tool that enables health care providers to identify risks within an agency, analyze them, and act to reduce the risks and evaluate the results. This is also true when deviations from standards occur and not only when actual adverse events happen. Alerting the pharmacy to this type of error should help prevent it from occurring again. There was no problem with the health care provider’s order, only with how it was filled.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 10. The nursing staff have been using the SBAR format to structure communication for the past

few months. Successful implementation of this system would be present if the nurse manager made which statement? a. “There are fewer omissions in patient care than before implementing this system.” b. “Fewer nurses are coming in late when they are scheduled to work.” c. “The medications are given on time now.” d. “The patient length of stay has decreased since last year.”

ANS: A

Noting fewer omissions in patient care would indicate successful implementation of the SBAR format. SBAR promotes the provision of safe, efficient, timely, and patient-centered communication. Staff timeliness, medication preparation, and length of patient stays are not affected by implementation of N SBAR. DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Safe and Effective Care Environment

11. The nursing staff are assisting nursing students in learning military time for documenting.

Instruction by the nurses has been effective if the students identify that which entry reflects 40 minutes after midnight? a. 0040 b. 1240 c. 0004 d. 0400 ANS: A

0040 is 12:40 AM. 1240 is 12:40 PM. 0004 is 12:04 AM. 0400 is 4:00 AM. DIF: Cognitive Level: Understanding TOP: Nursing Process: Evaluation

OBJ: NCLEX: Safe and Effective Care Environment

12. The following is an example of what part of the SBAR communication mnemonic?

“Her blood pressure has decreased from 140/90 to 100/50 and she vomited 400 mL of bright red blood.” a. S b. A c. R

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d. B ANS: A

This is an example of S-Situation—what is happening at the present time. Background (explain the circumstances leading up to the situation). Assessment (what you think the problem is). Recommendation (what you would do to correct the problem).

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation MULTIPLE RESPONSE 1. Electronic health records (EHRs) can improve patient care. The following is an example of an

alert in an EHR. (Select all that apply.) a. Notification of medication being overdue b. Change in patient’s blood pressure that exceeds parameters c. Order entered for a medication the patient is allergic to d. Routine lab orders e. Critical lab value ANS: A, B, C, E

Alerts in EHRs notify nurses of critical changes in data that affect patient care and can be used to help nurses prioritize care. Overdue medications, critical lab values, and medication allergies are some of the examples of standard alerts. Alerts can also be tailored to patients to monitor for changes in their vital signs above certain parameters. When electronic health record alerts are used in the nurse’s practice, patient outcomes can be improved.

N DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 2. The Joint Commission standards require all patients admitted to a health care agency to have

the following documented. (Select all that apply.) a. Self-care assessment b. Discharge planning needs c. Environment assessment d. Physical assessment e. Religious practices ANS: A, B, C, D

Current TJC (2012) standards require that all patients who are admitted to a health care agency have an assessment of physical, psychosocial, environmental, self-care, patient education, and discharge planning needs. Religious practices are not a specific assessment although it could be included in the psychosocial assessment.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 3. The following is an excerpt of a discharge planning note. What elements of discharge

planning are present in this example? (Select all that apply.)

“Discussed learning about insulin injection technique. Patient will administer his own injection next time.”

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a. b. c. d.

Measurable patient goal Progress toward goal Need for referral Discharge date

ANS: A, B

The information within a recorded entry must be complete, containing appropriate and essential information. There are criteria for thorough communication for certain health situations. For example, when recording discharge planning, measurable patient goals or expected outcomes, progress toward goals, and need for referrals are always included.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 4. In a POMR charting method of documentation, which of the following items are used? (Select

all that apply.) a. Progress notes b. Database c. Medical diagnosis d. Problem list e. Care plan ANS: A, B, D, E

The problem-oriented medical record (POMR) is a structured method of documentation that emphasizes a patient’s problems. It is organized using the nursing process. Organization of data is by problem or diagnosis. Ideally each member of the health care team contributes to a single list of identified patient problems. Each recording includes a database, problem list, care plan, and progress notes. N DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation

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Chapter 04: Patient Safety and Quality Improvement Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse is caring for an older patient who has a non–weight-bearing cast on the left lower

extremity. The patient ambulates without using a walker despite repeated instruction from the nurse to call for assistance. Which response by the nurse is most likely to keep the patient from falling? a. Apply a vest restraint and offer frequent toileting. b. Plan fall prevention with patient, family, and health care provider. c. Inform family that the patient needs physical restraints. d. Document that the patient has a high potential for falling.

ANS: B

Planning an individualized fall prevention program with the help of the patient, family, and health care provider is more likely to reduce the patient’s risk of falls because the patient gains some control over the plan of care and still benefits from the input of the provider, family, and nurse. A combination of interventions is more useful in preventing falls. Including the patient in planning also gives him or her ownership of the plan, making it less likely the patient will disregard this plan. Restraints are associated with serious injuries and are not recommended for use unless nothing else has worked. Alternative methods of engaging the patient in a care plan that minimizes risks should be exhausted before resorting to restraints. Documenting the patient’s risk is important because it communicates the information and records the nurse’s acknowledgment of the risk, but it is not as effective as engaging the patient in planning care as a prevention technique because N it is indirect.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

2. The nurse plans a fall prevention program for a confused patient. Which task from the

program is suitable for the nurse to delegate to nursing assistive personnel (NAP)? a. Evaluating patient understanding of fall prevention plan b. Keeping the patient’s bed in the low position at all times c. Assessing the patient’s circulatory and respiratory status d. Instructing the patient’s family about alternatives to restraints ANS: B

The nurse may delegate keeping the bed lowered to the NAP because the NAP is trained to perform the task with proper nursing supervision. Skills used to prevent falls can often be delegated. The nurse does not delegate the remaining options because they involve aspects of the nursing process that require the advanced training of a nurse to perform.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

3. The nurse plans care for a patient who requires physical restraint. Which is a suitable goal for

this patient? a. The patient remains free of any injury. b. The nurse checks the restraint every hour.

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c. The nurse uses the least restrictive restraint. d. The patient allows the nurse to apply restraints.

ANS: A

When restraints become necessary, the patient must remain free of injury; thus the nurse plans frequent neurovascular checks and removes the restraint on a regular basis to inspect the skin for pressure points and breakdown and perform range-of-motion exercises to maintain joint flexibility. Checking the restraint is a nursing intervention; it is not a goal because it is not patient centered. Using the least restrictive restraint can defeat the purpose of a restraint.

When a restraint is required, the nurse uses the proper restraint to keep the patient safe and facilitate the therapeutic regimen. This is not a suitable goal because it focuses on the nurse. If the patient or staff members’ safety is at risk, the nurse applies restraints without the patient’s permission.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

4. The nurse applies a physical restraint to the patient. Which entry should the nurse make after

applying the restraint? a. Performed restraint application reluctantly b. Applied bilateral soft lamb’s wool wrist restraints; skin pink, moist, and intact c. Will perform a neurovascular assessment every 4 hours d. Checked provider’s prescription for prn restraints ANS: B

The nurse documents the type of restraint applied and the condition of the skin where the restraint was placed in the progress notes to communicate the information to the health care N subjective statements about the nurse. Neurovascular team. The nurse does not document assessments of a patient’s extremity must take place at least every 2 hours because skin breakdown can occur very quickly. The nurse does not accept prn prescriptions for restraints according to nursing standards and federal regulations.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 5. The patient sustains a minor leg abrasion and stops breathing for a few seconds during a

tonic-clonic seizure. Which is the best nursing documentation after the patient’s seizure? a. Type of muscle contractions b. Size and description of the abrasion c. Length of the patient’s apneic episode d. Description of the seizure in detail ANS: D

Describing the seizure in detail is the best documentation after a seizure because it is the most comprehensive item listed and includes the type of muscle contractions observed during the seizure, the description of injuries, how the injuries occurred, and the description of any breathing abnormalities.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation

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6. A patient at risk for falling is being ambulated. Which action by the nurse is most important to

prevent the patient from falling? a. Raising the bed to an appropriate working height b. Placing nonskid shoes on the patient c. Dangling the patient on the side of the bed for 10 minutes d. Turning on the brightest lights in the room ANS: B

Placing nonskid surfaces on the patient’s feet helps to prevent falls. The height of the bed should be as low as possible before attempting to have the patient stand. Dangling prevents dizziness, but the length of time differs, and it is not required for all patients. Adequate light is important, but the brightest lights are not needed.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

7. The nurse is orienting a group of new nurses and explaining the concept of sentinel events and

their causes. What should the nurse explain as a common root cause of all sentinel event? a. Medication errors b. Falls c. Communication failures d. High patient-to-nurse ratios ANS: C

Communication failures are one of the most common root causes of all sentinel events. A sentinel event is an unexpected occurrence involving death, serious physical or psychological injury, or risk thereof. Although the other elements may cause sentinel events, they are not as N frequent as communication failures.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation 8. The nurse discovers smoke in the second-floor utility room. What intervention should he or

she implement first? a. Find the fire extinguisher and try to extinguish the fire. b. Evacuate the entire second floor to the first-floor lobby. c. Rescue any patients, visitors, or staff in immediate danger. d. Pull the nearest alarm box and call the telephone operator.

ANS: C

The first step after identifying an actual or potential fire is to rescue victims at risk for injury from the fire, including patients, visitors, or staff, to reduce injuries from the fire. The second step is to activate the alarm. The third step is to contain the fire: find the extinguisher and empty the container onto the fire or source of the smoke. Finally the evacuation begins if the fire is uncontrolled or the smoke is excessive. This follows the acronym RACE. DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

9. The daughter of a patient tells the nurse that using the bathroom is embarrassing for the

patient and she refuses to use a nurse call system when she needs to get up. Which is the best response by the nurse?

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a. b. c. d.

Ask the patient why she does not use the nurse call system.

Instruct the daughter to remain at the patient’s side.

Tell the patient that getting up requires cooperation.

Discuss nurse call system alternatives with patient and daughter.

ANS: D

Discussing nurse call system alternatives with the patient and daughter is the best method of engaging the patient in planning nursing care. This recognizes the patient as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient’s preferences, values, and needs. Including the patient in planning alternatives also gives him or her ownership of the plan and increases the likelihood of cooperation. Asking a “why” question is not an ideal response because it is confrontational and requires the patient to justify feelings. Remaining with the patient is an impractical solution.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

10. Although the interdisciplinary team is responsible for the safety of the patient, who has the

ultimate responsibility for making the patient’s bedside area safe? a. The nurse b. Housekeeping c. Nursing assistive personnel (NAP) d. The maintenance department ANS: A

The nurse has the ultimate responsibility for making the patient’s bedside area safe. Other personnel assist with their specific roles, but the nurse oversees the safety.

N DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

11. The nurse listens to a family’s request to bring a few familiar items into the room of a patient

who is confused. What response by the nurse is best? a. No, because personal items can increase patient agitation. b. No, because personal items can create too much clutter. c. Yes, personal items are likely to restore cognitive function. d. Yes, personal items can comfort a confused person.

ANS: D

Personal items can comfort and calm a confused person because familiar items are part of the patient’s customary environment, patterns, and habits; in addition, these items personalize an otherwise strange environment and surround the patient with recognizable things. The personal items are likely to engage the patient but on their own do nothing to restore cognitive function.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

12. The nurse plans a restraint-free environment but cannot find activities to engage an agitated

middle-aged patient. Which should the nurse implement to maintain the patient’s safety? a. Request help from interdisciplinary team members. b. Transfer the patient to a private room to protect others.

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c. Document that the patient is uncooperative and hostile. d. Ask the health care provider for a sedation prescription.

ANS: A

A nurse’s expertise does not include all facets of health care, so the nurse collaborates with other experts to meet the patient’s safety and psychosocial needs. After assessing the patient, the experts make recommendations, and the nurse incorporates the activities into the patient’s plan of care. Putting the patient in a private room decreases the risk of injury to other patients; but it isolates the patient, increases the need for distraction, and increases the risks to the staff and patient. Documentation should always be descriptive and never judgmental. In this case the nurse would document the patient’s own words in quotation marks. Sedation increases the risk of falls from potential adverse effects, including hypotension, dizziness, and confusion.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

13. A patient has been wandering and is at risk for falling. Which approach by the nurse regarding

the use of chemical and physical restraints in the long-term care setting should be considered initially? a. Use nonprescription restraints first. b. Obtain with a telephone prescription. c. Implement alternative measures first. d. Notify patient’s family within 24 hours.

ANS: C

According to the standards governing the use of restraints, the nurse must implement several alternative measures in a serious attempt to avoid applying restraints. The patient must be N before restraints are implemented unless the patient is a assessed by the health care provider serious and imminent risk to self and others. The patient’s family is notified in a timely manner but is not an initial consideration.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

14. The nurse plans a safety program for the patients on a medical-surgical unit. Which patient

has the greatest likelihood of falling? a. A 79-year-old after a pacemaker battery replacement b. A 68-year-old anemic patient who is dehydrated and has heart failure c. A 21-year-old 2 hours postarthroscopy after a college football injury d. A 33-year-old patient post–right salpingectomy for ectopic pregnancy ANS: B

The patient with anemia and dehydration with heart failure is the sickest patient and has the highest risk of falling. The patient will be taking other medications, including antihypertensive agents that increase the risk of falls caused by confusion, dizziness, or orthostatic hypotension. The replacement of a pacemaker battery in a stable patient is a low-risk, routine procedure. The 21-year-old recovering from the arthroscopy is most likely a healthy adult who is stable while ambulating. The 33-year-old postsalpingectomy is most likely to be healthy but may be a little hypotensive if much bleeding occurred before surgery or from side effects of analgesia.

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DIF: Cognitive Level: Analyzing TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

15. The nurse finds the patient pulling on the nasogastric tube (NGT) and surgical drain and fears

that the patient will pull them out. Which nursing intervention should the nurse implement to maintain the patient’s self-esteem and avoid applying restraints? a. Cover or camouflage tubes and drains. b. Provide constant activity for the patient. c. Instruct family members to watch the patient. d. Keep the patient close to the nurses’ station.

ANS: A

Covering the medical devices is a good intervention. If the patient cannot see them, he or she will be less likely to fidget with them. The nurse most likely will not be able to provide constant activity for the patient. That strategy may also fatigue the patient. Engaging the family in the care of the patient is reasonable; however, the nurse does not rely on the family to provide nursing care. Keeping the patient out by the nurses’ station allows the nurse to observe the patient closely; however, this is likely to lower the patient’s self-esteem because his or her problem is on public display and not all patients are stable enough to do so.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

16. The patient wearing bilateral wrist restraints complains hand numbness, and the nurse assesses

pale, cool fingers. Which is the nurse’s priority intervention? a. Notify the provider quickly. b. Remove the wrist restraints.

N c. Try another type of restraint. d. Increase the restraint padding.

ANS: B

The patient displays clinical indicators of neurovascular impairment, and a delay in resolving the problem can result in tissue damage, so the nurse removes the restraint, thoroughly assesses the extremities, and plans nursing care. Before another type of restraint is applied, the nurse completes the assessment and notifies the provider as necessary. Increasing the padding may be a reasonable intervention after the nurse’s assessment and provider notification.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

17. The patient is having a generalized tonic-clonic seizure. To maintain the airway, which

intervention should the nurse implement after the patient’s motor activity ceases? a. Apply chin-lift position. b. Insert a curved oral airway. c. Sit the patient in upright position. d. Turn the patient to the side.

ANS: D

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After the seizure has ended, position the patient on the side to prevent aspiration. Chin-lift is an effective method of maintaining a patient’s airway; however, it does not protect the patient against aspiration. Oral airways are not inserted during a seizure unless the patient’s jaw relaxes enough to properly insert the airway without causing tissue damage. The upright position is contraindicated for airway maintenance.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

18. The nurse is instructing a patient who has a difficult-to-control seizure disorder on home care

issues. Which issue affecting safety is most important for the nurse to address with patient teaching before discharge? a. Avoiding substances containing alcohol b. Maintaining a current list of medications c. Keeping a supply of medications at work d. Purchasing lawn equipment with a safety switch ANS: D

The most important issue to address is to have the patient purchase any motorized lawn equipment with a safety switch that will stop the machine when the handle is released. Thus the patient avoids injury if he has a seizure while operating the equipment. Although the patient should avoid alcohol to decrease the risk of possible alcohol-drug interactions, and should keep a list of current medications to avoid confusion over the therapeutic regimen, failure to do so poses a lesser risk than using motorized equipment if a seizure occurs.

Likewise, although keeping a supply of medication at work is a good idea, it is not a safety risk not to do so.

N

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

19. A child had surgery on the face and needs to keep the hands away from the surgical site.

Which restraint should the nurse use to accomplish this outcome? a. A jacket restraint b. Mitten restraints c. A mummy restraint d. Elbow restraints ANS: D

The nurse applies bilateral elbow restraints (freedom splint) so the child cannot touch the operative area. They prevent elbow flexion. The child will still be able to hug the parent or hold onto objects. Mitten restraints are inadequate because the hands could still access the face. A mummy restraint is used for short-term examination of a child. Although it does confine, the mummy restraint is more like swaddling. The use of jacket restraints has been discouraged because of safety risks associated with their use and the child’s entire upper body does not need to be restrained.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

20. The nurse participates in the investigation of an incident in the agency. As a result of the root

cause analysis, what would the nurse expect as the ultimate outcome?

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a. b. c. d.

Identification of the person at fault An appropriate consequence for the individual at fault Reason the event occurred A plan for the prevention of this event

ANS: D

A plan for prevention of a similar event happening again is the ultimate outcome of this investigation. The investigation will determine all contributing factors in the occurrence of the event, with the goal of identifying methods to prevent those failures from recurring.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

21. The nurse is giving report to the night 1900–0700 shift and describes a confused elderly

patient who wanders. What action by the oncoming nurse is most appropriate? a. Ask the family about how patient communicates needs. b. Assess the patient with the Mini-Mental State Exam in the morning. c. Recommend the oncoming nurse request prn sedation medications. d. Move the patient to a room near the nurses’ station.

ANS: A

Often patients wander due to an unmet need, such as hunger or needing to use the bathroom.

The nurse should first ask the family if the patient “communicates” these needs by wandering.

This will help the nurse plan the most individualized care. Cognitive assessments should be done at night or when cognitive status usually diminishes. Sedation medications are not indicated and can cause safety problems. It may or may not be possible to move the patient but a more wholistic approach considers the patient’s needs.

N DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

22. The nurse is caring for a patient who has brought in a personal CPAP device to use at night.

What does the nurse need to do in addition to contacting respiratory therapy? a. Have the device inspected by the appropriate hospital department for safety. b. Have the patient take it home and use one from the hospital supply. c. Tell the patient that the personal machine cannot be used. d. Notify the provider to get permission for the patient to use the machine.

ANS: A

If a patient brings a device, it must be inspected for safe wiring and function before use through the process established by the agency. A patient should be able to use his or her own equipment such as CPAP since it is fitted for personal use. The provider cannot give permission without the safety inspection.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

23. The nurse is caring for a patient and is exposed to a chemotherapy drug during IV

administration. Where can the nurse obtain information about the drug that is necessary for an exposure-related incident? a. The nurse’s supervisor b. Poison control center

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c. SDS sheets d. Employee health services ANS: C

Chemicals in medications (e.g., chemotherapy drugs), anesthetic gases, disinfectants, and cleaning solutions are potentially toxic. They injure the body after skin or mucous membrane contact, after ingestion, or when vapors are inhaled. Health care agencies provide employees access to Safety Data Sheets (SDSs, formerly called Material Data Safety Sheets or MSDS) for each hazardous chemical in the workplace. An SDS contains information about properties of the chemical (melting point, boiling point, flash point, etc.), toxicity, health effects, first aid, reactivity, safe handling, storage, disposal, protective equipment to use, and spill-handling procedure. The nurse’s supervisor, employee health services, or poison control center may also have the information, but they will go to the same place (the SDS sheets) to obtain that information.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

24. A student is caring for a patient admitted with acute alcohol withdrawal. The patient is very

agitated and flailing about in the bed. What action by the student requires the registered nurse to intervene? a. Coordinates with the nursing staff so someone is always with the patient. b. Restrains the patient so prevent falling out of bed and medical device removal. c. Requests order to remove urinary catheter placed in the emergency department d. Places the patient on safety precautions and communicates this action.

ANS: B

Restraints are always used as aNlast resort, but in patients experiencing acute alcohol withdrawal, restraints are known to increase agitation. The other options are correct interventions.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

25. A patient is having a seizure and has fallen to the floor. After placing a pillow under the

patient’s head, what action does the nurse take next? a. Call for help. b. Suction the airway. c. Position patient supine. d. Hold arms securely.

ANS: A

After cushioning the patient’s head, the nurse should call for help. The nurse may or may not need to suction the airway. The patient should be placed in a side-lying position if possible.

Do not restrain limbs; if the patient is at risk for injury, move objects away from the patient.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

26. A nurse is caring for a child who has frequent seizures. The family does not want the seizures

treated and appear to be in awe when they occur. What action by the nurse is best? a. Inform social services about the noncompliant family.

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b. Teach the family the profound consequences of untreated seizures. c. Assess the family’s cultural values and norms related to seizures. d. Ask the family to leave during a seizure and treat the child then.

ANS: C

The nurse should always assess patients’ and families’ culture values, norms, and expectations. This family’s culture may place special significance on the seizures which is leading them to reject treatment. The nurse should teach the family but without the negative focus of “profound consequences”. Treating the child against the parents’ wishes (without a court order) is an ethical violation. It is too early to label the family as noncompliant.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Psychosocial Integrity

27. After noticing a fire in a patient’s room, what action by the nurse takes priority? a. Yelling for help b. Removing the patient from the room c. Pulling the fire alarm d. Calling security ANS: B

The actions steps in case of a fire are RACE: Rescue those in danger, Activate the fire alarm, Confine the fire, and Extinguish the fire. The first would first remove anyone in that patient’s room.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

N 28. At a safety workshop nurses are being taught to use the fire extinguishers on common fires.

What action by the nurse requires the teacher to review the material? a. Grabbing an ABC-type fire extinguisher b. Pulling the pin completely out of the extinguisher c. Aiming at the highest point of the flames d. Using the extinguisher in a sweeping motion ANS: C

When using a fire extinguisher, aim at the base of the flames. The other actions are appropriate.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Safe and Effective Care Environment

MULTIPLE RESPONSE 1. The nurse is caring for a patient who just received a diagnosis of a seizure disorder. What

supplies should the nurse gather to have at the bedside? (Select all that apply.) a. A suction device with catheters b. Extra pillows to pad the bed c. A padded tongue blade d. Oxygen source and nasal cannula e. Intubation equipment

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ANS: A, D

A suction device with catheters and an oxygen source with nasal cannula will help maintain the airway should it become a problem. Extra pillows on the bed could cause suffocation during a seizure; firm padding on the sides of the bed are recommended instead. Padded tongue blades are no longer used in the care of patients with seizures. Intubation equipment is not routinely needed.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

2. A nurse notes smoke coming from a garbage can in an otherwise empty nursing station.

Which actions should the nurse take? (Select all that apply.) a. Activate the fire alarm. b. Use a type ABC fire extinguisher. c. Rescue the patients from the unit. d. Put wet towels along the base of the doors. e. Use a type B fire extinguisher. f. Aim the nozzle at the top of the fire.

ANS: A, B

Activate the fire alarm first; then use a type ABC fire extinguisher to put out the fire. An ABC type is the most commonly used extinguisher and will work on ordinary combustibles, liquids, and electrical fires. Aim the nozzle of the extinguisher at the base of the fire, not the top. The fire is just smoking; so there is no need to evacuate at this time. The patients are safer where they are since they are not in the area where the fire is smoldering. This small fire could be extinguished easily by the time wet towels are placed along the base of the doors.

DIF: Cognitive Level: ApplyingN TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

3. Which of the following are examples of alternatives to restraint use in patient care? (Select all

that apply.) a. Frequent observation of patients b. Involving patients and families c. Frequent reorientation d. Four side rails e. Wraparound belt with quick release ANS: A, B, C, E

Modifications of the environment are effective alternatives to restraints. More frequent observation of patients, involvement of family caregivers during visitation, and frequent reorientation are also helpful measures. Having all four side rails up is considered a restraint.

A wraparound lap belt that the patient can release is not a restraint.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

4. The Joint Commission restricts the use of restraints to the least restrictive device necessary to

prevent disruption of needed care. The order for restraints must include which of the following? (Select all that apply.) a. Type

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b. c. d. e.

Duration Purpose Location Size

ANS: A, B, C, D

Order must include purpose, type, location, and time or duration of restraint. Long-term care settings require informed consent from a family member prior to use. Orders may be renewed according to the time limits for a maximum of 24 consecutive hours. Size is determined by the nurse’s judgment.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

5. A nurse is assessing a patient after a seizure. What precipitating factors does the nurse

consider as possibly causing the seizure? (Select all that apply.) a. Hypoglycemia b. Hypoxia c. Alcohol abuse d. Electrolyte imbalances e. Emotional excitement ANS: A, B, C, D

Emotional excitement is not a usual cause of seizures. All other options are possible causes of seizures the nurse would assess for.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation N

OBJ: NCLEX: Safe and Effective Care Environment

6. The nurse is reminding the unlicensed assistive personnel about manifestations of a possible

impending seizure. What manifestations does the nurse include? (Select all that apply.) a. Staring b. Rapid eye blinking c. Not responding d. Sudden fever e. Head nodding ANS: A, B, C, E

Staring, rapid eye blinking, brief periods of not responding, and head nodding are some signs of a possible pending seizure. Febrile seizures are common in children, but a sudden fever is not a manifestation of a pending seizure.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Teaching-Learning

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Chapter 05: Infection Control Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The patient is in isolation in a negative-pressure room for active tuberculosis. The patient is

too weak to cover the mouth and nose with a tissue when coughing. Which is the most important intervention for the nurse to implement for self-protection while providing nursing care? a. Cover the patient’s mouth and nose snugly with a surgical mask. b. Wear an N-95 mask, gloves, face shield, and isolation gown. c. Place tissues and a contaminated waste container within reach. d. Use a properly fitted surgical mask and gloves to help with tissues.

ANS: B

Wearing suitable protective barriers is the most important intervention to implement because it protects the nurse from the airborne particles and the pathogens that can land on surfaces from droplets of the patient’s coughing. The nurse wears a mask suitable for airborne precautions to prevent inhalation of suspended Mycobacterium tuberculosis in the air and gloves, gown, and goggles to protect clothing and mucous membranes from contact with body fluids because of the patient’s poor hygiene due to his weakened state. Respirator masks are used in airborne precautions because these masks filter what the wearer inhales. The patient should wear a mask if he or she must leave the room because a surgical mask controls what the wearer exhales; a mask for the patient is not indicated in the isolation room. The nurse can inhale airborne particles through the pores of a surgical mask, regardless of how well it fits, because a surgical mask controls N what is exhaled, not inhaled. The nurse should provide ample tissues and a waste receptacle within reach, but this is not the most effective action to prevent the nurse from contracting the TB. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

2. The nurse is caring for several patients under contact precautions. Which option is possible for

the nurse to use if two of her patients have “like” infections? a. Double gloving b. Single gloving c. Cohorting d. Hand sanitizer only ANS: C

When a hospitalized patient has an infection, a nurse decides on the optimal room placement to minimize the chances of infection spreading to other patients. Two patients with “like” infections can be placed in the same room; this is called cohorting.

Double gloving is used during procedures to make it easier to remove one pair. Hand sanitizer is not effective against Clostridium difficile (“C. diff”) or when hands are visibly soiled.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

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3. The nurse bathes a patient who has an infection transmitted by the oral-fecal route such as C.

difficile, and notes a small tear in one glove. Which group of interventions does the nurse use for self-protection? a. Finish the bath, apply fresh gloves, and use hand sanitizer. b. Continue the bath and change gloves when finished. c. Apply a new glove over the torn one to finish the bath. d. Remove the gloves, wash hands, and apply new gloves.

ANS: D

For self-protection the nurse interrupts the bath to avoid additional exposure to a potential pathogen by removing the gloves, washing both hands with soap and water, and applying fresh gloves for protection against exposure so the nurse can finish the bath. The nurse risks infection by continuing the bath with a portal of entry on the glove. The nurse should perform hand hygiene before applying fresh gloves. Hand sanitizer is not effective with C. difficile.

Applying clean gloves over the torn gloves encases the potential pathogens and increases the risk of exposure to the pathogen.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

4. The nurse completes care for the patient on droplet precautions. Which procedure does the

nurse implement to prevent transmitting the pathogen to other people? a. Removes gloves and mask at the bedside and gown in hallway. b. Removes all personal protective equipment (PPE) in the soiled utility room. c. Removes gloves first, gown second, and mask third in the patient’s doorway. d. Removes mask first, gloves second, and gown third outside the patient’s room.

ANS: C

N

The nurse removes PPE to prevent self-contamination. He or she removes the gloves first to avoid contaminating the head, then removes the gown by unfastening neck ties and pulling it away and rolling into a bundle, then removing mask. These actions occur in the patient’s doorway to contain the pathogen and prevent transmission to people outside the room. The nurse risks contamination if the gloves and mask are removed at the bedside; if the mask is removed before the contaminated gloves, the nurse risks contaminating the head while untying the strings of the mask. PPE should be removed together, at the same location, and away from the source of contamination to facilitate containment of the pathogen. Removing PPE in the hallway or utility room would risk transmitting the pathogen to others.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

5. A patient on isolation precautions tries to leave the isolation room because of loneliness

despite repeated instructions to remain in the room. Which action should the nurse implement as a patient advocate? a. Allow visitors to remove masks while in the patient’s room. b. Talk with the patient about ways to reduce the sense of loneliness. c. Remind the patient that the isolation is for the patient’s benefit. d. Leave the door open slightly so the patient can see into hallway.

ANS: B

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The nurse sets specific times to remain in the patient’s room as a patient advocate to help him or her develop coping strategies for handling the loneliness of isolation and provide periodic company. Visitors should not enter the room without a properly fitted respirator or mask for their protection. The nurse can remind the patient about the purpose of isolation to help him or her understand the plan of care, although this intervention alone does not address the patient’s greatest need, which is to have company or periodic companionship. The door cannot remain ajar because the risk of transmitting the infection is increased with the door open.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

6. Gloves are effective protective barriers from pathogens when caring for patients in isolation.

Which patient factor associated with the gloves should the nurse investigate for patients in isolation? a. Patient resistance to therapy b. Transmission mode of organism c. Patient potential for latex allergy d. Virulence of infectious organism ANS: C

The patient potential for latex allergy is the most important patient factor related to using gloves with patients in isolation. Allergic reactions to latex may be triggered even if latex does not touch the patient. Wear unpowdered latex-free gloves. Several alternatives to latex gloves exist. If the patient is allergic to latex, the nurse can use nonlatex gloves to prevent hypersensitivity reactions. Neither virulence nor transmission mode of a pathogen is a patient factor.

N

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

7. The nurse is getting ready to provide a sterile dressing change. Which nursing action is

consistent with principles used to prepare a sterile field? a. Identify that items below waist height are contaminated. b. Use opened packages of dressing supplies within the same shift. c. Identify that sterile drapes have a 5.08 cm (2-inch) contaminated border. d. Replace bottle caps if the inside of the cap is not touched.

ANS: A

Items below waist level are considered contaminated and are discarded quickly to avoid contaminating the rest of the sterile field. Packages of sterile supplies must be sealed to be considered sterile. Sterile drapes have a 2.5 cm (1-inch) perimeter that is considered contaminated. Replace bottle caps if the inside of the cap and the edge of the bottle remain sterile.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

8. The nurse teaches the patient the proper handwashing technique before discharge and asks for

a return demonstration. Which hand-hygiene technique indicates that patient teaching by the nurse is effective? a. The patient washes hands with running water.

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b. Soap, water, and friction are used by the patient. c. The patient washes hands with very hot water. d. A basin with warm soapy water is used.

ANS: B

The patient understands that proper handwashing requires soap, water, and friction to remove microorganisms from the skin and rinse them away. Running water is insufficient to wash hands properly because water alone cannot remove as many microorganisms as soap and water can remove. The patient risks tissue damage, dry skin, and irritation from hot water.

Washing hands in a basin may remove surface debris, but the hands are not decontaminated because the debris remains in the rinse water.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Safe and Effective Care Environment

9. The nurse is caring for a patient who is 4 years old and in isolation. Which approach should

the nurse implement to reduce the patient’s anxiety? a. Put the child in a room with a locked door. b. Ask the parents to keep the child in the room. c. Explain isolation to the child by using a cartoon. d. Put the mask, gown, and gloves on in view of the child.

ANS: D

The nurse should let the child see his or her face before putting on the mask so the child knows who is behind the mask and is not frightened. The nurse could even bring a mask for the child to play with in the nurse’s presence to reduce anxiety. The nurse should explain isolation to the child and use educational material suitable to the patient’s developmental N level. However, the child is unlikely to grasp the meaning and implications of isolation, necessitating repeated explanations and guidance. Although the nurse may ask for the parents’ help in keeping the child in the room, the nurse retains the responsibility for maintaining transmission precautions and the child’s safety. Locking the door is a restraint and puts the child at risk in an emergency.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

10. In which of the following situations should the nurse use surgical asepsis? a. Performing urinary catheter care b. Inserting a nasogastric tube c. Inserting a Foley catheter d. Performing nasogastric tube care ANS: C

Nurses use surgical aseptic techniques at the patient’s bedside during procedures that involve inserting devices into normally sterile body cavities such as insertion of a Foley catheter. A nasogastric tube is not going into a sterile cavity. Clean technique is used for the other situations.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

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11. The nurse is caring for a 4-year-old child who has rubella. Which transmission precautions

should the nurse implement to prevent rubella exposure? a. Contact precautions b. Droplet precautions c. Airborne precautions d. Standard precautions ANS: B

The nurse implements droplet precautions for the patient with rubella because large droplets expelled by the patient during coughing, talking, or sneezing transmit the virus. Contact and airborne precautions are not indicated because rubella is not transmitted by direct contact or suspended particles in the air. Standard precautions are suitable for all patients but do not prevent rubella transmission without additional droplet precautions.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

12. The nurse evaluates the handwashing technique of nursing assistive personnel (NAP). Which

behavior by NAP requires additional training by the nurse? a. Rubs sudsy hands for 5–10 seconds. b. Uses warm running water and soap. c. Dries the hands from the fingers to the wrists. d. Keeps the hands and forearms below the elbows.

ANS: A

The nurse improves the NAP’s handwashing technique by providing feedback to increase the length of hand scrubbing to 15–20 seconds for thorough removal of microorganisms. The nurse finishes the feedback by N directing the NAP to rinse the hands under running water without recontaminating them. Using warm, running water and soap effectively loosens microorganisms from the skin and rinses them off the hands. Drying hands from fingers to wrists is good technique because the hands are dried from the cleanest to the least clean area.

Keeping the hands in a dependent position is good handwashing technique because it prevents hand contamination from water that touched the unwashed section of the arm.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Safe and Effective Care Environment

13. The nurse assists the health care provider during the insertion of a central venous catheter.

Which is the most effective intervention for the nurse to implement to prevent patient infection? a. Adhere to the principles of surgical asepsis. b. Close the door of the sterile procedure room. c. Sterilize working surfaces for the procedure. d. Restrict foot traffic into the sterile procedure room.

ANS: A

Adhering to principles of surgical asepsis is the best method of preventing an infection during a sterile procedure because it is the most comprehensive step. The remaining options are proper actions for the nurse who is adhering to the principles of the surgical asepsis.

DIF: Cognitive Level: Remembering

OBJ: NCLEX: Safe and Effective Care Environment

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TOP: Nursing Process: Implementation 14. The nurse sets up a sterile field and notes several tiny holes in the sterile drape of the table

that served as the wrap for the pack. What does the nurse do to facilitate completion of the procedure? a. Uses a sterile towel to cover the existing holes. b. Replaces the entire sterile field and the supplies. c. Moves the sterile supplies to a replacement drape. d. Avoids using any of the sterile items near the holes.

ANS: B

The nurse removes the entire sterile field, including any supplies added to the setup, because the holes compromised the sterility of the pack and its contents; in addition, contacting the contaminated drape contaminates every sterile item added to the sterile field. Even if the contents of the pack remained sterile, once the drape was used as a sterile field, the field was contaminated by the holes. The nurse cannot proceed with a sterile procedure using a contaminated field despite the goal of facilitating the procedure. Ignoring the potential contamination increases the risk of infection.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

15. The nurse completes preparation of the sterile field to change a patient’s dressing when the

patient’s dinner tray arrives. Which action should the nurse take? a. Use the sterile field on another patient in another room. b. Change the dressing using clean technique to save time. c. Set the tray aside and proceed with the dressing change.

N drape and let the patient eat. d. Cover the setup with a sterile ANS: C

The nurse should set the dinner tray aside and proceed with the dressing change. The nurse should change the sterile gloves. Discarding the sterile setup would waste both time and money. The nurse avoids moving the sterile field to another patient’s room to decrease the risk of contamination from air currents and accidental contact. The nurse should explain to the patient why the dinner tray is being set aside, efficiently finish the dressing, offer to rewarm the meal, delegate serving the tray to nursing assistive personnel (NAP), and thank the patient for patience and understanding. The timing of the dressing change should be rescheduled to prevent this from happening again.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

16. While setting up a sterile field for a procedure, the nurse knocks a linen-wrapped sterile

package to the floor. Which reaction allows the nurse to maintain safe practice? a. Inspect the package for tears. b. Brush away the visible debris. c. Record the procedure as clean. d. Replace the sterile package.

ANS: D

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The nurse replaces the linen-wrapped sterile package dropped on the floor because touching the floor contaminates the package. If the package had a plastic wrapper, the contents may be usable, depending on agency policy, because dust and moisture do not penetrate plastic like they can penetrate the linen. Clean technique may not be substituted when sterile technique is required.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

17. The nurse helps the health care provider get supplies and monitor the patient during an

emergency insertion of a femoral line at the patient’s bedside. Which nursing behavior helps to maintain the sterile environment? a. Avoid reaching over the field. b. Wear a sterile cap and booties. c. Use sterile examination gloves. d. Place a face mask on the patient.

ANS: A

The nurse avoids reaching over the sterile field to avoid contamination. A head cover and booties are not sterile, even when used during a sterile procedure. Sterile gloves are not indicated for the tasks the nurse is performing to assist the health care provider. There is no need to place a face mask on the patient for a procedure occurring on the upper thigh.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

18. The nurse is preparing to put on sterile gloves. What should the nurse do to begin this

N procedure? a. Pull the first glove up and over the nondominant hand. b. Place the fingers of the dominant hand under the cuff of the first glove. c. Let the cuff of the glove roll up over the hand for more coverage. d. Hold the inside surface of the first glove to pull over the hand.

ANS: D

To begin donning sterile gloves, the nurse slips the fingers of the nondominant hand into the glove to lift it and pull it over the dominant hand. As long as the cuff does not roll up and the glove remains intact, the exterior of the glove remains sterile.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

19. The nurse has just finished a sterile dressing change. Which technique should he or she use to

remove sterile gloves? a. Pull the first glove off with the sterile glove hand. b. Reach inside the first glove to pull it off quickly. c. Pull the edge of the glove down to create a cuff. d. Wipe off the gloves with an antiseptic wipe first.

ANS: A

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To remove sterile gloves, the nurse pulls the first glove off with the opposite sterile hand and holds it in the remaining gloved hand. Then he or she inserts a bare finger under the remaining glove to pull it down and inside out. The nurse then discards the gloves. He or she avoids reaching inside the first glove with a gloved hand to prevent self-contamination.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

20. The nurse is caring for a patient with C. difficile. What type of precautions should the nurse

use? a. Airborne b. Droplet c. Contact d. Protective ANS: C

The nurse implements contact precautions because C. difficile spores live in the environment and on surfaces, including health care workers’ hands, and are spread through contact. There is no need for airborne or droplet precautions because C. difficile spores are not transmitted by those routes. Protective precautions are used for immunocompromised patients.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

21. The nurse is preparing a sterile field with several items on it. Which action should the nurse

implement to maintain a sterile field? a. Flip sterile objects onto the sterile field.

N of the field. b. Put fluid holders near the edge c. Wear sterile gloves to open sterile packs. d. Open the inner flaps of the sterile packages first.

ANS: B

The nurse places holders for fluid near the edge of the sterile field, allowing the circulating nurse to pour fluids into the holders without reaching over and contaminating the sterile field.

Flipping sterile objects onto the sterile field increases the risk of contamination. Sterile gloves are unnecessary to open sterile packages because the outside of the package is clean; the nurse can use bare hands to open the package and retain package sterility. The nurse opens the outer flaps of sterile packages first because it is impossible to open the inner flaps first since they are covered with an outer wrap.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

22. The nurse is orientating a nursing assistant and is discussing handwashing principles. Which

statement from the nursing assistant indicates a good understanding of those principles? a. If my hands are visibly soiled, I cannot use an alcohol rub. b. I do not need to wash my hands if I have used gloves. c. I must always use soap and water after a dressing change. d. I can always use an alcohol rub instead of soap and water.

ANS: A

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The nurse (and nursing assistant) must always use soap and water when hands are visibly soiled or when caring for a patient with C. difficile. Hand hygiene with an alcohol-based hand rub can be used in all other situations and also must be done after removing gloves.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Safe and Effective Care Environment

23. The nurse is preparing to transfer a sterile voided urine specimen from the patient’s bathroom

to the laboratory. What supplies should he or she gather to complete this procedure? a. Clean gloves, biohazard bag, mask b. Plastic bag, gown, gloves c. Sterile gloves, gown, biohazard bag d. Clean gloves, plastic bag, biohazard label ANS: D

Clean gloves are used even though the specimen is sterile. After the outside of the container is dried, the specimen container is labeled in front on the patient and is placed in a plastic bag. A biohazard label is attached if not already printed on the bag. A mask or gown is not needed unless splashing is a possibility, and there is no information in the question about the chance of splashing. Sterile gloves are not needed to obtain a sterile voided urine specimen.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

24. The nurse is preparing to enter a room for the patient on contact precautions. In which order

should the nurse don personal protection equipment? a. Gloves, gown, cap, eyewear N b. Gown, cap, eyewear, gloves c. Cap, eyewear, gown, gloves d. Eyewear, cap, gloves, gown ANS: B

The nurse should don PPE in the following order: Gown, cap, mask (if worn), protective eyewear (goggles, face shield), and then gloves, which should pull over the sleeves of the gown.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

MULTIPLE RESPONSE 1. Which of the follow elements are present in the chain of infections? (Select all that apply.) a. Source of growth b. Mode of transmission c. Infectious agent d. Susceptible host e. Portal of exit f. Catalyst g. Port of entrance ANS: A, B, C, D, E, G

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The presence of a pathogen does not mean that an infection will begin. An infection develops in a cyclical process called the chain of infection, which includes six elements: (1) an infectious agent or pathogen, (2) a reservoir or source for pathogen growth, (3) a portal of exit from the reservoir, (4) a method or mode of transmission, (5) a portal of entrance into the host, and (6) a susceptible host. An infection develops if the chain remains intact.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

2. The nurse is screening a patient for latex allergy. Which factors place the patient at a higher

risk for latex allergies? (Select all that apply.) a. High latex exposure b. History of using condom catheters c. Urogenital defects d. History of multiple childhood surgeries e. Gluten intolerance ANS: A, B, C, D

Risk factors for latex allergies include spina bifida, congenital or urogenital defects, history of indwelling catheters or repeated catheterization, history of using condom catheters, high latex exposure (e.g., health care workers, housekeepers, food handlers, tire manufacturers, workers in industries that use gloves routinely), history of multiple childhood surgeries, and people with family history of allergies such as hay fever or hives. Food allergies include kiwi, papaya, avocado, banana, peaches, chestnut, raw potato, and tomato.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

N

3. The nurse is orientating a new graduate nurse. Which statements by the orientee indicate a

high level of understanding about the principles of hand hygiene? (Select all that apply.) a. I need to perform hand hygiene before and after having direct contact with patients. b. I can use alcohol rub when my hands are not visibly soiled. c. I need to perform hand hygiene after I remove my gloves. d. I only need to wash my hands with soap and water when they are visibly soiled. e. I should perform hand hygiene before a sterile procedure.

ANS: A, B, C, E

Hand hygiene is performed before and after contact with patients, after removing gloves, and before performing sterile procedures. Alcohol-based rubs can be used except when hands are visibly soiled or when caring for patients with C. difficile.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Safe and Effective Care Environment

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Chapter 06: Disaster Preparedness Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. During a disaster drill, a patient presents with an open left femur fracture, BP 134/78 mmHg,

pulse 102 beats/minute, and pedal pulses 1+/4+ bilaterally. Into which category would the nurse triage this patient? a. Expectant b. Delayed c. Immediate d. Minimal ANS: B

A patient with an open fracture can be triaged into the delayed category when bleeding is controlled and pulses are strong. This patient’s pulses, although weak, are equal bilaterally, which indicates this is probably a normal finding in him or her. An expectant patient is one who is dead or expected to die. If this patient had uncontrollable bleeding, the nurse would triage him or her as immediate. The minimal category consists of individuals with minor or no visible injury.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

2. The trauma unit manager wishes to improve the unit’s nurses’ capabilities in mass casualty

situations. What action by the manager would be best?

N a. Prepare ongoing educational programming. b. Require nurses become certified in trauma care. c. Collaborate with a local nursing school on simulations. d. Involve the staff in disaster planning.

ANS: C

While all options would increase nurses’ knowledge, using simulations has been shown to be effective in promoting competence in disaster nursing. Students have also been shown to lack knowledge in this area, so collaborating with a nursing school would lead to improvement in both populations plus sharing the costs would make simulation more feasible for both.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

3. A trauma nurse has responded to the scene of a mass casualty incident. The nurse sees several

injured patients lying together in a heap. One of them does not appear to be breathing. What action by the nurse takes priority? a. Put on personal protective equipment. b. Assess the non-breathing patient first. c. Determine if the scene is safe to enter. d. Open the non-breathing patient’s airway.

ANS: C

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All options are appropriate, however; before entering any disaster scene, the nurse must first determine if it is safe to do so. Otherwise the nurse risks become another victim.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

4. A nurse has responded to the scene of hurricane devastation and must wear Level C protection

as there are potential biohazards present. What action by the nurse takes priority? a. Resting periodically and drinking water b. Ensuring the breathing apparatus remains intact c. Replacing gloves frequently on a schedule d. Keeping the hard hat securely in place ANS: A

Levels A, B, and C protective garments are self-enclosed and put the wearer at risk of dehydration and hyperthermia. The nurse needs to rest periodically and drink water so this does not occur. The self-contained breathing apparatus and hard hat are part of Level A protection. Regular gloves are worn with Level D protection.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

5. During a disaster drill, a patient presents with manifestations of inhalation anthrax exposure.

What action by the nurse indicates a need for further education? a. Places the patient in strict isolation. b. Prepares to administer ciprofloxacin. c. Educates close contacts on vaccination.

N d. Assists in obtaining hemodynamic monitoring.

ANS: A

Inhalation anthrax cannot be contracted through person-to-person contact, so strict isolation is not necessary. Ciprofloxacin and doxycycline are the two drugs used to treat anthrax. Close contacts might benefit from the vaccine, however; it is in short supply. Hemodynamic failure is a grave concern with inhalation anthrax so the patient would need hemodynamic monitoring.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Safe and Effective Care Environment

6. A patient is admitted with suspected smallpox infection. What action by the nurse indicates

further education is needed on this type of patient? a. Prepares to administer doxycycline. b. Cares for the patient using CDC isolation guidelines. c. Assesses and treats the patient’s pain. d. Encourages proper nutrition.

ANS: A

Smallpox is a virus, so antibiotics are not used unless secondary infections occur. Treatment is supportive in nature. The CDC has isolation guidelines for health care personnel to use when caring for such patients. Symptoms include headache, myalgias, and back pain and might require analgesics. Good nutrition is important for healing.

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DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Safe and Effective Care Environment

7. The nurse assisting at a disaster site smells what seems to be burned or bitter almonds. What

action by the nurse takes priority? a. Alert the authorities b. Evacuate downhill c. Begin decontamination d. Don PPE ANS: B

The smell of bitter almonds is characteristic of cyanide. The nurse needs to evacuate the area downhill, because cyanide is lighter than air and rises. Alerting the authorities should occur quickly, but the priority is to prevent further injury by evacuating people in the area.

Decontamination will begin when facilities are set up or when patients are transported. The nurse should already be wearing PPE, but if not, should start evacuation immediately then don PPE. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

8. A patient presents to the emergency department after a chemical exposure and reports blurry

vision and “my eyes burn”. What action by the nurse takes priority? a. Rinse the patient’s eyes with tap water for 15 minutes. b. Assess the patient’s airway, breathing, and circulation. c. Wash the patient’s face with soap and warm water. d. Remove the patient’s contact lenses before irrigating the eyes.

N

ANS: B

Circulation, breathing, and airway always come first, so the nurse assesses these areas as the priority. If the patient is stable, irrigation of the eyes with plain water for 10–15 minutes is the correct first treatment. The nurse would remove or have the patient remove the contact lenses prior to irrigation.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

9. An explosion has occurred at a factory that makes pool supplies and chemicals. One of the

victims presents to the emergency department with obvious shortness of breath. What medication does the nurse prepare to administer? a. Antitoxin b. Antidote c. Bronchodilator d. Antibiotic ANS: C

Chlorine is the suspected chemical exposure as it is used in pool maintenance. Chlorine can disrupt pulmonary function, so bronchodilators are indicated in this patient with respiratory distress. There is no antitoxin or antidote for chlorine exposure and antibiotics are ineffective on chemicals.

DIF: Cognitive Level: Applying

OBJ: NCLEX: Safe and Effective Care Environment

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TOP: Nursing Process: Implementation 10. After a radiation exposure, a patient was brought to the emergency department. What nursing

action is appropriate? a. Remove all clothing as quickly as possible. b. Conduct a focused assessment. c. Have a radiation assessment performed. d. Place patient in a room with a lead shield.

ANS: C

Prior to assessing or caring for a patient exposed to radiation, a radiation technologist will perform a brief radiation assessment of the victim. If the assessment is positive, a more thorough assessment will be done. The patient does not need to be in a room with lead shielding.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

11. An older employee of a nuclear energy plant was exposed to radiation. On initial assessment,

the patient appears stable. The nurse delegates frequent vital sign monitoring to the nursing assistive personnel. When questioned for the need to monitor the patient so often, what response by the nurse is best? a. “We don’t know how this radiation will affect the patient.” b. “Other health problems may mean the patient is worse than we think.” c. “We need to ensure the patient does not develop delirium.” d. “Organs in older people are more sensitive to radiation than in kids.”

ANS: B

N

Older adults often have coexisting medical conditions. The effects of radiation exposure may be worse than initially determined during triage. The nurse should delegate frequent vital signs in order to quickly spot any deterioration. Radiation exposure’s course of illness is well-known. The patient may or may not develop delirium, but frequent vital signs would not indicate it occurred. Children’s organs are more sensitive to the effects of radiation.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

12. An individual eating at an outdoor café suddenly grabs the chest and begins drooling

uncontrollably. A nurse at the scene assesses pinpoint pupils and muscle twitching. The patient states “I think someone tried to kill me.” After calling 911, what action by the nurse is best? a. Remove patient’s clothing and throw away. b. Refrain from touching patient without PPE. c. Assess for ciprofloxacin allergy. d. Request 911 dispatch a dosimeter to the scene.

ANS: B

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This patient has manifestations of “lethal” nerve gas agent exposure such as sarin or VX. Proper PPE is required to assess and treat the patient so the nurse does not also become a victim. Clothing will be disposed of in a biohazard bag according to CDC recommendations.

Ciprofloxacin is not used for nerve gas exposure. A dosimeter would be needed for a radiation exposure.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

MULTIPLE RESPONSE 1. A nursing student learns that which of the following are potential hazards at a disaster site?

(Select all that apply.) a. Downed powerlines b. Public alarm c. Toxic gases d. Secondary explosions e. Snipers f. Fire ANS: A, C, D, E, F

Public alarm is expected at the scene of a disaster and can be very disruptive, but it is not a primary potential hazard for responders. All other options are potential hazards at a disaster scene. Other possible hazards include smoke/toxic gasses, debris that can cause injury, ruptured gas lines, structural collapse, inclement weather, exposure to blood and/or body fluids, exposure to many types of hazardous materials, darkness, infections, and projectiles.

N responder incapacitated.

Any of these could render a first DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Teaching-Learning 2. A nurse is conducting a community education event of disaster preparedness. What items does

the nurse inform participants are needed in a basic disaster kit? (Select all that apply.) a. Gallon of water per person b. Utility knife c. First aid kit d. Pet supplies e. Household cleaners f. Plastic sheeting ANS: A, B, C, D, E

Plastic sheeting precut to fit over shelter openings would be needed in case of a chemical or radiological event. The other items are all needed in a basic disaster kit.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Teaching-Learning 3. What does the nurse learn about disaster preparedness as it relates to children as compared to

adults? (Select all that apply.) a. Less vulnerable to the effects of radiation. b. More likely to develop secondary infections.

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c. Hypothermia with contamination is more severe. d. Behavior changes are possible after traumas. e. PPE is more easily accepted as it is new and interesting.

ANS: B, D

There are some important differences in children the nurse is aware of. Their bodies are more vulnerable to the effects of radiation and toxins, they have immature immune systems so they are also vulnerable to secondary communicable diseases that might appear after a disaster, they become hypothermic more easily than adults, behavior changes can occur after a traumatic ordeal, and PPE may frighten children.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Teaching-Learning

N

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Chapter 07: Vital Signs Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The patient’s oral temperature is 39 C (102.2 F). Which conclusion can the nurse make

about the patient on the basis of this information? a. The patient is febrile. b. The patient is afebrile. c. An infection is present. d. Inflammation is present.

ANS: A

A temperature of 39 C is above normal, and the patient with an above-average temperature is febrile. Afebrile indicates a lack of fever but does not necessarily imply a subnormal temperature. An infection often causes a fever in the patient, but a physical examination and laboratory work or culture are necessary before concluding that the patient has an infection. A patient with an inflammation can have a fever, but the patient can have an inflammation without being febrile.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Diagnosis

OBJ: NCLEX: Physiological Integrity

2. The nurse is preparing to obtain a set of vital signs. Which is the most important factor for the

nurse to consider when measuring patient vital signs? a. Documentation of vital signs N requires timely and accurate recording. b. Normal limits are very narrow and are generally the same for all patients. c. Measuring equipment must be used correctly and appropriately. d. Environmental factors play a minor role on patient vital signs.

ANS: C

It is important that each device be used correctly and appropriately to ensure patient safety and to obtain correct, complete patient information. Improper equipment distorts the results, increasing the risk of patient injury. If data are obtained with improper equipment and patient treatment is based on the faulty data, the people who use the improper equipment and the faulty data are liable for the results. Documentation is an important part of taking vital signs; however, if the nurse uses improper equipment or technique to obtain vital signs, accurate and prompt recording is to no avail. Depending on the parameter, the normal limits are not relatively narrow. The benefit of a wider normal range is that the body is able to respond to stress and recover while remaining within normal limits. Environmental factors play a significant role on vital signs (e.g., an overly warm room affects patient temperature).

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

3. A patient has a severe upper respiratory and ear infection and has been experiencing diarrhea.

Assessment of the temperature would be most accurate if the nurse checked the temperature using which site? a. The rectum b. The axilla

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c. Under the tongue d. The tympanic membrane ANS: B

The axilla is the only area listed where there is no infection or health issue and where there is no interference to its accuracy. The rectum is an inappropriate site because of the diarrhea.

The oral route, under the tongue, is an inappropriate site because of the severe upper respiratory infection. If the patient cannot breathe through the nose, mouth breathing occurs, and the mouth cannot be closed to create a seal for an accurate temperature measurement. The tympanic membrane is an inappropriate site because of the ear infection.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

4. The nurse is validating the measurement of an infant’s pulse by a nursing student. Which

method should the nurse use to obtain the most accurate count? a. Compress the bell of the stethoscope over the apex of the heart. b. Locate the pulsations in the antecubital space. c. Palpate the superficial artery on the medial side of the wrist. d. Place the thumb and forefinger along the ridge on the outer side of the wrist.

ANS: B

Counting the pulsations in the antecubital fossa from the brachial artery would give the most accurate count. Compressing the bell of the stethoscope turns it into a diaphragm; the bell is never compressed during use. Placing the thumb and forefinger along the ridge on the outer side of the wrist locates the radial artery, the preferred site for measuring an adult’s pulse.

DIF: Cognitive Level: ApplyingN TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

5. A patient born without arms needs to have a blood pressure assessment. Which artery should

the nurse use to most accurately obtain this measurement? a. Femoral b. Carotid c. Brachial d. Popliteal ANS: D

The nurse can use the popliteal artery to measure blood pressure by applying a properly sized cuff to the patient’s thigh. The femoral artery does not provide an area for assessment of the blood pressure. The brachial arteries are in the arm. The carotid artery, which is in the neck, is impossible to use for blood pressure measurement because applying cuff pressure to temporarily occlude both carotid arteries would stop blood flow to the brain and risk cerebral hypoxia.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

6. The nurse is running a blood pressure screening clinic at the community health center. Which

action should the nurse implement to obtain an accurate measurement of a patient’s blood pressure on an upper extremity? a. Use a cuff with a cuff width that is 40% wider than the circumference of the arm.

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b. Limit the cuff deflation rate to 10 mm Hg per second or heartbeat. c. Record the second Korotkoff sound as the systolic pressure. d. Apply the diaphragm of the stethoscope lightly over the brachial artery.

ANS: A

For accurate results, a properly sized blood pressure cuff is at least 40% wider than the circumference of the patient’s arm on which the blood pressure is measured. Deflating the cuff at 10 mm Hg is excessively fast. The systolic blood pressure is the first Korotkoff sound.

The diaphragm is placed firmly over the brachial artery to prevent environmental sound from interfering with blood pressure auscultation.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

7. The patient is unstable, so the nurse is using an electronic blood pressure device to measure

blood pressures every 15 minutes. What should the nurse do to verify the accuracy of the electronic blood pressure measurements? a. Check when the device was last calibrated. b. Know that the device adheres to current medical industry standards. c. Take a manual blood pressure within several minutes of the electronic reading. d. Verify that the systolic pressure is within 20% of patient baseline.

ANS: C

If the blood pressure readings from the electronic blood pressure measurement device are close to the patient’s blood pressure on auscultation using a sphygmomanometer, the nurse assumes that the electronic device is accurate. Knowing when the device was calibrated does not guarantee its current accuracy. Maintaining medical industry standards also does not mean the device is currently accurate.NA systolic measurement accurate within 20% of the patient’s baseline is grossly inaccurate and using such a measurement can potentially lead to catastrophic results.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

8. A patient has an electronic blood pressure cuff that inflates every 15 minutes for a reading.

Which activity by the nursing student would require the nurse to intervene? a. The cuff is positioned carefully on the gown sleeve for comfort. b. The cuff is removed every 2 hours for a skin assessment. c. The alarm limits on the electronic device are checked frequently. d. The cuff is rotated to the other extremity every few hours as possible.

ANS: A

The cuff should be directly on the patient’s skin, not over the gown, for an accurate reading.

All other actions are appropriate.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

9. The nurse delegates temperature measurement to nursing assistive personnel (NAP). For

which patient should the nurse instruct the NAP to use the tympanic thermometer? a. 10-year-old patient with a left leg fracture b. 12-hour-old infant in the newborn nursery

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c. 5-year-old patient with bilateral otitis media d. 15-year-old patient who had bilateral tympanoplasties today ANS: A

The 10-year-old patient is a suitable candidate for use of the tympanic thermometer if the NAP uses proper technique for positioning the sensor because of the age and condition of the child. The anatomy of the ear canal makes it difficult to position the probe accurately in neonates. Whenever ear infections are present, a tympanic thermometer can cause injury and record an inaccurate reading because of fluid, wax, or infectious material in the ear. Tympanic temperatures are prohibited when ear surgery has just been performed because they increase the risk for injury and infection.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

10. The nurse needs to measure the adult patient’s temperature, but the patient has just finished a

cup of coffee. Which is the best type of temperature for the nurse to obtain accurate results efficiently? a. Rectal b. Axillary c. Tympanic d. Disposable ANS: C

The nurse obtains a tympanic temperature because the hot coffee will affect an oral reading. A tympanic temperature is a more reliable indicator of body temperature than the oral reading because a tympanic temperature is a core temperature. Rectal temperatures for adult patients N continuous temperature monitoring is required or if no other are reserved for occasions when core temperature site is available; in addition, rectal temperatures are embarrassing for an alert adult patient. Axillary temperatures are not as reliable as tympanic temperatures and do not reflect core temperature. Disposable thermometers are the least accurate method.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

11. The nurse is preparing to obtain a rectal temperature. Nursing care is correct if the nurse

inserts the thermometer how far into the rectum of an adult? a. 1.3 cm (1/2 inch) b. 3.5 cm (1 1/2 inches) c. 5.1 cm (2 inches) d. 6.4 cm (2 1/2 inches) ANS: B

The nurse inserts the thermometer 2.5–3.5 cm (1–1 1/2 inches) to obtain a rectal temperature on an adult. The sensor tip will be deep enough into the rectum to eliminate environmental effects but not too deep to risk penetration or trauma to intestinal tissue. 1.3 cm (1/2 inch) is not far enough for an accurate reading. 5.1 and 6.4 cm (2 and 2 1/2 inches) are too far to insert the thermometer into an adult.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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12. While inserting a rectal thermometer, the nurse encounters resistance. What action should the

nurse take? a. Remove the thermometer immediately. b. Ask the patient to take a few deep breaths. c. Apply mild pressure to advance the thermometer. d. Remove the thermometer and reinsert gently.

ANS: A

If resistance is felt, the nurse should remove the thermometer probe. Applying pressure to advance the thermometer is contraindicated to prevent complications such as harm to the mucosa. If there is an obstruction or a large amount of stool, having the patient take a few deep breaths will not solve the problem. The obstruction or impaction will have to be dealt with first. If the nurse removes and then reinserts the thermometer, the stimulation reactivates the sphincter reflex. The resistance will more than likely still be present.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

13. The nurse notes that the patient’s tympanic temperature is 37.88 C (100.2 F) at 4 PM on the

patient’s second postoperative day. What should the nurse do initially? a. Check the leukocyte count. b. Collaborate for cultures. c. Ask the patient to drink some fluid. d. Offer the patient another blanket.

ANS: C

The nurse should ask the patient to drink more fluid and cough and deep breathe, because N indicate dehydration and atelectasis in postoperative low-grade temperatures frequently patients; in addition, patient temperatures generally peak in late afternoon. The nurse evaluates the patient’s temperature again in 2 hours and expects to obtain a lower temperature.

If not, the nurse assesses the patient for infection and collaborates with the provider to plan care. Until the nurse tries fluid and verifies the temperature, collaborating for specimen cultures is premature; in addition, the provider potentially will not want to culture for a low-grade temperature.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

14. The nurse is teaching a family member how to check a teenager’s temperature using a

tympanic thermometer. Which step is most important for the nurse to include in order to obtain an accurate reading? a. Pull the pinna down and back. b. Pull the pinna up and back. c. Place the probe loosely into the ear canal. d. Point the probe toward the eye.

ANS: B

To obtain a tympanic temperature using proper technique, the nurse inserts the thermometer tip into the ear, and pulls the pinna up and back for children older than 3. The tip must fit securely in the ear canal to block environmental effects. The tip of the thermometer should point toward the patient’s nose for proper positioning.

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DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

15. A patient taking a new cardiac medication suddenly develops an irregular pulse. The nurse

plans to obtain an apical-radial pulse. What action by the nurse is best? a. One nurse counts the apical pulse while another counts the radial pulse at the same time. b. The nurse delegates the task to two experienced nursing assistants. c. The nurse feels the radial pulse while watching the cardiac monitor. d. The nurse takes the apical pulse first, followed by the radial pulse.

ANS: A

The correct technique for measuring the apical-radial pulse for a deficit is for one nurse to take the apical pulse while another nurse takes the apical pulse at the same time for 60 seconds. The two measurements are compared. A difference of 2 beats is significant. Since the patient has had a change in status, this task cannot be delegated. The other two described techniques are incorrect.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

16. The nurse is preparing to measure the patient’s blood pressure with an electronic blood

pressure device. Which concept is most important for the nurse to consider? a. Use the extremity closest to the nurse. b. The cuff size must match the extremity being used. c. The brachial artery is always the best one to use. d. The temporal artery is usedNif neither arm is available.

ANS: B

The cuff must be the appropriate size for the extremity used. If the thigh is used, the nurse must use a larger cuff. The extremity used has nothing to do with proximity to the nurse. It depends on the patient’s status. In some instances, the brachial artery in the upper arm is not available for blood pressure assessment. The temporal artery is impossible to use for blood pressure measurement because the temporal arteries are on the lateral aspects of the skull.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

17. The nurse is preparing to assess the apical pulse. At which location should the nurse listen to

obtain an accurate apical pulse on an adult patient? a. At the fifth intercostal space at the left sternal border b. At the fifth left intercostal space at the midclavicular line c. At the second intercostal space at the left midclavicular line d. At the second right intercostal space at the midclavicular line ANS: B

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To auscultate an adult’s apical pulse, the nurse places the stethoscope at the left fifth intercostal space at the midclavicular line directly over the point of maximal impulse and the location for auscultating the mitral valve. The fifth left intercostal space at the left sternal border locates the tricuspid valve. The second intercostal space at the left midclavicular line locates the pulmonic valve. The second right intercostal space at the midclavicular line locates the aortic valve.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

18. The nursing assistant reports the following vital signs for four patients just evaluated. Which

patient should the nurse see first? a. 25 respirations per minute for a toddler b. 38 respirations per minute for a newborn c. 12 respirations per minute for an 8-year-old child d. 14 respirations per minute for an adult patient ANS: C

A child’s respiratory rate should be 18–30 breaths per minute. A respiratory rate of 12 is too low, so the nurse assesses this patient as the priority. The other values are within normal limits.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

19. At what distance above the antecubital fossa does the nurse position a blood pressure (BP)

cuff when using the brachial artery to measure BP? N a. 2.5 cm (1 inch) b. 0.6 cm (1/4 inch) c. 1.3 cm (1/2 inch) d. 5.1 cm (2 inches) ANS: A

The nurse positions the BP cuff 2.5 cm (1 inch) above the antecubital fossa when using the brachial artery. This allows proper placement of the stethoscope.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

20. The nurse uses a blood pressure (BP) cuff that is too narrow for the arm of a patient with

morbid obesity. What problem will the nurse encounter because of the cuff used? a. The Korotkoff sounds will not be heard. b. Only a palpable BP can be obtained. c. The stethoscope cannot be positioned correctly. d. A false high BP reading will occur.

ANS: D

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Using a cuff that is too narrow results in a false high BP measurement and makes care planning impossible. A properly sized cuff should be obtained as quickly as possible. Until it arrives, the nurse should continue to measure BP with the smaller cuff and observe the patient to ensure safety. Obesity potentially leads to diminished Korotkoff sounds. The assessment finding will warrant further investigation such as rechecking the blood pressure in several minutes. A palpable BP provides a systolic pressure only; the nurse obtains a palpable BP by inflating the cuff to occlude the artery and then palpating the brachial or radial pulse. The point at which the pulse returns is the systolic pressure. The nurse should have less difficulty positioning the stethoscope because the narrow cuff exposes more skin.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

21. The nurse is assessing a new orientee’s knowledge of when to take vital signs. The following

statement indicates a need for more education. a. “I should take vital signs upon admission.” b. “I should take vital signs when there is any change in condition.” c. “I should take vital signs at the beginning and end of a blood transfusion.” d. “I should take vital signs if a patient reports feeling different.”

ANS: C

Vital signs should be taken in all of those situations including before and after blood transfusions, but they also need to be taken during blood transfusions. The nurse would want to clarify that statement to make sure the nurse knows to check the vital signs during blood transfusions.

DIF: Cognitive Level: Evaluating N TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

22. While positioning the patient for a routine blood pressure check, the patient asks the nurse

why a support was placed under the arm before the BP cuff was applied. Which response by the nurse is most accurate? a. “This method prevents any problems in obtaining an accurate reading.” b. “This method helps the arm relax so the reading will be correct.” c. “I want you to be as comfortable as possible during this time.” d. “Just sit back and relax and let me get this reading right now.”

ANS: B

Supporting the arm ensures the muscles are relaxed, improving the likelihood for an accurate reading. Comfort is important but not the primary reason for providing support. Many variables can cause an inaccurate reading, including the wrong cuff size or improper placement of the stethoscope. Telling the patient to just “sit back and relax” ignores the patient’s question and is not an appropriate response.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning 23. The nurse assesses the patient’s respirations and notes the patient routinely takes two to three

breaths followed by an irregular period of apnea. How does the nurse document this finding? a. Biot’s respirations b. Cheyne-Stokes respirations

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c. Kussmaul’s respirations d. Hyperpneic respirations ANS: A

This is an accurate description of Biot’s respirations. Cheyne-Stokes respirations have an irregular rate and depth characterized by alternating periods of apnea and hyperventilation.

Kussmaul’s respirations are abnormally deep but regular. Hyperpneic respirations are increased in depth and can often be seen during exercise.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

24. The nurse is caring for a lethargic, 18-year-old patient with a respiratory rate of 32 breaths per

minute. What is the first action the nurse should take? a. Place the patient in high-Fowler’s position. b. Assess the remaining vital signs. c. Reassess the respiratory rate. d. Notify the health care provider.

ANS: A

The patient’s head should be elevated quickly to promote better lung expansion. The remaining vital signs can be assessed after taking actions to improve the patient’s breathing.

The health care provider will be notified, but the nurse’s first responsibility is to the patient.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

25. The nurse has delegated the task N of obtaining a pulse oximetry reading to the NAP. Which of

the following statements by the NAP indicates a need for further education? a. “The pulse oximetry reading was 95%.” b. “The patient’s pulse rate was 78 according to the readout.” c. “I made sure the patient did not have nail polish on.” d. “I made sure the patient was not receiving a respiratory treatment.”

ANS: B

Pulse oximetry is used to determine the percentage of hemoglobin saturated with oxygen, not the patient’s pulse rate. The patient’s nail polish should be removed and the patient should not be receiving respiratory treatments or PT during the readings because it can affect them. The readings are given in percentages.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

26. The patient’s oral temperature is 37.1 C (98.78 F) at 1 PM. Which of the following actions

should the nurse take next? a. Administer acetaminophen 650 mg by mouth now. b. Offer the patient an additional blanket. c. Document that the patient is afebrile. d. Compare this with the patient’s prior readings.

ANS: C

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This temperature is within normal limits. Because the temperature reading is within normal limits, other interventions are not needed. Providing a blanket would increase the temperature.

Comparing the temperature with other readings would be done if the temperature was outside of the normal range. Treating the patient with acetaminophen would be done if the patient’s temperature was elevated and you had a health care provider order.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. The nurse is going to measure the patient’s oxygen saturation. The nurse knows pulse

oximetry readings can be influenced by which of the following factors. (Select all that apply.) a. Nail polish b. Respiratory treatments c. Poor circulation to the site d. Tremors e. Hemoglobin levels f. Latex allergy ANS: A, B, C, D, E

There are many factors that can influence pulse oximetry readings, including nail polish on the fingers where the reading is taken, poor circulation to the extremities, tremors, respiratory treatments, and hemoglobin or hematocrit levels. It is important to select the correct site to take the reading to get the best accuracy. Latex allergy would not affect the reading but would preclude the use of disposable sensors.

N DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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Chapter 08: Health Assessment Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse admits the patient with mild chest pain from the emergency department. Which

should the nurse implement first to gain patient cooperation during a physical assessment? a. Explain the procedure and its purpose. b. Perform assessment in stages over the day. c. Complete assessment within 3–5 minutes. d. Assess painful areas before nontender areas.

ANS: A

First and foremost, the nurse should explain the procedure and its purpose. The patient is more likely to cooperate during a physical assessment if he or she knows what to expect and what the purpose of the procedure is. The nurse explains how the information is used to plan individualized nursing care. The nurse completes the assessment in as few stages as possible because he or she needs the assessment data to plan care. The nurse will assess painful and tender areas last.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. The nurse assesses a patient with light skin and observes normally shaped nail beds exhibiting

pallor and a slight bluish color. Which would the nurse implement first? a. Provide a warm heating pad.

N b. Collaborate with the health care provider. c. Assess the patient’s oxygen saturation. d. Check for restricted venous return.

ANS: C

Nail beds in a patient with light skin are a view of the patient’s capillary bed at the periphery.

Pallor and a bluish color in the capillary bed indicate inadequate oxygenation because oxygenated blood is dark red resulting in pink nail beds. The nurse would assess the oxygenation more thoroughly and intervene if needed. A heating pad is not warranted. The nurse will collaborate with the provider, but needs more data first. Since this is a problem in the arterial blood flow, checking venous return is not indicated.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

3. The nurse is performing a neurological assessment. Which patient behaviors demonstrate a

level of consciousness within normal limits? a. States name, age, and date but not location. b. Is lethargic; responds logically to questions. c. Responds verbally, but words are unintelligible. d. Responds to questions spontaneously; is alert and oriented.

ANS: D

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The patient who responds to questions spontaneously and is alert and oriented exhibits neurological findings that are within normal limits. The patient is conscious, responds to the environment, and has congruent thought processes. The patient who does not know the location is disoriented to place. Lethargy is not a normal finding despite correct responses.

Unintelligible speech is abnormal.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

4. How often should the nurse perform a general assessment of the patient? a. At least every 4 hours b. As often as it is needed c. When the patient requests it d. At the rate set by agency policy ANS: B

The nurse performs a general assessment at the beginning of the shift and as often as needed afterward; however, the nurse frequently performs a focused assessment to make clinical judgments and problem solve. Every 4 hours is time consuming unless indicated by patient condition. Patients do not determine when to perform an assessment, but the nurse is responsive to patient concerns and resolves the problem to the patient’s satisfaction. Agency policy sets the minimum standard for patients at different levels of acuity, but the nurse always uses judgment to determine when to assess the patient.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

5. The nurse is assessing a patientNwith a cast extending from just below the left knee to the toes.

Which assessment contains a desirable patient outcome? a. The toes are pink bilaterally. b. The cast is warm at the ankle. c. Paresthesia is present in the left foot. d. The cast is snug at the knee.

ANS: A

Bilateral pink toes indicate adequate oxygenation to the periphery and support the outcome, “Patient has pink and warm toes bilaterally while wearing cast.” This also implies that the cast fits properly without areas of constriction. An area of warmth on a cast potentially indicates an infection. Paresthesia indicates nerve compression or irritation; when this occurs with a cast in place on the affected extremity, it usually indicates swelling of the extremity, potentially leading to impaired perfusion. A tight cast potentially restricts blood flow and compresses nerves, leading to tissue damage and paresthesias.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

6. The patient has an irregular, elevated, localized area of edema on the left forearm. Which term

should the nurse use when documenting? a. Tumor b. Wheal c. Macule

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d. Vesicle ANS: B

An irregular, elevated, localized area of edema is a wheal. The nurse documents the approximate size of the wheal. A tumor is a solid mass of abnormal growth larger than 1–2 cm (0.4–0.8 inches). A macule is a flat change in skin pigmentation such as a freckle or petechiae. A vesicle is a round elevation of skin filled with serous fluid.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

7. The nurse is concerned with possible impaired peripheral perfusion after performing a

patient’s assessment. Which assessment finding about the patient’s lower extremities supports the nurse’s suspicion? a. The ankle bones are prominent. b. The skin is warm and pink bilaterally. c. The legs ache when in a dependent position. d. The peripheral pulses are absent on both legs.

ANS: D

Clinical indicators of impaired perfusion to a lower extremity include absent or diminished pulses, cool and dusky skin, and pain on exertion; if the disease is advanced, the patient potentially has pain at rest. Prominent ankle bones are normal. Warm pink skin is a clinical indicator of adequate tissue oxygenation. Aching in the lower extremities when in the dependent position is characteristic of venous insufficiency.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Assessment N

OBJ: NCLEX: Physiological Integrity

8. The nurse is listening to the patient’s lungs. Which information should the nurse use to

document normal patient lung sounds? a. Rales in the right lower lobe b. No adventitious breath sounds c. Pleural friction rub in the left lung d. Inspiratory wheezing in the upper lobes ANS: B

A clinical indicator of normal lung sounds is a lack of adventitious breath sounds, meaning that the patient does not exhibit crackles, rhonchi, rubs, stridor, or wheezing. Rales are the same as crackles and indicate fluid or atelectasis in the alveoli. Pleural friction rubs are not normal and indicate inflammation of the pleural lining. Wheezing indicates constriction of the airway as heard during an asthma attack.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

9. The nurse is instructing a patient how to breathe during auscultation of the lungs. Instruction

by the nurse has been effective if the patient breathes in which manner? a. Takes rapid shallow breaths. b. Breathes with the mouth open. c. Coughs and then takes a deep breath. d. Takes a deep breath and holds it.

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ANS: B

The nurse instructs the patient to breathe with the mouth open because this facilitates air movement and amplifies patient lung sounds. In addition, the nurse instructs the patient to take slow deep breaths. Rapid shallow breaths quickly induce hypocarbia, leading to lightheadedness and fatigue, and impair auscultation of breath sounds because the sounds are too faint to assess. Coughing and deep breathing are instructions to facilitate the mobilization of pulmonary secretions. Holding the breath impairs the nurse’s ability to auscultate air movement for a respiratory assessment.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

10. A patient has the following intake: a cup of oatmeal, a half cup of ice, 3 ounces of apple juice,

and 6 ounces of coffee. What is the total intake the nurse should document on the intake portion? a. 210 mL b. 390 mL c. 600 mL d. 630 mL ANS: B

The oatmeal is not counted because it is not fluid. A half cup of ice = 120 mL because it equals 50% of the measured volume. The juice is 3 ounces = 90 mL, and 6 ounces of coffee = 180 mL. Therefore, the total is 120 + 90 + 180 = 390 mL. DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment N

OBJ: NCLEX: Physiological Integrity

11. Which aspect of obtaining health information can the nurse delegate to nursing assistive

personnel (NAP)? a. Auscultate apical pulse of a patient with acute angina. b. Take vital signs of a patient who might be discharged. c. Complete lung assessment of a patient with pneumonia. d. Clarify effects of antihypertensive therapy for a patient.

ANS: B

The task of taking vital signs of a patient who may be discharged may be delegated to NAP. Assessing the apical pulse on a patient with acute angina, completing a lung assessment, and evaluating the effects of therapies cannot be delegated to NAP. DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

12. The nurse is teaching a nursing student the correct technique for assessing an apical pulse.

Which method when used by the student demonstrates adequate knowledge? a. Percusses the left ventricular wall. b. Palpates along the left sternal border. c. Directs the patient to lie in a supine position. d. Listens at the fifth intercostal space at the point of maximal impulse (PMI).

ANS: D

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To locate the apical pulse, the nurse locates the fifth intercostal space on the left midclavicular line; this point should coincide with the patient’s PMI. Evaluation of the heart rarely includes percussion. Palpation along the left sternal border reveals cardiac thrusts and thrills; however, the apical pulse is not proximate to the sternal border. The nurse positions the patient with the head of the bed at 30 degrees for patient comfort and to facilitate cardiac assessment.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

13. The nurse is preparing to assess the patient’s abdomen. Nursing care is appropriate if which

maneuver is seen? a. The abdomen is auscultated after percussion. b. The nurse instructs the patient to extend the legs. c. The nurse inspects the abdomen before auscultation. d. The assessment begins with palpation, followed by auscultation.

ANS: C

For an abdominal assessment, the nurse begins with inspection followed by auscultation to prevent accidental stimulation of movement, potentially leading to inaccurate assessment data.

The nurse has the patient bend at the knees to relax the abdominal wall, making abdominal palpation easier. Palpation never precedes auscultation of the abdomen.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

14. An older adult is being assessed by the nurse. Which finding does the nurse consider

abnormal when assessing the patient’s risk for fall? a. Use of an assistive device N b. Wearing glasses c. Get-up-and-go test completed in 35 seconds d. Romberg’s test position held for 25 seconds ANS: C

The get-up-and-go test is an assessment that should be conducted as part of a routine evaluation of older adults. The test detects people at risk for falling. The normal time it takes a person to complete the test is 10–20 seconds, so this is an abnormal result. The Romberg’s reflex is normally negative, meaning that when the patient stands with feet together, arms down at sides, and eyes open (20–30 seconds) or closed (20–30 seconds), there is minimal to no swaying. Using an assistive device or wearing glasses does not put the patient at risk for falling unless they are not using their devices.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

15. The nurse assesses a patient with arterial occlusive disease in the lower extremities. Which

activity by the nurse is most appropriate? a. Use a Doppler device to locate pulses. b. Massage the feet and ankles twice daily. c. Elevate the legs slightly when in the chair. d. Measure the circumference of the thighs daily.

ANS: A

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The nurse uses a Doppler device to locate peripheral pulses for a patient with arterial occlusive disease because arteries in this health alteration are often difficult to locate as they slowly narrow and impair oxygenated blood flow. Massaging areas of impaired arterial perfusion are contraindicated because the patient is already at risk for breakdown. The legs of the patient with arterial occlusive disease usually need to be dependent to allow gravity to help pull oxygenated blood to the periphery. Elevating the legs promotes venous return and increases the difficulty of oxygenating the tissue because the vessels need to deliver oxygenated blood through inadequate arteries. Thigh measurement is indicated for thromboembolic events, venous insufficiency, or other disorders that impair venous return.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

16. A patient with back pain asks why the nurse needs so many details about health history. What

is the most effective response by the nurse? a. “You seem reluctant to provide information.” b. “We need complete data to plan nursing care.” c. “It will take a short time to answer all questions.” d. “We need to determine contributors to your pain.”

ANS: B

The nurse explains that comprehensive data facilitate individualized patient care, lower patient risks of injury, and increase patient safety. Determining factors that contribute to the patient’s pain is part of a pain assessment and one of the details that help the nurse plan individualized patient care. Stating that the patient seems reluctant to provide information is placing an interpretation on the motives and may be completely off base if the patient is just trying to understand the process. Commenting that not much time is needed to answer the questions is N not responsive to the patient’s question.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

17. The nurse assesses an adult patient with a cardiopulmonary illness and hears a grating sound

over the lower lateral lung during inspiration that does not clear with coughing. What would the nurse most likely document as a result of the assessment findings? a. Rhonchi b. Pleural friction rub c. Wheezes d. Crackles ANS: B

A pleural friction rub is heard over the anterior lateral lung field if the patient is sitting upright. It has a grating quality that is best heard during inspiration. It does not clear with coughing. It indicates inflamed parietal pleura rubbing against visceral pleura. Rhonchi indicate fluid or mucus in larger airways causing turbulence in the airways. Rhonchi can sometimes be cleared by coughing. Wheezes are heard all over the lung fields and indicate a narrowed or obstructed bronchus. Crackles, formerly called rales, are most common in dependent lobes and indicate fluid in the small airways.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

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18. The nurse is assessing an older patient and finds the heart rate to be 52 beats per minute and

irregular. Suddenly the patient complains of dizziness and “feeling faint.” Which action does the nurse take next? a. Ask the patient about valve replacement surgery. b. Apply 3 L of oxygen via nasal cannula. c. Assess the patient’s blood pressure. d. Explain that this is a normal finding in older adults.

ANS: C

An irregular heart rate and dizziness are abnormal findings and symptoms, and the nurse immediately checks the blood pressure to obtain more data about cardiac output. The health care provider will be notified immediately for follow-up. An electrocardiogram (ECG) will be ordered along with other studies. History is important, but the current status is the priority.

The patient may or may not need oxygen.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

19. The nurse assesses the patient admitted with constipation. Which assessment finding warrants

further investigation? a. No aortic bruit b. Firm liver edge c. Bowel sounds audible d. Abdomen distended and taut ANS: D

N and taut is a significant finding for a patient with A distended abdomen that is round constipation because it potentially indicates a bowel obstruction and the patient may need emergency care. Absence of aortic bruits, a firm liver edge, and audible bowel sounds are normal findings.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

20. The nurse assesses the patient with altered musculoskeletal function. Which is the best reason

supporting the nurse’s motive for asking detailed questions? a. Explore how the patient’s family reacts to the disability. b. Evaluate patient concerns about the problem at this time. c. Determine how the alteration affects the patient’s lifestyle. d. Validate the amount of physical rehabilitation completed.

ANS: C

Determining how the altered musculoskeletal function affects the patient’s lifestyle is the best reason for the nurse to ask detailed questions. With skillful follow-up questioning, the nurse learns the most comprehensive information about the patient, including family reactions, patient concerns, and rehabilitation issues.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

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21. The nurse observes yellow sclerae while assessing the patient’s eyes. What does the nurse

look for to validate this finding? a. A history of pallor b. Jaundice c. Cyanosis d. Ecchymosis ANS: B

The nurse concludes that the yellow sclerae are indicators of jaundice, an accumulation of bilirubin in the skin. Jaundice is also seen in the mucus membranes and skin. Pallor is skin without a pink cast. Skin with a bluish or dusky cast is an indicator of cyanosis. Ecchymosis is purplish to yellow green and results from subcutaneous bleeding.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

22. The nurse assesses the patient’s lungs to find high-pitched musical sounds on inspiration and

expiration. Which description does the nurse use to document the findings? a. Rhonchi b. Wheezes c. Crackles d. Friction rub ANS: B

High-pitched musical breath sounds are wheezes that result from bronchospasm; the smaller the constricted airways, the higher the pitch of the wheeze. Rhonchi are low-pitched rumblings indicative of fluid in larger airways; rhonchi are potentially cleared with coughing.

Crackles are higher pitched andNsharper sounding than rhonchi, indicating fluid or atelectasis in dependent lobes of the lungs. A friction rub is heard on inspiration and expiration but characteristically is a grating sound. A friction rub is frequently accompanied by pain and fever.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

23. The nurse is performing a cardiovascular assessment at the fifth intercostal space at the

midclavicular line. What would the nurse be attempting to check? a. S3 b. Point of maximal impulse (PMI) c. Murmur d. Visible pulsations ANS: B

The nurse expects to find the PMI at the fifth intercostal space at the midclavicular line because this is where the left ventricle is the closest to the chest wall. The nurse follows palpation of the PMI with auscultation of the apical pulse. If the patient’s heart is dilated or hypertrophic, the PMI shifts to the left toward the anterior axillary line. S3 or murmur auscultated near any heart valve is generally abnormal along with visible pulsations (called a lift or heave) coming from the heart.

DIF: Cognitive Level: Understanding

OBJ: NCLEX: Physiological Integrity

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TOP: Nursing Process: Assessment 24. The nurse documents the patient’s swollen lower extremities and measures the depth of a

4-mm indentation made 1 minute ago. Which is the best description for the nurse to use to describe the patient’s lower extremities? a. 2+ pitting edema b. Mild pitting edema c. 2+ nonpitting edema d. Severe nonpitting edema ANS: A

2+ pitting edema is the best description of a lasting indentation of swollen legs at a depth of 4 mm. Mild and severe are subjective terms open to interpretation. Documentation must include that the edema is pitting because the indentation lingers for at least a minute.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

25. The nurse assesses the pupils of an older patient. What unexpected finding might the nurse

identify about the patient’s pupils? a. They are 3 mm in size. b. Both of them are round. c. Absence of convergence. d. They respond to light spontaneously.

ANS: C

Convergence of the pupils indicates appropriate accommodation. A lack of convergence would indicate an abnormality N to be investigated further. A 3-mm size, roundness, and responsiveness to light are expected findings of an eye assessment, indicating that the oculomotor cranial nerve (III) is intact.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

26. The nurse assesses the adult patient’s spine. Which expected finding does the nurse identify

about the patient’s alignment and posture? a. Upper spine bent slightly b. Spine in straight alignment c. Slumping to nondominant side d. Dominant side of patient favored ANS: B

The anterior–posterior alignment of the spine should be a straight line from the skull to the sacrum. The other findings would be unexpected. An excessive thoracic curvature is kyphosis, which is common with vertebral compression fractures of the thoracic spine. Slumping to the nondominant side and favoring the dominant side are abnormal findings, indicating muscular weakness or abnormal spine alignment.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

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27. The nurse assesses a possible melanoma on the patient’s skin. Which characteristic does the

lesion have that is consistent with a melanoma? a. Regular borders b. Larger than 6 mm c. Symmetrical borders d. Reddened coloration ANS: B

Melanomas are usually larger than 6 mm in diameter. In addition, melanomas are usually asymmetrical lesions with irregular borders and blue, black, or variegated coloring.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

28. The nurse assesses the oral mucosa for pathological color changes. Which finding would the

nurse see in the patient’s mouth, and what does it indicate? a. Ecchymosis resulting from low hemoglobin b. Cyanosis due to hypoxia c. Petechiae which are seen only in the mouth d. Erythema because of over-exertion ANS: B

The nurse can assess cyanosis in the mouth, which is especially helpful for assessing dark-skinned people. Ecchymosis is not usually seen in the mouth and would not be due to low hemoglobin. Petechiae are usually invisible in patients’ mouths. It is possible to observe erythema in the mouth, keeping in mind that the tongue can be beefy red in color.

DIF: Cognitive Level: Understanding N TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

29. The patient has iron deficiency anemia. What sign causes the nurse to intervene as a priority? a. Pallor b. Jaundice c. Cyanosis d. Erythema ANS: C

The nurse’s priority is to prevent cyanosis because it is a late sign of hypoxia. The patient is most likely pale already, so the nurse cannot prevent pallor. Because the patient has a narrow margin between adequate oxygenation and hypoxia, the nurse’s priority is to prevent hypoxia until the patient’s iron stores and erythrocyte counts increase to restore pinkness to the skin.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

30. The nurse is assessing the temperature of the lower legs. Which method should the nurse use

to best assess the patient’s skin temperature subjectively? a. Oral thermometer b. Dorsum of the hand c. Tympanic thermometer d. Thumb and index finger

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ANS: B

To evaluate the patient’s skin temperature according to the nurse’s opinion, the nurse uses the dorsal aspect of the hand because this skin is thin and more sensitive to temperature changes.

An oral or tympanic thermometer evaluates temperature objectively and provides information about the temperature of the body, not the extremities. Thumb and index finger are not used to evaluate the skin temperature subjectively because these are the most frequently used fingers and the skin is likely to be thicker and less sensitive to slight temperature fluctuations.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

31. The school nurse alerts parents to observe for chickenpox. Which clinical indicator does the

nurse instruct the parents to observe for chickenpox? a. Wheals b. Nodules c. Macules d. Vesicles ANS: D

When chickenpox first erupts, the lesions are small, fluid-filled skin elevations called vesicles.

Wheals are irregular elevated areas found with mosquito bites. Nodules are an elevated but solid mass. The vesicles of chickenpox change to pustules as the illness wanes.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

32. The patient is being assessed for a possible respiratory problem. In which position should the

N expansion during a thoracic assessment? patient be placed to facilitate chest a. Prone b. Side lying c. High-Fowler’s d. Dorsal recumbent ANS: C

The nurse helps the patient assume high-Fowler’s position to facilitate lung expansion during a thoracic assessment. The prone position would place the patient face down on the bed, making it impossible to see the chest expansion. The dorsal recumbent position is used in an abdominal exam. Side lying is a position used by the nurse to assess the posterior thorax of a patient who cannot cooperate with the examination.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

33. The nurse is preparing to begin the thoracic assessment of a patient. What is the initial step of

the thoracic assessment? a. Percussion of the lateral thorax b. Palpation of the anterior thorax c. Measurement of the respiratory rate d. Inspection of the posterior thorax ANS: D

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The nurse begins a thoracic assessment by inspecting the posterior thorax to identify any factors that can impair chest expansion or cause respiratory distress. Lateral percussion is not used in a respiratory assessment because the biggest lung fields are across the patient’s back.

Palpation of the anterior thorax follows assessment of the posterior thorax. Measuring the respiratory rate follows the posterior thoracic inspection.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

34. The nurse begins to assess the patient’s respiratory system. Which assessment by the nurse

best determines the patient’s diaphragmatic excursion? a. Observation of respiratory effort b. Percussion over air-filled regions c. Auscultation of thorax symmetrically d. Palpation of chest inspiratory movement ANS: D

The nurse palpates the patient’s thoracic movement by placing hands on each side of the spine with thumbs adjacent to one another and instructs the patient to breathe deeply. On inspiration the nurse observes or measures the respiratory excursion, a reflection of the patient’s inspiratory volume. Observing respiratory effort reveals data on the work of breathing. The nurse percusses over areas of suspected fluid accumulation to determine the size of the fluid from consolidation from pneumonia or a pleural effusion. The nurse symmetrically auscultates the thorax to compare bilateral breath sounds.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

N

35. The nurse is preparing to auscultate the pulmonic area. At which site should the nurse place

the stethoscope? a. At the costovertebral angle b. Over the costochondral junction c. At Erb’s point d. On the left side at the second intercostal space ANS: D

The nurse locates the pulmonic area at the second intercostal space, on the left side at the midclavicular line. This location is useful for assessing the pulmonic valve. The costovertebral angle is at the inferior aspect of the sternum. The costochondral junction is the point where a bony rib meets the cartilage connecting the rib to the sternum. The third intercostal space, Erb’s point, is a useless location for cardiac or respiratory assessments.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

36. The nurse is performing an abdominal assessment. Which action indicates proper technique? a. Assesses the painful areas first. b. Auscultates each quadrant for 5 minutes. c. Palpates lightly to locate painful and tender areas. d. Positions the patient with the arms behind the head.

ANS: C

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The nurse lightly palpates the abdomen to determine any painful or tender areas so the patient does not worry about the nurse aggravating the pain and the nurse can conduct a comprehensive abdominal assessment. Assessing painful areas first can terminate the assessment if the assessment exacerbates patient pain. Auscultating for 5 minutes is excessive for routine assessment. The nurse positions the patient with arms at the side and knees flexed to facilitate relaxation of the abdominal wall.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

37. The nurse admitted a patient with clear lungs and 2 days later has rhonchi in the left lung.

Which should the nurse implement next? a. Place the patient in high-Fowler’s position. b. Obtain a stat portable chest x-ray film. c. Notify the health care provider immediately. d. Complete a full respiratory assessment.

ANS: D

Because this is a new finding for the patient, the nurse facilitates suitable patient care by obtaining a comprehensive patient assessment to communicate to the health care provider.

There are no data indicating that the patient is in respiratory distress requiring a STAT film.

The nurse should notify the health care provider promptly, but he or she needs to finish the complete respiratory examination first as long as the patient is not in acute distress.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

N 38. The nurse assesses peripheral perfusion.

Which does the nurse find in a patient with arterial insufficiency? a. Edema b. Warm skin c. Palpable pulses d. Pain with exercise ANS: D

The patient with arterial insufficiency usually reports pain with exercise because the blood flow through arteries in the lower extremities is insufficient to meet tissue oxygen demands.

The tissue reverts to anaerobic metabolism with increased accumulation of carbon dioxide and lactic acid, precipitating pain in the tissues. The pain often improves with rest and dependent positioning. Edema is consistent with venous insufficiency. Warm skin and palpable pulses are consistent with adequate arterial perfusion of tissues.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

39. The nurse is performing a neuromuscular assessment. Which method should the nurse use to

evaluate muscle strength? a. Measure the muscle size. b. Perform range of motion. c. Apply pressure against resistance. d. Observe the patient’s gait and transfers.

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ANS: C

The nurse applies pressure against the patient’s resistance to measure muscle strength to make the subjective evaluation safe. Muscle size is not part of the assessment for strength. Range of motion indicates flexibility of joints. Observing a patient’s gait is a valuable measure of the patient’s muscle strength but is not used initially because it increases the risk of patient injury.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

N

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Chapter 09: Specimen Collection Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse obtains blood specimens in the clinic and prefers using an antecubital vein. Which

characteristics of veins in this area justify the nurse’s preference for the antecubital site? a. It is easily accessed in the hand. b. It causes less pain and bleeding. c. It is large, straight, and close to the surface. d. It is superficial and the most distal.

ANS: C

The nurse uses the antecubital area for blood draws because these veins are superficial, large, straight, and well anchored; these characteristics increase the chances of a successful blood draw on the first puncture. The antecubital area does not include the hand. Except for punctures in the hand, venipunctures tend to cause the same degree of pain and bleeding, regardless of the location. The most distal veins in the arm are located in the hand, and these veins are reserved for IV fluids.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

2. The health care provider orders a urine test. Which is the most important information for the

nurse to consider before collecting the urine specimen needed for the test? a. That the specimen collection precedes antibiotic administration.

N b. That the urine aspirated from the collection bag is suitable. c. Whether the urine test requires sending a sterile specimen. d. Whether the patient can provide peri-care properly.

ANS: C

The most important information for the nurse to know is whether the specimen needs to be sterile. If the test requires a sterile specimen, the nurse uses sterile technique to collect an uncontaminated specimen. If not, collecting the specimen with clean technique is adequate.

The patient’s ability to cleanse the perineum or whether to use urine aspirate are decisions answered by determining if the procedure needs to be sterile. If the urine sample is for a culture and sensitivity, it should be collected prior to administering antibiotics, but the question is asking about any urine sample.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

3. The patient accidentally discards voided urine during a 24-hour urine collection. What should

the nurse do next? a. Instruct the patient to call for help before voiding. b. Consult with the laboratory for further instructions. c. Discard all urine and begin another 24-hour collection. d. State on the laboratory requisition that one specimen is missing.

ANS: C

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The 24-hour specimen is invalid, so the nurse starts a new collection and reinforces instructions to the patient. A new container is obtained, and the collection is restarted. The nurse cannot send the specimen to the laboratory missing one specimen because the urine sent does not contain all urine from the last 24 hours.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

4. The nurse is preparing to obtain a blood specimen. Which is the most important intervention

for the nurse to complete before obtaining a blood specimen? a. Verify patient identification. b. Perform patient skin preparation. c. Ask the patient for an arm preference. d. Tell the patient that the procedure is slightly painful.

ANS: A

The nurse verifies patient identification before obtaining the blood specimen and uses at least two patient identifiers to ensure accurate identification because the nurse exposes the patient to potentially life-threatening complications by mislabeling a specimen. Skin preparation occurs only after the patient has been identified correctly. The remaining interventions are helpful, but only after the patient has been correctly identified.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Implementation

OBJ: NCLEX: Safety and Infection Control

5. The nurse evaluates the venipuncture site before leaving the patient’s room with the blood

specimen. Which nursing observation is an unexpected outcome?

N a. A dot of blood covers the venipuncture site. b. Heart rate is stable and regular at 80 beats/min. c. A soft subcutaneous lump appears at the venipuncture site. d. The patient complains of stinging with removal of the needle.

ANS: C

A soft subcutaneous lump at the venipuncture site after withdrawing the needle potentially indicates hematoma formation; this is undesirable because it increases the risk of patient infection at the site and is likely to cause patient discomfort. A dot of blood can indicate leakage from the venipuncture site but is usually a benign finding indicating clot formation. A stable heart rate and rhythm is a highly desirable outcome of venipuncture. Stinging on removal of the needle is expected.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

6. During a home visit, the patient with diabetes mellitus tells the nurse that she is having a very

difficult time obtaining blood for glucose monitoring. Which intervention does the nurse use to help the patient obtain a good blood sample? a. Asks the health care provider to order a different monitoring device. b. Instructs the patient to position the lancet on the side of finger or forearm. c. Teaches the patient to find a good site and use it repeatedly. d. Tells the patient to run warm water over the hand before testing.

ANS: B

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The nurse eliminates all patient-related factors that potentially interfere with glucose monitoring such as technique, dexterity, vision, or lack of knowledge. Regardless of the device being used for glucose testing, if the patient has difficulty implementing the procedure, changing devices is potentially futile if the same mistakes are repeated. Thus the nurse assists the patient with proper lancet positioning on the side of the finger or forearm to obtain enough blood for glucose monitoring. If the patient lacks experience with the lancet, has a long history of glucose monitoring that causes accumulation of scar tissue at puncture sites, or avoids deep punctures because of pain, he or she requires teaching to refine and reinforce the proper technique for obtaining a blood droplet. The nurse avoids suggesting warm water because patients with diabetes often have neuropathies and vasculopathies as complications of hyperglycemia; thus the patient is likely to have impaired tissue perfusion and sensation to extremities.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

7. The nurse is teaching a patient about the proper procedure for testing stool for occult blood.

The nurse’s teaching has been effective if the patient makes which statement? a. “I apply a very thick smear of stool onto the guaiac slide.” b. “The electronic meter calculates a reading within minutes.” c. “It is best if I get two separate samples from the same stool.” d. “I call my doctor for white paper with stool and developer on it.”

ANS: C

The patient is correct to say that more than one sample from the stool specimen is required for more conclusive results because occult blood from the gastrointestinal tract is not always equally dispersed through the stool.

N A thin smear is adequate for testing. An electronic meter is not used for guaiac testing. The stool is not placed on the paper until the patient is actually ready to test a sample.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

8. The patient’s blood glucose level was 134 mg/dL at 7 AM and is now 61 mg/dL at 3 PM.

Which intervention should the nurse implement first? a. Assess the patient for confirmatory findings. b. Check calibration of the blood glucose meter. c. Administer insulin according to a sliding scale. d. Instruct the patient to have orange juice and crackers.

ANS: A

As long as the patient is not in acute distress, the nurse assesses the patient for hypoglycemia to determine whether the patient presentation matches the glucose results. If the nurse determines that the patient has clinical indicators of hypoglycemia, the nurse incorporates these findings to form a plan of suitable nursing interventions. Checking the calibration of the device is a reasonable intervention if it appears that there are no confirming findings for the reading. Insulin drives glucose into the cells, further decreasing blood sugar. Until the reading is confirmed, it is not clear that providing supplemental calories to elevate blood sugar is appropriate.

DIF: Cognitive Level: Applying

OBJ: NCLEX: Physiological Integrity

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TOP: Nursing Process: Implementation 9. A nurse is orienting another nurse to the procedures for collecting blood samples. Which

statement indicates that the orientee needs further education? a. “The tourniquet is placed so it can be removed by pulling one end.” b. “A healthy vein is elastic and rebounds on palpation.” c. “The specimen is labeled with only the patient’s name.” d. “I clean the area with antiseptic swabs first.”

ANS: C

All specimens are labeled with two forms of patient identification. After you collect the specimen and in the presence of the patient, you must label the container itself (not the lid) with the same two identifiers (e.g., patient name and hospital identification number), specimen source, collection date and time, series number (if more than one specimen), and anatomical site if appropriate (e.g., wound culture from knee versus abdominal incision). The other statements are all accurate for the methods involved in obtaining a blood specimen.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

10. A female patient needs to provide a midstream-voided urine specimen for examination. What

teaching by the nurse would provide a valid specimen? a. Use a clean specimen cup for testing. b. Collect at least 125–150 mL of urine. c. Wash the perineal area with soap and water. d. Void some urine and then collect the sample.

ANS: D

N

The nurse instructs the patient to void a small amount of urine and then pass the sterile container under the urine stream to collect urine for a clean-voided urine specimen. A sterile specimen container, not a clean container, is used. Urine testing requires 30–60 mL of urine.

The nurse provides three antiseptic wipes or cotton balls or gauze soaked in antiseptic solution for perineal cleansing in preparation for the specimen collection.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

11. A patient is unable to void on demand for a clean-voided specimen. What is the appropriate

action by the nurse? a. Notify the provider that the patient has anuria. b. Palpate the suprapubic area for retained urine. c. Catheterize the patient to obtain the urine specimen. d. Offer fluids, if allowed, and wait about 30 minutes.

ANS: D

The nurse encourages the patient to drink fluids to fill the bladder so the patient can produce a clean-voided urine specimen. The nurse implements this first because it is noninvasive and it is the most likely cause of being unable to void. Notifying the health care provider of anuria is premature. Palpating the bladder to determine urine volume is inappropriate for this procedure. Catheterizing is an invasive procedure and increases the risk of patient infection.

DIF: Cognitive Level: Applying

OBJ: NCLEX: Physiological Integrity

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TOP: Nursing Process: Implementation 12. The nurse is monitoring the collection of a 24-hour urine specimen. What action by the nurse

will yield the most accurate test results? a. Keep the patient on the unit during the test. b. Keep the urine in a collection bottle in a container of ice. c. Save all urine from the time the test begins. d. Leave the collection bottle in the patient’s bathroom.

ANS: B

Keeping the urine on ice prevents it from decomposing. The ice needs to be maintained throughout the entire test. As the ice melts, the cold water is poured out, and more ice is replaced so the entire level of urine is below the level of ice. The patient can leave the unit during testing, and the nurse notifies receiving personnel to save all urine. The nurse instructs the patient to void just before beginning so the patient starts the test with an empty bladder.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

13. The patient has an indwelling urinary catheter. What step should the nurse take first to obtain

a urine specimen from this patient? a. Apply sterile gloves for the procedure. b. Insert a small needle into the drainage tubing. c. Clamp the drainage tubing for several minutes. d. Disconnect the catheter and drain the urine into the cup.

ANS: C

The nurse clamps the clear drainage N tubing below the self-sealing sampling port for 10–30 minutes before collecting a urine specimen from an indwelling urinary catheter to allow accumulation of fresh urine. Sterile gloves are needed for the perineal preparation for a voided urine specimen; this specimen will come from the catheter. Inserting a needle into the drainage tubing potentially causes a crack or a leak in the tubing because the tubing is not designed for puncturing. The nurse avoids disconnecting any sterile drain unless necessary.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

14. The nurse is teaching a NAP to test urine with a reagent strip for chemical properties. Which

technique demonstrated by the NAP would indicate understanding of the process? a. Immerse the reagent strip in urine for 1 minute. b. Compare reagent strip to the color chart on the bottle. c. Obtain the patient’s first voided specimen in the morning. d. Add a chemical tablet to the urine and then test with a reagent strip.

ANS: B

After immersing the reagent strip in the patient’s urine and removing quickly, the nurse waits the exact number of seconds recommended before comparing the strip to the color chart on the bottle. The nurse avoids comparing the strip too early because the chemical reaction necessary to complete the test takes time to process. The first voided specimen of the day is frequently used for testing; however, the nurse obtains a urine specimen according to the provider’s prescription. Reagent strips are one-step procedures.

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DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

15. The nurse is preparing a patient with peptic ulcer disease for discharge to home. What

information does the nurse include in patient teaching about testing stool for occult blood? a. Positive results indicate active bleeding. b. It is necessary to eat poultry and fish before testing. c. Each stool specimen provides one sample for testing. d. Menstruation postpones the testing for occult blood.

ANS: D

When the patient is menstruating, testing for occult blood is ineffective because the test does not discriminate between menstrual blood and occult blood from the gastrointestinal tract. The nurse instructs the patient to wait until blood flow ceases, provide self-care of the perineum, and then test for occult blood. Positive results indicate the presence of blood but do not distinguish between new or old blood. The patient does not have to eat fish or poultry before testing but avoids red meat because it potentially increases the redness of stool. Each stool specimen provides two samples for testing.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning 16. A patient in the doctor’s office needs a throat culture. What should the nurse implement to

obtain a proper sample? a. Instruct the patient to lie flat and tilt head. b. Ensure the patient has been NPO. c. Avoid touching the swab toNany inflamed areas. d. Depress the anterior third of the tongue ANS: D

The nurse depresses the anterior third of the patient’s tongue to minimize the gag reflex. The patient sits upright and tilts the head back for the test. The patient does not need to be NPO, however; if the patient has recently eaten, gagging may produce emesis. The nurse obtains a swab of the inflamed area, which is the area most likely to be infected.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

17. The nurse is obtaining a nasal culture using a commercially prepared culture tube. After

placing the swab in the culture tube, what should the nurse do next? a. Take the swab and mix it in reagent to check for color changes. b. Place the swab into a culture tube and add a reagent to the tube. c. Label the specimen and enclose it in a plastic biohazard bag. d. Place the swab into the tube, close it securely, and keep it warm.

ANS: C

Specimens must be properly labeled to avoid diagnostic and therapeutic errors. The nurse cannot evaluate the results of the culture; the fluid captures the microorganisms, and the technician mounts the fluid on slides and visualizes the specimen under the microscope. The nurse avoids adding reagents to the tube, then refrigerates the specimen after properly releasing the fluid.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

18. The nurse is obtaining a sputum specimen from a patient without using suction. What should

the nurse have the patient do to produce enough sputum for a sample? a. Instruct the patient to obtain specimens over 4 hours. b. Try to obtain a sample immediately after eating. c. Rinse the mouth with water to loosen the mucus. d. Take several deep breaths and forcefully cough into a sterile container.

ANS: D

The nurse instructs the patient to take three to four deep breaths before expectorating; the series of deep breaths helps to mobilize secretions and increases the chance of obtaining sputum in a sufficient quantity. The nurse instructs the patient to produce 5–10 mL of sputum and sends the specimen directly to the laboratory before potential degradation. A specimen obtained immediately after a meal is likely to be contaminated with food or saliva. The nurse offers clear water for oral rinsing before asking the patient to provide a sputum specimen because toothpaste or mouthwash potentially kills pathogens that cause infection and skews the results of the culture.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

19. While the nurse tries to obtain a sputum specimen from the patient who has pneumonia, the

patient becomes short of breath, and the respiratory rate increases. Which intervention does the nurse implement next?

N a. Completes the sputum collection quickly b. Clears the patient’s airway with suctioning c. Provides prescribed supplemental oxygen d. Instructs the patient to lie flat and breathe deeply ANS: C

The nurse stops the procedure; provides supplemental oxygen; and instructs the patient to take several slow, deep breaths to restore oxygen saturation. Collection of the sputum is now secondary to the oxygenation level. The patient must be stabilized first; then the collection can continue. Suctioning is only appropriate when the airway is compromised. The nurse helps the patient to semi-Fowler’s or high-Fowler’s position, whichever is most comfortable for the patient, to facilitate chest expansion. The nurse avoids the supine position because lying flat increases the work of breathing.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

20. The nurse is trying to obtain urine from a pediatric patient for a urine culture. What is the

smallest amount of urine the nurse needs to obtain from a patient for a urine culture? a. 3 mL b. 5 mL c. 10 mL d. 20 mL ANS: A

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The smallest amount required for a urine culture is 3 mL. DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

21. The nurse is reviewing the findings from a basic analysis of gastric secretions. What

information would the nurse expect to find? a. Negative occult blood b. Black coloration of gastric secretions c. Clumps or clots of blood d. “Coffee-ground” secretions ANS: A

The nurse expects to find no evidence of gastric bleeding with gastric secretion analysis because the normal stomach lining is a thick layer of mucus. Black coloration, clumps or clots of blood, or “coffee-ground” secretions are all unexpected findings and are evidence of bleeding.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

22. The nurse notices a change in wound drainage and gets an order for a culture. Nursing care is

appropriate if which technique is used? a. Obtain samples of both skin and wound exudate. b. Rotate sterile swabs at a deep point in the wound. c. Use older secretions for a more valid specimen. d. Move the swabs back and forth across the wound.

N

ANS: B

To obtain a wound culture, the nurse rotates the sterile aerobic and anaerobic swabs deep within the wound to obtain a sample of wound exudate that potentially has not yet reached the wound edges. Moving the swab in a back-and-forth motion risks cross-contamination. The nurse avoids contaminating the wound culture with normal skin flora. The nurse also avoids using older secretions from the wound because the older secretions do not reflect the status of the wound.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

23. The nurse is preparing to obtain a blood specimen. Which step should the nurse implement

when preparing for venipuncture? a. Tie the tourniquet in a knot. b. Use the tourniquet for at least 1 minute. c. Place the tourniquet 5–10 cm (3–4 inches) above the selected site. d. Apply the tourniquet tight enough to occlude distal pulses.

ANS: C

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The nurse places the tourniquet around and above the selected site by 5–10 cm (3–4 inches) and tightens the tourniquet enough to occlude venous return but not distal pulses. A slipknot or a Velcro strip should be used for a quick, one-handed release of the tourniquet. The nurse should try to have the tourniquet in place for no longer than a minute, depending on the patient. The nurse is able to occlude the venous return without occluding arterial blood flow because the arterial system is a higher-pressure system and thus requires more pressure to stop blood flow than a vein requires.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

24. The nurse is preparing to draw a blood sample. Which technique should the nurse implement

when performing venipuncture? a. Insert the needle, bevel up, at a 45-degree angle. b. Select a vein that is rigid, cordlike, and prominent. c. Insert the needle at once after scrubbing the skin with alcohol. d. Pull the skin taut by placing the thumb about 2.5 cm (1 inch) below the site.

ANS: D

The nurse stabilizes the vein and minimizes rolling by pulling the vein with the thumb positioned about 1 inch below the insertion point to prevent contaminating the site. The needle is inserted at a 15- to 30-degree angle. The best vein to select will be prominent and straight with no signs of swelling or hematoma. The vein should rebound when palpated. The nurse allows the alcohol to dry before inserting the needle because the process kills microorganisms and the needle can carry alcohol into the puncture and increase the pain.

DIF: Cognitive Level: Remembering N TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

25. A newly diagnosed patient with diabetes is being taught the procedure for obtaining a blood

glucose specimen. What information should the nurse include in patient teaching about the procedure for capillary puncture? a. Puncture the center of the fingertip. b. Allow the alcohol to dry completely. c. Hold the finger upright for the puncture. d. Squeeze the finger to increase blood flow.

ANS: B

The nurse instructs the patient to allow the alcohol or other antiseptic time to dry before puncturing the skin because the drying kills the microorganisms and the needle can carry alcohol into the puncture, increase the pain, and skew the results. The least painful sites to puncture the fingertip are on the sides. The patient should be told to hold the finger in a dependent position before puncturing to engorge the fingertip with blood. Squeezing the finger has the potential to skew the results of the testing.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning 26. A test for occult blood is to be done tomorrow. Patient teaching by the nurse has been

appropriate if the patient chooses which menu for dinner tonight? a. Hamburger, noodles, dinner roll with butter, broccoli

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b. Beef stew, rice, garlic bread, applesauce c. Macaroni and cheese, mixed vegetables, apple slices d. Pork chop, mashed potatoes with gravy, peas, ice cream ANS: C

A diet free of red meat for 24 hours prior to collecting the sample helps to prevent a false-positive result when testing for occult blood. There is no meat in the menu selection, and it contains several high-fiber choices.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

N

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Chapter 10: Diagnostic Procedures Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The patient asks the nurse why an x-ray film with contrast medium is needed. How would the

nurse respond? a. “Most patients ask me that question.” b. “It enhances visualization of the internal structures.” c. “It guarantees accuracy of the x-ray film interpretation.” d. “Let me have you speak to the radiologist.”

ANS: B

The radiologist uses contrast medium to visualize internal structures not seen with regular x-ray films. The dye saturates the affected area for the x-ray film, and the image stands out against the tissue without dye. Because the health care provider and radiologist know the normal contour and appearance of internal structures, they can spot abnormalities such as filling defects, tumors, fistulas, and fractures. The nurse needs to be direct and answer the patient’s question. Nothing guarantees accuracy.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

2. A contrast medium study is being scheduled. Which statement by the patient during the

assessment warrants further investigation by the nurse? a. “I’m allergic to shellfish.”

N b. “I have small veins in my left arm.” c. “I’m really worried about the test results.” d. “I’m really terrified about this procedure.”

ANS: A

The nurse needs to establish whether the patient is truly allergic to shellfish, indicating sensitivity to iodine. The antiseptic used for the test has an iodine base and might cause a reaction; if so, the nurse or provider uses chlorhexidine or another agent for the skin preparation before the study. In addition, because many contrast mediums have an iodine base, the provider needs to choose an alternative dye. Establishing the nature of the reaction is important because the information provides valuable data for the radiologist to aid in choosing the proper contrast medium. It also establishes baseline data necessary when preparing for postprocedure nursing care. The nurse does need to investigate the statements of being worried or terrified, but those are not the priority. Small veins will not be used for this procedure.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

3. A patient is being monitored 2 hours after an angiogram using the femoral artery. What

assessment by the nurse best indicates outcomes are being met? a. The patient can’t remember the procedure. b. The left pedal and posterior tibial pulses are palpable. c. The patient hasn’t voided yet.

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d. Both of the patient’s feet are cool and pink.

ANS: B

Because the provider punctured a large artery during the procedure, the nurse assesses that blood flow distal to the insertion site is not compromised. Palpable pulses indicate the blood flow is intact. With sedation agents, it is common to not remember procedures. Not voiding within 2 hours is not a problem. If both patient’s feet are cool and pink, this is probably due to environmental factors. If only one foot was cool, the nurse would investigate further.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

4. The nurse is monitoring a patient during a gastroscopy. Which patient data need to be

communicated to the health care provider doing the procedure? a. The patient has been placed in the left lateral position. b. An anterior gastric erosion ulcer is present. c. The blood pressure has dropped 30 mm Hg. d. The patient is lethargic but can follow directions.

ANS: C

Inserting the endoscope can stimulate the vagus nerve, potentially leading to a slower heart rate and hypotension. Left lateral Sims’ position is suitable for gastroscopy. The patient should be drowsy with the medication used but able to follow basic directions. The nurse and health care provider use the gastric erosion identified during the gastroscopy to plan nursing care and patient therapy.

DIF: Cognitive Level: Applying TOP: Nursing Process: Evaluation N

OBJ: NCLEX: Physiological Integrity

5. The nurse provides patient teaching before a lumbar puncture. Which information does the

nurse include about patient activity during the procedure? a. “You can move freely during this procedure.” b. “I’ll place you in a semi-Fowler’s position.” c. “It is essential to remain still during the procedure.” d. “We’ll restrict your fluids after the test is done.”

ANS: C

The nurse instructs the patient to maintain the lateral position and lie without moving during the procedure, especially while the provider inserts the needle, because the goal is to put the needle in the subarachnoid space. Unexpected patient movement potentially leads to needle misplacement, patient injury, and increased risk of postprocedural headache and infection from leaking cerebrospinal fluid. The local anesthetic injection stings, and insertion of the needle potentially elicits a sharp, stabbing, or shooting pain that causes patients to flinch. The nurse assists the patient to maintain the position and offers reassurance and information. The nurse instructs the patient to indicate verbally that pain is present during the procedure but not to move. Unless fluids are contraindicated, providers typically prescribe flat positioning and normal fluid intake following the procedure.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning

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6. A patient has had increasing respiratory difficulty as a result of abdominal cancer. Which

information does the nurse provide to the patient about the purpose of having a paracentesis? a. It will relieve pressure and some of the discomfort in your abdomen. b. It will allow for analysis of the thoracic fluid for cytology. c. Fluid from the lung will be examined. d. The examination will extract a sample of bone marrow.

ANS: A

Paracentesis is the removal of abdominal fluid for examination and relief of pressure from severe ascites. The removal of the fluid can increase patient comfort and ease breathing. A thoracentesis removes fluid from the chest cavity. Lung fluid is not obtained during a paracentesis. A bone marrow aspiration recovers bone marrow cells.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

7. The nurse is explaining the procedure for a paracentesis. Which intervention by the nurse can

help prevent a complication of the procedure? a. Have the patient hold the breath for a few seconds. b. Ensure that the patient voids before the procedure. c. Place the patient in a supine position. d. Check vital signs every 2 hours after the procedure.

ANS: B

The nurse instructs the patient to void before the paracentesis because an empty bladder reduces the risk of an accidental bladder puncture. The patient doesn’t need to hold his or her breath. The nurse helps the patient into a sitting position because sitting decreases the size of N are measured every 15 minutes for 2 hours. the peritoneal cavity. Vital signs DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

8. A patient develops low back pain radiating to both sides of the body after a femoral approach

has been used for a cardiac catheterization. What should the nurse do while contacting the health care provider? a. Ambulate the patient to see if the pain diminishes. b. Monitor the vital signs every 5 minutes. c. Encourage oral intake of fluids as desired by the patient. d. Sit the patient in a high-Fowler’s position.

ANS: B

The patient may be experiencing a complication such as retroperitoneal bleeding, which is an emergency. Surgery or further intervention will most likely be required; therefore the patient needs to be NPO and kept in a position that supports the blood pressure best, which is supine.

The patient’s status must be monitored frequently because of the severity of the situation.

DIF: Cognitive Level: Applying TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

9. The patient arrives in the post anesthesia care unit after a cardiac catheterization via the left

femoral artery to assess the right atrium. Which patient datum is the nurse’s priority to assess perfusion of the affected extremity after the procedure?

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a. b. c. d.

Checking the left femoral region for bleeding Monitoring patient vital signs every 15 minutes Applying direct pressure at the patient’s IV site Palpating the right pedal pulse for pulsations

ANS: A

To access the right heart, the provider used a femoral approach, which is the site where bleeding would occur after the procedure. The nurse measures vital signs every 15 minutes after a cardiac catheterization; however, unless the femoral vein is bleeding, the vital signs provide secondary evidence about the perfusion to the affected extremity. The nurse palpates the unaffected extremity as a comparison for the affected extremity. Applying pressure is a nursing intervention and will not provide patient data regarding perfusion.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

10. The nurse prepares a patient for a pulmonary angiogram. What information should the nurse

include in patient teaching to prevent a postprocedure hemorrhage? a. The chemicals in the dye injection help prevent hemorrhage. b. The patient will be sleepy; so movement will be minimal. c. The patient’s affected leg will be immobilized after the procedure. d. Postprocedure analgesia will manage patient discomfort.

ANS: C

The nurse explains that the patient’s hips and knees will be kept straight and positioned for little movement for 2–6 hours after the procedure. The nurse also explains that flat straight extremities allow adequate hemostasis to prevent postprocedure bleeding by protecting the N integrity of the insertion site. Sleepiness is expected after the procedure and is not involved in prevention of a postprocedure hemorrhage. The contrast dye and postprocedure analgesia will not interfere with the ability of the blood to clot.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

11. The nurse is caring for the patient immediately after an angiogram has been finished. Which

action does the nurse take to prevent a complication of this procedure? a. Limit the patient’s total fluid intake. b. Encourage early patient ambulation. c. Elevate the head of the bed 30 degrees. d. Apply constant pressure to the insertion site.

ANS: D

Significant pressure applied to the insertion site of the angiographic catheter helps to ensure hemostasis and prevent a post-angiograph hemorrhage. The pressure is kept in place for up to 6 hours if no closure device was used. Fluid intake increases after an angiogram to flush the dye from the system quickly to prevent renal damage. Following the angiogram, the patient is kept supine.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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12. The nurse cares for a patient who had an angiogram of the aorta with a contrast medium

approximately 4 hours ago. Which is the priority patient assessment for the nurse to monitor for detection of an allergic reaction to the dye? a. Pallor b. Pruritus c. Tachycardia d. Cool skin ANS: C

The nurse monitors the patient’s respiratory and cardiac status for any indication of a hypersensitivity reaction to the dye. Tachycardia can be a delayed sign of an allergic reaction.

Other clinical indicators include flushing, itching, and urticaria. Pallor is usually an indicator of altered cardiovascular status. Pruritus and cool skin may be an indication of allergic reactions; however, they are not as high on the patient’s hierarchy of needs as the heart rate.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

13. A patient is admitted for possible leukemia. Prior to assisting with the definitive diagnostic

procedure, which question does the nurse ask? a. “Do you ever feel claustrophobic?” b. “Are you allergic to iodine or shellfish?” c. “Have you ever had an electrocardiogram?” d. “Can you lie on your stomach for 20–30 minutes?”

ANS: D

To rule out leukemia, the patient needs to have a bone marrow biopsy to examine the marrow for malignant white blood cells.NA bone marrow biopsy requires the patient to lie in the lateral or prone position when the provider chooses to obtain the bone marrow specimen from the iliac crest. These positions provide access to the hip and allow the provider to apply enough pressure to reach the marrow with the hollow core needle. If the patient cannot tolerate the positioning, the provider can choose the sternum. Allergies to shellfish and iodine are of key interest when performing tests that use contrast medium. Claustrophobia is important to determine before computed tomography or magnetic resonance imaging. The nurse asks about previous electrocardiograms to compare with current electrocardiograms.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

14. The nurse is teaching an older patient before a bronchoscopy. What information is the most

important for the patient to know to prevent a possible postprocedure complication? a. Deep breathe during the insertion of the bronchoscope for easy passage of the scope. b. Do not eat or drink anything after the procedure until the nurse says it is safe to drink. c. Turn on your right side while the bronchoscope is passed through the nose and throat. d. Avoid food and fluids for at least 8 hours before the procedure.

ANS: B

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The nurse cautions the patient to avoid taking anything by mouth after the bronchoscopy until approved by the nurse because the nurse determines when the gag reflex returns. The health care provider sprays a local anesthetic agent to depress the gag reflex before passing the bronchoscope. Ingesting oral food or fluid potentially causes choking or aspiration with a depressed gag reflex. The patient is NPO for 2–6 hours before the bronchoscopy to help prevent aspiration of gastric contents. IV sedation is often used to relax the patient, allowing for easy passage of the bronchoscope. The bronchoscope passes through the oropharynx into the trachea, not through the nose.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

15. The patient arrives in the intensive care unit after a bronchoscopy. Which patient assessment

is the nurse’s priority? a. Status of the gag reflex b. Level of sedation c. Circulatory status d. Respiratory status ANS: D

Respiratory status is the priority assessment in the immediate postprocedure period because bronchoscopy includes manipulation of a scope through the trachea and bronchi, potentially stimulating bronchospasm, laryngospasm, and respiratory distress. Cardiovascular status, or circulation, is the next patient priority on the hierarchy of needs. After the respiratory and cardiovascular assessments, the nurse assesses the patient’s neurological status and sedation level to monitor for return of function. The nurse assesses the gag reflex before administering anything by mouth.

N DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

16. The nurse is preparing to position a patient for a gastroscopy. Which action should the nurse

implement before getting the patient into position? a. Remove the patient’s dentures. b. Suction the oral cavity. c. Provide a sip of clear fluid. d. Position the patient upright in bed.

ANS: A

The nurse assists the patient in removing dentures before the procedure to protect the dentures, prevent accidental dislodgement, and facilitate patient comfort. Suctioning is not indicated before positioning. The nurse positions the patient in the left lateral Sims’ position during the procedure and in the semi-Fowler’s or the recovery position after the procedure.

The patient should be NPO prior to the procedure.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

17. An older patient has been NPO for 8 hours before a bronchoscopy. When the patient returns

from the test, which is the nurse’s priority assessment? a. Hydration status

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b. Level of orientation c. Skin integrity status d. A reaction to contrast medium used ANS: A

Older patients are especially prone to dehydration, and the risk increases after a prolonged NPO period because the nurse withholds food and fluid to prepare the patient for the procedure. The patient’s urinary output needs to be watched after hydration has been established. Emptying the stomach decreases the risk of aspiration of gastric contents during and after the procedure. Disorientation is a reasonable assessment for an older adult who has received inadequate fluid and risks dehydration; it may be a clinical indicator of dehydration.

The risk of skin breakdown is increased with dehydration. It is not as important as early detection of dehydration because preventing dehydration helps to prevent skin breakdown. A contrast medium is not used during a bronchoscopy. The procedure is a direct visualization.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

18. A patient is having a contrast medium study and has several allergies. During the injection of

the dye, the patient complains of having a brief, severe hot flash and slight chest pain. What nursing action is most indicated? a. Ask the patient how he or she is feeling since the dye was injected. b. Tell the patient that many patients feel the same way. c. Assess the patient’s vital signs while reassuring him or her. d. Explain to the patient that this is a normal sensation for this test.

ANS: C

Obtaining objective data is the N best indicator of the patient’s status. Asking the patient how he feels may be helpful, but it results in only subjective data. Telling the patient that others feel the same way is nontherapeutic. The patient concern should be answered honestly and completely. Many of the contrasts such as those for angiography can cause a sensation of warmth shortly after the injection, but specific evaluation of the patient’s status is required.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

19. The nurse is caring for a patient who had a lumbar puncture (LP) 1 hour ago. The patient is

drowsy and the pupils are dilated. After notifying the health care provider, what should the nurse do? a. Maintain airway. b. Reduce total fluid intake. c. Lie the patient flat. d. Maintain pressure on the LP site.

ANS: A

A patient undergoing an LP can develop an excessive loss of CSF, which causes reduced LOC, dilated pupils, and increased BP. The nurse should first maintain the airway. The nurse would then notify the health care provider, monitor vital signs, and prepare to transfer the patient to the ICU. The patient should not be flat because that would compromise the airway.

Pressure on the site will not stop the leak, and the patient should have not fluids restricted.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

20. The nurse is preparing a tired older patient for a thoracentesis. Which ability should the nurse

assess for when determining if the patient can tolerate the procedure safely? a. Cough only when requested. b. Swallow and clear the throat. c. Remain sitting but motionless. d. Inhale during needle insertion.

ANS: C

The nurse should assess the patient’s ability to remain motionless in a sitting position during the procedure so the provider can precisely place the needle in the fluid without puncturing adjacent structures inadvertently, including the heart and great vessels. The nurse instructs the patient to avoid coughing and throat clearing during a thoracentesis to prevent accidental injury. The nurse instructs the patient to hold his or her breath during a thoracentesis to prevent accidental injury to adjacent thoracic structures.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

21. A patient asks the nurse why being NPO for 6–8 hours before a contrast study is necessary.

Which response by the nurse is most accurate? a. “This will decrease the chance of an allergic response.” b. “Excessive hydration causes dilution of the contrast medium.” c. “It reduces the chance of postprocedure infection.” d. “Nausea is prevented if the stomach is empty.”

N

ANS: B

Excessive hydration causes dilution of the contrast medium, making structures more difficult to see. The hydration status has not affected the chance of an allergic response to the contrast medium. Postprocedure infection is rare with a contrast study and being NPO has nothing to do with its occurrence. Having an empty stomach does not prevent nausea. Nausea may result from the contrast medium used for the study.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

22. A patient is recovering after receiving sedation for a contrast medium study and has a score of

2 using the Modified Ramsay Sedation Scale. What action by the nurse is most appropriate at this time? a. Document the findings. b. Prepare to increase the oxygen flow. c. Administer a drug-reversal agent. d. Listen to the breath sounds.

ANS: A

A score of 2 reflects a patient who is cooperative, oriented, and tranquil. Documentation is the only action needed. There is no need to increase the oxygen flow based on the patient’s optimum status. A drug-reversal agent is not needed based on current assessment data. There are no data that point to the need to assess breath sounds at the current time.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

23. An hour after a patient has a thoracentesis, the patient’s oxygen saturation is 88%, and

respiratory rate is 34 breaths per minute. What actions by the nurse are priorities? a. Raise the head of the bed and call the nursing supervisor. b. Give oxygen to the patient and notify the physician. c. Look at the chest excursion and notify respiratory therapy. d. Open a chest tube insertion kit and notify the patient’s family.

ANS: B

The patient most likely has a punctured lung and needs respiratory support. He or she must not be left alone. Oxygen is needed, and the physician must be notified immediately. Raising the head of the bed does not increase the flow of oxygen. Further assessment is not a priority until the oxygen is on and either the physician or respiratory therapy is at the bedside. The nurse should not assume that a chest tube will be inserted. The tray must be kept closed until immediately before being used. The physician needs to be called before the family is called.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

24. The nurse is caring for a patient who received opioids for sedation during a procedure. After

the procedure the patient experiences oversedation that required the administration of a reversal agent. Which agent would the nurse administer? a. Flumazenil b. Naloxone c. Diphenhydramine N d. Epinephrine ANS: B

If a patient is oversedated, be prepared to administer emergency medications or reversal agents (e.g., naloxone [reversal of opioids] or flumazenil [reversal of benzodiazepines]). Other support drugs may also be given. Diphenhydramine would be given for an allergic reaction.

Epinephrine does not reverse opioids.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. A patient is going to have a cardiac procedure that requires moderate sedation. The nurse is

explaining to the patient what is included in the pre-sedation assessment. Which questions by the nurse are most appropriate? (Select all that apply.) a. “Have you arranged for someone to drive you home after the procedure?” b. “How frequently do you drink alcohol?” c. “Have you had any problems with anesthesia before?” d. “Do you have any drug allergies?” e. “Do you currently use any drugs? How frequently have you used drugs in the past?” f. “Is there a family history of drug use or abuse?”

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ANS: A, B, C, D, E

One of the risks for moderate sedation is if it progresses past the point and becomes deep sedation. Because of this risk, only trained individuals can give the sedation and a pre-assessment is completed to help ensure patient risk factors are known. The patient’s level of tolerance for the sedatives used can be affected by his or her history of drug and alcohol use. The patient must also arrange for someone to take him or her home after the procedure.

Current drug allergies will prevent an allergic reaction. Past family history does not impact the patient.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

2. The nurse is describing the “time-out” verification procedure to a nursing orientee. Which

statements by the orientee indicate a good level of understanding? (Select all that apply.) a. The time-out is done at the start of every invasive procedure. b. The time-out prevents wrong site errors. c. The time-out prevents wrong patient errors. d. The time-out is done by the surgeon. e. The time-out is required by The Joint Commission (TJC).

ANS: A, B, C, E

The time-out verification procedure is required by TJC and is done before every invasive procedure by the physician and all involved personnel. This is a safety procedure that prevents wrong patient, wrong site, and wrong procedure errors.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

N

3. The nurse is caring for a patient post cardiac catheterization who experiences a vasovagal

response when the sheaths are removed and pressure is applied. Which of the following symptoms is the patient likely to experience? (Select all that apply.) a. Feeling faint b. Light-headed c. Flushing d. Dizzy e. Itching ANS: A, B, D

A patient experiences a vasovagal response (occurs at the time of femoral puncture or after the procedure when femoral pressure is applied). Symptoms include feeling faint, dizzy, light-headed, and possible loss of consciousness for a few seconds. Bradycardic pulse is caused by stimulation of the vagus nerve via baroreceptors. Itching and flushing occur with contrast dye.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

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Chapter 11: Bathing and Personal Hygiene Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The patient is able to sit in the chair while the bed is being made. What nursing process step

should the nurse implement for bed making? a. Keep the bed in the low position. b. Pull the blanket up to the head of the bed. c. Instruct the patient to hold the side rail. d. Delegate the task to nursing assistive personnel (NAP).

ANS: D

The nurse delegates making an unoccupied bed to the NAP because the assistants are specifically trained in bed making and because the patient is stable enough to sit in a chair while the bed is made. This frees the nurse to perform tasks requiring skills specific to registered nurses.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

2. The patient is bedridden, in pain, and doesn’t want the head of the bed raised. Which method

should the nurse use to change the patient’s bed linens? a. Ask the patient to raise the lower body to remove the soiled linen. b. Keep the top sheets over the patient and slowly roll him or her to each side. c. Keep the patient on the left side and get extra help to remove soiled linens quickly.

N d. Fanfold the top linen to the bottom of the bed and replace with clean linen.

ANS: B

Because the patient is in pain and can’t get out of the bed, the nurse makes the bed using the occupied bed technique. To maintain patient comfort and privacy, the nurse keeps the patient covered while rolling from side to side slowly to prevent dizziness while exchanging the soiled and clean linens. The soiled linens are folded toward the center of the bed and tucked under the patient; then the fresh linens are applied. When the first side is completed, the patient is gently rolled over the ridge of linens in the center so the other side may be accessed.

The soiled linens are then removed, and the fresh linens are smoothed over and tucked in.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

3. A patient reports itching skin on the back. What should the nurse do initially to relieve the

patient’s discomfort? a. Administer an anti-itch cream. b. Assess the patient’s skin condition. c. Remind the patient to shift positions. d. Assess for skin allergies to laundry soap.

ANS: B

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The nurse addresses the patient’s itchy back by inspecting and assessing the patient’s back for hives, a rash, or redness; the nurse uses the data to formulate a plan of care to relieve the itching. The nurse does not have complete patient data to justify administering an anti-itch cream or recommend shifting positions until the assessment is completed. Being allergic to hospital sheets would cause a reaction on all skin surfaces that made contact with the sheets, not just the back.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

4. The nurse instructs the spouse of an elderly patient who is on bed rest on how to provide a

complete bed bath. What does the nurse include in the patient/family teaching? a. Prevent dryness with CHG solution. b. Clean the anus vigorously and dry with a towel. c. Wash the perineal area with warm running water. d. Daily bed baths can cause skin damage.

ANS: D

The nurse cautions the patient’s spouse that daily bathing can lead to dry skin and irritation for someone on complete bed rest because skin becomes thin, fragile, and prone to bruising and tears. CHG is used in specific hospitalized patients to prevent health care–associated infections. The nurse instructs the patient’s spouse to keep the perineum clean and dry; however, vigorous cleansing can lead to dry skin and irritation, potentially resulting in skin breakdown. Perineal cleansing with warm running water is impractical for home care.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

N

5. The nurse bathes an unconscious patient. Which action should the nurse implement to

maintain infection control during a bed bath? a. Use long strokes and lotion to massage both legs. b. Perform a complete assessment of the patient’s skin. c. Wash each eye carefully rinsing all traces of soap. d. Soap the entire front of the patient’s body and then rinse.

ANS: B

The nurse assesses the patient’s skin during a bed bath because the skin is a major part of the innate defense of the body against microorganisms. The nurse identifies areas of the patient’s skin with a potential for breakdown and plans preventive or restorative nursing care. Lower extremities are not massaged to prevent dislodging a potential thrombus. Warm water only is used to cleanse the eyes because soap is likely to cause patient discomfort if it seeps into the eyes. The nurse washes and rinses smaller areas of the body to complete a bed bath because wetting a large surface area can cause vasoconstriction and shivering in the patient from the cooling effects of evaporation.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

6. The nurse is preparing to bathe the patient. Which patient statement would best communicate

a desired outcome as a result of the nurse’s bathing and skin care? a. “The daily baths are great for my dry skin.”

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b. “The cold water felt good during the bath.” c. “I enjoyed the vigorous massage of my feet.” d. “I feel more relaxed than I have all day.”

ANS: D

Feelings of relaxation and cleanliness are positive in nature and thus are part of a desirable outcome for patient bathing. Daily bathing is discouraged for dry skin because, for patients with rashes, scaling, redness, cracking, or thin, fragile skin, bathing can remove vital skin moisture. Bath water should be warm, not cold. Gentle massage can be done, but not of the feet. Usually the back, shoulders, and sacral area are gently massaged after the bath.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

7. The patient’s skin is thin and tight. Which approach should the nurse implement to maintain

skin integrity? a. Increase bathing to 2 times daily. b. Use super-fatted soap or a prepackaged bath. c. Avoid lotions to help retain skin moisture. d. Massage the skin briskly to increase circulation.

ANS: B

The skin needs to be moist and supple for strength and elasticity. A lack of moisture is causing the patient’s tight skin, so the nurse plans care to retain surface oils and moisture.

Soap that is super-fatted (such as Dove) or a prepackaged bath product is less likely to remove surface oils vital to retaining skin moisture. Bathing frequency should be reduced, not increased. Hydrating the surface of the skin is less effective than providing adequate hydration N retention, but it is part of a total skin-care program. Brisk to the patient internally for moisture massaging is contraindicated for thin, tight skin.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

8. The patient has an endotracheal tube (ET) and is unresponsive to painful stimuli. Which

action should the nurse implement while providing oral care? a. Use suction to remove oral secretions. b. Test the gag reflex with squirts of water. c. Clean the teeth with a firm toothbrush. d. Prevent patient toothbrush biting with an airway.

ANS: A

Oral care is safely provided to patients without a gag reflex by using suction. As secretions build from brushing the teeth and rinsing, the nurse suctions them with a clean, blunt-tipped suction catheter because suctioning helps to prevent fluid buildup in the oropharynx, which can lead to aspiration. The gag reflex is not tested when a patient has an ET and is unresponsive to painful stimuli. A soft toothbrush or toothette is preferred for cleaning teeth.

The ET is the patient’s airway. If the patient is biting the ET, the ventilator settings need to be changed, or the patient’s condition is changing. The pressure alarm on the ventilator will sound if the patient bites the tube; however, the nurse leaves the alarm on to prevent patient injury. An airway is used to prevent the patient from biting the tube.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

9. The nurse is caring for an unconscious patient. The student nurse asks why oral care is

necessary since the patient does not eat. What response by the nurse is best? a. “Even an unconscious patient can choke on secretions.” b. “Oral care is part of daily hygiene for all patients”. c. “Not doing oral care might cause the patient discomfort.” d. “These patients are prone to infection that good oral care could prevent.”

ANS: D

The oral cavity plays a role in defense against infections. Because of changes associated with unconsciousness and the inability to care for their own oral cavities, patients are more prone to infections. Good oral care can help prevent them. The other statements are all accurate, but do not adequately explain the most important reason for performing oral care on this patient.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

10. A patient wants to put in his dentures after not wearing them for several days. Which

intervention by the nurse minimizes the risk of gum irritation that can lead to infection? a. Store the dentures in a clean, dry container. b. Scrub the dentures with medicated toothpaste. c. Check to see that the dentures are a snug fit. d. Use dental floss to clean between each tooth.

ANS: C

The nurse include checks the fitNof the dentures to ensure a snug bond between the gums and the dentures to prevent pressure points, soreness, and the formation of oral lesions that can irritate the gums and lead to infection. The nurse stores the dentures in a container with tepid water and a lid. Scrubbing the dentures cleans the surface of buildup, debris, and the microorganism count, but the nurse should use a commercial denture product. Dental floss is not used on dentures.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

11. An unconscious male patient’s beard has become soiled with blood and adhesive tape residue.

What should the nurse do initially to maintain the patient’s hygiene? a. Trim the beard to a short, manageable length. b. Shampoo the beard at the bedside and comb out debris. c. Determine if there are contraindications to trimming the beard. d. Use baby powder to soak up debris; comb debris out.

ANS: C

The nurse ensures that trimming or removing the beard is acceptable to the patient’s family because several cultures forbid removal of facial hair. In addition, patients can spend years growing a beard and want to keep it. Trim the beard only if permission is given and if there are no medical contraindications to the procedure. Shampooing the beard is impractical and likely to soak the bed and patient in the process. Baby powder is an ineffective method of cleaning hair.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

12. The nurse is preparing to shave a patient’s beard. Which approach is best for the nurse to use? a. Soften the beard with a cool, wet washcloth. b. Hold the razor at a 90-degree angle to the skin. c. Remove the hair in the direction of hair growth. d. Maintain the patient in a prone position for shaving.

ANS: C

To shave the patient, the nurse moves the razor in the direction of hair growth to avoid razor cuts and abrasions. A warm, moist washcloth is used to soften facial hair for removal. The nurse holds the razor at a 45-degree angle to the skin. The patient is placed in the semi-Fowler’s or supine position for shaving for easy access to the facial hair.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

13. The nurse is providing a bath for a patient at risk of deep vein thrombosis. Which technique

should the nurse use? a. Use short, light strokes when washing the legs. b. Use long, firm strokes when washing the legs. c. Use circular strokes up and down the legs. d. Pat the legs gently with a warm, wet washcloth.

ANS: A

The nurse uses short, light strokes when washing the legs to prevent dislodging any clots if present. Long, firm strokes areNcontraindicated because the pressure exerted against the walls of the veins could dislodge clots if present. Circular strokes up and down the legs are not used to clean the legs. The strokes move toward the heart to promote venous return. Patting the legs with a warm, wet washcloth would be ineffective in cleaning.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

14. The nurse determines that the patient is physically incapable of maintaining his personal

hygiene. What is the most appropriate nursing approach for this patient? a. Explain how important it is for the patient to care for him- or herself. b. Assess the patient’s psychological status. c. Encourage the family to take over the personal hygiene. d. Encourage the patient to help in any way possible.

ANS: D

The patient’s participation in any way possible can help his or her self-esteem, improve function, and increase endurance. Because of the patient’s diminished ability, assistance is needed and should be provided. The family should be encouraged to help with hygiene only if the patient wants them to help and in ways that are appropriate.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

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15. The patient with type 1 diabetes mellitus and peripheral arterial disease receives a bed bath.

Which foot care technique would the nurse use for this patient? a. Soak the feet in warm water. b. Allow the feet to stay moist. c. Use warm water to cleanse the feet. d. Cut the nails in a curved shape.

ANS: C

The nurse uses warm water to cleanse the feet of a patient with diabetes and impaired perfusion to a lower extremity gently to avoid injury to the foot from hot water, scrubbing, or harsh cleansing agents. Foot soaks are contraindicated for patients with diabetes. The feet are dried carefully after cleansing to prevent fungal overgrowth and irritation. Toenails are cut straight across to prevent ingrown toenails. A podiatrist cuts the nails to prevent patient injury.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

16. An older adult is admitted for a respiratory infection and is found to have very dry skin with

several areas exhibiting some cracking. What question is most important for the nurse to ask the patient? a. “Are you able to reach your feet when you bathe?” b. “Would you like me to give you a back massage?” c. “Do you get chilled easily when you bathe?” d. “How often do you usually bathe?”

ANS: D

Older adults have skin that is dry and can easily become cracked. Bathing too often can cause N this problem. This is the most important question to ask based on the assessment data. The other options do not relate to assessing the patient’s skin.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

17. The nurse identifies several abrasions on the patient’s skin. Which intervention does the nurse

use for the patient? a. Apply antibiotic ointment. b. Apply calamine lotion. c. Shave the immediate area. d. Wash the area with soap and water.

ANS: D

Washing an abrasion with soap and water is a suitable nursing intervention. Soap helps to emulsify dirt, debris, and microorganisms; water helps to remove these potential contaminants. An antibiotic ointment is not indicated because the wound is not infected.

Calamine lotion can be used for contact dermatitis. Shaving is inappropriate.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

18. The nurse offers personal hygiene to a very modest patient. Which does the nurse implement

to maintain patient dignity and respect? a. Uses the patient’s personal care products.

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b. Explains hospital policy and procedure. c. Provides care at scheduled times as promised. d. Determines cultural and personal preferences.

ANS: D

The nurse questions a modest patient about cultural and personal hygienic customs and preferences beforehand to display respect and caring. This helps to ensure that nursing actions facilitate patient hygienic preferences and avoids creating patient psychosocial or physical discomfort while providing hygiene. The patient may use personal care products as long as there is no contraindication. Explanations of policies and procedures are patient expectations and an aspect of patients’ rights, a legal and ethical matter, more than a display of respect. The objective is to provide culturally sensitive hygienic care for a modest patient; providing care at a given time is less important than the nature of the care.

DIF: Cognitive Level: Applying TOP: Integrated Process: Caring

OBJ: NCLEX: Physiological Integrity

19. A female patient is on bed rest. In which position should the nurse place her to provide

perineal care? a. Prone b. Supine c. Dorsal recumbent d. Fowler’s ANS: C

The nurse uses the dorsal recumbent position to provide perineal care for a female patient because this position provides the most access to the perineum while maintaining patient N recommended because bath water will flow in retrograde privacy. The prone position is not fashion and contaminate the vagina and urinary meatus with microorganisms from the anus.

The supine and Fowler’s positions are not recommended because they do not allow the best access to the perineal area.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

20. The nurse is caring for four patients with different diagnoses. Which patient should the nurse

shave with an electric razor? a. The patient with hypertension b. The patient with high cholesterol c. The patient with a closed head injury d. The patient with a pulmonary embolus ANS: D

A patient with a pulmonary embolus is treated with anticoagulant therapy. The nurse avoids shaving patients receiving anticoagulants with a razor to prevent prolonged bleeding of potential facial cuts from the razor. Hypertension, high cholesterol, and a closed head injury are unlikely to require precautions for prolonged bleeding caused by anticoagulation.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

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21. The nurse assesses the incontinent patient’s perineal skin and notes redness. What does the

nurse include in the patient’s plan of care to individualize nursing care? a. Minimize exposure of the perineum to soap and water. b. Apply an antiinflammatory agent to the affected area. c. Provide frequent perineal care, especially after incontinence episodes. d. Remove the incontinence brief and expose the skin to air for an hour.

ANS: C

To maintain skin integrity, reduce inflammation, and prevent deterioration of the affected area, the nurse provides more frequent perineal care paying special attention to ensuring urine does not remain in contact with the skin. Removing the incontinence brief is usually impractical; it can remain in place to contain urine and fecal matter, with prompt perineal care after exposure to urine or fecal matter. The risk of skin breakdown from incontinence does not improve with exposure to air because the basic problem is frequent skin exposure to irritating waste products and not an anaerobic environment. The nurse allows every patient adequate time to use the commode, bedpan, or bathroom, but, since this patient is incontinent, toileting time is not an issue. An antiinflammatory agent may or may not be needed but the first step would be to ensure the perineal area stays clean and dry.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

22. The nurse is planning to delegate foot care to the NAP for three patients. Which patient should

the nurse do the foot care for? a. Postoperative after a hip fracture b. Diabetic patient c. Patient with a head injury N d. Pneumonia patient ANS: B

The skill of foot and nail care may be delegated to nursing assistive personnel (NAP) except for patients with diabetes or patients with peripheral vascular disease or circulatory compromise.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

23. The nurse is getting ready to shampoo a patient’s hair and notices bites behind the ears and on

the hairline. After notifying the health care provider, what is the next step? a. Shampoo the hair as planned. b. Do not shampoo the hair. c. Put the person in isolation. d. Use a medication shampoo.

ANS: D

The CDC recommends treatment for persons diagnosed with an active infection (CDC, 2013).

Over-the-counter or prescription treatment may be needed. Isolation precautions are specified by agency policy.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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MULTIPLE RESPONSE 1. The nurse is orientating a NAP about bathing patients. Which statement by the NAP indicates

a good understanding of the process? (Select all that apply.) a. “I should let the nurse know if I see any redness on the patient’s skin.” b. “I should make sure I do not leave the patient unattended with side-rails down.” c. “I should provide females perineal care with the patients on their sides.” d. “I should report any unusual perineal drainage.” e. “I can disconnect the IV tubing to put on the gown.”

ANS: A, B, D

The skill of bathing can be delegated. The nurse instructs the NAP about reporting early signs of impaired skin integrity, including redness or pallor; reporting perineal drainage, discomfort, or tenderness; proper ways to position male and female patients with musculoskeletal limitations and indwelling catheters; and reporting fatigue or report of pain. The IV should be threaded through the gown. The female patient should be placed in the dorsal recumbent position for perineal care.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

N

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Chapter 12: Care of the Eye and Ear Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse prepares to remove the patient’s soft contact lenses. Which intervention does the

nurse implement to remove the lenses without traumatizing the cornea? a. Irrigate the eye with 50 mL of a sterile saline solution. b. Pull the lid down and instruct the patient to blink. c. Pinch the sides of the lens together and pop it out. d. Move the lens to the sclera and compress the lens gently.

ANS: D

To remove a soft contact lens from a patient’s eye, the nurse moves the lens to the sclera and gently compresses it. This maneuver disrupts the surface tension holding the lens to the eye, allowing the nurse to lift the lens off the eye without traumatizing the cornea. The nurse avoids flooding the eye with irrigation solution because it increases the risk of losing the lens.

The nurse asks the patient to blink to eject a hard lens. The nurse avoids pinching the lens since that would risk corneal trauma.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

2. The nurse irrigates the patient’s eye after the patient splashes an irritating liquid into it. Which

intervention does the nurse implement to prevent injury during eye irrigation? a. Positions the patient in high-Fowler’s position during the procedure.

N b. Prevents the tip of the irrigating system from contacting the eyeball. c. Reassures the patient that the eye cannot be closed during irrigation. d. Allows the irrigating solution to run from the outer to the inner canthus.

ANS: B

The nurse prevents additional injury to the patient’s eye during the eye irrigation by maintaining the irrigation system tip away from the eye. The nurse positions the patient in the side-lying position on the side of the affected eye to control the flow of irrigation solution.

The patient is allowed to blink periodically during the irrigation. The nurse directs the irrigation solution to flow from the inner to the outer canthus to prevent contamination of the eye from a contaminated area.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

3. The nurse and the patient discuss the patient’s need for a hearing aid. What information does

the nurse include in patient teaching? a. An in-the-ear hearing aid is easy to manipulate. b. The patient’s specific needs and abilities are determining factors. c. The choice of a hearing aid is basically a financial matter. d. Behind-the-ear models are inferior to the other types.

ANS: B

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The patient’s specific needs and abilities are the determining factors in selecting a model of hearing aid for use. Hearing aids are available in many styles to suit a patient’s individual needs. In-the-ear hearing aids are a poor choice for a patient with impaired manual dexterity because they are small. Behind-the-ear hearing aids are suitable for mild-to-profound hearing loss. Choosing a hearing aid is partially a financial decision, but not all models suit a patient’s needs effectively.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

4. The nursing assistive personnel (NAP) reports that the hearing-impaired patient is usually

alert and oriented with the hearing aid in place, but the patient is not responding to verbal communication this morning. What action does the nurse implement first? a. Document that the patient’s neurological status is poor. b. Assess the patient for clinical indicators of a stroke. c. Remove the hearing aid and clean it with a stiff brush. d. Instruct NAP to check the hearing aid battery.

ANS: D

Because the patient is usually alert and oriented, the nurse realizes that the most likely cause of the patient’s change in hearing is a defective hearing aid battery. The nurse directs the NAP to check the battery first because this is also a simple factor to eliminate. After checking the batteries, the nurse instructs the NAP to clean the hearing aid with the brush supplied by the manufacturer, which is the brush that the patient uses regularly. The nurse does not know yet whether the patient’s neurological status is poor. The NAP reports clinical indicators of normal neurological function, making a stroke unlikely.

N

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

5. The nurse instructs the patient on how to care for the hearing aid at home. What information

does the nurse include in patient teaching to prevent damage to the hearing aid? a. Store the hearing aid with a desiccant. b. Wash the hearing aid in hot soapy water. c. Keep the hearing aid in the bathroom. d. Clean the hearing aid with a pipe cleaner.

ANS: A

The nurse instructs the patient to store the hearing aid in a dry container with a desiccant to keep moisture and heat away from the device because moisture and heat can destroy the delicate electronic components of the hearing aid. The nurse instructs the patient to avoid immersing the hearing aid and inserting objects into it. The nurse also instructs the patient to avoid storing the hearing aid in the kitchen or bathroom to prevent exposure to moisture and heat.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning 6. The nurse is preparing to remove cerumen from an older adult’s ear. Nursing care is

appropriate if the nurse uses which procedure? a. Applies slight negative pressure to the ear canal.

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b. Asks the patient not to move while the ear is being irrigated. c. Cleans the ear canal with a soft cotton swab to remove any remaining cerumen. d. Instills cool irrigating fluid to break down the cerumen in the ear canal.

ANS: B

The nurse prepares the patient by explaining the procedure, including the need to remain still while the ear is being irrigated. To prevent damage to the tympanic membrane, negative pressure is never applied to the ear canal. The nurse avoids inserting a cotton swab into the ear canal because it is likely to push cerumen further into the ear. Cool irrigating fluid is contraindicated because it can cause nausea and vertigo.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning 7. The patient asks the nurse to irrigate both ear canals to improve hearing and comfort. The

patient has bilateral brown ear drainage and a history of a right mastoidectomy and perforation of the left tympanic membrane. Which intervention by the nurse takes priority? a. Inform the patient that the ears are infected. b. Perform an otoscopic examination of the canals. c. Collaborate with the audiologist about a hearing aid. d. Irrigate the ear canals with warm saline solution.

ANS: B

The nurse completes the ear assessment with an otoscopic examination of the ear canals to provide comprehensive patient data to the health care provider. The nurse wants to observe cerumen, the tympanic membrane, and origin of the drainage in both ears. He or she avoids irrigating an ear with drainage because the drainage implies that the tympanic membrane is N a diagnostic conclusion with the patient because he or she impaired. The nurse avoids sharing does not know that the ears are infected. The nurse’s scope of practice does not provide for collaboration with the audiologist about the need for a hearing aid. This is done by the health care provider after a thorough assessment to determine the patient’s plan of care and therapeutic regimen.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

8. The nurse assesses a 3-year-old patient with a dried bean in the left ear canal. Which action

does the nurse implement? a. Wait for the bean to fall out. b. Examine the ears with an otoscope. c. Collaborate with the health care provider. d. Irrigate the ear to flush out the bean.

ANS: C

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The nurse inspects the ears visually without the aid of an otoscope to complete the nursing assessment and then collaborates with the health care provider to remove the bean. The bean is not likely to fall out because it is more likely to increase in size by being in the moist environment of the ear canal. The nurse avoids an otoscopic examination because inserting the otoscope into the ear canal is likely to affect the bean and make it harder to remove. The nurse avoids irrigating the patient’s ear canal because the positive pressure from the irrigation solution is likely to affect the bean and make it harder to remove. In addition, a dried bean will absorb water, and its size will increase, further aggravating its removal.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

9. The nurse irrigates the patient’s right ear with saline solution to improve hearing. Which

patient symptom requires immediate nursing intervention? a. Patient hearing acuity remains stable. b. Patient senses that irrigant is slightly warm. c. Patient complains of nausea and vertigo. d. Patient drainage contains brown particles.

ANS: C

The nurse expects to irrigate the patient’s ear canal without causing patient discomfort, pain, nausea, or vertigo by warming the irrigation solution before instilling it. The nurse expects the patient to sense the warmth of the irrigation solution; this is an expected outcome. Irrigation drainage from the ear containing brown particles is consistent with clinical indicators for effective ear irrigation because this is evidence of cerumen removal; this is an expected finding if cerumen was in the ear canal before the procedure. Failure of patient hearing to improve after irrigation is a possible unexpected outcome, but it is not influenced by warming N of solution.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

10. The nurse is instructing a patient on the procedure to remove a hard contact lens. Instruction

by the nurse is correct if the patient uses which technique? a. Slides lens onto the sclera and pinches off the lens. b. Draws periorbital skin taut and asks the patient to blink. c. Uses a bulb syringe and applies suction to the lens. d. Squeezes the upper and lower lids together to pinch the lens.

ANS: B

To remove a hard lens from a patient’s eye, the nurse draws the skin surrounding the eye tightly and instructs the patient to blink. Pulling the skin creates mild tension, which the eyelid uses to dislodge the lens from the cornea. Sliding a contact lens onto the sclera and pinching off the lens is the procedure to remove a soft contact lens. To prevent a corneal abrasion, the nurse avoids using suction to remove a contact lens. He or she avoids squeezing the eyelids together to prevent eye and conjunctival trauma from the hard lens.

DIF: Cognitive Level: Applying TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

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11. After removing a soft contact lens, the nurse observes that the sides of the lens are sticking

together. Which intervention will the nurse implement before storing or reinserting the lens? a. Thoroughly soak the lens in saline solution. b. Rub the contact lens briskly to remove the debris. c. Pry the lens apart gently with a fingertip. d. Use the cleaning solution on the lens; then replace or store it.

ANS: A

A soft contact lens sticks together because it is dry. The nurse rehydrates the lens with saline solution; and the lens becomes soft, supple, less sticky, and suitable for the patient to wear or to store. Hard and soft contact lenses should never be rubbed because rubbing is likely to damage the lens. The nurse avoids prying apart the lens to prevent lens damage. Cleaning solution for lenses is intended to remove residue and debris from the lens but is not intended as a source of lens hydration. After using the cleaning solution, the nurse rinses the lens in saline solution before storage or reinsertion.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

12. The nurse admits a patient who wears a hearing aid for surgery. Which method does the nurse

use to assess the patient’s hearing acuity with the hearing aid in place? a. Whisper very softly behind the patient. b. Cover the patient’s unaffected ear before talking. c. Send the hearing aid to the audiologist for analysis. d. Check patient response using a normal voice level.

ANS: D

N patient’s hearing ability with the hearing aid in place and The nurse needs to determine the both ears available to hear. The nurse speaks with the patient in a normal tone of voice, assesses the patient’s ability to respond properly, and asks the patient whether this is baseline hearing acuity. If the patient has difficulty hearing the nurse with normal conversation, the nurse conducts a more detailed assessment and ensures that the hearing aid battery is good.

The nurse performs the assessment before surgery to alert the surgical team to the patient with a sensory impairment so an alternative method of communication may be identified.

Whispering is a hearing acuity test used to evaluate a patient without hearing aids. The nurse avoids sending the hearing aid to an audiologist because the nurse is able to determine whether the patient can hear.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

13. Which is the priority nursing diagnosis for a patient with altered sensory perception? a. At risk for injury b. Deficient knowledge c. Impaired communication d. Impaired social interaction ANS: A

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The patient with a sensory impairment is at high risk for injury because many methods of communication with the patient cannot be used or need alteration to accommodate the impairment. The sensory impairment may render the patient unable to follow important directions, visualize hazards, or provide information to the health care team. However, the nurse’s priority is to maintain safety first and then to manage the communication impairment to prevent injury effectively. Deficient knowledge is a suitable nursing diagnosis for the patient who has a sensory impairment in acute care because the patient is likely to miss important information and is unaware of potential solutions to the problem. The patient with a sensory impairment frequently has impaired social interaction, so this is a reasonable nursing diagnosis. However, safety is always more important than psychosocial issues.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Diagnosis

OBJ: NCLEX: Physiological Integrity

14. The family of an older adult brings the patient to the health care provider because the patient

seems to be confused or depressed at times. What approach by the nurse can best obtain valuable information about the underlying problem? a. Talk to the patient in a normal voice while standing away from him or her. b. Whisper questions to the patient to determine if the questions can be understood. c. Ask the family to explain the activity patterns of the patient. d. Ask the family for a list of what the patient usually eats.

ANS: A

The nurse can determine if the patient has a hearing impairment by standing a distance from him or her and speaking in a normal tone of voice. Hearing loss can cause the patient to be depressed or seem to be confused. The focus of the assessment needs to be on the patient, not the family. Whispering is inappropriate because this is not a level at which communication N usually occurs. The patient’s activity level can be affected by many things other than hearing.

The dietary pattern of the patient is not important at this time.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. The nurse plans care for a patient who has a hearing deficit. What actions when taken by the

nurse indicate a good understanding of appropriate care? (Select all that apply.) a. Face the patient before beginning to speak. b. Keep the lights dimmed low. c. Speak in a slow, clear, and loud voice. d. Eliminate external voices. e. Do not talk over the patient.

ANS: A, D, E

When patients have a hearing deficit, be sure they understand what you communicate to them.

Always face the patient before beginning to speak and make sure there is enough light for the patient to see your lips. Eliminate external noises; speak in a slow, clear, normal tone of voice.

Do not speak in a loud voice. Ask patients what communication styles they prefer. Never talk over or exclude a patient from conversation or decisions.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

2. The nurse is orienting a new graduate nurse about eye irrigation. Which statement indicates a

good level of understanding of the procedure? (Select all that apply.) a. “I should irrigate from inner to outer canthus.” b. “I should tell the patient not to blink.” c. “I should always remove the contact lenses first.” d. “I should hold the lids open by putting gentle pressure to the lower bony orbit.” e. “I should irrigate until clear or prescribed amount of time is reached.”

ANS: A, D, E

The eye is irrigated from the inner to outer canthus. The patient is allowed to blink periodically, which can help move secretions from the upper conjunctival sac. You should determine if the patient is wearing contact lenses. Do not remove contact lenses unless there is a rapid swelling, there is a chemical injury, or you cannot get rapid medical attention. You can remove them later if they do not flush out during irrigation. Continue irrigation with prescribed solution, volume, or time or until secretions are cleared.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

3. The nurse is performing eye care for a comatose patient. Which interventions indicate the

nurse has a good understanding of the appropriate care needed? (Select all that apply.) a. The nurse cleans the eye with water or saline. b. The nurse uses an eyedropper to instill the prescribed lubricant. c. The nurse wipes away excess lubricant moving from outer canthus to inner N canthus. d. The nurse applies eye patches when the blink reflex is absent. e. The nurse changes the eye patches every 8 hours.

ANS: A, B, D

To prevent damage to corneas in a comatose patient, eye care is performed. The nurse cleans the eyes with water or saline, wiping from inner canthus to outer canthus, using a separate washcloth or cotton ball for each eye. Lubricant is applied using an eyedropper, wiping excess from inner canthus to outer canthus. Eye patches are used when there is no blink reflex and are changed every 4 hours.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

4. The nurse is assessing an elderly patient’s ability to understand how to properly care for a new

hearing aid. Which of the following statements indicate further education is needed? (Select all that apply.) a. “I can wear my hearing aid in the shower.” b. “I should take it out when I go to the pool to swim.” c. “I can wear my hearing aid when I get my hair done.” d. “I need to make sure I don’t leave them in a hot car.” e. “I should store the batteries in a dry, safe place.”

ANS: A, C

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Patients should be instructed to avoid exposure of hearing aids to extreme heat, cold, or moisture. Do not leave in case near stove, heater, or sunny window. Do not use with hair dryer on hot settings or with sunlamp. Do not wear when bathing, during excess sweating, or when shampooing at a hair stylist. Do not use hair spray or other hair-care products while wearing hearing aids. Store batteries in a dry, safe place away from pets and children. Always keep a set of unused batteries in the home.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

N

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Chapter 13: Promoting Nutrition Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The patient has weakness of the left arm and hand after a stroke. Which is the best nursing

intervention to help maintain the patient’s self-esteem during feeding? a. Delegate feeding to nursing assistive personnel (NAP) to minimize food spillage. b. Encourage the patient to self-feed as much as possible. c. Ensure that foods are pureed so they may be consumed through a straw. d. Collaborate with speech therapist to improve the patient’s nutrition.

ANS: B

The nurse maintains and enhances the patient’s self-esteem by encouraging the patient with positive reinforcement, acknowledging the patient’s progress with self-feeding, and engaging him or her in conversation during feeding. Feeding the patient may reinforce feelings of inadequacy, worthlessness, or embarrassment. Taking food by straw may be contraindicated and increase the risk of aspiration, depending on the patient’s neuromuscular coordination for chewing and swallowing. The speech therapist can contribute to the patient’s nutritional status with specific feeding techniques, but this is not related to self-esteem.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. A patient has not eaten since admission to the long-term care facility 2 days ago. Which is the

best initial intervention for the nurse to prevent malnutrition in this patient?

N a. Make a diet request to the health care provider for full liquids. b. Ask the patient’s daughter why the patient will not eat. c. Remind the patient that nutrition is essential to better health. d. Assess the patient for possible reasons for the lack of intake.

ANS: D

The nurse gathers additional information by using the nursing process to prevent malnutrition for a new patient in the long-term care facility. Identifying barriers to nutrition begins with obtaining objective and subjective data by which the nurse gathers valuable nutritional information, including muscle function, teeth, cognition, and patient food preferences.

Requesting a diet change is premature and not based on assessment data. Asking the daughter for information reveals the daughter’s opinion, anecdotal information, and possibly biased observations about the patient. The use of the word “why” is also not therapeutic. Reminding the patient about nutrition may be a useless intervention if his or her cognition is low, if he or she has a sensory or communication disorder, or if he or she is depressed. In addition, the patient can interpret this as an insult to his or her intelligence.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

3. A patient with a neurological disease has difficulty swallowing. Which does the nurse include

in the plan of care? a. Limit oral intake to clear liquids. b. Allow adequate time for the feeding.

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c. Ask family members to coach the patient. d. Maintain low-Fowler’s position for meals.

ANS: B

The nurse plans an adequate amount of time for patient feeding to address complications from impaired swallowing. With nursing supervision and encouragement and in a relaxed manner, the food is prepared properly; the patient chews food thoroughly, swallows as necessary, and takes short breaks while eating. Clear liquids may be contraindicated for the patient.

Thickener may need to be added, depending on the patient’s status. Family coaching may pressure, misdirect, or shame the patient; increase the risk of aspiration or choking; and decrease the patient’s appetite. Low-Fowler’s position is contraindicated for swallowing difficulties and feeding because an upright position facilitates swallowing.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

4. The nurse plans care for a patient with impaired swallowing. Which outcome would indicate

the priority goal for this patient is being met? a. The patient holds food in the pockets of the mouth. b. The nurse observes no movement of the larynx during swallowing. c. The patient maintains a stabilized weight for 3 consecutive days. d. The patient’s lungs remain clear after eating.

ANS: D

A suitable outcome for a patient with impaired swallowing is that the lungs remain clear after eating, which indicates that the patient did not aspirate. A stable weight over 3 days indicates that the patient is ingesting and absorbing sufficient nutrients to avoid weight loss, which is N However, an intact airway and lack of aspiration and also indicative of goal outcome. respiratory complications take priority. Holding amounts of food in the pockets of the mouth indicates difficultly moving the food for chewing and swallowing. Movement of the larynx normally occurs during swallowing.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

5. The patient with impaired swallowing begins to choke while eating. Which action would the

nurse implement? a. Suction the airway until clear. b. Turn the patient to a prone position. c. Leave the room to get assistance. d. Instruct the patient to take deep breaths.

ANS: A

The nurse suctions the oropharynx of a patient with dysphagia who chokes while eating to maintain the airway, the highest priority on the patient’s hierarchy of needs. A positioning change is not indicated unless the patient starts to vomit or becomes unresponsive; then the nurse places the patient in the recovery position. The nurse should not leave the patient until the choking is resolved and the patient is stabilized. The patient should not take deep breaths, which may draw in food and aggravate choking.

DIF: Cognitive Level: Applying

OBJ: NCLEX: Physiological Integrity

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TOP: Nursing Process: Planning 6. An older patient has been eating approximately 50% of each meal for several days. Which

action does the nurse take to increase the patient’s nutritional intake? a. Serve the food at room temperature. b. Check for an altered taste perception. c. Encourage the patient to eat with a friend. d. Provide soft, bland foods and snacks.

ANS: B

The nurse assesses the patient for altered taste perception because the acuity of several senses deteriorates with aging, including the senses of taste and smell; these sensory functions are important for food enjoyment and appetite. To promote health and well-being, the nurse recognizes that the patient is at risk for malnutrition and assesses him or her to gather data for planning care because well-nourished patients are more likely to have positive health outcomes. Serving food at room temperature is an intervention but is not likely to be entirely helpful since it may or may not be the problem. The nurse should find out more information through assessment and then plan appropriately. Eating with a friend can make eating more enjoyable, but, if a physiological reason exists, the reason needs to be addressed first. Serving bland foods is not appropriate at this time. If there is an alteration in ability to taste and smell, bland foods might not be most appetizing to the patient.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

7. A patient with a neurological injury resulting in tremors is learning how to feed himself.

Which method would the nurse implement to best facilitate learning? a. Delay self-feeding until theNhand tremors subside. b. Show the patient a video of a man feeding himself. c. Provide one piece of adaptive equipment at a time. d. Instruct the patient while assisting him during eating.

ANS: D

To best facilitate patient learning, the nurse provides verbal instructions while demonstrating feeding techniques to explain each step, provide insight, and clarify directions. This also allows the nurse to assist the patient with eating as needed. Depending on the nature of the injury, the hand tremors can be permanent; so the patient needs to learn self-feeding with hand tremors. Showing a video may be an appropriate intervention, however; this alone is not optimal for teaching and answering questions. All required equipment for self-feeding should be provided to determine which is best for the patient because self-feeding with inadequate equipment can set up the patient for failure. In addition, some pieces of equipment such as a knife and fork are meant to be used simultaneously as needed.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

8. The nurse admits a patient who follows the Jewish faith and maintains a kosher diet. Which

food should the nurse withhold to maintain the patient’s dietary practices in accordance with this faith? a. Pork chops b. Noodles

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c. Rice d. Tea ANS: A

The nurse should avoid pork chops. Jewish people who follow the kosher diet are prohibited from eating pork, predatory fowl, shellfish, blood, and meat mixed with dairy products.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

9. The nurse prepares a dietary plan for a patient who practices Orthodox Judaism and notes that

no Jewish holidays are approaching. What choices does the nurse plan to exclude from the patient’s menu? a. Caffeinated tea b. Grilled cheese sandwich c. Milk products d. Lobster chowder ANS: D

The patient practicing Orthodox Judaism cannot eat shellfish; so the nurse eliminates lobster from the patient’s dietary plan. Orthodox Jewish dietary guidelines do not restrict dietary intake of dairy products except that dairy products are not mixed with meat. The patient’s religious practices allow caffeine in the diet. Caffeine is not prohibited.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

10. The nurse assists the patient who N had a recent cerebral vascular accident (CVA or stroke) with

drinking water, and the patient begins to choke. Which intervention is the best choice to meet the patient’s priority need? a. Provide oxygen. b. Suction the patient. c. Call for assistance. d. Recline the patient.

ANS: B

The patient’s priority needs, in order, are airway, breathing, and circulation (ABCs), so the nurse’s priority action is to maintain the airway. To accomplish this, the nurse suctions the patient to prevent an airway obstruction. After the airway is clear, the nurse can provide supplemental oxygen as prescribed if the patient continues to have difficulty or has oxygen desaturation from choking. If the patient continues to have difficulty, the nurse should call for help to obtain emergency equipment. The nurse can place the patient in the recovery position after choking if the patient loses consciousness, continues to choke, or starts to retch or vomit.

Reclining the patient is contraindicated because it increases the risk of aspiration.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

11. The nurse receives a report stating that a new patient has a nutritional deficit. Which physical

clinical indicator consistent with a nutritional deficit does the nurse expect to observe in the patient? a. Long, shiny hair

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b. Pale conjunctivae c. Pink oral mucosa d. Firm pink nails ANS: B

Pale conjunctivae are a clinical indicator of a nutritional deficit consistent with a low serum hemoglobin or hematocrit. The hematological deficiencies result in a low oxygen-carrying capacity and a deficient number of red blood cells in the blood. This decreases the ability of the erythrocytes to oxygenate the tissues adequately, thereby resulting in pale mucous membranes. Conjunctivae should appear reddish pink. Long, shiny hair and pink oral mucosa are clinical indicators of a patient who consumes an adequate diet. Nails are normally firm and pink.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

12. The nurse evaluates the plan of care for a patient who is malnourished. Which assessment

finding indicates to the nurse that the plan is effective? a. The tongue is large with a smooth surface. b. Eighty percent of food was consumed at the last meal. c. Patient reports sense of taste has returned. d. The patient has reddish-pink mucous membranes.

ANS: D

Reddish-pink oral and conjunctival mucous membranes are indications of a well-nourished person because this color is consistent with well-oxygenated tissue resulting from adequate amounts of hemoglobin and erythrocytes. A malnourished person is likely to have pale N individual does not receive adequate nutrition in the diet to mucous membranes because the provide the body with the necessary iron to synthesize hemoglobin, amino acids to manufacture protein, and other nutrients to manufacture red blood cells in adequate amounts.

The tongue is a vivid pink or deep red, with papillae present in adequately nourished individuals. Generally consuming 80% of meals is an acceptable dietary intake; however, a malnourished person usually needs to eat the entire meal on a consistent basis to restore and maintain health and wellness. An intact sense of taste is helpful in maintaining nutrition, but does not indicate if the patient is well-nourished or not.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

13. The health care provider prescribes a mechanical soft diet for the patient. Which food

selection would the nurse provide for the patient? a. White toast with peanut butter b. Pancakes with sliced bananas c. Scrambled eggs with bacon d. Strained soups and custard ANS: B

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Pancakes with sliced bananas are a suitable food choice for patients on a mechanical soft diet because this diet requires foods that are very easy to chew, require minimal chewing, or allow the patient to eat without teeth. Scrambled eggs are appropriate, but not the bacon. Toast requires chewing, which is unacceptable on the mechanical soft diet. Strained soups and custard are on the full liquid diet.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

14. The health care provider has started the patient on a clear liquid diet. Which item does the

nurse provide for the patient? a. Orange juice b. Ice cream c. Cranberry juice d. Vegetable juice ANS: C

Cranberry juice is a suitable choice for a patient on a clear liquid diet because this product is made with juice, flavored water, and possibly a sweetener. It is possible to actually see through the liquid. Orange juice, vegetable juice, and ice cream are all dense liquids that the nurse cannot see through. They are suitable for a full liquid diet.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

15. The nurse plans care for four patients and assigns patient feeding to nursing assistive

personnel (NAP). Which patient does the nurse watch during mealtime?

N of the meals served. a. The patient who refuses most b. The patient who has learned to use adaptive utensils. c. The patient who takes a long time to swallow. d. The patient who is taking ice chips on the first postoperative day.

ANS: C

Taking a long time may indicate trouble initiating a swallow. This is a symptom of oropharyngeal dysphasia. Until the nurse assesses the patient for dysphagia, consults with other members of the health care team, and collaborates on a plan of care, he or she must assume responsibility for the patient’s aspiration precautions. The nurse instructs the NAP to observe for choking and coughing after mealtime is over. The NAP may be instructed to assist the patient who refuses most meals by encouraging the patient, avoiding coercion to get the patient to eat, and reporting the amount of food eaten by the patient. With training and instruction, the NAP would also be able to assist the patient learning how to use adaptive utensils. The NAP is able to assist the postoperative patient with ice chips.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

16. After nursing teaching, which food identified by the patient reflects an understanding of the

soft diet? a. Hot oatmeal with low-fat milk b. Tomato stuffed with tuna salad c. Lean steak with a baked potato

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d. Thin spaghetti with tomato sauce ANS: D

Food on a soft diet must be low in fiber, easily digested, and easy to chew; thus thin spaghetti with tomato sauce is suitable. A soft diet is slightly different from a mechanical soft diet because soft-diet foods must be low in fiber and mechanically soft foods can contain fiber that are pureed or ground. The oatmeal is rich in fiber and is considered a high-fiber food. Fruits and vegetables need to be canned or cooked. The tuna salad has the mayonnaise, which provides quite a bit of fat. The meat must be chewed and is not easily digested.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

17. The nurse at a community center is preparing a program for older people at risk for

malnutrition who need community resources. Which is the best action for initiating the nurse’s program? a. Review each individual’s height, weight, and health history. b. Teach low-cost menus and methods for a balanced diet. c. Post flyers with instructions for obtaining free vitamins. d. Provide telephone numbers of food banks and free meals.

ANS: A

To start a community nutrition program, the nurse applies the nursing process and implements the first step, assessment and data gathering, to determine community needs. The nurse gathers suitable data for planning the program by screening older people for malnutrition and people at risk for malnutrition using a nutritional screening tool. The nurse analyzes the data, including height, weight, and health history to tailor the overall program; organizes suitable resources; plans for individual N nutritional assistance; and matches people who are malnourished or at risk with community resources such as food banks, free meals, and Meals on Wheels. The remaining choices do not help the nurse identify people at risk for malnutrition. Teaching about a balanced diet is a prevention technique, and obtaining free vitamins and providing contact information may help people find community resources but doesn’t identify their risk levels.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

18. The nurse prepares to insert a small-bore intestinal feeding tube. Which instruction does the

nurse provide to nursing assistive personnel (NAP) to assist with preparation? a. Immerse the feeding tube in an ice bath. b. Cut a 10.2-cm (4-inch) piece of adhesive tape. c. Inspect the patient’s nares for irritation. d. Remove the guidewire from the feeding tube.

ANS: B

The nurse instructs the NAP to cut a 10.2-cm (4-inch) strip of adhesive tape to secure the feeding tube to the patient’s nose while the nurse supervises the NAP’s action. Icing a feeding tube is never recommended because it would only make the tube stiffer and harder to insert.

The nurse is responsible for patient assessment before tube insertion because it requires clinical judgment and critical thinking. The guidewire remains in the feeding tube until placement is confirmed with an x-ray film.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

19. The nurse prepares to insert a small-bore feeding tube into a patient. Which step of the

procedure does the nurse expect during the insertion? a. Advance the tube as patient swallows. b. The tube coils in the oropharynx. c. The patient has trouble swallowing. d. Auscultate during air insufflation ANS: A

The nurse has the patient swallow water during tube placement to help pull the tube into the correct position. The water also serves as a lubricant. It is expected that the patient will swallow without difficulty to facilitate tube passage through the esophagus and not coil up in the oropharynx. Auscultating for placement would be done after the procedure but is not the recommended procedure to determine placement as it is unreliable.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

20. The nurse cannot advance the small-bore intestinal feeding tube into the patient’s oropharynx.

What nursing action will facilitate tube advancement without complications? a. Attempt to insert the tube into the other naris. b. Advance the stylet and then thread the tube over it. c. Remove the stylet, check it for kinks, and reinsert it. d. Use another stylet to move the tube into position.

N

ANS: A

The nurse attempts to insert the feeding tube and stylet into the opposite naris after encountering difficulty in the first naris because a physical obstruction is the most likely cause of the problem. The nurse avoids advancing the stylet if the feeding tube does not cover it because the unguarded stylet is likely to cause tissue trauma to the patient’s nasal passageways or oropharynx. Once the stylet is removed from the feeding tube, it cannot be reinserted without damaging the tube. Using a second stylet is contraindicated for tube manipulation.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

21. The nurse inserts a gastric feeding tube into the patient. Which method used by the nurse is

most accurate to verify placement of the patient’s feeding tube? a. Gets a pH of 4.0 from the feeding tube aspirate. b. Obtains a pH of 7.0 from the gastric aspirate. c. Listens at the tube distal to the pyloric sphincter. d. Locates the tube above the cardiac sphincter.

ANS: A

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The nurse inserts a gastric feeding tube and expects to confirm tube placement in the stomach; the nurse verifies gastric placement by measuring the pH of the aspirate and expects it to be 5.0 or less because hydrochloric acid from gastric parietal cells acidify gastric contents.

Feeding tube aspirate of 7.0 is most likely from the intestines. A gastric feeding tube is above the pyloric sphincter, the sphincter that controls gastric emptying into the duodenum. The cardiac sphincter is above the area where a pH sample could be obtained.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

22. The nurse assesses the patient who receives continuous enteral nutrition through a

nasointestinal tube. What is the priority intervention by the nurse if the patient’s bowel sounds are inaudible? a. Document “absent bowel sounds.” b. Gradually decrease the rate of the tube feeding. c. Monitor the patient for possible diarrhea. d. Stop the feeding and notify the health care provider.

ANS: D

The nurse stops the tube feeding and collaborates with the health care provider after assessing a patient who receives a continuous tube feeding with no evidence of peristalsis. Without peristalsis, the formula accumulates in the stomach, and eventually the patient can vomit, increasing the risk of aspiration. This finding may also indicate an obstruction or other problem that would contraindicate the feeding. The nurse should document that bowel sounds are absent, but this is not a priority over consulting with the provider. Any patient receiving tube feedings receives nursing assessments for diarrhea and constipation; in addition, if the patient has diarrhea, bowel sounds N are likely to be loud, frequent, and high pitched.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

23. The nurse is unable to aspirate any residual volume from the patient who receives intestinal

tube feedings at a rate of 200 mL every 6 hours by intermittent gavage. Which action by the nurse is most appropriate? a. Insert a nasogastric tube. b. Withhold the next feeding. c. Notify the patient’s health care provider. d. Administer the next feeding.

ANS: D

The nurse expects to aspirate no residual volume from the patient who receives intermittent intestinal tube feedings because the small-intestines are unable to sequester fluid. The placement of this type of tube is verified by x-ray film; and, if nothing is aspirated afterward, it is assumed that placement of the tube is correct.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

24. The nurse prepares the patient for discharge to home with instructions to self-administer

nasointestinal tube feedings. Which does the nurse include in patient teaching? a. Infuse the formula at room temperature to avoid abdominal cramping.

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b. Increase the amount of free water with persistent diarrhea or constipation. c. Flush the tube with 500 mL of water after each tube feeding. d. Allow the formula to infuse for 24–48 hours.

ANS: A

Tube feedings infused into the stomach or intestines bypass food warming that takes place as food passes through the mouth and esophagus; thus the nurse instructs the patient to infuse the formula at room temperature to avoid abdominal cramping. The patient should report diarrhea or constipation to the health care provider before implementing additional fluids since these may be indications of other complications of tube feedings. Flushing with 500 mL of water after each tube feeding is excessive and risks causing fluid volume overload in the patient and can raise the risk of vomiting and aspiration. Because nasointestinal feedings generally infuse continuously, the nurse instructs the patient to replace the feeding bag and tubing every 24 hours and flush the tubing before and after each new infusion. The nurse instructs the patient to infuse the same can of formula for up to 8 hours without adding formula over the infusion period.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

25. The patient is receiving nasointestinal tube feedings by continuous drip from an open system.

Which procedure should the nurse use when caring for this patient? a. Administer medication with a 10-mL syringe. b. Change the feeding tube bag every 8 hours. c. Add enough formula to the bag to last 24 hours. d. Check the placement of the tube with a 60-mL syringe.

ANS: D

N

The nurse checks tube placement and administers medication with a 60-mL syringe. The feeding tube bag is changed every 24 hours to prevent bacteria buildup in the system. The maximum time that formula can hang in an open system is 8 hours. The 10-mL syringe would cause excessive positive pressure into the feeding tube. Placement is checked using a 60-mL syringe.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

26. The nurse aspirates fluid from the nasointestinal tube. Which finding requires the nurse to

plan follow-up nursing interventions? a. The aspirated liquid totals 5 mL of greenish fluid. b. The feeding tube collapses with negative pressure. c. The nurse aspirates a small amount of the formula. d. The aspirated liquid appears pale and straw colored.

ANS: D

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The nurse plans follow-up nursing interventions after aspirating pale and straw-colored fluid because intestinal aspirate should be green, indicative of the bile concentration of the fluid.

Because the aspirate is inconsistent with clinical indicators for intestinal fluid, the nurse investigates further to verify tube placement before instilling anything into the nasointestinal tube. The nurse expects to aspirate a small amount of greenish fluid indicative of bile in the fluid. This also indicates placement of the nasointestinal tube in the intestines because the intestines cannot hold large amounts of fluid as the stomach can. The nasointestinal tube is expected to collapse with negative pressure because it is a soft pliable tube. A small amount of formula aspirated is not a problem and does not require follow-up. It is acceptable.

DIF: Cognitive Level: Applying TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

27. The nurse instructs the patient to self-administer nasointestinal tube feedings at home. Which

is the best instruction to include in patient teaching about aspirating the tube? a. Withhold tube feedings if unable to obtain aspirate. b. Check tube placement by instilling air into the tube. c. Administer the tube feedings at 7.22° C to 10° C (45° F to 50° F). d. Report aspirate with a pH less than 6.0 to the provider.

ANS: D

The nurse instructs the patient to report a pH less than 6.0 of the intestinal aspirate because this fluid should be alkaline and have a pH greater than 6.0 from exposure to intestinal fluid and bile. If a patient who is able to competently handle administering a nasointestinal feeding at home aspirates and obtains no fluid, the nurse assumes that the infusion is operating without difficulty because no aspirate is an expected finding. The nurse avoids instructing the patient to instill air to verify tube N placement; however, he or she instructs the patient to instill 30 mL of air before aspirating gastric fluid to displace the fluid and facilitate aspiration. Tube feeding formula should be at room temperature to avoid abdominal cramping.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

28. The nurse is planning care for the patient receiving nasogastric tube feedings. What

reassessment information would best indicate to the nurse that a successful therapeutic regimen has been established? a. Respirations are 28–32 breaths/min. b. The residual volume is less than 100 mL. c. A stable weight over 1 month. d. Urine output has increased from 25 to 30 mL/hr.

ANS: B

A clinical indicator of a successful therapeutic regimen in this patient is a residual volume below 100 mL. This indicates the stomach is emptying gastric contents into the duodenum and precipitating intestinal peristalsis. The peristaltic action moves the formula through the gastrointestinal tract to prevent formula accumulation in the stomach. Tachypnea in a patient with gastric tube feedings warrants further investigation by the nurse because tachypnea is consistent with clinical indicators for aspiration. A stable weight over one month is consistent with delivering inadequate calories. The patient should be gaining weight. The nurse expects urine output between 30 and 50 mL/hr, depending on the patient; however, this is not related to a successful feeding regime.

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DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

29. The nurse is caring for a patient on intermittent gavage tube feedings. Over what period of

time should the nurse infuse each feeding? a. Up to 8 hours b. Up to 24 hours c. 10–15 minutes d. 30–45 minutes ANS: D

The nurse allows the intermittent tube feeding to infuse over 30–45 minutes by gravity to reduce the risk of abdominal discomfort, vomiting, or diarrhea induced by bolus or excessively rapid formula infusions. Infusions of 8 or 24 hours defeat the purpose of an intermittent infusion because the therapy is mimicking normal eating patterns. Infusions of 10–15 minutes are too rapid and increase the risk of aspiration.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

30. After 2 days of administering the patient’s continuous nasogastric tube (NGT) feeding at 35

mL/hr successfully, the nurse aspirates 150 mL of formula. Which should the nurse implement first? a. Return the aspirate and continue with the feeding. b. Flush the tube with 30 mL of normal saline solution. c. Return the aspirate and reevaluate patient in 1 hour.

N with the provider. d. Collaborate about the aspirate ANS: A

Best evidence suggests that a single high gastric volume residual GRV should be monitored for the following hour, but enteral feeding should not be stopped or withheld for an isolated high GRV, so the nurse returns the 150-mL aspirate, documents the event, and communicates the finding to the next nurse. If on several occasions the nurse aspirates more than 150 mL, the nurse notifies the provider. Excessive NGT aspirate warrants further investigation by the nurse at that time and requires the nurse to assess the patient carefully on restarting the feeding. The nurse flushes the NGT after discarding the excessive NGT aspirate to maintain tube patency. The nurse returns the aspirate if the volume is less than 200 mL. There is no reason to contact the provider at this point.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

31. The patient receives three different medications through a nasogastric tube (NGT). Which

total fluid volume does the nurse anticipate instilling to administer these medications properly? a. 30 mL b. 60 mL c. 120 mL d. 150 mL ANS: C

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The nurse expects to instill at least 120 mL of fluid to administer three medications by NGT because he or she flushes the tube with 30 mL of water before and after each medication, resulting in four flushes or 120 mL. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

32. The nurse prepares to insert a patient’s nasogastric tube (NGT) for tube feedings. Which

patient assessment requires the nurse to collaborate with the patient’s health care provider before initiating the feeding? a. An intact gag reflex b. An occluded right naris c. Impaired swallowing d. Absent bowel sounds ANS: D

The nurse collaborates with the provider before initiating tube feedings for a patient without bowel sounds because any formula infused is likely to accumulate in the stomach and greatly increase the patient’s risk of aspiration. Even so, peristalsis is normally stimulated as food accumulates in the stomach, activates stretch receptors, and stimulates peristalsis in the smalland large intestines. Indications for NGT feedings exist for patients with and without a gag reflex. The nurse attempts NGT insertion into the left nostril when the right nostril is occluded. Patients with impaired swallowing are suitable candidates for NGT feedings.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

N for tube feedings. Which does the nurse implement while 33. The patient receives a prescription inserting a nasogastric tube for this patient? a. Advances the nasogastric tube while the patient swallows. b. Instructs the patient about self-care of the feeding tube. c. Eases insertion by icing down the nasogastric tube. d. Measures the length from the patient’s nose to the sternum.

ANS: A

The nurse instructs the patient to swallow while the tube advances because the coordinated muscular action of the esophagus helps to direct it down through the cardiac sphincter and into the stomach. The nurse can provide patient teaching after the tube insertion because instruction provided before the insertion is unlikely to be retained. Briefly immersing the end of the tube in warm water eases insertion by softening the end of the tube for passage through the nasal passageway. The nurse measures the length of the nasogastric tube properly by measuring from the tip of the nose to the earlobe to the xiphoid process.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

34. The nurse prepares to insert a nasointestinal tube into a patient. Which does the nurse

implement for proper tube placement? a. Measures from the nose to the earlobe to the xiphoid process. b. Removes the guidewire after verifying placement. c. Places the patient on the left side until verifying placement.

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d. Anchors the tube with tape after insertion.

ANS: B

The nurse maintains the guidewire in place until intestinal placement is verified because, once it is removed, it cannot be reinserted. If the tube needs repositioning, the nurse cannot manipulate it effectively. The nurse measures from the tip of the nose to the earlobe to the xiphoid process and adds 20–30 cm for a proper length. Positioning the patient on the left or right side does not facilitate migration of the tube into the intestines. The nurse anchors the nasointestinal tube in place after placement in the jejunum is verified.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

35. The nurse is determining whether an order for a nasogastric tube feeding is appropriate.

Which patient diagnosis would prevent the nurse from initiating a tube feeding? a. Septicemia b. Pancreatitis c. Gastric ileus d. Head trauma ANS: C

Gastric ileus, or gastroparesis, is a contraindication to nasogastric tube feedings because infused formula into the stomach is likely to remain in the stomach and accumulate. This increases the risk of aspiration and endangers the patient’s airway. The duty the nurse owes the patient is to withhold a tube feeding until bowel sounds are present. Pancreatitis, sepsis, and head trauma are indications for tube feedings as long as the patient has peristaltic action.

DIF: Cognitive Level: Remembering N TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

36. Before administering a continuous nasointestinal tube (NIT) feeding, the nurse verifies

placement of the patient’s NIT and flushes it with water. Which step does the nurse perform next? a. Instill the formula immediately after removing it from refrigeration. b. Infuse the formula over 10–15 minutes. c. Raise the syringe 18 inches above the insertion site. d. Attach the feeding bag to the proximal end of the NIT. ANS: D

For a continuous tube feeding, the nurse attaches the feeding bag tubing to the proximal end of the NIT to begin the infusion and connects the tubing through the infusion pump. Cold formula can cause cramping. Formula should be administered at room temperature. A continuous infusion infuses around-the-clock; if the feeding is an intermittent infusion, the nurse administers it over 30–60 minutes. The nurse administers a continuous infusion with a feeding bag; intermittent infusions can be administered with a syringe.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

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1. The nurse instructs the caregiver to administer the patient’s intermittent tube feeding. Which

does the nurse include in caregiver teaching? (Select all that apply.) a. Maintain tube patency with frequent irrigations. b. Keep the feeding tube capped between feedings. c. Complete feeding before checking tube placement. d. Weigh the patient twice a day for the first month. e. Store opened cans of formula in the refrigerator.

ANS: B, D

The nurse instructs the caregiver to cap the feeding tube for an airtight seal between feedings to prevent the contents of the tube from drying and occluding the tube. Flushing a feeding tube too frequently is associated with tube occlusion. The nurse confirms tube placement before infusing the formula. The nurse instructs the caregiver to refrigerate opened cans of formula. Bacteria grows at room temperature once the cans are opened, spoiling the formula.

The patient receiving home enteral nutrition should be weighed daily or weekly, depending on the patient’s condition.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning 2. The nurse instructs the new orientee to care for the gastrostomy site. Which items does the

nurse include in her teaching? (Select all that apply.) a. Cleanse the site with Betadine. b. Place the dressing under the external bar. c. Assess the site for evidence of drainage or infection. d. Apply a thin layer of skin barrier to exit site. e. Use sterile gloves for the procedure.

N ANS: C, D

The site should be cleansed with soap and water and assessed for excoriation, drainage, infection, or bleeding. The nurse should apply a barrier protective cream if ordered. The dressing goes over the external bar. Placing it under the bar can cause tissue erosion. Sterile gloves are not required; clean gloves are used.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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Chapter 14: Parenteral Nutrition Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nursing assistive personnel (NAP) reports that a patient receiving parenteral nutrition via

a central line is coughing and short of breath. Which action by the nurse is the priority? a. Clamp the IV tubing. b. Call for a chest x-ray. c. Notify the provider. d. Check a bedside glucose.

ANS: A

This patient has manifestations of an air embolus. The nurse would first clamp the IV tubing to prevent more air from entering the tube. The nurse will notify the provider and perhaps call for a chest x-ray, but the priority is to stop the problem. A bedside glucose is not warranted.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. A nursing student is teaching a patient about lab testing that will be done frequently while the

patient is on parenteral nutrition. Which statement by the student requires the registered nurse to intervene? a. “Your copper and zinc levels may change rapidly.” b. “We will check your protein levels about weekly.” c. “The staff will check your blood glucose frequently at first.”

N d. “Your white blood cell count can help us assess for infection.”

ANS: A

Trace elements such as copper and zinc are usually tested monthly or biannually because they do not fluctuate rapidly. The nurse would intervene to correct the student. The other statements are accurate.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

3. A patient has been receiving parenteral nutrition (PN) via a central line that has now occluded.

The patient also has a midline catheter. What modification of the PN does the nurse ensure prior to switching the PN to the midline catheter? a. Holding the lipid infusion b. Ensuring osmolality is less than 900 mOsm c. Doubling the insulin concentration d. Cutting the total fluid volume to 1500 mL ANS: B

PN formulations with an osmolality of greater than 900 mOsm should not be infused through midline, peripheral, or midclavicular lines due to the increased risk of phlebitis. Lipids can run through a midline catheter. There is no reason to double the insulin. Peripheral PN is usually delivered in a higher fluid volume than TPN, of about 2000–3000 mL.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

4. The nurse delegates some care activities to nursing assistive personnel (NAP). What action by

the NAP requires immediate intervention by the registered nurse? a. Performs fingerstick blood glucose monitoring and records results. b. Reports shortness of breath or headaches right away. c. Turns the alarming IV pump off and calls for the nurse. d. Informs the nurse promptly of any changes in vital signs.

ANS: C

Adjusting the IV pump in any way is beyond the scope of practice for a NAP, so the nurse would intervene immediately if this happened. The other actions are appropriate.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

5. The nurse is evaluating goals for a patient who has been on home parenteral nutrition for a

month. What finding indicates that a priority goal has been met? a. Weight has increased by 5 pounds (2.26 kg). b. Patient describes correct care of system. c. Exit site is free of redness, tenderness, or drainage. d. Fingerstick glucose readings are out of range only 20% of the time.

ANS: C

Patients on long-term PN are at risk for infections and sepsis. The site being free of signs of infection is a met outcome for a priority goal. The patient describing correct care is also a good outcome but not the priority.

N Weight should increase by 0.5–1.5 kg or 1–3 pounds each week, so this gain is below standards. Glucose readings ideally stay within range.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

6. A patient is receiving parenteral nutrition through a multi-lumen central venous catheter.

What intervention is most important related to this patient’s situation? a. Verify patient using two unique identifiers. b. Label each line of the tubing carefully. c. Wipe the end port of the tubing with alcohol. d. Check solution for particulates or discoloration.

ANS: B

The line used for PN should not be used for any other purpose. Clearly labeling each line of the tubing helps prevent errors. The other actions are appropriate for any patient on PN. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

7. The lab calls the charge nurse and reports a blood glucose reading of 220 mg/dL for a patient

on parenteral nutrition via a central line. What action does the charge nurse take first? a. Notify the provider and request sliding scale insulin. b. Inform the patient’s nurse about the need for an insulin drip. c. Asks the pharmacy to dilute the glucose concentration.

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d. Determine if the nurse drawing the blood follow protocol.

ANS: D

If the blood was drawn while the PN was infusing, or if the nurse who drew the blood did not follow the proper procedure (such as discarding the first syringe of blood), glucose readings can be artificially high. The charge nurse would first verify the process the nurse used before contacting the provider. The patient does not need an insulin drip for a glucose of 220. The charge nurse does not ask the pharmacy to dilute the glucose concentration; rather he or she anticipates sliding scale insulin being ordered. However, before requesting the insulin, the charge nurse ensures the reading is accurate.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

8. A provider has listed orders for Peripheral Parenteral Nutrition with lipids for four patients.

Which patient will the nurse clarify the orders about? a. 80-year-old on dialysis b. 18-year-old with anorexia nervosa c. 75-year-old with a bowel obstruction d. 35-year-old undergoing chemotherapy ANS: A

PPN is delivered in high fluid volumes, so patients with cardiac or renal problems may not be able to tolerate it. The nurse should verify the orders for the older patient on dialysis. The other patients are appropriate candidates.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation N

OBJ: NCLEX: Physiological Integrity

9. A faculty member is evaluating the student’s performance when hanging a bag of Total

Parenteral Nutrition. Which step indicates the student has completed the third check for accuracy? a. Checks the bag label with the medication record at the bedside. b. Reviews the chart to determine if the order has been entered in the system. c. Verifies that the bag of TPN is the same that is on the medication record. d. Reviews information on bag of TPN with pharmacist when delivered.

ANS: A

The third and final check for medication accuracy includes checking the bag label with the medication record and identifying the patient at the bedside.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

10. A nurse is preparing to discharge a patient who is going home on Total Peripheral Nutrition

(TPN). What action by the nurse is most helpful in ensuring positive outcomes for the patient? a. Refer the patient to a home nutrition therapy team. b. Order three months’ worth of supplies for the patient. c. Assess the patient’s psychological response to the therapy. d. Determine if any family members are willing to help.

ANS: A

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Patients on home TPN benefit greatly from the services provided by a home nutrition therapy team. Three months’ worth of supplies may be too much and might end up being wasteful.

Assessing the patient’s psychological response to therapy is important, but not as important as ensuring the patient has a nutrition team for support. Family members may or may not be willing to help, but the patient may not need their assistance.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

MULTIPLE RESPONSE 1. The faculty member describes conditions that indicate a need for parenteral nutrition to

nursing students. Which conditions does the faculty member include? (Select all that apply.) a. Abdominal trauma b. Severe pancreatitis c. Short-term bowel rest d. Poor appetite with malnutrition e. Serious malabsorption ANS: A, B, E

Some indications for parenteral nutrition (PN) include abdominal trauma, severe pancreatitis, and severe malabsorption. Parenteral nutrition is not used for short-term support (less than 14 days). Nurses should collaborate with the patient, family, and interdisciplinary team to promote the patient’s appetite and eating before turning to PN. DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning N

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Chapter 15: Pain Management Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse teaches the patient progressive self-relaxation techniques. Which would the nurse

implement first? a. Direct the patient to envision sailing on a sailboat. b. Instruct the patient to increase respiratory rate and depth. c. Establish the patient’s ability to participate and cooperate. d. Darken the patient’s room significantly and close the door.

ANS: C

The nurse begins by assessing the patient’s ability to participate and cooperate to tailor the teaching techniques and vocabulary to him or her. This increases the likelihood of the patient benefiting from the instruction. Envisioning pleasant things is part of teaching guided imagery but is not the initial step. After assessing the patient, the nurse provides a brief overview of the technique and sets a proper learning environment. Deep respirations are an indication of relaxation; however, instructing a patient to take deep breaths would not precede assessing the patient’s ability to cooperate.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

2. The nurse massages the patient to promote relaxation. Which is a suitable intervention for the

nurse to implement during the massage?

N a. Use the friction technique over the spine. b. Assess for pain, anxiety, and discomfort. c. Instruct the patient to sit upright and forward. d. Knead the patient’s scalp with warm lotion.

ANS: B

The nurse’s goal during a massage is to keep the patient comfortable and relaxed and induce a lingering sense of well-being and relaxation at the completion of the massage. If the patient is in pain, anxious, or uncomfortable, relaxation does not occur until the noxious stimuli are eliminated. The nurse asks the patient about pain and comfort during the massage and does not wait for the patient to offer such statements. The friction technique (i.e., strong, circular strokes enhancing perfusion at the skin’s surface) is contraindicated for bony prominences such as the spine because the regional skin is already thin and under tension by nature of its location over a bone. Sitting upright and forward can be contraindicated or uncomfortable for the patient. Occasionally the patient’s scalp is massaged with a few drops of oil on the fingertips; it is impossible to knead the scalp because the scalp is devoid of large, thick muscles.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

3. The patient has hypotension, receives as much opioid analgesia as the prescription allows, and

continues to have difficulty sleeping at night because of pain. Which should the nurse implement to relieve pain and improve sleep?

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a. b. c. d.

Encourage controlled breathing.

Provide a glass of warm milk at bedtime.

Give a sedative 1 hour before sleep.

Increase fluids and reposition the patient.

ANS: A

When adequate pain relief is not obtained via pharmacological means, the nurse offers nonpharmacological, alternative therapies. Controlled breathing is one way to promote relaxation and enhance pain control. Warm milk may be helpful to some patients, however; it is not known that the patient is allowed milk or can tolerate it. A sedative would not be an appropriate choice because the patient is already hypotensive. Increasing fluids will probably cause the patient to need to use the bathroom which will further interfere with sleep.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

4. The nurse wants to use massage to promote relaxation. In which patient diagnosis would

massage be potentially contraindicated? a. Spinal cord injury b. Hypertension c. Acute asthma d. Crohn’s disease ANS: A

Massage may be contraindicated after spinal cord injuries or surgery to head and neck because of risk of further injury. Patients with hypertension, acute asthma, and Crohn’s disease potentially benefit from a massage as relaxation therapy.

N DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

5. The patient with metastatic bone pain from cancer reports nausea and vomiting after receiving

periodic opioid analgesia intravenously. Which can the nurse implement to manage the patient’s pain effectively without nausea and vomiting? a. Dispense the opioid 30 minutes after providing food. b. Combine the opioid with a sedative or an antihistamine. c. Collaborate with the provider about antiemetic drug therapy. d. Replace the analgesic with a nonsteroidal antiinflammatory agent.

ANS: C

Nausea is a frequent side effect of opioid treatment. Fortunately, it is easily treated with antiemetics. The nurse would collaborate with the provider to obtain this medication for the patient. Giving opioids with food is a good idea for oral medications. The patient does not need a sedative or antihistamine. For metastatic bone pain, a NSAID will not provide adequate relief.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

6. The patient receives opioid analgesia along with naproxen after a total abdominal

hysterectomy. Which patient information leads the nurse to collaborate with the provider about this prescription?

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a. b. c. d.

The patient has not had a bowel movement since surgery.

The patient declines a massage after analgesic administration.

Respiratory rate drops from 22 to 16 breaths/min.

The patient receives famotidine for esophageal reflux.

ANS: D

A patient history of esophageal reflux is usually a contraindication for nonsteroidal antiinflammatory drug (NSAID) administration because of the increased risk of bleeding from prostaglandin inhibition. Constipation is a complication of surgery and opioid analgesia, but the nurse manages patient constipation by increasing patient ambulation and intake of fiber, fluid, and stool softeners. Declining a massage after receiving pain medication potentially indicates that the patient is satisfied with her comfort and relaxation status. Respirations at 16 breaths/min are within normal limits.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

7. The nurse prepares an oral opioid analgesic for the patient who has dementia and pain. After

checking the patient’s medication administration record (MAR) for the last administration time and the patient’s response to pain medication, the nurse chooses the correct analgesic and compares the patient’s picture and wristband to the medical record. Which is the most important intervention for the nurse to implement next? a. Fill a glass with water. b. Record the administration time. c. Check the medication dose. d. Help the patient to sit upright.

ANS: C

N

The most important intervention at this point is to check the MAR and verify the correct dose before administration to prevent adverse effects and toxicity. This is important from a safety standpoint and follows the rights of medication preparation and administration. The nurse would ensure the patient has adequate water to drink prior to giving the pill. Assisting the patient to a particular position may be required, but it is not the most important intervention now. The nurse should be focused on safety during the preparation and administration of medication. Medication documentation occurs after the medication is administered.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

8. The nurse decides that collaboration with the health care provider is needed to review and

possibly adjust the dose of analgesic for an 87-year-old patient. What is the most likely rationale for this request? a. Older adults have higher risks of injury with intramuscular (IM) injections. b. Analgesics aren’t necessary for older adults because of decreased pain sensation. c. Impaired cognition impairs reporting of pain by older patients. d. Liver and kidney metabolism is usually slower in older adults.

ANS: D

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As the adult ages, hepatic and renal clearance of medication usually decreases or slows, so medication has a longer duration of action, and doses exert a stronger effect than in younger people. The nurse helps to maintain patient safety and prevent injury by collaborating to adjust the dose of the analgesic. Risk of injury from an IM injection refers to the route of administration and is not dependent on the dose. Nothing in the question indicates that an IM injection is the mode of administration. The nurse uses the patient’s self-report of pain felt to help determine the need for pain relief; reporting pain refers to patient assessment. This option does not address the reason for adjusting the dosage.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

9. The adult patient who receives morphine sulfate intravenously by patient-controlled analgesia

(PCA) tells the nurse that the pain level is 8 on a scale of 0–10. Which is the best intervention for the nurse? a. Check the volume of morphine in the PCA syringe. b. Check the frequency of patient-controlled dosing. c. Collaborate with the provider to increase basal rate. d. Check the PCA pump for malfunction.

ANS: B

The PCA dose includes a basal rate to establish and maintain a therapeutic morphine serum level and a supplemental dose of morphine, the patient-controlled dose, for patient pain management. The nurse checks the frequency of patient self-dosing to gather additional information for a nursing assessment. If the patient is not supplementing the basal dose, the nurse instructs the patient to use the patient-controlled dose by directing the patient to depress the PCA button for pain control.

N The nurse allows 30 minutes to 1 hour to evaluate the plan. If the patient is using the PCA properly, the patient may benefit from an increased basal rate. If the patient is depressing the PCA button, the syringe of morphine may be empty; however, the PCA has an alarm to indicate low volume, and the nurse monitors the volume for narcotic control and intake and output (I&O), so it is unlikely that an empty syringe will be the problem. Collaborating with the provider to increase the PCA dose is premature because the nurse has not completed an assessment or implemented nursing interventions that potentially resolve the patient’s pain. It is reasonable to check the pump for malfunction after checking the patient-controlled dosing.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

10. The nurse cares for several postoperative patients using patient-controlled analgesia (PCA)

pain management with a combination of an opioid and a local anesthetic agent on the first postoperative day. Which patient will the nurse assess first? a. A patient after a bowel resection for recurrent colon cancer b. A patient after an internal fixation of an ankle fracture c. A first-time hospitalized patient after amputation of a leg d. A patient with emphysema who had a lung tumor resection ANS: C

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The nurse assesses the patient with the amputation first. Since this is the patient’s first hospitalization, it is unknown how he or she will react to the pain medications, and they can cause respiratory depression, especially in an opioid-naïve patient. The patient with chronic obstructive pulmonary disease (COPD) is probably the second patient the nurse assesses because the disease is pulmonary. If the patient hypoventilates because the pain is too great, he or she is likely to retain additional carbon dioxide, inadequately oxygenate, and potentially have respiratory acidosis and respiratory failure. The other patients would be assessed as soon as possible.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

11. The nurse assesses the patient who is 2 days postoperative to determine the need for

continuing patient-controlled analgesia (PCA). Which information does the nurse use to decide that the patient is ready for oral administration of analgesia? a. Patient is hypoventilating. b. Pain level ranges from 2 to 4. c. Sedation level is consistent. d. RR is 26 breaths/minute.

ANS: B

The nurse uses the patient’s pain level ranging from 2 to 4 to help determine that oral analgesia is suitable for him or her because the patient’s pain level is consistently below the mid-range on the pain scale. PCA is more suitable for moderate-to-severe pain, and oral analgesia is more suitable for low-to-moderate pain. Hypoventilation is an adverse effect of opioid analgesia, regardless of the administration method. A consistent sedation level is vague and provides little information N about patient status. It can indicate a serious neurological impairment or excessive dosing and warrants further investigation. An elevated respiratory rate can be a nonverbal indicator of pain and inadequate pain relief. However, this respiratory rate alone gives no indication of the best route for administration of analgesia.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

12. The patient who receives patient-controlled analgesia (PCA) with an opioid analgesic reports

that the pain level is 9 on a scale of 0–10. Which action does the nurse take first? a. Elevates the head of the bed (HOB) to 30 degrees. b. Increases the interval between demand doses. c. Increases the demand and the basal doses. d. Checks patient manipulation of the PCA button.

ANS: D

The nurse checks to ensure that the patient understands and executes depression of the PCA button for on-demand doses. If the patient does not operate the button or does so ineffectively, he or she receives inadequate pain control. The nurse can elevate the HOB if the patient is oversedated and difficult to arouse unless it is contraindicated. By elevating the HOB, the nurse repositions and enables the patient to receive more environmental stimulation. The patient receives less medication when the time between demand doses is increased. The nurse avoids increasing the basal rate and demand dose simultaneously to prevent oversedation because increasing each rate of administration increases the total potential dose twice.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

13. The nurse and a student nurse receive a patient in the post anesthesia recovery unit and

assesses the epidural analgesic infusion. Which assessment finding by the student is the nurse’s priority? a. The catheter tubing does not have a filter needle. b. The distal end of the tubing is attached to the catheter. c. The infusion contains an opioid and a local anesthetic. d. The pump settings match the provider prescription.

ANS: A

The tubing needs a filter needle to prevent bacteria from entering the infusion line. If the student reports that there is no filter present, this would be the priority for the nurse to address.

The other assessment findings are expected.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

14. The patient reports slight burning-like pain and numbness on the skin under a cold compress.

Which action by the nurse is most appropriate? a. Reassure the patient that some numbness is expected. b. Assess the entire patient before continuing the treatment. c. Remove the compress and assess the affected area. d. Provide a warm blanket for the patient’s treatment.

ANS: C

Burning pain and numbness indicate a possible complication from the cold therapy, so the N nurse stops the treatment immediately and assess the site prior to notifying the provider. The nurse would not just reassure the patient without assessing the problem. The nurse conducts a focused assessment; the patient does not need a head-to-toe assessment. The patient may or may not want or need a warm blanket, but this does not address the possibility of complications.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

15. The nurse teaches the patient in ambulatory care to apply ice packs to an injured knee. What

instructions does the nurse include in patient teaching? a. Leave the ice on for no more than 5 minutes. b. Remove the ice pack when the ice melts completely. c. A cold pack has the potential to cause tissue damage. d. Apply ice for an hour and then apply a heating pad.

ANS: C

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The nurse explains that prolonged application of ice can lead to tissue damage from prolonged vasoconstriction. The patient should be instructed to apply the ice for 10–20 minutes, then remove the ice for 30 minutes and check affected tissue before repeating the cycle to prevent tissue damage. Applying ice for 5-minute increments is subtherapeutic treatment. The nurse avoids teaching the patient to leave the ice in place until it melts because it is likely to result in ice application exceeding 20 minutes and increase the risk for tissue damage. Application of ice for 1 hour exceeds the 20-minute recommendation to prevent tissue damage.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

16. The school nurse provides first aid to the 10-year-old student with a new uncomplicated arm

fracture. The nurse wants to provide nonpharmacological pain relief and minimize regional edema. Which first-aid treatment does the nurse provide for the patient? a. A cold compress b. A covered ice bag c. An aquathermia pad d. A moist heat compress ANS: B

The nurse applies an ice bag with a cover between it and the student’s arm to reduce pain, swelling, and bleeding because cold therapy provides a regional anesthetic effect and vasoconstricts to limit regional blood flow. A cold compress is inadequate to provide regional vasoconstriction for a fractured arm. Heat application from an aquathermia pad or a moist compress is contraindicated for the fracture because both therapies increase blood flow and promote vasodilation. The fluid pressure in the area can increase from the heat to increase patient pain, bleeding, and edema.

N DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

17. The nurse plans care for four patients receiving heat therapy. Which patient will the nurse

consult with the provider about this order? a. Osteoarthritis b. Nephrolithiasis c. Chronic bronchitis d. Peripheral neuropathy ANS: D

The patient admitted for a peripheral neuropathy has the highest risk for a heat therapy injury because he or she has impaired sensation to the extremities, meaning that the patient has difficulty sensing pain, heat, and pressure. This patient is more likely to incur tissue damage from heat therapy because he or she has impaired ability to sense excessive heat. The nurse would consult the provider to determine other therapies for this patient’s pain. The patient with osteoarthritis can have a slightly higher risk of thermal injury from heat therapy if patient mobility is impaired because a self-protective mechanism is withdrawal from noxious sensations such as excessive heat. Patients with nephrolithiasis, kidney stones, and chronic bronchitis can be suitable candidates for heat therapy because these diagnoses are unrelated to peripheral perfusion, sensation, or movement.

DIF: Cognitive Level: Analyzing

OBJ: NCLEX: Physiological Integrity

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TOP: Nursing Process: Assessment 18. The nursing assistive personnel (NAP) reports that the patient is dizzy during a warm sitz

bath. Before moving the patient, what action by the nurse is the priority? a. Check the patient’s pulse rate. b. Dry off the patient completely. c. Ask the patient if he or she is able to ambulate. d. State that dizziness is common.

ANS: A

The nurse should assess the patient’s pulse rate to determine if the patient is stable enough to either continue the bath or ambulate back to bed with assistance. Unless a sphygmomanometer is readily available, taking the pulse is a good clinical indicator to evaluate hypotension indirectly because when the blood pressure falls, the heart rate increases to maintain the cardiac output. Dizziness is a common response to a warm bath for patients who are older or who have cardiovascular, neurovascular, or chronic pulmonary conditions, but the nurse needs to assess the patient before deciding what is happening. The patient will need to be dried off and the nurse can ask the patient if he or she is able to walk, but an objective assessment is better.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

19. In the postanesthesia care unit the nurse applies an ice bag to the patient’s leg at the surgical

site. Which therapeutic effect does the nurse expect from this treatment? a. Decreased pain and diaphoresis b. Decreased bleeding and vasoconstriction c. Vasodilation and decreasedNblood flow d. Increased oxygenation and increased inflammation ANS: B

The nurse applies cold therapy to the patient’s surgical site for regional vasoconstriction, which also decreases bleeding. Diaphoresis commonly occurs with dry heat therapy, but decreased pain can occur with cold or heat therapy, depending on the type of injury. Cold therapy causes vasoconstriction, not vasodilation, and blood flow is decreased as a result of vasoconstriction.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

20. The patient received treatment for a sprained ankle and is receiving home care instructions

regarding cold therapy. Which instructions does the nurse include? a. Place the gel pack on the ankle for 30 minutes every 4 hours. b. Wrap the ankle with a lightweight cloth before applying the ice bag to it. c. Wrap the elastic bandage firmly before applying the ice to the ankle. d. Immerse the foot in a pan of ice water every 2–4 hours.

ANS: B

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The patient needs to prevent direct exposure of the skin to the ice bag. The gel pack must be wrapped before being put against the ankle. The elastic bandage can interfere with circulation if wrapped too tightly, and the wrap itself can prevent the cold from being effective.

Immersion would require the patient to place his foot in a dependent position, which can increase swelling.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. The nurse assesses the patient and realizes that patient pain is interfering with postoperative

therapies. Which assessment findings indicate the patient may be a candidate for nonpharmacological interventions? (Select all that apply.) a. The patient has used guided imagery in the past successfully. b. Nonpharmacological relaxation methods appeal to the patient. c. The provider plans to discharge the patient to home in 2 days. d. The patient understands written information on relaxation techniques. e. The patient cannot receive additional analgesia for unresolved pain.

ANS: A, B, E

An integrated approach using pharmacological and nonpharmacological therapies is the most effective method of pain management. Patients who potentially benefit the most from integrated therapies share certain qualities, including successful use of nonpharmacological therapies in the past and a willingness to try alternative and/or complementary therapies. A patient who cannot receive additional pain medication despite continuing pain is likely to benefit from integrated therapyNas well. The discharge date is unrelated to assessing the patient before relaxation and guided imagery. The nurse can explain and demonstrate relaxation therapies and guided imagery without the patient reading.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

2. The nurse caring for a patient 1 day after a thoracotomy assesses that the patient is in pain, but

the patient denies having pain. Which does the nurse use to confirm the patient’s pain? (Select all that apply.) a. Facial grimacing during linen changes b. Eats a full liquid diet without assistance c. Uses the incentive spirometer every hour d. Patient’s culture forbids complaints of pain e. Has received nothing for pain since surgery f. Heart rate 110, blood pressure 169/90 ANS: A, D, E, F

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To confirm the pain assessment for a patient who states that she has no pain, the nurse looks for information consistent with a patient in pain. The patient’s verbal message and nonverbal cues are contradictory because facial grimacing is a hallmark sign of pain and discomfort, especially when the patient moves. A potential explanation for the inconsistent verbal and nonverbal messages is that the patient’s culture forbids admitting to pain, necessitating the use of other pain indicators. The lack of prior pain medication would indicate no trials of pain control at all. Tachycardia and hypertension can be good clinical indicators of pain when the patient expresses contradictory messages about pain; however, do not rely on vital sign measurements alone. Eating and breathing deeply are inconsistent with a patient in pain.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

3. The nurse assesses a patient who has an epidural catheter for patient-controlled analgesia

(PCA) on the second postoperative day. Which patient data does the nurse group together to establish the nurse’s priority? (Select all that apply.) a. Temperature 38.1° C (100.6° F) b. Patient ready for oral analgesia c. Low tension on epidural catheter d. Respiratory rate 14, sedation level 1 e. Epidural drainage looks like clear medication f. Hemoglobin 15 mg/dL, leukocytes 14,500 ANS: A, E, F

According to the nursing process, the nurse groups interrelated data together to draw a conclusion. This patient is febrile with leukocytosis and clear epidural drainage, clinical indicators of a potential infection.

N Because fluid is leaking from the insertion site, microorganisms have a potential portal of entry, even though the fluid is of unknown origin.

The nurse collaborates with the provider to discontinue the epidural catheter, initiate therapy to eradicate potential infection, and provide adequate pain management by another route. If the fluid is cerebrospinal fluid (CSF), the patient is at risk for a devastating neurological infection and sepsis. Patient readiness for oral analgesia is not as important to patient health and well-being as dealing with the potential infection. Low tension on the catheter, a respiratory rate within normal limits, and a low sedation level are desirable patient data. They are not disregarded by the nurse in formulating nursing care but are less important than a potential infection. The nurse plans nursing care to enhance positive patient assessments to promote health and well-being.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Diagnosis

OBJ: NCLEX: Physiological Integrity

4. The nurse prepares patient-controlled analgesia (PCA) for a postoperative patient in the post

anesthesia recovery unit (PACU). To rule out contraindications to therapy, which should the nurse assess before the patient receives PCA? (Select all that apply.) a. Consider patient cognitive level. b. Evaluate patient communication. c. Confirm two separate intravenous (IV) infusions. d. Determine patient physical ability. e. Assess for history of constipation. f. Verify patient medication allergies.

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ANS: A, B, D, F

The nurse assesses the patient’s cognitive level to verify suitability of PCA for pain management. If the patient cannot understand instructions, PCA will have little value to the patient in managing pain. The nurse evaluates communication to ensure patient ability to relate pain levels effectively; if the patient does not speak English or is cognitively impaired, the nurse establishes a method of nonverbal communication to determine pain level and effectiveness of therapy. The nurse ensures the patient’s physical ability to depress the PCA button. He or she checks patient allergies to medication before initiating PCA to prevent hypersensitivity reactions. One IV infusion is sufficient for PCA if the infusion is continuous or only infuses the PCA. If PCA is infused through the same tubing as intermittent infusions, the nurse risks bolus administration of the opioid and possibly the local anesthetic agent; this increases the risk of respiratory depression. Constipation does not contraindicate the use of PCA. DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

N

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Chapter 16: Promoting Oxygenation Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. A nurse is suctioning a patient through a tracheostomy. Which change in the patient’s status

would cause the nurse to discontinue the procedure? a. The heart rate changes from 84 to 106 beats/min. b. The respiratory rate does not improve. c. The oxygenation saturation changes from 96 to 91. d. The patient’s respiratory effort increases gradually.

ANS: A

The nurse monitors the patient’s vital signs and SpO2 continuously during suctioning. If the patient’s heart rate changes by 20 or more beats/min, the nurse stops suctioning. If the SpO2 drops below 90% (or 5% from baseline) the nurse would also stop. The patient’s respiratory rate would not be expected to improve during the procedure itself. A gradual increase in respiratory effort would indicate the patient still needs to be suctioned.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

2. A patient in respiratory distress is admitted to critical care. Which type of mask would the

nurse anticipate using to deliver the highest FIO2 without intubation? a. Simple b. Venturi mask N c. Partial rebreather d. Nonrebreather ANS: D

The nonrebreather is the mask that can deliver the highest possible FIO2 without intubation.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

3. A patient with a major chest injury was originally alert and oriented after recovery from

surgery but is now becoming apprehensive and dizzy. What action by the nurse takes priority? a. Notify the health care provider. b. Perform a cardiopulmonary assessment. c. Elevate the head of the bed to 60 degrees. d. Provide the patient with pain medication.

ANS: B

Apprehension, dizziness, anxiety, a decreased ability to concentrate, and fatigue are indicators of impaired gas exchange. The nurse needs to assess the patient’s cardiopulmonary status, including vital signs and pulse oximeter. The health care provider will be notified if there is a need for additional intervention. Elevating the head of the bed may be helpful, but the patient needs to be assessed immediately. Pain medication could decrease the respiratory system, which is already showing an adverse status, and there is no indication that the patient specifically needs pain medication.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

4. An older-adult patient with a nasal cannula and extension tubing is able to get out of bed

independently. What teaching by the nurse is indicated for this patient? a. Put on slippers whenever walking. b. Take off the oxygen if only going to the bathroom. c. Be careful not to trip over the extra oxygen tubing. d. Increase the flow rate a little before getting out of bed.

ANS: C

This older patient is at risk for tripping and falling over the extension tubing. Slippers need to be worn when ambulating, but the risk for tripping and falling is the priority. The patient should keep the oxygen on as long as the extension tubing reaches. If not, the nurse will help the patient by getting a portable oxygen cylinder. The oxygen rate is considered medication and should not be changed by the patient.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

5. An oxygen cylinder is turned on, and the gauge registers in the green range. What action does

the nurse take at this time? a. Apply the oxygen as ordered. b. Notify the respiratory therapy department. c. Obtain a new cylinder of oxygen. d. Adjust the flowmeter slightly below what is ordered.

N

ANS: A

The gauge should register in the green range, which indicates that there is an adequate amount of oxygen in the cylinder. The respiratory therapy department oversees oxygen administration, but there is no reason to contact them because there is no problem. The cylinder of oxygen being used is fine and does not need to be replaced at this time. The oxygen rate is considered medication and should not be changed.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

6. A patient with newly diagnosed asthma is asking why peak flow measurements are being

ordered. What is the best response by the nurse? a. They measure the minimum force used to breathe in during the breathing process. b. They measure the maximum flow that occurs during one quick, forced expiration. c. They measure the amount of circulating oxygen in the alveoli during breathing. d. They indicate the stability of your overall health.

ANS: B

The peak expiratory flow measurements are objective indicators of the patient’s current status and the effectiveness of the treatment. Decreased peak expiratory flow rate (PEFR) may indicate the need for further interventions such as increased doses of bronchodilators or antiinflammatory medications. The measurements focus on expiration, not inspiration, and do not reflect the amount of circulating oxygen in the alveoli. The peak expiratory flow measurements reflect only the respiratory system, not the overall health.

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DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

7. The nurse prepares to perform oropharyngeal suctioning on an adult. Nursing care is

appropriate if which wall suction pressure is used? a. 40–60 mm Hg b. 60–80 mm Hg c. 80–100 mm Hg d. 100–150 mm Hg ANS: D

The wall suction setting for adults is 100–150 mm Hg. The wall suction setting for infants is 40–60 mm Hg. The wall suction setting for children is 60–100 mm Hg. The setting of 80-100 mm Hg is not specifically indicated for any age-group.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

8. Nasotracheal suctioning is performed on a patient who is unable to take deep breaths. What

action by the nurse would best meet the patient’s needs before suctioning? a. Increase the oxygen rate of the nasal cannula. b. Elevate the head of the patient’s bed. c. Hyperoxygenate with oxygen attached to a mask. d. Gently flex the patient’s neck.

ANS: C

Hyperoxygenating before suctioning can minimize postsuctioning hypoxemia if a patient is N unable to take a deep breath. The oxygen rate cannot be changed without an order from the health care provider. Elevating the head of the bed can allow lung expansion but does little if the patient is unable to take deep breaths. Hyperextending the neck opens the airway; flexing the neck closes the airway.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

9. While the nurse prepares to suction the patient’s tracheostomy tube, the patient coughs up

mucus, which is visible at the opening of the tube. Which action by the nurse is most appropriate at this time? a. Hyperoxygenate this patient. b. Suction the visible secretions. c. Listen to the lung sounds. d. Wipe the mucus off with tissue.

ANS: B

The secretions need to be suctioned to remove them; then the patient would be hyperoxygenated. Listening to the lung sounds will be done after suctioning to determine the effectiveness and whether the patient’s airway is clear. Wiping the secretions with a tissue would bring nonsterile tissue to the opening of the tube, which is contraindicated. The fibers could also go down the tube.

DIF: Cognitive Level: Remembering

OBJ: NCLEX: Physiological Integrity

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TOP: Nursing Process: Implementation 10. The nurse is attempting to prevent ventilator-associated pneumonia (VAP) in a newly

intubated patient. Which activities would best support this goal? a. Brushing teeth with chlorhexidine at least every 8 hours b. Maintaining the endotracheal pressure at 10 cm H2O c. Positioning the patient flat during tube feedings d. Repositioning the patient every 4 hours ANS: A

Oral care with chlorhexidine decreases the colonization of bacteria. Brushing the teeth also helps remove plaque, which can harbor bacteria. The endotracheal cuff pressure should be at 20–25 cm H2O to decrease movement of secretions to the lower airways. The patient should be elevated during tube feedings to prevent aspiration, which can lead to VAP. The patient needs to be repositioned every 2 hours.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

11. A patient with a water-sealed chest tube unit is connected to suction. Patient care is correct if

the nurse takes which action? a. Monitors the bubbling of sterile water in the water-seal chamber. b. Strips the tube every 2 hours for 15 seconds to prevent clots. c. Clamps the chest tube when transporting the patient. d. Keeps two toothed clamps at the bedside for an emergency.

ANS: A

Intermittent bubbling is normalNduring expiration when the air is being evacuated from the pleural cavity. Continuous bubbling during both inspiration and expiration indicates a leak in the system. Stripping the tube increases negative pressure within the tube and is generally not recommended. The chest tube system is kept unclamped when transporting the patient. The clamps must be toothless or have guards on them to prevent puncture of the chest tube or tubing.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

12. The patient with a mediastinal tube placed 22 hours ago has produced 350 mL of drainage

since insertion. Which action by the nurse would be most appropriate? a. Notify the health care provider of excessive bleeding. b. Document the drainage output in the patient record. c. Place extra dressings and tape over the insertion site. d. Clamp the mediastinal tube to test tolerance for removal.

ANS: B

The amount of drainage is within normal range and should be documented in the patient record. A total of approximately 500 mL in the first 24 hours is within expectations. There is no excessive bleeding; therefore the health care provider does not need to be notified. There is no need to reinforce the insertion site with extra dressing material. Clamping the mediastinal tube is not indicated since it has only been in 22 hours and has an expected amount of drainage.

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DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

13. The nurse is preparing to assist the physician in the removal of a chest tube. Which item does

the nurse is available to be placed over the insertion site as soon as the chest tube is removed? a. Petroleum gauze or Xeroform gauze b. Gauze with Elastoplast c. 2  2–inch gauze with tincture of benzoin d. Steri-Strips under a bioclusive dressing ANS: A

First the petroleum gauze or Xeroform gauze is placed over the wound to prevent any leakage of air. Gauze with Elastoplast would not be used nor would Steri-Strips, 2  2–inch gauze, or tincture of benzoin.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

14. The nurse sees that a patient with a chest tube has intermittent bubbling in the water-seal

chamber 4 hours after the chest tube was inserted. What action by the nurse is most appropriate at this time? a. Notify the physician. b. Check for an air leak. c. Listen to the lung sounds. d. Document the findings.

ANS: D

N

Intermittent bubbling is expected while air is being evacuated from the pleural cavity. The actions of notifying the physician, checking for an air leak, and listening to the lung sounds are not required since the chest tubes appear to be functioning correctly.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

15. The nurse assesses the SaO2 a patient who receives oxygen at 3 L/min by nasal cannula. The

SaO2 at 8 AM was 94 mm Hg, and at 10 AM it was 92 mm Hg. Which action by the nurse is most appropriate? a. Collaborate with the provider to use an oxygen mask. b. Plan follow-up nursing care for patient hypoxemia. c. Request that the laboratory confirm the patient’s results. d. Continue with the current therapy and nursing care.

ANS: D

The nurse continues with the current therapy and nursing care because the difference between oxygen values is insignificant, probably representing a normal variation occurring from minute to minute. The nurse continues to monitor the patient closely because the SaO2 is approaching the lower limit for an acceptable reading. Collaborating for a mask is unnecessary because the patient’s SaO2 is close to normal limits and there is no indication that the patient is exhibiting signs of hypoxemia.

DIF: Cognitive Level: Applying

OBJ: NCLEX: Physiological Integrity

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TOP: Nursing Process: Implementation 16. The nurse is working with a patient receiving oxygen. What can the nurse delegate to nursing

assistive personnel (NAP) during the administration of oxygen? a. Adjusting the flow rate of the oxygen b. Reporting changes in patient’s behavior c. Instructing the patient about oxygen at home d. Assisting during endotracheal intubation ANS: B

The NAP needs to be instructed to report to the nurse changes in vital signs or pulse oximetry and changes in the patient’s anxiety or behavior. The nurse should adjust the flow rate of the oxygen since oxygen is considered a medication. The nurse must also provide the patient teaching. The nurse assists the provider during endotracheal intubation because the procedure is sterile, can require the nurse to administer emergency medication, and requires critical thinking and clinical judgment.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

17. A home care patient receives oxygen by nonrebreather (NRB) mask. Which does the nurse

include when teaching the caregiver about the oxygen-delivery system? a. Keep the plastic bag at the end of the mask inflated continually. b. Adjust the oxygen flow rate with the valve in front of the mask. c. Offer fluids frequently and apply moisturizer to prevent dry skin. d. Remove the elastic head strap to prevent skin breakdown at the ears.

ANS: A

N

To prevent inhalation of carbon dioxide, the nurse instructs the caregiver to maintain an inflated bag at the end of the mask because it serves as an oxygen reservoir for the patient. If the bag deflates, the patient is at risk of inhaling excessive levels of carbon dioxide. The nurse regulates the oxygen flow rate by adjusting the flowmeter on the oxygen source; the NRB mask does not have a mixing valve. It does not dehydrate the patient. It requires a tight seal for effective therapy.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

18. The nurse hears the patient’s wheezing and gasping from the hallway and notes that the

patient’s oxygen saturation has decreased to 92%. Which nursing intervention does the nurse implement first? a. Place the patient in high Fowler’s position. b. Suction the oropharynx. c. Insert an artificial airway. d. Review the last arterial blood gases (ABGs).

ANS: A

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The nurse implements a noninvasive intervention to enhance the patient’s airway before instituting an invasive measure because, although the patient’s airway is impaired, he or she continues to oxygenate fairly well but is working very hard to do so. By quickly adjusting the patient’s position to maximize gas exchange and chest expansion, the nurse intervenes and gains additional valuable data for planning additional nursing care. There is no indication the patient needs suctioning or an artificial airway at this time. ABGs are not necessary yet.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

19. The nurse suctions the patient’s endotracheal tube, and the patient becomes hypoxic. Which is

the priority nursing intervention to increase patient oxygenation? a. Assess breath sounds. b. Discontinue suctioning. c. Instruct the patient to cough. d. Ventilate the patient manually.

ANS: D

If the patient becomes hypoxic, the nurse ventilates him or her manually with supplemental oxygen to increase oxygenation. The nurse implements measures to oxygenate the patient quickly to avoid adverse and potentially life-threatening complications, including arrhythmias and cardiopulmonary arrest. He or she assesses the patient after providing supplemental oxygen and before seeking assistance because the hypoxia is most likely transient. The nurse discontinues suctioning to stop the decline in patient oxygen saturation; however, this action alone does not increase oxygenation. Instructing the patient to cough is a reasonable response to hypoxia, especially if the patient has pulmonary secretions; however, manual ventilation provides supplemental oxygen N in addition to ventilation to increase patient oxygenation.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

20. The patient uses continuous positive airway pressure (CPAP) at home and tells the home care

nurse that the mask fits too tightly. Which action is most important for the nurse to take? a. Changing the mask to a simple face mask b. Teaching the patient the rationale for a tight c. Enlarging several of the air holes on the mask d. Loosening the straps of the mask for the patient’s comfort ANS: B

The nurse teaches the patient that the mask of the CPAP must fit tightly to prevent collapse of the upper airway because the device is unable to establish positive airway pressure without a tight seal. The nurse cannot make the decision to change the type of mask used. Loosening the straps allows air to leak from the system so positive pressure never builds. If the CPAP has holes, they are integrated into the system so the nurse should not enlarge them because it alters the function of the mask.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

21. The nurse institutes oxygen therapy for the patient. Which goal should the nurse set as a

positive patient outcome of airway maintenance?

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a. b. c. d.

Increased pulse rate Increased restlessness A complaint of slight lethargy An oxygen saturation of 95%

ANS: D

Oxygen saturation at 95% is a positive patient outcome of oxygen therapy because it indicates a PaO2 between 80 and 100 mm Hg, which is within normal limits. The nurse expects normal sinus rhythm, heart rate between 60 and 100 beats/min, and a calm patient, indicating adequate oxygenation. Patients can become tachycardic as a compensatory mechanism for hypoxemia; older patients exhibit restlessness as an initial indicator of hypoxemia.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

22. The patient is lethargic and unable to clear oral secretions effectively. How does the nurse

manage the suctioning of the oropharyngeal secretions from the patient? a. Uses a Yankauer suction device. b. Loosens oral secretions with normal saline solution. c. Suctions the nose, mouth, and throat with a catheter. d. Uses a clean catheter to suction the nose and mouth.

ANS: A

A Yankauer suction device is a strawlike tube that can effectively suction oral secretions. The nurse avoids instilling saline solution into the patient’s oropharynx to prevent aspiration.

Suctioning the nose and throat is not indicated. A sterile catheter is used for nasopharyngeal suctioning to prevent contamination of the nasal passages or trachea.

N DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

23. The nurse suctions the patient’s artificial airway. Which adverse effect related to suctioning

does the nurse monitor as the priority during the procedure? a. Fatigue b. Anxiety c. Coughing d. Dysrhythmias ANS: D

Artificial airways require airway suctioning, which poses risks such as cardiac dysrhythmias; laryngeal spasm; and bradycardia, which is associated with stimulation of the vagus nerve.

The onset of dysrhythmias indicates that the patient is physiologically not tolerating the procedure and the nurse would stop. Fatigue can occur after suctioning because suctioning induces coughing and transient hypoxemia. Suctioning is often unsettling for patients because it takes the patient’s breath away, literally, and usually induces coughing and gagging. But the priority is the dysrhythmias because they can lower cardiac output.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

24. The nurse uses a closed-system (in-line) endotracheal (ET) suctioning system for the patient.

Which does the nurse implement to prevent airway interference?

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a. Inserts the catheter between ventilator cycles to avoid airway interference. b. Inserts the catheter 25.4 cm (10 inches) and applies continuous suction during

withdrawal. c. Visualizes the colored indicator line in the sheath of the catheter before completing

the procedure. d. Withdraws the suction catheter and discards it after completing the procedure.

ANS: C

The nurse visualizes the colored indicator line of the catheter after withdrawing the suction catheter from the ET because it indicates that the catheter is completely removed from the airway. The nurse inserts the catheter for suctioning during patient inhalation to avoid respiratory cycle interference for suctioning. The catheter is inserted until resistance is met to avoid suctioning in the main left or right bronchi. The closed-system suctioning system allows the nurse to use the same catheter for repeated patient suctioning by using sterile technique.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

25. The nurse performs tracheostomy care for the patient. Which instruction does the nurse give

to nursing assistive personnel (NAP) to implement while changing the ties of the tracheostomy tube? a. Prevent the patient from coughing out the tube. b. Don sterile gloves before providing assistance. c. Inject sterile saline solution into the tracheostomy. d. Hold the tracheostomy tube securely in place.

ANS: D

The nurse instructs the NAP toNhold the tracheostomy tube firmly in place to prevent accidental dislodgement and to maintain a gentle hold because excessive pressure can induce patient coughing. The NAP wears clean gloves to hold the tracheostomy tube in place.

Injecting sterile saline solution into the tracheostomy tube is contraindicated.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

26. A patient admitted for asthma is weak and tired. Which patient position does the nurse use for

patient performance of a peak expiratory flow rate (PEFR)? a. Standing b. Side lying c. High-Fowler’s d. Reclining in chair ANS: C

The nurse uses high-Fowler’s position to promote optimum lung expansion. Standing for patient performance of PEFR to facilitate chest expansion would be unsafe. Side lying and reclining in a chair for PEFR measurement are not ideal because these positions impair chest expansion.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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27. The nurse teaches the patient controlled coughing. Which will the nurse include in patient

teaching for effective technique? a. Cough in a low-Fowler’s position hourly. b. Inhale and cough deeply with the mouth open. c. Self-reposition and cough every 4 hours. d. Breathe in quickly 3–4 times vigorously.

ANS: B

The nurse teaches the patient to inhale deeply to mobilize pulmonary secretions and to cough deeply to expectorate the secretions. Low-Fowler’s position is contraindicated for coughing because it is too low to facilitate expectoration and because many patients are unable to tolerate a low position. Coughing and repositioning every 4 hours are inadequate. The patient should be taught to inhale slowly and cough with force.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

28. The nurse fills the suction-control chamber with water to the 20-cm line while setting up a

water-seal chest drainage system. Which rationale does the nurse use to explain this intervention? a. Creates a method for counting respirations. b. Compensates for leaks in tubing connections. c. Maintains up to 20 cm of intrapleural pressure. d. Facilitates bubbling for pressure over 20 mm Hg. ANS: C

Lungs inflate as a result of negative intrapleural pressure pulling parenchymal tissue to the N fluid holding it to the chest wall. A 20-cm amount of chest wall and a thin layer of serous water in the water-seal chamber limits negative intrapleural pressure to 20 cm and prevents parenchymal tissue damage; the water prevents positive pressure from entering the intrapleural space and compressing the lungs. Positive pressure destroys negative intrapleural pressure. Respirations are counted by watching the chest rise and fall. Compensatory mechanisms for leaking within the system do not exist; the only remedy is to tighten the connections. Bubbling occurs with an air leak in the water-seal drainage system.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

29. The nurse notes that the patient’s chest tube pulled out by 5.1 cm (2 inches) during turning

and repositioning. Which is the initial action by the nurse? a. Instruct the nursing assistive personnel (NAP) to apply pressure for 5 minutes. b. Replace the water-seal drainage system with a sterile waterless unit quickly. c. Hold a towel firmly over the site and send for petrolatum gauze. d. Push the tube into place and apply an occlusive sterile dressing.

ANS: C

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The nurse secures the tube in place with a clean towel (or closest handy clean material) and sends the NAP for sterile petroleum gauze. The nurse securely wraps the gauze around the base of the chest tube insertion to re-create an airtight seal so negative intrapleural pressure can be restored. The nurse applies pressure to the site to prevent the wound from drawing in room air because this intervention requires clinical judgment and critical thinking to seal the wound completely. A standard or a waterless system is suitable for the patient’s water-seal drainage; however, neither system is effective therapy until the airtight insertion site is reestablished. The portion of the tubing pulled out is now contaminated and should not be pushed into place. The nurse should collaborate with the health care provider for a chest x-ray film to evaluate the status of the lung after the accident.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

N

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Chapter 17: Safe Patient Handling Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. A patient’s physical mobility is impaired because of paralysis of both lower extremities.

Which is the best method for the nurse to use to place the patient in semi-Fowler’s position? a. Help the patient push up in bed by bending his or her knees. b. Raise the head of the bed (HOB) to 45 degrees and pull the patient to it. c. Roll the patient to one side using pillows to support his or her back. d. Pull the patient to the (HOB) using a drawsheet and then raise the HOB. ANS: D

With the assistance of another staff member and using a drawsheet, the nurse bends the patient’s knees to reposition the legs, pulls the patient to the HOB, elevates the HOB to 45 degrees, and removes wrinkles from the drawsheet. The patient is unable to push up because of paralysis. Elevating the HOB first increases the force needed to move the patient up in the bed and the risk of injury. Rolling the patient to the side achieves Sims’ or lateral position or assists with logrolling; rolling the patient may be necessary to place the drawsheet under him or her before moving the patient up in bed.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

2. The nurse is caring for a patient after a motor vehicle crash and instructs the patient to avoid

turning independently because the spine is unstable. What explanation of bed mobility does N the nurse provide the patient? a. “We will use a ceiling lift to get you out of bed.” b. “Several staff will logroll you to change position.” c. “You have to remain on your back until your spine is stable.” d. “Physical therapy will get you out of bed in the morning.”

ANS: B

The nurse does not allow the patient to turn to the side unassisted because an unstable spine cannot maintain normal alignment since the integrity of one or more vertebrae is disrupted. If the patient moves, he or she risks exacerbating the spinal cord injury by abnormal movements of vertebral bone fragments. To maintain patient safety, the nursing staff turns the patient by logrolling and thereby keeps the head, neck, and spine in straight alignment, thus preventing bone fragments from shifting and potentially increasing the damage. The patient does not need a ceiling lift because he or she will not be getting out of bed until the spine is more stable. Remaining on the back will greatly increase the risk of pressure injury. Physical therapy may be tasked with getting the patient out of bed, but again until the spine is stabilized, the patient will not be getting out of bed.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

3. The nurse and an assistant are moving a dependent patient from the supine to the lateral

position. Which should the nurse implement to begin repositioning? a. Support the upper arm and leg with pillows.

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b. Move the patient away from the center toward a side of the bed. c. Elevate the patient’s head with two or three pillows. d. Wedge a pillow under the abdomen and chest.

ANS: B

The nurse and assistant move the patient to one side of the bed to create space on the bed for turning and avoid dangling the patient’s arms and legs over the side of the bed. The nurse supports the upper arm and leg after the patient is turned. Usually one pillow under the head is suitable for the lateral position; two or three pillows hyperflex the patient’s head. If necessary, a pillow is wedged under the patient’s chest and hips to support the patient in the lateral position, allowing him or her to relax in this position.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

4. After 3 hours in the supine position, an older patient reports being stiff and too uncomfortable

to move. Which intervention is most appropriate? a. Find an assistant to help move the patient to lateral position now. b. Express concern about the discomfort and encourage turning. c. Assess the patient’s need for pain medication before repositioning. d. Explain how important repositioning is for preventing pneumonia.

ANS: C

Lying motionless is common behavior for patients in pain. This older patient is likely to have thin, fragile skin and by not moving for 3 hours, has an increased risk of skin breakdown from tissue hypoxia. The nurse assesses the patient’s pain and determines a need for pain medication before attempting to reposition him or her. To preserve skin integrity and promote N the patient to another position to facilitate the flow of patient comfort, the nurse moves oxygen-rich blood to the tissue, to assess the entire back for skin breakdown, and to provide hygiene if necessary. Expressing concern about the pain does nothing to assess or treat the discomfort. Explaining the need to reposition to prevent pneumonia is helpful when the patient is comfortable enough to pay attention to what is being said.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

5. The patient with a hemiparesis is very hesitant to transfer from the bed to the chair. Which

action does the nurse take first to accomplish the transfer? a. Explain how the transfer of the patient will be done safely. b. Ask questions about how the patient usually transfers. c. Document that the patient declined help for the transfer. d. State that the health care provider ordered a transfer.

ANS: B

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By applying the nursing process, the nurse probes gently to gather information about the patient’s reluctance to transfer, including the methods used to complete other transfers, how many transfers have occurred, and events during the transfers that left the patient fearing or dreading further transfers. The nurse takes these data and plans nursing care in response. If the nurse assumes that the problem is fear, the patient’s true needs may not be met by even the most detailed explanation of safety measures. The first response should be to assess the problem and develop a plan of action. Refusal to transfer should be documented only if, after every effort to understand and address the patient concerns, the patient continues to refuse. By stating that the health care provider ordered a transfer, the nurse passes responsibility for transferring to the health care provider. This is unprofessional. The patient can feel coerced to transfer by the nurse’s implication that the patient has no choice; this is a legally tenuous position for the nurse to assume.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

6. The nurse assists the patient with transferring from bed to chair by using a transfer belt.

Which is the first instruction that the nurse gives to the patient after properly positioning him or her? a. “Place your arms around my neck to stand up.” b. “Bend both knees slightly when standing up.” c. “Hold the transfer belt for stability during transfer.” d. “Rock to help stand while pushing up with your hands.”

ANS: D

A rocking motion and pushing up with the hands moves the patient’s body in the direction of the transfer. The nurse is also rocking, and together they move as a unit. Having the patient N hold the nurse around the neck increases the risk of injuring the nurse during a transfer. The nurse flexes at the knees and hips to lower his or her center of gravity; this is a more powerful force for transferring and decreasing the risk of back injury than standing upright and leaning toward the patient. The patient wears the transfer belt, and the nurse grabs the belt from underneath as the patient rocks forward. The nurse’s force on the belt and the nurse’s and patient’s weight shifting work as a unit to assist the patient to a standing position.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

7. While the nurse is attempting to transfer a patient to a standing position, the patient cannot get

off the bed. Which is the initial intervention for the nurse to implement? a. Return the patient to a safe position on the bed. b. Put a second transfer belt on the patient. c. Get additional personnel to help with the transfer. d. Assess the patient for unknown weakness.

ANS: A

The initial intervention for the nurse is to return the patient to a safe position. The nurse would then reassess for the cause of the weakness. The nurse should assess the patient’s fatigue, pain and discomfort, muscle strength, understanding of the patient’s role in standing, and willingness to participate. The nurse organizes the data that he or she gathers, draws conclusions, and plans care. Further assessment is indicated after the patient is safe.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

8. The nurse wants to transfer a patient from the bed to the chair by using a mechanical lift. The

patient has difficulty following directions, and the nurse cannot find help. Which is the most important action for the nurse to implement? a. Assure the patient that the lift is safe. b. Use two safety chains on a canvas sling. c. Delay the transfer until help is found. d. Double-check the wheel locks on the lift.

ANS: C

To maneuver the patient safely with a mechanical lift, the nurse must find an assistant to help on the opposite side of the bed and help hold the chair as the nurse lowers the patient onto it.

Whenever a patient has difficulty comprehending or following directions, additional help needs to be obtained. Reassuring the patient about the safety of the lift is appropriate but is less important than ensuring his or her safety on the lift. The chains attach to the sling, providing a strong bond between the lift and the sling, but they are not specifically designated as safety devices. Double-checking the wheel locks on the lift is important to patient safety, but the nurse should not even begin this transfer until an assistant is available.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

9. The nurse is teaching other caregivers about using a mechanical lift. What does the nurse

include in the instructions focusing on patient safety? a. Place the base of the lift under the side of the bed.

N the patient’s torso. b. Use the longer chains to support c. Ask the patient to hold the head up while in the sling. d. Instruct the patient to hold the chains during the transfer.

ANS: A

The nurse ensures patient safety while transferring a patient with a mechanical lift by securing the base of the lift under the side of the bed. The base will also be set at its widest point for stability. The longer chain is used to support the patient’s legs. The patient lies in a supine position with the head relaxed on a small pillow if necessary. The nurse instructs the patient to cross the arms on the chest because the sling wraps around the patient very tightly, potentially resulting in injury.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

10. The nurse transfers the patient from the bed to the chair using a mechanical lift. Which should

the nurse do before leaving the patient’s room to ensure patient safety? a. Remove the sling from under the patient. b. Document patient response to the transfer. c. Secure the nurse call system within the patient’s reach. d. Return the base of the lift to its original position.

ANS: C

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To prevent patient injury from unnecessary reaching or attempts to get up, the nurse places the nurse call system close to the patient, makes sure that the patient can use the nurse call system, asks what the patient needs, and assesses the patient for safety before leaving the room. The sling remains under the patient while the patient is sitting in the chair as long as it does not increase the risk of skin breakdown or patient discomfort. With the sling in place, the nurse facilitates transferring the patient to the original position. The base may be left open and stored over the bed while the patient is in the chair. Once the patient is back in bed, the lift is returned to the original position and removed from the room.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

11. A 225-pound (102-kg) patient is unconscious and needs to be transferred from the bed to the

stretcher. Which action is most critical for the nurse to initiate before moving the patient? a. Obtain a friction-reducing device and at least two other staff members. b. Instruct a nurse to stand at the head of the patient. c. Suspend the intravenous (IV) lines and Foley catheter from the stretcher. d. Wrap the patient in a sheet to prevent injury to the arms and legs.

ANS: A

The nurse effectively manages patient safety by using a friction-reducing device and at least three people to move a patient who is this weight. Suspending the Foley catheter from the stretcher is fine, but the IV lines must be hung from the stretcher for proper infusion. The patient must be observed closely during the transfer; wrapping the patient in a sheet obscures critical observations that can prevent accidents and injury to the patient.

DIF: Cognitive Level: Applying N TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

12. The nurse is preparing to place a patient in the Sim’s position. What action should the nurse

take during the positioning? a. Place a pillow under both knees. b. Put a footboard against both feet. c. Insert a pillow under the flexed upper arm. d. Straighten the arms at the patient’s sides.

ANS: C

The nurse places a small pillow under the patient’s flexed upper arm when the patient is in the Sim’s (semi-prone) position to maintain proper limb alignment. The knees are not elevated with a pillow in this position. If excessive pressure on the knees occurs, the entire anterior surface is padded to relieve the pressure, maintain normal body alignment, and prevent hyperextension at the knees. A footboard is used for patients in the supine position to prevent footdrop. The nurse flexes the patient’s arms and positions them at the shoulder level.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

13. While transferring a patient who has been bedridden for several weeks, the nurse notes that

the patient becomes fatigued rapidly. What assessment data does the nurse expect to find to validate the patient’s changing status? a. Increased pulse and increased respirations

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b. Decreased pulse and increased respirations c. Increased pulse and decreased respirations d. Decreased pulse and decreased respirations ANS: A

The patient’s body is responding to the increased workload on the heart and lungs and is manifested by elevations in both the pulse and respirations.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

14. A patient who is weak but motivated after surgery is going to ambulate for the first time.

Which nursing intervention is most likely to facilitate patient safety? a. Ask the patient if this weakness has occurred before. b. Obtain a full set of vital signs after ambulating the patient. c. Encourage the patient to hold onto a staff member in the hall. d. Assess the patient for any potential cause of weakness or dizziness before ambulating. Assist patient in changing positions slowly.

ANS: D

To safely assist the patient in getting out of bed and ambulating for the first time postoperatively, the nurse assists the patient to change positions slowly and assesses the patient’s response to each change. The nurse would not need to assess for this weakness occurring in the past since it is related to surgery. Obtaining vital signs after ambulation will demonstrate patient tolerance but won’t promote safety during ambulation. Holding a staff member might injure both patient and staff if the patient falls; it would be safer to hold onto handrails or other assistive devices like a walker.

N DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

15. The patient will be transferred to the chair an hour after receiving pain medication for the first

time. Which activity is most important for the nurse delegate to nursing assistive personnel (NAP)? a. Determine the patient’s current pain level. b. Record the vital signs before ambulation. c. Position the gait belt around the patient. d. Assist the patient putting on socks.

ANS: C

The NAP will place the gait belt on the patient. Whenever there is doubt about a safe transfer, the transfer or gait belt should be used. The nurse determines the patient’s pain level because it requires nursing assessment and nursing judgment after medication is given. The nurse checks the vital signs because the patient just had medication for the first time and the nurse needs to evaluate the patient’s response. Socks, unless they have treads, afford little protection for ambulation. The priority for the NAP is patient safety, which includes applying the gait belt.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

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16. The nurse is teaching a patient’s family how to maintain personal safety and prevent injury

when lifting or moving the patient. Which concept does the nurse include in the instructions? a. Carry the weight above the waist. b. Keep the patient close to the mover. c. Bend at the waist for heavy lifting. d. Tighten the stomach and back muscles.

ANS: B

Decrease the force required to lift or move a patient by keeping the patient close to the person moving the patient. The mover provides a more stable base for moving a patient by keeping the patient close to the mover’s center of gravity; if the patient’s weight is higher than that of the mover, the mover becomes top heavy and more unstable and needs more force to move the patient. Bending at the waist increases the distance between the mover and the patient, making the mover’s foundation less stable and less powerful. This also increases the risk of injury. To move a significant weight without injury, the nurse tightens the abdominal and gluteal muscles in preparation for work.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

17. The nurse teaches the caregiver to maintain the patient’s safety when transferring to a chair.

Which teaching does the nurse include to address the weakness of the patient’s right side? a. Place the chair to the patient’s right side after sitting the patient on the edge of the bed. b. Place the chair to the patient’s left side after sitting the patient on the edge of the bed. c. Place the chair wherever the patient wants it after sitting the patient on the edge of N the bed. d. Place the chair wherever it’s most convenient for the caregiver after sitting the patient on the edge of the bed.

ANS: B

The nurse instructs the caregiver to place the chair on the patient’s strong side for safety and support.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

18. The patient’s nurse is directing staff who are moving a patient onto a stretcher with a slide

board. Two nurses are positioned on the side of the stretcher. Where is the third nurse positioned? a. On the side of the stretcher b. At the head of the bed c. At the foot of the bed d. On the side of the bed without the stretcher ANS: D

Two nurses position themselves on the side of the stretcher while the third nurse positions self on the side of the bed without the stretcher.

DIF: Cognitive Level: Remembering

OBJ: NCLEX: Safe and Effective Care Environment

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TOP: Nursing Process: Implementation 19. A nursing student is preparing to ambulate a patient using a transfer belt. Which action by the

student requires intervention from the faculty member? a. Places the belt under the patient’s arms. b. Ensures the belt fits snugly. c. Holds the belt with palms facing upward. d. Rocks back and forth with patient before standing.

ANS: A

The transfer belt fits low across the waist. The other actions are correct.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

MULTIPLE RESPONSE 1. The charge nurse is orienting a new NAP about the steps of proper body mechanics. Which of

the follow statements are correct steps? (Select all that apply.) a. Avoid twisting. b. Bend at the knees. c. Tighten stomach muscles as you lift. d. Straighten the legs. e. Keep the weight close to the body.

ANS: A, B, E

You want to avoid twisting. You want to bend at the knees to maintain center of gravity and N bent as you lift. Keep the weight close to your body. Do not keep the trunk erect and the knees straighten the legs. You tighten your stomach muscles before you lift.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

2. Which of the following patients are at higher risk of complications from improper

positioning? (Select all that apply.) a. Post hip fracture who has osteoarthritis b. Has a COPD exacerbation c. A patient who is paraplegic d. Suffered a stroke last week e. The patient with Alzheimer disease ANS: A, C, D, E

Patients with alterations in bone formation or joint mobility, impaired muscle development, and central nervous system (CNS) damage may experience motor impairment, proprioceptive loss, or cognitive dysfunction, all of which affect mobility.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

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3. The nurse is getting ready to transfer a patient from the bed to a chair for the first time after

surgery. Which of the following are important to assess as factors in the transfer process?

(Select all that apply.) a. Sensory status b. Temperature c. Upper arm strength d. Postural hypotension e. Cognitive status f. Pain level ANS: A, C, D, E, F

To provide for a safe transfer it is important to assess sensory status, including central and peripheral vision, adequacy of hearing, and presence of peripheral sensation loss. This will impact the ability of the patient to contribute to a safe transfer. Patients with visual and hearing losses need transfer techniques adapted to deficits. Immobile patients can have decreased muscle strength, tone, and mass, which affect the ability to bear weight or raise the body. Assess presence of weakness, dizziness, or orthostatic (postural) hypotension.

Determine patient’s risk of fainting or falling during transfer. The move from a supine to a vertical position redistributes about 500 mL of blood; immobile patients may have decreased ability for the autonomic nervous system to equalize blood supply, resulting in orthostatic hypotension. Assess the patient’s cognitive status, including ability to follow verbal instructions. Assess the patient for pain (e.g., joint discomfort, muscle spasm) and measure level of pain using a scale from 0 to 10. Offer prescribed analgesic 30 minutes before transfer.

Temperature does not affect the transfer process. However, if the patient had a fever, the nurse would address that prior to moving the patient.

DIF: Cognitive Level: ApplyingN TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

4. The nurse is transferring a patient and he or she sustains an injury during the transfer. What

steps must the nurse take? (Select all that apply.) a. Stay with the patient. b. Notify the health care provider. c. Complete an occurrence report per agency policy. d. Evaluate the incident. e. Provide supportive care to the patient.

ANS: A, B, C, D, E

If a patient sustains an injury during transfer it is important to: –Stay with patient and notify the health care provider immediately.

–Provide necessary supportive care until the patient is stable.

–Evaluate incident that caused injury (e.g., assessment inadequate, change in patient status, improper use of equipment, insufficient number of caregivers to assist).

–Complete occurrence report according to agency policy.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

5. A nurse has assessed several patients using the Banner Mobility Assessment Tool (BMAT).

Which actions by the nurse are appropriate for the patient’s BMAT results? (Select all that apply.)

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a. b. c. d. e.

Patient failed Sit and Shake: use sit-to-stand lift Patient failed Stretch and Point: assess patient’s weight-bearing ability Patient is reluctant to participate: ask patient about ability to stand Patient passes Stand: ask patient to march in place Patient passes Walk: assess for stability and safety awareness

ANS: B, D, E

The BMAT tool is part of a mobility assessment. It includes Sit and Shake, Stretch and Point, Stand, and Walk. The patient who failed Stretch and Point needs an assessment of his or her ability to bear weight on at least one leg as the next step. Once the patient has demonstrated the ability to stand, the nurse instructs the patient to march in place and advance step. If the patient is successful with this, the nurse then assesses his or her stability and safety awareness.

The patient who fails Sit and Shake will need a total lift. For safety, do not ever rely on self-report from the patient or family about the patient’s ability to sit, stand, and ambulate.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

6. The nurse successfully transfers a patient from the bed to the chair and back. What

information does the nurse to include in the progress notes? (Select all that apply.) a. The visitors involved in assisting the patient to transfer b. Home care instructions for the patient about transferring c. The patient’s blood pressure before and after each transfer d. A description of the patient’s response to each transfer e. Presence of NAP needed for transfer purposes ANS: B, C, D, E

N response to each transfer in objective terms to record the The nurse documents the patient’s events and subjective terms to relate the patient’s response to communicate information.

Factors to consider in the documentation are breathing difficulties, dizziness, balance, muscle strength, patient complaints, type and degree of assistance the patient requires to transfer, and progress toward goals and outcomes. To prevent patient and visitor injuries, visitors should not assist the patient to transfer; however, the NAP can. Home care instructions are suitable before discharge and teaching should occur at each encounter. Patient blood pressure is recorded on the graphic flow or vital signs sheet and demonstrates stability or change in patient’s condition in response to the intervention.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment TOP: Integrated Process: Communication and Documentation

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Chapter 18: Exercise, Mobility, & Immobilization Devices Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse delegates helping the older patient ambulate with a walker without wheels to

nursing assistive personnel (NAP). Which instructions does the nurse provide to the NAP? a. Show the patient how to slide the walker a few steps ahead. b. Check the patient for non-skid shoes before using the walker. c. Be sure that the patient places all weight on the front of the walker. d. Ensure that the patient is wearing soft slipper socks while walking.

ANS: B

The nurse instructs the NAP to check the patient for supportive, non-skid shoes to prevent injury to the patient’s feet and provide sure footing while using the walker. The patient should be instructed to lift the walker and set it into place to advance. Sliding is not safe because it does not provide a stable foundation and is more likely to lead to patient falls. The patient should not place all weight on the front of the walker because this will cause the walker to tip.

The patient should be instructed to place weight in the center of the walker for stability. Soft slipper socks do not provide adequate support for the ambulating patient and are more likely to lead to falls.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

2. The nurse instructs the patient, who has right-sided weakness, to use the cane during

N

ambulation and assesses the patient’s use of the cane. Which assessment would the nurse address before the patient ambulates with the cane? a. The cane makes a tapping sound each time the patient touches it to the floor. b. The patient holds the cane in the unaffected hand for support. c. The patient holds the cane 10–15 cm (4–6 inches) to the side of the left foot. d. The patient ambulated 4 times with the cane in physical therapy.

ANS: A

The cane should have a rubber tip on the end and should be silent when the rubber tip contacts the floor, indicating that the rubber is intact; if the cane clicks each time it hits the floor, the rubber cannot effectively maintain the patient’s stability. Using the cane on the unaffected side is proper technique for ambulating with a cane. Holding the cane 10–15 cm (4–6 inches) to the side of the unaffected foot is appropriate. The patient’s history of cane use is valuable information for subsequent instruction and gives the nurse a basis for comparison.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

3. A patient is being moved into a dangling position before ambulating. To decrease the chance

of orthostatic hypotension, what activity can the patient do? a. Sit on the side of the bed for a minute before standing up. b. Take several deep breaths while moving into the dangling position. c. Push up into the dangling position on the side of the bed. d. Stretch all of the muscles in the body.

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ANS: A

Sitting on the side of the bed stabilizes the redistribution of the blood during the position change. Deep breathing helps lung expansion but does not affect the change in the blood distribution during position changes. Pushing up from the side of the bed helps the patient transition to standing, but it doesn’t prevent orthostatic hypotension. There are many muscles throughout the body that cannot be stretched voluntarily.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

4. The nurse is preparing to increase the amount of ambulation that the patient is able to tolerate.

Which is the best method for the nurse to assess a patient’s ability to ambulate? a. Interview the patient’s visitors. b. Discuss ambulation goals. c. Review the patient progress notes. d. Measure the distances ambulated.

ANS: B

Mutual goal setting between the nurse and the patient is a beginning point. Watching the patient ambulate is essential but working with the patient is beneficial. Even if the patient’s visitors are health care professionals, the nurse must assess the patient before taking action.

Reviewing progress notes provides valuable baseline data for comparison to the nurse’s assessment; however, the nurse assesses the patient to determine the nurse’s future care.

Measuring the distance covered by the patient is valuable information and is one part of the data the nurse gathers for the nursing assessment.

DIF: Cognitive Level: ApplyingN TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

5. The health care provider prescribes partial weight bearing of the left leg for the postoperative

patient. Which instruction does the nurse include in patient teaching? a. Prevent the left leg from touching the floor at all times. b. Rest the left leg gently on the floor to stand with crutches. c. Distribute weight equally to each leg while crutch walking. d. Step with the left leg first to ascend the stairway with crutches.

ANS: B

The nurse instructs the patient to rest the left leg on the floor without applying any weight to it when standing with the crutches to avoid full weight bearing on the affected leg. Equal distribution of weight is weight-bearing activity, and this is contraindicated for the patient.

The patient steps with the unaffected leg first to provide a stable method for ascending stairs.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

6. The nurse is planning to perform range-of-motion exercises on a patient who has had a stroke

and has mobility issues. Which of the following principles does the nurse follow? a. Complete the exercises in a bottom-up approach. b. Repeat each movement 8 times during the exercise period. c. Always use gloves if there are skin lesions. d. Complete the exercises in a head-to-toe sequence.

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ANS: D

Complete exercises in head-to-toe sequence. Repeat each movement 5 times during the exercise period. Inform the patient how these exercises are performed and how they can be incorporated into activities of daily living (ADLs). Use gloves if wound drainage or skin lesions are present; however, this is not specific to providing range of motion.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

7. The nurse teaches a patient who is alert and oriented to use a cane for left leg weakness.

Which does the nurse include in patient teaching? a. Use a firm grip to grasp the cane with the right hand. b. Place the cane about 30.5 cm (12 inches) in front of the right leg. c. Distribute weight evenly between the cane and the left leg. d. Move the right leg forward first, the cane next, and left leg last.

ANS: A

The nurse instructs the patient to hold the cane on the unaffected, or right, side to broaden the patient’s base of support because using the unaffected side offers more support. The cane should be placed 15–25 cm (6–10 inches) in front of the unaffected leg. The patient is instructed to distribute the body weight between both legs, to begin walking by moving the affected leg first to be even with the cane, and then to move the unaffected leg forward past the cane. This method provides support for the affected leg with the cane and realigns the patient’s center of gravity.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation N

OBJ: NCLEX: Physiological Integrity

8. The nurse instructs the patient how to incorporate range-of-motion exercises into activities of

daily living (ADLs). With which of the patient’s joints can the nurse perform the most movements for the ADLs? a. Hip b. Shoulder c. Ankle d. Wrist ANS: A

The hip can be moved into flexion, extension, internal rotation, external rotation, abduction, and adduction while performing ADLs. The shoulder can be moved into flexion, extension, and abduction. The ankle can dorsiflex and plantar flex. The wrist can be moved into flexion, extension, abduction, and adduction.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

9. Nursing assistive personnel (NAP) are working with patients performing range-of-motion

exercises. Which activity can the nurse delegate to NAP? a. Determine the patients’ current pain level. b. Assist stable patients with their range-of-motion exercises. c. Force the joint motion gently a slight bit with each session. d. Place socks on patients before exercising the lower extremities.

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ANS: B

The nurse can delegate range-of-motion exercises to NAP because training and education have been provided to allow them to perform the task safely. The nurse determines the patient’s pain level because it requires nursing assessment and nursing judgment. The joint motion should never be forced when performing range-of-motion exercises. Placing socks on patients before exercising the lower extremities has no purpose and is not done with range-of-motion exercises.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

10. A patient’s pulse has gone from 78 at rest to 98 after ambulating. What nursing action is

indicated at this time? a. Ask the health care provider to order a wheelchair for the patient. b. Plan an adequate rest period before and after ambulating. c. Sit the patient on the bed for 15 minutes before ambulating. d. Increase the amount of range-of-motion exercises done daily.

ANS: B

The patient’s pulse rate has elevated over 20% of the baseline, which indicates a poor response to the level of activity. Rest needs to be provided immediately before and after the period of ambulation, or the amount of ambulation should be decreased until the patient adjusts to the activity. The patient would not be ambulating if riding in a wheelchair and would not build up tolerance to activity. Dangling helps decrease orthostatic hypotension but not activity intolerance. Range-of-motion exercises help with joint movement, not activity tolerance.

N DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

11. The nurse teaches the patient’s caregiver how to respond if the patient begins to fall while

ambulating. Which instruction does the nurse provide to minimize potential injury to the patient and the caregiver? a. Get the nearest chair and put it behind the patient. b. Ease the patient to the side to protect his or her head. c. Straighten your leg and help the patient slide to the floor. d. Hold onto the gait belt and pull the patient close to you.

ANS: C

If the patient complains of dizziness or begins to fall, instruct the caregiver to extend a leg under him or her and allow him or her to slide down the leg and gently reach the floor. This is the best method of preventing injury to the patient and caregiver because the caregiver engages strong muscles to act as an angle between the patient and the floor, slowing the speed of the patient’s descent. If the caregiver has to release the patient to get the chair, the patient is left unstable and is likely to suffer a fall or injury. The caregiver risks personal injury trying to direct the patient’s fall unless strong muscles such as the legs are used. The nurse uses back muscles to hold the gait belt with a patient fall and risks a serious back injury from twisting and reaching in the process.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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12. The patient ambulates with two crutches, and the nurse notes that the patient’s weight is

resting on the axilla. Which intervention is best? a. Document that the patient is using the crutches properly. b. Encourage the patient to minimize the weight on the axilla. c. Ensure the patient’s crutches fit him or her properly. d. Increase the layer of padding to the top of the crutches.

ANS: C

Using crutches correctly the patient will place most of his or her weight on the hands, not the axilla. Placing weight on the axilla can cause nerve damage. While encouraging the patient to minimize the weight on the axilla is fine, the nurse must first assess the fit of the crutches. If they are too short, excess pressure will be placed in the axilla. The patient is not using the crutches appropriately so the nurse does not document that. More padding encourages more weight on the axilla.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

13. The patient is postoperative day 1 after surgery on the right knee and is to begin to walking

with crutches using the three-point gait. Which action by the patient indicates the nurse needs to review the teaching? a. Moves the right crutch first, left crutch second, and right leg last. b. Begins in the tripod position and bears all weight on the left leg. c. Slips three fingerbreadths between the crutch padding and the patient’s axilla. d. Flexes elbows at approximately 20 degrees while walking with crutches.

ANS: A

N

The three-point gait requires the patient to advance both crutches at the same time with the affected leg while the unaffected leg bears the body weight. This technique allows the patient to avoid weight bearing on the affected leg by using a stable base of support. Moving the right crutch and then the left crutch is not the correct coordination for a three-point gait. The other options are correct for using a three-point gait.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

14. The nurse is instructing a patient with a right hip replacement to descend stairs by using

crutches. Which does the nurse include in patient teaching? a. Use the handrail on the right side. b. Shift the weight to the left leg to begin. c. Keep crutches very close to the hips. d. Place the left leg on the stair below first.

ANS: B

The nurse instructs the patient to begin in the tripod position and thus shift the body weight to the unaffected leg to maintain balance and a base of support. The patient uses both crutches, one on each side, to descend a stairway to provide a wide base of support and avoid hopping down each step on one foot. The crutches should be held 15 cm (6 inches) laterally to provide a wider base of support. The nurse instructs the patient to position the crutches on the stair below before shifting weight to the crutches and moving the right leg forward.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

15. The patient is currently learning how to use crutches so there is minimal weight on the

affected leg. Which type of crutch-walking technique will the nurse be reinforcing? a. Two-point gait b. Three-point gait c. Swing-to gait d. Swing-through gait ANS: B

The three-point gait is appropriate for patients who have partial weight bearing, can toe touch, or have weight bearing as tolerated. The two-point gait is appropriate for weight bearing as tolerated or full weight bearing. The swing-to gait is used by patients whose lower extremities are paralyzed or who wear weight-supporting braces on their legs. The swing-through gait requires the ability to bear partial weight on both feet.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

16. The nurse is measuring vital signs when the patient, who is standing, reports dizziness. What

is the nurse’s priority intervention? a. Call for immediate assistance. b. Help the patient to lie on the floor. c. Help the patient to a seated position. d. Inform the patient that the dizziness will pass.

N

ANS: C

The nurse helps the patient sit after the complaint of dizziness to prevent a fall. If necessary, the nurse then calls for help. Safety is always the priority when giving care. Sitting helps restore the patient’s blood pressure to normal levels, relieving the dizziness. Assisting the patient to the floor is indicated if the patient is so dizzy as to fall. Telling the patient that the dizziness will pass is a reasonable response after the patient has been seated.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

17. The nurse has assessed a patient using the Well’s score and documented the score as an 8.

What intervention by the nurse is most appropriate? a. Document the findings in the patient’s chart. b. Collaborate with the provider on DVT prevention. c. Inform the provider the patient is ready for more activity. d. Consult with physical therapy for balance training.

ANS: B

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The Well’s score rates the patient’s risk of developing a deep vein thrombosis (DVT). A score of −2 to 0 indicates low probability. A score of 1–2 indicates moderate probability. A score of 3–8 indicates a high probability of developing a DVT, so the nurse collaborates with the provider to provide prevention measures for the patient. The nurse does document the findings, but it is more important to notify the provider. The Well’s score is not related to progressive activity or balance.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. The nurse is explaining to a nursing student the importance of making sure the patient is

wearing the ordered sequential compression devices (SCDs) when in bed. Which of the following statements indicate a good understanding of the purpose of SCDs by the student?

(Select all that apply.) a. Used to prevent DVTs. b. Alright to walk while wearing. c. Can be used if patient has a DVT. d. Does not affect Virchow’s triad. e. Prevent venous stasis.

ANS: A, D

SCDs are prescribed to help prevent DVTs. They affect Virchow’s triad by improving venous stasis. Patients should not attempt to ambulate while wearing them. They are not used when a patient has a confirmed DVT.

N DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

2. The student nurse is reviewing Virchow’s triad. What information does the student learn?

(Select all that apply.) a. Associated with arterial insufficiency. b. Includes vessel wall abnormalities. c. Dehydration is a cause of hypercoagulability. d. Pregnancy can lead to venous stasis. e. Genetically mediated risk of blood clotting.

ANS: B, C, D

Virchow’s triad includes venous stasis, vessel wall abnormalities, and hypercoagulability and indicates risk for deep vein thrombosis, not arterial insufficiency. Dehydration is one cause of hypercoagulability and pregnancy can lead to venous stasis. Virchow’s triad is not genetically determined.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

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Chapter 19: Urinary Elimination Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse is preparing to insert an indwelling urinary catheter into a female patient who is

having major open-heart surgery and will be in the intensive care unit after surgery. Which statement about the purpose of the catheter by the patient best indicates that teaching by the nurse was effective? a. “An empty bladder always helps prevent bladder infections.” b. “The catheter drains residual urine in case you get a urinary obstruction.” c. “The catheter prevents urinary infections.” d. “The catheter allows us to monitor your urine output closely after surgery.”

ANS: D

During acute illness, a patient may require urinary catheterization for close monitoring of urine output or to facilitate bladder emptying when bladder function is compromised. An empty bladder does help prevent bladder infections by decreasing the risk of residual urine; however, a bladder infection is not as immediate a threat to the patient as fluid and electrolyte imbalance. A urinary catheter drains urine from an obstruction, but this is not this patient’s problem. The catheter does not prevent urinary infections.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. The nurse inserts an indwelling urinary catheter into an adult patient who has been unable to

N

void. Which assessment finding would the nurse expect? a. The patient complains of burning. b. The urine output exceeds 30 mL in the first hour. c. The patient develops a fever. d. The urine is yellow and blood tinged.

ANS: B

The nurse expects the catheter to drain more than 30 mL of urine in the first hour as an indication of adequate urine output because it has been a while since the patient voided. A patient complaint of burning or the development of a fever would be unexpected findings and warrant further assessment. Blood-tinged urine would also be an unexpected finding and warrant further assessment.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

3. The nurse evaluates the effectiveness of the patient’s intermittent urinary catheterization for

residual urine. Which of the following requires follow-up nursing intervention? a. The patient is passing urine in the bathroom. b. The urine is clear yellow and without odor. c. The bladder is nonpalpable above the pubic bone. d. The patient reports frequency and urgency.

ANS: D

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Patient reports of frequency and urgency are consistent with clinical indicators of a bladder infection, which indicates that the intermittent catheterization has been ineffective. Follow-up nursing interventions include increasing patient fluids to dilute and flush out urinary pathogens and collaborating with the provider for potential alterations to the therapeutic regimen, including urine culture and sensitivity. If the patient passes urine in the bathroom, he or she has enough bladder control to reach the bathroom before urinating, which is consistent with clinical indicators of normal urinary function. Normal urine is clear, yellow, and without strong odors and indicates that intermittent urinary catheterization is effective therapy. A nonpalpable bladder indicates an empty bladder and effective intermittent urinary catheterization.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

4. In which position would the nurse place a female patient when preparing to insert a urinary

catheter? a. Prone b. Supine c. High-Fowler’s d. Dorsal recumbent ANS: D

The nurse assists the female patient to the dorsal recumbent position for insertion of a urinary catheter because this position exposes the perineum adequately to visualize the urinary meatus and maintain aseptic technique during the procedure. Positioning the patient on her stomach, flat in bed, or sitting upright impairs the nurse’s ability to expose the perineum, visualize the urinary meatus, maintain aseptic N technique, and drain urine from the bladder.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

5. Which technique does the nurse use to cleanse the perineum of a female patient during urinary

catheter insertion? a. Rinse the perineum with warm antiseptic solution. b. Swab the perineum 3 times from the anus to the urinary meatus. c. Use the nondominant hand to keep the labia spread apart continuously. d. Use the nondominant hand to cleanse from the urinary meatus to the rectum.

ANS: C

The nurse uses the nondominant hand to spread apart the labia and maintain the position until the catheter is in place; once the nurse contaminates the nondominant hand by touching the perineum, he or she cannot use that hand to manipulate sterile equipment. Rinsing the perineum is impractical and not necessary. To prevent infection, the nurse uses the dominant hand to cleanse from the urinary meatus to the rectum in one motion.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

6. The nurse is changing an external urinary catheter on a male patient. Which observation by

the nurse requires additional attention? a. The patient urinates at least every 4 hours.

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b. The patient’s urine is dark yellow and clear. c. The skin of the penis under the catheter is dusky. d. The patient applies the catheter independently.

ANS: C

Regardless of the location, dusky skin is cause for concern because it is a clinical indicator of tissue hypoxia. If the tissue is hypoxic, the perfusion is probably inadequate to meet tissue oxygen demand and increases the risk of skin breakdown. Urinating at least every 4 hours is a desirable outcome. Clear, light yellow urine is a desirable outcome because it indicates urine that is free of sediment and not infected. Ability to perform self-care for a urinary catheter depends on the physical abilities and motivation of the patient, but it is generally a desirable outcome.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

7. Discharge teaching for a male patient with an external urinary catheter would include which

of the following instructions? a. Retract the foreskin of the penis before applying the catheter. b. Remove the hair at the base of the penis before applying the catheter. c. Apply a petroleum-based skin barrier to the penis first. d. Press the catheter adhesive to encourage adherence to the penis.

ANS: D

The nurse would instruct the patient to squeeze around the penis gently to firmly secure the adhesive to the penis to prevent leaking. Retracting the foreskin before applying an external catheter and removing the hair at the base of the penis are not indicated. Applying a N the ability of the adhesive to adhere to the skin. petroleum-based product impairs DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

8. Four hours after applying an external urinary catheter, the nurse observes no urine output in

the drainage bag. Which intervention does the nurse implement first? a. Check the catheter tubing for an obstruction. b. Ask the patient if he or she feels the urge to void. c. Notify the provider of inadequate urine output. d. Increase the patient’s fluid intake over the next hour.

ANS: B

Ask the patient if he or she senses the urge to void because it may indicate a full bladder. The patient can also have urinary retention with an urge to void but no urine output. If the patient states that he has no urge to void, the nurse can scan the bladder to evaluate its contents.

Catheter tubing kinks do not affect the flow of urine with an external urinary catheter in the same way they would if an indwelling catheter were used. There could be some wetting of the perineum with leakage if the catheter tubing is kinked. The nurse would not notify the health care provider until performing patient assessment. Increasing the patient’s intake can be contraindicated but can be effective to increase urine output.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

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9. The nurse set up the sterile field and is preparing to cleanse a male patient before inserting a

urinary catheter. What step is essential for the nurse to use when cleaning the penis? a. Keep the foreskin over the penis tip. b. Use long strokes down the shaft of the penis. c. Hold the penis at a right angle to the body. d. Hold the cotton balls in the dominant hand.

ANS: C

The nurse uses the nondominant hand to hold the penis at a right angle to the body for cleansing so the dominant hand remains sterile to insert the catheter. The nurse retracts the foreskin during cleansing because the meatus is covered partially by the foreskin; the only method of cleansing the meatus is to retract the foreskin. Cleansing the shaft of the penis is unnecessary. The cotton balls remain on the sterile field until needed by the nurse.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

10. The patient reports a sharp stabbing pain when the nurse inflates the balloon during insertion

of an indwelling urinary catheter. What would the nurse do in response to the patient report of pain? a. Deflate the balloon. b. Remove the catheter. c. Advance the catheter 2 inches. d. Reassure the patient that it will pass.

ANS: A

The nurse deflates the balloon promptly because the balloon inflation precipitated the pain.

The balloon is probably still inNthe urethra. It had not been inserted far enough into the patient.

It is unnecessary to remove the catheter. After deflating the balloon, the nurse advances the catheter by 2 inches or more before attempting reinflation. Simply reassuring the patient will not solve the problem.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

11. The nurse reviews an order for a continuous bladder irrigation after prostate surgery. Which

action does the nurse take before starting the bladder irrigation? a. Label the irrigation solution genitourinary (GU) irrigation only. b. Change the irrigation tubing at least once every 12 hours. c. Infuse the irrigation solution at 100 mL/hr for clear urine. d. Ensure that the patient has a triple-lumen urinary catheter.

ANS: D

The nurse first confirms that the patient has a triple-lumen urinary catheter before beginning the irrigation. This type of catheter is usually placed while the patient is in the operating room.

The nurse labels the irrigation solution properly according to agency policy for patient safety and to prevent inadvertent intravenous infusion. The nurse changes the irrigation tubing according to agency policy; every 12 hours is excessive and is likely to contribute to an infection. The nurse titrates the irrigation solution either to the provider’s order, to keep the drainage free of clots, or by agency policy.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

12. The nurse infused a continuous bladder irrigation solution at 250 mL/hr for 12 hours. The

total output amount measured was 3720 mL. What will the nurse record for the patient’s urinary output? a. 550 mL b. 720 mL c. 3000 mL d. 3720 mL ANS: B

The nurse determines the patient’s urine output by subtracting the total volume of irrigation solution infused from the total urinary catheter output because the nurse infused and drained the irrigation solution.

Urinary drainage = 3720 Total of irrigation fluid = (12 hours  250 mL/hr) = 3000 Actual urine output = 720 mL DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

13. The nurse assesses a patient’s suprapubic catheter. Which observation warrants further

investigation by the nurse? a. The catheter does not drain urine continuously. b. The catheter remains in the stoma at all times. c. The patient’s urine is dark yellow and without odor. d. The patient urinates a smallNvolume from the urethra.

ANS: A

The nurse expects the suprapubic urinary catheter to drain urine continuously; if the flow decreases or stops, the nurse suspects an obstruction or adherence of the catheter against the bladder wall. Regardless of the cause, the nurse investigates interrupted flow of urine to prevent infection, tissue trauma, and patient discomfort. The nurse expects the suprapubic catheter to stay in the stoma, the urine to be yellow and odorless, and the patient to urinate a small volume from the urethra.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

14. The nurse determines that the patient’s urinary output from the suprapubic catheter is 150 mL

for 8 hours. What does the nurse implement as a follow-up nursing intervention? a. Encourage the patient to change positions. b. Clamp the urinary catheter for 30 minutes. c. Contact the health care provider for a diuretic. d. Assess the patient’s intake and catheter patency.

ANS: D

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Before concluding that the patient’s urinary output is deficient, the nurse completes an assessment to eliminate inadequate intake and catheter obstruction as the potential causes of the low urine output. The nurse expected at least 240 mL of urine in 8 hours. Changing positions will not allow the catheter to drain more freely unless the tubing has been kinked by the patient’s body. Clamping the catheter is wholly counterproductive. The nurse needs to complete the urinary assessment before determining that a diuretic is suitable therapy for the patient; if a diuretic were proper, the patient would exhibit other clinical indicators of fluid volume overload such as crackles, edema, and jugular venous distention.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

15. The nurse assesses the patient’s skin around the suprapubic catheter and observes extremely

reddened skin. Which is the best nursing intervention to promote skin integrity? a. Apply an antiseptic ointment. b. Keep the suprapubic insertion site dry. c. Attach a different bag to the skin. d. Fit the stoma with a tight skin barrier.

ANS: B

The best nursing intervention for reddened skin is to keep the area clean and dry. Reddened skin does not necessarily indicate infection; thus the antiseptic ointment can be contraindicated. The catheter drains into a bag and is not attached directly to the skin. There is no stoma when a patient has a suprapubic catheter.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

N

16. The nurse encounters resistance during the insertion of a urinary catheter in a male patient.

Which action would the nurse implement first? a. Tell the patient to bear down. b. Ask the patient to inhale quickly. c. Apply force to insert the catheter. d. Remove the catheter immediately.

ANS: A

Having the patient bear down as if urinating relaxes the urinary sphincter, making catheter insertion easier. If the patient is not bearing down, doing so may eliminate any resistance Asking the patient to inhale quickly is counterproductive because it effectively creates a Valsalva maneuver and stiffens the sphincter muscle. To prevent tissue trauma, the nurse never applies force to insert a urinary catheter. Removing the catheter is premature until holding the tip against the sphincter has been tried to relax the muscle.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

17. The nurse is making patient care assignments for the staff. Which elimination activity can the

nurse delegate to nursing assistive personnel (NAP) for a patient with an indwelling urinary catheter? a. Catheterizing the patient b. Irrigating the catheter

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c. Obtaining a urine culture d. Providing catheter care ANS: D

The nurse delegates care of an indwelling urinary catheter to the NAP because the NAP is trained to perform this task as part of hygienic care. The nurse catheterizes the patient, irrigates a urinary catheter, and obtains a urine specimen for a culture because each task is a sterile procedure performed by the nurse.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

18. A patient is going to have an indwelling catheter for the next few weeks as a result of

postoperative complications. Which action does the nurse use to prevent the most common complication of an indwelling urinary catheter? a. Maintain slight tension on the tubing. b. Keep the collection bag several inches from the floor. c. Empty the collection bag every 24 hours. d. Clean the catheter from the meatus to the tubing.

ANS: D

Cleansing the indwelling urinary catheter by using circular motions from the urinary meatus to the collection bag tubing decreases the microorganism count on the catheter and prevents a urinary tract infection. The nurse secures the catheter to the patient’s leg to prevent retrograde catheter movement into the bladder, which can introduce potential pathogens into the bladder and increases the risk of a urinary tract infection. The nurse keeps the urinary collection bag below the patient’s hips to facilitate drainage and prevent retrograde flow of urine to the N bladder. The collection bag is emptied at least every shift to prevent infection by removing a potential source of bladder contamination.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

19. The nurse notes that 8 hours after removing the patient’s indwelling urinary catheter, the

patient has not voided. Which action would the nurse take first? a. Run a trickle of water in the bathroom. b. Apply a rolling motion over the bladder. c. Ask about voiding difficulties in the past. d. Instruct the patient to run warm water on the perineum.

ANS: C

The nurse assesses the patient for a history of voiding difficulties, especially after removal of an indwelling catheter, and asks the patient about successful strategies that facilitated voiding.

Patient difficulties often arise from the physical distortion of the urinary meatus and sphincters by the urinary catheter; after the urethra and sphincters return to normal and regional edema improves several hours later, the patient voids. Running water in the bathroom, running warm water over the perineum, and applying gentle pressure to the bladder are suitable techniques to stimulate urination after assessing the patient. But the nurse needs to assess the patient first.

DIF: Cognitive Level: Applying

OBJ: NCLEX: Physiological Integrity

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TOP: Nursing Process: Assessment 20. The nurse delegates the application of an external urinary catheter to nursing assistive

personnel (NAP), including application of an external urinary catheter. Which aspect of applying the external catheter must the nurse perform? a. Placing the adhesive from the kit to hold the catheter in place b. Checking the condition of the penis and scrotum before the procedure c. Providing perineal care before catheter placement d. Allowing a space between the tip of the penis and the catheter ANS: B

The nurse assesses the penis and scrotum before the NAP begins the procedure to establish baseline data. The nurse performs assessment tasks because assessing requires nursing judgment and planning skills. He or she delegates using adhesive to hold the catheter in place, providing hygiene, and allowing a space between the tip of the penis and the end of the catheter for urine flow because the NAP is trained to perform these elimination tasks.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

21. A male patient is having difficulty using the urinal in bed. What does the nurse do to facilitate

voiding? a. Applies an external urinary catheter. b. Assists the patient to the upright position. c. Encourages the patient to void every hour. d. Instructs the patient to increase his fluid intake.

ANS: B

N

The nurse assists the patient into an upright position to facilitate voiding into a urinal because men are accustomed to voiding in a standing position. If sitting upright is ineffective and the patient can be upright without dizziness or weakness, the nurse assists the patient to dangle or to stand for urination into a urinal. Applying an external catheter facilitates containing the urine but should not be used as the first option. Voiding hourly or increasing fluid intake does not address the issue of the patient having difficulty voiding in bed.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

22. A female patient with a hysterectomy now needs to have her bladder scanned because of

difficulty voiding after back surgery. What action does the nurse take to obtain the most accurate scan? a. Place the scanner head on the symphysis pubis using ultrasound gel. b. Set the gender designation on the scanner as “male.” c. Place the scanner head above the symphysis pubis without ultrasound gel. d. Set the gender designation on the scanner as “female.”

ANS: B

Since the female reproductive organs are absent, the internal structure is similar to that of a male for bladder scanning purposes. The scanner head is placed above the symphysis pubis, not on the bone. Ultrasound gel and the area above the symphysis pubis are used. The female gender designation would be incorrect after a hysterectomy for bladder scanning purposes.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

23. A nurse is caring for an older patient who is recovering from a serious illness. The patient has

an indwelling urinary catheter. The nurse notes the onset of new confusion. What action by the nurse is best? a. Enlist a sitter to keep the patient safe. b. Obtain an order for a urinalysis. c. Assess the patient’s intake and output. d. Check the patient’s recent lab data.

ANS: B

Older adults often do not exhibit the normal signs of urinary tract infections but may display changes in orientation and behavior. The nurse will contact the provider and request a urinalysis. A sitter may or may not be needed for safety. Assessing I&O and lab data may or may not be helpful, but with a catheter, the patient is at risk for developing a catheter associated urinary tract infection.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. The nurse is reviewing the interventions for prevention of urinary catheter infections

(CAUTIs). Which of the following interventions will help prevent infection? (Select all that apply.)

N a. Maintain a closed system. b. Perform routine perineal hygiene daily. c. Only open the system when necessary. d. Secure the catheter to prevent pulling on the catheter. e. Maintain an unobstructed flow of urine.

ANS: A, B, D, E

Evidence-based interventions to prevent CAUTIs include maintaining a closed system; performing perineal care daily, or as needed; securing the catheter to prevent pulling; and maintaining an unobstructed flow of urine. The system would not be opened.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. The nurse is providing instructions to the NAP on applying a condom catheter on a male

patient. Which of the following does the nurse instruct the NAP to report? (Select all that apply.) a. Patient reports pain at the site or when voiding. b. Redness or irritation at the site where the condom catheter is applied. c. Skin breakdown of the glans penis or penile shaft. d. Inability to apply the catheter. e. Urinary incontinence.

ANS: A, B, C, E

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Patient reports of pain and any skin irritation or breakdown should be immediately reported to the nurse for follow-up. If the patient has retracted anatomy, the nurse can choose to apply a different type of external urine collection device. The reason for the condom catheter is for urinary incontinence and therefore would not need to be reported.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

3. The nurse is reviewing the instructions for applying a condom catheter with the NAP. Which

of the following statements indicates an understanding of the procedure? (Select all that apply.) a. “I should shave the pubic hair first.” b. “With my dominant hand, I hold the rolled condom sheath.” c. “I allow 1–2 inches of space between the tip of the penis and the end of the condom.” d. “I should not use any additional adhesive tape around the penis.” e. “I should first provide perineal care.”

ANS: B, C, D, E

Perineal care is completed and then the hair is clipped, not shaved. The nondominant hand holds the penis while the dominant hand holds the condom. The securing device supplied by the manufacturer is used. One to two inches of space is left at the tip of the penis and the end of the condom.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

4. The charge nurse is reviewing N patients on the unit who have indwelling urinary catheters for

appropriateness of this treatment. Which of the following have catheters for appropriate reasons? (Select all that apply.) a. Frequently incontinent b. On high dose steroids c. Receiving fluid resuscitation for burns d. Critically ill e. On hospice, for comfort ANS: C, D, E

Appropriate reasons for using a catheter include high volumes of fluids, critically ill needing close monitoring of intake and output, and for comfort care at the end of life. A patient who is frequently incontinent or one receiving high doses of steroids does not need a catheter.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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Chapter 20: Bowel Elimination Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nursing assistive personnel (NAP) informs the nurse that the patient with a nasogastric

tube has a reddened area on the naris. What action by the nurse is best? a. Remove the tube and assess the patient for nausea and distention. b. Instruct the NAP to clean off the holding device and apply a new one. c. Assess the patient’s skin condition and reposition the tube at the naris. d. Request a consultation by the Wound Ostomy and Continence Nurse.

ANS: C

Device-related pressure ulcers are possible from an NG tube. The nurse would assess the patient and possibly reposition the tube at the naris. The nurse does not remove an NG tube without an order. Applying a new securement device will not help the patient’s skin if the problem is the tube pushing against the naris. The nurse may need to consult the Wound Ostomy and Continence Nurse, but the nurse’s own assessment comes first.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. A nurse and nursing assistive personnel are working with four patients who need enemas.

Which patient is the priority for the nurse to assess before and after the procedure? a. Older and confused b. On cardiac medications N c. Chronically constipated d. Has postoperative pain ANS: B

The nurse would assess the patient on cardiac medications before and after the enema, because enemas and other types of rectal tissue manipulation can cause a vagal response. The patient might become dizzy and faint from his or her heart rate slowing down. The nurse would assess all patients but the one on cardiac medications would be the priority.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

3. A student nurse has placed a patient on a bedpan. What assessment requires the faculty to

intervene? a. The fracture pan has the deep, lower open end under the back. b. The patient has helped lift the hip by using overhead traction. c. The rim of the regular bedpan is towards the foot of the bed. d. The head of the patient’s bed is raised to 30°.

ANS: A

For a fracture pan, the deep, lower, open end goes toward the foot of the bed. The other assessments show good care by the student.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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4. A student nurse is preparing to administer a cleansing enema to an adult patient. How much

fluid does the student anticipate needing for one enema? a. 250–350 mL b. 300–500 mL c. 750–1000 mL d. 1500–1800 mL ANS: C

For an adult the appropriate amount of solution is 750–1000 mL. A toddler would need 250–350 mL and a school-age child needs 300–500 mL. 1500–1800 mL is too much.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

5. The nursing assistive personnel reports to the nurse that a patient getting an enema cannot

hold the solution. What recommendation does the nurse provide? a. Have the patient sit on the toilet for the enema. b. Give the enema while the patient is on a bedpan. c. Use a fecal management system instead. d. Slow the infusion rate and use absorbent pads.

ANS: D

Slowing the infusion rate of the enema might assist the patient in holding the solution in. If the patient still continues to leak solution, use absorbent padding on the bed. Sitting on the toilet can damage rectal mucosa. Sitting on the bedpan is impractical. The fecal management system is for severe diarrhea.

N DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

6. The nurse is inserting a fecal management system for a patient with severe diarrhea. What

action shows good technique during this procedure? a. Uses the index finger to guide the tube’s placement. b. Inflates the cuff balloon prior to insertion. c. Inflates the cuff with 75 mL of saline. d. Attaches collection bag after tube is inserted.

ANS: A

When inserting the cuff of the tube, the nurse uses the index finger as a guide. The cuff is inflated with 45 mL of water after the cuff is in place. The system is set up before it is inserted with the collection bag attached to the tubing.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

7. The nurse is caring for several patients with severe diarrhea. Which patient is an appropriate

candidate for the fecal management system? a. On anticoagulants. b. Has severe hemorrhoids. c. Is 13 years of age. d. Has Clostridium difficile diarrhea.

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ANS: D

The patient with C. diff can develop severe diarrhea with incontinence of stool. This patient is the appropriate candidate for this treatment. The other patients have contraindications for use of the fecal management system.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

8. A patient is weak, has diarrhea, and is refusing to use the bedpan but is on bed rest and unable

to get out of bed. Which is the best nursing intervention to maintain patient dignity? a. Keep the bedpan out of the patient’s sight until it is needed. b. Reassure the patient that most people use the bedpan willingly. c. Instruct the patient that the only alternative for elimination is to use the bedpan. d. Explain how the nurse will ensure privacy and safety.

ANS: D

The nurse increases the likelihood of the patient using the bedpan by explaining how the he or she ensures safety and privacy while the patient uses it. The nurse places the nurse call system and other items that the patient needs or wants within easy reach, covers the patient sufficiently for privacy and warmth, pulls the privacy curtain, and prevents other people from entering the room while the patient sits on the bedpan. Telling the patient that is the only alternative is not really helpful. Hiding the bedpan is deceitful and defeats the purpose of placing it at the bedside if the patient has a sudden stool. Comparing the patient to other patients to induce cooperation shames the patient and is improper; in addition, it denies the patient the right to information and informed consent.

DIF: Cognitive Level: ApplyingN TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

9. A patient in skeletal traction for a fractured pelvis needs to use the bedpan. Which technique

does the nurse use to position the patient on the bedpan? a. Logroll the patient and maintain skeletal traction. b. Place a bedpan under the patient while the hips are lifted. c. Remove weights on the traction and turn the patient. d. Warm the bedpan before placing it under the patient.

ANS: B

If the patient is able to use the feet to lift the hips, this will be the easiest way to get the bedpan under the patient. The nurse may also help lift the patient’s hips. Logrolling may or may not be allowed. The nurse would not disrupt the traction. Warming the bedpan is comforting but doesn’t make positioning easier.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

10. The nurse prepares to insert a nasogastric (NG) tube into a patient. Which explanation does

the nurse give to the patient to explain the use of the NG tube? a. An NG tube eases distention and nausea. b. The tube can sample gastric secretions. c. It causes peristalsis to return more quickly. d. It prevents vomiting from ever occurring.

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ANS: A

The nurse explains to the patient that the NG tube removes gastric contents to decompress the stomach, relieving nausea and distention. The tube gives the gastrointestinal tract a chance to rest before oral nutrition resumes. The tube is not small, nor thin, nor is it predominantly used to sample gastric contents. The NG tube does not stimulate peristalsis. It only removes gases and fluid. With the tube properly placed and functioning, vomiting should not occur, but the nurse should never guarantee that it won’t ever occur.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

11. The patient is alert and cooperative for insertion of a nasogastric (NG) tube. In which position

will the nurse place the patient for the procedure? a. In high Fowler’s position b. In left lateral Sims’ position c. Leaning forward on the over-bed table d. Any position that is comfortable ANS: A

The nurse instructs the patient to sit upright and lean back slightly to facilitate passage of the NG tube because, if the patient starts to cough and gag during the insertion, he or she will be in the optimum position already. This position also enhances the patient’s ability to swallow and gravity can partially aid in the tube’s passage. The nurse avoids instructing the patient to assume reclining and left lateral positions because they increase the risk of patient aspiration during the procedure. The nurse instructs the patient to assume the proper position for the procedure because he or she is responsible for the outcome and for facilitating passage of the N tube.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

12. During the insertion of the nasogastric (NG) tube into a patient’s left nares, the nurse meets

strong resistance. What action by the nurse would have minimized the chance that this problem would occur? a. Use a small-diameter tube. b. Apply lubricant to the NG tube. c. Instruct the patient to bear down. d. Assess the patency of both nostrils.

ANS: D

To prevent tissue trauma and minimize patient discomfort during NG tube insertion, the nurse assesses the patency of both nares before insertion. This helps the nurse determine which naris is more patent and the best naris to use for the initial attempt. If the prescription calls for an NG tube, a small-diameter tube is unsuitable because a small tube does not allow aspiration of gastric contents. If the nares are obstructed, additional lubricant cannot overcome the obstruction and can cause significant patient trauma if the nurse attempts an insertion. The nurse avoids instructing the patient to bear down during NG tube insertion because the Valsalva maneuver engorges tissue and is more likely to impair passage of the tube.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

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13. The nurse is inserting a nasogastric (NG) tube and assessing the patient during the procedure.

Which assessment finding indicates a potentially serious problem? a. Restlessness b. Drop in SaO2 c. Nasal pressure d. Mouth breathing ANS: B

A drop in SaO2 indicates that the tube has entered the patient’s airway. Patient restlessness and fidgeting should diminish after NG tube placement, especially if the tube helps to relieve nausea and abdominal distention. However, restlessness could be associated with a different problem. The patient is expected to feel some nasal pressure after tube placement; however, the pressure should dissipate with time as the patient adjusts to it. The nurse should assess the naris and surrounding skin per agency policy to ensure no tissue damage occurs. Patients often breathe through the mouth after NG tube placement initially until adjusting to the tube in the nose.

DIF: Cognitive Level: Applying TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

14. The nurse inserts a nasogastric (NG) tube to the measured length. Which method is the best

way to confirm placement of the NG tube without an x-ray film? a. Measure the pH of the gastric aspirate. b. Ask the patient if the tube is comfortable. c. Instill air and listen over the stomach. d. Advance the tube past the measured length.

N

ANS: A

After inserting the NG tube to the measured length, the nurse asks the patient to speak, visualizes the tube in the posterior oropharynx, and analyzes the gastric aspirate for pH. If the tube is in the esophagus, the patient should be able to speak, the tube should be aligned with the esophagus, and the pH should be less than 4.0. The NG tube is usually uncomfortable initially. The nurse avoids instilling air into the tube as a method of confirming placement because the tube can be in the lungs. Air injected into the stomach increases patient discomfort and gastric distention. The tube is advanced after initial placement assessments when confirmation indicates that it is not in the trachea but potentially has not reached the stomach.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

15. The patient’s nasogastric (NG) tube drains approximately 400 mL/day of yellow-green

drainage. When the patient reports nausea, which intervention should the nurse implement first? a. Irrigate the tube with 50 mL of water. b. Assess the patency of the NG tube. c. Replace the NG tube with a larger tube. d. Elevate the patient’s head and reassess.

ANS: B

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The nurse should assess NG tube patency and drainage from the last few hours to gather additional information about the patient’s nausea. If the NG tube drains 400 mL/day, it should drain 15–20 mL/hr; thus the nurse can observe for drainage. The nurse irrigates the NG tube after confirming its placement. Tube irrigation helps to prevent accumulated debris that increases the risk of tube occlusion. The nurse avoids relieving the patient’s problem with a larger-gauge NG tube; he or she inserted a properly sized tube in the patient. Raising the head of the bed is a reasonable response to help facilitate gastric emptying; however, because the patient has an NG tube, the nurse should verify tube placement first to avoid potential aspiration of gastric contents.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

16. The nurse is providing routine care for a patient with a nasogastric (NG) tube. Care by the

nurse is correct if which technique is used? a. Alternates NG tube placement between the nares daily. b. Provides patient oral care daily and lubricant to the lips. c. Keeps the head of the bed flat with the tube in place. d. Prevents pressure on the nasal tissue.

ANS: D

The nurse secures the NG tube in place by anchoring it without pressure on the tip of the nares so pressure points do not develop. The nurse avoids alternating NG tube placement daily because tube insertion is uncomfortable and routine changing is not indicated. He or she provides oral care every 2–3 hours to maintain moist, intact oral mucosa and help to prevent patient infection. The head of the bed is elevated to prevent aspiration and minimize irritation from swallowing since the tubeNis irritating.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

17. The nurse prepares to irrigate a patient’s nasogastric (NG) tube. Which intervention does the

nurse implement to irrigate the NG tube? a. Observe sterile technique for each irrigation. b. Inject 50 mL of warm tap water into the tube. c. Gently instill 30 mL of normal saline solution. d. Delegate the procedure to nursing assistive personnel (NAP).

ANS: C

The nurse instills normal saline solution to irrigate the NG tube to maintain fluid and electrolyte balance and minimize electrolyte depletion from hypotonic fluids. The nurse uses clean technique for irrigating. Water is not recommended for NG irrigation. Irrigating the NG tube is a nursing task that the nurse cannot delegate because it requires clinical judgment and critical thinking skills.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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18. The nurse records a patient’s intake and output for an 8-hour period and notes nasogastric

(NG) tube irrigation with 50 mL of normal saline solution every 4 hours and lactulose syrup, 30 mL, instilled through the NG tube with 30 mL of normal saline solution. Which total should the nurse record as the patient’s intake over 8 hours? a. 30 mL b. 160 mL c. 110 mL d. 210 mL ANS: B

The patient’s 8-hour intake is 160 mL, obtained by adding 50 mL of saline  2, 30 mL of lactulose, and 30 mL of saline to equal 160 mL. DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

19. The nurse is caring for four patients. Which patient’s assessment information supports the

nurse’s decision to remove the nasogastric (NG) tube after the health care provider writes the order? a. Restless, confused, without bowel sounds b. Difficulty swallowing from left-sided stroke c. Not passing gas with lack of appetite d. Incisional pain after gastric surgery ANS: D

Incisional pain is not a reason to maintain a nasogastric tube. The nurse manages the patient’s pain with analgesic, keeping in mind that opioids usually lead to constipation. The restless N patient and the patient with dysphagia are at high risk for aspiration because the patient potentially cannot protect the airway and needs the NG tube to help prevent aspiration of gastric contents. The patient who is not passing gas and is experiencing anorexia is not a suitable candidate for NG tube removal because lack of intestinal gas indicates peristaltic impairment. The anorexia is a logical sequela of impaired peristalsis because patients lose their appetites with gastric paresis.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

20. During preparation for removal of a nasogastric (NG) tube, the patient becomes anxious.

Which action does the nurse take to reassure the patient? a. Grasp the tube and remove it quickly. b. Medicate the patient with an analgesic. c. Tell the patient this procedure is painless. d. Inform the patient that it only takes a few seconds.

ANS: D

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The nurse teaches the patient that the procedure takes a few seconds and usually causes little discomfort. He or she can also mention that tissues and a warm face cloth are provided after the procedure for patient comfort. The nurse encourages the patient to blow his or her nose after removing the tube. The nurse removes the tube in a smooth and steady motion and avoids medicating the patient unless it is indicated; removing an NG tube generally is not an indication for analgesia. The nurse avoids telling the patient that the procedure is painless because he or she cannot guarantee it and avoids making false promises.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

21. A right-handed nurse needs to remove the patient’s nasogastric (NG) tube. Which intervention

maintains patient safety during removal of the NG tube? a. Leaving the suction on the low setting b. Clamping and then pulling out the tube c. Standing on the patient’s left side d. Asking the patient to inhale deeply ANS: B

The nurse clamps the NG tube and pulls it out smoothly and steadily, clamps the tube to prevent aspiration of drainage, and helps to prevent aspiration by instructing the patient to hold his or her breath during removal. Deep inhalation can increase the risk for aspiration if it is ill timed. The nurse turns off the suction during the procedure to avoid tissue trauma and decreasing the patient’s oxygenation. The right-handed nurse stands on the patient’s right side to remove the NG tube; this is not a safety maneuver but is for the nurse’s convenience.

DIF: Cognitive Level: Applying N TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

22. The nurse is preparing to insert a nasogastric (NG) tube in an adult patient. Which technique

does the nurse use to measure the length of the tube before gastric intubation? a. Measure and mark a point 72 cm (30 inches) from the end. b. Measure from the nose to the middle of the sternum. c. Measure from the nose to the ear to the patient’s navel. d. Measure from the nose to the earlobe to the xiphoid process.

ANS: D

The nurse measures the patient using the traditional method of measuring from the patient’s nose to the ear to the xiphoid process at the bottom of the sternum. A standard 72-cm (30-inch) length for the NG tube fits some patients and not others; thus this method cannot suitably measure all patients. Measuring to the middle of the sternum results in a short tube, especially since the ear is not involved in the measurement. Measuring to the umbilicus results in an overly long tube.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

23. During insertion of a nasogastric (NG) tube, the patient begins to cough and gag. Which

intervention should the nurse implement for the patient’s benefit? a. Withdraw the tube into the posterior pharynx. b. Stop the procedure, anchor the tube, and request an x-ray film.

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c. Tell the patient that the gagging will pass, and advance the tube. d. Remove the tube and allow the patient to regain composure.

ANS: A

Coughing and gagging during NG tube insertion are expected; thus the nurse is prepared to manage the patient’s distress. The nurse withdraws the NG tube into the posterior pharynx and waits until the coughing and gagging stop. The nurse avoids leaving the NG tube in the area that is causing gagging and coughing because he or she wants to help the patient avoid these as much as possible and complete the procedure. To display caring and concern, the nurse avoids just commenting that the gagging will pass and provides meaningful, facilitative instructions. He or she avoids removing the tube because the patient will have to have the procedure started all over again.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

24. A patient’s nasogastric tube needs to be irrigated. Which action does the nurse implement first

to prevent complications? a. Introduces 30 mL of sterile fluid. b. Verifies the placement of the tube. c. Aspirates gastric contents. d. Positions the patient on the left side.

ANS: B

The nurse verifies the nasogastric placement before instilling anything into the tube to prevent fluid instillation into the lungs. Instilling saline solution can help prevent depletion of electrolytes because it is an isotonic fluid; however, the nurse does not implement this before verifying tube placement. The N nurse can aspirate the irrigation fluid to prevent fluid volume excess, when the patient is on a fluid restriction, or during the initial insertion. Positioning the patient on the left side can help to prevent aspiration; however, the nurse should verify tube placement before beginning the irrigation.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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Chapter 21: Ostomy Care Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The patient notices that the newly formed ileostomy stoma is pinkish red and slightly puffy.

Which information would the nurse include during patient teaching? a. This is what a new healthy stoma looks like. b. Any bleeding indicates that a problem is present. c. Healthy stomas are usually pale pink and flat. d. There should be very little drainage from the stoma.

ANS: A

The nurse instructs the patient to expect a healthy stoma to be pinkish red, indicating adequate oxygenated blood flow, and slightly puffy because it is new. Since the stoma is highly vascular, there may be a little blood. A pale pink stoma indicates decreased blood flow. The stoma should be raised. New stomas drain and are pouched immediately after being created.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning 2. A patient with a colostomy made as a result of abdominal trauma 4 days ago closes eyes

during stoma care. What patient outcome is most important for the nurse to help the patient achieve? a. The patient needs no assistance to perform this procedure within a few days. b. The patient will ask questions about what clothing to wear before discharge.

N c. The patient touches the stoma while looking at it within the next 2 days. d. The patient’s family learns how to pouch the stoma within 1 week.

ANS: C

Patients usually need time to adjust to an abrupt body image change and a change in bodily function. Looking at the stoma and touching it would indicate the beginning of adapting to the changes. The patient needs to be able to be independent eventually in caring for his ostomy, but it is not expected that he would be caring for the stoma within a few days. The patient needs to talk about what type of clothing will work with the stoma well before discharge but adjusting to the change in his body must come first.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Psychosocial Integrity

3. The nurse is teaching the patient how to size the skin barrier around the stoma. Which

instructions does the nurse include? a. Use the measurement guide for a proper fit. b. Extend the skin barrier to cover the incisional area. c. Make a wick from toilet tissue before changing the skin barrier. d. Trim the skin barrier to fit slightly over the stoma margin.

ANS: A

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The nurse instructs a patient to measure the stoma with the measurement template so the stoma will have enough room to fit and to ensure that there is no excessive pressure on the stoma to impair its blood flow. The nurse instructs the patient to avoid covering the incisional area because it is unnecessary and can interfere with healing if the barrier covers a new surgical incision. Toilet tissue wicks can leave residue on the stoma. If a wick is made to absorb drainage, it should be made using gauze. The nurse avoids extending the skin barrier over the stoma to maintain adequate blood flow to the tissue.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning 4. The nurse instructs a patient about home colostomy care. What information does the nurse

include in patient teaching about caring for the pouch? a. Empty the pouch at least every 4 hours around-the-clock. b. Change the pouch every 3–7 days. c. Empty the pouch when it is at least three-fourths full. d. Change the pouch every other day.

ANS: B

The nurse instructs the patient to change the pouch every 3–7 days unless it begins to leak, in which case the patient should change it earlier. The nurse encourages the patient to use the pouch as long as possible, within reason, because ostomy supplies are costly. The pouch is emptied when it is one-half to two-thirds full to prevent it from pulling away from the body. It can be emptied before going to bed and when the patient awakens. The nurse encourages the patient to empty the pouch before it is two-thirds full because a pouch filled to this level is very heavy and more likely to leak.

N

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning 5. The nurse evaluates the effluent from the patient’s new ileostomy. What does the nurse expect

the effluent to look like immediately after surgery? a. Formed stool b. Stool that is like thick liquid c. Watery stool d. Semi-formed stool ANS: C

Stool from an ileostomy can range from thin to thick liquid. Since no food is present, the effluent would be watery. Formed and semi-formed stool is more consistent with colostomy stool. The normal ileostomy stool when food is present is the consistency of a thickened liquid because there is a lot of water in the effluent since most water absorption occurs in the large intestine.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

6. The nurse cares for a patient on the fourth postoperative day after an ileostomy. The patient

tells the nurse that she doesn’t think she can cope and refuses to look at the ileostomy. What approach by the nurse would be most helpful in this situation? a. Explore with the patient exactly what her concerns are.

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b. Tell her when she can start wearing regular clothing. c. Tell the patient that most patients have these feelings. d. Ensure that only female caregivers are assigned to her.

ANS: A

The nurse needs to find out the patient’s deepest concerns and find support for her. Assuring the patient that others have felt the same way ignores her feelings and concerns. A discussion about appropriate clothing does not address the patient’s deeper concerns. Female caregivers may or may not be available to care for the patient and would not ensure that the patient’s most pressing need is met.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Psychosocial Integrity

7. The home-health nurse pouches an ostomy for a patient with serious financial constraints.

What would the nurse recommend to the patient about ostomy care? a. Use soap and warm water for peristomal cleansing. b. Leave the pouch in place for 3–7 days. c. Place several pin holes in the pouch for flatus to escape. d. Use a firm pouching system on a round, hard abdomen.

ANS: B

A pouch is expected to last 3–7 days and does not need to be changed more frequently.

Allowing the pouch to remain in place as long as possible saves on the cost of supplies. The nurse helps the patient find community resources for assistance in procuring needed supplies.

The nurse avoids using soap for peristomal cleansing because it can leave a residue on the skin, which can impair the protective properties of the skin barrier, leading to skin breakdown.

N be avoided because it allows intestinal gas to drift out of Punching holes in the pouch should the pouch. The patient is likely to notice the odor and change the pouch to reduce it, incurring unnecessary expense with extra pouch changes. A firm, round abdomen requires a softer, more flexible pouch system to secure the skin barrier.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

8. The patient’s urinary output from a urostomy is 150 mL in the last 4 hours. What action does

the nurse take? a. Document the amount. b. Notify the physician. c. Encourage more fluids. d. Check the skin turgor.

ANS: A

The amount is above the 30 mL/hr minimum for urinary output and is normal. None of the other options is necessary in this situation.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

9. A patient has a new urostomy because of bladder cancer. The patient asks how to manage “all

of this urine” at night. Which response by the nurse is best? a. “You’ll get up and empty the bag whenever you wake up at night.”

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b. “We give you a larger pouch to wear at night to hold the extra urine.” c. “We’ll attach a large bedside drainage bag to the outlet of the pouch.” d. “It’s really nothing to worry about until you start eating regular meals.”

ANS: C

A bedside drainage bag is attached to the pouch outlet, which is opened during the night to allow the urine to drain. It is closed and disconnected if the patient will be up. With this attachment, the patient won’t have to empty the smaller bag overnight. A larger pouch would become heavy and could pull away from the body at night. Urine will begin to flow immediately; thus, telling the patient not to worry is inaccurate and ignores the question.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

10. The nurse notices that the patient’s stoma is darker than before, purplish in color, and dry. The

patient has been taking care of the ostomy independently. What action will the nurse take initially? a. Document the findings. b. Ask how the patient is measuring the stoma. c. Call the health care provider. d. Rub the stoma to see if it bleeds.

ANS: B

The first action is to find out from the patient the technique used for determining the size of the opening for the stoma. If it is too tight, the blood supply to the stoma could be decreased.

Information needs to be obtained before documenting or notifying anyone else. Rubbing the stoma may cause injury. Since the stoma should be highly vascular, slight bleeding might be N seen when it is cleaned.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

11. A patient with a urostomy requires a sterile urine specimen for culture and sensitivity. Which

action will the nurse take to obtain the sterile specimen? a. Have the patient void into a sterile cup after being cleaned. b. Collect the specimen from a new urine pouch. c. Insert a sterile catheter into the urinary stoma. d. Let urine drip from the stoma into a sterile specimen cup.

ANS: C

The nurse must catheterize the urostomy to obtain a sterile urine sample. A patient with a urinary diversion cannot void. A new urine pouch is clean, not sterile. Letting urine drip from the stoma into a sterile specimen cup does not yield a sterile specimen. The patient’s skin is not sterile, and the urine could irritate the skin.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

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1. The nurse is educating a patient about care of a stoma after discharge. Which of the following

statements indicate a good level of understanding? (Select all that apply.) a. “Applying gentle pressure with my hand over the skin barrier helps it stick.” b. “I should also use a skin prep such as a paste or adhesive first.” c. “I can get a pouch that absorbs gas odors.” d. “I can access community resources if supplies are too expensive.” e. “I need to change the pouch every 3–7 days.”

ANS: A, C, D, E

The patient will apply a pouch to clean, dry skin without other skin preparations, paste, or adhesives unless there is a specific problem keeping a pouch intact. The adhesives on the skin barriers are pressure and heat sensitive; thus have the patient apply gentle pressure with the hand over the skin barrier for several minutes to facilitate the adherence of the barrier to the skin. Some pouches have effective gas filters that absorb odors and allow for flatus to escape slowly from the pouch through a charcoal filter. Pouches should be changed every 3–7 days.

There are community resources the patient can explore if supplies are too expensive.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

2. The home care nurse is visiting a patient who was recently discharged with an ostomy. Which

of the following statements require the nurse to provide some additional teaching? (Select all that apply.) a. “I have been buying sterile gloves to use when changing my pouch.” b. “I have been covering the pouch with saran wrap when I shower.” c. “I empty the pouch directly into the toilet.” d. “I always inspect my skin whenever I change the skin barrier.”

N e. “I keep the new pouches in the bathroom linen closet.”

ANS: A, B

The home care nurses should evaluate the patient’s home toileting facilities and ability to position self to empty the pouch directly into the toilet. The patient may shower without covering the pouch. Ostomy care does not require any sterile supplies; however, family caregivers should wear gloves to avoid direct contact with stool. Patients should avoid placing pouches in extremely hot or cold locations because temperature affects barrier and adhesive materials. It is important for the patient to assess the skin under the barrier.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

MATCHING

Match the terms with the descriptions below. a. A stoma that appears dry, black or purple, and does not bleed when washed gently. b. These keep the ureters from becoming stenosed where they are attached to the ileal conduit. c. A segment of the small-intestine that is brought up through the abdominal wall. d. A stoma that is below the skin level on the abdominal wall. e. A segment of the large intestine that is brought up through the abdominal wall.

1. Stents

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2.

3.

4.

5.

Colostomy Ileostomy Retracted stoma Necrotic stoma

1. ANS: B DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment MSC: Stents keep the ureters from becoming stenosed where they are attached to the ileal conduit in a urinary diversion.

2. ANS: E DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment MSC: A colostomy is created by bringing a section of the large intestine through the abdominal wall.

3. ANS: C DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment MSC: An ileostomy is created by bringing a section of the small-intestine through the abdominal wall.

4. ANS: D DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment MSC: A retracted stoma is situated below the level of the abdominal wall.

5. ANS: A DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment MSC: A necrotic stoma has lost blood supply and appears black or purple, is dry instead of moist, and does not bleed slightly when washed gently.

N

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Chapter 22: Preparation for Safe Medication Administration Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. A patient received a drug that caused an unpredictable and unusual effect. Which term does

the nurse use to describe this effect? a. Toxic b. Allergic c. Therapeutic d. Idiosyncratic ANS: D

An unpredictable overreaction or underreaction to a medication is an idiosyncratic reaction.

Toxic medication effects occur with prolonged therapy, excessive dosing, or impaired metabolism or systemic accumulation in the patient. They are adverse effects with the potential to cause patient injury and death. Allergic reactions are unpredictable, unless the patient has a history of a medication allergy and result from an immunological patient response to the medication involving antibody formation. A therapeutic response is a desirable or intended patient response.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

2. The nurse administers a combination medication for a desirable patient response derived from

the combination of agents. Which type of medication effect does the nurse anticipate?

N a. Tolerance b. Synergistic c. Dependence d. Subtherapeutic ANS: B

The nurse anticipates a synergistic effect because the two different medications work better in combination than either agent works alone. Drug tolerance means that a larger dose of medication is needed to produce the same therapeutic effect over time. Drug dependence is psychological or physical. The patient takes the medication for an effect other than the therapeutic effect, resulting in psychological dependence. Physical dependence involves physiological adaptation to the medication that results in severe adverse effects if withdrawn abruptly. A subtherapeutic effect is less than therapeutic; the therapy treats the disorder inadequately.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

3. A patient looks at the medication in the cup and tells the nurse that one of the tablets is

unfamiliar. Which action would the nurse take next? a. Tell the patient that the medications are correct. b. Recheck the medication and the medication order. c. Call the pharmacy to bring the correct medication. d. Remove the medication and document the incident.

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ANS: B

A safe nursing intervention is to recheck both the medication and the order because the drug in question may be a new prescription, a new strength of the same medication, or a different generic form of the same medication. Regardless of the cause, the problem needs clarification.

Telling the patient that the medications are correct is premature and misleading, denies the patient the right to information, and possibly leads to an error. The nurse does not know if the medications are correct yet. After checking the medications against the medication administration record (MAR) and the original prescriptions, he or she can call the pharmacy for help. The nurse removes the entire cup of medications and rechecks all of them.

Documenting the incident is premature because the nurse needs to complete the investigation first.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

4. The nurse admits a patient who has an acute kidney infection but refuses to take any

medication. Which is the best initial nursing intervention to implement the therapeutic regimen? a. Notify the health care provider of the situation. b. Inform the patient about the risk of renal failure. c. Talk with the patient about taking the antibiotics. d. Disguise the medications so the patient takes them.

ANS: C

The basis of the patient’s refusal is unknown; discussing the situation with the patient provides the nurse with an opportunity to clarify misunderstandings, provide information, and gather valuable patient data to N plan nursing care. Notifying the health care provider is premature. The nurse takes care of the situation initially by educating the patient.

Emphasizing the risk of renal failure may be interpreted as an indirect threat by the patient.

The patient has the right to refuse taking the medication, and disguising the medication is neither indicated nor appropriate.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

5. The nurse discharges a patient from the ambulatory surgical center with a prescription for an

opioid analgesic. The patient can take the medication every 4–6 hours as needed for pain.

What does the nurse include in patient teaching about the prescription before discharging the patient? a. Take the medication for severe pain. b. Use the medication to facilitate healing. c. Wait 4–6 hours before taking the next dose. d. Take every 4–6 hours until the bottle is empty.

ANS: C

This is a prn order and has a minimum time interval of every 4 hours. The most important instruction is not to take the medicine any more frequent than that. The patient should not wait until pain is severe before using it. Opioids do not facilitate healing. The patient does not need to take the entire bottle of medication.

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DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning 6. The nurse administers a patient’s medication; within 30 minutes the patient has bilateral

wheezing and large red blotches on the face and is anxious and dizzy. What action by the nurse is best? a. Encourage the patient to drink plenty of fluids. b. Direct a colleague to contact the provider right away. c. Retrieve an antihistamine from the medication supply. d. Document potential patient allergy to medication.

ANS: B

The patient has clinical indicators of a moderate-to-severe hypersensitivity reaction, most likely related to the medication. The wheezing increases the risk of impairing the patient’s airway, and the blood pressure can be low already, as evidenced by patient dizziness. The nurse should stay with the patient and wait for emergency equipment, supplies, and personnel to assist. In the meantime, he or she should plan to support the patient’s airway, breathing, and circulation. Hydrating the patient will not help. An antihistamine potentially helps to reverse some of the allergic effects; however, the nurse should not leave the patient. The nurse documents the events after the patient is stable.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

7. A patient has been taking high doses of an opioid medication for severe pain. Which

assessment data indicate the most toxic effect of this medication? a. Nausea and vomiting N b. Respiratory depression c. Erythema and skin rash d. Bloating and constipation ANS: B

Respiratory depression is an undesirable and potentially fatal effect of medication that occurs with prolonged therapy, excessive dosing, impaired metabolism, or systemic accumulation in the patient. Respiratory depression can quickly deteriorate into respiratory failure, tissue damage, and death without airway and respiratory support. Nausea and vomiting can be clinical indicators of a toxic effect; however, they lack the same fatal potential as respiratory depression. The reddened skin rash is consistent with a hypersensitivity reaction. Bloating and constipation are most likely adverse effects of medication with a very low risk of fatality.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

8. The nurse prepares to administer a parenteral medication. Which route of administration does

the nurse use for the medication? a. Oral b. Topical c. Sublingual d. Intramuscular ANS: D

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Parenteral medications are always injected into a vessel or tissue; thus, intramuscular administration is suitable. The other routes are suitable for nonparenteral medications.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

9. An older adult who lives alone takes three different white, flat, unscored medications every

day. He has trouble remembering if he has taken the correct pill at the correct time. What strategy would best help this patient maintain independence and safety in taking his medications? a. Place a piece of different colored tape on each pill bottle. b. Take the medications out of the bottles and place them in a pill holder. c. Have a neighbor give the patient his pills once each day. d. Ask the patient how he wants to identify the medications.

ANS: A

Color coding the pill bottles has the most likelihood of success. It’s essential to keep the medications in their original containers for safety. A system could be set up with the patient to make clear which medications he needs to take at what time. Placing the similar-looking pills in to a pill container could cause more confusion for the patient. Their identities need to be maintained for correct scheduling. Having someone administer the medications reduces the patient’s independence and could become burdensome. Since the patient has not been able to manage his medications to date, an open-ended question about how he wants to identify his medications may be confusing. Suggesting a plan allows the patient to recognize a solution and agree to see if it works.

DIF: Cognitive Level: Applying N TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

10. Which schedule would the nurse select to achieve a therapeutic level if the medication is

prescribed for administration 4 times a day? a. 8 AM, 10 AM, 2 PM, and 8 PM b. 10 AM, 2 PM, 6 PM, and 8 PM c. 10 AM, noon, 4 PM, and 6 PM d. 8 AM, 2 PM, 8 PM, and 2 AM ANS: D

The nurse administers medications 4 times a day by evenly spacing out the medications over a 24-hour period so a steady, therapeutic blood level can be achieved.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

11. The nurse is reviewing concepts of safe medication preparation and administration with a

group of nursing students. Which statement does the nurse include during the review? a. Use sterile technique for most nonparenteral medications. b. Administer the medication prepared by the medication nurse. c. Leave the medication on the meal tray if the patient requests it. d. Verify medication dosage is within a safe dosage range.

ANS: D

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The students should be reminded to verify medication calculations to ensure that the math is correct. Calculate medication doses accurately and use appropriate measuring devices. Verify that the dose prescribed is within a safe dosage range and is appropriate for the patient. Clean technique is used for nonparenteral medication. Nurses should avoid administering medication prepared by another nurse. They should also avoid leaving medication at the bedside or on the meal tray because the nurse will not witness the medication administration and cannot document the time that the medication was taken. In addition, the patient can spill the medication, dispose of it, or leave it on the tray.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

12. The nurse is preparing to administer a controlled substance. Which action must the nurse take

first if controlled medication is discarded? a. Save the unused portion for the next dose. b. Document the amount wasted. c. Have a nurse witness the wasting of the drug. d. Administer the unused portion on another patient.

ANS: C

The nurse discards the unused portion of the patient’s controlled substance medication and has another nurse witness the event; then both nurses document the transaction. The nurse follows agency policy about discarding controlled substances. Documenting the amount wasted occurs after the waste has been discarded and witnessed by another nurse. Unused portions of the patient’s medication may not be administered to another patient, even if they are kept sterile or saved for a later dose.

N

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

13. The nurse is having difficulty reading a medication order. Which is the best action for the

nurse to take to prevent a medication error? a. Clarify the order with the health care provider who wrote it. b. Talk with the pharmacist who knows what is usually ordered. c. Ask a nurse who knows the health care provider to read it. d. Have a nurse interpret the written medication order.

ANS: A

To prevent patient injury and decrease nursing liability, the nurse clarifies illegible prescriptions and handwriting with the health care provider who wrote it. Asking the pharmacist about what is usually ordered does not reflect what may be in the current order.

Asking another nurse to try to read the order doesn’t eliminate the chance of error.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

14. A prescription reads, “Aspirin 325 mg 2 tablets orally for pain.” What action does the nurse

take when the patient has pain? a. Add “by mouth” to the prescription for clarification. b. Clarify the administration frequency and if it is a prn or standing order. c. Clarify the dose per tablet with the pharmacist.

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d. Administer the dose whenever the patient requests it.

ANS: B

A complete prescription includes the drug name, dose, route, the frequency, and the time interval, which can be either a standing time (every 4 hours) or a prn time frame (every 4 hours, prn). The nurse speaks with the provider to clarify the frequency of administering aspirin. The nurse does not alter the prescription unless instructed by the provider, and the order already states orally. The prescriber is the person with whom the nurse must clarify the order. Aspirin is not administered whenever the patient requests it. It has a frequency of administration.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

15. The nurse administers oral medications according to the unit-dose system. Which technique

does the nurse include? a. Prepare the medications for several patients at the same time. b. Remove the medication from the package and take it to the patient’s room. c. Compare the packaged medication with the health care provider’s prescription. d. Take the prescribed dose into the patient’s room in the original packaging.

ANS: D

The nurse brings the medication to the patient in the original packaging, provides explanations and information to the patient, and opens the package at the bedside. This helps maintain safety, provides reassurance to the patient that the correct medication is being administered, and limits waste. This policy lowers the risk of contaminating the medication on the way to the patient’s room, provides a second opportunity to read the label on the medication, and facilitates patient teaching. TheNnurse prepares medication for one patient at a time to avoid confusion. Medication remains in the original packaging until the nurse is at the bedside. The medication administration record is compared to the provider’s original prescription.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. The nurse is working with a group of students and asks them to list the common causes of

medication errors. Which of the following are among the common causes of medication errors? (Select all that apply.) a. Distractions b. Illegible handwriting c. Drug product nomenclature d. Labeling errors e. Medication unavailable f. Damaged labels ANS: A, B, C, D, E

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Medication safety is a priority goal for safe nursing practice. It begins by having a thorough understanding of the medications being administer and whether patients have any drug allergies. Then it is important to follow safe preparation and administration standards, which are part of the six rights of medication administration. There are many causes of medication errors, including distractions, illegible handwriting, drug product nomenclature, labeling errors, medication unavailable, and excessive workload. Damaged labels do occur but are not one of the more common causes of medication errors.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. The nurse is explaining pharmacokinetic effects to a new nurse working on the unit. Which of

the following statements alerts the nurse that a good level of understanding has been achieved? (Select all that apply.) a. “The trough is the lowest level of drug in the blood.” b. “The peak is the highest level of drug in the blood.” c. “With IV administration, the serum level falls more slowly.” d. “Toxic concentration is when toxic effects occur.” e. “Peak levels always occur in 30 minutes.”

ANS: A, B, D

Pharmacokinetics affects how much of a drug dose reaches the site of action. The goal in administering a medication is to achieve a constant blood level within a safe therapeutic range. The toxic concentration is the level at which toxic effects occur. When a medication is administered repeatedly, its serum level fluctuates between doses. The highest level is called the peak concentration and the lowest level is the trough concentration. After peaking, the serum concentration falls progressively.

With IV infusions, the peak concentration occurs N quickly, but the serum level also begins to fall immediately. Each medication reaches its peak at different times.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

3. The nurse is describing the role of the pharmacist in medication administration. Which of the

following are correct? (Select all that apply.) a. Assess the medication plan. b. Review the orders for accuracy and validity. c. Prepare the correct medication. d. Deliver them to the nursing unit. e. Adjust incorrect medication orders.

ANS: A, B, C, D

Pharmacists assess the medication plan and ensure that orders are valid. The pharmacist is then responsible for preparing the correct medications and delivering them to the nursing unit where they are stocked in a medication administration station. If there are errors, the pharmacist consults with the health care provider who wrote the order to have those errors corrected.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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COMPLETION 1. The provider prescribes aluminum hydroxide gel 2 ounces. The nurse has aluminum

hydroxide in 30-mL containers in the patient’s medication drawer. How many containers does the nurse administer to the patient? _______ containers.

ANS:

2 two The nurse administers two containers at 30 mL per container because 1 ounce = 30 mL. The prescription calls for aluminum hydroxide 60 mL; thus, to administer 60 mL, the nurse needs two containers.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. The patient is to receive 750 mg of a medication. The pharmacy sent 500-mg scored tablets.

How many tablets does the nurse administer? The nurse administers _____ tablets.

ANS:

1 1/2 The nurse administers 1 1/2 tablets = 500 mg + 250 mg = 750 mg. The nurse calculates the dosage with a proportion equation.

N Cross-multiply and divide: 1  750 = 500x Solve for x: 750 ÷ 500 = 1 1/2 tablets DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

3. The dose ordered for the patient is 37.5 mg intramuscularly (IM). How many milliliters of the

medication does the nurse administer from a 100-mg/2-mL syringe? Administer _____ mL. ANS:

0.75 The nurse administers 0.75 mL of a 2-mL syringe containing 100 mg and uses a proportion equation to calculate the dosage.

Cross-multiply and divide: 37.5  2 = 100x Solve for x: 75 ÷ 100 = 0.75 mL DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

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4. The nurse needs to administer 1000 mcg of a medication and has 1-mg tablets. How many

tablets does the nurse administer? Administer _____ tablet.

ANS:

1 one The nurse administers 1 tablet, because 1 mg = 1000 mcg.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

5. The nurse needs to administer 2 tsp of a medication to the patient. How much of the

medication does the nurse administer? _____ mL. ANS:

10 1 tsp = 5 mL; 2  5 mL = 10 mL. DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

6. The nurse needs to administer a medication to a toddler who weighs 20 kg. The dosage is 50

mg/kg/day in two divided doses, and the medication is available as an elixir at 25 mg/mL. How many milliliters of medication will the nurse administer at each scheduled dose? The nurse administers _____ mL each dose.

N

ANS:

20 First calculate the daily dose in milligrams per day.

Then calculate how many milliliters of elixir to administer daily.

Finally calculate the dosage at each scheduled time with two doses/day.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

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Chapter 23: Nonparenteral Medications Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The health care provider prescribes a sublingual medication, and the pharmacy sends an oral

form. Which action does the nurse take? a. Administer the identical drug orally. b. Call the pharmacy for the correct formulation. c. Withhold the drug and notify the provider. d. Calculate the oral equivalent dose for the patient.

ANS: B

The nurse can administer the sublingual medication in sublingual form only; changing the route of administration is practicing medicine and is outside the scope of practice for the nurse. The nurse cannot administer the oral medication, even if it is the identical drug, because it is the wrong route and violates a patient medication right. Withholding the medication until the provider is notified is risky and unnecessary because the nurse can ask the pharmacy to send the correct form of the medication. If the pharmacy does not carry the prescribed form, the nurse should contact the provider. Many medications come in several forms; thus, determining an equivalent dose of a medication in another form is possible; however, the nurse needs a prescription for both forms of the medication to administer the oral form.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation N

OBJ: NCLEX: Physiological Integrity

2. An alert and oriented patient is to receive oral medication. Which does the nurse implement to

administer the prescribed medication? a. Evaluates the patient’s ability to take the medications unassisted. b. Leaves the medications on the breakfast tray for the patient to take later. c. Asks the patient if holding the medications in the hand is preferred. d. Holds the medicine cup to the patient’s lips and tips it into the mouth.

ANS: C

Patients can participate in medication administration by holding the medication in the cup or hand before placing it in the mouth. The nurse already knows that this patient is alert. If the provider allows the patient to self-medicate in the hospital, the nurse supervises the activity and ensures patient self-administration of the medications on time. The nurse never leaves medication on the breakfast tray for many reasons. He or she needs to verify that the patient has taken the medication so that correct documentation may occur. Holding the cup for the patient is unnecessary and potentially insulting to the patient.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

3. The nurse approaches a group of patients, one of whom is to receive a dose of medication.

Which is the best method for the nurse to identify the patient needing the medication? a. Question the entire group by calling for the specific patient. b. Request that the other patients identify the patient.

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c. Ask the patients who is scheduled to receive medications now. d. Follow agency policy and professional standards to ensure accurate identification.

ANS: D

To identify the patient needing the medication, the nurse checks the patient identification bracelet and asks the patient to state his or her name. The nurse then compares the spelling of the name and the medical record number on the bracelet to the MAR. The nurse does not rely on other individuals to identify the patient for the medication administration to avoid the risk of misidentification. The use of at least two identifiers is the only approved method of identifying a correct patient.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

4. The nurse needs to document a medication that has just been administered. Which technique

does the nurse use to document medication administration when in a hurry? a. Document the medication immediately before administration. b. Record the time administered and the nurse’s name immediately after administration. c. Record medication administration time, route, and dose at the end of the shift. d. Delegate recording administration time and the nurse’s name in the record.

ANS: B

The nurse records his or her name and administration time immediately after medication administration to maintain an up-to-date, accurate patient medical record. Documentation is not done before administration because the activity has not yet happened. It is risky to document at the end of the shift because the chance of a documentation omission or error N that passes. Correct documentation is one of the six rights increases with the amount of time of medication administration. Documentation of medication administration may never be delegated. Being hurried is not a reason to skip the safety checks and proper documentation.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

5. The nurse instructs the patient about applying a transdermal patch. Which does the nurse

include in patient teaching? a. Choose a site with moderate exposure to the sun. b. Remove the old patch before applying a new patch. c. Put the new patch at the same site to promote even absorption. d. Apply a warm compress to the site before application.

ANS: B

To prevent overdoses and tolerance to patches, the nurse instructs the patient to remove the old patch, cleanse the site, and apply the next patch to a different place. Sun exposure can promote medication degradation and increase the absorption rate. The nurse avoids instructing the patient to apply a warm compress to prevent rapid medication absorption that potentially can lead to overdose.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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6. The nurse prepares to administer artificial tears to the patient’s eyes twice daily. Which will

the nurse implement when administering the patient’s eyedrops as the priority? a. Dispense the eyedrops to the inner corner of each eye. b. Wash the eyes with a warm, wet washcloth. c. Check the patient identifiers before administration. d. Determine the patient’s history of taking this medication.

ANS: C

The nurse verifies patient identifiers before administering medication, regardless of the route.

He or she avoids dispensing eyedrops to the inner corner of the eye to avoid irritating the cornea. Eyedrops are instilled into the conjunctival sac. The nurse would wash the patient’s eyes if they were matted or were draining, but that would not be the priority over proper patient identification. The nurse can assess for the patient’s history of using this medication, but that also does not take priority over identifying the patient.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

7. The patient reports blurred vision after the instillation of eyedrops. What action does the nurse

implement first? a. Withhold the patient’s ophthalmic drops. b. Warm the eyedrops for subsequent doses. c. Notify the ophthalmologist of the findings. d. Ask the patient questions to clarify what is meant by “blurred.”

ANS: D

The nurse questions the patient for additional information before determining the scope of his N vision can be either an adverse effect of the medication or or her complaint because blurred expected because of the type of medication being instilled. The nurse gathers additional information before deciding to withhold the eyedrops. The nurse avoids warming eyedrops because it can increase the absorption rate and patient discomfort. Notifying the provider is not indicated.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

8. A patient’s family member is afraid of hurting the patient when giving eardrops per discharge

instructions. Which action will the nurse take first? a. Observe caregiver administration of eardrops. b. Provide a demonstration of eardrop instillation. c. State that eardrop instillations do not injure ears. d. Agree that instillation of eardrops is challenging.

ANS: B

The nurse needs to demonstrate the procedure with a clear explanation based on what the family member is stating. An opportunity for a return demonstration must be provided, with the nurse supporting the family member and coaching as needed. The risk for patient injury is low for eardrops, but it exists. Instilling eardrops is a simple skill; however, when the caregiver expresses concern about medication administration, the duty the nurse owes to the patient is to provide encouragement and teaching to prevent patient injury. Stating the eardrop administration is challenging does not provide any useful information to the family member.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

9. The nurse is preparing to administer eardrops to a 5-year-old child. Nursing care is

appropriate if which technique is used by the nurse? a. Warm the eardrops in a microwave oven on low. b. Pull the auricle upward and outward. c. Apply eardrops to a cotton ball and insert them in the affected ear. d. Instruct the child to lie with the affected ear on a warm compress.

ANS: B

The nurse pulls the patient’s pinna upward and outward to provide access to deeper ear structures for a patient over the age of 3 years. Eardrops are never warmed in a microwave oven because of the risk of overheating the medication; microwave heating potentially leads to patient burns or decreased effectiveness of the eardrops. If cotton balls are used with eardrops, they are nonmedicated and inserted into the ear canal gently for a brief period of time after the drops have been instilled. The eardrops would drain out of the ear quickly if the patient lies on a warm compress with the affected ear down.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

10. A patient with chronic obstructive pulmonary disease uses a metered-dose inhaler (MDI).

Which information does the nurse provide to ensure the patient receives the maximum benefit of the medication? a. Administer two puffs of medication in rapid succession.

N around the mouthpiece of the inhaler. b. Maintain a firm seal with lips c. Dispense the glucocorticoids 30 seconds after a bronchodilator. d. Instruct the patient to press the MDI after breathing in and out deeply.

ANS: B

The nurse instructs the patient to maintain a firm seal around the mouthpiece of the MDI to facilitate dispensing medication into the lungs so the patient benefits from a full dose of the medication undiluted by room air. The nurse also instructs the patient to take a bronchodilator before any subsequent medications administered by an MDI such as glucocorticoids. An MDI delivers medication by inhalation and does not lend itself to delivering two puffs in rapid succession because a short wait is usually required for the medication to reach deeper parts of the lung. Not only is it difficult to activate the MDI quickly, but the patient may not have the ventilatory capacity to quickly inhale two puffs. When administering glucocorticoids after a bronchodilator, the nurse waits 5 minutes to give the bronchodilator time to work and then administers the second agent. To use an MDI, the nurse instructs the patient to exhale and then inhale slowly and deeply to drive the inhalation medication into the lungs.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

11. The nurse needs to administer a rectal suppository to a patient to treat constipation. Which

action may the nurse delegate to the nursing assistive personnel (NAP)? a. Inserting the suppository into patient’s rectum b. Notifying the patient’s health care provider of the suppository results

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c. Documenting the administration of a suppository after insertion d. Informing the nurse of the patient’s bowel movement ANS: D

The nurse instructs the NAP to report the results of the suppository, which in this case would be the expulsion of feces. Administration of medication is the nurse’s responsibility. The health care provider will learn the results of the suppository by reading the nurse’s documentation or when making rounds unless other instructions were given. Documentation of the medication administration is the nurse’s responsibility.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

12. The nurse prepares to administer acetaminophen 650 mg rectally to an adult patient. Which

does the nurse implement to administer the suppository properly? a. Assists the patient to right lateral position and flexes the left leg. b. Performs a preadministration digital rectal examination. c. Washes hands and applies sterile gloves before the procedure. d. Inserts the suppository 10 cm (4 inches) into the patient’s rectum.

ANS: D

The nurse inserts the suppository about 10 cm (4 inches) into the adult patient’s rectum to clear the rectal sphincters because the sphincters help to keep the medication in the patient’s rectum. The nurse assists the patient into the left lateral position to take advantage of the normal anatomy of the descending colon. This curvature in the colon helps to sequester the medication, contain it in the patient, and increase its effectiveness. The nurse avoids performing a digital examination before inserting a suppository because it is not indicated.

N Washing hands is always a reasonable nursing action, but sterile gloves are not indicated.

Clean gloves are sufficient for this procedure because the nurse wants to avoid contamination from the rectum.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

13. The nurse administers a vaginal suppository. What information will the nurse include in

patient teaching about postadministration care? a. Use a tampon to hold the suppository in place. b. Place a perineal pad in her underpants when getting up. c. Expect a moderate localized burning and itching. d. Remain in the semi-Fowler’s position for 2 hours.

ANS: B

The nurse instructs the patient to place a perineal pad in her underpants because there will be a small amount of vaginal drainage after insertion of a suppository as the suppository melts. The nurse instructs the patient to avoid tampon use during the use of vaginal suppositories because the tampon absorbs the liquid, which decreases the effectiveness of the suppository. Burning and itching after administration of a vaginal suppository are unexpected. The patient should remain in supine position – not semi-Fowler’s – because in this position, gravity has no effect on the absorption rate.

DIF: Cognitive Level: Applying

OBJ: NCLEX: Physiological Integrity

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TOP: Nursing Process: Implementation 14. The nurse is preparing a liquid medication. Which technique does the nurse use to ensure an

accurate dose? a. Open the unit-dose package and pour contents into a medicine cup. b. Use a measuring cup with both metric and dram markings for accuracy. c. Request pharmacy dispense small doses in pre-filled, one time use syringes. d. Perform hand hygiene and don gloves, if needed, and identify the patient.

ANS: C

Best practice requires the pharmacy to dispense doses of oral medications in pre-filled syringes if the drug is not available in correct dose unit-dose containers. The nurse does not pour liquid medication from a unit-dose container into a medicine cup. Medicine cups should no longer contain apothecary markings, such as fluid drams. Hand hygiene, donning gloves, and identifying the patient are all required actions but do not pertain to dispensing the most accurate dose of liquid medications.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

15. The nurse prepares medication for a patient 1 hour after admission. What information about

the patient is the nurse’s priority assessment before the initial administration of medication? a. The diet history b. Any drug tolerance c. Any allergy history d. The surgical history ANS: C

N

To prevent patient injury, the nurse interviews the patient about allergies, including food and medication, before administering any medication. If the patient admits to drug or food allergies, the nurse probes him or her for additional information about the allergy to determine the nature of the reaction. Diet history is a reasonable assessment because malnutrition increases the risk of patient injury from medications that are protein bound and can increase the risk of complications from nutritionally related problems but it is not the priority. Drug tolerance is a reasonable assessment if the patient is receiving pain medication or another agent to which he or she potentially develops tolerance but is also not the priority. Surgical history is the lowest-priority assessment for this patient; however, the nurse gathers information about the patient’s surgical history for the admission assessment to complete the patient profile.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

16. The nurse is helping a dyspneic older adult with severe arthritis to use a nebulizer for

respiratory medications. Nursing care would be correct if the nurse takes which action during the medication administration? a. Instructs the patient to hold the mouthpiece with the hands. b. Uses a mask to deliver the ordered medication. c. Places the patient in a supine position for the treatment. d. Has the patient drink some fluid before the treatment.

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ANS: B

Using a face mask does not require the patient to remember to hold the mouthpiece correctly and would be appropriate for this patient with arthritis. The patient may be unable to hold the mouthpiece correctly because of the weakness and arthritis of the hands. Patients receiving respiratory treatments should be upright when possible. Patients who are dyspneic need to breathe rather than take in fluids, which alters their breathing pattern. The dyspnea can also cause aspirations if fluids are taken.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

17. The nurse needs to administer enteric-coated aspirin to the patient. The pharmacy does not

carry enteric-coated aspirin. Which is the best nursing approach for this situation? a. Pour tablets from stock without touching them. b. Withhold the medication and notify the health care provider. c. Have another nurse witness taking two aspirin tablets from the bottle. d. Inform the patient that family needs to bring this medication in.

ANS: B

The best choice for the nurse is to withhold the medication and notify the provider that enteric-coated aspirin is not available. The purpose of administering enteric-coated aspirin is to decrease gastric upset and complications; thus uncoated aspirin is an unsuitable substitute.

The nurse needs another order to administer nonenteric-coated aspirin. The nurse pours tablets from any stock container without touching them to maintain infection control. Aspirin is not the same medication as enteric-coated aspirin and thus cannot be administered to the patient; therefore, the nurse would not pour these tablets from stock. Having another nurse witness the procedure does not solve the problem. The patient’s family should not have to bring the N medication in unless it is a very rare medication.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

18. The patient is to receive a buccal medication. Which information does the nurse include in

patient teaching? a. Hold the medication under the tongue. b. Chew the medication before swallowing. c. Swallow the medication after 30 seconds. d. Hold the medication between the cheek and gums until it dissolves.

ANS: D

For proper administration of buccal medication, the nurse instructs the patient to hold the medication between the cheek and gums until it has dissolved. Medication administered under the tongue is delivered sublingually. The nurse instructs the patient to chew a chewable tablet.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

19. The nurse prepares to administer cyclosporine eyedrops to a patient with dry eyes. Which of

the following actions does the nurse implement before instilling the eyedrops? a. Apply mild pressure on the entire eye. b. Apply the eye ointment along inner edge of lower eyelid.

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c. Remove any periorbital crusting with a warm face cloth. d. Wipe away any crusting from the outer to the inner canthus.

ANS: C

Before instilling any eyedrops, the nurse cleanses the periorbital area with a warm face cloth if needed to remove the debris gently. The nurse can apply pressure to the inner corner of the eye after instillation to decrease systemic absorption of the medication but should not apply pressure over the entire eye. Eyedrops, not ointment, have been ordered. The nurse wipes the eyes from inner to outer canthus.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

20. The nurse teaches the patient how to administer eye ointment. Instruction by the nurse has

been correct if the patient demonstrates which technique? a. Moistens the finger with sterile saline. b. Places a thin ribbon of ointment along the conjunctiva. c. Rubs the medication briskly after application. d. Looks downward before application of the ointment.

ANS: B

A thin ribbon of ointment is placed evenly along the inner edge of the lower eyelid on the conjunctiva from the inner to the outer canthus. The finger can be moistened if applying an intraocular disk, not eye ointment. The patient can rub the lid lightly after the medication is applied as long as rubbing is not contraindicated. The patient needs to look up to move the sensitive cornea away from the conjunctival sac to reduce the blink reflex during application of the ointment.

N DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

21. The patient has a scored white tablet, a capsule, buccal medication, and an enteric-coated

tablet. Which medication will the nurse administer last? a. The scored white tablet b. The capsule c. The buccal medication d. The enteric-coated tablet ANS: C

The buccal medication must be able to dissolve between the cheek and the gums to provide the correct absorption. Any liquid must be postponed until the buccal medication has dissolved. For therapeutic effect, it makes no difference in which order the other medications are given. They will be absorbed in the areas of the body where expected.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

22. The nurse plans care for the patient who has newly diagnosed asthma and receives albuterol

nebulizer therapy. The patient’s respiratory rate is 34 breaths per minute, and breath sounds reveal wheezing throughout both lung fields. Which outcome is the nurse’s priority for this patient within 24 hours? a. The patient self-administers the medication using the nebulizer.

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b. The patient correctly describes the use of a small-volume nebulizer. c. The patient recites side effects and clinical indicators to report. d. The patient’s respiratory rate falls to an acceptable level.

ANS: D

Airway and breathing are usually at the top of patient priorities; thus, the nurse works to improve the patient’s respiratory status first. Expected outcomes include improved oxygen saturation and breathing patterns. Self-administration is contraindicated for the patient during an acute episode. Describing the use of a nebulizer and verbalizing information are indicated before discharge and not during an acute episode.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

23. The nurse is preparing to administer eardrops to a 28-month-old child. Nursing care is

appropriate if which technique is used by the nurse? a. Warm the eardrops in a sink of warm water. b. Pull the pinna down and straight back. c. Place the child in a restraint to avoid injury. d. Administer the drops as soon as possible after removing them from the refrigerator.

ANS: B

The nurse pulls the patient’s pinna down and straight back to facilitate the medication reaching the inner ear. Eardrops should be administered at room temperature, not warmed up or cold from the refrigerator, because cold eardrops can cause vertigo. A restraint might or might not be required, but that is not an expected part of the procedure.

N DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

24. A patient is to receive three medications via an enteral feeding tube. What action by the nurse

best contributes to maintaining the patency of the tube? a. Pouring the medications slowly into the tube b. Checking the gastric residual volume before feeding c. Elevating the head of the bed at least 45 degrees d. Flushing the tube between medications and after the last one ANS: D

Flushing the tube with water helps it to remain patent by rinsing away any of the residual medication left in it. Pouring the medications into the tube slowly does nothing for patency.

Checking the gastric residual volume identifies only how the stomach is emptying. Elevating the head of the bed helps to prevent aspiration, not tube clogging.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

25. The nurse is caring for a patient with an enteral feeding tube. During assessment, the nurse

finds that the patient’s oxygen saturation level has dropped significantly and the respiratory rate and effort have increased. What action does the nurse take first? a. Stop any infusion through the feeding tube. b. Assess all of the patient’s vital signs.

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c. Notify the health care provider. d. Reposition the patient.

ANS: A

The patient is exhibiting signs of aspiration, and feeding and medications through the tube must be stopped first. This is done quickly; if not done, none of the other actions will not be effective. It’s essential that the nurse goes to the source of the problem. The vital signs can be checked after the tube feeding has been stopped and the patient repositioned for better airway clearance. The health care provider can be notified after the nurse has intervened by turning off the tube feeding, repositioning the patient for optimal airway clearance, and taking vital signs.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

26. The nurse is administering medications to a patient who had a stroke and has some difficulty

swallowing. What assessment by the nurse would indicate that goals for a priority nursing diagnosis have been met? a. The patient’s lungs are clear 1 hour after administration. b. The nurse assesses the medication’s therapeutic effect. c. The patient is able to swallow medications one at a time. d. The nurse does not note any adverse reactions.

ANS: A

A patient who has difficulty swallowing is at high risk for aspiration. Assessing clear lungs after administering medications would demonstrate that the patient did not aspirate. Assessing the therapeutic effect of the medication and not noting any adverse reactions are also good outcomes, but not the priority. N Being able to take medications 1 at a time is not related to aspiration.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. The nurse is preparing medications for a patient who cannot swallow pills. Which of the

following medications cannot be crushed? (Select all that apply.) a. Capsule b. Scored tablet c. Enteric-coated tablet d. Buccal tablet e. Unscored tablet ANS: A, C, D

Capsules and enteric-coated tablets are not crushed because the coating of these drugs protects the stomach from irritation or protects the drug from destruction by stomach acids. The buccal tablet needs to dissolve or remain in the mouth for proper absorption. The nurse can crush the scored or unscored tablet because the medication absorption will not be altered.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

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2. The faculty member instructs students to be cautious when teaching patients how to use an

inhaler because there are many problems associated with this method of administration.

Which of the following are potential problems when using inhalers? (Select all that apply.) a. Incorrect activation b. Not shaking the cannister c. Not keeping the cannister cool d. Not taking medication as directed e. Failing to clean the mouthpiece ANS: A, B, E

Potential problems when using an inhaler include incorrect activation, not shaking the cannister first, and failing to clean the mouthpiece which can become clogged. Inhalers are kept at room temperature. Not taking medication as directed demonstrates non-adherence and the nurse needs to investigate the cause.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

3. A patient’s feeding tube has become blocked. What actions by the nursing student would

require the faculty member to intervene? (Select all that apply.) a. Uses tepid water and large bore syringe to flush the tube. b. Flushes tube with water before and after each medication. c. Follows manufacturer guidelines before using pancrelipase. d. Attempts to irrigate the tube using room temperature cola. e. Checks agency policy regarding use of a declogging stylus.

ANS: B, D

N

Correct options for attempting to unblock a feeding tube include attempting to flush with tepid water and large bore syringe, following manufacturer’s instructions if pancrelipase is used, and using a declogging stylus if agency policy allows. The faculty would intervene if the student attempted to unclog the tube using cola. Flushing before and after each medication is important to prevent clogs. But if the tube is already clogged, this won’t help.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

4. A new nurse has a patient who is a high risk of aspiration. The new nurse reviews methods to

keep the patient safe with an experienced nurse. Which interventions do the nurses discuss as protective strategies? (Select all that apply.) a. Avoid using straws with medication administration. b. Assess the patient’s ability to swallow pills. c. Place medications on the weaker side of the mouth. d. Consult with speech therapy about thickened liquids. e. Give medications then instruct the patient to lie down and rest.

ANS: A, B, D

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Appropriate actions to protect the patient from aspiration include avoiding straws, assessing the patient’s ability to swallow pills, and considering a speech therapy consultation to determine if the patient requires thickened liquids. Medications should be placed on the stronger side of the mouth. The patient should remain in an upright position after eating, drinking, or taking medications if possible.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

COMPLETION 1. The nurse is teaching a patient how to calculate how long the metered-dose inhaler (MDI)

cannister can be used. If the cannister contains 200 puffs and the patient administers 2 puffs 3 times each day, how long will the cannister last? The cannister will last for _____ days.

ANS:

33 Two puffs  3 times daily = 6 puffs per day; 200 puffs/6 puffs per day = 33.3 days; therefore, the cannister will last 33 days with correct medication administration.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

N

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Chapter 24: Parenteral Medications Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse is teaching a patient to self-administer subcutaneous heparin at home. What does

the nurse include in patient teaching? a. Use a 22-gauge, 1-inch needle for the heparin injections. b. Change needles after withdrawing the heparin from the vial. c. Instruct the patient and family to recap all needles used at home. d. Administer the heparin in the abdomen, 2 cm away from umbilicus.

ANS: D

The nurse instructs the patient to inject heparin in the “love handles” which is about 2 cm away from the umbilicus on the abdomen. A 22-gauge needle is too large for a subcutaneous injection; a 25- or 27-gauge needle is a better choice because a finer needle creates a smaller hole. As a result, the medication tends to remain in the subcutaneous space, the patient is more comfortable, and the skin develops scar tissue more slowly. Changing needles is not necessary. Needles are never recapped; the patient at home should obtain a sharps container or use an impenetrable container to hold used needles. The patient should label the container to prevent injury to others.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. The nurse prepares to administer 2.2 mL of an oil-based medication intramuscularly to a fit

N

young adult patient who is 5 feet 10 inches tall and weighs 165 pounds. Which needle and syringe combination will the nurse choose to administer the injection? a. 20-gauge, 1 1/2-inch needle on a 3-mL syringe b. 21-gauge, 1 1/2-inch needle on a 5-mL syringe c. 23-gauge, 1-inch needle on a 3-mL syringe d. 25-gauge, 1-inch needle on a 5-mL syringe ANS: A

The patient is well proportioned; because the medication is a thick solution requiring a deep intramuscular (IM) injection, the nurse chooses a slightly larger gauge needle, 20-gauge, which is 1 1/2 inches long, to accommodate the thick medication and to reach deep within the muscle. A 21-gauge needle is appropriate, but the syringe is too large. A 23-gauge needle is too small, and the oil would not be able to get through the lumen. A 25-gauge, 1-inch needle is far too narrow and short for an IM injection.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

3. A nurse sustains an accidental needlestick injury while performing a venipuncture on a

patient. What is the nurse’s priority? a. Determine whether the needle was sterile. b. Follow agency policy for employee injuries. c. Inform the provider to screen the patient for antibodies. d. Obtain patient history of communicable diseases.

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ANS: B

The nurse’s priority after a needlestick injury is obtaining immediate treatment as outlined in agency policy. He or she needs baseline testing and, depending on the patient’s history and test results, administration of preventive treatments. The needle cannot be sterile after a venipuncture. The nurse’s priority is his or her own safety and receiving prompt treatment; informing the provider and gathering subjective data are secondary in importance.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

4. When administering an intramuscular (IM) injection, the nurse obtains blood during

aspiration. What action by the nurse is appropriate? a. Wait 30 minutes before giving the ordered medication. b. Notify the health care provider of the situation. c. Continue to administer the ordered medication. d. Stop the administration and discard the syringe.

ANS: D

The injection is stopped, the needle is withdrawn, and the filled syringe is discarded. A new dose of medication is prepared in a new syringe with a new needle for the patient. Waiting 30 minutes is not necessary because the medication is due and can be given as soon as a new syringe is prepared. Notifying the health care provider is unnecessary. Continuing with the injection is dangerous because the medication could be given intravenously instead of intramuscularly.

DIF: Cognitive Level: Applying TOP: Nursing Process: PlanningN

OBJ: NCLEX: Physiological Integrity

5. The nurse is teaching a patient to self-administer insulin. Which of the following does the

nurse include in patient teaching? a. Insert the needle into abdominal tissue at a 90-degree angle. b. Include an air space when drawing up the prescribed dose. c. Aspirate before injecting to ensure that the needle is not in a vessel. d. Instruct the patient to use an insulin syringe with a 1-inch needle.

ANS: A

The nurse instructs the patient to insert the needle at a 90-degree angle to inject insulin into subcutaneous tissue to reduce adverse effects of the injection. The 5/8-inch needle is long enough to reach subcutaneous tissue for proper administration of insulin but not long enough to reach muscle. The nurse instructs the patient to remove all air bubbles from the syringe before administering the insulin. Aspiration is unnecessary for subcutaneous injections because the tissue is avascular. A 1-inch needle is too long.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

6. The nurse instructs a patient with diabetes mellitus about subcutaneous insulin administration.

What does the nurse include in patient teaching? a. Remember that NPH insulin is clear and is drawn up last when mixing types. b. Prepare for hyperglycemia 2 hours after taking insulin. c. Keep insulin refrigerated after administering the first dose.

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d. Carry 15 g of carbohydrates with you at all times.

ANS: D

Patients who take insulin are advised to carry 15 g of fast-acting carbohydrates with them at all times in case of a hypoglycemic episode. NPH is cloudy and drawn up first.

Hyperglycemia would not be an expected effect after insulin administration. The vial of insulin being currently used is kept at room temperature.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

7. The nurse’s outcome for the patient is, “Patient self-administers subcutaneous heparin before

discharge.” What does the nurse include in patient teaching? a. Expect large areas of bruising around the injection site. b. Promote heparin absorption by massaging the injection site. c. Choose one large area for consistent heparin absorption. d. Inject heparin into the abdomen but avoid the umbilical area.

ANS: D

The nurse instructs the patient to inject heparin into the abdomen and avoid the area around the umbilicus because it is surrounded by dense tissue that delays absorption. The nurse instructs the patient to expect small areas of bruising around the injection site; to avoid massaging the site because it increases absorption and promotes bruising; and to choose various sites, reminding the patient that bruising occurs and the patient may want to keep the areas covered.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation N

OBJ: NCLEX: Physiological Integrity

8. The nurse is caring for a 14-year-old patient with diabetes mellitus who does not want to

self-administer insulin because it is too painful. Which information does the nurse use in response to the patient’s concern? a. Adolescents are usually enthusiastic about self-care. b. Insulin mixed with a local anesthetic decreases pain. c. The health care provider orders oral insulin for patients with pain. d. There are techniques that will minimize the pain of the injection.

ANS: D

Insulin injections are likely to cause mild pain but there are techniques that may be taught to the patient to minimize the pain. The pain will not be eliminated, and this information needs to be shared with the patient. Initially many adolescents are unenthusiastic participants in insulin self-administration. The nurse avoids mixing insulin with a local anesthetic because the benefit does not outweigh the risk. Oral insulin is not available.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

9. The nurse is reviewing the records of four patients on heparin therapy. Which patient does the

nurse determine has the highest risk for a bleeding disorder during heparin therapy? a. A 10-year-old patient with an acute viral infection b. A female patient who gave birth more than 6 weeks ago c. A patient who takes a nonsteroidal anti-inflammatory drug

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d. A 60-year-old patient with kidney stones ANS: C

The patient who takes a nonsteroidal anti-inflammatory drug has the highest risk of a bleeding disorder complicating heparin therapy because this classification of medication has known risk factors for bleeding, especially gastrointestinal bleeding. The patient who gave birth more than 6 weeks ago probably has the second highest risk. After 6 weeks’ postpartum, involution is usually complete; thus, hemorrhaging from the uterus is unlikely. The patients with the acute viral infection and kidney stones have a lower risk of bleeding while on heparin.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

10. The nurse prepares to administer a 3-mL intramuscular (IM) injection of an antibiotic to a thin

older patient. What action does the nurse take to administer the medication correctly? a. Prepares the patient for a subcutaneous injection. b. Divides the injection into two separate syringes. c. Positions the patient for injection in the dorsogluteal area. d. Avoids aspirating when injecting in the deltoid muscle.

ANS: B

Older adults may have decreased muscle mass and can tolerate up to 2 mL of an injection; thus the nurse divides the dosage into two separate IM injections to promote patient comfort and prevent tissue damage. A 3-mL injection contraindicates use of the subcutaneous route; subcutaneous injections range from 0.5 to 1 mL in volume. The nurse avoids the dorsogluteal area because of the risk of injury to the sciatic nerve and aspirates during IM injections, regardless of the location.

N DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

11. The nurse prepares an IM injection to administer a medication available in a glass ampule.

Which step does the nurse take to administer the injection properly? a. Labels the ampule with date and time of the first dose. b. Ensures that the cartridge is fully seated into the syringe. c. Cleans the rubber top carefully before inserting the needle. d. Uses a filter needle to withdraw the contents of the ampule.

ANS: D

An ampule is a glass container for a single dose of medication. The nurse protects the hands to break open the ampule and removes its contents with a syringe and filter needle to prevent aspiration of glass fragments. The nurse removes the filter needle and replaces it with a regular needle before administering the medication to the patient. Ampules are not amenable to reuse because they are open to air and thus contamination. The nurse opens an ampule and withdraws the contents into a syringe; a cartridge of medication is a prefilled syringe used with a reusable injection device. Ampules do not have rubber tops.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

12. The nurse prepares to administer an irritating medication by the Z-track technique. Which

technique does the nurse use to administer this intramuscular (IM) injection properly?

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a. b. c. d.

Inserts the needle and pulls the skin laterally before injecting the medication.

Has the patient lie in a supine position to prevent medication leakage.

Waits 10 seconds and releases the skin before withdrawing the syringe.

Pulls the patient’s skin laterally before inserting the needle.

ANS: D

The nurse pulls the patient’s skin to the side before inserting the needle using the Z-track technique to prepare the seal for the medication after injection. When the skin is released after the needle is withdrawn, it assumes its original place and helps to contain the medication. The nurse retracts the patient’s skin and inserts the needle. Supine positioning does not prevent medication leakage. The nurse waits 10 seconds but withdraws the needle and then releases the skin.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

13. A toddler is to receive an intramuscular injection. What action can the nurse take to make the

injection less traumatic? a. Have the parents hold the toddler down during the injection. b. Collaborate with the health care provider about what to do. c. Encourage the toddler to move the leg after the injection. d. Obtain an order for EMLA cream or vapo-coolant spray.

ANS: D

Use of EMLA cream on the injection site l hour before the injection or vapo-coolant spray just before the injection decreases the pain. The parents should support the child during the injection, not help to hold him or her down during a painful procedure. The nurse should N to ask the health care provider. Moving the leg after the know what to do and does not need injection helps to disperse the medication but does nothing about the trauma of the injection.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

14. The nurse is providing teaching for a patient who needs an intradermal test for tuberculosis.

What information does the nurse include? a. Check with the health care provider in 2 hours for test results. b. Relaxation helps make this type of injection painless. c. A total of 0.1 mL of solution will be injected into the muscle. d. The test must be read in 48–72 hours.

ANS: D

The time period for reading the results of the tuberculin skin test is within 48–72 hours after it has been done. The nurse or provider reads the test results 48–72 hours after the injection.

Relaxation doesn’t make a difference since the procedure involves a minor skin prick and generally causes a mild transient pain. The nurse injects 0.1 L of solution but not into the muscle.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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15. The nurse is instructing a nursing student in proper technique for an intradermal injection.

Which does the nurse use to evaluate proper technique for a tuberculin skin test after injecting the solution? a. The nurse palpates a deep, firm pocket of the test solution. b. The nurse observes a nearly clear bubble slightly under the skin. c. A small trickle of blood appears at the puncture site within minutes. d. A 2-cm (3/4-inch) pink, flattened area develops at the injection site within 1 hour.

ANS: B

The nurse observes a small bubble (bleb) just under the surface of the skin on needle withdrawal after a properly administered tuberculin skin test; an intradermal injection deposits medication below the skin but above subcutaneous tissue. The wheal is practically clear, denoting that the medication is in an avascular area. The pocket of test solution is relatively soft and superficial. Blood should not trickle from the injection site; if it does, the injection is potentially too deep. Within 1 hour, most intradermal tests are completely absorbed unless the patient has a reaction to the fluid, as with allergy testing or a positive tuberculin skin test.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

16. The nurse evaluates the tuberculosis skin test results for a patient who recently emigrated

from Southeast Asia. Which result is consistent with the presence of tuberculosis antibodies in the patient’s system if the nurse reads the test 72 hours after injection? a. The injection site is an 11-mm red, warm, swollen area. b. The skin around the injection site is black, dry, and scaly. c. The nurse palpates a hard, dense, raised area 14 mm across. d. According to the patient, the skin around the injection site feels cool.

N ANS: C

A tuberculin skin test indicating the presence of antibodies results in a palpable, indurated area at the injection site greater than 10 mm in diameter for a recent immigrant from Southeast Asia because many immigrants from that area are exposed to tuberculosis. In addition, tuberculosis immunizations are common in Southeast Asia; if a patient is tested after receiving the tuberculosis vaccine, the intradermal skin test will always be positive. Patients with no known risk factors have a positive test with a 15-mm induration, and an immunocompromised patient has a positive test with a 5-mm induration. This site is suspicious, but if it is not indurated, it does not indicate a positive result. Black, dry, scaly skin is consistent with necrotic tissue. A cool sensation around the injection site after a tuberculin skin test is an unusual finding.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

17. The nurse prepares an insulin injection for the patient who has diabetes mellitus. Which does

the nurse implement for correct insulin administration? a. Gives regular insulin within 15–30 minutes of meals. b. Injects insulin just removed from the refrigerator. c. Examines vials of NPH insulin for abnormal cloudiness. d. Administers NPH insulin for sliding-scale insulin dosing.

ANS: A

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The nurse administers regular insulin subcutaneously within 15–30 minutes of the patient’s meal because it starts to work in 30 minutes to 1 hour; thus the patient eats around the same time as the insulin administration to avoid severe hyperglycemia, which occurs if the patient eats and does not take insulin, or hypoglycemia, which occurs if the patient does not eat and takes insulin. Although insulin can be stored in a refrigerator to prevent decomposition, it needs to be at room temperature when administered, so the vial being used currently is not refrigerated. The nurse can draw up the dose and have it checked; then it will be time to administer it. NPH insulin has a cloudy appearance. Regular insulin is used for sliding-scale insulin and as needed insulin.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

18. The nurse evaluates the patient’s ability to self-administer a subcutaneous injection of the

anticoagulant enoxaparin. What action by the patient indicates a need for additional patient teaching? a. Inserts the needle at a 45-to-90-degree angle. b. Massages the area after performing the injection. c. Administers the injection without aspirating. d. Injects at least 7.6 cm (3 inches) from the umbilicus.

ANS: B

The nurse wants the patient to avoid massaging the injection site after administering enoxaparin to prevent the formation of large hematomas and decrease the risk of additional bleeding and tissue damage. The nurse instructs the patient to inject the enoxaparin and withdraw the needle without massaging the site afterward. If the patient massages the area to dispel pain or discomfort, he orNshe reports this to the nurse or provider because it is an unusual finding. The patient demonstrates proper injection technique with injections at 45–90 degrees, avoiding aspiration and injecting at least 2 inches away from the umbilicus.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

19. The patient wants to receive insulin by continuous subcutaneous injection (CSCI). Which

injection site does the nurse suggest for the patient? a. The upper arm b. The upper chest c. The lower abdomen d. The thigh ANS: C

The nurse instructs the patient to use the tissue in the lower abdomen, which has sufficient subcutaneous tissue and where insulin is most consistently absorbed. The upper arm and thigh are potential sites, but since most patients are active, the needle could become displaced with normal activity. The upper chest does not have as much subcutaneous tissue as the abdomen.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

20. Which technique does the nurse use to administer a parenteral medication properly? a. Inserts the needle with the bevel facing downward.

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b. Pushes the needle through the patient’s tissue slowly. c. Applies sterile technique to draw up the medication. d. Uses a 16- or 18-gauge needle with aqueous solutions.

ANS: C

The nurse uses sterile technique while drawing up the medication and for needle changes to prevent the introduction of pathogens to the patient and increased risk of infection. The hub and the inside of the syringe are sterile, as is the needle. The nurse attaches a sterile needle with the cap firmly in place to the syringe without contaminating the hub of the syringe. The nurse removes the cap without contaminating the needle to inject the medication. The bevel remains up for an injection. The nurse quickly inserts the needle into the patient to minimize the pain. Sixteen-gauge needles are not used for injections into soft tissue; parenteral, oil-based, viscous solutions require an 18-to-25-gauge needle.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

21. Which angle should the nurse use to administer an intramuscular (IM) injection for a patient

who is 5 feet 6 inches tall and weighs 140 pounds? a. 15 degrees b. 45 degrees c. 60 degrees d. 90 degrees ANS: D

The nurse administers an IM injection at a 90-degree angle to the surface to ensure injecting the medication into the muscle. An angle less than 90 degrees increases the risk of injecting N tissue. the medication into subcutaneous DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

22. The nurse administers intradermal injections for allergy testing. Which is the best technique

for the nurse to use for skin testing? a. Select a 22-gauge needle. b. Inject at a 45-degree angle. c. Choose the back for the first test. d. Inject below the antecubital space.

ANS: D

The nurse chooses a clear site without bruises, inflammation, edema, or other factors that potentially impair absorption. Three to four fingerbreadths below the antecubital space or 1 hand width above the wrist are suitable sites. The nurse can use both arms if more extensive testing is indicated because each forearm can manage 12–20 tests. A 22-gauge needle is too large. The nurse injects at a 5-to-15-degree angle. The back is a suitable testing site, but the forearms are better because they are accessed more easily and visible.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

23. The nurse instructs a patient’s partner to administer subcutaneous regular Humulin insulin.

What information should the nurse include in the partner’s teaching?

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a. b. c. d.

Select a 25-gauge, 5/8-inch needle.

Massage the site after the injection.

Always insert the needle at a 90-degree angle.

Use a different injection site each time.

ANS: A

To ensure subcutaneous delivery of the insulin, the nurse instructs the partner to use a 25-gauge, 5/8-inch needle and to insert the needle at a 45-to-90-degree angle into the elevated skin area. The nurse instructs the partner to avoid massaging the injection site. The needle is inserted at a 45-to-90-degree angle, depending on the site and the amount of subcutaneous tissue present. Rotating sites is done within the same anatomical area so the absorption is consistent.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

24. The nurse is preparing to administer the anticoagulant enoxaparin subcutaneously. Which

injection site is most appropriate for the nurse to use? a. Thighs b. Deltoid area c. Sides of abdomen d. Ventrogluteal area ANS: C

The sides of the abdomen are the preferred injection sites for enoxaparin to minimize bruising and discomfort. There are no major blood vessels or nerves in these areas. The nurse avoids injecting enoxaparin into the thighs because it potentially increases hematoma formation and N The nurse avoids injecting enoxaparin into the deltoid discomfort from physical activity. region because it is likely to be more visible; in addition, patient activity can increase the risk of hematomas and discomfort. The nurse avoids the ventrogluteal site because injecting there potentially increases discomfort when the patient is trying to rest.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

25. The nurse needs to administer an intramuscular (IM) injection to a patient who is 7 months

old. Which is the best site for the nurse to use for the injection? a. Deltoid b. Dorsogluteal c. Ventrogluteal d. Vastus lateralis ANS: D

The preferred IM injection site for patients under the age of 12 months is the vastus lateralis muscle because it is a relatively large muscle mass without major nerves and blood vessels, has a consistent layer of fat, and has a good safety record. The deltoid is suitable for well-developed children and adolescents with use of a 5/8-inch needle. The dorsogluteal site is contraindicated because of the major anatomical structures that it contains. The ventrogluteal site is a safe site for injections in all age-groups; however, the vastus lateralis is the preferred site for infants.

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DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

26. The nurse is preparing to give an injection in the ventrogluteal injection site. Which pair of

anatomical landmarks does the nurse use for this site? a. Greater trochanter and knee b. Acromion process and axilla c. Anterior superior iliac spine and iliac crest d. Posterior superior iliac spine and iliac crest ANS: C

To locate the ventrogluteal muscle with the patient on the left side, the nurse palpates the head of the femur and the anterior superior iliac spine with the left hand. Place the heel of the right hand on the greater trochanter, with the thumb pointing to the groin and the index finger toward the anterior superior iliac spine. Extend the middle finger back to the iliac crest toward the buttocks, creating a V between the index finger and the middle finger; the injection site is deep in the middle of this V. The remaining anatomical landmarks are used with other sites, not the ventrogluteal.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

27. The nurse is preparing to give a patient a medication via a piggyback infusion. What is the

safest action for the nurse to take? a. Fill the tubing with medication before connecting it to the Y-port. b. Obtain a second IV site where the infusion will be administered. c. Ask the patient his or her preference about starting a new IV line. d. Consult with the health careNprovider to obtain the best approach.

ANS: A

Preventing air bubbles, which can cause an air embolus, is essential before attaching the secondary infusion to the primary infusion line. There is no need to start a second IV site unless the medication is incompatible with what is running or if blood or blood products are infusing. The patient doesn’t have the knowledge about what approach is best. The nurse should know what to do in this situation.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

28. The nurse is preparing to administer morphine sulfate IV push to a patient in pain. The

morphine comes pre-drawn into a syringe with 0.3 mL of fluid. What action by the nurse is best? a. Dilute the medication to prevent it from collecting in “dead spaces.” b. Verify with the pharmacy that the dose sent is the correct amount. c. Using sterile technique, transfer the medication to a tuberculin syringe. d. Give the medication as ordered and document the patient’s response.

ANS: A

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For IV medications that are in very small volumes, the nurse dilutes the drug in a larger volume of normal saline or sterile water per agency policy. This prevents the medication from being hung up in the “dead spaces” of the IV tubing and delivery system. The nurse is able to verify if the correct dose was sent and would not need to verify with pharmacy. Transferring the medication to another small syringe without diluting it doesn’t accomplish anything. The nurse does give the medication and document the response, but first needs to ensure that the entire dose is being administered.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

29. The faculty member observes a student nurse administering an IV push medication through a

saline lock. What action by the student requires the faculty to intervene? a. Checks a resource for the rate of administration. b. Flushes after the medication with saline quickly. c. Follows the medication with a heparin flush. d. Stays with the patient for several minutes after the IV push.

ANS: B

The saline flush that follows the IV push medication is given at the same rate as the medication to prevent adverse reactions. The other actions are appropriate.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

30. A patient is to receive an antibiotic via IV piggyback through a running IV. After completing

the 3 safety checks what action by the nurse is next?

N central supply. a. Obtain an infusion pump from b. Assess the patient’s IV site for redness or swelling. c. Determine if the antibiotic is compatible with the running IV fluid. d. Prime the IV tubing, hang the IV piggyback, and program the pump.

ANS: C

When infusing a medication via IV piggyback into a running IV, the nurse must determine if the two medications are compatible. This would be done prior to obtaining a pump, assessing the IV site, and priming preparing the tubing and pump for the infusion. The patient’s IV pump should be able to run the piggyback at the same time as the primary line, but if not, the nurse would need to obtain another one.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

31. A patient is receiving the first of three ordered blood transfusions. The nurse needs to

administer an IV antibiotic. What action by the nurse is most appropriate? a. Wait until after the transfusions are complete. b. Stop the transfusion, flush the line, hang the antibiotic. c. Ensure the blood bag in hanging lower than the piggyback. d. Starts a new IV site in order to give the antibiotic on time.

ANS: D

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Nothing else should run with blood or blood products, so the nurse would start another IV line in order to give the antibiotic on time. Waiting until the transfusions are complete would make the antibiotic very late. Stopping the transfusion to flush the line and ensuring the blood bag is hanging lower than the piggyback are inappropriate since nothing should infuse with the blood.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

32. A patient has an IV solution running via IV pump. The nurse needs to administer an IV push

medication that is not compatible with the primary solution. What action by the nurse is best? a. Discontinue the running IV solution. b. Flush the tubing before and after giving the medication. c. Start a new IV site on the opposite arm. d. Ask the provider for an alternative route.

ANS: B

If the medication is incompatible with the running IV solution, the nurse would temporarily clamp the tubing, flush with normal saline, administer the medication, flush again, and restart the primary solution. None of the other options are necessary.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. The nursing manager is concerned N about the number of needlesticks the staff is experiencing.

Which of the following actions would help this situation? (Select all that apply.) a. Ensure that sharps containers are readily available through the unit. b. Request administration invests in needless and engineered safety syringes. c. Instruct the staff to recap needles slowly and carefully to avoid injury. d. Review incident reports to see if there is a common cause of needlesticks. e. Volunteer to evaluate sharps engineered safety needle brands.

ANS: A, B, D, E

Several things can be done to improve this situation, including having plentiful and well-placed sharps disposal containers, requesting the system change over to needleless or safety engineered syringes, and volunteering to help evaluate these products. Reviewing incident reports can indicate patterns that could be addressed. Used needles should never be recapped.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. A nurse has taught a patient general information about insulin administration. When using the

teach-back method, what statements by the patient indicates good understanding? (Select all that apply.) a. “I will check the bottle before use for any changes in appearance.” b. “I will rotate my injection sites around my abdomen.” c. “I will give my injection at least 2 inches from my belly button.” d. “I don’t need to check my blood glucose if my dose doesn’t change.”

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e. “I don’t have to refrigerate the bottle of insulin I am using.”

ANS: A, B, C, E

Patients should be taught to inspect insulin bottles before use for any change in appearance, rotate sites within the same anatomical location (preferably the abdomen), inject the insulin while avoiding the 2 inches around the umbilicus, and keeping the in-use bottle of insulin at room temperature. Patients on insulin need to check the blood glucose regularly.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

3. The student nurse is administering an IM injection to an 8-year-old. Which actions require

intervention by the faculty member? (Select all that apply.) a. Selects a 1-inch needle. b. Cleanses the deltoid muscle. c. Prepares the ventrogluteal site. d. Chooses a 21-gauge needle. e. Injects up to 3 mL of fluid.

ANS: C, E

The preferred site for a child ages 3–10 is the deltoid where up to 2 mL of fluid can be injected. A 1-inch, 21-gauge needle is appropriate.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

4. After teaching students about IV push medications, the faculty quizzes them on the

advantages and disadvantages of N this route of administration. Which responses by the students are correct? (Select all that apply.) a. Medications given IV push have a rapid onset of action. b. The risk of infiltration or extravasation is higher. c. All medications can be delivered by IV push. d. Barriers to absorption are eliminated. e. Doses can be titrated quickly to patient need.

ANS: A, B, D, E

Not all medications can be given IV push (or IV at all). The other statements are correct.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

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Chapter 25: Wound Care and Irrigation Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse assesses several preoperative patients for potential postoperative referrals to the

wound care team. Which patient assessment does the nurse use to identify the patient who is least likely to have delayed postoperative wound healing? a. Eight weeks postpartum from live vaginal birth in for tubal ligation b. Older than 70 years, coronary artery disease, and hypertension c. Six-week course of radiation therapy for a cancerous tumor d. Chronic obstructive lung disease on long-term prednisone therapy ANS: A

The patient with the lowest risk of delayed wound healing is the patient scheduled for a tubal ligation because she is likely to be 40 years old or younger, decreasing the risk for chronic disease. She is likely to have generally good health as evidenced by a live vaginal birth. The older patient with coronary artery disease and hypertension has atherosclerotic lesions in the heart aggravated by high blood pressure. The patient is likely to have atherosclerotic lesions in other vessels because atherosclerosis is a nonselective disease; thus the patient is at risk for delayed healing because of the potential for impaired tissue perfusion. Radiation therapy increases the risk of postradiation scarring and fibrosis which increases the risk of delayed healing. The patient taking prednisone is at high risk for delayed healing because glucocorticoids suppress inflammation and the immune system.

DIF: Cognitive Level: Analyzing N TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

2. The nurse assesses a patient with a surgical incision. What is an expected patient outcome on

the fourth postoperative day? a. The temperature is 103.1° F (39.5° C) at 8 AM and noon. b. The incision is slightly reddened and swollen without drainage. c. The skin is spongy and warm around the incision. d. The patient’s pain has been increasing gradually.

ANS: B

By the fourth postoperative day the patient’s surgical incision is expected to have slight redness and swelling but no drainage, indicating a physiological, expected, inflammatory response to tissue injury. A temperature of 39.5° C is febrile and warrants further investigation to rule out infection. Spongy, warm skin around the wound area can indicate infection and requires follow-up. Increasing pain can indicate that the wound status is deteriorating and needs to be assessed.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

3. The nurse prepares to assess the patient’s wound after removing the dressing. Which does the

nurse implement to promote infection control? a. Scrubs the drain insertion site in a back-and-forth manner. b. Cleans the incision from wound edges toward the center.

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c. Applies clean gloves after removing the old dressing; inspects the wound. d. Dons sterile gloves, removes the dressing, and inspects the wound.

ANS: C

First the nurse applies clean gloves, and then removes soiled dressings and examines dressings for quality of drainage (color, consistency), presence of odor, and quantity of drainage (note if dressings were saturated, slightly moist, or had no drainage). The nurse discards dressings in a waterproof biohazard bag, removes and discards gloves, performs hand hygiene, and applies clean gloves. Then the nurse inspects the wound and determines the type of wound healing (e.g., primary or secondary intention). The wound is cleansed from the cleanest to the dirtiest area to avoid contamination of the cleaner area. The nurse does not need to put on sterile gloves to remove the dressing but does need to change gloves before inspecting the wound.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

4. The nurse teaches a patient about self-care of two Jackson-Pratt drains after breast surgery.

What does the nurse include in patient teaching? a. Empty the drain every 2 hours and measure the contents. b. Maintain a small, steady amount of tension on the drain tubing. c. Record the amount removed from each drain separately. d. Keep the collection end of the drain lower than the patient’s waist.

ANS: C

Since the patient has two Jackson-Pratt drains, the amount removed from each drain should be recorded separately to allow the health care provider to know their effectiveness and when they can be removed. The bulbNshould be emptied when it is approximately two-thirds full, and a household device should be used to measure the contents as precisely as possible. The nurse instructs the patient to avoid putting tension on the tubing and to keep the bulb below the insertion site. Waist level is probably as low as the tubing can reach and still allow slack in the tubing.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

5. The nurse teaches a patient about Steri-Strips after suture removal. What information does the

nurse include in patient teaching? a. They provide a skin barrier. b. They provide gentle support. c. They prevent scarring of the wound. d. They collect additional drainage.

ANS: B

Steri-Strips provide continued support to the incision after sutures or staples are removed. The nurse instructs the patient to expect the Steri-Strips to curl up and eventually fall off the skin and instructs the patient not to remove them. Steri-Strips do not provide a barrier since they are not applied continuously along the incision. The method of skin closure, site, and patient status determine the level of scarring. Steri-Strips are able to absorb only a few drops of drainage.

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DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

6. The nurse performs a dressing change for a patient with a negative-pressure wound therapy

device. Which step does the nurse implement to facilitate wound healing? a. Cuts the foam smaller than wound edges. b. Uses black foam to prevent granulation tissue from forming. c. Determines if the patient needs pain medication before beginning the procedure. d. Checks the dressing to ensure that the device’s tubes are functioning.

ANS: D

The nurse checks the dressing and tubing placement frequently to prevent new skin breakdown and aggravation of impaired tissue. The foam is cut to fit the entire wound bed, including tunnels and undermined areas, because the therapy cannot facilitate wound healing if it cannot reach the damaged tissue. Black foam is used to assist in granulation tissue formation. Pain medication might be needed, but it does not affect wound healing unless the nurse can’t manipulate the wound enough for a proper fit.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

7. The nurse applies Steri-Strips to the patient’s surgical site after suture removal. During patient

teaching, what does the nurse instruct the patient to avoid doing? a. Limit heavy lifting activities. b. Ambulate several times a day. c. Soak in the bathtub for relaxation. d. Use a pillow to support incision.

N

ANS: C

The nurse instructs the patient to avoid soaking in the bathtub. Soaking in water decreases the longevity of the Steri-Strips. The nurse instructs the patient to avoid heavy lifting completely to prevent exposing the new incision to excessive pressure. If the incision separates or eviscerates, the patient’s risk of infection and complications increases. The nurse encourages the patient to ambulate several times a day to prevent deconditioning, thromboembolic events, pneumonia, and constipation. The patient is also instructed to support the incision with a pillow for turning, coughing, deep breathing, and other activities as necessary.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

8. The nurse evaluates the surgical incision before removing the patient’s staples. What

assessment finding would suggest staple removal is contraindicated for now? a. The area could have an increased risk of visible scarring. b. There is a small open area along the incision. c. The site is without drainage or erythema. d. The patient is quite anxious about the staple removal.

ANS: B

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The nurse avoids removing staples from an incision with an open area because this indicates the incision has delayed healing. If the nurse removes the staples too soon, the risk of infection increases from wound dehiscence or evisceration. The method of wound closure, healing progression, and patient nutritional status determines scarring; staple removal generally has no effect on scarring. A surgical incision without drainage or redness has clinical indicators consistent with a healing wound. Patients are frequently anxious about procedures perceived as potentially painful; thus, the nurse instructs the patient to expect a stinging sensation.

DIF: Cognitive Level: Applying TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

9. The nurse prepares to remove the patient’s sutures and staples. Which step does the nurse

implement before proceeding with the removal? a. Assess the type of suture material used. b. Snip off both ends of the suture material. c. Cleanse crusting with hydrogen peroxide. d. Plan staple removal for postoperative day 5.

ANS: A

The nurse determines the type of material used for wound closure before removing the staples or sutures for efficient time management and proper preparation for removal. To avoid patient exposure, discomfort, and dissatisfaction, the nurse avoids starting the procedures without suitable supplies. The nurse avoids snipping off both ends of the suture material to keep the sutures visible at all times, ensuring that he or she always has an end to grasp for removal.

Hydrogen peroxide is avoided for wound care or removal of staples or sutures because it is too harsh for topical use. Generally N postoperative day 5 is too early for staple removal; staples are more typically removed on days 7–10.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

10. A patient has an abdominal wound with a Hemovac drain in place. Which technique does the

nurse implement to maintain optimal suction in the drain? a. Replace the Hemovac drain when full. b. Attach the tubing to the patient’s gown. c. Compress the Hemovac on a flat surface after emptying. d. Apply high continual suction to the Hemovac plug.

ANS: C

To maintain the gentle suction designed into the Hemovac drainage system, the nurse empties the drainage into a measuring cup; compresses the Hemovac on a firm, flat surface; and reinserts the plug into its opening on the Hemovac. The surgeon places the drain in surgery so the unit is removable but not replaceable. The Hemovac container is attached to the patient’s gown for activity; if the nurse fails to attach it, the weight of the drain creates excessive tension on the tubing and increases the risk of accidental removal. Suction is never applied to a Hemovac without a specific order for the amount and type of suction. If the amount of suction is not specified, the nurse uses low suction.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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11. The nurse assesses a patient’s wound and notices leakage at the edge of the transparent film of

the negative-pressure wound therapy. Which does the nurse implement to promote wound healing and prevent infection? a. Apply strips of transparent film to repair the leak. b. Change the patient’s negative-pressure wound therapy dressing. c. Patch the leaks with an adhesive dressing. d. Contain leakage with a large ABD dressing.

ANS: B

If the nurse notes a leak from the transparent dressing, he or she repairs it with pieces of transparent dressing. Unless the leak cannot be controlled, the nurse would not need to change the entire system. Adhesive dressing is avoided because it can irritate the skin and is too porous for establishing negative pressure. Likewise, an ABD pad is too porous to allow negative pressure to be reestablished.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

12. The nurse is performing a wound assessment after removing the soiled dressing. What finding

would indicate a problem requiring additional assessment? a. An incisional ridge continues to be present. b. The patient experiences less discomfort. c. There is a lack of new drainage. d. The patient states, “My wound smells funny.”

ANS: D

N the wound for clinical indicators for infection since an odd The nurse would need to evaluate smell may indicate a developing infection. A wound culture may be required. Ridge formation, decreased discomfort, and lack of drainage are consistent with clinical indicators of a healing surgical incision without infection.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

13. The nurse prepares to apply a dressing for a patient who has a full-thickness wound with

moderate exudate and necrosis. Which is the best nursing intervention to help the patient achieve an expected long-term outcome for this wound? a. Assess the wound for sinus tracts and tunneling. b. Provide the patient with supplemental oxygen. c. Pack the wound lightly with a dry gauze dressing. d. Provide a well-balanced diet with high-quality protein.

ANS: D

Improving the patient’s nutrition is imperative for wound healing. A well-balanced diet with high-quality protein is required to maintain an adequate supply of substrate for wound healing. Assessing the wound is an important function, but does not help achieve the desired outcome. There is nothing in the stem that indicates the patient needs oxygen. The type of wound care will be specified by the provider, but a dry gauze dressing will not promote healing.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

14. The nurse assigns patient care to nursing assistive personnel (NAP). Which wound care task

can the nurse assign to NAP? a. Applying a hydrocolloid dressing b. Assessing the dimensions of the wound c. Reporting visible drainage on dressing d. Changing the first postoperative dressing ANS: C

The nurse assigns reporting visible drainage on the dressing to the NAP because the NAP is trained to perform that wound care task. The remaining wound care tasks require critical thinking and nursing judgment, assessment, and evaluation skills that the nurse cannot delegate because he or she owes these duties to the patient. In addition, the nurse avoids delegating the first postoperative dressing change because it is a sterile procedure requiring the same nursing skills and judgment.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

15. The nurse needs to apply a dry sterile dressing. Which does the nurse implement first? a. Inspect the appearance of the wound. b. Remove excess moisture from the wound. c. Cleanse the wound with sterile saline solution. d. Prepare the sterile field for supplies.

ANS: A

N

After removing the old dressing, the nurse assesses the wound for color, size, depth, drainage, and edema and compares the findings with baseline data. The nurse uses the conclusions from the assessment to plan follow-up nursing care. After the assessment the nurse creates the sterile field to maintain the integrity of sterile supplies in preparation for the dressing change.

He or she then cleanses the wound using sterile saline or an antiseptic swab and blots the excess moisture to reduce the risk of infection.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

16. While cleaning a wound, the nurse determines that undermining is at the top of the wound.

Which documentation of the wound by the nurse is best? a. Dark pink wound with undermining at 2 o’clock b. Wound clean and without odor with slight undermining toward patient’s head c. See photograph of wound taken today d. Pale pink wound 2 cm  3 cm  2 cm deep with undermining at 12 o’clock ANS: D

The best documentation is “Pale pink wound 2 cm  3 cm  2 cm deep with undermining at 12 o’clock.” This entry contains the size, color, and location of the undermining of the wound.

The other entries omit key information.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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17. The nurse is preparing to remove the skin staples from an older adult’s incision. Which action

will the nurse take to prevent a complication as a result of age and its effect on healing? a. Be prepared to use skin glue on the edges of the wound. b. Have Steri-Strips ready to use after the staples are removed. c. Increase the amount of protein in the patient’s diet. d. Assess the skin edges before the patient is discharged.

ANS: B

Steri-Strips can help support tissues after the staples are removed. Skin glue can be irritating to older tissue. Increased protein aids skin health, but the need is immediate, and additional protein won’t help right now. The skin edges should be assessed frequently during the remainder of the patient’s hospitalization.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

18. The nurse is irrigating a wound with a wide opening. What equipment would be appropriate

for the nurse to use? a. A 10-mL syringe with a 20-gauge needle b. A 35-mL syringe with a 19-gauge angiocatheter c. A 50-mL syringe with a 27-gauge needle d. A 60-mL syringe with a 24-gauge angiocatheter ANS: B

The 19-gauge catheter lumen and the volume of the syringe provide the ideal pressure for cleaning the wound and removing debris. A 10-mL syringe is too small. The 20-gauge needle N is similar to the size of the angiocatheter and could be used. A 27-gauge needle and a 24-gauge angiocatheter are both too small.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

19. The nurse is preparing to perform a wound irrigation on a 7-year-old child who is

uncooperative. Which of the following will be the most helpful in alleviating the child’s fear? a. Restrain the child because. b. Have the parents leave the room. c. Describe the wound irrigation in detail. d. Use a doll to show how you will irrigate the wound.

ANS: D

Some pediatric patients may become frightened and may verbally or physically attempt to prevent the wound irrigation. Describing the wound irrigation using a doll may help to alleviate the fear. When possible, include parents in the procedure.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

20. The nurse is caring for a patient who has a Jackson-Pratt drain in place on postoperative day

1. The NAP reports there is no drainage and the patient is complaining of pain at the site.

What will the nurse do first? a. Notify the health care provider.

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b. Inspect the area around the drain. c. Ask the patient to rate his or her pain level. d. Administer pain medication.

ANS: B

In order to plan and implement care the nurse first assesses the situation. The nurse would assess the area around the drain, then ask the patient to rate the pain. The patient may or may not need pain medication and the nurse might or might not need to notify the provider.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

21. The nurse is assessing the negative-pressure wound therapy system and notes a large leak. The

previous nurse had already attempted to repair the leak by applying more transparent dressing three different times. What action by the nurse is most appropriate? a. Add another layer of transparent dressing to the leak. b. Inform the provider that the system is not working. c. Notify the wound, ostomy, and continence nurse. d. Replace the transparent film over the filler gauze.

ANS: D

Multiple layers of transparent dressing are not placed over the filler gauze because they can cause maceration of tissue. The nurse would replace the entire film. This may or may not require the nurse to remove the entire system and start over. The system is not the problem, it is the leak. The nurse should attempt to fix the problem prior to consulting other care team members.

DIF: Cognitive Level: ApplyingN TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

22. The provider suspects a patient has a wound infection. What action does the nurse take first? a. Administer the ordered antibiotic. b. Obtain wound cultures. c. Assess the patient’s pain. d. Change the dressing.

ANS: B

Antibiotics will be given if the wound is indeed infected, but to determine if it is infected (and with which microorganism), the nurse collects cultures first, then administers the antibiotic.

Assessing pain and changing the dressing are not the priorities.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

23. A patient’s wound does not seem to be healing. What assessment finding would the nurse

correlate with this situation? a. Blood glucose 126 mg/dL b. Hemoglobin 8.2 g/dL c. Hematocrit 32% d. White blood cell count 8500/mm3 ANS: B

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A low hemoglobin (less than10 g/dL) leads to impaired tissue oxygenation, which is needed for healing. The other values are within normal limits. The blood sugar does not specify whether it is fasting, post prandial, or random.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

24. A nurse assesses the patient’s wound and notes the following appearance. What action by the

nurse is most appropriate?

a. b. c. d.

Consult the wound, ostomy, and continence nurse.

Document the findings in the patient’s chart.

Prepare to obtain wound cultures.

N Educate the patient on wound packing.

ANS: B

This is a wound healing by primary intention. Wound-healing edges are pulled together and approximated with sutures, staples, or adhesive, and healing occurs by connective tissue deposition. This is a normal appearance, so the only action needed is to document an assessment in the patient’s chart.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

25. The nurse is preparing to remove a patient’s sutures. What technique demonstrates correct

technique?

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a. b. c. d.

Snip first suture distal to knot, then snip second suture on the same side.

Snip suture distal to knot and pull through skin in one smooth motion.

Place end of suture extractor under suture and pull upwards.

Pull the exposed suture through the skin and out through the other side.

ANS: A

N

These are blanket continuous sutures. The nurse first snips the first suture distal to the knot and close to the patient’s skin. Next the nurse snips the second suture on the same side. Then the nurse will grasp the knotted end and gently pull with continuous smooth action, removing suture from beneath skin. The nurse repeats this process until the entire line of sutures is removed. Pulling a single knotted suture is done for interrupted sutures. There is no suture extractor. Never pull the exposed suture material through the epidermis as it is considered contaminated.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

26. The nurse is caring for a patient whose wound looks like the following. What wound care

does the nurse prepare to implement for this wound?

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a. b. c. d.

Use a cotton-tipped applicator to measure any undermining.

Lightly palpate the edges for a healing ridge.

Determine if the wound is able to be closed by sutures.

Assess and treat the patient’s pain.

ANS: A

This is a wound healing by secondary intention and is left open to heal by scar formation.

Appropriate wound care includes measuring any undermining with a sterile cotton-tipped applicator. A healing ridge would be felt with an incision healing by primary intention.

Closing a wound after it has been left open for a time is tertiary intention. All patients with wounds need their pain assessed and treated.

N

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. The nursing student is listing the phases of full-thickness wound healing to the nursing

mentor. Which of the following phases listed indicate the needs further education? (Select all that apply.) a. Inflammatory phase b. Hemostasis c. Primary intention d. Proliferation e. Remodeling f. Secondary intention ANS: C, F

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Wound healing occurs in four stages. (1) Hemostasis: Blood vessels constrict; clotting factors activate coagulation to stop bleeding. Clot formation seals disrupted vessels so blood loss is controlled and acts as a temporary bacterial barrier. Growth factors are released, which attract cells needed to begin tissue repair. (2) Inflammatory phase: Vasodilation occurs, allowing plasma and blood cells to leak into the wound, noted as edema, erythema, and exudate.

Leukocytes (WBCs) arrive in the wound to begin cleanup. Macrophages appear and regulate the wound repair. (3) Proliferation/rebuilding phase: New capillaries are created, restoring the delivery of oxygen and nutrients to the wound bed. At the same time new granulation tissue is formed. Collagen is synthesized and begins to provide strength and structural integrity to a wound. Contraction reduces the size of the wound. Epithelial resurfacing (the construction of new epidermis) begins to cover the wound. (4) Maturation/remodeling phase: Collagen is remodeled to become stronger and provide tensile strength to the wound. Outer appearance in an uncomplicated wound will be that of a well-healed scar. Healing by primary intention occurs when the wound edges of a clean surgical incision remain close together. Wounds left open and allowed to heal by scar formation are classified as healing by secondary intention.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

2. The nurse is assessing a wound that is healing by secondary intention. Which of the following

assessments are important to address? (Select all that apply.) a. Wound dimensions b. Tissue type c. Wound edges d. Periwound skin e. Presence of sutures N f. Undermining ANS: A, B, C, D, F

When assessing a wound that is healing by secondary intention (e.g., pressure ulcer or contaminated surgical or traumatic wound), it is important to assess the anatomical location of the wound, the wound dimensions, undermining, the extent of tissue loss, the tissue type, the presence of exudate, the wound edges, and the periwound skin. Sutures are not used on a wound healing by secondary intention.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

3. The nurse is preparing to use high-pressure pulsatile lavage to irrigate a necrotic wound.

Which of the following statements indicate a need for further education on this type of irrigation? (Select all that apply.) a. “I can set the psi between 15 and 17.” b. “I should never use this on exposed blood vessels.” c. “It is okay to use this on skin grafts.” d. “I should not use this on exposed muscles or tendon.” e. “I should never use this on patients with a coagulation disorder.”

ANS: A, C, E

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Pulsatile high-pressure lavage is often the irrigation of choice for necrotic wounds. Pressure settings should be set per provider order (usually between 4 and 15 psi) and should not be used on skin grafts, exposed blood vessels, muscle, tendon, or bone. Use with caution if the patient has coagulation disorder or is on anticoagulants.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

4. The nurse is listing factors that affect wound healing to a student nurse. What factors does the

nurse include? (Select all that apply.) a. Nutrition b. Age c. Obesity d. Racial differences e. Medications ANS: A, B, C, E

Factors that influence wound healing include nutrition, age, obesity, and medications. Racial differences do not play a part.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

N

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Chapter 26: Pressure Injury Prevention and Care Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient with a small chronic pressure ulcer on the ankle. Which

activity can the nurse delegate to nursing assistive personnel (NAP)? a. Measure the wound for length, width, and depth. b. Reposition the patient at least every 2 hours. c. Ask the patient to rate the pain during the dressing change. d. Examine the wound bed for the type and amount of tissue.

ANS: B

The nurse delegates patient repositioning to the NAP after the dressing change because the NAP is trained to perform this patient care activity. The nurse assesses the wound for type and amount of tissue in the wound bed, measures the wound, and assesses patient pain control because assessment is a major nursing responsibility.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

2. The nurse admits a patient to the surgical unit and determines that the patient’s Braden Scale

score is 18. Which does the nurse include in the patient’s initial plan of care? a. Using moisturizing lotion to massage the sacrum b. Assisting the patient to turn and reposition every 4 hours c. Keeping the skin clean and dry with frequent bathing N d. Maintaining the head of the bed at approximately 30 degrees ANS: D

A Braden score of 18 indicates mild risk for pressure injuries. The nurse elevates the head of the bed to 30 degrees or less to reduce shear forces. If the patient sits in the Fowler’s or semi-Fowler’s position, the lower back and buttocks receive excessive force from the his or her weight pressing into the mattress, which can increase the risk of skin breakdown.

Moisturizing lotion applied to areas at risk for friction is indicated for any patient in bed. The nurse avoids massaging the skin over bony prominences such as the sacrum because the tissue lacks supportive structures such as muscle and fat to distribute pressure over a large surface and provide oxygenated blood. Although the patient has a slight risk for skin breakdown, repositioning and turning every 4 hours is inadequate to maintain adequate tissue oxygenation.

Excessive bathing increases the risk of skin breakdown by stripping the skin of essential oils and moisture. The skin may be kept clean and dry with daily and as-needed bathing using mild soap or commercial bathing products.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

3. A patient has a pressure injury with dry wound base. Which action by the nurse provides the

most appropriate wound care? a. Using dry gauze dressings and a liquid antimicrobial on the wound b. Optimal nutritional support and the use of hydrogel dressings c. Bathing frequently with soap and the use of transparent film dressings

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d. Using nonstick pads and enzymatic débriding agents ANS: B

The use of hydrogel dressings have been found to bring moisture to a dry wound base.

Nutrition is extremely important for wound healing so the nurse works to optimize the patient’s healthy intake. Gauze dressings absorb moisture, which is contraindicated, and a liquid antimicrobial is not indicated. Daily bathing with a mild soap is sufficient to keep the area clean. Transparent film dressings are used on partial-thickness wounds with minimal drainage. Nonstick pads are suitable for abrasions so the dressing does not adhere to the wound. Enzymatic débriding agents promote removal of dead tissue.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

4. The student nurse a patient’s pressure ulcer. Which assessment datum does the student use to

support the identification of a stage 3 pressure ulcer? a. Nonblanching and reddened areas of intact skin b. Extensive destruction of the skin and muscle c. Full-thickness skin loss from the surface down to the bone d. Full-thickness skin loss from the surface down to the fascia ANS: D

A stage 3 ulcer involves damage or necrosis of subcutaneous tissue extending down to, but not through, the fascia. A nonblanching area of reddened skin is a stage 1 pressure ulcer.

Stage 4 pressure ulcers are full-thickness ulcers involving extensive tissue destruction and necrosis of subcutaneous tissue, fascia, muscle, and bone.

DIF: Cognitive Level: Remembering N TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

5. The nurse assesses several patients using the Braden Scale. Which patient will need the most

intensive interventions? a. Score of 1 b. Score of 6 c. Score of 14 d. Score of 17 ANS: B

A score of 6 on the Braden Scale indicates very high risk for pressure injuries. A score of 14 indicates a moderate risk for pressure injuries while 17 indicates mild risk. A patient cannot get a score of 1.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

6. The nurse is caring for four patients at risk for impaired skin integrity. Which patient requires

the most frequent assessment and possible intervention? a. A malnourished, homeless patient with a nasogastric tube who is bedridden b. A college football player with bilateral long leg casts after a motorcycle accident c. An older adult ambulating after hip replacement surgery d. A school-age child recovering from a tonsillectomy and adenoidectomy

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ANS: A

The homeless patient has three major factors that can contribute to skin breakdown: poor nutrition, being bedridden, and having a nasogastric tube. The edges of the casts on the football player need to be watched for irritation, but he is at low risk for skin breakdown because of his youth, nutritional status, and activity level. The older adult after hip replacement surgery would be at higher risk for skin breakdown if he or she were bed- or chair-ridden, although her age is a factor because of the decrease of tissue under the skin. The school-age child has no risk factors for skin breakdown.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

7. The nurse is assessing a newly admitted patient with a pressure ulcer on the hip. Which

clinical indicator does the nurse use to assess a stage 2 pressure ulcer? a. Deep, open wound b. Persistent redness c. Boggy consistency d. Superficial blistering ANS: D

A stage 2 pressure ulcer is a superficial, partial-thickness skin loss presenting as an abrasion, blister, or shallow wound. A deep crater is consistent with clinical indicators for a stage 3 or stage 4 ulcer. Persistent redness and a boggy or firm consistency are characteristics of a stage 1 pressure ulcer.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

N

8. The nurse uses the Braden Scale to assess the patient’s pressure ulcer risk. Which patient

score mandates that the nurse implement aggressive prevention measures because of being at high risk for skin breakdown? a. Less than 9 b. 15–18 c. 19 d. 23 ANS: A

A Braden Scale score less than 9 indicates that the patient has a very high risk for development of a pressure ulcer. These scores are indicative of a patient who has impaired sensation, very frequent exposure to moisture, moderate-to-severe activity impairment, and inadequate nutrition. Braden Scale scores 13 and 14 indicate a moderate risk, scores 15–18 indicate a mild risk, and a score above 19 includes patients with the lowest risk for development of pressure ulcers. A patient with a score of 23 has no risk of skin breakdown.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

9. The patient is at risk for development of a pressure ulcer. Which problem related to the

patient’s iron deficiency anemia and smoking habit supports the nurse’s decision to address the anemia for prevention of a pressure ulcer? a. Decreased tissue perfusion

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b. Decreased mobility impairment c. Increased skin moisture d. Increased level of consciousness ANS: A

Iron deficiency anemia and smoking lead to decreased oxygen-carrying capacity of the blood, which increases the risk of cell death. Restoring iron levels improves the oxygen-carrying capacity of the patient’s blood by supplying adequate oxygen for cell metabolism and energy production. Decreased mobility impairment and increased level of consciousness would be desired outcomes and are not problems related to iron deficiency anemia. Increased skin moisture most often occurs from fecal or urinary incontinence, not anemia.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

10. The patient has a clean partial-thickness wound. Which dressing material should the nurse

choose for dressing this ulcer? a. Moist gauze b. Foam dressings c. Transparent film d. Alginate dressings ANS: C

Transparent film is a suitable dressing for this clean partial-thickness wound with minimal exudate. Moist gauze can be used on a dry wound to deliver moisture. Alginate dressings are unsuitable because the ulcer does not need absorption of moderate-to-heavy exudate. Foam dressings prevent dehydration of the wound and absorb exudate.

N DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

11. The nurse assesses the patient’s pressure ulcer and notes tissue maceration around the wound.

Which action does the nurse take to address this issue? a. Measures the wound bed. b. Uses a skin barrier. c. Applies a foam dressing. d. Obtains a wound culture.

ANS: B

Macerated skin around a wound is consistent with tissue exposure to irritating agents or moisture. The nurse cleanses the area gently and applies a moisture barrier to protect the skin.

Although skin needs moisture and a moist environment facilitates wound healing, frequent exposure to moisture or other agents that strip the skin of surface protection increases the risk of skin breakdown. Examples of such agents would be urine or feces, especially diarrhea.

Measuring the wound bed is an appropriate nursing assessment, but does not address the macerated tissue. Moderate-to-heavy exudate is an indication for a foam dressing. A wound culture is not indicated because macerated tissue is not necessarily infected.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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12. The patient’s pressure ulcer needs packing and has a moderate-to-heavy amount of drainage.

Which type of dressing should the wound care nurse use on the ulcer? a. Foam b. Hydrogel c. Impregnated gauze d. Calcium alginate ANS: D

An alginate dressing can both absorb various amounts of drainage and be packed into the defect to fill the wound. Foam dressings are suitable for moderate-to-heavy amounts of wound drainage but are not used for packing. A hydrogel dressing is unsuitable for a wound with heavy drainage because it is designed to maintain a moist environment for the wound bed.

Impregnated gauze dressings are used for débridement.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

13. A patient with darkly pigmented skin is on bed rest and is being assessed for a possible stage

1 pressure injury. What datum about the area of concern will best help the nurse determine the correct staging assessment? a. The skin will be slightly broken. b. The skin color is darker than surrounding tissues. c. The tissue is the same temperature as surrounding tissues. d. The skin blanches easily.

ANS: B

Early detection of pressure ulcers for a patient with dark skin is problematic because initial N skin changes are difficult to distinguish.

Characteristics of impaired skin integrity for patients with dark skin include changes in skin color, especially skin darkening or areas of purplish or bluish tones as cells begin to exhibit clinical indications of hypoxia. If the skin is already broken, the patient is not “at risk” but rather has a skin integrity issue. The tissue can be warmer or cooler than adjacent tissue. Blanching may not be visible in a person with darkly pigmented skin.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

14. The patient requires prone positioning for a severe respiratory condition. Which areas are at

risk for developing a pressure ulcer and require pillow bridging as a prevention strategy? a. Chin and knees b. Nose and elbows c. Occipital and parietal areas d. Sacrum and coccyx ANS: A

In the prone position, the nurse positions the patient face down on the bed with the head turned to the side or with a special face pillow that has a hollow center. Areas subject to pressure injury in this position include the chin, knees, and pre-tibial crest. The other areas are not subject to excessive pressure in the prone position.

DIF: Cognitive Level: Understanding

OBJ: NCLEX: Physiological Integrity

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TOP: Nursing Process: Assessment | Nursing Process: Planning 15. A patient has a slight skin breakdown in the perianal area from incontinent stools. For which

combination of therapies does the nurse obtain an order? a. Moisture barrier ointment b. Hydrogen peroxide for cleansing c. Fecal incontinence bag d. Calcium alginate dressings ANS: C

A moisture barrier ointment will protect the perianal skin from further breakdown from exposure to fecal material.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

16. The nurse assesses the patient’s pressure ulcer after 2 weeks of ambulatory wound care and

observes pink tissue at the base of the wound. Which intervention by the nurse is most appropriate? a. Refer the patient to a dietitian to improve nutrition. b. Alter the wound care to include a débriding agent. c. Collaborate with the health care provider for wound culture. d. Recommend a hydrocolloid wound dressing.

ANS: D

Pink tissue in the wound base is consistent with clinical indicators of granulation tissue; thus the nurse recommends using a hydrocolloid dressing to maintain a moist environment and protect the wound base becauseNa moist environment facilitates healing. The appearance of granulation tissue indicates that the patient’s wound is healing. The patient may or may not need a referral to a dietitian and the nurse would assess for nutritional deficits that would make this referral appropriate. The wound does not contain cellular debris or necrotic tissue; thus débridement is not indicated. The wound does not have clinical indicators of infection, which would include exudate and foul odor.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

17. The nurse is positioning a patient at risk for development of a pressure injury. Which potential

pressure point(s) does the nurse relieve by assisting the patient to a side-lying position? a. Symphysis pubis b. Ischial tuberosities c. Greater trochanters d. Occipital prominence ANS: D

The nurse positions the patient in the lateral position to prevent pressure on the back of the patient’s head. Pressure can develop over bony prominences when a patient is allowed to remain in one position too long. The patient exerts pressure on the symphysis pubis in the prone position although it is not common. The nurse assists the patient to the supine position to avoid pressure on the ischial tuberosities and the greater trochanters.

DIF: Cognitive Level: Understanding

OBJ: NCLEX: Physiological Integrity

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TOP: Nursing Process: Planning 18. The nurse observes a thick, dark brown covering over a large wound and needs to stage the

wound. What action by the nurse is most appropriate? a. Removing this covering with a sterile forceps and scissors b. Filling the base of the patient’s ulcer with a silicone lotion c. Placing a hydrocolloid dressing directly over the tannish-brown covering d. Deferring staging until the brown covering has been removed ANS: D

The dark brown covering is eschar, which has formed as a result of the severe tissue injury.

Until the base of the wound can be seen, the true depth and therefore the stage cannot be determined. Eschar is not always removed. If the nurse applies the dressing over eschar, the dressing effectively seals the necrotic tissue onto the wound bed. Silicone lotion is contraindicated for use in a large crater. A hydrocolloid dressing creates its own seal and cannot be used until the eschar has been removed.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

19. Which rationale pertaining to a patient best justifies the suggestion by the nurse to use a

support surface or special mattress? a. It eliminates pain and discomfort. b. It prevents joint contractures. c. It eliminates the need for turning. d. It reduces risks of immobility.

ANS: D

N

The nurse recommends a support surface or special mattress for the patient to reduce the risks associated with immobility (i.e., impaired skin integrity) by reducing or relieving pressure on the patient’s skin, especially at the bony prominences. Support surfaces or special mattresses do not eliminate pain and discomfort. Contractures are prevented with range of motion, physical therapy, and splints. The nurse continues to turn and reposition the patient on a support surface as part of care.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

20. The patient’s sacrum has nonblanching redness on Monday. On Wednesday the nurse

determines that the pressure ulcer on the patient’s sacrum is stage 2 despite skin care, including an air-filled mattress overlay. Which is the best nursing intervention to implement now? a. Document the extreme progression of the patient’s pressure ulcer. b. Collaborate with the health care provider for physical therapy. c. Reassess the patient’s need for a different support surface or bed. d. Increase the frequency of bathing and linen changes as needed.

ANS: C

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The patient’s pressure ulcer is deteriorating. This means that the current skin care plan is unsuccessful and needs reevaluation; thus, the nurse should assess the patient for a different support surface. He or she should document the patient’s skin assessment, but the best response to the patient’s deterioration is to reassess the skin care plan and amend it. Nursing collaboration for physical therapy is a reasonable response and potentially benefits the patient on a support surface, especially if the patient is on bed rest; however, the nurse needs to first assess the patient to determine whether physical therapy is indicated for the patient. He or she provides bathing for a patient with a pressure ulcer on a routine and as-needed basis but avoids planning frequent baths and linen changes as therapy because excessive bathing strips the skin of essential moisture and surface oils.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

21. The student nurse is caring for a patient with a continuous bedside pressure mapping device

and asks the faculty to explain the purpose of this intervention. What response by the faculty is best? a. Reduces the need to turn the patient frequently. b. Provides real-time data regarding pressure on patient surfaces. c. The alarm alerts the staff when the patient tries to exit the bed. d. They adjust the flow of air in specialty beds.

ANS: B

A continuous bedside pressure mapping device provides real-time data about pressure the patient’s body surfaces are encountering. The staff would use this data to reposition the patient as needed, guided by the pressure images. It does not reduce the need to turn patients often, alarm when the patient attempts to get up, or adjust the flow of air in specialty beds.

N DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

22. A nurse is caring for four patients who all have a Braden Scale score of 13. What intervention

by the nurse is most appropriate? a. Delegate turning all the patients at the same time. b. Consult the wound-ostomy-continence nurse. c. Assess the factors that increase each patient’s risk. d. Request specialty beds or overlays for each patient.

ANS: C

Many factors are assessed with the Braden Scale, including sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The nurse would plan care based on the individual factors that increase each patient’s risk of pressure injury. This holistic approach would have the best chance of being successful. Turning all patients at the same time is not individualizing care. The nurse may or may not need to consult the wound-ostomy-continence nurse. Depending on the risk factors, a specialty bed or overlay may be appropriate for some patients.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

23. The nurse assesses the patient’s skin. What does the nurse document for this injury?

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a. b. c. d.

Stage 1 pressure injury Stage 2 pressure injury Incontinence dermatitis Unstageable injury

N

ANS: B

This picture shows a stage 2 pressure injury.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. The nurse is planning care for a group of patients and is concerned about skin breakdown and

delayed wound healing. Which of the following patients are likely to be at a higher risk for impaired wound healing should they develop a pressure ulcer? (Select all that apply.) a. An elderly patient with mobility issues b. A young diabetic patient in traction and on bed rest c. A teenager receiving chemotherapy d. An elderly person with stage IV congestive heart failure e. A middle-aged patient with frequent headaches having back surgery ANS: A, B, C, D

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Risk factors that delay wound healing include age (older adults have a diminished inflammatory response), obesity, diabetes, compromised circulation, malnutrition, immunosuppressive therapy, chemotherapy, and high levels of stress. An elderly person is at risk due to age; a diabetic is at risk especially if in traction; the teenager on chemotherapy is at risk due to the chemotherapy, which can also affect nutrition status and immunity. The elderly patient with heart failure has two risk factors: his age and circulatory status. The patient with frequent headaches having back surgery currently has no specific risk factors.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

2. The nurse is concerned about device-related pressure ulcers in a group of patients. Which of

the following interventions are most appropriate to reduce this risk? (Select all that apply.) a. Perform frequent skin assessment under devices and tubes. b. Remove the device periodically to protect the skin. c. Rotate tubes to different positions to relieve pressure. d. Implement pressure injury care bundles. e. Do not remove the adhesive tape until it is time to remove the device.

ANS: A, C, D

Medical devices known to contribute to pressure ulcers include nasogastric tubes, endotracheal tubes, urinary catheters, and other plastic, rubber, or silicone tubes. It is thought that the device-related pressure ulcer may occur because of poor fixation or positioning of the equipment. To prevent breakdown, the following should be done: 1. Frequently perform skin assessment around and under devices and tubes.

2. Remove adhesive tape and assess underlying skin; determine if another type of tape is needed.

N 3. Rotate tubes to different positions to decrease pressure in the area where the tube is in contact with the skin. For example, endotracheal (ET) tubes can be moved from one side of the mouth to the other.

4. Double-check and determine that the tube or device is properly positioned and has proper fixation to decrease unnecessary tube movement and skin damage.

5. Implement care bundle for pressure ulcer prevention.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

3. The nurse is delegating care to the NAP. Which of the following indicates the nurse is

appropriately delegating tasks related to pressure ulcer care? (Select all that apply.) a. The nurse asks the NAP to report any redness in the patient’s skin. b. The nurse explains to the NAP to reposition the patient every 2 hours. c. The nurse asks the NAP to assess the patient’s risk factors for skin breakdown. d. The nurse explains to the NAP which positions the patient should be repositioned in. e. The nurse asks the NAP to record the patient’s nutritional intake.

ANS: A, B, D, E

The skill of pressure ulcer risk assessment may not be delegated to nursing assistive personnel (NAP). Instruct the NAP about the following: 1. Explaining frequency of position changes and specific positions individualized for the patient.

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2. Reviewing need to report to you any redness or break in the patient’s skin or any abrasion from adhesives, tubes, assistive devices, or other medical devices.

3. Recording the patient’s nutritional intake is important as malnutrition delays wound healing.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

4. A malnourished patient has a deep pressure injury. The nurse collaborates with the patient to

obtain foods containing which substances in meals and snacks to benefit wound healing?

(Select all that apply.) a. Calcium b. Protein c. Vitamin C d. Zinc e. Selenium ANS: B, C, D

Malnutrition delays wound healing. Nutrients important to healing include protein, vitamin C, and zinc. Calcium and selenium are substances found in a healthy diet, but do not specifically contribute to wound healing.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

5. Which medical devices place the patient at risk for device-related pressure injury? (Select all

that apply.) a. Oxygen mask b. Indwelling catheter c. Compression stockings d. Immobilization devices e. Nasogastric tubes

N

ANS: A, B, C, D, E

Any medical device touching the patient can lead to pressure injury.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

MATCHING

Match the patient factors to the pathophysiology of delayed wound healing. a. Decreased inflammatory response b. Causes vasoconstriction c. Presence of less vascular tissue d. Immunosuppression and decreased collagen synthesis e. Vascular changes and leukocyte malfunction 1. Obesity 2. Smoking 3. Advanced Age

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4. Diabetes 5. Corticosteroids 1. ANS: C DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: Fatty tissue has reduced blood supply because it is less vascular.

2. ANS: B DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: Smoking leads to vasoconstriction.

3. ANS: A DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: A normal age-related change is a decrease in the immune system functioning, including reduction in the inflammatory response which is needed for healing.

4. ANS: E DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: Exposure to high blood glucose in diabetes has many deleterious effects, including vascular changes that reduce blood flow to tissues and leukocyte malfunction.

5. ANS: D DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MSC: Use of corticosteroids can cause immunosuppression and decreased collagen synthesis.

N

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Chapter 27: Dressings, Bandages, and Binders Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse applies a circumferential gauze dressing to a patient’s amputated leg. Which

method should the nurse use to decrease edema in the extremity? a. Montgomery straps b. An adhesive tape wrap c. A figure-eight wrap d. A circular turns dressing ANS: C

The nurse applies a dressing around the extremity using the figure-eight method to avoid restriction of blood flow and main venous return. This allows the dressing to be anchored by wrapping gauze in alternating directions that ascend and descend with oblique, overlapping turns. The terminal end of the dressing is secured with a short piece of tape, taking care not to restrict blood flow in any manner. Montgomery straps are contraindicated for dressing an extremity because the circumference is usually too small to make them practical. Adhesive tape potentially constricts blood flow to the extremity if it is wrapped tightly over itself in a circumferential manner. Circular turns dressings are used on small parts like fingers or toes, but are too constricting to use on larger body parts.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

N

2. The nurse assigns patient care to nursing assistive personnel (NAP). Which wound care tasks

should the nurse assign to this staff member? a. Apply the hydrocolloid dressing. b. Assess dimensions of the wound. c. Report visible drainage on the dressing. d. Change the first postoperative dressing.

ANS: C

The nurse assigns reporting visible drainage on the dressing to the NAP because this individual is trained to perform this wound care task. It is essential to review what needs to be looked for and what to report back to the nurse. The remaining wound care tasks require critical thinking and nursing judgment, assessment, and evaluation skills that the nurse cannot delegate because he or she owes these duties to the patient. In addition, the nurse avoids delegating the first postoperative dressing change because it is a sterile procedure requiring the same nursing skills and judgment.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

3. The nurse plans care for the patient’s wound that requires a moist-to-dry dressing. Which

should the nurse use for an expected patient outcome several hours after applying a new dressing? a. The patient states that the dressing feels cold. b. The dressing is dry and intact.

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c. The dressing has bright red drainage. d. The patient states that the pain level is 8 on a scale of 1–10.

ANS: B

The nurse uses a moist-to-dry dressing for wound débridement and exudate collection because cellular debris and exudate in a wound bed delay healing. The nurse expects the dressing to absorb wound drainage and to be dry and intact. The dressing should feel cold as the nurse applies the moist gauze, not later. It should absorb drainage, not cause drainage to increase and penetrate the layers of dressing material. Pain rated as 8 on a scale of 1–10 is severe and warrants further investigation by the nurse because a dressing should provide patient comfort.

DIF: Cognitive Level: Applying TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

4. The wound care nurse prepares to dress the wounds of four patients. Which wound should

receive a transparent film dressing? a. A clean, superficial laceration b. A deep leg ulcer with infection c. A puncture wound with bleeding d. A large laceration over the eyebrow ANS: A

An indication for a transparent film dressing includes a clean, superficial laceration because transparent dressings adhere to wounds and are nonabsorbent. A transparent dressing is contraindicated for a deep ulcer because the dressing is adherent; in addition, a deep ulcer most likely drains exudate or requires débridement, contraindicating the use of the dressing.

The nurse avoids using the transparent dressing for the bleeding puncture wound because he N or she first applies a pressure dressing to stop the bleeding and then dresses the wound with an absorbent dressing to collect subsequent drainage. Because the dressing is adherent, the nurse avoids using a transparent dressing over a large laceration. The laceration is likely to require sutures or Steri-Strips to close the wound; thus the nurse avoids using a dressing that can pull on the fragile wound edges.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

5. The nurse is caring for a patient with a history of chronic respiratory problems who has an

abdominal binder in place. Which should the nurse instruct nursing assistive personnel (NAP) to report as an unexpected outcome? a. The skin around the binder is dry without redness or edema. b. The patient experiences difficulty moving around in bed. c. The patient’s pain level has changed from 8 to 6 on a scale of 1–10. d. The respiratory rate has decreased from 17 to 15 breaths per minute.

ANS: B

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The patient’s activity should not be hampered by the binder. The nurse needs to assess the patient’s ability to move in bed before the binder is applied and reassess after the binder has been in place for a short time. The binder may be too tight, and loosening it may be enough to allow more mobility by the patient. Assessing the skin around the binder and evaluating trends in data are nursing tasks requiring nursing assessment skills and nursing judgment and evaluation; thus the nurse avoids delegating skin assessments and data analysis. Determining the patient’s pain level is a nursing function requiring assessment skills. The nurse expects the NAP to report the respiratory rate, even if normal, and the nurse draws conclusions about the data reported.

DIF: Cognitive Level: Applying TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

6. The nurse delegates applying a binder over the patient’s abdominal incision to nursing

assistive personnel (NAP). Which does the nurse include in the NAP’s instructions? a. Start the binder right under the axilla. b. Place the patient in a semi-Fowler’s position. c. Secure the binder with metal fasteners. d. Remove the old dressing and apply a binder.

ANS: C

The nurse instructs the NAP to secure the binder with metal fasteners, Velcro strips, or safety pins to keep the dressing in place. This prevents the binder from opening accidentally and increasing the risk of patient infection. If the NAP starts right under the axilla, the binder will encase the thorax, potentially impairing the patient’s ability to oxygenate, ventilate, cough, and deep breathe thereby increasing the risk of hypoxia, acidosis, atelectasis, and pneumonia.

The NAP is instructed to placeNthe patient in the supine position to apply the binder because in that position the patient may assist the NAP by rolling from side to side. This allows the NAP to place the fanfolded binder under the patient so it may be drawn around the abdomen. The nurse instructs the NAP to apply the binder after the sterile dressing change is completed to prevent patient infection and protect the wound.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

7. The nurse prepares to perform a dressing change on an ulcerated area. Which principle does

the nurse apply while performing a dressing change? a. The dead space found in an ulcer should be packed tightly. b. The wound should be débrided using multiple dry gauze pads. c. The dressing should absorb exudate without damaging the wound bed. d. The wound bed should be dried to stimulate granular tissue.

ANS: C

The dressing should absorb drainage but, when removed, should not interfere with the healing that has occurred in the wound bed. The dead space in a wound is lightly packed to absorb exudate. The purpose of a dry dressing is protection for wounds with minimal drainage. Dry dressings do not interface with the wound, and débridement uses a wet-to-dry or moist-to-dry dressing. If exudate saturates a dry dressing, the nurse removes and changes it quickly or reinforces it. The nurse keeps the wound bed moist to promote healing, because a moist wound bed stimulates formation of granulation tissue, and keeps the area around the wound dry to keep it clean.

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DIF: Cognitive Level: Understanding TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

8. The nurse is preparing to dress an open, shallow wound with a moderate amount of drainage.

Nursing care is correct if the nurse chooses which dressing material? a. Alginate nonwoven b. Adhesive transparent dressing c. Hydrocolloid adhesive d. Foam nonadherent pad ANS: C

Hydrocolloid dressings are the best choice for this wound. They are adhesive dressings composed of gelatin, pectin, and absorbent material suitable for stages 1–4 pressure ulcers with minimal-to-moderate exudate. Although hydrocolloid adhesive is a versatile product, the nurse considers its propensity for skin maceration if left in place beyond its recommended time. Alginate dressings are absorbent and indicated for use with partial- and full-thickness wounds that drain moderate-to-heavy amounts of exudate. This dressing is expensive and needs to be changed daily. Transparent film dressing is appropriate for shallow wounds with minimal exudate to protect the wound and promote autolytic débridement. Foam pads are used for partial- and full-thickness wounds that drain moderate-to-heavy amounts of exudate; a secondary dressing is required.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

9. The nurse removes the patient’s hydrocolloid dressing and observes minimal clear, watery

drainage. Which action should N the nurse take at this time? a. Evaluate for leukocytosis. b. Change to foam dressing. c. Collaborate with the health care provider. d. Document serous drainage.

ANS: D

The nurse documents that there is serous drainage after the dressing change to record the wound drainage accurately. Serous drainage is a benign finding. Leukocytosis indicates infection, inflammation, or malignancy. If the patient has leukocytosis, the nurse determines that the wound is probably not the cause because serous drainage is a benign finding and inconsistent with clinical indicators of infection. The nurse uses a dressing indicated for wounds with minimal exudate and does not need to collaborate with the health care provider because serous drainage from the wound is consistent with a successful wound care protocol.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

10. The nurse prepares to change the patient’s dressing over a surgical incision without drainage

but palpates a ridge along the suture line. Which dressing should the nurse apply to this wound? a. Foam pad b. Wet-to-dry c. Transparent film

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d. Dry sterile gauze ANS: D

The nurse uses a dry sterile gauze dressing over the surgical incision because a nondraining incision with a healing ridge is consistent with clinical indicators of a properly healing surgical incision. The nurse chooses this dressing because the incision needs protection. The surgical incision has no drainage; thus a foam pad dressing is contraindicated because it is intended for use with partial- to full-thickness wounds with moderate-to-heavy drainage. A wet-to-dry dressing is contraindicated for use with a nondraining surgical incision but is indicated for mechanical débridement of wounds. A transparent film dressing is a reasonable choice to protect the wound because the wound may be observed through it; however, the nurse avoids choosing this dressing to cover a surgical incision because removing the dressing pulls on the fragile borders of the incision.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

11. The nurse needs to apply a dry sterile dressing. Which should the nurse implement first? a. Inspect the appearance of the wound. b. Remove excess moisture from the wound. c. Cleanse with sterile saline solution. d. Prepare the sterile field for supplies.

ANS: A

After removing the old dressing, the nurse assesses the wound for color, size, depth, drainage, and edema and compares the findings with baseline data. The nurse takes the conclusions from the assessment to plan follow-up nursing care. After the assessment, the nurse creates the sterile field to maintain the Nintegrity of sterile supplies in preparation for the dressing change. He or she cleanses the wound using sterile saline or an antiseptic swab and blots the excess moisture to reduce the risk of infection.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

12. The nurse is caring for a patient who requires a moist-to-dry dressing. Which action by the

nurse is appropriate during the procedure? a. Applies a dry absorbent outer dressing. b. Packs flat gauze into the wound bed. c. Soaks the wound packing with antiseptic. d. Moistens the old dressing before removal.

ANS: A

The nurse applies a dry secondary dressing over the wound for protection and infection control and to contain the moist packing. He or she squeezes excess moisture from the fine mesh gauze and packs the wound with the gauze compressed from squeezing to facilitate drainage and debris collection. The gauze used for packing is soaked with sterile saline solution or another isotonic solution. To facilitate débridement, the nurse removes the old dressing without dampening it.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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13. The nurse inspects a patient’s surgical incision and notes dehiscence several inches long.

Which is the most important intervention for the nurse to implement? a. Call for assistance. b. Place a sterile moist dressing on the wound. c. Apply direct pressure over the wound dressing. d. Apply a pressure dressing over the open area.

ANS: B

The most important interventions for the nurse to take are to have the patient lie still, place moist sterile dressings over the area and cover it with dry pads, and notify the health care provider. The nurse should not put any pressure on the area that has dehisced. A pressure dressing is contraindicated for this type of opening. A pressure dressing would be used over a bleeding wound or puncture area after a procedure.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

14. The nurse assesses the patient’s transparent film dressing and observes white opaque exudate

and reddened and edematous wound edges. Which is the priority intervention for the nurse to implement? a. Record the observation in the patient’s record. b. Remove the white exudate carefully. c. Obtain an order for a wound culture. d. Apply a light absorbent dressing.

ANS: C

The nurse suspects an infected wound because exudate can indicate wound debris from an infection. Although all of theseNimplementations may be performed, the priority is to start effective treatment for the suspected infection, so the culture must be obtained as soon as possible. The nurse notifies the health care provider so an order can be written for the culture then obtains a wound specimen sample for testing. The nurse must obtain the culture before antimicrobial therapy begins. The wound assessment is recorded after completing wound care and obtaining the culture.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

15. The nurse is applying a gauze bandage to hold a dressing on a patient’s wrist since the patient

is allergic to tape. Which technique would be most appropriate for the nurse to use? a. Montgomery straps b. A 7.6-cm (3-inch) bandage wrapped proximal to distal c. A 2-inch bandage using the spiral wrap technique d. A loosely wrapped elastic bandage using a recurrent turn ANS: C

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The nurse needs to secure the dressing in place using a small bandage because the wrist is small and a spiral wrap covers the area effectively without compression. A Montgomery strap is inappropriate because of its large size and adhesive backing. A 7.6-cm (3-inch) bandage is most commonly used for the adult leg and should be wrapped distal to proximal to promote venous return. An elastic bandage is generally used for simple intermittent compression. The recurrent turn is used to cover uneven body parts such as the head or the residual limb after an amputation.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

16. The nurse is assisting a patient with putting on an abdominal binder. In which position does

the nurse place the patient? a. Semi-Fowler’s b. Supine c. Prone d. High-Fowler’s ANS: B

The nurse positions the patient in supine position with head slightly elevated and knees slightly flexed. None of the other positions would allow the nurse to secure the binder correctly.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

17. The patient started bleeding profusely from a surgical wound on the thigh. Nursing care is

N action to care for this patient? appropriate if the nurse takes which a. Assesses the wound for sinus tracts and tunneling. b. Applies roller gauze over the gauze pads on the extremity using a figure-eight pattern. c. Obtains sterile gauze and sterile gloves. d. Has nursing assistive personnel (NAP) apply the pressure dressing.

ANS: B

Assessing the wound for sinus tracts and tunneling would increase the hemorrhaging. Since this is a fresh wound there is no need to do this. The figure-eight pattern of wrapping acts as a pressure dressing, exerting even pressure over the extremity. Assessment has indicated that the patient is hemorrhaging. Pressure needs to be applied to the area to prevent blood loss and patient deterioration. Sterile technique is not the priority at this time. As long as the dressings are clean, they can be applied. The nurse needs only clean gloves. The skill of applying a pressure bandage in an emergent situation should not be delegated to the NAP. If the application requires more than one person, the NAP can assist the nurse as directed.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

18. The wound care nurse prepares wound care supplies. Which patient assessment datum cues

the nurse to provide Montgomery straps to promote wound healing? a. Heavy exudate b. Deep laceration

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c. Femoral dressing d. Wound dehiscence ANS: A

The patient with heavy exudate will need repeated dressing changes and Montgomery ties will allow access to the wound while protecting the skin. The repeated removal of an adhesive bandage in this situation could damage the skin. A deep laceration often requires varying amounts of surgical repair after cleansing. After approximating the laceration with sutures or staples, the nurse would apply a dry dressing. A femoral dressing usually covers the crease created by the hip and thigh; thus the area does not lend itself to Montgomery straps. Because of leg movement and the close proximity to the groin, a simple dressing works best. Wound dehiscence requires surgical repair. If tension on the suture line is an issue, the patient can benefit from a binder to support the incision.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

19. The nurse dresses the surgical incision on the patient’s elbow. Which method of securing the

bandage should the nurse use with this patient? a. Spiral b. Circular c. Recurrent d. Figure-eight ANS: D

The nurse uses a figure-eight bandage to cover the patient’s elbow dressing because it involves oblique, overlapping turns of the gauze roll, lending itself to use on a joint. By N the humorous and radial and ulnar bones, the bandage alternating the oblique turns around anchors the dressing and immobilizes the joint. Overlapping, ascending turns of the spiral dressing effectively anchor a dressing to the upper or lower arm separately but do not secure the dressing at the elbow effectively because the dressing anchors at the beginning and the end. Bandage turns overlapping one another are as effective for the elbow as the spiral dressing. The recurrent dressing is most effective on the skull or a stump because the bandage folds back on it to cover the region. The nurse avoids choosing this bandage for an elbow because the bandage needs to cover a center portion of the arm versus the terminal end of an extremity.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

20. The nurse is preparing to change a moist-to-dry dressing on a patient. After correctly

identifying the patient, what is the next most appropriate step for the nurse to perform? a. Assess patient/family’s knowledge of the purpose of the dressing change. b. Assess the dressing for the presence of drainage. c. Ask the patient to rate his or her wound pain. d. Review the order for the type of dressing.

ANS: C

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The first step the nurse should do after identifying the patient is to determine if the patient is having any wound pain. It is important to administer prescribed analgesic as needed 30 minutes before the dressing change because giving pain medication before dressing change achieves peak effect of the drug during the procedure. Assessing the dressing for drainage, reviewing the orders, and assessing the patient’s knowledge are important but can be done after the pain has been assessed and treated so that the pain medication can have time to reach peak effect when the dressing change begins.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

21. The nurse has applied a transparent dressing to facilitate débridement of the pressure ulcer.

How often should the nurse change that dressing? a. Every 6 days b. Every day c. Every 3–4 days d. Every 12 hours ANS: B

Transparent dressings are normally changed every 3 or 4 days or as needed; however, if using the dressing to facilitate autolytic débridement, it should be changed every 24 hours.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

N

1. The nurse is working with a student nurse to provide care to a patient with a pressure injury.

The student nurse describes characteristics of an ideal dressing. Which of the following statements indicate the student needs more education? (Select all that apply.) a. The dressing should keep the wound bed dry. b. The dressing can be removed without causing trauma. c. The dressing should conform to the body to allow for movement. d. Cost should not be a consideration. e. Should be easy for the patient to change after discharge.

ANS: A, D

The characteristics of an ideal dressing include a dressing that is able to absorb exudate yet keep the wound bed moist but the surrounding periwound area dry and intact, be appropriate for infected wounds, conform to the body for ease of movement, maintain physiological wound environment, and be cost-effective. If the patient cannot change the dressing, assistance can be obtained such as a visiting nurse.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. The nurse is caring for a patient with a pressure injury. The nurse would expect which of the

following outcomes if the patient’s wound is healing? (Select all that apply.) a. Pain intensity is reduced during dressing changes. b. The depth of wound is reduced. c. The amount of exudate increases.

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d. The amount of necrotic tissue decreases.

ANS: A, B, D

Outcomes of wound healing include a reduction in the volume of exudate and amount of necrotic tissue. In addition, periwound erythema resolves, there is a reduction in wound dimensions or depth, and there is a reduction in pain intensity during dressing changes.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

COMPLETION 1. A highly absorbent nonwoven material that forms a gel when exposed to wound drainage is

called a(n) __________ dressing.

ANS:

alginate This product is derived from brown seaweed and used for moderate-to-heavy exudating wounds.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. A _______ is a fungal or bacteria-embedded slimy matrix of proteins and sugars that adhere

to the surface of a wound bed.

ANS:

N

biofilm These biofilms are known to contribute to infections, especially in chronic wounds. Biofilms contribute to inflammation and an increased production of exudates and slough.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

3. A ______dressing is contraindicated in ischemic wounds with dry eschar and third-degree

burns or wounds that tunnel.

ANS:

foam Foam dressings are used to protect wounds and maintain a moist healing environment. They are contraindicated in ischemic wounds with dry eschar and third-degree burn wounds.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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Chapter 28: Intravenous Therapy Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. After inserting a peripheral IV line into the patient, the nurse provides patient teaching about

the IV insertion site. What information does the nurse give to the patient? a. Expect minor pain at the insertion site. b. Report redness at the insertion site. c. Remain on bed rest with the IV infusion. d. Disconnect IV tubing to change a gown.

ANS: B

The nurse instructs the patient to report redness at the insertion site for early detection of IV complications, including infection and phlebitis. The IV site should cause very little discomfort if the infusion is proceeding without problems. Pain associated with an IV infusion indicates vein irritation from infusing fluid, irritating medication, infiltration, extravasation, infection, or phlebitis. Patients with IV infusions are not confined to bed. The nurse instructs the patient to call for help when changing the gown because, if the gown has no snaps at the shoulder, the nurse must feed the IV tubing and bag through the opening of the gown when the gown is changed.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. The nurse is trying to access the best insertion site on a patient for IV therapy. Which

N

principle would the nurse use to achieve this goal? a. Avoid using soft, bouncy veins. b. Choose the patient’s best proximal vein. c. Choose a site large enough for adequate blood flow. d. Always use the smallest-gauge IV catheter available.

ANS: C

The site must be large enough to prevent interruption of venous flow while allowing adequate blood flow around the catheter. The nurse chooses a site for venipuncture with soft, bouncy veins because these veins are more easily punctured and stabilized during the insertion. The most distal vein is the best for insertion to maintain the maximum number of potential sites for future use. The smallest-gauge IV catheter suitable for both the therapy and the patient’s vein should be selected, which may not be the smallest available.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

3. The health care provider’s order reads, “Administer 5% dextrose solution with normal saline

(D5NS) intravenously now.” What action does the nurse perform first? a. Infuse a bolus of D5NS to the patient now. b. Regulate an IV infusion pump at 125 mL/hr. c. Call the health care provider to clarify the order. d. Perform venipuncture with a butterfly needle.

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ANS: C

The only recourse for the nurse is to clarify the order because it is incomplete. It is missing an infusion rate. You would not start an IV or give the IV until you have the infusion rate information. Butterfly needles would not be used for a continuous infusion.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

4. The prescription for the patient’s IV infusion reads, “100 mL/hr.” The nurse observes that the

patient’s IV line infused 125 mL in addition to the ordered volume after 2 hours. Which is the most important intervention for the nurse to implement? a. Compare weight to baseline data. b. Replace the infusion pump batteries. c. Assess the patient for respiratory distress. d. Reduce the infusion rate below 75 mL/hr.

ANS: C

The nurse assesses the patient for respiratory distress after an excessive infusion of 125 mL of IV fluid because excess total body fluid often leaks into the pulmonary vascular bed to decrease gas exchange. This may lead to hypoxemia and dyspnea because the patient has difficulty with oxygenation, and there can be enough fluid overload to precipitate heart failure in a patient with heart disease or respiratory failure in a patient with pulmonary disease.

Weighing the patient is a reasonable nursing intervention to differentiate patient weight gain from fluid or caloric intake but would be done later. Verifying patient safety and well-being is a better choice and is more important than differentiating the weight because the extra fluid can cause dyspnea, desaturation, and heart failure. Checking the infusion pump batteries is a reasonable intervention if the pump operates on battery power. The nurse can reduce the N infusion rate to 75 mL/hr after collaborating with the health care provider. The nurse cannot change the infusion rate independently because doing so is out of the nurse’s scope of practice.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

5. The patient has an intermittent infusion device inserted in the hand. Which strategy does the

nurse use to prevent the IV catheter from being dislodged? a. Instruct the patient how to protect the IV site. b. Apply a new sterile dressing every day. c. Change the IV tubing at least daily. d. Flush the IV catheter every morning.

ANS: A

The most important prevention strategy for the nurse to implement is to instruct the patient to protect the IV site by reducing trauma, keeping the IV line in sight, and getting out of bed properly. Less manipulation or trauma to the IV site reduces IV irritation and maintains a better seal at the skin to prevent the entry of microorganisms. IV dressings for primary and secondary infusions are changed at least every 5–7 days, or when needed due to soiling or disruption. Daily flushing of the IV access is not related to preventing the catheter from being dislodged. The nurse changes the IV tubing according to agency policy to prevent infection, depending on the type of solution being infused. Intermittent infusion devices are flushed more often than once a day.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

6. The nurse observes fine white crystals in the IV tubing that is infusing an antibiotic. Which

action by the nurse is most appropriate? a. Tell the patient that this is a common occurrence. b. Stop the infusion and notify the health care provider. c. Flush the tubing with normal saline solution. d. Attach a 0.22-micrometer inline IV filter.

ANS: B

White crystals in IV tubing indicate precipitation of a substance in the infusion, most likely the medication because it is the solute with the highest concentration. If the crystals enter the patient, they can behave like emboli, occluding tiny vessels, and cause regional irritation. At a minimum, the crystals usually occlude the IV line. The nurse stops the infusion, discards the IV tubing, checks to ensure compatibility of all agents in the infusion, and notifies the health care provider. The IV access potentially needs to be changed. The nurse avoids telling the patient that this is a common occurrence because it is a complication of an IV infusion. He or she avoids flushing the tubing because injecting a fluid bolus increases the risk of infusing a crystal into the patient. He or she uses an IV filter when indicated for effective therapy.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

7. The nurse observes that the patient’s left cephalic IV site is cool, swollen, and mildly tender,

although the IV line is infusing at the prescribed rate. Which action does the nurse take first?

N his or her arm on two pillows. a. Instruct the patient to elevate b. Discontinue the IV infusion and start one in the right arm. c. Apply a warm, moist compress to the IV site. d. Reassess the IV site in 2 hours for any change.

ANS: B

The patient’s IV site is infiltrated; thus, the nurse should discontinue the infusion immediately and start another IV infusion, preferably in the other arm. If the right arm is contraindicated, the nurse chooses a subsequent site that is proximal to the original site to avoid additional irritation of the vein. An infiltrated IV site increases the risk of regional phlebitis. The nurse can apply a warm, moist compress to facilitate healing and provide comfort once the IV line has been removed. After the nurse discontinues the IV infusion, he or she instructs the patient to elevate the arm to reduce edema because this technique facilitates venous return.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

8. The nurse is explaining to nursing assistive personnel (NAP) how to help maintain the

patient’s IV therapy. What action regarding IV therapy can be delegated to the NAP? a. Adjusting the infusion rate b. Changing the IV dressing c. Reporting patient complaints d. Administering IV antibiotics ANS: C

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The nurse delegates very little to the NAP related to IV therapy. The NAP is expected to report patient complaints to the nurse because he or she receives training to perform this task; however, the nurse must determine the meaning of the complaint and how to resolve it. The nurse retains responsibility for adjusting the infusion rate, changing the dressing, and administering IV antibiotics because these nursing tasks require critical thinking and nursing judgment.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

9. The nurse feels resistance while trying to flush the IV line with a 5-mL syringe of normal

saline solution before administering a medication by IV bolus. Which action does the nurse implement next? a. Use a 3-mL syringe to flush. b. Aspirate the IV line for a blood return. c. Check for causes of resistance. d. Inject the IV medication slowly.

ANS: C

The nurse checks for causes of resistance, such as clamped or kinked tubing. If the IV site is occluded, the nurse discontinues the IV infusion and inserts another IV line in another site.

Using a 3-mL syringe increases the potential pressure delivered by the flush. The smaller the syringe, the higher the pressure exerted on the vein. Blood return is only one indicator of IV patency; thus, the nurse avoids basing follow-up nursing care on the blood return alone. He or she avoids injecting the medication to prevent complications.

DIF: Cognitive Level: Applying N TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

10. The nurse infuses a unit of blood, but after 4 hours the blood infusion is not complete. Which

action is most appropriate? a. Check the IV access for patency. b. Increase the infusion rate of the blood. c. Discontinue the blood infusion. d. Assess the patient for an ABO mismatch.

ANS: C

The nurse infuses whole blood or packed red blood cells within a 4-hour time limit; thus, if the infusion is incomplete at the end of 4 hours, the nurse must discontinue it to decrease the risk of adverse transfusion effects because the blood has warmed sufficiently to promote microorganism growth. Checking the IV access for patency is a reasonable intervention because at the end of 4 hours the IV access is likely to have fibrin deposits or small accumulations that impede infusion rates. However, the nurse must discontinue the blood infusion first because after 4 hours, the blood is not safe to infuse. He or she avoids increasing the infusion rate to complete the transfusion because it increases the risk of fluid volume overload. Although delayed transfusion reactions occur, if a mismatch exists between the blood and the patient, the patient is more likely to manifest reaction within the first few minutes of the transfusion.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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11. The nurse prepares to administer blood to the patient. Which is the nurse’s priority action? a. Determining patient history of autologous blood donations b. Assessing patient baseline vital signs before the transfusion c. Confirming the rate of the blood infusion with the health care provider d. Identifying patient blood type, cross-match, and blood product ANS: D

The most critical intervention to administer blood products safely is to accurately identify patient, blood type, cross-match, and blood product because an identification error potentially leads to devastating adverse effects, including hypersensitivity reactions, renal damage, and death. The nurse follows agency policy throughout the process of blood administration to prevent complications from the administration of blood products. Assessing patient vital signs for baseline data is very important for comparison during the transfusion because the data provide the nurse with a basis of comparison to evaluate patient changes. The patient’s history of blood donations is irrelevant information unless the donations left the patient grossly anemic. The nurse clarifies any orders when a question develops. If the order for blood is properly written, or if agency policy dictates the rate of infusion, there is no need to routinely consult the provider about the rate.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

12. The nurse prepares to relocate an IV catheter because of signs of infiltration. The IV was

located in the patient’s nondominant hand. Which criterion would be best for the nurse to use when deciding on the location of the new IV site? a. Use a site distal to the original site.

N b. Place it wherever a vein is suitable. c. Place the new site in a smaller vein. d. Continue to use the nondominant extremity.

ANS: B

Since an IV site has infiltrated, it is no longer appropriate to use, even though it is on the nondominant extremity. The nurse must now find a site where the vein is of adequate size, location, and pliability and place the IV catheter there. The most distal site is suitable for an original IV site, but it should not be used if an IV line is being reinserted in the same extremity because of possible infusion difficulty, especially when infiltration is present. The new site should not be limited to only a smaller vein, which also may not be possible.

Although it is ideal to use the patient’s nondominant hand, it may not be possible if the prior IV infusion has infiltrated. Injury and pain to the patient could occur.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

13. The nurse is caring for a patient with a peripheral IV access that is used intermittently for

medications but is not a continuous infusion. Which technique does the nurse use for routine care of this peripheral line? a. Flush with a low concentration of heparin. b. Always change the end cap with each medication dose. c. Change the IV insertion site every day. d. Flush with 0.9% saline solution.

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ANS: D

Guidelines for the nursing care and maintenance of IV access devices include regular flushes with normal saline solution to assess for and maintain patency since the line is not used constantly. Heparin flushes are not considered routine but are specifically ordered for use in certain patients. The end cap does not need to be changed with every medication dose unless this is agency policy, but it does need to be swabbed with an antiseptic. Routine nursing care of an IV site should prevent phlebitis and infiltration. Changing the IV insertion site daily causes patient discomfort, increases costs, and is contraindicated.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

14. The nurse assesses the patient’s IV insertion site and notes that it is warm, red, and tender.

Which intervention does the nurse implement first? a. Slow the infusion rate. b. Discontinue the IV infusion. c. Apply cool compresses. d. Apply warm compresses.

ANS: B

The nurse must discontinue the IV infusion with a warm, red, and tender appearance because these clinical indicators are consistent with an infection. The nurse also discontinues the IV infusion to decrease the risk of sepsis, tissue loss, and a thromboembolic event. If the site is infected, slowing the infusion rate is unlikely to help. Cool compress application is an improper therapy for the problem. The nurse applies a warm compress after discontinuing the IV line from the inflamed tissue.

N DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

15. The nurse is preparing to administer blood. What solution is most appropriate for the nurse to

use when priming the blood administration set? a. 0.45 normal saline b. 0.9 normal saline c. D5 0.45 normal saline d. Dextrose 5% in water ANS: B

The only compatible solution for blood administration is normal saline because it is an isotonic solution (0.9 normal saline). The remaining solutions, especially the dextrose solution, can cause problems with blood administration and are contraindicated.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

16. The nurse is setting up to administer a unit of blood. Which is the most important nursing

intervention during preparation for this procedure? a. Prepare a normal saline solution. b. Obtain a Y-tubing for administration. c. Provide the patient with information. d. Identify the blood product and patient.

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ANS: D

Before administering blood, the nurse checks the identification of the patient and the blood product according to agency policy, which includes several patient identifiers. Accurate identification decreases the risk of patient injury, infection, or death from patient-blood mismatch. The nurse prepares the Y-tubing with normal saline before the blood transfusion is started. He or she takes time to teach the patient before beginning the transfusion.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

17. The patient has a peripheral infusion for the administration of antibiotics. Which action is

most effective for the nurse to use to detect an IV therapy–related infection? a. Use clean technique for dressing changes. b. Palpate the insertion site through the dressing. c. Change the IV tubing at 12-hour intervals. d. Routinely apply an antimicrobial to the IV site.

ANS: B

The nurse palpates the insertion site gently through the dressing to detect any infection by checking for tenderness, edema, or swelling. Removing the dressing exposes the insertion site to contamination from the nurse’s contact and environment and risk to the tissues. The nurse uses aseptic technique for IV dressing changes. IV tubing changes every 12 hours are excessive and costly. The nurse applies antimicrobial agents to the insertion site according to agency policy, however; applying an antimicrobial to the site per agency policy does not serve the purpose of detecting an IV therapy-related infection.

DIF: Cognitive Level: Understanding N TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

18. The nurse assesses several patients who are receiving IV therapy. Which clinical indicator

cues the nurse to take special precautions while infusing IV fluids on one of the patients? a. Poor skin turgor b. Bilateral crackles c. Mild hypotension d. High serum sodium ANS: B

The nurse scrutinizes IV therapy for patients with crackles in the lungs because it is consistent with clinical indicators of fluid overload and pulmonary edema. As a result, the nurse administers IV fluids to the patient with heightened scrutiny to avoid administering excess IV fluids. Poor skin turgor, hypernatremia, and hypotension indicate a potential need for additional fluid volume.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

19. The nurse is preparing to insert a peripheral IV line. Which technique does the nurse

implement to prepare for the IV insertion? a. Slap the selected vein gently several times. b. Select a proximal site on the extremity. c. Shave the hair in the area of the insertion site.

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d. Tie a tourniquet above the selected insertion site.

ANS: D

The nurse applies a tourniquet to the patient’s arm to engorge the vein selected for IV insertion. This facilitates catheter insertion because a larger vein is easier to enter without transecting the vein than a small vessel. The nurse avoids tapping and massaging the vein before IV insertion because these actions increase the risks of hematoma formation and vasoconstriction. The most distal site on the extremity suitable for IV therapy is selected, and hair around the potential IV insertion site is clipped if needed, not shaved, because shaving increases the risks of impaired skin integrity and infection through microabrasions.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

20. The nurse is caring for several patients who have IV lines. What responsibility does the nurse

have related to the assessment and maintenance of a peripheral IV site? a. Elevating the patient’s arm to maintain the ordered flow b. Padding the IV site for skin protection c. Inspecting the insertion site on a regular schedule d. Changing the site every day at the same time ANS: C

The nurse inspects the insertion site regularly for early detection of inflammation, infection, phlebitis, and leakage to fulfill the duty the nurse owes to the patient for preventing complications. Elevating the patient’s arm is unnecessary. Changing the site daily increases patient risk for infection and trauma. Padding the site obstructs direct observation of the site and prevents early detection of complications; the best method of protecting the IV site is N observing site. patient education and continuously DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

21. The nurse assesses the patient’s IV site. Which clinical indicator does the nurse recognize as

being most consistent with phlebitis? a. An elevated heart rate b. Decreased skin temperature c. Erythema along the vein line d. Edema around the insertion site ANS: C

The nurse scrutinizes the IV insertion site for redness along the outline of the vein through the skin. The erythema indicates inflammation of the vein. Tachycardia is consistent as a clinical indicator for infection. Cool skin is consistent with clinical indicators for infiltration. Regional edema is consistent with clinical indicators for inflammation and infection.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

22. The nurse observes bleeding on the dressing of a site where the IV was discontinued. Which

action should the nurse take first? a. Hold pressure on the site. b. Replace the dressing.

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c. Apply a warm compress. d. Lower the site below the level of the heart.

ANS: A

The nurse needs to hold pressure on the site since it is continuing to bleed after the IV was discontinued. Replacing the dressing will not address the cause. A warm compress causes vasodilation to increase localized blood flow. Lowering the site will increase the bleeding.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

23. A patient in the emergency department needs a blood transfusion of A− blood, and none is

available. Nursing care would be correct if the nurse administered blood of which type? a. A+ b. O+ c. O− d. AB− ANS: C

The nurse can administer O− because it doesn’t contain any proteins or substances that the patient doesn’t already have. O+ and A+ nor AB− cannot be administered because the presence of the Rh factor would cause a reaction in the patient. The patient has antibodies to the B antigens found in the AB− blood.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

N infusion via a central venous access device. Which outcome 24. The nurse is administering an IV would best substantiate the nurse’s assessment that the patient has not experienced a complication? a. The patient gains 2 1/2 pounds in 2 days. b. The patient’s insertion site is warm and dry. c. The patient has subcutaneous emphysema. d. The patient’s neck veins are less distended today than yesterday.

ANS: B

The insertion site should be warm and appear dry. Increased temperature locally would indicate infection. The rapid weight gain indicates fluid overload. Subcutaneous emphysema would indicate pneumothorax, hemothorax, hydrothorax, or an air embolus. Distended neck veins would indicate incorrect placement or catheter migration.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

25. The nurse is preparing to change the IV solution after the current one infuses. What action is

most appropriate for the nurse to take? a. Hang another bag of the identical IV solution. b. Change the tubing when preparing a new IV bag. c. Allow IV fluid to empty into the upper part of the tubing. d. Change the bag when approximately 50 mL is left in the old bag.

ANS: D

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When the old bag has about 50 mL left (when the fluid remains only in the neck of the bag), the nurse changes the bag. Hanging the identical IV solution can contradict the prescription so the nurse needs to ensure the orders have not changed. Changing the tubing with each new bag is unnecessary and wasteful. The nurse stops the infusion before air reaches the IV tubing.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

26. The nurse is caring for a patient with a peripheral IV line and needs to change the dressing.

What action by the nurse prevents accidental dislodgement of the IV catheter? a. Stabilize the IV catheter until the tape is in place. b. Place folded gauze under the IV catheter hub. c. Wear clean gloves to remove the old dressing. d. Clean in a circular motion away from the site.

ANS: A

To prevent accidental catheter dislodgement, the nurse stabilizes the IV catheter with the nondominant hand until the agency-approved covering is in place during the IV dressing change. The nurse places a folded 2  2–inch gauze pad under the hub to prevent excessive skin pressure from the hub. He or she wears clean gloves to remove the old dressing to prevent self-contamination. The insertion site is cleansed using a circular motion from the center to the exterior of the site to prevent recontamination.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

27. The nurse is preparing to initiate a blood transfusion. Which step of the procedure does the

N nurse implement first? a. Begin the infusion at 2 mL/min. b. Establish a single-line infusion. c. Check vital signs in 30 minutes. d. Shake the blood gently to mix the preservative.

ANS: A

The nurse initiates infusion of the blood very slowly at 2 mL/min to prevent the infusion of a large-volume bolus of potentially incompatible blood. Most transfusion reactions occur during the first 15 minutes of the infusion; thus, the nurse continues the slow rate for 15 minutes while closely monitoring the patient. The nurse needs to infuse blood products through a Y-tubing administration set. The nurse evaluates the patient’s vital signs within 5–15 minutes of starting the infusion or according to agency policy. The nurse avoids shaking blood products because violent movement damages erythrocytes and increases their hemolysis.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

28. A patient on an anticoagulant is going home and needs the peripheral IV line removed. Which

action is essential for the nurse to take? a. Pull the IV catheter out smoothly but quickly. b. Apply sterile gloves before going to the patient’s bedside. c. Check the most recent clotting studies. d. Apply pressure over the insertion site for 5–10 minutes.

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ANS: D

The patient taking an anticoagulant has a longer bleeding time; thus, the nurse applies pressure to the puncture site for 5–10 minutes after catheter removal to minimize blood loss and prevent hematoma formation. The nurse removes the catheter slowly to avoid patient injury or damage to the catheter. He or she applies clean gloves because the dressing and catheter are contaminated. Checking the most recent coagulation is helpful, but, regardless of the results, extra pressure should be applied over the insertion site after removal for 5–10 minutes.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

29. The nurse administers blood to the patient and observes that the patient has tachycardia, chills,

and lower back pain. What action does the nurse take first? a. Notify the health care provider. b. Notify the blood bank. c. Complete the vital signs. d. Remove the IV tubing.

ANS: D

Once the nurse suspects a transfusion reaction, he or she immediately stops the infusion so the patient receives no additional blood from the current bag and quickly primes different IV tubing with saline solution. He or she uses this to replace the blood tubing but retains the blood and the tubing for the blood bank. He or she completes the vital signs and notifies the health care provider and the blood bank. Stopping the infusion is the priority to limit the transfusion reaction as much as possible.

N DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

COMPLETION 1. The health care provider prescribes 500 mL of 0.25% normal saline intravenously over 4

hours for the patient. At which rate does the nurse infuse the IV solution into the patient using IV tubing with a drop factor of 15 gtts/mL? _____ gtts/min.

ANS:

31 gtts/min

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. The prescription for the patient’s IV fluid reads, “Infuse 1000 mL over 10 hours.” At which

rate does the nurse infuse the IV fluids using IV tubing with a drop factor of 15 gtts/mL? _____gtts/min.

ANS:

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25 gtts/min

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

3. A patient has IV fluids prescribed at 40 mL/hr through microdrip tubing. Which rate does the

nurse use to infuse the patient’s IV fluid? _____ gtts/min.

ANS:

40 gtts/min When the nurse uses microdrip tubing, he or she realizes that the infusion rate in drops per minute equals the hourly rate because the drip factor for this tubing is 60 gtts/mL. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

4. The order calls for the patient to receive 500 mL of IV fluid over 4 hours, and the nurse uses

IV tubing with a drop factor at 10 gtts/mL. Which rate should the nurse use on an electronic infusion pump for IV fluids to administer this prescription? ________ mL/hr.

ANS:

125 mL/hr

N The electronic infusion pump administers fluid in milliliters per hour; thus, the nurse programs the pump to infuse 125 mL/hr. The nurse obtains the infusion rate by dividing the total volume to be infused by the number of total hours for the infusion: 500 ÷ 4 = 125. If the nurse uses gravity to administer the fluid, he or she should use the roller clamp to limit the drops per minute to 21 gtts/min by using tubing with a drop factor of 10 gtts/mL. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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Chapter 29: Pre-Operative and Post-Operative Care Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse instructs the patient about scheduled surgery involving general anesthesia and about

postoperative care. Which does the nurse include during this time? a. Determine patient cultural and religious preferences. b. Avoid eating or drinking anything 2 hours before surgery. c. Ask for antianxiety medication in the operating room. d. Follow the rules for beginning to exercise after the incision has healed.

ANS: A

Patients must be asked about their cultural practices and religious beliefs that may alter their or their family caregiver’s acceptance of necessary education and procedures. A minimum time for avoiding food and drink has been set at 2 hours, but agency policies will differ.

Antianxiety medications, if used, will be given in the preoperative area. Patient will begin to do light exercise, such as ambulation or physical therapy, long before the incision has healed.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. The patient is prepared for shoulder surgery and tells the preoperative nurse that the scar will

be invisible after the surgery. Which action does the nurse take at this time? a. Tell the patient that this surgery always leaves a scar. b. Change the operative consent form to reflect what the patient says.

N c. Inform the surgeon that the patient is not ready for surgery. d. Notify the surgeon of the patient’s statement before medication is given.

ANS: D

The patient’s statement about an invisible scar is inconsistent with shoulder surgery because skin incisions always leave a scar. The inconsistent statement cues the nurse to verify the patient and the procedure on the surgical consent form and then, once patient identity is secure, address the patient’s misunderstanding and ask the surgeon to speak with him or her.

The nurse avoids changing the consent form. The nurse does not know yet whether the patient is ready for surgery; he or she resolves the patient misunderstanding or misidentification first.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

3. The patient’s family has had many experiences with surgical complications. What information

is most important for the nurse to use to understand the patient’s stress in the perioperative period? a. Ask the patient if medications will calm him or her before surgery. b. Identify specific concerns regarding the surgical experience. c. Explain to the patient that stress is easily identified and managed. d. Tell the patient that complications rarely occur with surgical procedures today.

ANS: B

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The patient’s perception of the perioperative experience creates a point of reference for evaluation of the situation. Asking about fears, cultural practices, and religious beliefs allows the nurse to anticipate the patient’s and family caregiver’s priorities and adapt the plan to give appropriate instruction and support. The nurse should get more information so potential concerns can be identified. Anxiolytics can relieve stress quickly by sedating the patient but do nothing to resolve the patient’s stressor. Stressors can be difficult to identify and are usually more difficult to manage. Telling the patient that complications are rare is dismissive of the patient’s concern and does not provide any useful information.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

4. The nurse interviews a preoperative patient who evades all questions about medications taken

at home. Which is the best response for the nurse to use to facilitate safe, effective nursing care? a. “I feel that you’re uneasy about discussing medications.” b. “Why don’t you want to talk about your medications?” c. “You’re avoiding me; so you must have a big secret.” d. “Don’t you think that it’s important to discuss medications?”

ANS: A

The best response is to validate the nurse’s perception of the patient’s behavior in a nonthreatening manner in order to elicit more information from the patient. The nurse avoids asking a “why” question because it may make a patient feel defensive. Stating that the patient is avoiding the question has the potential to be beneficial for interviewing, but concluding that the patient has a secret may be perceived as an accusation, sarcasm, or humor and lacks professionalism. It is unlikely to N elicit more information. Asking a question that implies a position that the patient hasn’t advocated (you don’t think medications are important to discuss) is judgmental and unlikely to uncover the patient’s true concerns.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

5. The nurse determines that the patient is at risk for atelectasis caused by pain from back

surgery 3 hours ago. Which is the best goal for the nurse to help the patient achieve? a. The patient’s lungs will be clear when auscultated every 2 hours. b. The nurse will manage the patient’s pain with oral morphine. c. The patient will perform coughing and deep breathing as directed. d. The patient will ambulate 4 hours after surgery.

ANS: A

This goal is appropriate for the patient, objective, attainable, and specific. Goals are for patient actions or outcomes, not the nurse. Performing coughing and deep breathing as directed is vague. Early mobility is critical after surgery, however; the patient may not be allowed up so soon after back surgery and that goal is not as specific as the respiratory outcome.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

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6. A nurse admits a patient to ambulatory surgery. The patient’s history includes multiple

surgeries over the last 10 years. In addition, when the patient wears antiembolism stockings or has tape on the skin, a rash develops. Which action does the nurse take initially? a. Use sterile gloves to provide care to this patient. b. Remove latex products from the patient’s room. c. Inform the surgeon about the patient’s hypersensitivity to latex. d. Gather additional information about potential allergies.

ANS: D

A rash or other local response when items touch the skin could potentially alert the nurse to latex allergy. The nurse would continue assessing allergies. Sterile gloves are not needed for routine care. Removing latex products from the room is premature. The nurse does not yet know if the patient has a latex allergy, so notifying the surgeon is also premature.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

7. The nurse instructs the patient about postoperative coughing and deep-breathing exercises

following abdominal surgery. Which technique does the nurse teach the patient to facilitate cooperation? a. Begin coughing and deep breathing when the patient is ready. b. Take a deep breath, hold it for 10 seconds, and exhale slowly. c. Support the incision when doing these exercises. d. Perform coughing and deep breathing every four hours.

ANS: C

The nurse engages the patient in postoperative coughing and deep breathing by instructing him or her to splint the incisionNsimilar to when the patient is turning. By holding the incision, the patient stabilizes the edges of the wound and puts less stress on the incision. The nurse does not allow the patient to decide when and if coughing and deep breathing are done. He or she involves the patient actively. Simply taking a deep breath and holding it before exhaling does not clear secretions from the respiratory tract. Coughing and deep breathing (or use of a device such as a spirometer) are done every 1–2 hours.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

8. A patient will be on bed rest for several days after extensive surgery. Which activity does the

nurse teach the patient to prevent complications from decreased perfusion? a. Avoid any fluids by mouth until the patient begins passing gas. b. Flex and rotate the ankles several times every hour while awake. c. Rest quietly to allow the maximum action of the opioid analgesics. d. Stay positioned on either side with pillows between the legs.

ANS: B

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The nurse instructs the patient to perform ankle flexion and rotation to promote venous return from the lower extremities, which helps prevent thromboembolic complications and increases arterial perfusion to provide oxygen for the tissues while the patient is not ambulating. Passing gas has no correlation to decreased perfusion in the patient’s lower extremities. Pain needs to be controlled, but this has little to do with potential impaired tissue perfusion in the lower extremities. Placing pillows between the legs when positioned on the side provides comfort and is a passive method of preventing compression of the lower leg by the upper one. This is not the most effective way of preventing decreased perfusion to the lower extremities.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

9. The nurse plans assignments for the staff in an ambulatory surgery center. Which assignment

can the nurse delegate to nursing assistive personnel (NAP)? a. Bring the preoperative medications prepared by the nurse to the patient. b. Administer a preoperative enema to the patient. c. Instruct the patient to arrange for a ride home and a companion after surgery. d. Reinforce preoperative teaching related to the patient’s postoperative diet.

ANS: B

The nurse delegates administering the preoperative enema to the NAP because this is within the scope of practice for this person. Handling medications is a nursing responsibility and cannot be delegated. Patient teaching remains a nursing responsibility because it involves assessment, planning, and evaluation components.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

N

10. The patient asks why preoperative application of compression stockings has been ordered.

Which response by the nurse is most appropriate? a. “They prevent any chance of blood clots after surgery.” b. “They are required since you will be on bed rest.” c. “They are connected to a pump and improve circulation.” d. “They help improve circulation and reduce the risk of blood clots in your legs.”

ANS: D

The purpose of compression stockings is to promote circulation during periods of immobilization, reducing the risk of an embolism. They cannot prevent any chance of blood clots because blood clots can develop in other body areas for other reasons. They are usually used for patients on bed rest or with limited mobility, but that doesn’t explain the purpose of them. The devices connected to a pump to promote circulation in the lower extremities are called sequential compression devices.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

11. The nurse admits a patient for ambulatory surgery. The patient tells the nurse that he or she

skipped breakfast but drank a cup of coffee and some juice. Which does the nurse implement next? a. Asks the patient to estimate the fluid volume. b. Instructs the patient to dress and return home.

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c. Notifies the anesthesiologist and surgeon. d. Changes or delays surgery for several hours.

ANS: A

The nurse obtains additional information from the patient before collaborating with the surgical team so he or she can present a complete picture of the patient’s consumption.

Drinking fluids before surgery increases this risk of aspiration of gastric contents. The nurse notifies the surgical team and collaborates with them to decide about rescheduling, delaying, or proceeding with the patient’s procedure. The nurse does not change or delay the surgery independently. This is a collaborative effort within the patient’s surgical team.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

12. The nurse prepares the patient for surgery to begin in 1 hour, but the pregnancy test included

in the preoperative orders written yesterday is not in the medical record. Which action does the nurse implement first? a. Call the laboratory to get the test results. b. Collaborate with the surgeon. c. Draw a stat pregnancy test. d. Ask the patient if she is pregnant.

ANS: A

The nurse should first find out if the test results are available before doing anything else. If the results cannot be found, the nurse obtains a blood specimen for a stat pregnancy test because the provider ordered one before surgery and the order is still valid. If the results have not been found after the specimen for the pregnancy test is drawn and sent to the lab, the nurse notifies the surgeon about the situation.NThe nurse avoids sending the patient to surgery on the basis of her verbal report because she may be unaware of a pregnancy or she may be concealing the truth.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

13. The nurse assesses a patient before hip surgery. Which piece of information is most critical

for the nurse to report to the surgeon before surgery? a. The patient is complaining of a pounding headache. b. There is a bruise on the patient’s left anterior chest. c. The patient uses continuous positive airway pressure (CPAP) at home. d. The blood pressure is 20 mm Hg higher than baseline.

ANS: C

The nurse reports the use of CPAP since this may indicate that the patient has obstructive sleep apnea, which poses a risk after surgery. The headache could potentially result from anxiety or hypoglycemia and should be reported, but not as the priority. A bruise on the patient’s chest is not near the operative area. The elevated blood pressure could be a result of preoperative anxiety.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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14. The nurse assesses a patient before surgery. Which piece of patient information requires

follow-up nursing interventions? a. The patient’s father died during surgery last year. b. The patient was exposed to chickenpox 8 weeks ago. c. The serum hemoglobin level is 13.5 g/dL. d. The patient’s weight is 136 pounds; height is 5 feet 6 inches.

ANS: A

The patient’s risk for developing chickenpox is past. The serum hemoglobin level is fine for surgery. The data indicate a normal weight for the patient’s height. The nurse will follow up on the cause of the father’s death to determine if malignant hyperthermia was involved. This is an inherited, life-threatening emergency.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

15. While being prepared for surgery, the patient tells the nurse about forgetting to take the

ordered antibiotics in preparation for the surgery. What action by the nurse is most appropriate? a. Document what the patient just said. b. Order the missed medication in a parenteral form. c. Notify the patient’s surgeon. d. Ask the patient why he or she didn’t take it.

ANS: C

The nurse must alert the surgeon of the patient’s lack of compliance regarding taking the ordered antibiotics so the surgeon can decide whether to continue or postpone the operation N and what needs to occur if the operation proceeds. The nurse will document what the patient said, but it is more critical to alert the surgeon. The CDC has identified prophylactic antibiotics, as recommended, to be crucial in preventing surgical site infections. The nurse cannot order a medication, even though the patient said that the surgeon has ordered it, because there is no order available; nor can the nurse change the medication route of administration. Asking a “why” question is nontherapeutic because it puts the patient in a defensive position.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

16. The nurse is explaining the purpose and procedure regarding informed consent to a nursing

student. What information is included in the explanation? a. The nurse provides information about the risks and benefits of the procedure. b. Informed consent only describes the details of the surgery itself. c. The nurse verifies it is complete and consistent with patient’s understanding. d. The nurse obtains consent after administration of any preoperative medication.

ANS: C

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The nurse’s role is to verify the patient’s signature and verify that it is complete and consistent with the patient’s understanding. The nurse must know the policies of the agency regarding what to do if the patient later states a lack of understanding. The informed consent states what is being done by whom and includes contingency plans, risks, and benefits. The nurse can help the patient understand the information, but the nurse does not provide it. The health care provider who performs the procedure provides informed consent and includes details about the procedure. The patient is potentially incompetent after receiving preoperative medication such as sedatives and opioids; thus the nurse verifies that the consent is in order before administering preoperative medication. However, medications such as prophylactic antibiotics would not alter the patient’s ability to consent.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

17. The nurse assesses a patient before knee surgery. Which assessment finding reported by the

nurse will most likely require the surgery to be delayed? a. A 10-year history of smoking a pack of cigarettes per day b. A reddened, swollen, and painful calf c. An upper respiratory infection last month d. A low-normal serum hemoglobin level ANS: B

Calf pain, tenderness, and swelling are consistent with clinical indicators of a deep vein thrombosis or an infection; thus the surgery most likely will be rescheduled after resolution of these findings. The history of smoking is important but most likely will not delay the operation. The patient should be fully recovered from an uncomplicated upper respiratory infection last month. Low-normal N hemoglobin is sufficient to clear the patient for surgery.

DIF: Cognitive Level: Analyzing TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

18. The nurse provides instructions about postoperative exercises to the patient who is scheduled

for a laparotomy. What does the nurse include in patient teaching? a. Tighten the thighs pushing the knee into the bed 5 times every 1–2 hours. b. Cough and deep breathe every time you change position. c. Use your hands to splint your incision because they are cleaner than the pillow is. d. Reposition in bed every 4 hours.

ANS: A

Quadriceps setting is an exercise to help improve circulation and consists of tightening the thighs and pressing the knee down toward the bed. This should be done 5 times every 1–2 hours. The patient should cough and deep breathe every 1–2 hours; the post-surgical pain may keep the patient from changing position frequently. A pillow, blanket, or the hands can help splint the incision. The patient should be mobilized soon after the operation and does not need a specific turning schedule.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

19. The nurse admits the patient to the postanesthesia care unit (PACU) after minor hand surgery

with minimal sedation and regional anesthesia. Which action by the nurse is priority?

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a. b. c. d.

Position the head to maintain a patent airway.

Elevate the affected hand higher than the level of the heart.

Monitor the circulatory status in the operative hand.

Measure the core body temperature.

ANS: A

Although the patient did not receive general anesthesia, the nurse’s priority is maintaining the airway because short-acting benzodiazepines and opioids used during conscious sedation potentially depress respirations. If the patient is very lethargic, he or she may have trouble maintaining the airway and require temporary support. After establishing a stable airway, breathing, and circulation, the nurse elevates the hand according to the provider’s preference while assessing it. Monitoring the circulatory status in the hand that was operated on is essential but not a priority. Checking the temperature is important but is not the priority.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

20. The nurse is caring for a patient who had an ovarian cyst removed under general anesthesia 12

hours ago. Which is the most important goal for this patient? a. The patient will cough and deep breathe every hour for 48 hours. b. The patient will have bowel sounds within 24 hours after surgery. c. The patient will exercise the feet and ankles 3 times this shift. d. The patient will ambulate tonight and 3 times tomorrow.

ANS: D

The most important goal for this patient is ambulation because it promotes lung expansion, restoration of peristalsis, peripheral perfusion, venous return, and tissue integrity and thereby N pneumonia, constipation, thromboembolic events, skin decreases atelectasis and prevents breakdown, and infection. The patient should not cough and deep breathe every hour for 48 hours. She must be allowed to sleep. Establishing bowel sounds within 24 hours after surgery is an unrealistic goal. Ankle and foot exercises promote perfusion and venous return, which help to prevent circulatory problems, but ambulation is best.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

21. The nurse is caring for a shivering patient immediately after back surgery under general

anesthesia. Which nursing intervention is most suitable for this patient? a. Apply warm blankets to stop the shivering. b. Administer medication to relax the muscles. c. Give the patient antipyretics to reduce the fever. d. Tell the patient that shivering is to be expected after surgery.

ANS: A

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To warm the patient, the nurse applies warm blankets or a warming device to eliminate shivering because shivering consumes massive amounts of oxygen in skeletal muscle. If the patient has a respiratory or cardiovascular problem, shivering potentially aggravates it significantly. Medication is not indicated for shivering unless it becomes unresolved. The patient may have a fever causing shivering, but it is more likely to be from the cold operating room, impaired thermoregulation from anesthesia, or open body cavities that lose heat. There is also no data on the patient’s temperature. Telling the patient that this is expected does nothing to relieve the shivering.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

22. The nurse is caring for the patient who is vomiting after arriving in the PACU. Which action

does the nurse implement first? a. Reposition the patient on the side. b. Give the ordered antiemetic. c. Prepare to insert a nasogastric (NG) tube. d. Apply oxygen at 10 L/min by face mask.

ANS: A

Surgical patients can vomit for several reasons and the nurse’s priority is to ensure the patient maintains a patent airway. This is accomplished by turning the patient to the side if allowed and having suction equipment available. After ensuring the patient’s airway is protected, the nurse can give antiemetic medications. An NG tube is not warranted at this time. Oxygen will not benefit the patient if the patient’s airway is lost, plus putting a face mask on the patient will increase the risk of aspiration.

N

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

23. The patient had shoulder surgery 2 hours ago, and the Hemovac drain is filling at a continuous

rate, requiring the nurse to empty it frequently. Which does the nurse do first? a. Notify the surgeon. b. Continue to document the output. c. Irrigate the Hemovac with sterile saline. d. Attach a larger Hemovac drain.

ANS: A

The nurse calls the surgeon because the amount of drainage varies with a procedure and the nurse needs to know a specific amount for this patient and surgery so the patient can be monitored appropriately. The nurse also uses critical thinking to determine that the amount of drainage is more than expected because the drain needs to be emptied frequently. The surgeon may need to take the patient back to surgery if a problem exists. The nurse should continue to monitor and document the drainage but that is not the priority. Because the volume of drainage is large, the more important action is to call the surgeon. Surgical drains are not designed for irrigation. The Hemovac is an integrated unit that includes the drainage container and attached drain that is placed in the surgical site at the conclusion of a procedure; to change a Hemovac, the provider replaces the tubing and container. This is not with the nursing role.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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24. The nurse is caring for the patient after general anesthesia. How often does the nurse perform

routine patient assessment and documentation in the postanesthesia care unit (PACU)? a. Every 5 minutes b. Every 5–15 minutes c. Every 15–30 minutes d. Every 30 minutes to 1 hour ANS: B

The nurse assesses the patient every 5–15 minutes in the PACU because he or she is recovering from general anesthesia and suppression of several vital functions, including maintaining an airway, breathing, and the gag reflex. If adverse responses are occurring, a patient could need reassessment every 5 minutes or less, but usually every 5–15 minutes is sufficient. Assessing at intervals of 30 minutes or more is dangerous because complications develop quickly and subtly, leaving the patient exposed to risks for extended periods.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

25. At what point in the surgical recovery process does the nurse need to ambulate the

hospitalized patient for the first time? a. At discharge from the postanesthesia care unit (PACU) b. After discharge to home and before complete recovery c. Between induction for surgery and arrival in the PACU d. After discharge from the PACU and before discharge to home ANS: D

N Unless the patient is being discharged from ambulatory surgery, the nurse needs to ambulate the patient for the first time on the surgical unit after discharge from the PACU and before discharge to home because postoperative ambulation is critically important to prevent postoperative complications. Unless the patient is discharged to home, he or she remains on bed rest until after the transfer to a surgical unit for continuing postoperative care. Ambulation on the surgical unit depends on many factors, although the nurse will encourage the patient to do so as much as possible. The patient is likely to be groggy from anesthesia and affected by pain medication, making ambulation dangerous at that time. The nurse owes a duty to the patient to ambulate before discharge to home unless it is contraindicated. Surgery occurs between induction and arrival in the PACU. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

26. The patient in the PACU is coughing up white mucus after having been intubated for surgery.

What action would be most appropriate for the nurse to maintain a patent airway? a. Administer supplemental oxygen. b. Place the patient in a supine position. c. Perform oropharyngeal suctioning. d. Prepare for endotracheal intubation.

ANS: C

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In the immediate postoperative period, patients frequently have pulmonary secretions from mechanical ventilation during surgery. The nurse suctions the patient as necessary to help remove the secretions from the airway. Supplemental oxygen is ineffective therapy to clear an airway. The supine position is contraindicated for patients in the immediate postoperative period unless the patient is hypotensive. The nurse avoids preparing for endotracheal intubation unless the patient develops respiratory failure.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

27. After instructing the patient in using the incentive spirometer (IS), the nurse instructs nursing

assistive personnel (NAP) to encourage the patient to use it. What does the nurse provide to the NAP as a rationale for using the IS after surgery? a. It helps to maintains venous return. b. It helps prevent atelectasis and pneumonia. c. It prevents any type of respiratory infection. d. It strengthens the lungs for recovery.

ANS: B

Using the IS involves inhaling; as the lungs fill with air, alveoli that collapse in surgery pop open from expansion of the chest wall. In addition, IS promotes airway clearance by stimulating coughing and gas exchange as secretions are removed from the lungs. This helps prevent atelectasis and pneumonia. Inhalation does promote venous return to the heart, but this is not the reason for using an IS with postoperative patients. Incentive spirometry cannot prevent any type of respiratory infection from occurring. The IS is not intended to strengthen the lungs.

N

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

28. The nurse assesses the patient on the first postoperative day after major abdominal surgery.

Which is the most important patient outcome that requires follow-up interventions by the nurse? a. The pain level is 2 on a scale of 0–10 after an analgesic. b. The patient is voiding an average of 45 mL/hr. c. Bowel sounds are inaudible in all quadrants. d. The patient performs breathing exercises every 6–8 hours.

ANS: D

Increasing the frequency of breathing exercises is important because breathing is a vital function. The patient decreases the risk of atelectasis and pneumonia after surgery with frequent coughing, deep breathing, incentive spirometry, and ambulation. A pain level of 2 is within normal limits for a postoperative patient requiring routine postoperative nursing care.

The urine output is normal. Inaudible bowel sounds after major abdominal surgery for up to the first 48 hours or so would be expected.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

29. A patient on the post-surgical nursing unit has rhinorrhea, muscle aching, and profuse

sweating. What action by the nurse is most appropriate?

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a. b. c. d.

Notify the surgeon of the findings.

Assess the patient for drug abuse.

Administer pain medication.

Assess the patient’s cardiac history.

ANS: B

Symptoms of opioid withdrawal include rhinorrhea, muscle aching, sweating, nausea, diarrhea, dysphoric mood, lacrimation, dilated pupils, piloerection, yawning, fever, and insomnia. The nurse would assess the patient for a history of drug abuse. After completing the assessment, the nurse would notify the surgeon. Pain medication is not warranted at this time.

Although sweating may be seen in cardiac disorders, the other signs are not, so the nurse would first assess for drug abuse.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

30. The nurse has assessed the Aldrete score on four patients in PACU. Which patient is the most

appropriate to transfer to the post-surgical nursing unit? a. Score 0 b. Score 4 c. Score 8 d. Score 10 ANS: D

The Aldrete score for postanesthesia monitoring ranges from 0 to 10, with 10 being the optimal score. A patient with a score of 10 is able to move all four extremities, breathe and cough freely, has a BP within 20 mm Hg of preoperative baseline, is fully awake, and N maintains his or her oxygen saturation >92% on room air. The patient whose score is 0 is apneic and unresponsive, among other things. A score of 4 does not demonstrate readiness for transfer yet. A score of 8 is good, but 10 is better.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. The student nurse has learned about complications from general anesthesia. Which of the

following are included? (Select all that apply.) a. Hypotension b. Dysrhythmias c. Hallucinations d. Increased intraocular pressure e. Edema of the face and throat ANS: A, B, C

Some complications of general anesthesia include hypotension, heart rhythm abnormalities, and hallucinations. Increased intraocular pressure can be seen with neuromuscular blocking agents. Edema of the face and throat can occur with local anesthesia allergies.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

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2. What does the student nurse learn about age-related differences in surgical patients? (Select

all that apply). a. Perform assessments and procedures guided by a child’s developmental level. b. Dehydration is not as likely to occur in children due to lower fluid volume. c. Temperature management is a priority in children due to immature thermoregulation d. The older patient may need more time to learn information and practice skills. e. The older adult’s liver and kidney function does not influence drug action.

ANS: A, C, D

For pediatric patients, use the child’s developmental level to help plan the best way to perform assessments and procedures. Children are more vulnerable to fluid volume deficits because of their higher percentage of body fluids. Temperature management is a priority as children’s immature thermoregulatory systems often lead to temperature variations. Kidney and liver function decline with age, so drug metabolism, action, and excretion are all affected.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Physiological Integrity

N

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Chapter 30: Emergency Measures for Life Support Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse is caring for four patients on the intermediate care unit and plans emergency care

for the patients. Which patient is unsuitable for cardiopulmonary resuscitation (CPR)? a. The older adult patient with end-stage lung disease b. The patient with a valid order for a no-code status c. The patient who doesn’t speak English and cannot make his or her wishes known d. The patient whose family does not want the patient resuscitated ANS: B

The patient who has a valid order to withhold patient resuscitation from the health care provider or according to agency policy should not receive CPR if breathing stops, the heart stops beating, or the patient cannot maintain an airway. The nurse communicates the patient’s directive to withhold resuscitative measures to the entire nursing staff because inadvertent CPR can result in legal liability. Unless the patient specifies that CPR is to be withheld, the nurse must institute resuscitative measures as the need arises despite a grim diagnosis or advanced age. A patient who cannot speak English needs to have an interpreter to provide information on emergency options and assist the patient to complete advance directives. This is a priority for non-English speaking persons. Unless the patient is incompetent, the family cannot decide his or her code status because it violates the patient’s right to self-determination and to refuse treatment.

DIF: Cognitive Level: Understanding N TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

2. The nurse walks into a patient’s room and finds the patient on the floor with eyes closed.

Which does the nurse implement first? a. Initiate cardiac compressions. b. Call for a code from the room. c. Help the patient back into the bed. d. Verify patient unresponsiveness.

ANS: D

The nurse assesses the patient for unresponsiveness by touching him or her and calling, “Are you okay?” before activating a code. Although unresponsiveness can be caused by many factors, the nurse wants to stimulate the patient and improve breathing first if possible. The nurse avoids initiating chest compressions until assessing for a pulse because chest compressions over a beating heart can precipitate arrhythmias. Until the patient’s status is assessed, a code should not be activated. The nurse should not move the patient alone; if CPR is needed, the hard floor is a suitable surface until enough help arrives to put the patient back into bed. The nurse is not aware of why the patient is on the floor; thus the team members must consider the possibility of a spinal cord injury; however providing CPR and resuscitation is the priority.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

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3. The nurse determines that the patient is in cardiac arrest. Which does the nurse delegate to

nursing assistive personnel (NAP)? a. Deliver chest compressions. b. Help with patient positioning as directed. c. Inform the family about the patient. d. Prepare emergency medications.

ANS: B

The nurse instructs the NAP to help position the patient, including logrolling onto a backboard or other positions for resuscitative measures, because the NAP receives training to perform the task. Agency policy usually dictates nursing responsibilities during a code. Although NAP are trained to perform basic cardiopulmonary resuscitation (CPR) and use the automatic external defibrillator (AED), the nurse is present; thus the nurse delivers chest compressions.

The nurse does not delegate family communication to the NAP because the nurse has the critical thinking skills and clinical judgment to discuss the patient with the family and provide meaningful information and this is within the scope of nursing practice. The nurse retains responsibility for medications during a code because he or she receives training to administer emergency medications properly.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

4. The nurse participates in the patient’s resuscitation. Which patient assessment finding does the

nurse determine to be an undesirable event during cardiopulmonary resuscitation (CPR)? a. Bruising is present over the anterior thorax. b. The abdomen has become distended. c. The patient has an advance directive.

N d. An airway is in place without gagging.

ANS: B

Abdominal distention is undesirable during CPR because it is consistent with clinical indicators of air in the stomach, which can potentially occur from esophageal intubation with the endotracheal tube or ventilating the patient with an Ambu bag and airway. Because distention increases the risk of patient aspiration or expiration, the resuscitation team investigates the distention, verifies endotracheal tube placement, and inserts a nasogastric tube for decompression. Thoracic bruising from chest compressions is usually unavoidable; however, since the bruises can upset the family, the nurse should discuss them with the family to ensure understanding. The health care team welcomes the patient’s advance directive to clarify resuscitative measures promptly. Maintaining an airway without patient gagging is a desirable event during the code because it facilitates patient oxygenation and ventilation.

However, although this allows for breathing, the code team would rather discontinue the airway with spontaneous patient respirations and airway maintenance.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

5. The patient is in cardiac arrest, and the nurse uses the automatic external defibrillator (AED).

Which does the nurse implement to use the AED? a. Places the AED next to the patient, turns on the unit, and follows the prompts. b. Receives training in advanced cardiac life support (ACLS). c. Applies a shock in coordination with the chest compressions.

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d. Uses the automatic defibrillator instead of conventional cardiopulmonary

resuscitation (CPR).

ANS: A

The nurse places the AED next to the patient near the chest or head and then turns on the unit.

The unit has verbal prompts. The AED is user friendly with clear instructions labeled on the gel pads and instructions embedded on the AED unit. An AED user needs to follow directions correctly to use an AED effectively. ACLS training is unnecessary to use an AED. The nurse avoids delivering shocks and chest compressions together to prevent accidental electrocution.

An AED is used along with conventional CPR because the AED does not compress the chest; its only function is analyzing the patient’s electrocardiogram (ECG) and delivering defibrillations.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

6. The patient’s resuscitation lasts 30 minutes. The code team leader has directed the efforts to

stop. What action by the nurse is the priority? a. Request the chaplain speak to the family. b. Begin performing post-mortem cares. c. Provide privacy but stay available to the family. d. Gather funeral home information.

ANS: C

The priority for the nurse after a patient’s death is to use his or her authentic presence as an intervention. The nurse provides the family privacy and remains available to answer questions and to provide support. A chaplain may or may not be welcomed by the family; the nurse N would offer this option. Post mortem cares are done but the priority for the nurse is supporting the family; this care can be delegated to NAP. The nurse will need funeral home information but this can wait until the family is more settled.

DIF: Cognitive Level: Applying TOP: Integrated Process: Caring

OBJ: NCLEX: Physiological Integrity

7. The nurse has just called a code and is preparing to perform cardiopulmonary resuscitation

(CPR) on a child. Where does the nurse position the hands for chest compressions? a. Puts both hands over the upper half of the child’s sternum. b. Places the heel of one hand on the lower half of the sternum. c. Puts the heels of both hands on the lower third of the sternum. d. Places two fingers below the left nipple line at the sternum.

ANS: B

The nurse uses the heel of one (or two) hand(s) and on the lower half of the sternum to deliver chest compressions to a child to avoid traumatizing the distal sternal edge. Compressing the chest on the upper half or the lower third of the sternum risks trauma to the patient. Two fingers cannot deliver enough pressure to deliver effective chest compressions to a child.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

8. The nurse has been performing cardiopulmonary resuscitation (CPR) on an adult. Which

artery does the nurse check to evaluate the effectiveness of chest compressions?

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a. b. c. d.

Radial Carotid Brachial Temporal

ANS: B

The nurse evaluates the effectiveness of chest compressions during CPR by palpating a carotid pulse because it is a large artery close to the heart. He or she uses an artery proximal to the heart because the chest compressions are unlikely to perfuse the patient’s periphery. The nurse avoids using the radial and brachial arteries because they are distal to the heart. The temporal artery is too small to provide an evaluation of the effectiveness of CPR. DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

9. The nurse and a colleague begin cardiopulmonary resuscitation (CPR) on an adult patient.

Which ratio of chest compressions to rescue breaths is used? a. 5:1 b. 5:2 c. 10:1 d. 30:2 ANS: D

The latest guidelines issued by the American Heart Association recommend a ratio of chest compressions to rescue breaths of 30:2 to balance the need to circulate blood and oxygenate the adult patient. The remaining options are not suitable for two-person CPR. DIF: Cognitive Level: Remembering N TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

10. On entering a patient’s room, the nurse determines that the patient is unresponsive but has a

pulse and is breathing. Which action does the nurse implement next? a. Have another nurse check the carotid pulse. b. Activate the emergency response system. c. Perform a jaw thrust to open the airway. d. Begin performing CPR. ANS: D

Since this patient has a pulse and respirations, but is unresponsive, the nurse calls the emergency response team to determine the next steps in care. The nurse should be able to assess a pulse without needing a second chance, and if the person is breathing, a pulse should be present. If the person is breathing adequately, the airway is patent. There is no reason to start CPR on a person with a pulse who is breathing.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

11. The nurse needs to perform chest compressions for a pulseless child. Which depth does the

nurse use for each chest compression? a. One half to 1 inch in depth b. One to 1 1/2 inches in depth c. One half the depth of the chest

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d. One third the depth of the chest ANS: D

The nurse performs chest compressions on a child by compressing the chest by at least one third the depth of the child’s chest, or about 2”. This effectively displaces blood from the heart without traumatizing regional tissue.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

12. The nurse determines that the patient had a cardiac arrest while ambulating in the hall. Which

method should the nurse use to position the patient properly during cardiopulmonary resuscitation (CPR)? a. Head tilt and right side-lying position b. Logrolling and jaw thrust c. Supine and head tilt d. Jaw thrust and semi-Fowler’s position ANS: B

The nurse uses logrolling to position the patient onto a hard surface for chest compressions because emergency care must be implemented as though the patient has an unstable spine.

Logrolling maintains spine alignment until injury to the spine is ruled out. The nurse uses the jaw thrust to open the airway of a patient with a suspected unstable spine and determines whether the patient has spontaneous respirations without hyperextending the neck. The patient collapsed in the hallway and potentially suffered head or neck trauma; thus, until the status of the spine is determined, the nurse treats the patient as though the spine is unstable. Side-lying position during CPR is contraindicated because it is impossible to deliver effective chest compressions unless the patientNis supine on a hard, flat surface. Supine positioning also facilitates blood flow to the brain to minimize cerebral hypoxia.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

13. A visitor has coded in the hospital cafeteria, and several nurses witnessed the code. What is

the proper procedure for initiating use of the automatic external defibrillator (AED)? a. Provide 5 cycles of cardiopulmonary resuscitation (CPR) before shocking. b. Place AED pads and shock as soon as possible, if needed. c. Insert an oropharyngeal airway before shocking. d. Place the AED pads on either side of the chest.

ANS: B

Once an AED is available the nurse turns it on, applies it, and lets it analyze the patient’s rhythm. The AED will deliver a shock if the rhythm is appropriate for it. The pads do go on either side of the chest but have specific placement. An oropharyngeal airway is not needed prior to shocking.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

14. An AED has been applied and a shock delivered to a patient. What action does the nurse take

at this time? a. Provide 2 minutes of cardiopulmonary resuscitation (CPR) before beginning

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rhythm analysis and the shock sequence again. b. Provide three cycles of CPR before beginning rhythm analysis and the shock sequence again. c. Move nearby furniture away from the patient. d. Announce “clear” and perform a visual check that no one is touching the patient.

ANS: A

Two minutes of CPR are to be performed before beginning the rhythm analysis and the shock sequence again. Most newer AEDs will direct responders to not touch the patient for rhythm analysis instead of needing to rely on someone keeping time. Delegate someone to remove excess furniture or equipment from the immediate area. Directing personnel to stand clear of the patient should be done before the shock is performed, not after. The patient needs ongoing assessment by the nurse.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

15. A nurse is instructing staff nurses in the use of the automatic external defibrillator (AED).

Which information is essential for the nurse to share with the class? a. For children younger than 8 years old, pediatric AED pads should be used. b. The AED takes approximately 30 seconds to analyze the cardiac rhythm. c. The AED is used when the patient is unconscious and has no respirations. d. The AED is placed near the patient’s feet during use.

ANS: A

AED pads designed for children should be used for children younger than 8 years of age. If child pads are not available, use adult pads. The AED takes approximately 5–15 seconds to N used when the patient has no pulse, and is placed near the analyze the cardiac rhythm. It is patient’s chest or head.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

16. A student nurse is performing compressions on an adult. The rate of compressions drops to

90/min. What action by the faculty member is best? a. Ask the student if he or she is too tired to continue. b. Assess for a pulse at the femoral or carotid artery. c. Remind the student to switch to ventilations after 2 minutes. d. Tell the student he or she needs faster compressions.

ANS: D

The compression rate for an adult is 100–120/min. A rate of 90 is too slow and not effective.

The faculty would remind the student to switch places after 2 minutes or ask if the student is too tired to continue, but the priority is effective CPR. Pulses would be checked at the femoral artery preferably, because the carotid artery is difficult to access during a code.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

17. A student nurse is performing CPR on a child manikin. What action does the faculty member

evaluate as effective technique? a. Performs compressions with two fingers at the nipple line.

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b. Compresses at a rate of at least 130/min. c. Gives breaths to the intubated child every 6 seconds. d. Continues 30:2 ratio with two rescuers.

ANS: C

Once the patient has an advanced airway, compressions are no longer interrupted for ventilations which are then delivered every 6 seconds, or about 10 times per minute. Using two fingers just below the nipple line is appropriate for infant CPR. The compression rate for children is 100–120/min. Two rescuer child CPR uses a 15:2 ration of compressions to breaths.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

18. The coronary care unit is receiving four patients in the next hour. Which patient does the

charge nurse anticipate will receive targeted temperature management? a. Unwitnessed cardiac arrest, initial rhythm asystole b. Witnessed cardiac arrest, rapid defibrillation with AED c. Witnessed cardiac arrest, alert but amnesic for event d. Unwitnessed cardiac arrest with multiple medical problems ANS: B

The best outcomes are seen in patients who had a cardiac arrest with an initial rhythm that was shockable. In this patient, not only was the rhythm shockable, but defibrillation was provided rapidly. Asystole is not a shockable rhythm. An alert patient would not be a candidate for targeted temperature management. Not enough is known about the patient with multiple medical problems to suggest targeted temperature management.

N DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Physiological Integrity

19. A patient is receiving targeted temperature management after cardiac arrest. What explanation

of this treatment does the nurse provide the family? a. It improves neurological outcomes after cardiac arrest. b. It manages the fever produced by defibrillation. c. It salvages the damaged heart muscles. d. It keeps the fluid and electrolytes in balance.

ANS: A

The purpose of targeted temperature management is to reduce neurological deficits after cardiac arrest. It is not used for fever control, salvaging damaged heart muscle, or maintaining fluid and electrolyte balance.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning 20. The nurse is caring for a patient receiving targeted temperature management. It has been 20

hours since the therapy was initiated. What assessment finding indicates goals are being met? a. Patient is awake, alert, and oriented. b. Patient’s temperature is 35° C (95° F). c. Only the patient’s sodium level is abnormal. d. The patient’s oxygen saturation is 88%.

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ANS: B

The target is a temperature of 32–36° C (89.6-96.8° F) for 24 hours. This patient’s temperature is in the target range, indicating goals for the therapy are being met. The patient will not be awake, alert, and oriented; if he or she were, this therapy would not be needed.

Electrolytes are maintained in normal ranges. Oxygen saturation is maintained at greater than 90% or above.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

21. The nurse is caring for a post-cardiac arrest patient who has needed an oral airway for 20

hours. What action by the nurse is most appropriate? a. Remove the oral airway. b. Consult the provider. c. Replace the airway after 24 hours. d. Document ongoing need.

ANS: B

An oral airway is a temporary solution to maintaining a patient’s airway and can cause tissue damage. The nurse will consult the provider about a more appropriate long-term management strategy. The nurse would not simply remove the airway if it is still needed, nor is replacing it every 24 hours required. The nurse documents the treatment and the patient’s response.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

22. A new pediatric nurse is askingNthe charge nurse why an oral airway is not rotated while being

inserted in pediatric patients. What response by the charge nurse is best? a. The airways are so small, you will not be able to hold on to it. b. Oral pharyngeal airways actually are not used in pediatric patients. c. Rotating the airway can possibly further obstruct the child’s airway. d. You risk damaging the child’s soft palate by rotating the airway.

ANS: D

Rotating a pediatric oral airway while inserting it will damage the delicate soft palate of the child. There is no other reason why it is not done.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. The nurse is assessing an unconscious patient for placement of an oropharyngeal airway. In

addition to a present gag reflex, what other conditions would make the use of the airway contraindicated? (Select all that apply.) a. A semi-conscious patient b. A patient with a loose tooth c. A patient who had facial trauma d. A patient who has had oral surgery e. A patient with copious secretions

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ANS: A, B, C, D

An oropharyngeal airway should never be inserted in a patient with recent oral trauma, oral surgery, or loose teeth. A semi-conscious patient may vomit or have spasms of the larynx if an airway is inserted.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

2. The nurse in a trauma center is preparing to insert an oropharyngeal airway device. Which

interventions will assist in this task? (Select all that apply.) a. Place the patient in a prone position. b. Hold the airway curved end up initially. c. Use a padded tongue blade to open patient’s mouth. d. Measure the airway to obtain the right size. e. Rotate the airway 90 degrees as it is inserted.

ANS: B, C, D, E

The nurse will place the patient in a supine or semi-Fowler’s position. Hold the oral airway with the curved end up and insert the distal end until the airway reaches the back of the throat; then turn the airway over 180 degrees and follow the natural curve of the tongue. Option: Hold the airway sideways and insert halfway; rotate the airway 90 degrees while gliding it over the natural curvature of the tongue. Make sure the outer flange is just outside the patient’s lips. The airway must be measured to ensure the right size.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

N guidelines with the faculty. What statements by the student 3. A student nurse is reviewing CPR indicate the need for a review? (Select all that apply.) a. End-tidal CO2 should be above 20, if available. b. A size 1 or 2 oral airway fits most adults. c. Compressions on an adult should be at least 100/min. d. Adult-sized AED pads cannot be used on children. e. Adult CPR uses 30 compressions followed by 2 breaths.

ANS: B, D

If available, end-tidal CO2 is kept above 20 mm to indicate adequate respirations.

Compressions on an adult are 100–120/min in a sequence of 30 compressions followed by 2 breaths. A size 1 or 2 oral airway fits children aged 1–6. Pediatric AED pads are preferable for children, but if they are not available, adult pads can be used.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

4. The charge nurse is assessing staff CPR skills. What actions by the staff are appropriate for

infant CPR? (Select all that apply.) a. Uses the 2-thumb encircling method with 2 rescuers. b. Provides compressions at a rate of 140/min. c. Inserts an appropriately sized oral airway. d. Attaches the AED as soon as it’s available. e. Compresses the chest approximately 1".

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ANS: A, C, E

For infant CPR the two-thumb encircling method for compressions is used when there are 2 rescuers, who compress the chest approximately 1" at 100–120 times per minute. A size 0-00 oral airway is appropriate for infants. Manual defibrillation is used on infants.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Physiological Integrity

5. A student nurse is practicing using the AED. What actions by the student show the need for

remediation? (Select all that apply.) a. Dries wet skin before applying AED pads. b. Uses pediatric pads on an adult if bigger ones aren’t available. c. Places pads on the back if the chest is wet. d. Attaches the pads then turns the device on. e. Modifies pad position for pacemakers.

ANS: B, C, D

The student needs remediation on these steps because pediatric pads will not be effective on an adult; he or she should dry the patient’s chest off and apply pads to the chest, not the back; and turns the device on first. The student is correct in drying wet skin prior to applying pads and modifying pad placement for pacemakers.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Physiological Integrity

MATCHING

N

Match the unexpected response with the appropriate action. a. Consult with provider for appropriate diagnostic testing. b. Ensure AED pads have appropriate contact on the skin. c. Remove the oral airway. d. Consult provider for definitive therapy. e. Assess rate and depth of ventilations.

1.

2.

3.

4.

5.

Unable to insert oral airway.

Burns are visible under AED pads.

Resuscitated patient reports abdominal pain.

Oxygen saturation decreased after inserting oral airway.

Patient’s abdomen visibly distended during CPR.

1. ANS: D DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation MSC: If the patient needs an airway and the nurse is unable to insert an oral airway, the nurse will consult the provider about more advanced methods of controlling the airway.

2. ANS: B DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation MSC: If burns are occurring the nurse will assess that the patient's skin is dry and that the pads have good contact. If more pads are available, the nurse would change pads to a different position if possible.

3. ANS: A DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation

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MSC: Injuries to bones and internal organs are possible during CPR, so the nurse consults with the provider about obtaining appropriate diagnostic testing.

4. ANS: C DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation MSC: If insertion of an oral airway causes the patient's condition to deteriorate, the nurse removes the oral airway and reassesses the situation.

5. ANS: E DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation MSC: Ventilations that are too deep or too rapid can cause gastric insufflation, potentially leading to vomiting and aspiration. The nurse checks to ensure ventilations are appropriate.

N

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Chapter 31: End-of-Life Care Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who just died. Which action does the nurse take first to

determine if the patient is an organ or tissue donor? a. Delegate the task to nursing assistive personnel (NAP). b. Determine the patient’s legal representative. c. Request a copy of the patient’s driver’s license. d. Ask the spouse to sign an organ donation consent.

ANS: B

The nurse needs to determine if patient is an organ/tissue donor. Federal law mandates that family members be given a chance to authorize organ/tissue donation. The nurse should then call the organ/tissue request and procurement team (consult agency policy). Discussing organ donation and obtaining consent are tasks that the nurse cannot delegate because they require clinical judgment and critical thinking skills and are usually done by a special team. A copy of the patient’s driver’s license can be impractical or impossible to obtain soon enough to donate viable organs; generally the family knows the patient’s wishes about organ donation. If the spouse is the patient’s legal representative, he or she can provide consent.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Psychosocial Integrity

2. The family of the patient receiving hospice care is at the bedside expecting an imminent death.

N

They become upset when the patient suddenly becomes restless and disoriented. Which action by the nurse is most appropriate? a. Apply oxygen with a face mask. b. Ask the family to leave the room. c. Speak to the patient calmly and softly. d. Administer extra pain medication.

ANS: C

Restlessness and agitation are common patient assessments as death approaches and are part of the body’s preparation for death. The nurse explains that the upsetting behavior occurs frequently in the dying process and provides actions for the family to implement. For restlessness and agitation, the family can massage the hands or feet or play soothing music.

Oxygen by face mask can increase patient distress and impair any ability to communicate. The nurse avoids asking the family to leave the room. The nurse explains that the patient’s behavior is very common, reflective more of the dying process than actual distress. The nurse administers pain medication according to the prescription and clinical judgment.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Psychosocial Integrity

3. During postmortem care, the patient’s family says that the patient didn’t have his dentures to

place in his mouth. Which action does the nurse take at this time? a. Place a rolled-up towel under the patient’s chin. b. Stuff the mouth with cotton to maintain the facial contour.

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c. Tell the family to take the dentures to the funeral home. d. Ask the family what they want to do about this situation.

ANS: A

If there are no dentures to place in the mouth after death, a rolled-up towel will help keep the patient’s mouth positioned appropriately, if this action is culturally acceptable. Cotton is not used by the nurse to maintain the patient’s mouth position. The dentures are easiest to place in the mouth immediately after death. It could be hours to several days until the patient’s body is taken to the funeral home, depending on whether an autopsy is done or not. The nurse should know what to implement regarding this situation.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Psychosocial Integrity

4. The patient is in the final stage of dying. Which action does the nurse implement? a. Maintain a darkened, cool room. b. Elevate the head of the bed. c. Catheterize the patient frequently. d. Provide warm, soothing liquids.

ANS: B

The nurse elevates the head of the bed as tolerated to facilitate breathing; in addition, the patient looks more comfortable slightly elevated in bed, which can be comforting to the family. The nurse does not alter the temperature of the room unless requested to. The patient may be more relaxed if the lighting is dim rather than brightly lit. Because urine production slows significantly as death approaches, urinary catheters are usually unnecessary. Patients eat less and less as death approaches; simple items such as ice chips, a teaspoon of tea, or an ice N pop are usually sufficient.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Psychosocial Integrity

5. The nurse provides postmortem care for an unfamiliar patient. Which approach should the

nurse use to best care for the body after death? a. Ask about the patient’s cultural or spiritual practices. b. Remove tubes and lines before they become difficult to remove. c. Cover the patient and transfer the body to the morgue. d. Remove the old patient identification (ID) band and apply a new one.

ANS: A

To best prepare the patient’s body after death, the nurse should exercise cultural sensitivity by inquiring about cultural or spiritual practices that the patient or family desires and implementing the practices to the best of the nurse’s ability. If family members are present, they often assume the responsibility for these rituals. Depending on the circumstances surrounding the death and on state law, the nurse may be required to leave all equipment and supplies in place. The nurse must check before removing any tubes or lines. He or she implements proper postmortem care for any patient, which includes much more than covering the patient with a sheet. The nurse leaves the original patient ID band to ensure patient identification in the morgue. The postmortem kit usually contains additional tags for patient identification.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Psychosocial Integrity

6. The nurse is caring for a patient who is dying but is receiving palliative care. What reason

should the nurse give to the patient’s family for this type of care? a. It eliminates all adverse symptoms. b. It improves the patient’s quality of life. c. It increases the daily caloric and fluid intake. d. It improves the amount of activity tolerated.

ANS: B

Palliative care focuses on symptom management, including pain control, to improve the quality of the patient’s life up to death. Palliative care is not curative and does not eliminate all adverse symptoms; it does not necessarily increase the daily caloric and fluid intake nor is its focus to improve the patient’s activity tolerance.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Psychosocial Integrity

7. The nurse is caring for a Hindu patient receiving hospice care. Which does the nurse expect to

facilitate for the family when the patient dies? a. Allowing the family members to wash and prepare the patient’s body b. Helping the family arrange for burial of the body c. Communion and prayers by the hospital minister d. Discussion of the finality of death ANS: A

Hindu family members take anNactive role in preparing the body of a family member after death. Cremation, not burial, is traditional. Most likely the family will request the presence of a Brahmin priest who may chant prayers. A belief in reincarnation is held by those of the Hindu religion.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Psychosocial Integrity

8. The nurse plans nonpharmacological comfort measures for a patient who is dying. What

activity by the nurse is most appropriate? a. Keep the head of the bed lowered. b. Provide regular hygiene and skin care. c. Reduce the amount of analgesics given. d. Encourage the patient to eat frequently.

ANS: B

Patients near death can be incontinent; thus the nurse provides hygiene and skin care to enhance his or her appearance, provide comfort, and maintain dignity. Unless the patient is unable to tolerate it, the nurse keeps him or her in semi-Fowler’s position to facilitate breathing. The nurse administers adequate pain relief around-the-clock for the dying patient.

Often eating increases discomfort in dying patients, so the nurse does not encourage feeding, but responds to the patient’s request for fluids or food.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Psychosocial Integrity

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9. The nurse wants to provide specialized nursing care for a patient with a serious degenerative

illness that is not life threatening but for which there is no cure. Which approach would the nurse use in the care of this patient? a. Hospice care b. A combination of hospice care and palliative care c. Palliative care d. Experimental curative therapy with hospice care ANS: C

The nurse knows that palliative care enhances the quality of life for the patient at any time during serious illness and is helpful with a long-term chronic illness. Hospice care is holistic patient care that helps the patient and family prepare for death. A combination of hospice care and palliative care would be used for a patient who is dying. When a patient enters hospice care, there are no further attempts to cure; rather the focus is on relief of adverse symptoms and promotion of the best quality of life possible for the remaining time a patient has.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Psychosocial Integrity

10. The nurse is caring for a patient who is dying. What action by the nurse facilitates family

grieving? a. Understand that grief can begin long before the patient dies. b. The family needs to say good-bye to the patient. c. Update the family on every patient change. d. Provide a list of the area funeral homes and available services.

ANS: A

N

Grief is a process that often begins before a patient dies. Survivors grieve as they anticipate a loss and continue to feel the grief after the patient dies. The nurse provides support, resources, information, and comfort based on the family’s needs and desires. He or she usually allows the family to visit at will when a patient is near death so that the family can and processing the events. Individuals process death and grieve in many different ways, and not everyone wants an opportunity to say good-bye; however, if a family member wishes to do so, the nurse facilitates the family’s wishes. The nurse avoids becoming involved in the decision about the funeral home and declines to offer an opinion about available businesses; however, he or she can provide an area telephone book and a telephone for the family.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Psychosocial Integrity

11. The family wants to see their family member who has just died. What actions does the nurse

take when the family comes to visit? a. Provide hygienic care, including hair care, in their presence. b. Tell the family to ask any questions that they have about the patient. c. Place patient valuables in the body bag to go with the body to the morgue. d. Share other families’ past experiences of grief so they know they are not alone.

ANS: B

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When a family suffers a loss, grief can make it difficult to gather coherent thoughts and questions. The nurse should let the family know that they can ask questions when they are ready. The patient should have already been cleaned, including having the hair combed and dentures placed if present, unless that is not culturally acceptable. Any patient valuables should be given to the patient’s family. The focus is on the family experiencing the loss, not other families.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Psychosocial Integrity

12. The nurse is explaining to the patient the transition phase from palliative care to hospice care.

Which statement by the patient indicates a good understanding of the process? a. “I will go into a hospice bed.” b. “I will no longer focus on a cure.” c. “My pain-management program will change.” d. “My physician team will change.”

ANS: B

As a patient’s condition changes, the goals of care may shift away from curing an illness to care completely focused on symptom management and maintaining the highest possible quality of life. Ideally, patients who receive palliative care would move seamlessly into hospice care when they no longer benefit from curative treatments. They do not necessarily go to a hospice bed, and their pain-management program may change but it may stay the same initially. The physician team may also be the same.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Psychosocial Integrity

N

13. The family of a dying patient is distressed that their loved one does not want to eat or drink

and is constantly asking the patient to eat or drink something. What response by the nurse is best? a. Tell the family they shouldn’t try to force food and fluid on the patient. b. Tell the family that it’s the patient’s right to refuse food and fluids. c. Explain to the family that loss of interest in food and fluid is normal at the end of life. d. Explain to the family that blood flow to the intestines decreases and eating is not desired.

ANS: D

Near the end of life, as blood flow diminishes to all areas of the body, anorexia develops because the intestines are no longer working properly. Eating and drinking can cause discomfort and patients often refuse oral intake. While all options are correct statements, the best option is the one that explains the reason behind their loved one’s action to the family.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Psychosocial Integrity

14. The family of a dying patient asks the nurse “Why bother giving the patient laxatives and

stool softeners now?” What response by the nurse is best? a. “They were ordered by the provider so I have to give them.” b. “I don’t know but I can find out and let you know.”

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c. “Constipation causes abdominal discomfort so we try to prevent it.” d. “You don’t want the patient to get constipated, do you?”

ANS: C

Constipation can lead to abdominal distention and discomfort, so nursing care attempts to prevent it from occurring. Opioids, decreased food and fluid intake, and limited activity all can contribute to constipation before the blood flow to the intestines is impaired. The nurse understands why all medications are being given, but if he or she truly does not know the answer to a question, the correct response is to admit it, say you will find out, and say you will let the person asking know. Implying that the family member does not care about possible constipation is rude and demeaning.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Psychosocial Integrity

15. A patient with bone cancer and severe pain is nearing the end of life and is now unresponsive.

The nurse continues to administer round-the-clock opioid analgesics. What does the nurse explain to the nursing student about this activity? a. “The patient was in pain before so it’s wise to assume the pain is still present.” b. “These medications are ordered to be given around-the-clock.” c. “This is a standing palliative care medication routine.” d. “Opioids help with breathing and restlessness, making the family feel better.”

ANS: A

Just because the patient cannot express his or her views does not mean the patient is not in pain. The disease causing the severe pain has not gotten better, so there is no reason to think the patient’s pain has gone. Having a constant blood level of the medication helps maintain N will continue to give the pain medication around-the-clock. consistent pain control. The nurse Telling the student that they are ordered this way does not give the student any useful information. Treatments are individualized in both palliative and hospice care. Opioids can help with breathing difficulties and restlessness, but the intervention is based on patient, not family, need.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Psychosocial Integrity

16. The nurse and nursing assistive personnel are collaborating to perform post-mortem care on a

recently deceased patient. What action by the NAP requires the nurse to intervene? a. Raises the head of the bed 30 degrees. b. Closes the patient’s eyes. c. Ties the hands together over the abdomen. d. Replaces the patient’s dentures in the mouth.

ANS: C

The weight of the arms and hands across the body causes tissue damage, so the nurse intervenes to correct the NAP. The other actions are appropriate.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

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1. The nurse is explaining the similarities between palliative care and hospice care to the family

of a patient. Which statements indicate a need for further education? (Select all that apply.) a. Palliative care is used for patients nearing the end of their life. b. Palliative care is only for those patients who are terminally ill. c. Patients who are receiving palliative care continue treatments aimed at cure. d. Patients are active participants in their care and decisions. e. Patients are cared for by an interdisciplinary team.

ANS: A, B

The following are similarities between palliative care and hospice care: Prioritize for quality of life and relief from pain and other distressing symptoms.

Integrate the physical, psychological, social, and spiritual dimensions into the care plan.

Affirm life and regard dying as a normal process.

Involve the patient and family as active participants in all decisions and care.

Rely on the expertise of an interdisciplinary team for planning and implementing care.

Appropriate for all patients, regardless of diagnosis, age, or setting.

DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation

OBJ: NCLEX: Psychosocial Integrity

2. The nurse is caring for a dying patient and delegates hourly oral care to the nursing assistive

personnel. What actions does the NAP perform? (Select all that apply.) a. Swabbing mouth with alcohol-containing mouthwash b. Applying nonpetroleum lip balm when lips are dry c. Wiping mouth out with moist toothette or cloth every 2 hours d. Applying antifungal balm to patient’s tongue and gums N e. Brush the patient’s teeth once a day ANS: B, C

The NAP provides oral care by using nonpetroleum lip balm to dry lips and moist toothettes or washcloths to wipe out the patient’s mouth. Alcohol-containing mouthwashes will hasten drying of mucus membranes. Antifungal balm is a medication, applied by the nurse. The patient needs oral hygiene more than once a day and may or may not include brushing the teeth, depending on if the patient has teeth and if it causes too much discomfort.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Psychosocial Integrity

3. A patient on hospice care has been nauseated for two days, but now feels better and wishes to

drink a little fluid. What fluid would the nurse bring the patient? a. Coca-Cola b. Milkshake c. Orange juice d. Chicken broth e. Ice chips ANS: D, E

As nausea subsides, patients tolerate clear liquids best. The nurse would avoid any caffeinated liquids, milk, and fruit juices. Chicken broth or ice chips would be the best alternative.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Psychosocial Integrity

MATCHING

Match the symptoms seen near the end of life with an appropriate intervention. a. Raise the head of the bed. b. Use light blankets. c. Gentle massage. d. Give frequent hygiene. e. Hold hand and speak quietly.

1.

2.

3.

4.

5.

Bluish extremities Unresponsiveness Restlessness Incontinence Labored breathing

1. ANS: B DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity TOP: Nursing Process: Implementation MSC: Bluish extremities are often cool or cold and covering them with light blankets is comforting.

2. ANS: E DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity TOP: Nursing Process: Implementation MSC: Holding the patient's hand and speaking quietly is appropriate as the patient may still be able to hear.

3. ANS: C DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity TOP: Nursing Process: Implementation N MSC: Restlessness is often relieved by gentle massage, soothing music, and dim lighting.

4. ANS: D DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity TOP: Nursing Process: Implementation MSC: The incontinent patient may require frequent hygiene and the nurse would assess if the patient is becoming exhausted from this activity. If so, or if the skin is excoriated, an indwelling urinary catheter may be preferred.

5. ANS: A DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity TOP: Nursing Process: Implementation MSC: Elevating the head of the bed often helps with alterations in breathing. The nurse also administers pain medication and anxiolytics.

Match the religious faith with a common practice. a. May wish to face the east as they are dying. b. A family member may stay with the body until burial. c. A peaceful environment at the time of death is preferred. d. Rituals of confession or anointing the sick may occur. e. Only the family should wash the body after death.

6.

7.

8.

9.

Judaism Buddhist Islam Hinduism

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10. Christianity 6. ANS: B DIF: Cognitive Level: Understanding OBJ: NCLEX: Psychosocial Integrity TOP: Integrated Process: Caring MSC: After death of a Jewish patient a family member may remain with the body until the burial has occurred.

7. ANS: C DIF: Cognitive Level: Understanding OBJ: NCLEX: Psychosocial Integrity TOP: Integrated Process: Caring MSC: A peaceful environment is optimal for Buddhists so if the patient is awake, he or she can meditate or contemplate their death.

8. ANS: A DIF: Cognitive Level: Understanding OBJ: NCLEX: Psychosocial Integrity TOP: Integrated Process: Caring MSC: A Muslim may wish to face Mecca, which is in the east, as they are dying.

9. ANS: E DIF: Cognitive Level: Understanding OBJ: NCLEX: Psychosocial Integrity TOP: Integrated Process: Caring MSC: Only the family of a Hindu patient who has died should touch the body and they are responsible for washing and preparing it.

10. ANS: D DIF: Cognitive Level: Understanding OBJ: NCLEX: Psychosocial Integrity TOP: Integrated Process: Caring MSC: Some Christian rituals near the time of death include rituals of confession and anointing of the sick.

N

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Chapter 32: Home Care Safety Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse is working with a client on the plan of care. Which client behavior does the nurse

recognize as most illustrative that the client will cooperate with a plan of care? a. Willingness to attempt a return demonstration b. Refusal to talk about the needed assistive device c. States that a few days of rest are all that is needed for recovery d. States the equipment is too complex to learn ANS: A

The client who is willing to perform a return demonstration for the nurse is demonstrating a health-seeking behavior; thus the nurse plans interventions to facilitate client motivation and drive to master the task. The client who refuses to talk about the equipment is angry or in denial. The client who states that resting will solve the problem is in denial. The client who states the task is too difficult has a poor self-image and can benefit from slow, steady teaching and encouragement.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

2. The nurse plans discharge teaching for several clients. Which client and family are most likely

to benefit from the nurse’s teaching plan? a. The client’s oxygen saturation ranges from 88% to 90%.

N b. Client is 2 days postoperative after emergency amputation. c. The family lacks financial resources for supplies and equipment. d. The family agrees to the therapeutic diet and exercise plan.

ANS: D

The family that agrees to the therapeutic diet and exercise plan is most likely to benefit from the nurse’s teaching plan because the members are enthusiastic and positive, providing motivation and energy to succeed. They are willing to change their behavior when change is required. The hypoxic client will most likely have difficulty following directions and retaining information while struggling for oxygen. The client who had an emergency amputation is not ready for discharge because it is unlikely that the client received enough physical therapy; in addition, the client most likely had significant blood loss and could still be unstable. The client and family lacking financial resources for home health care need community resources before the teaching plan can be implemented.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

3. The nurse finishes discharge teaching for the client after a home assessment. Which action by

the client requires follow-up information from the home care nurse? a. Stores a flashlight next to the bed. b. Checks batteries in the smoke detector. c. Stores the area rugs in the basement. d. Leaves a loaded gun in the nightstand.

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ANS: D

The nurse needs to teach the client to keep the gun unloaded in a locked area and the bullets in a separate area for safety. Storing a flashlight, checking smoke detector batteries, and removing area rugs are suitable safety measures.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

4. A client’s family insists that the client live with one of the family members permanently

because of a shuffling gait, but the client refuses. Which approach is most effective to provide a safe environment while also acting as a client advocate? a. Conduct a home assessment focusing on fall prevention. b. Explain community services for older clients. c. Help the client check the fit of his shoes. d. Tell the family he can do whatever she wants.

ANS: A

The shuffling gait is a safety hazard and could cause the client to fall. The nurse first conducts a safety assessment of the house to determine factors promoting safety and factors that do not promote safety. It is possible that some modifications (i.e., wall railings) would be sufficient to keep the client safe at home. Checking shoes for fit is important as shoes that are too big or don’t fit totally on the foot can be a tripping hazard, but this is not as important as a comprehensive home safety assessment. Explaining the community services available will not provide safety for this client. Telling the family that he or she can do whatever he or she wants ignores the client’s specific safety needs, the families concerns, and effectively removes them from the discussion.

N DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

5. The client’s son tells the nurse that his parent is unable to learn about new medications

because of her advanced age. Which does the nurse include in family teaching? a. Older clients lack the motivation to learn. b. Older clients can learn if one speaks loudly. c. Visual aids are not helpful for older adults. d. The ability to learn remains intact despite aging.

ANS: D

The nurse instructs the family that older clients are willing and able to learn new things, including how to self-administer new medication. In fact, nursing research indicates that learning new things is a stimulant for improved cognitive function. Learning can take more time for older clients, but they are capable nonetheless, unless they have a cognitive disorder that would prevent learning, such as dementia. Lack of motivation is a generalization. Many older clients have a hearing impairment; thus, the nurse speaks clearly and directly in front of the client to facilitate hearing. Visual aids are as helpful for older adults as they are for any age-group. Using visual aids is more dependent on the client’s learning style than on age.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

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6. The nurse instructs the client to perform self-injections of insulin. Which does the nurse

include in client teaching to prevent a home accident to other family members? a. Trains the client to avoid rubbing the injection site. b. Instructs the client to store used needles in a hard plastic bottle with a tight lid. c. Shows the client how to draw up precise insulin doses. d. Ensures that the client has low-dose syringes for small doses.

ANS: B

The nurse instructs the client to dispose of used needles in a hard plastic bottle with a tight lid (or a medically approved sharps container if one is available) to prevent accidental needlestick injuries to other family members; if small children are in the home, the nurse suggests keeping the bottle in a locked cabinet. The nurse instructs the client to protect his or her skin integrity by not rubbing the injection site. The nurse shows the client how to draw up precise doses of insulin and ensures that the client uses the best equipment to avoid hyperglycemic or hypoglycemic emergencies. However, problems in these areas should not cause accidents involving other family members.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

7. The nurse prepares to discharge an older client who has fallen in the hospital to home. Which

safety measure does the nurse include in client and family teaching? a. Install a grab bar near the shower or tub. b. Take medications at bedtime to avoid side effects. c. Install additional towel bars near the shower or tub. d. Wear socks during the day for foot health.

ANS: A

N

A grab bar is rigid and can provide effective support in case of a near fall. Medications may need to be spaced during the day, or may include diuretics that cause nocturia, possibly leading to a fall at night. Other medications may also increase the risk for falling if taken at night. Towel bars are ineffective safety bars; the nurse instructs the client to install safety bars in the bathroom. A fall-prone client should wear a well-fitting pair of shoes during the day because socks are slippery.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

8. A frail older client is being driven to the grocery store. Which aspect of safety prevention is

most important for the nurse to stress to this client? a. Tell the client to get out of the car slowly. b. Move the client’s seat at least 10 inches from the air bag. c. Instruct the driver to let the client off at the door. d. Instruct the client to avoid rib and chest injury by not using the seatbelt.

ANS: B

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Frail older adults should not ride in the passenger seat of the car with airbags unless the seat can be at least 10 inches from the airbag. The impact of the airbag, if deployed, can cause serious injury because of the client’s frailty. There are no data supporting the client’s orthostatic hypotension. He or she should change positions slowly anytime, not only when riding in a car. Letting the client off at the door is a poor suggestion as the frail person may need help and may not be able to stand there waiting for the driver to return. Anyone in a car needs to wear a seat belt.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

9. The nurse is helping a client with diminished sight to remain as independent in the home as

possible. Which does the nurse include as a priority in client teaching to improve home safety for the client? a. Turn on a light before he or she walks into a dark room. b. Clean the top of the stove and appliances at least twice a week. c. Post emergency numbers on the front of the refrigerator. d. Use fluorescent lighting to decrease glare.

ANS: A

The nurse instructs the client with diminished sight to light living areas. This decreases the chance of bumping into things and becoming injured. The top of the stove and the other appliances should be clean and grease-free, but the cleaning schedule will depend on the cooking schedule; more or less cleaning may be needed. The nurse instructs the client to post emergency numbers with large print to increase his or her ability to see them. The numbers should also be posted by the phone or in an easily accessible place. The front of the refrigerator may or may not beNthe ideal place. Fluorescent lighting should not be used as it causes worse glare.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

10. The nurse prepares to teach the client about managing multiple medications at home. Which

client outcome does the nurse hope to accomplish as a result of client teaching? a. The client demonstrates proper disposal of medications in the toilet. b. The client stores the medication bottles on the bathroom counter. c. The client can read each medication label and explain when to take each one. d. The client explains ways to decrease the number of times he or she takes the medications.

ANS: C

The nurse’s goal is to ensure that the client is able to identify and understand each prescription ordered and when to take it. Although the FDA does not recommend routine flushing of discarded medications down the toilets, some medications with high abuse potential should be flushed. Medications should be stored in a dark, locked, dry place, not on an open counter exposed to water. The nurse instructs the client to avoid mixing several medications in the same container because this can cause confusion.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

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11. The nurse is teaching the client how to safely take a diuretic and an antihypertensive pill.

Which information does the nurse write for the client to reduce client risk of falls while maintaining the therapeutic medication regimen? a. Take the diuretic in the morning at 8 AM and the antihypertensive pill at 1 PM. b. Take both medications at the same time so the client can remember. c. Change positions slowly, especially from lying down to standing. d. Take the medications with orange juice to maintain the potassium level.

ANS: A

The nurse instructs the client to take a diuretic early in the day so trips to the bathroom will not interrupt sleep at night. Taking the medications at different times minimizes the side effects (e.g., lowering the blood pressure too fast and causing dizziness, which can lead to falls). The two types of medications taken together could cause a major drop in blood pressure and cause the client to fall. The nurse instructs the older client to change positions slowly, but this doesn’t include instructions about scheduling the medications. There is no information to support whether or not the medications deplete potassium.

DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

12. The nurse is caring for an older client who has been getting more confused recently. What

other characteristics might the family notice that alerts the nurse that the client may be at risk for wandering? a. The client paces and cannot be redirected easily. b. The client sleeps 6 hours at night and naps during the day. c. The client gets tired when cleaning the kitchen after cooking dinner. d. The client uses a space heater for supplemental heat.

N ANS: A

Pacing with difficulty being redirected is a characteristic that the family needs to report to the nurse. Six hours of sleep at night with a daytime nap is an expected sleep pattern for an older client. Tiring after cleaning the kitchen following cooking dinner is not unexpected for an older client. A space heater is not necessarily a hazard for a client with confusion as long as it is used appropriately. The space heater is also not related to wandering.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

13. The nurse completes a home safety assessment and recommends removing a few pieces of

large furniture to widen the pathway for a client who ambulates with a walker. However, the client refuses to allow furniture to be removed. Which action should the nurse take at this time? a. Remove the furniture because it is a safety hazard. b. Discuss the unsettling nature of change with the client. c. Instruct the client about potential injuries from falls. d. Explain the nursing responsibility to reduce the risk.

ANS: B

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The nurse invites the client to discuss change and its potential to cause distress (even when the change is desirable) to gather additional information about client refusal to remove a few pieces of furniture. The client can fear loss of control, grieve loss of function, or deny his physical limitations. The more the nurse knows about the client’s feelings and thoughts about the situation, the greater the potential for the nurse to facilitate client home safety. The nurse has no right to move the client’s furniture because the client retains the right to self-determination and to refuse therapy. The nurse should provide information about the client’s risk from falling; however, he or she should phrase the information carefully to avoid a threatening or condescending manner. The client’s safety is not about the nurse, and it is unethical for the nurse to use guilt to coerce the client.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

14. The nurse teaches an older client about minimizing the risk of falls at home. Which does the

nurse include in client teaching to prevent falls? a. Install extra towel bars in the bathtub and near the toilet. b. Arrange the furniture so that pathways are wide enough and clear. c. Have a neighbor check on the client every afternoon. d. Secure throw rugs to the floor with double-sided tape.

ANS: B

To prevent falls in the home, the nurse instructs the client to keep furniture arrangements so that the furniture can be walked around easily and keep walking paths free of clutter. If a change must occur, the client should practice moving around in the new arrangement with assistance as much as possible and use full lighting during any ambulation. Towel bars are not sturdy. Safety grab bars shouldNbe installed in the bathroom to help prevent falls. The neighbor can help to prevent a fall by assisting the client with awkward tasks but checking in once a day will not prevent a fall. Throw rugs and area rugs are trip hazards because they create an uneven surface, with or without tape.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

15. The nurse assesses a home care client who has a possible cognitive impairment. Which does

the nurse implement to validate the assessment finding before planning suitable nursing care? a. Collaborate for a psychiatric evaluation. b. Call a social worker to assess client needs. c. Ask family members for additional information. d. Review how the client takes care of things at home.

ANS: D

The nurse reviews home maintenance duties with the client before planning suitable nursing care or follow-up nursing interventions for a client who has a possible cognitive impairment.

After completing the client interview, the nurse compares the client assessment findings to the appearance of the house to evaluate the consistency of client perceptions. This information provides valuable information about client self-care abilities. The nurse does not need a psychiatric evaluation or a social worker yet but can include the request in follow-up nursing care. The nurse completes the client evaluation first before obtaining additional information from the family.

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DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

16. The home care nurse assists a client with impaired fine-motor skills. Which should the nurse

implement to benefit the client? a. Large-print medication labels b. An easily opened medication organizer c. A telephone with a vibrating ringer d. A color-coded medication schedule ANS: B

The nurse facilitates client self-administration of medications by organizing the medication in easy-open containers for this client. Large-print labels and color-coded systems assist a client with a visual impairment. A telephone equipped with a vibrating ringer assists a client with a hearing impairment.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

17. The nurse prepares the client to self-administer medications at home. Which does the nurse

implement to increase the chance of client compliance with the therapeutic regimen? a. Provides client with a list of medication websites. b. Instructs client to decrease dose when feeling better. c. Discusses strategies for client use to prevent addiction. d. Develops a clear medication schedule with client help.

ANS: D

Many clients take medication improperly and thereby increase the risks of adverse effects and N ineffective therapy. One method to increase client compliance is to simplify medication administration with a schedule for client use. The nurse develops the schedule with the client’s assistance to engage the client in therapy and tailor the schedule to suit the client’s needs. Clients take medication improperly because many misunderstand the risk of noncompliance with therapy; thus, the nurse instructs the client about the risks and benefits of therapy and noncompliance to increase client ability to make an informed decision. The nurse instructs the client to take the medication as prescribed. Clients may fear addiction to medication, including medications that are not addictive, primarily from lack of education; the nurse explains that most medications are not addictive. In addition, the nurse explains the low rate of addiction to opioids for clients with real pain. The nurse educates the client on self-administration of other addicting agents and how to avoid addiction.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

18. The nurse is conducting a home safety assessment and notes the client has a fire extinguisher

near the stove. What action by the nurse is most appropriate? a. Praise the client for having the extinguisher. b. Have the client demonstrate/explain use of the extinguisher. c. Check to see if the extinguisher is still fully charges. d. Create a schedule for the client to change the extinguisher batteries.

ANS: B

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While the nurse does offer the client positive reinforcement for having a fire extinguisher and checks that it is ready for use, the extinguisher will be of no use unless the client can actually use it. The nurse asks the client to explain how to use the extinguisher, and might encourage a role play where the client demonstrates how he or she would use it. This also allows the nurse to ensure the client can manipulate it. The fire extinguisher does not have batteries.

DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

19. The nurse assesses a client using the Folstein test (Mini Mental Status Exam [MMSE]) and

the client scores a 15. What action by the nurse is most appropriate? a. Consult the provider about a physical therapy referral. b. Arrange a full neurocognitive assessment for the client. c. Assess the client’s food and beverage preferences. d. Teach the client and family ways to prevent falls.

ANS: B

The Folstein test, or Mini-Mental Status Exam, is a screening tool for cognitive impairment. If the client scores 21 or less, he or she needs further assessment. The nurse arranges for a comprehensive neurocognitive evaluation. The Folstein test is not used to assess physical functioning, nutrition, or fall risk.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

MULTIPLE RESPONSE

N

1. The Joint Commission has identified goals related to client safety in the home. These goals

focus on which of the following? (Select all that apply.) a. Patient identification b. Medication safety c. Fall prevention d. Patient education e. Safety risk identification ANS: A, B, C, E

The Joint Commission has identified five goals that include: 1. Identifying patients correctly (following procedure to be sure patients receive the correct medications).

2. Using medicines safely (ensuring a patient has one up-to-date medication list and understands his or her medications) 3. Preventing infection (using hand hygiene) 4. Preventing clients from falling (recognizing fall risks and implementing preventive strategies) 5. Identifying client safety risks (specifically risks associated with oxygen therapy).

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

2. The nurse is assessing a client who has fallen at home using the mnemonic SPLATT. This

refers to what assessment factors? (Select all that apply.)

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a. b. c. d. e. f.

Location of fall Time of fall Severity of fall Trauma after fall Place of fall Activity at time of fall

ANS: A, B, D, F

SPLATT refers to: Symptoms at time of fall Previous fall Location of fall Activity at time of fall Time of fall Trauma after fall DIF: Cognitive Level: Remembering TOP: Nursing Process: Assessment

OBJ: NCLEX: Safe and Effective Care Environment

3. The nurse is working with a client who needs to make adaptations to the home environment

before the client can safety return home. Which of the following principles are important to consider? (Select all that apply.) a. Ask the client about his or her financial situation. b. Make changes that support the client’s independence. c. Only make the changes necessary to address disabilities. d. Let the client make the final decision whenever possible. e. Educate the family about preserving client autonomy.

N ANS: A, B, D, E

It is important to make changes in the client’s home environment to keep him or her as independent as possible, yet still consider the client’s financial resources. Whenever possible, the client should be the final decision maker in the types of changes to be made. The nurse should consider the client’s physical strengths and remaining functional abilities, not just the disabilities. It is important to educate family caregivers about the importance of preserving client autonomy so they can be supportive of the client.

DIF: Cognitive Level: Applying TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

4. A student is preparing a presentation on violence in the community setting. What information

does the student include in this presentation? (Select all that apply.) a. Unintentional injury and violence is the number 5 cause of death in all Americans. b. Injuries are the leading cause of death in people aged 1–44 years. c. Injuries are the leading cause of disability in people of all age-groups. d. Violence and injury lead to higher medical costs and loss of productivity e. Sex, race, and socioeconomic status are important variables in violence effect.

ANS: B, C, D

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Injuries are the leading cause of death in people 1–44 years of age and the leading cause of disability in people of all ages, regardless of race, sex, or socioeconomic status. Violence and injury lead to higher medical costs and loss of productivity. Unintentional injury and violence are in the top 15 leading killers of Americans of all ages.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning

OBJ: NCLEX: Safe and Effective Care Environment

5. The nurse is educating a family caregiver on signs that indicate the client might be at risk for

wandering. What information does the nurse include? (Select all that apply.) a. Following the caregiver around b. Going into the same room frequently c. Walking without an obvious purpose d. Frequent fidgeting while sitting e. Looking for “missing” people or pets ANS: A, B, C, E

Shadowing the caregiver; going to the same place repeatedly; walking without an obvious purpose; and looking for “missing” people, places, and pets all are signs the client is at risk for wandering. Continuous moving, pacing, or walking is a sign, however; fidgeting while sitting is not.

DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

6. The home care nurse is visiting an adult client who has two young children under the age of 4.

What strategy can the nurse teach the client to best protect the children from hazards in their home? (Select all that apply.) N a. Store medications in the parent’s bedroom and keep the children out. b. Get down on the floor to look at the environment from the children’s view. c. Place safety plugs in the electrical outlets throughout the house. d. Using a night light in the children’s bathroom. e. Store guns in a locked safe and ammunition in a separate locked environment.

ANS: B, C, D, E

The nurse instructs the parents or caregivers to get down on the floor and look at the environment from the children’s view to identify dangers present in the home. Telling the children they cannot enter the adult’s bedroom is impractical and if they found the medication, they might ingest it. Safety plugs are important to cover the electrical outlets. A night light in the children’s bathroom takes care of a specific time period in a specific place which can be helpful at night. Guns and ammunition should be stored separately in locked containers.

DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation

OBJ: NCLEX: Safe and Effective Care Environment

MATCHING

Match the type of medication to its safety hazard. a. May cause hypotension if taken with blood pressure medications. b. May cause falls when taken at night and client has urgent nocturia. c. May cause sedation and confusion at any time these are taken.

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d. May cause orthostatic hypotension or dizziness.

1.

2.

3.

4.

Diuretics Antihypertensives Opioid pain medication Antidysrhythmics

1. ANS: B DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Nursing Process: Assessment MSC: Diuretics cause urination, which can be urgent. If the client takes the diuretic at night, he or she is at risk for falling due to rushing to the bathroom.

2. ANS: D DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Nursing Process: Assessment MSC: When blood pressure is lowered, the client can experience orthostatic hypotension and/or dizziness, both of which can contribute to falling.

3. ANS: C DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Nursing Process: Assessment MSC: Opioids often lead to sedation and confusion, which not only put clients at risk for falling, but also for other injuries if they are doing something that requires them to remain alert.

4. ANS: A DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Nursing Process: Assessment MSC: Antidysrhythmics and antihypertensives often cause dizziness when taken together.

Match the risk with an appropriate N intervention a. Install broad-beam lighting. b. Paint surfaces with non-glossy paint. c. Install a shelf by the door client uses most often. d. Complete a pill count weekly. e. Dispose of medications crushed and mixed with cat litter.

5.

6.

7.

8.

9.

Client has difficulty seeing clearly due to glare.

Client living alone may have cognitive deterioration.

Client has pets and children often visit.

Client gets fatigued and has near-falls.

Client enjoys short night time walks.

5. ANS: B DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Nursing Process: Implementation MSC: Satin and non-glossy paints and finishes will reduce glare from walls, and on countertops and cabinets.

6. ANS: D DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Nursing Process: Implementation MSC: If the nurse suspects the client who is self-administering medications has some cognitive impairment, a weekly pill count will help validate that medications are being taken correctly.

7. ANS: E DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

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TOP: Nursing Process: Implementation MSC: To properly dispose of oral medications, pills should be crushed and/or dissolved in water, then mixed with old coffee grounds or kitty litter to reduce the chance of someone trying to ingest them.

This is especially important if there are children and pets around.

8. ANS: C DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Nursing Process: Implementation MSC: If the client still runs errands, he or she may be very fatigued when coming home. Putting up a shelf near on often-used door gives the client a place to set objects like grocery bags right inside the doorway.

9. ANS: A DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Nursing Process: Implementation MSC: Broad-beam lighting is good for the outdoors, where a wide beam of light will provide illumination for the client who is outside at night.

N

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