Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Chapter 1: Using Evidence in Nursing Practice MULTIPLE CHOICE 1. Evidence-based practice is a problem-solving approach to making decisions about patient care
that is grounded in: A) the latest information found in textbooks. B) systematically conducted research studies. C) tradition in clinical practice. D) quality improvement and risk management data. ANS: B
The best evidence comes from well-designed, systematically conducted research studies described in scientific journals. Portions of a textbook often become outdated by the time it is published. Many health care settings do not have a process to help staff adopt new evidence in practice, and nurses in practice settings lack easy access to risk management data, relying instead on tradition or convenience. Some sources of evidence do not originate from research. These include quality improvement and risk management data; infection control data; retrospective or concurrent chart reviews; and clinicians’ expertise. Although non–research-based evidence is often very valuable, it is important that you learn to rely more on research-based evidence. DIF: Cognitive Level: Comprehension REF: Text reference: p. 2 OBJ: Discuss the benefits of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment (management of care)
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2. When evidence-based practice is used, patient care will be: A) standardized for all. B) unhampered by patient culture. C) variable according to the situation. D) safe from the hazards of critical thinking. ANS: C
Using your clinical expertise and considering patients’ cultures, values, and preferences ensures that you will apply available evidence in practice ethically and appropriately. Even when you use the best evidence available, application and outcomes will differ; as a nurse, you will develop critical thinking skills to determine whether evidence is relevant and appropriate. DIF: Cognitive Level: Application REF: Text reference: p. 2 OBJ: Discuss the benefits of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment (management of care) 3. When a PICOT question is developed, the letter that corresponds with the usual standard of
care is: A) P. B) I. PRIMEXAM.COM
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank C) C. D) O. ANS: C
C = Comparison of interest. What standard of care or current intervention do you usually use now in practice? P = Patient population of interest. Identify your patient by age, gender, ethnicity, disease, or health problem. I = Intervention of interest. What intervention (e.g., treatment, diagnostic test, prognostic factor) do you think is worthwhile to use in practice? O = Outcome. What result (e.g., change in patient’s behavior, physical finding, change in patient’s perception) do you wish to achieve or observe as the result of an intervention? DIF: Cognitive Level: Knowledge REF: Text reference: p. 3 OBJ: Develop a PICO question. TOP: PICO KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 4. A well-developed PICOT question helps the nurse: A) search for evidence. B) include all five elements of the sequence. C) find as many articles as possible in a literature search. D) accept standard clinical routines. ANS: A
The more focused a question that you ask is, the easier it is to search for evidence in the scientific literature. A well-designed PICOT question does not have to include all five elements, nor does it have to follow the PICOT sequence. Do not be satisfied with clinical routines. Always question anN dU usR eS crI itic al T thB in.kC ing to consider better ways to provide patient NG OM care. DIF: Cognitive Level: Analysis REF: Text reference: p. 4 OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 5. The nurse is not sure that the procedure the patient requires is the best possible for the
situation. Utilizing which of the following resources would be the quickest way to review research on the topic? A) CINAHL B) PubMed C) MEDLINE D) The Cochrane Library ANS: D
The Cochrane Library Database of Systematic Reviews is a valuable source of synthesized evidence (i.e., preappraised evidence). The Cochrane Database includes the full text of regularly updated systematic reviews and protocols for reviews currently happening. MEDLINE, CINAHL, and PubMed are among the most comprehensive databases and represent the scientific knowledge base of health care. DIF: Cognitive Level: Synthesis REF: Text reference: p. 4 OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 6. The nurse is getting ready to develop a plan of care for a patient who has a specific need. The
best source for developing this plan of care would probably be: A) The Cochrane Library. B) MEDLINE. C) NGC. D) CINAHL. ANS: C
The National Guidelines Clearinghouse (NGC) is a database supported by the Agency for Healthcare Research and Quality (AHRQ). It contains clinical guidelines—systematically developed statements about a plan of care for a specific set of clinical circumstances involving a specific patient population. The NGC is a valuable source when you want to develop a plan of care for a patient. The Cochrane Library Database of Systematic Reviews, MEDLINE, and CINAHL are all valuable sources of synthesized evidence (i.e., preappraised evidence). DIF: Cognitive Level: Synthesis REF: Text reference: p. 4 OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 7. The nurse has done a literature search and found 25 possible articles on the topic that she is
studying. To determine which of those 25 best fit her inquiry, the nurse first should look at: A) the abstracts. B) literature reviews. C) the “Methods” sections. NURSINGTB.COM D) the narrative sections. ANS: A
An abstract is a brief summary of an article that quickly tells you whether the article is research based or clinically based. An abstract summarizes the purpose of the study or clinical query, the major themes or findings, and the implications for nursing practice. The literature review usually gives you a good idea of how past research led to the researcher’s question. The “Methods” or “Design” section explains how a research study is organized and conducted to answer the research question or to test the hypothesis. The narrative of a manuscript differs according to the type of evidence-based article—clinical or research. DIF: Cognitive Level: Application REF: Text reference: p. 7 OBJ: Discuss elements to review when critiquing the scientific literature. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 8. The nurse wants to determine the effects of cardiac rehabilitation program attendance on the
level of postmyocardial depression for individuals who have had a myocardial infarction. The type of study that would best capture this information would be a: A) randomized controlled trial. B) qualitative study. C) case control study. D) descriptive study.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: B
Qualitative studies examine individuals’ experiences with health problems and the contexts in which these experiences occur. A qualitative study is best in this case of an individual nurse who wants to examine the effectiveness of a local program. Randomized controlled trials involve close monitoring of control groups and treatment groups to test an intervention against the usual standard of care. Case control studies typically compare one group of subjects with a certain condition against another group without the condition, to look for associations between the condition and predictor variables. Descriptive studies focus mainly on describing the concepts under study. DIF: Cognitive Level: Synthesis REF: Text reference: p. 5 OBJ: Discuss ways to apply evidence in nursing practice. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 9. Six months after an early mobility protocol was implemented, the incidence of deep vein
thrombosis in patients was decreased. This is an example of what stage in the EBP process? A) Asking a clinical question B) Applying the evidence C) Evaluating the practice decision D) Communicating your results ANS: C
After implementing a practice change, your next step is to evaluate the effect. You do this by analyzing the outcomes data that you collected during the pilot project. Outcomes evaluation tells you whether your practice change improved conditions, created no change, or worsened conditions.
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DIF: Cognitive Level: Application REF: Text reference: p. 8 OBJ: Discuss ways to apply evidence in nursing practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe and Effective Care Environment (safety and infection control) MULTIPLE RESPONSE 1. To use evidence-based practice appropriately, you need to collect the most relevant and best
evidence and to critically appraise the evidence you gather. This process also includes: (Select all that apply.) A) asking a clinical question. B) applying the evidence. C) evaluating the practice decision. D) communicating your results. ANS: A, B, C, D
EBP comprises six steps (Melnyk and Fineout-Overholt, 2010): 1. Ask a clinical question. 2. Search for the most relevant and best evidence that applies to the question. 3. Critically appraise the evidence you gather. 4. Apply or integrate evidence along with one’s clinical expertise and patient preferences and values in making a practice decision or change. 5. Evaluate the practice decision or change.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 6. Communicate your results. DIF: Cognitive Level: Analysis REF: Text reference: p. 2 OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 2. In a clinical environment, evidence-based practice has the ability to improve: (Select all that
apply.) A) the quality of care provided. B) patient outcomes. C) clinician satisfaction. D) patients’ perceptions. ANS: A, B, C, D
EBP has the potential to improve the quality of care that nurses provide, patient outcomes, and clinicians’ satisfaction with their practice. Your patients expect nursing professionals to be informed and to use the safest and most appropriate interventions. Use of evidence enhances nursing, thereby improving patients’ perceptions of excellent nursing care. DIF: Cognitive Level: Application REF: Text reference: p. 9 OBJ: Discuss the benefits of evidence-based practice. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 3. During the application stage of evidence-based practice change, it is important to consider:
(Select all that apply.) A) cost. NURSINGTB.COM B) the need for new equipment. C) management support. D) adequate staff. ANS: A, B, C, D
One important step for an individual or an interdisciplinary EBP committee is to consider the resources needed for a practice change project. Are added costs or new equipment involved with a practice change? Do you have adequate staff to make the practice change work as planned? Do management and medical staff support you in the change? If the barriers to practice change are excessive, adopting a practice change can be difficult, if not impossible. DIF: Cognitive Level: Application REF: Text reference: p. 8 OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) COMPLETION
is a guide for making accurate, timely, and appropriate clinical
1.
decisions. ANS:
Evidence-based practice
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Evidence-based practice is a guide for making accurate, timely, and appropriate clinical decisions. DIF: Cognitive Level: Knowledge REF: Text reference: p. 2 OBJ: Define the key terms listed. TOP: Evidence-Based Practice KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment (management of care) 2. Evidence-based practice requires good
.
ANS:
nursing judgment Evidence-based practice requires good nursing judgment; it does not consist of finding research evidence and blindly applying it. DIF: Cognitive Level: Comprehension REF: Text reference: p. 2 OBJ: Discuss the benefits of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment (management of care) 3. While caring for patients, the professional nurse must question
.
ANS:
what does not make sense Always think about your practice when caring for patients. Question what does not make sense to you, and question what you think needs clarification. DIF: Cognitive Level: AnalysN isURSINGRE F:.C Text p. 2 TB OMreference: TOP: OBJ: Describe the six steps of evidence-based practice. Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 4. A systematic review explains whether the evidence that you are searching for exists and
whether there is good cause to change practice. In , all entries include information on systematic reviews. Individual randomized controlled trials (RCTs) are the gold standard for research. ANS:
The Cochrane Library A systematic review explains whether the evidence that you are searching for exists and whether there is good cause to change practice. In The Cochrane Library, all entries include information on systematic reviews. Individual randomized controlled trials (RCTs) are the gold standard for research. DIF: Cognitive Level: Analysis REF: Text reference: pp. 4-6 OBJ: Describe the six steps of evidence-based practice. TOP: Evidence-Based Practice KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
are the gold standard for research.
5. ANS:
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Randomized controlled trials Individual randomized controlled trials (RCTs) are the gold standard for research (Titler and others, 2001). An RCT establishes cause and effect and is excellent for testing therapies. DIF: Cognitive Level: Knowledge REF: Text reference: p. 6 OBJ: Explain the levels of evidence in the literature. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 6. The researcher explains how to apply findings in a practice setting for the types of subjects
studied in the
section of a research article.
ANS:
“Clinical Implications” Clinical Implications A research article includes a section that explains whether the findings from the study have “clinical implications.” The researcher explains how to apply findings in a practice setting for the types of subjects studied. DIF: Cognitive Level: Application REF: Text reference: p. 7 OBJ: Discuss elements to review when critiquing the scientific literature. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 7.
is the extent to which a study’s findings are valid, reliable, and relevant to your patient population of interest. ANS:
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Scientific rigor Scientific rigor is the extent to which a study’s findings are valid, reliable, and relevant to your patient population of interest. DIF: Cognitive Level: Application REF: Text reference: p. 7 OBJ: Define the key terms listed. TOP: Randomized Controlled Trials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care) 8. Patient fall rates are an example of a
type of study in the evidence
hierarchy. ANS:
quality improvement data Data collected within a health care agency offer important trending information about clinical conditions and problems. Staff in the agency review the data periodically to identify problem areas and to seek solutions. DIF: Cognitive Level: Application REF: Text reference: p. 5 OBJ: Define the key terms listed. TOP: Quality Improvement KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment (management of care)
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 2: Admitting, Transfer, and Discharge MULTIPLE CHOICE 1. The patient is scheduled to go home after having coronary angioplasty. What would be the
most effective way to provide discharge teaching to this patient? A) Provide him with information on health care websites. B) Provide him with written information on what he has to do. C) Sit and carefully explain what is required before his follow-up. D) Use a combination of verbal and written information. ANS: D
For discharge teaching, use a combination of verbal and written information. This most effectively provides patients with standardized care information, which has been shown to improve patient knowledge and satisfaction. DIF: Cognitive Level: Application REF: Text reference: p. 12 OBJ: Identify the ongoing needs of patients in the process of discharge planning. TOP: Admission to Discharge Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. While preparing for the patient’s discharge, the nurse uses a discharge planning checklist and
notes that the patient is concerned about going home because she has to depend on her family for care. The nurse realizes that successful recovery at home is often based on: A) the patient’s willingness to go home. B) the family’s perceived ability to care for the patient. C) the patient’s ability to livN eU alR onSeI . NGTB.COM D) allowing the patient to make her own arrangements. ANS: B
Discharge from an agency is stressful for a patient and family. Before a patient is discharged, the patient and family need to know how to manage care in the home and what to expect with regard to any continuing physical problems. Family caregiving is a highly stressful experience. Family members who are not properly prepared for caregiving are frequently overwhelmed by patient needs, which can lead to unnecessary hospital readmissions. DIF: Cognitive Level: Analysis REF: Text reference: p. 22 OBJ: Identify the ongoing needs of patients in the process of discharge planning. TOP: Medication Reconciliation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 3. The patient arrives in the emergency department complaining of severe abdominal pain and
vomiting, and is severely dehydrated. The physician orders IV fluids for the dehydration and an IV antiemetic for the patient. However, the patient states that she is fearful of needles and adamantly refuses to have an IV started. The nurse explains the importance of and rationale for the ordered treatment, but the patient continues to refuse. What should the nurse do? A) Summon the nurse technician to hold the arm down while the IV is inserted. B) Use a numbing medication before inserting the IV. C) Document the patient’s refusal and notify the physician. D) Tell the patient that she will be discharged without care unless she complies.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: C
The Patient Self-Determination Act, effective December 1, 1991, requires all Medicare- and Medicaid-recipient hospitals to provide patients with information about their right to accept or reject medical treatment. The patient has the right to refuse treatment. Refusal should be documented and the health care provider consulted about alternate treatment. DIF: Cognitive Level: Application REF: Text reference: p. 13 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Patient Self-Determination Act KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 4. An unconscious patient is admitted through the emergency department. How and when is
identification of the patient made? A) Determined only when the patient is able B) Postponed until family members arrive C) Given an anonymous name under the “blackout” procedure D) Determined before treatment is started ANS: B
If a patient is unconscious, identification often is not made until family members arrive. Delaying treatment can cause deterioration of the patient’s condition. Blackout procedures are intended mainly to protect crime victims. DIF: Cognitive Level: Application REF: Text reference: p. 12 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: The Unconscious Patient KEY: Nursing Process Step: Im ple men tatio n NURSI NG TB.C OM MSC: NCLEX: Physiological Integrity 5. During admission of a patient, the nurse notes that the patient speaks another language and
may have difficulty understanding English. What should the nurse do to facilitate communication? A) Use hand gestures to explain. B) Request and wait for an interpreter. C) Work with the family to gather information. D) Complete as much of the admission assessment as possible using simple phrases. ANS: B
If the patient does not speak English or has a severe hearing impairment, the clerk must have access to an interpreter to assist during the admission procedure. Translation services are preferable to using family members to ensure correct translation of medical terminology. Hand gestures and simple phrases may not be adequate for everything that will be discussed at the time of admission. DIF: Cognitive Level: Application REF: Text reference: p. 15 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: The Patient Who Does Not Speak English KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 6. The patient has been admitted to the emergency department after being beaten and raped. She
is agitated and is frightened that her attacker may find her in the hospital and try to kill her. What should the nurse tell her? A) She is safe in the hospital, and she needs to provide her name. B) She can be admitted to the hospital without anyone knowing it. C) Her records will be used as evidence in the trial. D) Since she has come to the hospital, she has to be examined by the doctor. ANS: B
A patient who has been a victim of crime can be admitted anonymously under an agency’s “blackout” or “do not publish” procedure. HIPAA places limits on the institution’s ability to use or disclose the patient’s PHI. The Patient Self-Determination Act prohibits the hospital from requiring her to submit to an examination. DIF: Cognitive Level: Analysis REF: Text reference: pp. 13-14 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Victim of Crime KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 7. The patient is admitted to the ICU after having been in a motor vehicle accident. He was
intubated in the emergency department and needs to receive two units of packed red blood cells. He is conscious but is indicating that he is in pain by guarding his abdomen. To admit this patient, the nurse first will focus on: A) examining the patient and treating the pain. B) orienting the family to the ICU visitation policy. C) making sure that the consent forms are signed.
RIS IANG D) informing the patient of hNisUH PA riT ghB ts. . COM ANS: A
When a critically ill patient reaches a hospital’s nursing division, the patient immediately undergoes extensive examination and treatment procedures. Little time is available for the nurse to orient the patient and family to the division, or to learn of their fears or concerns. DIF: Cognitive Level: Analysis REF: Text reference: p. 15 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Role of the Nurse KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse is admitting the patient to the medical unit. The patient indicates that he has had
several surgeries in the past and has been a diabetic for the past 15 years. He also earlier that morning, but the pain has finally gone since he received a “pain shot” in the emergency department. What does this information prompt the nurse to do next? A) Provide the patient with an allergy arm band and document his allergies. B) Postpone routine admission procedures immediately. C) Ask the patient if he wants a smoking room. D) Have all family or friends leave the room. ANS: A
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Provide the patient with an allergy armband listing allergies to foods, drugs, latex, or other substances; document allergies according to hospital policy. Postpone routine admission procedures only if the patient is having acute physical problems. Smoking is prohibited throughout the hospital, and family or friends can remain if the patient wishes to have them assist with changing into a hospital gown or pajamas. DIF: Cognitive Level: Analysis REF: Text reference: p. 16 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Allergies KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. At what age is separation anxiety a common problem? A) School-aged children B) Preschoolers C) Middle infancy D) Newborns ANS: C
Separation anxiety is most common from middle infancy throughout the toddler years, especially from ages 16 to 30 months. Preschoolers are better able to tolerate brief periods of separation, but their protest behaviors are more subtle than those of younger children (e.g., refusal to eat, difficulty sleeping, withdrawing from others). School-aged children are able to cope with separation but have an increased need for parental security and guidance. DIF: Cognitive Level: Synthesis REF: Text reference: p. 18 OBJ: Explain the role of the patient’s family in the admission, transfer, or discharge process. TOP: Pediatric ConsiderationsNURSINGKE Y. : C NuOrsM ing Process Step: Assessment TB MSC: NCLEX: Psychosocial Integrity 10. The patient is being transferred from the emergency department to another institution for
treatment. Which of the following cannot be delegated to nursing assistive personnel (NAP)? A) Helping the patient get dressed B) Gathering IV equipment to go with the patient C) Escorting the patient to the transport area D) Assessing the patient’s respiratory status before transport ANS: D
The assessment and decision making conducted during transfers cannot be delegated to nursing assistive personnel. NAP can assist the patient with dressing, can gather and secure the patient’s personal belongings and any necessary equipment, and can escort the patient to the nursing unit or transport area. DIF: Cognitive Level: Application REF: Text reference: p. 19 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 11. When does the plan for patient discharge from a health care facility begin? A) At admission B) After a medical diagnosis has been determined
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank C) When the patient’s physical needs are identified D) After a home environment assessment is completed ANS: A
Planning for discharge begins at admission and continues throughout the patient’s stay in the agency. Separating the processes of admission and discharge is a critical error; the two are simultaneous and continuous. DIF: Cognitive Level: Comprehension REF: Text reference: p. 22 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 12. The phase of the discharge process where medical attention dominates discharge planning
efforts is known as the A) transitional B) continuing C) acute D) multidisciplinary
phase.
ANS: C
The discharge process occurs in three phases: acute, transitional, and continuing care. In the acute phase, medical attention dominates discharge planning efforts. During the transitional phase, the need for acute care is still present, but its urgency declines and patients begin to address and plan for their future health care needs. In the continuing care phase, patients participate in planning and implementing continuing care activities needed after discharge. There is no multidisciplinaryNstagRe; tI ha. rgCe plM U S heNdGisc TB O anning process is comprehensive and multidisciplinary. DIF: Cognitive Level: Comprehension REF: Text reference: p. 22 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. Once a patient’s discharge has been completed, which activity may be delegated to assistive
personnel? A) Provision of prescriptions to the patient B) Completion of the discharge summary C) Gathering of the patient’s personal care items D) Provision of instructions on community health resources ANS: C
The assessment, care planning, and instruction included in discharging patients cannot be delegated to nursing assistive personnel. The nurse may direct the NAP to gather and secure the patient’s personal items and any supplies that accompany the patient. DIF: Cognitive Level: Application REF: Text reference: p. 22 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Discharge Planning KEY: Nursing Process Step: Implementation
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Safe and Effective Care Environment 14. The nurse is providing discharge instruction to an 80-year-old patient and her daughter. The
patient lives in a two-story home. When asked if the patient has difficulty climbing stairs, the patient says “No,” but the nurse notices a look of surprise on the daughter’s face. What should the nurse do in this circumstance? A) Speak with the daughter separately. B) Cancel the discharge immediately. C) Order a visiting nurse consult. D) Notify the physician. ANS: A
Patients and family members often disagree on the health care needs of a patient after discharge. Identifying these discrepancies early leads to more accurate development of the discharge plan. It often is necessary to talk with the patient and family separately to learn about their true concerns or doubts. DIF: Cognitive Level: Application REF: Text reference: p. 23 OBJ: Explain the role of the patient’s family in the admission, transfer, or discharge process. TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 15. The patient has decided that he would like to create an advance directive. The nurse is asked if
she would be a witness. What is the best response for the nurse to make to this request? A) Agree to be a witness. B) Refuse to be a witness. C) Contact social work. D) Contact the physician. NURSINGTB.COM ANS: C
A social worker often fulfills this requirement. Witnesses for an advance directive document should not be medical personnel, and direct refusal does not meet the nurse’s obligation to meet the patient’s needs. Referral to a department that can ensure this service is required. DIF: Cognitive Level: Application REF: Text reference: p. 14 OBJ: Explain the purpose and importance of advance directives. TOP: Advance Directives KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. The patient is being admitted to the intensive care department with multiple fractures and
internal bleeding. Which of the following are considered roles of the nurse in this situation? (Select all that apply.) A) Anticipate physical and social deficits to resuming normal activities. B) Involve the family and significant others in the plan of care. C) Assist in making health care resources available to the patient. D) Identify the psychological needs of the patient. ANS: A, B, C, D
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The nurse identifies patients’ ongoing health care needs; anticipates physical, psychological, and social deficits that have implications for resuming normal activities; involves family and significant others in a plan of care; provides health education; and assists in making health care resources available to the patient. Separating the processes of admission and discharge is a critical error; the two are simultaneous and continuous. DIF: Cognitive Level: Application REF: Text reference: p. 11 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Admission to Discharge Process KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 2. Under the Health Insurance Portability and Accountability Act (HIPAA), a patient must:
(Select all that apply.) A) provide his true name before he can be treated. B) be informed of his privacy rights. C) have his personal health information used for treatment or payment only. D) have his personal health information used on a need-to-know basis only. ANS: B, C, D
HIPAA is a federal law designed to protect the privacy of patient health information, referred to as PHI, or protected health information. Three key concepts of HIPAA are (1) institutions are required to inform patients of the privacy rights they have and how the institution will handle their PHI; (2) the institution and health care providers are to use or disclose the patient’s PHI only for the purpose of treatment or payment or for health care operations; and (3) health care providers disclose only the minimum amount of PHI necessary on a need-to-know basis to accomplish the purpose of the use.
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DIF: Cognitive Level: Knowledge REF: Text reference: pp. 13-14 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: HIPAA KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 3. The patient is admitted to the unit for a cardiac catheterization. Which of the following can be
delegated to nursing assistive personnel (NAP)? (Select all that apply.) A) Obtaining admission vital signs B) Preparing the patient’s room C) Gathering and securing personal care items D) Orienting patient and family to the nursing unit ANS: B, C, D
The nursing assessment conducted during admission to a health care facility cannot be delegated to NAP. You cannot delegate admission vital signs as they provide a baseline for all further comparisons. The nurse directs NAP to (1) prepare the patient’s room with necessary equipment before admission; (2) gather and secure the patient’s personal care items; (3) escort and orient the patient and family to the nursing unit; and (4) collect ordered specimens. DIF: Cognitive Level: Analysis REF: Text reference: p. 15 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Delegation Considerations KEY: Nursing Process Step: Implementation
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Safe and Effective Care Environment 4. Which of the following are considered “advance directives”? (Select all that apply.) A) Living will B) Power of attorney for health care C) Notarized handwritten document D) Nursing progress note ANS: A, B, C
Advance directives may include a living will, power of attorney for health care, or a notarized handwritten document. DIF: Cognitive Level: Analysis REF: Text reference: p. 14 OBJ: Explain the purpose and importance of advance directives. TOP: Advance Directives KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. The patient is being transferred from the intensive care unit to the acute care unit. The nurse
must ensure that the following activities are completed: (Select all that apply.) A) providing the receiving nurse with a report before the transfer. B) determining any equipment needs for the patient during the transfer. C) providing an updated report after transferring the patient to the receiving unit. D) making sure a registered nurse accompanies the patient. ANS: A, B, C
When providing a “handoff” of a patient to another unit, it is essential that information about the patient’s care, treatment, services, and current condition and any recent or anticipated changes are communicated aN ccurR atelI y toGmeB et.pC atieM nt safety goals. The nurse first provides a U nurse. S NThis T allows O the receiving nurse to prepare for the telephone report to the receiving patient (e.g., preparing the room, securing necessary equipment). As clinically appropriate, a nurse or technician accompanies the patient during transport, providing the receiving nurse with the patient’s medical record; introducing the patient to the receiving nurse; and providing an updated report, including any changes in clinical status or plan of care. DIF: Cognitive Level: Application REF: Text reference: p. 19 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Continuum of Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment COMPLETION 1. Completing and documenting an accurate medication history from the patient is the important
first step in the
process.
ANS:
medication reconciliation Medication reconciliation compares the patient’s home medication list versus the medication orders at admission, transfer, or discharge to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Knowledge REF: Text reference: p. 17 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Medication Reconciliation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 2. If a patient is having acute physical problems, postpone routine admission procedures until the
patient’s immediate needs are met. A
assessment is needed at this point.
ANS:
focused If a patient is having acute physical problems, postpone routine admission procedures until you meet the patient’s immediate needs. Complete a focused assessment at this point. DIF: Cognitive Level: Analysis REF: Text reference: p. 15 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Admission Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. When transferring a patient, the nurse must ensure that the patient will receive ANS:
continuity of nursing care When patients transfer, you need to ensure continuity of nursing care. The aim is to continue health care so as to avoid therapeutic interruptions that may hinder progress toward recovery. DIF: Cognitive Level: Synthesis REF: Text reference: p. 19 OBJ: Describe the nurse’s roleNin m ain tain ing co. ntC inuiM ty of care through a patient’s admission, I G TB UR S transfer, and discharge from an acute careN facility. O TOP: Continuity of Care KEY: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment 4. The greatest challenge in effective discharge planning is
.
ANS:
communication The greatest challenge in effective discharge planning is communication. The communication problem is minimized when an organization has a discharge coordinator or a case manager who is responsible for discharge planning. DIF: Cognitive Level: Comprehension REF: Text reference: p. 22 OBJ: Describe the nurse’s role in maintaining continuity of care through a patient’s admission, transfer, and discharge from an acute care facility. TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. A document that provides a patient’s instructions in terms of future medical care or that
designates another person(s) to make medical decisions if the individual loses decision-making capacity is known as an . ANS:
advance directive
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.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank An advance directive is a document that provides a patient’s instructions about future medical care or that designates another person(s) to make medical decisions if the individual loses decision-making capacity. An advance directive conveys the patient’s choice in continuing medical care when the patient is unable to speak or make decisions. DIF: Cognitive Level: Knowledge REF: Text reference: p. 14 OBJ: Explain the purpose and importance of advance directives. TOP: Advance Directives KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
NURSINGTB.COM
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 3: Communication MULTIPLE CHOICE 1. The patient is a 54-year-old man who has made a living as a construction worker. He dropped
out of high school at age 16 and has been a laborer ever since. He never saw any need for “book learning,” and has lived his life “my way” since he was a teenager. He has smoked a pack of cigarettes a day for 40 years and follows no special diet, eating a lot of “fast food” while on the job. He now is admitted to the coronary care unit for complaints of chest pain and is scheduled for a cardiac catheterization in the morning. Which of the following would be the best way for the nurse to explain why he needs the procedure? a. “The doctor believes that you have atherosclerotic plaques occluding the major arteries in your heart, causing ischemia and possible necrosis of heart tissue.” b. “There may be a blockage of one of the arteries in your heart, causing the chest discomfort. He needs to know where it is to see how he can treat it.” c. “We have pamphlets here that can explain everything. Let me get you one.” d. “It’s just like a clogged pipe. All the doctor has to do is ‘Roto-Rooter’ it to get it cleaned out.” ANS: B
To send an accurate message, the sender of verbal communication must be aware of different developmental perspectives as well as cultural differences between sender and receiver, such as the use of dialect or slang. DIF: Cognitive Level: Application REF: Text reference: p. 28 OBJ: Explain the communication process. TOP: Verbal Communication N R I G B.C M O KEY: Nursing Process Step: ImpU lemS entaN tionT MSC: NCLEX: Psychosocial Integrity 2. The nurse is assessing a patient who says that she is feeling fine. The patient, however, is
wringing her hands and is teary eyed. The nurse should respond to the patient in which of the following ways? a. “You seem anxious today. Is there anything on your mind?” b. “I’m glad you’re feeling better. I’ll be back later to help you with your bath.” c. “I can see you’re upset. Let me get you some tissue.” d. “It looks to me like you’re in pain. I’ll get you some medication.” ANS: A
When assessing a patient’s needs, assess both the verbal and the nonverbal messages and validate them. In this case, if you see a patient wringing her hands and sighing, it is appropriate to ask, “You seem anxious today. Is there anything on your mind?” It is not enough to accept only the verbal message if nonverbal signals conflict, and it is inappropriate to jump to conclusions about what the nonverbal signals mean. DIF: Cognitive Level: Application REF: Text reference: pp. 36-37 OBJ: Explain the communication process. TOP: Nonverbal Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 3. Nonverbal communication incorporates messages conveyed by:
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
touch. cadence. tone quality. use of jargon.
ANS: A
Nonverbal communication describes all behaviors that convey messages without the use of words. This type of communication includes body movement, physical appearance, personal space, and touch. Cadence, tone quality, and the use of jargon are all part of verbal communication. DIF: Cognitive Level: Knowledge REF: Text reference: p. 28 OBJ: Explain the communication process. TOP: Nonverbal Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 4. The patient is an elderly male who had hip surgery 3 days ago. He states that his hip hurts, but
he does not like how the medicine makes him feel. He believes that he can tolerate the pain better than he can tolerate the medication. What would be the best response from the nurse? a. Explain the need for the pain medication using a slower rate of speech. b. Explain the need for the pain medication using a simpler vocabulary. c. Explain the need for the pain medication, but ask the patient if he would like the doctor called and the medication changed. d. Explain in a loud manner the need for the pain medication. ANS: C
Suggesting, which is presenting alternative ideas for patient consideration relative to problem solving, can be effective in hN elpi ngStI heNpGatie UR TBnt.mCain OMtain control by increasing the patient’s perceived options or choices. Nurses often use elder-speak, which includes a slower rate of speech, greater repetition, and simpler grammar than normal adult speech, when caring for older adults. However, many older patients perceive this type of communication as patronizing. DIF: Cognitive Level: Application REF: Text reference: p. 31 OBJ: Identify the purpose of therapeutic communication, communication in various phases of the nurse-patient relationship, and special issues related to communication. TOP: Communication with the Elderly KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 5. When comparing therapeutic communication versus social communication, the professional
nurse realizes that therapeutic communication: a. allows equal opportunity for personal disclosure. b. allows both participants to have personal needs met. c. is goal directed and patient centered. d. provides an opportunity to compare intimate details. ANS: C
Therapeutic communication empowers patients to make decisions but differs from social communication in that it is patient centered and goal directed with limited disclosure from the professional. Social communication involves equal opportunity for personal disclosure, and both participants seek to have personal needs met. Nurses do not share with patients intimate details of their personal lives.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Application REF: Text reference: p. 30 OBJ: Develop skills for therapeutic communication in various phases of the nurse-patient relationship. TOP: Establishing the Nurse-Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 6. The nurse is explaining a procedure to a 2-year-old child. Which is the best approach to use? a. Showing the needles and bandages in advance b. Telling the patient exactly what discomfort to expect c. Using dolls and stories to demonstrate what will be done d. Asking the child to draw pictures of what he or she thinks will happen ANS: C
Some age-appropriate communication techniques for a 2-year-old child include storytelling and drawing. Showing the child needles or telling the child about discomfort would increase anxiety. Having a child draw what he expects does not explain what is going to happen. DIF: Cognitive Level: Application REF: Text reference: p. 36 OBJ: Develop skills for therapeutic communication in various phases of the nurse-patient relationship. TOP: Establishing the Nurse-Patient Relationship—Pediatric Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 7. The nurse is about to go over the patient’s preoperative teaching per hospital protocol. She
finds the patient sitting in bed wringing her hands, which are sweaty, and acting slightly agitated. The patient states, “I’m scared that something will go wrong tomorrow.” How should the nurse respond? NURSINGTB.COM a. Redirect her focus to dealing with the patient’s anxiety. b. Tell the patient that everything will be all right and continue teaching. c. Tell the patient that she will return later to do the teaching. d. Give the patient antianxiety medication. ANS: A
Anxiety interferes with comprehension, attention, and problem-solving abilities and thus interferes with the patient’s care and treatment. To ensure the effectiveness of treatment, the nurse should try to help the patient understand the source of the anxiety. Ignoring the anxiety, medicating for it, and postponing the discussion are all inappropriate. DIF: Cognitive Level: Application REF: Text reference: p. 36 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Establishing the Nurse-Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 8. The nurse is attempting to teach the patient and his family about his care after discharge. The
patient and the family demonstrate signs of anxiety during the teaching session. The nurse should consider doing what? a. Using more gestures or pictures b. Focusing on the physical complaints c. Getting another staff member to speak to the patient d. Repeating information to the patient and the family at a later time
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS: D
Remember that patients and their family members who are under stress often require repeated explanations. Increasing gestures and pictures is additional stimulation that may increase anxiety. Physical complaints should be acknowledged, but dwelling on them can also increase the patient’s anxiety. Involving another staff member would cause a break in the continuity of care. DIF: Cognitive Level: Application REF: Text reference: p. 38 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Establishing the Nurse-Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 9. The patient is an elderly man who was brought to the hospital from an assisted-living
community with complaints of anorexia and general malaise. The nurse at the assisted-living community reported that the patient was very ritualistic in his behavior and fastidious in his dress and always took a shower in the evening before bed. The patient became very angry and upset when the patient care technician asked him to take his bath in the morning. What does this behavior tell the nurse? a. The patient is exhibiting anxiety because of a change in his rituals. b. The patient is suffering from sensory overstimulation. c. The patient is basically an angry person. d. The patient has to follow hospital protocol. ANS: A
Patients often become ritualistic and intent on performing activities a certain way. Anxiety develops as a result of a specN ificR eveI nt oG r a gBe. neCral M pattern of change.
U S N T
O
DIF: Cognitive Level: Analysis REF: Text reference: p. 38 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Gerontological Considerations—Anxiety KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 10. The nurse is preparing to give an intramuscular injection to the patient in room 320. The
patient care technician comes to the medication room and tells the nurse that the patient in room 316 is very angry with his roommate and is threatening to hit him. How should the nurse respond? a. Tell the patient care technician to calm the patient down until she can get there. b. Have the angry patient’s roommate moved to another location. c. Tell the angry patient to calm down until she can get there. d. Tell the angry patient that he has to act civilized in the hospital, and that’s that. ANS: B
A potentially violent patient needs to be in an environment with decreased stimuli and to have protection from injury to self and against others. Encourage other people, particularly those who provoke anger, to leave the room or area. De-escalation is a skill that cannot be delegated to nursing assistive personnel (NAP). DIF: Cognitive Level: Application REF: Text reference: pp. 39-40 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Communicating With the Angry Patient
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 11. Which behavior should the nurse who is communicating with a potentially violent patient
employ? a. Sit closer to the patient. b. Speak loudly and firmly. c. Use slow, deliberate gestures. d. Always block the door to prevent escape. ANS: C
Make sure that gestures are slow and deliberate rather than sudden and abrupt. There is less chance for misinterpretation of the message, and slow, deliberate gestures are less threatening. Keep an adequate distance between yourself and the patient to reduce your risk of injury and to avoid making the patient feel pressured. Try to talk in a comfortable, reassuring voice. Position yourself closest to the door to facilitate escape from a potentially violent situation. Do not block the exit; if the patient feels unable to escape, this may cause a violent outburst. DIF: Cognitive Level: Application REF: Text reference: p. 40 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Communicating With the Angry Patient KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity 12. The patient is sitting at the bedside. He has not been eating and is just staring out of the
window. The nurse approaches the patient and asks, “What are you thinking about?” What type of communication technique is this? a. Restating NURSINGTB.COM b. Clarification c. Broad openings d. Reflection ANS: C
Broad openings encourage patients to select topics for discussion. They affirm the value of the patient’s initiative. Restating is repeating a main thought that the patient has expressed. Clarification is attempting to put into words vague ideas or asking the patient to explain what he or she means. Reflection is directing back to the patient ideas, feelings, questions, or content. DIF: Cognitive Level: Knowledge REF: Text reference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 13. A patient tells the nurse, “I want to die.” Which response is the most appropriate for the nurse
to make? a. “Why would you say that?” b. “Tell me more about how you are feeling.” c. “The doctor should be told how you feel.” d. “You have too much to live for to think that way.” ANS: B
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Broad openings encourage the patient to select topics for discussion and indicate acceptance by the nurse and the value of the patient’s initiative. “Why” questions can cause defensiveness and can hinder communication. Saying you will inform the doctor leads the conversation away from the patient’s feelings. Saying the patient has too much to live for is false reassurance and negates the patient’s feelings. DIF: Cognitive Level: Application REF: Text reference: p. 31 |Text reference: p. 42 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity 14. The patient states, “I don’t know what my family will think about this.” The nurse wishes to
use the communication technique of clarification. Which of the following statements would fit that need best? a. “You don’t know what your family will think?” b. “I’m not sure that I understand what you mean.” c. “I think it would be helpful if we talk more about your family.” d. “I sense that you may be anxious about something.” ANS: B
The definition of clarification is attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse’s understanding, or asking the patient to explain what he or she means. Repeating main thoughts expressed by patients is known as “restating.” Using questions or statements that help patients expand on a topic of importance is known as “focusing.” Asking a patient to verify the nurse’s understanding of what the patient is thinking or feeling is known as “sharing perceptions.” DIF: Cognitive Level: ApplicN atiU onRSINGRT EB F:.C TeO xtMreference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity 15. A patient tells the nurse, “I think that I must be really sick. All of these tests are being done.”
Which response by the nurse uses the specific communication technique of reflection? a. “I sense that you are worried.” b. “I think that we should talk about this more.” c. “You think that you must be very sick because of all the tests.” d. “I’ve noticed that this is an underlying issue whenever we talk.” ANS: C
Reflecting is directing back to the patient ideas, feelings, questions, or content, validating the nurse’s understanding of what the patient is saying, and signifying empathy, interest, and respect for the patient. Asking the patient to confirm your sense of his or her anxiety is “sharing perceptions.” Stating that “we should talk about this more,” that is, putting forth questions or statements to expand on a topic, is “focusing.” Pointing out underlying issues or problems that occur repeatedly is known as “theme identification.” DIF: Cognitive Level: Application REF: Text reference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 16. The patient is admitted to the hospital with complaints of headache, nausea, and dizziness.
She states that she has a final exam in the morning and needs to do well on it to pass the course, but she can’t seem to get into it. She appears nervous and distracted, and is unable to recall details. She most likely is showing manifestations of anxiety. a. mild b. moderate c. severe d. panic state of ANS: C
Severe anxiety manifests as a focus on fragmented details, as well as headache, nausea, dizziness, inability to see connections between details, and poor recall. Mild anxiety manifests as increased auditory and visual perception, increased awareness of relationships, and increased alertness and ability to problem-solve. Moderate anxiety manifests as selective inattention, decreased perceptual field, focus only on relevant information, muscle tension, and diaphoresis. Panic state of anxiety manifests as an inability to notice surroundings, feelings of terror, and inability to cope with any problem. DIF: Cognitive Level: Analysis REF: Text reference: p. 36 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Manifestations of Anxiety KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 17. The patient is admitted to the emergency department for trauma received in a fist fight. He
states that he could not control himself. He says that his wife left him for another man. He thinks it was because he was always too tired after working to do things. He says he has to work, and there is nothing he could do to change things. He says that he feels trapped in his N. Wh RSatIwNas GTthe B.C M job, but he knows nothing elseU alteO rcation with the other man probably a manifestation of? a. Mild anxiety b. Depression c. Severe anxiety d. Moderate anxiety ANS: B
Symptoms of depression include apathy, sadness, sleep disturbances, hopelessness, helplessness, worthlessness, guilt, anger, fatigue, thoughts of death, decreased libido, ruminations of inadequacy, psychomotor agitation, verbal berating of self, spontaneous crying, dependency, and passiveness. Mild anxiety manifests as increased auditory and visual perception, increased awareness of relationships, increased alertness, and an increased ability to problem-solve. Moderate anxiety manifests as selective inattention, decreased perceptual field, focus only on relevant information, muscle tension, and diaphoresis. Severe anxiety manifests as a focus on fragmented details, headache, nausea, dizziness, an inability to see connections between details, and poor recall. DIF: Cognitive Level: Analysis REF: Text reference: p. 42 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Manifestations of Depression KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
1. Verbal communication includes which of the following? (Select all that apply.) a. Speech b. Personal space c. Body movement d. Writing ANS: A, D
Verbal communication includes both spoken word and written word. Nonverbal communication describes all behaviors that convey messages without the use of words. This type of communication includes body movement, physical appearance, personal space, and touch. DIF: Cognitive Level: Analysis REF: Text reference: p. 28 OBJ: Explain the communication process. TOP: Verbal Communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 2. In caring for patients of different cultures, it is important for the nurse to: (Select all that
apply.) a. use appropriate linguistic services. b. display empathy and respect. c. use accurate health history-taking techniques. d. use patient-centered communication. ANS: A, B, C, D
The following factors are essential in providing effective care for culturally and linguistically diverse patients: (1) use of appropriate linguistic services (e.g., interpreter or bilingual health care workers) and/or other coNmm onTsB tr. atC egie URuni SIcati NG OMs, (2) display of empathy and respect for culturally and linguistically diverse patients, (3) use of accurate health history-taking techniques for diagnostic and treatment purposes and health teaching, and (4) use of patient-centered communication behaviors, including participatory decision making. It also is helpful to speak plainly and to avoid mimicking a patient’s accent or dialect. DIF: Cognitive Level: Comprehension REF: Text reference: p. 30 OBJ: Identify the purpose of therapeutic communication, communication in various phases of the nurse-patient relationship, and special issues related to communication. TOP: Cultural Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 3. In establishing the nurse-patient relationship, personal self-disclosure by the nurse is useful
for which of the following goals? (Select all that apply.) a. To educate the patient b. To build the therapeutic alliance c. To encourage the patient’s independence d. To offer opinions that may influence the patient’s decisions ANS: A, B, C
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Personal self-disclosure is used with caution and only in selected situations. Personal self-disclosure by the nurse is useful for the following goals: (1) to educate the patient, (2) to build a therapeutic alliance with the patient, and (3) to encourage the patient’s independence. Barriers to therapeutic communication include giving an opinion, offering false reassurance, being defensive, showing approval or disapproval, stereotyping, and asking “Why?” The use of “why” questions causes increased defensiveness in the patient and hinders communication. DIF: Cognitive Level: Application REF: Text reference: p. 30 OBJ: Develop skills for therapeutic communication in various phases of the nurse-patient relationship. TOP: Establishing the Nurse-Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 4. In dealing with angry patients, the nurse realizes that anger: (Select all that apply.) a. may be important to recovery. b. may be a means to cope with grief. c. often hides a specific problem. d. should not be allowed to compromise care. ANS: A, B, C, D
It is important for you to understand that in many cases the patient’s ability to express anger is important for recovery. For example, when a patient has experienced a significant loss, anger becomes a means to help cope with grief. Some patients express anger toward the nurse, but the anger often hides a specific problem or concern. Allow patients to express anger openly, and do not feel threatened by their words. However, do not allow a patient’s anger to threaten or compromise care. DIF: Cognitive Level: ApplicN atiU onRSINGRT EB F:.C TeO xtMreference: p. 38 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Establishing the Nurse-Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 5. The nurse observes that the patient is pacing in his room with clenched fists. When asked
“What’s wrong?” the patient states, “There’s nothing wrong. I just want out of here.” He then bangs his fist on the table and yells, “I’ve had it!” How should the nurse respond? (Select all that apply.) a. Tell the patient that he needs to calm down. b. Pause to collect her own thoughts. c. Block the doorway. d. Notify the proper authorities. ANS: B, D
Awareness and control of your own reaction and responses will facilitate more constructive interaction. Maintain an open exit. Position yourself closest to the door to facilitate escape from a potentially violent situation. Do not block the exit so the patient feels escape is unattainable; this may cause a violent outburst. An angry patient loses the ability to process information rationally and therefore may impulsively express anger through intimidation. If a strong likelihood of imminent harm to another is present upon discharge, notify the proper authorities (e.g., nurse manager).
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Synthesis REF: Text reference: pp. 39-41 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Communicating With the Angry Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity COMPLETION 1. The nurse is starting her first set of morning rounds. As she interacts with the patient, her
questions revolve around his reactions to his disease process. She also asks if there is anything that she can do to make him more comfortable. This type of interaction is known as . ANS:
therapeutic communication Therapeutic communication is an application of the process of communication to promote the well-being of the patient. DIF: Cognitive Level: Analysis REF: Text reference: p. 29 OBJ: Identify guidelines to use in therapeutic communication. TOP: Therapeutic Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 2. An active process of receiving information that nonverbally communicates to the patient the
nurse’s interest and acceptance is classified as
.
ANS:
NURSINGTB.COM listening Definition: An active process of receiving information and examining one’s reaction to messages received. Therapeutic value: Nonverbally communicates to the patient the nurse’s interest and acceptance. DIF: Cognitive Level: Knowledge REF: Text reference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 3. The patient is talking about his fear of having surgery but is being vague and is using a lot of
jargon. The nurse states, “I’m not sure what you mean. Could you tell me again?” This is an example of . ANS:
clarification Clarification is attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse’s understanding, or asking the patient to explain what he or she means. This may help to clarify the patient’s feelings, ideas, and perceptions, and may provide an explicit correlation between them and the patient’s actions. DIF: Cognitive Level: Application REF: Text reference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Diagnosis
MSC: NCLEX: Psychosocial Integrity
4. Directing the conversation back to patient ideas, feelings, questions, or content is known as
. ANS:
reflection Reflection or directing back to the patient ideas, feelings, questions, or content validates the nurse’s understanding of what the patient is saying and signifies empathy, interest, and respect for the patient. DIF: Cognitive Level: Knowledge REF: Text reference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 5. The patient tells the nurse that his mother left him when he was 5 years old. The nurse
responds by saying, “You say that your mother left you when you were 5 years old?” This is an example of . ANS:
restating Restating is a technique whereby the nurse repeats the main thought that the patient has expressed. It indicates that the nurse is listening, and validates, reinforces, or calls attention to something important that has been said. DIF: Cognitive Level: Application REF: Text reference: p. 31 OBJ: Explain the communicatN ioU nR prS ocI esN s.GTB.COM TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 6. The patient has been agitated for the entire morning but refuses to say why he is angry.
Instead, whenever the nurse speaks to him, he smiles at her while clenching his fist at the same time. The nurse states, “I can see that you’re smiling, but I sense that you are really very angry.” This is an example of . ANS:
sharing perceptions Sharing perceptions is asking the patient to verify the nurse’s understanding of what the patient is thinking or feeling. It conveys to the patient the nurse’s understanding and has the potential for clearing up confusing communication. DIF: Cognitive Level: Application REF: Text reference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Communication Techniques KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 7. Lack of verbal communication for a therapeutic reason is known as ANS:
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.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank therapeutic silence Lack of verbal communication for a therapeutic reason is known as therapeutic silence. It allows the patient time to think and gain insights, slows the pace of the interaction, and encourages the patient to initiate conversation, while conveying the nurse’s support, understanding, and acceptance. DIF: Cognitive Level: Comprehension REF: Text reference: p. 31 OBJ: Explain the communication process. TOP: Therapeutic Silence KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 8. Anxiety that is the source of inattention, decreased perceptual field, and diaphoresis is
classified as
.
ANS:
moderate anxiety Moderate anxiety is characterized by selective inattention, decreased perceptual field, the ability to focus only on relevant information, muscle tension, and/or diaphoresis. DIF: Cognitive Level: Comprehension REF: Text reference: p. 36 OBJ: Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients. TOP: Anxiety KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 4: Documentation and Informatics MULTIPLE CHOICE 1. The patient is a 24-year-old man who is diagnosed with possible HIV infection while being
treated for active pneumonia. He has stated that the nurse may share test result information with his significant other but nothing else at this time. With whom may the nurse communicate regarding this information? a. The patient’s parents b. The patient’s significant other only c. No one in the hospital until the patient says so d. The patient’s physician, significant other, and laboratory personnel ANS: D
All members of the health care team are legally and ethically obligated to keep patient information confidential. Do not discuss the patient’s examinations, observations, conversations, or treatments with other patients or staff not involved in the patient’s care, unless permission is granted by the patient. DIF: Cognitive Level: Application REF: Text reference: p. 49 OBJ: Describe measures to maintain confidentiality of patient information. TOP: Confidentiality KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. Which of the following is the best example of objective charting? a. “The patient states that he has been having severe chest discomfort.” b. “The patient is lying in bN edUaR ndSsI eeNmGsTtoBb.eCinOcM onsiderable pain.” c. “The patient appears to be pale and diaphoretic and complains of nausea.” d. “The patient’s skin is ashen and respiratory rate is 32 and labored.” ANS: D
A record or report contains descriptive, objective information about what you see, hear, feel, and smell. An objective description is the result of direct observation and measurement, such as “respiratory rate 20 and unlabored.” Objective documentation should include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. The only subjective data included in a record are what the patient actually verbalizes. Write subjective information with quotation marks, using the patient’s exact words whenever possible. For example, you record, “Patient states, ‘my stomach hurts.’” Avoid terms such as appears, seems, and apparently, which are often subject to interpretation. For example, the description “the patient seems to be in pain” does not accurately communicate the facts to another caregiver. The phrase seems is not supported by any objective facts. DIF: Cognitive Level: Analysis REF: Text reference: p. 50 OBJ: List guidelines for effective communication and reporting. TOP: Objective Documentation KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 3. Which of the following is the best example of accurate documentation? a. “Abdominal wound is 5 cm in length without redness, edema, or drainage.”
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. “OD to be irrigated qd with NS.” c. “No complaint of abdominal pain this shift.” d. “Patient watching TV entire shift.” ANS: A
The use of exact measurements in documentation establishes accuracy. For example, charting that an abdominal wound is “5 cm in length without redness, edema, or drainage” is more descriptive than “large wound healing well.” It is essential to know the institution’s abbreviation list, and to use only accepted abbreviations, symbols, and measures (e.g., metric), so that all documentation is accurate and is in compliance with standards. For example, the abbreviation for every day (qd) is no longer used. If a treatment or medication is needed daily, the nurse should write out the word “daily” or “every day” on the written order or care plan. The abbreviation qd (every day) can be misinterpreted to mean O.D. (right eye). The term “no complaint” may indicate stoicism on the part of the patient. He may have been in excruciating pain but never complained of it. It also creates a question related to the assessment skills of the nurse. It is essential to avoid unnecessary words and irrelevant details. For example, the fact that the patient is watching TV is only necessary to report when this activity is significant to the patient’s status and plan of care. DIF: Cognitive Level: Evaluation REF: Text reference: pp. 51-52 OBJ: List guidelines for effective communication and reporting. TOP: Accurate Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Patients on the unit have their vital signs taken routinely at 0800, 1200, 1600, and 2000. At
1000, a patient complains of feeling “light-headed.” The nurse takes the patient’s vital signs and finds blood pressure to be lower than usual. Within 15 minutes, the patient says that he NU RSblo INod GTpressur B.CO M finds that it is now back to normal. feels better. The nurse recheck s the e and How should the nurse handle documentation for this episode? a. Document the 1000 vital signs in the graphic record only. b. Not report the incident because it was a transient episode. c. Document the vital signs in the graphic and progress record. d. Document the vital signs as 12 o’clock signs. ANS: C
When documenting a significant change on a flow sheet, you describe the change, including the patient response to nursing interventions, in the progress notes. For example, if a patient’s blood pressure becomes dangerously low, record the blood pressure in the progress notes, as well as relevant assessment such as pallor and dizziness and any interventions performed to raise the blood pressure. Common issues in malpractice caused by inadequate or incorrect documentation include failing to give a report or giving an incomplete report to an oncoming shift and failing to document the correct time of events. DIF: Cognitive Level: Application REF: Text reference: pp. 53-54 OBJ: Identify the purpose of the patient record. TOP: Flow Sheets and Graphic Records KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. The nurse manager is attempting to determine the staffing needs of the unit. One tool that she
may use to determine the level of care needed would be: a. the standardized care plan.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. the acuity record. c. the patient care summary. d. flow sheets. ANS: B
Health care organizations use a patient acuity system as a method of determining the intensity of nursing care required for a group of patients. Acuity measurements for patients on a unit serve as a guide for determining staffing needs. An acuity recording system determines the hours of nursing care and the number of staff required for a nursing unit. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration. DIF: Cognitive Level: Analysis REF: Text reference: p. 54 OBJ: Identify the purpose of the patient record. TOP: Acuity Records KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 6. A preprinted guideline used to care for patients with similar health problems is known as the: a. acuity record. b. standardized care plan. c. patient care summary. NURSINGTB.COM d. flow sheet. ANS: B
Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines that are used in caring for patients with similar health problems. Health care organizations use a patient acuity system as a method of determining the intensity of nursing care required for a group of patients. Acuity measurements for patients on a unit serve as a guide for determining staffing needs. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration. DIF: Cognitive Level: Analysis REF: Text reference: p. 54 OBJ: Identify the purpose of the patient record. TOP: Standardized Care Plans KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 7. The patient is ready to go home from the hospital. What does the nurse provide to the patient
and his family before he leaves the facility? a. Discharge summary b. Standardized care plan
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank c. Patient care summary d. Flow sheet ANS: A
When a patient is discharged from a health care institution, the members of the health care team prepare a discharge summary. A discharge summary provides important information related to the patient’s ongoing health problems and need for health care after discharge. You enhance discharge planning when you are responsive to changes in patient condition and involve the patient and family in the planning process. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration. DIF: Cognitive Level: Application REF: Text reference: p. 55 OBJ: Identify the purpose of the patient record. TOP: Discharge Summary Forms KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 8. Which is a delivery model that coordinates and links health care services to patients and
families? a. Critical pathways b. Charting by exception c. SOAP d. Case management
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ANS: D
Case management is a delivery model that coordinates and links health care services to patients and families while streamlining costs and maintaining quality. Critical pathways state the goals and important elements of care based on best practice and patient expectations by documenting, monitoring, and evaluating variances and providing resources and outcomes. This system involves completing a flow sheet that incorporates those standard assessment and intervention criteria by placing a check mark in the appropriate standard box on the flow sheet to indicate normal findings and routine interventions. The logic for SOAP (IE) notes is similar to that for the nursing process: Collect data about the patient’s problems, draw conclusions, and develop a plan of care. DIF: Cognitive Level: Analysis REF: Text reference: p. 57 OBJ: List guidelines for effective communication and reporting. TOP: Case Management KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Safe and Effective Care Environment 9. The patient has been in the hospital for a hip replacement. According to his critical pathway,
he should have his Foley catheter discontinued on the fourth day after surgery. Instead, the patient has it removed on the third day and is voiding normally with no problems. This would be a sign of: a. a negative variance.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. positive case management. c. a positive variance. d. use of SBAR. ANS: C
Variances are unexpected occurrences, unmet goals, and interventions not specified within the critical pathway time frame that reflect a positive or negative change. A positive variance occurs when a patient progresses more rapidly than is anticipated in the case management plan (e.g., use of a Foley catheter is discontinued a day early). A negative variance occurs when activities on the critical pathway do not happen as predicted, or outcomes are unmet (e.g., oxygen therapy is necessary for a new-onset breathing problem). Case management is a delivery model that coordinates and links health care services to patients and families while streamlining costs and maintaining quality. SBAR is a technique that provides a framework for communication between members of the health care team about a patient’s condition. SBAR is a concrete mechanism used for framing conversations, especially critical ones, requiring a nurse’s immediate attention and action. DIF: Cognitive Level: Analysis REF: Text reference: p. 59 OBJ: Describe the role of critical pathways in multidisciplinary documentation. TOP: Variances KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 10. Which is a primary difference between home care and hospital care? a. Documentation systems need to provide information for the home health nurse
only. b. Documentation no longer affects reimbursement. c. Services are assumed and need less documentation. NwR I G stB.C M d. The patient and the family U itnSessNmoT of theOcare provided. ANS: D
One primary difference is that the patient and the family rather than the nurse witness most of the care provided. Documentation systems need to provide the entire health care team with the necessary information to work together effectively, supply quality control, and justify reimbursement from Medicare, Medicaid, or private insurance companies. DIF: Cognitive Level: Analysis REF: Text reference: p. 59 OBJ: Explain guidelines used in documentation of home care and long-term care. TOP: Home Care Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 11. The patient has been transferred to the nursing home from the acute care hospital. A report
was called from the hospital and was received by the RN in charge of the nursing home unit. Upon arrival, which approach is used to assess the patient? a. The Long-Term Care Facility Resident Assessment Instrument b. The case management model c. Collaborative pathways d. The charting by exception model ANS: A
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Each resident in long-term care is assessed using the Long-Term Care Facility Resident Assessment Instrument as mandated by the Omnibus Budget Reconciliation Act of 1989 (OBRA) and updated in 1998. Case management is a delivery model that coordinates and links health care services to patients and families while streamlining costs and maintaining quality. The collaborative pathways are multidisciplinary care plans that include key interventions provided and expected outcomes within an established time frame. The charting by exception model involves completing a flow sheet that incorporates those standard assessment and intervention criteria by placing a check mark in the appropriate standard box on the flow sheet to indicate normal findings and routine interventions. DIF: Cognitive Level: Analysis REF: Text reference: p. 60 OBJ: Explain guidelines used in documentation of home care and long-term care. TOP: Long-Term Care Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nursing assistant tells the RN that when the patient’s vital signs were taken, the patient
complained that she was in a lot of pain. The nursing assistant then tells the nurse that she charted the patient’s complaint when she charted the vital signs. What instruction does the nurse need to provide to the nursing assistant? a. The nursing assistant needs to make sure she uses the SBAR format when entering notes. b. Nursing assistants are not allowed to chart vital signs. c. Only the nurse can write in the progress notes. d. The nursing assistant needs to write using blue ink to distinguish from the RN note. ANS: C
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The task of writing a progress note may not be delegated to nursing assistive personnel (NAP). The nurse instructs the NAP about what repetitive care activities should be documented on flow sheets, including vital signs, intake and output (I&O), and routine care related to ADLs. DIF: Cognitive Level: Analysis REF: Text reference: p. 61 OBJ: Identify the purpose of the patient record. TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 13. The patient was in bed with all side rails up. During the night, the patient tried to get up to go
to the bathroom and fell while trying to climb over the side rails. After meeting the patient’s needs and assessing that the patient was not harmed, what step should the nurse take (if any)? a. Complete an incident report and put it in the medical record. b. Chart what happened and state that an incident report has been filled out. c. Do nothing because the patient was not harmed. d. Document what happened in the patient record without mentioning the incident report. ANS: D
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Document in the patient’s record an objective description of what you observed and follow-up actions taken without reference to the incident report. Incident reports are not a part of the permanent medical record but are an important source of risk management data for identifying and addressing the causes of errors made in health care organizations. You complete the report even if an injury does not occur or is not apparent. DIF: Cognitive Level: Analysis REF: Text reference: p. 62 OBJ: Complete an incident report accurately. TOP: Incident Reports KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Nursing documentation: (Select all that apply.) a. ensures continuity of care. b. provides legal evidence. c. evaluates patient outcomes. d. increases the risk of litigation. ANS: A, B, C
Nursing documentation ensures continuity of care, provides legal evidence, and evaluates patient outcomes. Effective documentation ensures continuity of care, maintains standards, and reduces errors. DIF: Cognitive Level: Knowledge REF: Text reference: p. 47 OBJ: List guidelines for effective communication and reporting. TOP: Communication Y: Nursing Process Step: Assessment N R I GKEB .C M NnviTronmentO MSC: NCLEX: Safe and EffectivU e CS are E 2. What is the goal of information management? (Select all that apply.) a. Support decision making. b. Improve patient outcomes. c. Ensure patient safety. d. Improve health care documentation. ANS: A, B, C, D
The goal of information management is to support decision making and improve patient outcomes, improve health care documentation, ensure patient safety, and improve performance in patient care, treatment and services, governance, management, and support processes. DIF: Cognitive Level: Knowledge REF: Text reference: p. 49 OBJ: Identify the purpose of the patient record. TOP: Information Management KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Nursing documentation must have which of the following characteristics? (Select all that
apply.) a. Factual b. Organized c. Public d. Complete
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS: A, B, D
Quality documentation and reporting have six characteristics: they are factual, accurate, complete, current, organized, and confidential. DIF: Cognitive Level: Comprehension REF: Text reference: p. 50 OBJ: List guidelines for effective communication and reporting. TOP: Guidelines for Reporting and Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment COMPLETION 1. A patient’s private health information is legally protected by the
.
ANS:
Health Insurance Portability and Accountability Act (HIPAA) Health Insurance Portability and Accountability Act HIPAA HIPAA protects patients’ private health information. This governs all areas of health information management, including, for example, reimbursement, coding, security, and patient records. DIF: Cognitive Level: Application REF: Text reference: p. 49 OBJ: Describe measures to maintain confidentiality of patient information. TOP: Confidentiality KEY: Nursing Process Step: Implementation G MSC: NCLEX: Safe and EffecN tivU eR CS arI eE n vi N TroBnm.eCntOM 2. To limit liability, nursing documentation must clearly indicate that the nurse provided
individualized, goal-directed nursing care to a patient based on the ANS:
nursing assessment To limit liability, nursing documentation must clearly indicate that the nurse provided individualized, goal-directed nursing care to a patient based on the nursing assessment. DIF: Cognitive Level: Application REF: Text reference: p. 50 OBJ: List guidelines for effective communication and reporting. TOP: Guidelines for Reporting and Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
documentation should include your observations of patient behavior.
3. ANS:
Objective Objective documentation should include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. DIF: Cognitive Level: Analysis
REF: Text reference: p. 50
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.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: List guidelines for effective communication and reporting. TOP: Objective Documentation KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe and Effective Care Environment 4. The abbreviation for every day (
) is no longer used.
ANS:
qd The abbreviation for every day (qd) is no longer used. If a treatment or medication is needed daily, the nurse should write out the word “daily” or “every day” on the written order or care plan. The abbreviation qd (every day) can be misinterpreted to mean O.D. (right eye). DIF: Cognitive Level: Application REF: Text reference: p. 51 OBJ: List guidelines for effective communication and reporting. TOP: Accurate Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. When making written entries in the patient’s medical record, describe the nursing care
provided and the
.
ANS:
patient’s response The information within a recorded entry or a report must be complete, containing appropriate and essential information. Make written entries in the patient’s medical record, describing nursing care that you administer and the patient’s response. DIF: Cognitive Level: Application REF: Text reference: p. 52 OBJ: List guidelines for effectN ive com io. nC andOM reporting. UR SImun NGicat TB TOP: Complete Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
provide a quick, easy reference for health care team members in assessing
6.
the patient’s status. ANS:
Flow sheets Flow sheets provide a quick, easy reference for health care team members in assessing the patient’s status. DIF: Cognitive Level: Application REF: Text reference: p. 54 OBJ: Identify the purpose of the patient record. TOP: Flow Sheets and Graphic Records KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 7. Standardized care plans are effective ways to plan care for the patient. To be most effective,
however, the SCP must be
.
ANS:
individualized to meet the patient’s needs Standardized care plans must be individualized for each patient. Most standardized care plans allow for the addition of specific patient outcomes and target dates for achievement of these outcomes.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Application REF: Text reference: p. 54 OBJ: Identify the purpose of the patient record. TOP: Standardized Care Plans KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 8. Multidisciplinary care plans that include key interventions and expected outcomes within an
established time frame are known as
.
ANS:
critical pathways Critical pathways are multidisciplinary care plans that include key interventions and expected outcomes within an established time frame. DIF: Cognitive Level: Comprehension REF: Text reference: p. 57 OBJ: Describe the role of critical pathways in multidisciplinary documentation. TOP: Critical Pathways KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
provide a format for documenting a patient’s health status and
9.
progress. ANS:
Progress notes Progress notes provide a format for documenting a patient’s health status and progress. DIF: Cognitive Level: Analysis REF: Text reference: p. 61 TOP: Patient Record OBJ: Identify the purpose of tN he pR atienIt reG cordB U S N T . .C OM KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 5: Vital Signs MULTIPLE CHOICE 1. The patient is brought to the emergency department complaining of severe shortness of
breath. She is cyanotic and her extremities are cold. In an attempt to quickly assess the patient’s respiratory status, the nurse should: a. remove the patient’s nail polish to get a pulse oximetry reading. b. use a forehead probe to get a pulse oximetry reading. c. use a finger probe to get a pulse oximetry reading. d. check the color of the patient’s nail polish before attempting a reading. ANS: B
Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacologic vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Assess for factors that influence measurement of SpO2 (e.g., oxygen therapy; respiratory therapy such as postural drainage and percussion; hemoglobin level; hypotension; temperature; nail polish [Cieck et al., 2010]; medications such as bronchodilators). DIF: Cognitive Level: Analysis REF: Text reference: p. 101 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Pulse Oximetry KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
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2. A person’s core temperature is considered the most accurate since it is: a. reflective of the surrounding environment. b. the same for everyone. c. controlled by the hypothalamus. d. independent of external influences. ANS: C
The core temperature, or the temperature of the deep body tissues, is under the control of the hypothalamus and remains within a narrow range. Skin or body surface temperature rises and falls as the temperature of the surrounding environment changes, and it fluctuates dramatically. Body tissues and cells function best within a relatively narrow temperature range, from 36° C to 38° C (96.8° F to 100.4° F), but no single temperature is normal for all people. For healthy young adults, the average oral temperature is 37° C (98.6° F). An acceptable temperature range for adults depends on age, gender, range of physical activity, hydration status, and state of health. DIF: Cognitive Level: Analysis REF: Text reference: p. 67 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Core Temperature KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse takes the patient’s temperature using a tympanic electronic thermometer. The
temperature reading is 36.5 C (97.7 F). The nurse knows that this correlates with:
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. 37.0 C (98.6 F) rectally. b. 37.0 C (98.6 F) orally. c. 36.0 C (97.7 F) axillary. d. 36.0 C (97.7 F) orally. ANS: B
It generally is accepted that axillary and tympanic temperatures are usually 0.5 C (0.9 F) lower than oral temperatures. It generally is accepted that rectal temperatures are usually 0.5 C (0.9 F) higher than oral temperatures. DIF: Cognitive Level: Analysis REF: Text reference: p. 67 OBJ: Discuss factors involved in selecting temperature measurement sites. TOP: Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette.
The patient has just returned from his “cigarette break.” The nurse is about to take the patient’s temperature orally and should: a. wait about 15 minutes before taking his temperature. b. give him oral fluids to rinse the nicotine away before taking his temperature. c. give him a stick of chewing gum to chew and then take his temperature. d. take his oral temperature and record the findings. ANS: A
The nurse should verify that the patient has not had anything to eat or drink and has not chewed gum or smoked within the 15 minutes before oral temperature is measured. Oral food and fluids and smoking and gum can alter temperature measurement.
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DIF: Cognitive Level: Synthesis REF: Text reference: p. 71 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Oral Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. When evaluating the patient’s temperature levels, the nurse expects the patient’s temperature
to be lower: a. in the morning. b. after exercising. c. during periods of stress. d. during the postoperative period. ANS: A
Temperature is lowest during early morning. Muscle activity and stress raise heat production. Drugs may impair or promote sweating, vasoconstriction, or vasodilation, or may interfere with the ability of the hypothalamus to regulate temperature. DIF: Cognitive Level: Comprehension REF: Text reference: p. 70 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Temperature Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. When inserting a rectal thermometer, the nurse encounters resistance. The nurse should:
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
apply mild pressure to advance. ask the patient to take deep breaths. remove the thermometer immediately. remove the thermometer and reinsert it gently.
ANS: C
If resistance is felt during insertion, withdraw the thermometer immediately. Never force the thermometer. This prevents trauma to the mucosa. With the nondominant hand, separate the patient’s buttocks to expose the anus. Ask the patient to breathe slowly and relax. This fully exposes the anus for thermometer insertion and relaxes the anal sphincter for easier thermometer insertion. DIF: Cognitive Level: Application REF: Text reference: p. 72 OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures. TOP: Rectal Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. An appropriate procedure for measurement of an adult’s temperature with a tympanic
membrane sensor is: a. pulling the ear pinna down and back. b. moving into the ear in a figure-eight pattern. c. fitting the probe loosely into the ear canal. d. pointing the probe toward the mouth and chin. ANS: B
Move the thermometer in a figure-eight pattern. Pull the ear pinna backward, up, and out for an adult; fit the speculum tipN snuR an.alCandMdo not move; and point the speculum tip U glySIinNthGeTcB O toward the nose. DIF: Cognitive Level: Application REF: Text reference: p. 75 OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures. TOP: Rectal Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The patient is a 1-year-old male infant who is admitted with possible sepsis. The patient is
irritable and agitates easily. What should the nurse do to assess the patient’s temperature? a. Take an oral temperature before doing anything else. b. Take an axillary temperature using the upper axilla. c. Place the child in Sims’ position for a rectal temperature. d. Take a rectal temperature as the last vital sign. ANS: D
Critically ill children sometimes have cool skin but a high core temperature because of poor perfusion to the skin. Children may assume the prone position for rectal temperature measurement. With children who cry or are restless, it is best to take temperature as the last vital sign. Use axillary temperatures for screening purposes only, not to detect fevers in infants and young children. Use the lower axilla to record temperature in side-lying infants. DIF: Cognitive Level: Application REF: Text reference: p. 76 OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank temperatures. TOP: Temperature Assessment in Pediatric Patients KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The patient is returning from a cardiac catheterization. The puncture site is in the right femoral
artery. The patient is having vital signs assessed every 15 minutes. Along with vital signs, the nurse assesses the pedal pulses of the right and left feet. Which of the following would be of major concern? a. Both pedal pulses were bounding. b. The femoral artery could be palpated. c. The right pedal pulse was weaker than the left. d. The radial artery pulse was 88. ANS: C
If a peripheral pulse distal to an injured or treated area of an extremity feels weak on palpation, the volume of blood reaching tissues below the affected area may be inadequate, and surgical intervention may be necessary. A full bounding pulse is an indication of increased volume. When the pulse wave reaches a peripheral artery, you can feel it by palpating the artery lightly against underlying bone or muscle. The pulse is the palpable bounding of the blood flow. The usual range for adults is 60 to 100 beats per minute. DIF: Cognitive Level: Analysis REF: Text reference: p. 77 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Pulse Assessment KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 10. The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette.
RS The patient has just returned N frU om hiI sN “cG igT arB et. teCbO reM ak.” The nurse is about to take the patient’s radial pulse and should: a. wait about 15 minutes before taking his pulse. b. use her thumb to detect the pulse and get an accurate count. c. press hard to detect the pulse and get an accurate count. d. take his pulse for 15 seconds and multiply by 4. ANS: A
If a patient has been smoking, wait 15 minutes before assessing pulse. Anxiety, activity, and smoking elevate heart rate. Assessing radial pulse rate at rest allows for objective comparison of values. Fingertips are the most sensitive parts of the hand for palpating arterial pulsation. The nurse’s thumb has pulsation that interferes with accuracy. Pulse assessment is more accurate when moderate pressure is used. Too much pressure occludes pulse and impairs blood flow. If the pulse is regular, count the rate for 30 seconds and multiply the total by 2. If the pulse is irregular, count the rate for a full 60 seconds. Assess the frequency and the pattern of irregularity. DIF: Cognitive Level: Analysis REF: Text reference: p. 78 OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Pulse Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. When evaluating the radial pulse measurement technique of the nursing assistant, the nurse
identifies appropriate technique when the assistant:
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
has the patient’s arm elevated. positions the patient supine or sitting. applies significant pressure to the pulse site. counts the pulse for 15 seconds and multiplies by 4.
ANS: B
Assist the patient to assume a supine or sitting position. If the patient is supine, place the patient’s forearm straight alongside or across the lower chest or upper abdomen with the wrist extended straight. If the patient is sitting, bend the patient’s elbow 90 degrees and support the lower arm on the chair or on the nurse’s arm. Slightly extend or flex the wrist with the palm down until the strongest pulse is noted. Lightly compress against the radius, obliterate the pulse initially, and then relax pressure so the pulse becomes easily palpable. Pulse is assessed more accurately with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. If the pulse is regular, count the rate for 30 seconds and multiply the total by 2. If the pulse is irregular, count the rate for 60 seconds. Assess frequency and pattern of irregularity. DIF: Cognitive Level: Comprehension REF: Text reference: p. 79 OBJ: Appropriately delegate vital sign measurements to nursing assistive personnel (NAP). TOP: Delegation of Pulse Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse is caring for an infant in the NICU. While taking vital signs, the nurse finds that the
baby’s heart rate is 195. The nurse calls the physician, knowing that the normal heart rate should be: a. 60 to 100 beats per minute. b. 100 to 160 beats per minute. I G B.C M N R c. 90 to 140 beats per minute.U S N T O d. 220 beats per minute or higher. ANS: B
The infant’s heart rate at birth ranges from 100 to 160 beats per minute at rest. By adolescence, the heart rate varies between 60 and 100 beats per minute and remains so throughout adulthood. By age 2, the pulse rate slows to 90 to 140 beats per minute. DIF: Cognitive Level: Analysis REF: Text reference: p. 82 OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Assessing Apical Pulse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. The patient has been in the hospital for several days for urosepsis. He has been responding
favorably to treatment, and his vital signs have been “normal” for 2 days. When the nurse takes his vital signs, however, the patient’s apical pulse is 152 and regular. The nurse suspects that the: a. patient is having a reaction to his narcotic medication. b. patient may be suffering from hypothermia. c. patient’s fever may have returned. d. patient may be an athlete. ANS: C
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Fever or exposure to warm environments increases heart rate. Large doses of narcotic analgesics and hypothermia can slow heart rate. A well-conditioned patient may have a slower than usual resting heart rate, which returns more quickly to resting rate after exercise. DIF: Cognitive Level: Synthesis REF: Text reference: p. 82 OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Assessing Apical Pulse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. What steps should the nurse take to conduct an assessment of a possible pulse deficit? a. A nurse measures the pulse after the patient exercises. b. Two nurses check the same pulse on opposite sides of the body. c. Two nurses assess the apical and radial pulses and determine the difference. d. The current pulse is compared with previous pulse measurements for differences. ANS: C
Locate apical and radial pulse sites. One nurse auscultates the apical pulse, and one nurse palpates the radial pulse. Both nurses count the pulse rate for 60 seconds simultaneously. Subtract the radial rate from the apical rate to obtain the pulse deficit. The pulse deficit reflects the number of ineffective cardiac contractions in 1 minute. If a pulse deficit is noted, assess for other signs and symptoms of decreased cardiac output. DIF: Cognitive Level: Application REF: Text reference: p. 85 OBJ: Explain the implications of a pulse deficit. TOP: Pulse Deficit KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. An appropriate method of assessing a patient’s respirations is for the nurse to: a. place the bed flat. NURSINGTB.COM b. remove all supplemental oxygen sources from documentation. c. explain to the patient that respirations are being assessed. d. gently place the patient’s hand in a relaxed position over the upper abdomen. ANS: D
Place the patient’s arm in a relaxed position across the abdomen or lower chest, or place the nurse’s hand directly over the patient’s upper abdomen. Be sure the patient is in a comfortable position, preferably sitting or lying with the head of the bed elevated 45 to 60 degrees. Sitting erect promotes full ventilatory movement. A position of discomfort may cause the patient to breathe more rapidly. Documentation should include any supplemental oxygen that the patient is receiving. Inconspicuous assessment of respirations immediately after pulse assessment prevents the patient from consciously or unintentionally altering the rate and depth of breathing. DIF: Cognitive Level: Application REF: Text reference: p. 88 OBJ: Accurately assess a patient’s respirations. TOP: Respiratory Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse is about to take vital signs on a newborn patient in the nursery. She should: a. assess respiratory rate after taking a rectal temperature. b. observe the child’s chest while the child is sleeping. c. call the physician if the rate is over 40. d. expect that the child will have short periods of apnea.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: D
An irregular respiratory rate and short apneic spells are normal for newborns. Assess respiratory rate before other vital signs or assessments are taken. Children up to age 7 breathe abdominally, so respirations are observed by abdominal movement. Average respiratory rate (breaths per minute) for newborns is 30 to 60; for infants (6 months to 1 year), 30 to 50; for toddlers (2 years), 25 to 32; and for children from 3 to 12 years, 20 to 30. DIF: Cognitive Level: Analysis REF: Text reference: p. 90 OBJ: Accurately assess a patient’s respirations. TOP: Pediatric Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse should report an assessment of a. 14; adult patient b. 16; 8-year-old patient c. 25; toddler d. 38; newborn
respirations per minutes for a(n)
.
ANS: B
Acceptable average respiratory rate (breaths per minute) for newborns is 35 to 40; for infants (6 months), 30 to 50; for toddlers (2 years), 22 to 32; and for children, 20 to 30. Adults average 12 to 20 respirations per minute. DIF: Cognitive Level: Application REF: Text reference: p. 90 OBJ: Identify ranges of acceptable vital sign values for infant, child, and adult. TOP: Respiratory Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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18.1 During the normal cardiac cycle, blood pressure reaches a peak, followed by a trough, in the 8 cycle. What is the peak known as? . a. Pulse pressure b. Systole c. Diastole d. Korotkoff phase ANS: B
Blood pressure is the force exerted by blood against the vessel walls. During a normal cardiac cycle, blood pressure reaches a peak, followed by a trough, or low point, in the cycle. The peak pressure occurs when the heart’s ventricular contraction, or systole, forces blood under high pressure into the aorta. The difference between systolic pressure and diastolic pressure is the pulse pressure. When the ventricles relax, the blood remaining in the arteries exerts a minimum or diastolic pressure. Diastolic pressure is the minimal pressure exerted against the arterial wall at all times. As the sphygmomanometer cuff is deflated, the five different sounds heard over an artery are called Korotkoff phases. DIF: Cognitive Level: Knowledge REF: Text reference: p. 90 OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation. TOP: Systolic Blood Pressure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. The patient is complaining of a severe headache. The nurse takes the patient’s blood pressure
and finds it to be 240/110. What is the pulse pressure?
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
110 240 130 350
ANS: C
The difference between systolic pressure and diastolic pressure is the pulse pressure. For a blood pressure of 240/110, the pulse pressure is 130. The diastolic pressure is 110. The systolic pressure is 240. The sum of the systolic and diastolic pressures is 350. DIF: Cognitive Level: Analysis REF: Text reference: p. 90 OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation. TOP: Pulse Pressure KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. During his initial screening, the patient’s blood pressure was noted to be elevated. Two
months after the first assessment, he was noted to have a blood pressure of 150/92 and 166/96 at different times during the visit. It is now a month and a half later, and the nurse is concerned because the patient’s initial blood pressure on this visit was 154/94. She is preparing to take a second blood pressure, understanding that another reading in this range could lead to a diagnosis of: a. hypotension b. prehypertension c. hypertension d. orthostatic hypotension ANS: C
Hypertension is defined as syNstol d pr es. suCreO(M SBP) of 140 mm Hg or greater, diastolic RicSbIlooNG B U T blood pressure (DBP) of 90 mm Hg or greater, or taking antihypertensive medication (NHBPEP, 2003). One blood pressure recording revealing a high SBP or DBP does not qualify as a diagnosis of hypertension. However, if you assess a high reading (e.g., 150/90 mm Hg), encourage the patient to return for another checkup within 2 months. The diagnosis of hypertension in adults requires an average of two or more readings taken at each of two or more visits after an initial screening. Hypotension occurs when the systolic blood pressure falls to 90 mm Hg or below. Prehypertension is a designation for patients at high risk for developing hypertension. In these patients, early intervention through adoption of healthy lifestyles reduces the risk of or prevents hypertension. Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., lightheadedness, dizziness) and low blood pressure when rising to an upright position. DIF: Cognitive Level: Synthesis REF: Text reference: p. 91 OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation. TOP: Hypertension KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 21. The patient is an 86-year-old woman who is being admitted for dehydration and pneumonia.
The patient is lying in bed but tells the nurse that she needs to go to the bathroom. The nurse tells the patient that she will stay with her and will help her get there. The patient states, “That’s OK. I can make it on my own.” The nurse should: a. help the patient to the bathroom and stay with her. b. allow the patient to get up on her own and go to the bathroom.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank c. allow the patient to go to the bathroom and call for help if needed. d. insert a Foley catheter. ANS: A
Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., lightheadedness, dizziness) and low blood pressure when rising to an upright position. Orthostatic changes in vital signs are good indicators of blood volume depletion. In severe cases of orthostatic hypotension, loss of consciousness may occur. Foley catheters are believed to be a major source or urinary tract infection. DIF: Cognitive Level: Synthesis REF: Text reference: p. 91 |Text reference: p. 98 OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation. TOP: Orthostatic Hypotension KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 22. The nurse chooses a sphygmomanometer that has a circular gauge and a needle that registers
the millimeter calibrations. This type of device is known as a(n) a. mercury b. electronic c. aneroid d. direct (invasive)
manometer.
ANS: C
The aneroid manometer has a glass-enclosed circular gauge containing a needle that registers millimeter calibrations. Metal parts in the aneroid manometer are subject to temperature expansion and contraction and must be recalibrated at least every 6 months to verify their accuracy. Before using the aneroid manometer, make sure the needle is pointing to zero. With mercury manometers, pressuN reU cR reat edNbG yT inB fl. atC ion of the compression cuff moves the column I M S O of mercury up the tube against the force of gravity. Millimeter calibrations mark the height of the mercury column. Electronic or automatic blood pressure machines consist of an electronic sensor positioned inside a blood pressure cuff attached to an electronic processor. You measure arterial blood pressure either directly (invasively) or indirectly (noninvasively). The direct method requires electronic monitoring equipment and the insertion of a thin catheter into an artery. The risks associated with invasive blood pressure monitoring require use in an intensive care setting. DIF: Cognitive Level: Knowledge REF: Text reference: p. 91 OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation. TOP: Manometers KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 23. The nurse is working on the general surgical unit and is caring for a patient who has a right
total mastectomy. To take the patient’s vital signs and to accurately assess the patient’s blood pressure, it will be necessary to: a. place the blood pressure cuff on the left upper arm. b. place the blood pressure cuff on the right upper arm. c. place the blood pressure cuff on the right lower arm. d. use direct (invasive) blood pressure measurement. ANS: A
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Determine the best site for blood pressure assessment. Avoid applying the cuff to an extremity when intravenous fluids are infusing, an arteriovenous shunt or fistula is present, or breast or axillary surgery has been performed on that side. The risks associated with invasive blood pressure monitoring require use in an intensive care setting. DIF: Cognitive Level: Application REF: Text reference: p. 93 OBJ: Describe factors involved in selecting an extremity to measure blood pressure. TOP: Manometers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. Which site is used to auscultate blood pressure? a. Radial b. Ulnar c. Brachial d. Temporal ANS: C
Place the stethoscope over the brachial artery to measure blood pressure. Use the radial site for the radial pulse, the ulnar site for the ulnar pulse, and the temporal site for the temporal pulse. DIF: Cognitive Level: Application REF: Text reference: p. 77 OBJ: Describe factors involved in selecting an extremity to measure blood pressure. TOP: Brachial Pulse KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. The nurse is caring for a 2-year-old child who is admitted with croup and crying. To take the
child’s vital signs, the nurse sNhou Rld:SINGTB.COM U a. place the pediatric blood pressure cuff on the left arm. b. place the blood pressure cuff on the right thigh. c. skip the blood pressure measurement. d. place the blood pressure cuff on the left thigh. ANS: C
Blood pressure is not a routine part of assessment in children younger than 3 years. The right arm is preferred for blood pressure measurement in children older than 3. Thigh blood pressure is the least preferred and the most uncomfortable method for children. DIF: Cognitive Level: Analysis REF: Text reference: p. 98 OBJ: Describe factors involved in selecting an extremity to measure blood pressure. TOP: Teaching Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. When the benefits of the different types of blood pressure monitoring devices are compared,
which of the following patients would be the best candidate for noninvasive electronic blood pressure measurement? a. A 49-year-old postsurgical patient with no history of heart disease on q15min vital signs b. A 22-year-old patient undergoing active grand mal seizures c. A 68-year-old patient with diagnosed peripheral vascular disease d. A 54-year-old patient with chronic atrial fibrillation
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: A
These devices are used when frequent assessment is required, as in critically ill or potentially unstable patients; during or after invasive procedures; or when therapies require frequent monitoring. Patients with irregular heart rate, peripheral vascular disease, seizures, tremors, and shivering are not candidates for this device. DIF: Cognitive Level: Analysis REF: Text reference: p. 99 OBJ: Discuss the benefits and disadvantages of using an automatic blood pressure machine. TOP: Noninvasive Electronic Blood Pressure Measurement KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 27. The patient was found in an alley on a cold winter night and is admitted with hypothermia
from environmental exposure. She is elderly and is having difficulty breathing. Her breath sounds are diminished, and the tip of her nose is cyanotic. The nurse wants to assess the oxygen level in the patient’s blood. She decides to use the pulse oximeter. The best way to apply this to this patient would be with a(n): a. finger probe. b. earlobe sensor. c. forehead sensor. d. toe sensor. ANS: C
In adults, you can apply reusable and disposable oximeter probes to the earlobe, finger, toe, bridge of the nose, or forehead. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacologic vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas.
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DIF: Cognitive Level: Analysis REF: Text reference: p. 101 OBJ: Accurately assess a patient’s oxygenation status using pulse oximetry. TOP: Oxygen Saturation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. The patient is admitted in a near comatose state with a blood glucose level of 750. His
respiratory rate is 42 breaths per minute, and his respiratory pattern is deep and regular. What is this type of breathing known as? a. Cheyne-Stokes respiration b. Biot’s respiration c. Bradypnea d. Kussmaul’s respiration ANS: D
Respirations are abnormally deep, regular, and increased in rate. This is common in diabetic ketoacidosis. With Cheyne-Stokes respirations, respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. The respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses, and breathing slows and becomes shallow, climaxing in apnea before respiration resumes. With Biot’s respirations, respirations are abnormally shallow for two to three breaths followed by an irregular period of apnea. With bradypnea, the rate of breathing is regular but abnormally slow (fewer than 12 breaths per minute).
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Analysis REF: Text reference: p. 89 OBJ: Accurately assess a patient’s respirations. TOP: Breathing Patterns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. What is a disadvantage of using the disposable sensor pad for pulse oximetry? a. It is less restrictive. b. It contains latex. c. It is less expensive to use. d. It is available in different sizes. ANS: B
A disposable sensor pad can be applied to a variety of sites, including the earlobe of an adult and the nose bridge, palm, or sole of an infant. It is less restrictive for continuous SpO2 monitoring. It is expensive and contains latex, which some patients may not be able to tolerate. The skin under the adhesive may become moist and may harbor pathogens. It is available in a variety of sizes, and the pad can be matched to infant weight. DIF: Cognitive Level: Application REF: Text reference: p. 101 OBJ: Accurately assess a patient’s oxygenation status using pulse oximetry. TOP: Oxygen Saturation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is preparing to take the patient’s temperature. Which of the following may cause
the temperature to fluctuate? (Select all that apply.) a. Age NURSINGTB.COM b. Stress c. Hormones d. Medications ANS: A, B, C, D
Older adults have a narrower range of temperature than younger adults. A temperature within an acceptable range in an adult may reflect a fever in an older adult. Undeveloped temperature control mechanisms in infants and children cause temperature to rise and fall rapidly. Stress elevates temperature. Women have wider temperature fluctuations than men because of menstrual cycle hormonal changes; body temperature varies during menopause. Some drugs impair or promote sweating, vasoconstriction, or vasodilation, or interfere with the ability of the hypothalamus to regulate temperature. DIF: Cognitive Level: Analysis REF: Text reference: p. 70 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. Which of the following processes are involved in respiration? (Select all that apply.) a. Ventilation b. Diffusion c. Oximetry d. Perfusion
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS: A, B, D
Three processes are involved in respiration: ventilation, mechanical movement of gases into and out of the lungs; diffusion, movement of O2 and CO2 between the alveoli and the red blood cells; and perfusion, distribution of red blood cells to and from the pulmonary capillaries. DIF: Cognitive Level: Comprehension REF: Text reference: p. 86 OBJ: Accurately assess a patient’s respirations. TOP: Respiratory Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is about to teach the patient about risk factors for hypertension. Which of the
following are risk factors for hypertension? (Select all that apply.) a. Obesity b. Cigarette smoking c. High blood cholesterol d. Renal disease ANS: A, B, C, D
Persons with a family history of hypertension, premature heart disease, lipemia, or renal disease are at significant risk. Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued exposure to stress from psychosocial and environmental conditions are factors linked to hypertension. DIF: Cognitive Level: Knowledge REF: Text reference: p. 93 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Teaching Considerations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
N R I G B.C M U S N T O
4. The nurse is about to take a patient’s blood pressure. Which of the following conditions would
cause the nurse to obtain a false high reading? (Select all that apply.) a. Bladder or cuff too narrow b. Bladder or cuff too wide c. Patient’s arm below the level of the heart d. Inflating the cuff too slowly ANS: A, C, D
Bladder or cuff too narrow or too short, arm below heart level, or inflating the cuff too slowly will give a false high reading. A bladder or cuff too wide will give a false low reading. DIF: Cognitive Level: Analysis REF: Text reference: p. 92 OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation. TOP: Common Mistakes in Blood Pressure Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION 1.
, a subjective symptom, is also referred to as a vital sign, along with the physiological signs. ANS:
Pain
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Pain, a subjective symptom, is also referred to as a vital sign, along with the physiological signs. DIF: Cognitive Level: Comprehension REF: Text reference: p. 66 OBJ: Identify when it is appropriate to assess each vital sign. TOP: Pain as a Vital Sign KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. When heat loss mechanisms are unable to keep pace with heat production,
is
the result. ANS:
fever Fever occurs when heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature. DIF: Cognitive Level: Analysis REF: Text reference: p. 67 OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Core Temperature KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is taking a rectal temperature on an adult patient. She expects to insert the
thermometer
_ inches.
ANS:
1.5 Gently insert the thermometer into the anus in the direction of the umbilicus 3.5 cm (1.5 inches) for an adult. Do not force the thermometer.
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DIF: Cognitive Level: Application REF: Text reference: p. 72 OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures. TOP: Rectal Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The patient has been sleeping and has been lying on his right side. The nurse is ready to take
his temperature using a tympanic thermometer. She needs to insert the thermometer into his ear. ANS:
left If the patient has been lying on one side, use the upper ear. Heat trapped in the ear facing down will cause a false high temperature reading. DIF: Cognitive Level: Application REF: Text reference: p. 74 OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures. TOP: Tympanic Membrane Temperature Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. An irregular heartbeat, often found in children, that speeds up with inspiration and slows
down with expiration is known as a sinus
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.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS:
dysrhythmia Children often have a sinus dysrhythmia, which is an irregular heartbeat that speeds up with inspiration and slows down with expiration. DIF: Cognitive Level: Analysis REF: Text reference: p. 80 OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Pulse Assessment—Pediatric Considerations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
is the sound of the tricuspid and mitral valves closing at the end of ventricular
6.
filling. ANS:
S1 S1 is the sound of the tricuspid and mitral valves closing at the end of ventricular filling, just before systolic contraction begins. DIF: Cognitive Level: Application REF: Text reference: p. 81 OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Assessing Apical Pulse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7.
is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction. ANS:
S2 S2 is the sound of the pulmonNiU c aRnS dI aoNrtG icTvB al. veCsO clM osing at the end of the systolic contraction. DIF: Cognitive Level: Application REF: Text reference: p. 81 OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Assessing Apical Pulse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral
pulse site creates a
.
ANS:
pulse deficit An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. Pulse deficits frequently are associated with dysrhythmias and warn of potentially decreased cardiac function. DIF: Cognitive Level: Comprehension REF: Text reference: p. 85 OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Pulse Deficit KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. To take a manual blood pressure, the nurse places the cuff of the
patient’s upper arm. ANS:
sphygmomanometer
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around the
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The most common technique of measuring blood pressure is auscultation using a sphygmomanometer and stethoscope. DIF: Cognitive Level: Comprehension REF: Text reference: p. 90 OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation. TOP: Sphygmomanometer KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. After applying the sphygmomanometer to the patient’s upper arm, the nurse inflates the cuff
to the proper level, and then, using a stethoscope, listens for the sounds. ANS:
Korotkoff The most common technique used for measuring blood pressure is auscultation with a sphygmomanometer and stethoscope. As the sphygmomanometer cuff is deflated, the five different sounds heard over an artery are called Korotkoff phases. The sound in each phase has unique characteristics. Blood pressure is recorded with the systolic reading (first Korotkoff sound) before the diastolic reading (beginning of the fifth Korotkoff sound). DIF: Cognitive Level: Application REF: Text reference: p. 90 OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation. TOP: Korotkoff Sounds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
occurs when the systolic blood pressure falls to 90 mm Hg or below.
11. ANS:
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Hypotension Hypotension occurs when the systolic blood pressure falls to 90 mm Hg or below. Although some adults normally have a low blood pressure, for most people, low blood pressure is an abnormal finding associated with illness. DIF: Cognitive Level: Knowledge REF: Text reference: p. 91 OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation. TOP: Hypotension KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 12. The percent to which hemoglobin is filled with oxygen is known as ANS:
arterial blood oxygen saturation Pulse oximetry is the noninvasive measurement of arterial blood oxygen saturation—the percent to which hemoglobin is filled with oxygen. DIF: Cognitive Level: Knowledge REF: Text reference: p. 101 OBJ: Accurately assess a patient’s oxygenation status using pulse oximetry. TOP: Oxygen Saturation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 6: Health Assessment MULTIPLE CHOICE 1. The nurse is visiting the patient for the first time this shift. She introduces herself and asks the
patient several questions related to his condition. While doing so, and without being obvious, she is looking at the color of his eyes and is assessing his ears and nose for discharge and the symmetry of his mouth. Which assessment technique is the nurse using? a. Palpation b. Percussion c. Inspection d. Auscultation ANS: C
Inspection is the visual examination of body parts or areas. An experienced nurse learns to make multiple observations, almost simultaneously, while becoming very perceptive of abnormalities. Palpation uses the sense of touch. Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and to discover fluid in body cavities. Auscultation is listening with a stethoscope to sounds produced by the body. DIF: Cognitive Level: Application REF: Text reference: p. 108 OBJ: Describe the techniques used with each assessment skill. TOP: Inspection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The patient is admitted with N feU veR rS anI dN acGuT teBlo.wCeO r aMbdominal pain. He has taken Tylenol but
says he still feels feverish. Before taking the patient’s temperature, the nurse may: a. touch the patient’s skin with the dorsum of her hand. b. touch the patient’s skin with the pads of her fingers. c. palpate the skin using the bimanual method. d. tap the patient’s skin using the fingertips. ANS: A
The dorsum (back) of the hand is more sensitive to temperature variations. The pads of the fingertips detect subtle changes in texture, shape, size, consistency, and pulsation of body parts. Bimanual palpation involves one hand placed over the other while pressure is applied. The upper hand exerts downward pressure as the other hand feels the subtle characteristics of underlying organs and masses. Seek the assistance of a qualified instructor before attempting deep palpation. Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and to discover fluid in body cavities. DIF: Cognitive Level: Application REF: Text reference: p. 108 OBJ: Describe the techniques used with each assessment skill. TOP: Palpation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. What should the nurse do when preparing to complete an assessment for a 16-year-old
patient? a. Focus on illness behaviors.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. Plan for a diminished energy level. c. Treat the patient as an individual. d. Have the parents present throughout. ANS: C
Older children and adolescents tend to respond best when treated as adults and individuals and often can provide details about their health history and severity of symptoms. Routine examinations of children have a focus on health promotion and illness prevention, particularly in the care of well children with competent parenting and no serious health problems. The focus is on growth and development, sensory screening, dental examination, and behavioral assessment. Children who are chronically ill, disabled, in foster care, or foreign-born adopted may require additional assessment. The adolescent has a right to confidentiality. After talking with the parents about historical information, the nurse arranges to be alone with the adolescent to speak further privately and to perform the examination. DIF: Cognitive Level: Application REF: Text reference: p. 112 OBJ: Describe how to conduct a physical examination on patients from diverse cultures. TOP: Children and Adolescents KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. In providing a physical assessment of an 88-year-old patient, the nurse should: a. do it as quickly as possible to prevent fatigue. b. assume that the patient will have disabilities. c. prepare to perform a mental status examination. d. always do the exam in the small exam room to prevent chills. ANS: C
Inclusion of a review of menN talUsR tatu hl. yC reco Is isNGhigTB Mmmended when the nurse performs an S O examination of an older adult. Allow extra time, and be patient, relaxed, and unhurried with older adults. Do not assume that aging is always accompanied by illness or disability. Older adults are able to adapt to change and to maintain functional independence. Provide adequate space for an examination, particularly if the patient uses a mobility aid. DIF: Cognitive Level: Application REF: Text reference: p. 112 OBJ: Describe how to conduct a physical examination on patients from diverse cultures. TOP: Older Adults KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The general survey begins with a review of the patient’s primary health problems and an
evaluation of the patient’s vital signs, height and weight, general behavior, and appearance. It also provides information about the patient’s illness, hygiene, skin condition, body image, and emotional state. Which of the following cannot be delegated to nursing assistive personnel? a. Reporting subjective signs and symptoms b. Measuring the patient’s height and weight c. Monitoring I&O d. Obtaining initial vital signs ANS: D
Because the initial set of vital signs are part of the general health assessment they must be taken by the nurse. After that, the NAP may take vital signs for a stable patient. The nurse directs NAP to report a patient’s subjective signs and symptoms to the nurse, to measure the patient’s height and weight, and to monitor oral intake and urinary output.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Application REF: Text reference: p. 113 OBJ: Identify data to collect from the nursing history before an examination. TOP: Delegation Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. Petechiae are noted on the patient as a result of the nurse finding: a. bluish-black patches. b. tenting. c. pinpoint-sized red dots. d. large areas of raised, irritated skin. ANS: C
Petechiae appear as tiny, pinpoint-sized, red or purple spots on the skin caused by small hemorrhages in the skin layers and may indicate a blood-clotting disorder, a drug reaction, or liver disease. Bluish-black patches are more indicative of malignant melanoma. With reduced turgor, the skin remains suspended or “tented” for a few seconds before slowly returning to place. This indicates decreased elasticity and possible dehydration. Large areas of raised, irritated skin are not characteristic of petechiae. DIF: Cognitive Level: Application REF: Text reference: p. 116 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Petechiae KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse is assessing the patient by grasping a fold of skin on his forearm. She notices that
the skin remains suspended for a longer than normal period. What could this indicate? a. Stage I pressure ulcer NURSINGTB.COM b. Increased blood flow to the area c. Localized vasodilation d. Dehydration ANS: D
With reduced turgor, the skin remains suspended or “tented” for a few seconds before slowly returning to place. This indicates decreased elasticity and possible dehydration. A stage I pressure ulcer may cause warmth and erythema (redness) of an area. Skin temperature reflects an increase or decrease in blood flow. Normal reactive hyperemia (redness) is a visible effect of localized vasodilation, the body’s normal response to lack of blood flow to underlying tissue. DIF: Cognitive Level: Analysis REF: Text reference: p. 117 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Assessment of Skin Hydration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. The nurse is preparing to examine a patient who has chronic lung disease. She realizes that the
patient most likely will need to be in which position for the examination? a. Sitting upright b. Supine c. Side-lying d. Prone
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: A
Position the patient sitting upright. This promotes full lung expansion during examination. Patients with chronic respiratory disease will likely need to sit up throughout the examination because of shortness of breath. Only if the patient is unable to tolerate sitting would a supine position or a side-lying position be used. DIF: Cognitive Level: Analysis REF: Text reference: p. 128 OBJ: Describe proper positioning for the patient during each phase of the examination. TOP: Positioning for Examination of Thorax and Lungs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. Which of the following may a nursing assistant be responsible for determining? a. Vital signs b. Cranial nerve function c. Neck vein distention d. Auscultation of bowel sounds ANS: A
Assistive personnel can be trained to count apical pulse and peripheral pulses after the nurse’s initial assessment. Assistive personnel need to be instructed to recognize temperature and color changes, along with changes in peripheral pulses. Comprehensive heart and neck vessel assessment should not be delegated to assistive personnel. However, assistive personnel should know to report the development of abdominal pain or changes in the patient’s bowel habits or dietary intake. DIF: Cognitive Level: Comprehension REF: Text reference: p. 113 OBJ: Use physical assessmentNtech ues and sk. illC s du URniq SI NG TB OMring routine nursing care. TOP: Delegation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 10. The nurse is caring for a patient who is recovering from an acute myocardial infarction. While
providing cardiac education, the nurse realizes that the patient needs more education when he: a. describes changes in his behavior that may improve cardiovascular function. b. describes the schedule, dosage, and purpose of his medication. c. states that he will take his medication when he has chest pain or when his heart rate is greater than 100. d. describes the benefits of taking his medication regularly. ANS: C
The patient should not take medications for cardiovascular function intermittently. Medication should be taken on the regular prescribed schedule to prevent additional cardiac events. Describing changes in his behavior that may improve his cardiovascular function indicates that the patient understands steps he may take to improve his own health. The ability to accurately describe the schedule, dose, and purpose of his medication indicates that the patient understands his treatment. Understanding the benefits of taking his medication regularly should improve patient compliance with therapy. DIF: Cognitive Level: Analysis REF: Text reference: p. 132 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Cardiovascular Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
11. Which of the following is an expected outcome for a patient after cardiac assessment? a. Apical pulse rate equals 58 beats per minute b. Carotid bruits present c. PMI palpable at left fifth intercostal space at midclavicular line d. Jugular veins distended with patient in sitting position ANS: C
Locate the PMI by palpating with fingertips along the fifth intercostal space at the midclavicular line. Sinus bradycardia: Pulse rhythm is regular, but rate is slower than normal at 40 to 60 beats/min. Place bell of stethoscope over each carotid artery while auscultating for blowing sounds (bruit). Ask the patient to hold a breath for a few heartbeats so that respiratory sounds will not interfere with auscultation. Narrowing of the carotid artery lumen by arteriosclerotic plaques causes disturbance in blood flow. Blood passing through the narrowed section creates turbulence and emits a blowing or swishing sound. Normal veins are flat when the patient is sitting, and pulsations become evident as the patient’s head is lowered. DIF: Cognitive Level: Analysis REF: Text reference: p. 133 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Cardiovascular Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. Where is the pulmonic area for auscultation found? a. Second intercostal space on the right side b. Second intercostal space on the left side c. Third intercostal space (Erb’s point) d. Fourth intercostal space along the sternum ANS: B
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The pulmonic area is at the second intercostal space on the left side. The aortic area is at the second intercostal space on the patient’s right side. The second pulmonic area is found by moving down the left side of the sternum to the third intercostal space, also referred to as Erb’s point. The tricuspid area is located at the fourth left intercostal space along the sternum. DIF: Cognitive Level: Application REF: Text reference: p. 134 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Heart Sounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. While performing a cardiovascular assessment on a patient with suspected left-sided
congestive heart failure, the nurse is unable to palpate the PMI with the patient lying supine. What might her next step be? a. Have the patient turn onto his left side. b. Have the patient lean forward. c. Have the patient move to a sitting position. d. Palpate the PMI to the right of the midclavicular line. ANS: A
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank If palpating the PMI is difficult, turn the patient onto the left side. This maneuver moves the heart closer to the chest wall. Different positions help to clarify the types of sounds heard. Sitting position is best to hear high-pitched murmurs (if present). In the presence of serious heart disease, the PMI will be located to the left of the midclavicular line if related to an enlarged left ventricle. In chronic lung disease, the PMI is often to the right of the midclavicular line as a result of right ventricular enlargement. DIF: Cognitive Level: Application REF: Text reference: p. 135 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Cardiovascular Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. Which is the best position in which to place the patient to hear low-pitched cardiovascular
sounds? a. Supine b. Sitting up c. Dorsal recumbent d. Left lateral recumbent ANS: D
Different positions help to clarify types of sounds heard. Sitting position is best to hear high-pitched murmurs (if present). Supine is a common position to hear all sounds. Left lateral recumbent is the best position to hear low-pitched sounds. DIF: Cognitive Level: Application REF: Text reference: p. 135 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Cardiovascular Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IN ntU egR riS tyINGTB.COM 15. What technique should the nurse implement for assessment of the carotid artery? a. Massaging the arteries briskly b. Using the diaphragm of the stethoscope c. Palpating each carotid artery separately d. Placing the patient in a supine position ANS: C
Palpate each carotid artery separately with index and middle fingers around the medial edge of the sternocleidomastoid muscle. Ask the patient to raise the chin slightly, keeping the head straight. Note rate and rhythm, strength, and elasticity of the artery. Also note if the pulse changes as the patient inspires and expires. Do not vigorously palpate or massage the artery. Stimulation of the carotid sinus may cause a reflex drop in heart rate and blood pressure. Place the bell of the stethoscope over each carotid artery, auscultating for a blowing sound (bruit). To assess venous pressure, have the patient recline at a 45-degree angle and slowly recline into the supine position, avoiding neck hyperextension or flexion. Measure the distance between the angle of Louis and the highest point of vein pulsation. DIF: Cognitive Level: Application REF: Text reference: p. 138 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Assessment of Carotid Artery KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. Which of the following is an unexpected finding after a cardiac assessment?
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
A pulse rate of 72 beats per minute Jugular vein pulsation with the patient supine PMI found at the midclavicular line A sustained swishing sound during systole or diastole
ANS: D
Murmurs are sustained swishing or blowing sounds heard at the beginning, middle, or end of systole or diastole. They are caused by increased blood flow through a normal valve, forward flow through a stenotic valve or into a dilated vessel or chamber, or backward flow through a valve that fails to close. Expected outcomes following completion of procedure: Heart rate is between 60 and 100 beats per minute (adolescent through adult) and without extra sounds or murmurs; jugular veins distend when patient lies supine and flatten when patient is in sitting position; and point of maximal impulse (PMI) is palpable at fifth intercostal space at left midclavicular line in the adult. DIF: Cognitive Level: Analysis REF: Text reference: p. 138 OBJ: Communicate abnormal findings to appropriate personnel. TOP: Murmurs KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 17. Which technique is most appropriate for a nurse to implement during the assessment of the
abdomen? a. Assessing painful areas first b. Auscultating for 5 minutes over each quadrant c. Positioning the patient in a supine position with the arms behind or over the head d. Palpating painful masses or organ enlargement deeply and firmly ANS: B
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To auscultate bowel sounds, place the diaphragm of the stethoscope lightly over each of the four abdominal quadrants. Listen 5 minutes over each quadrant before deciding that bowel sounds are absent. Painful areas are assessed last. Manipulation of a body part can increase the patient’s pain and anxiety and can make the remainder of the assessment difficult to complete. Placing the arms under the head or keeping the knees fully extended can cause the abdominal muscles to tighten. Tightening of muscles prevents adequate palpation. If masses are palpated, note size, location, shape, consistency, tenderness, mobility, and texture. DIF: Cognitive Level: Comprehension REF: Text reference: p. 148 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Abdominal Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. How should the nurse document an exaggeration of the posterior curvature of the thoracic
spine found during the assessment of a 90-year-old patient? a. Lordosis b. Osteoporosis c. Scoliosis d. Kyphosis ANS: D
Kyphosis is an exaggeration of the posterior curvature of the thoracic spine (hunchback).
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Lordosis is an increased lumbar curvature (swayback). Osteoporosis is a metabolic bone disease that causes a decrease in quality and quantity of bone. Scoliosis is a lateral curvature of the spine. DIF: Cognitive Level: Application REF: Text reference: p. 157 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Curvature of the Spine KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. The patient is diagnosed with Bell’s palsy. The nurse assesses the patient and notices drooping
of the patient’s right eye and the right side of his mouth. When the functions of the following nerves are compared, the most likely cause of these symptoms would be a dysfunction of the: a. seventh cranial nerve. b. trigeminal nerve (CN V). c. oculomotor nerve (CN III). d. glossopharyngeal nerve (CN IX). ANS: A
Assess cranial nerve (CN) VII (facial) by noting facial symmetry. Have the patient frown, smile, puff out their cheeks, and raise their eyebrows. Expressions should be symmetrical; Bell’s palsy causes drooping of the upper and lower face; cerebrovascular accident (CVA) causes asymmetry. Assess cranial nerve CN V (trigeminal) by applying light sensation with a cotton ball to symmetric areas of the face. Sensations should be symmetric; unilateral decrease or loss of sensation is possibly due to a CN V lesion or a lesion in higher sensory pathways. Assess CN III (oculomotor), IV (trochlear), and VI (abducens) by assessing extraocular movement (EOM) functioning. Ask the patient to follow the movement of your finger through the six cardinal positions of gaze; measure pupillary reaction to light reflex and Nht.RTShes INeGcrTanial B.C M accommodation using a penligU neOrves are most likely to be affected by increasing intracranial pressure (ICP), which causes a change in pupil response or pupil size; sometimes pupils change shape (more oval) or react sluggishly. ICP impairs EOMs. Damage to CN IX causes impaired swallowing; damage to CN X causes loss of gag reflex, hoarseness, and a nasal voice. When the palate fails to rise and the uvula pulls toward the normal side, this indicates a unilateral paralysis. DIF: Cognitive Level: Synthesis REF: Text reference: p. 159 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Cranial Nerves KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. Measurement of the patient’s ability to differentiate between sharp and dull sensations over
the forehead tests which cranial nerve? a. Abducens b. Facial c. Trigeminal d. Oculomotor ANS: C
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The trigeminal nerve is tested by applying light sensation with a cotton ball to symmetric areas of the face. Sensations should be symmetric; unilateral decrease or loss of sensation may be caused by a CN V lesion. Assess CN III (oculomotor), IV (trochlear), and VI (abducens) by assessing extraocular movement (EOM) functioning. Ask the patient to follow the movement of your finger through the six cardinal positions of gaze; measure pupillary reaction to light reflex and accommodation using a penlight. The facial nerve is tested by having the patient smile, frown, puff out their cheeks, and raise and lower their eyebrows while you look for asymmetry. The oculomotor nerve is tested by assessing directions of gaze and by testing pupillary reaction to light and accommodation. DIF: Cognitive Level: Application REF: Text reference: p. 159 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Cranial Nerves KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. The nurse is assessing the neurologic status of a patient. She uses the handle end of a reflex
hammer to stroke the lateral aspect of the sole of the foot. She notes that the great toe dorsiflexes and the other toes spread out like a fan. What does this indicate? a. A positive Romberg’s test b. A negative Babinski’s reflex c. A hyperactive patellar tendon reflex d. A normal reflex in a child younger than age 2 ANS: D
After the soles of the feet are stroked, if Babinski’s reflex is present, the great toe will dorsiflex, accompanied by fanning of the other toes. This indicates CNS dysfunction. Dorsiflexion of the great toe and fanning of the others are normal findings in a child younger NUveRtSheIpNatie GTntB.C M feet together, arms at sides, once with than age 2. Romberg’s test: Ha standOwith eyes open and once with eyes closed (for 20 to 30 seconds each time). Protect the patient’s safety by standing at their side; observe for swaying. Plantar response (Babinski’s reflex): Using the handle end of the reflex hammer, stroke the lateral aspect of the sole, from the heel to the ball of the foot. The toes should flex inward and downward. Knee reflex: Palpate the patellar tendon just below the patella. Tap the pointed end of the reflex hammer briskly on the tendon. Knee reflex is the most common DTR assessment performed. The normal response is knee extension. DIF: Cognitive Level: Synthesis REF: Text reference: p. 159 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Babinski’s Reflex KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22. How does a nurse appropriately measure intake and output? a. Recording 50% of ice chip consumption b. Checking urinary output every 24 hours c. Emptying the chest tube drainage every 2 hours d. Subtracting liquid medications from the total intake ANS: A
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank All liquids consumed must be counted including liquids with meals, gelatin, custards, ice cream, popsicles, sherbets, and ice chips (recorded as 50% of measured volume [e.g., 100 mL of ice chips equals 50 mL of water]) for the intake record. Liquid medicines such as antacids are counted as fluid intake, as are fluids with medications. The output record must include all fluids leaving the body. Instruct the patient (or family) to call the nurse to empty contents of the urinal, urine hat, or commode each time it is used so the fluid may be measured. Blood collected in a wound drain is also counted. Chest tube drainage is emptied ONLY when the container is nearly full. A closed system is necessary to maintain lung reexpansion. DIF: Cognitive Level: Application REF: Text reference: p. 162 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Intake KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. Which skin condition would cause a nurse to suspect chickenpox? a. Wheals b. Nodules c. Pustules d. Vesicles ANS: D
A vesicle is a circumscribed elevation of skin filled with serous fluid, smaller than 1 cm (e.g., herpes simplex, chickenpox). A wheal is an irregularly shaped, elevated area of superficial localized edema that varies in size (e.g., hive, mosquito bite); it is not characteristic of chickenpox. A nodule is an elevated solid mass, deeper and firmer than a papule, 1 to 2 cm (e.g., wart), and not characteristic of chickenpox. A pustule is a circumscribed elevation of skin similar to a vesicle but filled with pus; it varies in size (e.g., acne, staphylococcal NsticRSofIcNhick GTenpox. B.COM infection) and is not characteriU DIF: Cognitive Level: Application REF: Text reference: p. 118 OBJ: Discuss normal physical findings for patients across the life span. TOP: Primary Skin Lesions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. Which patient position maximizes the nurse’s ability to assess the patient’s body for
symmetry? a. Sitting b. Supine c. Prone d. Dorsal recumbent ANS: A
Sitting upright provides full expansion of the lungs and allows better visualization of symmetry of upper body parts. The supine position maximizes the nurse’s ability to assess pulse sites. The prone position is used only to assess extension of the hip joint. The dorsal recumbent position is used for abdominal assessment because it promotes relaxation of abdominal muscles. DIF: Cognitive Level: Application REF: Text reference: p. 111 OBJ: Discuss normal physical findings for patients across the life span. TOP: Positions for Physical Assessment KEY: Nursing Process Step: Assessment
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity 25. During assessment of a patient with anemia, a nurse is alert for the presence of: a. pallor. b. jaundice. c. cyanosis. d. erythema. ANS: A
Pallor is a decrease in color caused by a reduced amount of oxyhemoglobin resulting from decreased blood flow caused by anemia or shock. Jaundice is caused by increased deposit of bilirubin in tissues caused by liver disease or destruction of red blood cells; it is not characteristic of anemia. Cyanosis is caused by an increased amount of deoxygenated hemoglobin due to heart or lung disease or a cold environment; it is not characteristic of anemia. Erythema is caused by increased visibility of oxyhemoglobin due to dilation or increased blood flow because of fever, direct trauma, blushing, or alcohol intake; it is not characteristic of anemia. DIF: Cognitive Level: Application REF: Text reference: p. 116 OBJ: Discuss normal physical findings for patients across the life span. TOP: Skin Color Variations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. A nurse is documenting a patient’s breath sounds. Crackles are heard as: a. loud, low-pitched, coarse sounds. b. high-pitched, musical squeaks. c. dry, grating sounds on inspiration. d. high-pitched, fine soundsNaU t tR heSeInN dG ofTinBs. piC raO tioMn. ANS: D
Fine crackles are high-pitched, fine, short, interrupted crackling sounds heard during the end of inspiration; they usually are not cleared with coughing. Rhonchi are loud, low-pitched, rumbling, coarse sounds heard most often during inspiration or expiration that may be cleared by coughing. Wheezes are high-pitched, continuous, musical sounds like a squeak heard continuously during inspiration or expiration; they are usually louder on expiration and do not clear with coughing. Pleural friction rub has a dry, grating quality heard best during inspiration; it does not clear with coughing and is heard loudest over the lower lateral anterior surface. DIF: Cognitive Level: Application REF: Text reference: p. 126 OBJ: Discuss normal physical findings for patients across the life span. TOP: Adventitious Breath Sounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 27. A student nurse is working with a patient who has asthma. The primary nurse tells the student
that wheezes can be heard on auscultation. The student expects to hear: a. coarse crackles and bubbling. b. high-pitched musical sounds. c. dry, grating noises. d. loud, low-pitched rumbling. ANS: B
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Wheezes are high-pitched, continuous, musical sounds like a squeak heard continuously during inspiration or expiration; they are usually louder on expiration. Coarse crackles and bubbling are not descriptive of wheezes. Dry, grating noises are heard with a pleural friction rub. Loud, low-pitched rumbling is characteristic of rhonchi. DIF: Cognitive Level: Application REF: Text reference: p. 126 OBJ: Discuss normal physical findings for patients across the life span. TOP: Adventitious Breath Sounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 28. A nurse is documenting a patient’s breath sounds. Rhonchi are heard as: a. loud, low-pitched, coarse sounds. b. high-pitched, musical squeaks. c. dry, grating sounds on inspiration. d. high-pitched, fine sounds at the end of inspiration. ANS: A
Rhonchi are loud, low-pitched, rumbling, coarse sounds heard most often during inspiration or expiration; they may be cleared by coughing. Wheezes are high-pitched, continuous, musical sounds like a squeak heard continuously during inspiration or expiration; they are usually louder on expiration and do not clear with coughing. Pleural friction rub has a dry, grating quality heard best during inspiration and does not clear with coughing; it is heard loudest over the lower lateral anterior surface. Fine crackles are high-pitched fine, short, interrupted crackling sounds heard during the end of inspiration; they usually are not cleared with coughing. DIF: Cognitive Level: Application REF: Text reference: p. 126 OBJ: Discuss normal physicalNfiU ndRinS gI s fN orGpT atB ien.tsCaO crM oss the life span. TOP: Adventitious Breath Sounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The purpose of the physical assessment is to: (Select all that apply.) a. compare the patient’s status with previous findings. b. help the nurse gather additional data. c. help select the best nursing measures. d. teach patients about better health promotion. ANS: A, B, C, D
In acute care settings, you perform a brief physical assessment at the beginning of each shift to identify changes in the patient’s status for comparison with the previous assessment. After gathering data, the nurse groups significant findings into patterns of data that reveal actual or risk nursing diagnoses. Each abnormal finding directs the nurse to gather additional data. The information is useful in selecting the best nursing measures to manage the patient’s health problems. During the physical assessment is an ideal time to offer patient teaching and encourage promotion of health practices, such as breast and genital self-examination. DIF: Cognitive Level: Comprehension REF: Text reference: p. 105 OBJ: Discuss the purposes of physical assessment. TOP: Purpose of the Physical Assessment
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The nurse is preparing to examine a comatose patient on a ventilator. Before beginning the
procedures, she: (Select all that apply.) a. speaks to the patient to minimize anxiety. b. drapes the body parts not being examined. c. encourages the patient to ask questions. d. uses medical terms to let the patient know that she is professional. ANS: A, B
Minimize patients’ anxiety and fear by conveying an open, receptive, and professional approach. Using simple terms, thoroughly explain what you will do, what the patient should expect to feel, and how the patient can cooperate. Even if the patient appears unresponsive, it still is essential to explain your actions. Provide access to body parts while draping areas that are not being examined. DIF: Cognitive Level: Application REF: Text reference: p. 111 OBJ: List techniques to promote the patient’s physical and psychological comfort during an examination. TOP: Preparing the Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The patient has come to the clinic complaining of bleeding from what she calls a “mole” on
her neck. She states that her mother died from skin cancer at a fairly early age because she was fair-skinned and had a lot of exposure to the sun. Because of this, the patient has been going for tanning sessions regularly for several years to keep her dark and to protect her from the sun. The nurse prepares to examine the “mole” while being especially watchful for: (Select NURSINGTB.COM all that apply.) a. uneven shape of the mole (asymmetry). b. ragged or blurred edges of the mole border. c. pigmentation that is not uniform. d. size of the mole. ANS: A, B, C, D
The warning signs of skin cancer using the ABCD mnemonic include: A for Asymmetry— look for uneven shape; B for Border irregularity—look for edges that are blurred, notched, or ragged; C for Color—pigmentation is not uniform; blue, black, brown variegated, tan, or areas of unusual color such as pink, white, gray, or red; and D for Diameter—greater than the size of a typical pencil eraser. Also, identify any skin lesion or nevi that starts to bleed or ooze or feels different (swollen, hard, lumpy, itchy, or tender to thetouch). DIF: Cognitive Level: Analysis REF: Text reference: p. 116 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Melanoma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. While performing a physical examination, the nurse incorporates health promotion by
teaching the patient about how to reduce the risk of lung cancer. The nurse explains that besides cigarette smoking, exposure to other substances may lead to this disease. Some of these substances are: (Select all that apply.)
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
arsenic. asbestos. radiation. air pollution.
ANS: A, B, C, D
Explain to patients that exposure to radiation, arsenic, and asbestos from occupational, medical, and environmental sources; air pollution; history of tuberculosis; and second-hand smoke contribute significantly to lung cancer. DIF: Cognitive Level: Knowledge REF: Text reference: p. 131 OBJ: Discuss ways to incorporate health promotion and health teaching into an assessment. TOP: Lung Cancer KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. In teaching the patient about prevention of cervical cancer, the nurse teaches the patient about
the risk factors for cervical cancer. Risk factors for cervical cancer include which of the following? (Select all that apply.) a. History of human papillomavirus (HPV) infection b. Multiple sex partners c. Smoking d. Multiple pregnancies ANS: A, B, C, D
Determine whether the patient has a history of human papillomavirus (HPV), condyloma acuminatum, herpes simplex, or cervical dysplasia; has multiple sex partners; smokes cigarettes; or has had multiple pregnancies. These are risk factors for cervical cancer.
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DIF: Cognitive Level: Comprehension REF: Text reference: p. 151 OBJ: Discuss ways to incorporate health promotion and health teaching into an assessment. TOP: Cervical Cancer KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. The patient is 3 days post abdominal surgery. The nurse uses her stethoscope to listen for
bowel sounds. This assessment technique is known as
.
ANS:
auscultation Auscultation is listening with a stethoscope to sounds produced by the body. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 109-110 OBJ: Describe the techniques used with each assessment skill. TOP: Auscultation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The female nurse is preparing to assess and possibly change a scrotal dressing on a
34-year-old patient. Before changing the dressing, she should ANS:
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.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank have a third person of the patient’s gender come into the room Have a third person of the patient’s gender in the room during assessment of genitalia. This prevents the patient from accusing the nurse of behaving in an unethical manner. DIF: Cognitive Level: Application REF: Text reference: p. 111 OBJ: Make environmental preparations before conducting an assessment. TOP: Preparing the Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is providing health education to a group of adolescent females. The topic is
“Preventing Skin Cancer.” As part of the health promotion education, the nurse recommends that they avoid tanning under direct sun at midday and avoid . ANS:
tanning beds Do not use indoor sunlamps or tanning beds because these are sources of UV radiation. DIF: Cognitive Level: Analysis REF: Text reference: p. 105 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Melanoma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4.
is a major cause of lung cancer, cerebrovascular disease, heart disease, and chronic lung disease. ANS:
Smoking Smoking is a major cause of N luU ngRcSaI ncN erG ,T heB ar. tC diO seM ase, and chronic lung disease (emphysema and chronic bronchitis). Smoking accounts for 29% of all lung cancer deaths in the United States. DIF: Cognitive Level: Knowledge REF: Text reference: p. 127 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Smoking KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 5. When performing an assessment of the cardiovascular system, the nurse evaluates the skin
and nails of the patient. Inadequate tissue perfusion is known as
.
ANS:
ischemia Inadequate tissue perfusion results in inadequate delivery of oxygen and nutrients to cells, a condition called ischemia. This is caused by constriction of vessels or by occlusion (blockage) from clot formation. DIF: Cognitive Level: Knowledge REF: Text reference: p. 132 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Ischemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 6. The patient has been immobile at home after having had leg trauma in an automobile accident
and is now being admitted with calf pain and localized swelling of the calf muscle. One test that is contraindicated in assessment of this patient is testing for . ANS:
Homans’ sign Homans’ sign is no longer considered a reliable indicator for the presence or absence of DVT and should not be considered a reliable test. Trauma to the vein or muscle, reduced mobility, and increased blood clotting are reliable risk factors. If the calf is swollen, tender, or red, notify the patient’s health care provider for further assessment and evaluation. If there is a strong suspicion of DVT, testing for Homans’ sign is contraindicated. If a clot is present, it may become dislodged from its original site during this test. This could result in a pulmonary embolism. DIF: Cognitive Level: Analysis REF: Text reference: p. 140 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Deep Vein Thrombosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The patient has been in the ICU following an acute myocardial infarction 3 days earlier.
During an initial assessment of the patient, the nurse detects a heart murmur that the patient did not have previously. The nurse should . ANS:
notify the physician Impaired blood flow through the heart indicates the need for immediate medical attention. Some murmurs are benign.
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DIF: Cognitive Level: Analysis REF: Text reference: p. 138 OBJ: Communicate abnormal findings to appropriate personnel. TOP: Murmurs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The patient is noted to have difficulty swallowing. The nurse realizes that the most probable
cause of this difficulty is damage to cranial nerve
.
ANS:
IX Damage to CN IX causes impaired swallowing; damage to CN X causes loss of gag reflex, hoarseness, and nasal voice. When the palate fails to rise and the uvula pulls toward the normal side, this indicates a unilateral paralysis. DIF: Cognitive Level: Synthesis REF: Text reference: p. 159 OBJ: Use physical assessment techniques and skills during routine nursing care. TOP: Cranial Nerves KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. When breast self-examination is done, it should be done once a month. For women who
menstruate, the best time is
.
ANS:
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 2 or 3 days after a period ends For women who menstruate, the best time to do BSE is 2 or 3 days after a period ends, when the breasts are least likely to be tender or swollen. Women who no longer menstruate should pick a day, such as the first day of the month, to regularly do a BSE. DIF: Cognitive Level: Application REF: Text reference: p. 106 OBJ: Identify self-screening assessments commonly performed by patients. TOP: Breast Self-Examination KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. Increased visibility of oxyhemoglobin caused by dilation or increased blood flow is known as
. ANS:
erythema Red skin (erythema) is caused by increased visibility of oxyhemoglobin caused by dilation or increased blood flow. DIF: Cognitive Level: Application REF: Text reference: p. 116 OBJ: Discuss normal physical findings for patients across the life span. TOP: Skin Color Variations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. A late sign of decreased oxygen levels may cause a change in skin color known as
. ANS:
NURSINGTB.COM cyanosis Bluish (cyanosis) coloring of the skin is caused by hypoxia (late sign of decreased oxygen levels). DIF: Cognitive Level: Application REF: Text reference: p. 116 OBJ: Discuss normal physical findings for patients across the life span. TOP: Skin Color Variations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
is a yellow-orange skin color seen with increased deposit of bilirubin in
12.
tissues. ANS:
Jaundice Jaundice, a yellow-orange skin color, is seen with increased deposits of bilirubin in tissues. DIF: Cognitive Level: Knowledge REF: Text reference: p. 116 OBJ: Discuss normal physical findings for patients across the life span. TOP: Skin Color Variations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 7: Medical Asepsis MULTIPLE CHOICE 1. The nurse understands that the priority nursing action needed when medical asepsis is used
includes: a. handwashing. b. surgical procedures. c. autoclaving of instruments. d. sterilization of equipment. ANS: A
Medical asepsis, or clean technique, includes procedures used to reduce the number, and prevent the spread, of microorganisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis. Surgical asepsis, or sterile technique, includes procedures used to eliminate all microorganisms from an area. Sterilization destroys all microorganisms and their spores. The techniques used in maintaining surgical asepsis are more rigid than those performed under medical asepsis. DIF: Cognitive Level: Application REF: Text reference: pp. 166-167 OBJ: Explain the difference between medical and surgical asepsis. TOP: Medical Asepsis KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 2. Handwashing with soap and water is: a. the most effective way to reduce the number of bacteria on the nurse’s hands. Mashing hands. b. more effective than alcohN olU -bRaS seI dN prG odTuB ct. sC foO rw c. necessary for hand hygiene if hands are visibly soiled. d. not necessary if the nurse wears artificial nails. ANS: C
Soap and water is still necessary for hand hygiene if hands are visibly soiled. Recent research has shown that handwashing with plain soap sometimes results in paradoxical increases in bacterial counts on the skin. Alcohol-based products have been more effective for standard handwashing or hand antisepsis than soap or antiseptic soaps. Studies have shown the efficacy of alcohol-based hand sanitizers in reducing infection in a variety of settings from intensive care to long-term care. Studies have shown that health care workers with chipped nail polish or long or artificial nails have high numbers of bacteria on their fingertips. For this reason, the CDC recommends that health care workers not wear artificial nails and extenders, and that they keep natural nails less than one-quarter of an inch long when caring for high-risk patients. DIF: Cognitive Level: Analysis REF: Text reference: p. 168 OBJ: Describe factors that can influence nursing staff compliance with hand hygiene. TOP: Hand Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. When caring for patients, the nurse understands that the single most important technique to
prevent and control the transmission of infection is: a. hand hygiene.
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. the use of disposable gloves. c. the use of isolation precautions. d. sterilization of equipment. ANS: A
The most important and most basic technique in preventing and controlling transmission of infection is hand hygiene. Use of disposable gloves may help reduce the transmission of infection, but it is not the single most important technique to prevent and control the transmission of infection. Neither the use of isolation precautions nor the sterilization of equipment is the single most important technique to prevent and control the transmission of infection. DIF: Cognitive Level: Application REF: Text reference: p. 168 OBJ: Describe factors that can influence nursing staff compliance with hand hygiene. TOP: Hand Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Which of the following measures is appropriate when a nurse is washing his or her hands? a. Use very hot water. b. Leave rings and watches in place. c. Lather for at least 15 to 20 seconds. d. Keep the fingers and hands up and the elbows down. ANS: C
Perform hand hygiene using plenty of lather and friction for at least 15 to 20 seconds. Interlace fingers and rub palms and back of hands with circular motion at least 5 times each. Keep fingertips down to facilitate removal of microorganisms. Hot water can be damaging to the skin. Regulate the flow oN f wa soNtG hatTtB h. e tC emp RterSI Merature is warm. Warm water removes U O less of the protective oils on the hands than hot water. Jewelry and watches can be a place for pathogens to hide. Push wristwatch and long uniform sleeves above wrists. Avoid wearing rings. If worn, remove during washing. This provides complete access to fingers, hands, and wrists. Wearing of rings increases the numbers of microorganisms on the hands. The position of hands and arms will aid in washing pathogens away. Wet hands and wrists thoroughly under running water. Keep hands and forearms lower than elbows during washing. Hands are the most contaminated parts to be washed. Water flows from the least to the most contaminated area, rinsing microorganisms into the sink. DIF: Cognitive Level: Application REF: Text reference: p. 171 OBJ: Perform proper procedures for hand hygiene. TOP: Hand Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse shows an understanding of the psychological implications for a patient on isolation
when planning care to control the risk for: a. denial. b. aggression. c. regression. d. isolation. e. depression. ANS: D
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank A sense of loneliness may develop because normal social relationships become disrupted. The nurse should plan care to control the risk that the patient may feel isolated. Denial and regression are not risks related to isolation. Aggression is not a risk for the patient on isolation precautions. DIF: Cognitive Level: Application REF: Text reference: p. 168 OBJ: Perform correct isolation techniques. TOP: Isolation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 6. An appropriate technique for the nurse to implement for the patient on isolation precautions is
to: a. b. c. d.
double-bag all disposable items and linens. put another gown over the one worn if it has become wet. place specimen containers in plastic bags for transport. hand items to be reused directly to a nurse standing outside the room.
ANS: C
Transfer the specimen to a container without soiling the outside of the container. Place the container in a plastic bag and label the outside of the bag or as per agency policy. Specimens of blood and body fluids are placed in well-constructed containers with secure lids to prevent leaks during transport. Use single bags that are impervious to moisture and sturdy to contain soiled articles. Use the double-bagging technique if necessary for heavily soiled linen or heavy wet trash. Linen or refuse should be totally contained to prevent exposure of personnel to infective material. Avoid allowing the isolation gown to become wet; carry the wash basin outward, away from the gown; avoid leaning against wet tabletops. Moisture allows organisms to travel through the gown to the uniform. Remove all reusable pieces of equipment. Clean any contaminated surfaces with hospital-approved disinfectant. All items N Rted,INorGsTterilize B.CO M must be properly cleaned, disinUfecS d for reuse. DIF: Cognitive Level: Application REF: Text reference: p. 176 OBJ: Perform correct isolation techniques. TOP: Isolation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. Before entering the room of a patient on isolation where all protective barriers are required,
the nurse first puts on the: a. gown. b. gloves. c. eyewear. d. mask/respirator. ANS: A
Apply the gown first, making sure that it covers all outer garments. Pull sleeves down to the wrist. Tie securely at the neck and waist. Next, apply either a surgical mask or a fitted respirator around the mouth and nose. Goggles or a face shield is put on after the gown and mask are applied. Gloves are put on last. DIF: Cognitive Level: Application REF: Text reference: p. 174 OBJ: Perform correct isolation techniques. TOP: Isolation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 8. The patient is presenting to the hospital with a high fever and a productive cough. He says that
he hasn’t felt right since he returned from visiting Somalia about a month before admission. He also states that he has lost about 20 pounds in the last month and frequently wakes up in the middle of the night sweaty and “clammy.” What should the nurse prepare to do? a. Place the patient on contact isolation. b. Place the patient in a negative-pressure room. c. Place the patient on droplet precautions. d. Use standard precautions only. ANS: B
Suspect tuberculosis (TB) in any patient with respiratory symptoms lasting longer than 3 weeks accompanied by other suspicious symptoms, such as unexplained weight loss, night sweats, fever, and a productive cough often streaked with blood. Isolation for patients with suspected or confirmed TB includes placing the patient on airborne precautions in a single-patient negative-pressure room. In addition to standard precautions, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient’s environment. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection and colonization with multidrug-resistant bacteria judged by the infection control program as follows: (1) enteric with a low infectious dose or prolonged environmental survival, including Clostridium difficile, Escherichia coli, Shigella, hepatitis A, or rotavirus; (2) skin infections that are highly contagious or that may occur on dry skin, including diphtheria (cutaneous), herpes simplex virus (neonatal or mucocutaneous), impetigo, major (noncontained) abscesses, cellulitis, decubiti, pediculosis, scabies, staphylococcal furunculosis in infants and young children, or zoster; or (3) viral/hemorrhagic conjunctivitis or viral hemorrhagic infection (Ebola, Lassa, or Marburg). In addition to standard precautions, use droplet precautions for patients known or suspected to have serious illnN esse mitt ed.bCyO laM rge particle droplets. Examples of such RsStrIans G B U N T illnesses include invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, epiglottitis, and sepsis; and invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis. Other serious bacterial respiratory infections spread by droplet transmission include diphtheria (pharyngeal), Mycoplasma pneumoniae, pertussis, pneumonic plague, streptococcal pharyngitis, pneumonia, and scarlet fever in infants and young children. Serious viral infections spread by droplet transmission include adenovirus, influenza, mumps, parvovirus B19, and rubella. DIF: Cognitive Level: Synthesis REF: Text reference: p. 172 OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: Airborne Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. For patients with which of the following conditions should the nurse implement airborne
precautions? a. Rubella b. Influenza c. Tuberculosis d. Pediculosis ANS: C
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank In addition to standard precautions, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include measles, varicella (including disseminated zoster), and TB. Airborne precautions are not appropriate for viral infections spread by droplet transmission, including adenovirus, influenza, mumps, parvovirus B19, and rubella. Contact precautions would be appropriate for a patient with pediculosis. DIF: Cognitive Level: Comprehension REF: Text reference: p. 173 OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: Airborne Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The patient is admitted to the pediatric unit with severe pertussis. The nurse explains to the
parents and the child that the patient will be treated with the use of: a. airborne precautions. b. standard precautions only. c. droplet precautions. d. contact isolation. ANS: C
In addition to standard precautions, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include invasive Haemophilus influenzae type b disease, invasive Neisseria meningitidis disease, and other serious bacterial respiratory infections spread by droplet transmission, such as diphtheria (pharyngeal), Mycoplasma pneumoniae, and pertussis. Pertussis is spread by large particle droplets. For infection spread via airborne routes, use airborne precautions, in addition to standard precautions. Examples of such illnesses include measles, varicella, and N R blo IN GallB.C M TB. Standard precautions applyUtoS od, T bodyOfluids, secretions, excretions, nonintact skin, and mucous membranes. Persons who have infections that are spread by large particle droplets, such as pertussis, need more than just standard precautions. Pertussis is not spread through direct patient contact. For patients known or suspected to have serious illnesses easily transmitted by direct patient contact, or by contact with items in the patient’s environment, use contact precautions in addition to standard precautions. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection, Clostridium difficile, Escherichia coli, Shigella, hepatitis A, rotavirus, and skin infections that are highly contagious or that may occur on dry skin. DIF: Cognitive Level: Analysis REF: Text reference: p. 173 OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: Droplet Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. Droplet precautions will be instituted for the patient admitted to the infectious disease unit
with: a. streptococcal pharyngitis. b. herpes simplex. c. pulmonary TB. d. measles. ANS: A
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Droplet precautions are instituted when droplets are larger than 5 µm, as in the case of streptococcal pharyngitis. Contact precautions are instituted for herpes simplex. Airborne precautions are instituted for pulmonary TB and measles. DIF: Cognitive Level: Analysis REF: Text reference: p. 73 OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: Droplet Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The patient has been hospitalized for several days and has received multiple intravenous
antibiotic medications. This morning, the patient had three episodes of severe, foul-smelling diarrhea. The nurse should institute: a. contact precautions. b. standard precautions only. c. airborne precautions. d. droplet precautions. ANS: A
In addition to standard precautions, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient’s environment. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection and colonization with multidrug-resistant bacteria judged by the infection control program as follows: (1) enteric with a low infectious dose or prolonged environmental survival, including Clostridium difficile, Escherichia coli, Shigella, hepatitis A, or rotavirus; or (2) skin infections that are highly contagious or that may occur on dry skin. Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. Patients who may be infected by pathogens that can be spread NUay RSnee IN G ore. B.C M through direct patient contact m d mT ThO e patient is not exhibiting signs of infection/colonization by pathogens that can be spread via the airborne route. In addition to standard precautions, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include measles, varicella, and TB. The patient is not exhibiting signs of infection/colonization by pathogens that can be spread via large particle droplets. In addition to standard precautions, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include invasive Haemophilus influenzae type b disease, pertussis, pneumonic plague, streptococcal pharyngitis, pneumonia, and scarlet fever in infants and young children, as well as mumps, parvovirus B19, and rubella. DIF: Cognitive Level: Analysis REF: Text reference: pp. 172-173 OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: Contact Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. What should the nurse do to break the chain of infection at the reservoir level? a. Change a soiled dressing. b. Keep drainage systems intact. c. Cover the nose and mouth when sneezing. d. Avoid contact of the uniform with soiled items. ANS: A
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The reservoir is the site or source of microorganism growth. Control: sources of body fluids and drainage. Perform hand hygiene. Bathe the client with soap and water. Change soiled dressings. Dispose of soiled tissues, dressings, or linen in moisture-resistant bags. Place syringes, uncapped hypodermic needles, and intravenous needles in designated puncture-proof containers. Keep table surfaces clean and dry. Do not leave bottled solutions open for prolonged periods. Keep solutions tightly capped. Keep surgical wound drainage tubes and collection bags patent. Empty and dispose of drainage suction bottles according to agency policy. The portal of entry is the site through which a microorganism enters a host. Urinary: Keep all drainage systems closed and intact, maintaining downward flow. The portal of exit is the means by which microorganisms leave a site. Respiratory: Avoid talking, sneezing, or coughing directly over a wound or sterile dressing field. Cover nose and mouth when sneezing or coughing. Wear mask if suffering respiratory tract infection. Transmission is the means of spread. Reduce microorganism spread. Perform hand hygiene. Use personal set of care items for each client. Avoid shaking bed linen or clothes; dust with damp cloth. Avoid contact of soiled item with uniform. DIF: Cognitive Level: Analysis REF: Text reference: p. 167 OBJ: Identify nursing care measures intended to break the chain of infection. TOP: Breaking the Chain of Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The patient is admitted with mumps. The nurse knows that she will have to: a. put the patient in a private room. b. place the patient on standard precautions. c. wear a mask when closer than 3 feet to the patient. d. place the patient on contact precautions. ANS: C
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For diseases transmitted by large droplets (larger than 5 µm), such as streptococcal pharyngitis, pneumonia, scarlet fever in infants or small children, pertussis, mumps, meningococcal pneumonia or sepsis, or pneumonic plague, place the patient in a private room, or cohort the patient and wear a mask when closer than 3 feet from the patient. For diseases transmitted by small droplet nuclei (smaller than 5 µm), such as measles, chickenpox, disseminated varicella zoster, and pulmonary or laryngeal TB, place the patient on airborne precautions in a private room with negative airflow of at least six air exchanges per hour, and wear a respirator or mask. Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. For diseases transmitted by direct patient or environmental contact, such as colonization or infection with multidrug-resistant organisms, respiratory syncytial virus, major wound infection, herpes simplex, and scabies, place the patient on contact precautions in a private room, or cohort the patient. Wear gloves and gowns. DIF: Cognitive Level: Analysis REF: Text reference: p. 173 OBJ: Identify nursing care measures intended to break the chain of infection. TOP: Breaking the Chain of Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. For an infection to take place, which of the following must be present? (Select all that apply.)
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
Pathogen and reservoir Portals of exit and entry Mode of transmission Susceptible host
ANS: A, B, C, D
The mere presence of a pathogen does not mean that an infection will begin. Development of an infection occurs in a cyclic process, often referred to as the chain of infection, which depends on the following six elements: an infectious agent or pathogen, a reservoir or source for pathogen growth, a portal of exit from the reservoir, a mode of transmission, a portal of entry to the host, and a susceptible host. DIF: Cognitive Level: Analysis REF: Text reference: p. 166 OBJ: Explain how each element of the infection chain contributes to infection. TOP: Chain of Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. If hands are not visibly soiled, the nurse may use an alcohol-based hand rub in which of the
following situations? (Select all that apply.) a. Before having direct contact with patients b. After contact with a patient’s intact skin c. After contact with body fluids or excretions d. After removing gloves ANS: A, B, C, D
If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands before having direct contact with patients, before putting on sterile gloves, and before inserting indwelling urinary cNath eter s, N peGrip he. raC l va R I B Mscular catheters, or other invasive devices; U S T O after contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure, lifting a patient); after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled; when moving from a contaminated body site to a clean body site during care; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; and after removing gloves. DIF: Cognitive Level: Application REF: Text reference: p. 169 OBJ: Perform proper procedures for hand hygiene. TOP: Hand Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is planning to care for a patient diagnosed with possible tuberculosis (TB).
Assessment of possible TB may be based on which of the following? (Select all that apply.) a. A positive AFB smear or culture b. Signs or symptoms of TB c. Cavitation on chest x-ray study d. History of recent exposure e. TB skin test ANS: A, B, C, D
Signs of infectious pulmonary or laryngeal TB include documentation of positive AFB smear or culture, signs or symptoms of TB, cavitation on chest x-ray study, history of recent exposure, and physician progress notes indicating a plan to rule out TB.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Comprehension REF: Text reference: p. 172 OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: Assessment of Potential TB KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION 1. Infection control practices that reduce and eliminate sources and transmission of infection are
known as
.
ANS:
transmission-based precautions Transmission-based precautions are infection control practices that reduce and eliminate sources and transmission of infection and help to protect patients and health care providers from disease. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 172-173 OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: Transmission-Based Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse has a “scratchy throat” and has been sniffling for 2 days. While at work, she wears
a protective mask when coming into contact with her patients. She does this in an attempt to protect them from a . ANS:
health care–acquired infectioN n (HRAII ) G B.C M Health care–acquired infectionU s (HSAIsN ) arT e those O that develop as a result of contact with a health care facility/provider; the infection was not present or incubating at the time of admission. DIF: Cognitive Level: Analysis REF: Text reference: p. 166 OBJ: Identify nursing care measures intended to break the chain of infection. TOP: Health Care–Acquired Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
is the absence of pathogenic (disease-producing) microorganisms.
3. ANS:
Asepsis Asepsis is the absence of pathogenic (disease-producing) microorganisms. DIF: Cognitive Level: Comprehension REF: Text reference: p. 166 OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: Asepsis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is preparing to provide care for the patient. Before making patient contact, she
washes her hands. This practice is known as ANS:
.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank medical asepsis Medical asepsis, or clean technique, includes procedures used to reduce the number, and prevent the spread, of microorganisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 166-167 OBJ: Explain the difference between medical and surgical asepsis. TOP: Medical Asepsis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5.
, also known as sterile technique, includes procedures used to eliminate all microorganisms from an area. ANS:
Surgical asepsis Surgical asepsis, or sterile technique, includes procedures used to eliminate all microorganisms from an area. Sterilization destroys all microorganisms and their spores. DIF: Cognitive Level: Knowledge REF: Text reference: p. 167 OBJ: Explain the difference between medical and surgical asepsis. TOP: Surgical Asepsis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The primary strategies for prevention of infection transmission with regard to contact with
blood, body fluids, nonintact skin, and mucous membranes are known as
.
ANS:
NURSINGTB.COM standard precautions Standard precautions, the primary strategies for prevention of infection transmission, apply to contact with (1) blood, (2) body fluids, (3) nonintact skin, and (4) mucous membranes, as well as with equipment or surfaces contaminated with these potentially infectious materials. DIF: Cognitive Level: Comprehension REF: Text reference: p. 172 OBJ: Perform correct isolation techniques. TOP: Standard Precautions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. OSHA and CDC guidelines require health care workers who care for suspected or confirmed
TB patients to wear special
.
ANS:
respirators OSHA and CDC guidelines require health care workers who care for suspected or confirmed TB patients to wear special respirators. These respirators are high-efficiency particulate masks that have the ability to filter particles at 95% or better efficiency. Health care workers who use these respirators must be fit-tested in a reliable way to obtain a face-seal leakage of 10% or less. DIF: Cognitive Level: Application REF: Text reference: p. 172 OBJ: Perform correct isolation techniques. TOP: OSHA Guidelines—Respirators KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
8. The nurse is applying for a position at a local hospital. As part of the employment criteria, she
will be required to be assessed for TB exposure. She should be prepared for the blood test to be scheduled. ANS:
QuantiFERON-TB Gold test (QFT-G) The CDC now recommends use of the QuantiFERON-TB Gold test (QFT-G) (CDC, 2005), a blood test, in place of the traditional TB skin test. The advantages of the QFT-G test are that it does not boost responses measured by subsequent tests, and the results are not subject to reader bias. DIF: Cognitive Level: Comprehension REF: Text reference: p. 172 OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection. TOP: OSHA Guidelines—TB Testing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. The nurse knows that the basic concept of all patient care that is implemented to prevent the
spread of infection from blood, body fluids, secretions, excretions, nonintact skin, and mucus membranes is . ANS:
standard precautions Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. DIF: Cognitive Level: Application REF: Text reference: p. 172 OBJ: Discuss how to apply criN tiU caR l tS hiI nkN inG gT inB th. eC prO evM ention of the transmission of infection. TOP: Standard Precautions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 8: Sterile Technique MULTIPLE CHOICE 1. When the following concepts are compared, which is most important in maintaining a safe
environment by following aseptic principles? a. Performing a surgical hand scrub b. Applying a sterile gown c. Recognizing the importance of following aseptic principles d. Applying a mask and protective eyewear ANS: C
A nurse in an operating room follows a series of steps toward sterile technique, such as applying a mask, protective eyewear, and a cap; performing a surgical hand scrub; and applying a sterile gown and sterile gloves. In contrast, a nurse who is performing a sterile dressing change at a patient’s bedside or in the home setting may only wash the hands and apply sterile gloves. Regardless of the procedures followed or the setting, the nurse needs to recognize the importance of following strict aseptic principles. DIF: Cognitive Level: Application REF: Text reference: p. 181 OBJ: Identify principles of surgical asepsis. TOP: Aseptic Principles KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is preparing to provide wound care for her patient. She realizes that the most
effective way to decrease the bacterial count on her hands is to wash her hands using: a. soap and water only. N R I G B.C M b. a nonalcohol antiseptic alon Ue. S N T O c. a 50% alcohol-based antiseptic alone. d. a 60% to 95% alcohol-based antiseptic alone. ANS: D
Studies have shown that antiseptics containing 60% to 95% alcohol alone, or 50% to 95% alcohol, when combined with other selected antiseptics (e.g., chlorhexidine), lower bacterial counts on the skin more effectively than do other antiseptics without alcohol. An alcohol-based hand rub may be used as a preoperative hand scrub after an initial 15-second prewash with plain soap and water. DIF: Cognitive Level: Synthesis REF: Text reference: p. 182 OBJ: Identify principles of surgical asepsis. TOP: Antiseptic Hand Wash KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is applying for a job at a local hospital. She wants to look her best for the interview
and decides to wear artificial nails. She does this knowing that artificial nails: a. are appropriate in the ICU setting as long as the nurse washes her hands frequently. b. can lead to fungal growth under the nail. c. can actually lower the bacterial count on the hands because they cover the natural nail. d. are banned only in areas where patients are critically ill. ANS: B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Numerous reports identify that fungal growth frequently occurs under artificial nails as a result of moisture becoming trapped between the natural nail and the artificial nail. Because of the risks for infection posed by artificial nail use, health care workers who have direct contact with patients at high risk (e.g., those in intensive care units or operating rooms) should not wear artificial nails. Health care workers who wear artificial nails or nail extenders are more likely to harbor gram-negative pathogens on their fingertips, both before and after handwashing. Many health care institutions have chosen to ban artificial nails and extenders in all clinical areas, with the rationale that all patients are at risk for infection. DIF: Cognitive Level: Application REF: Text reference: p. 182 OBJ: Identify principles of surgical asepsis. TOP: Artificial Nails KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. When removing the mask after an aseptic procedure, what should the nurse do first? a. Remove gloves. b. Untie top strings of mask. c. Untie bottom strings of mask. d. Untie top strings and let mask hang. ANS: A
Remove gloves first, if worn. This prevents contamination of hair, neck, and facial area by contaminants on gloves. Untie the top strings of the mask after untying the bottom strings. This prevents the top part of the mask from falling down over the clothing. If the mask falls and touches the clothing, it will be contaminated. DIF: Cognitive Level: Application REF: Text reference: p. 184 OBJ: Apply and remove a cap, mask, and eyewear correctly. TOP: Removing the Mask NpUleRmS KEY: Nursing Process Step: Im enI taN tioGnTB.COM MSC: NCLEX: Physiological Integrity 5. An appropriate principle of surgical asepsis is that: a. the entirety of a sterile package is sterile once it is opened. b. all of the draped table, top to bottom, is considered sterile. c. an object held below the waist is considered contaminated. d. if the sterile barrier field becomes wet, the dry areas are still sterile. ANS: C
A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated. Once a sterile package is opened, a 2.5-cm (1-inch) border around the edges is considered unsterile. Tables draped as part of a sterile field are considered sterile only at table level. A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated. DIF: Cognitive Level: Application REF: Text reference: p. 182 OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly. TOP: Sterile Field KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. A patient requires a sterile dressing change for a mid-abdominal surgical incision. An
appropriate intervention for the nurse to implement in maintaining sterile asepsis is to: a. put sterile gloves on before opening sterile packages.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. discard items that may have been in contact with the area below waist level. c. place the povidone-iodine bottle well within the sterile field. d. place sterile items on the very edge of the sterile drape. ANS: B
A sterile object held below a person’s waist is considered contaminated. To maintain sterile asepsis, discard items that may have been in contact with the area below waist level. Sterile gloves are not put on before opening sterile packages, because the outside of the package is not sterile. The nurse uses hand hygiene and opens sterile packages while being careful to keep the inner contents sterile. Povidone-iodine and chlorhexidine are not considered sterile solutions and require separate work surfaces for prepping. The edges of a sterile field are considered to be contaminated. Sterile items should be placed in the middle of the sterile field to maintain sterile asepsis. DIF: Cognitive Level: Application REF: Text reference: p. 182 OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly. TOP: Sterile Field KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. Which patient may the nurse suspect will be at risk for a latex allergy? a. Patient with food allergies b. Patient with diabetes c. Patient with arthritis d. Patient with hypertension ANS: A
Individuals at risk for latex aN llergRy inIcluG de tB e wiM of food allergies. Patients with C U SareNnot Thato.sincreased Oth a history diabetes, arthritis, and hypertension risk for latex allergies. DIF: Cognitive Level: Application REF: Text reference: p. 191 OBJ: Identify individuals at risk for latex allergy. TOP: Latex Allergy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. Which of the following is an appropriate technique for the nurse to use when performing
sterile gloving? a. Put the glove on the nondominant hand first. b. Interlock the hands after both gloves are applied. c. Pull the cuffs down on both gloves after gloving. d. Grasp the outside cuff of the other glove with the gloved hand. ANS: B
After the second glove is on, interlock the hands above waist level. Be sure to touch only sterile sides. Gloving of the dominant hand first improves dexterity. The cuffs usually fall down after application. With a gloved dominant hand, slip fingers underneath the second glove’s cuff. The cuff protects gloved fingers. Sterile touching sterile prevents glove contamination. DIF: Cognitive Level: Application REF: Text reference: p. 194 OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly. TOP: Applying Sterile Gloves KEY: Nursing Process Step: Implementation
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity 9. The nurse is preparing to insert a urinary catheter. The package is dry but shows signs of
yellowing inside the plastic wrapper, as if the package was wet at one time. What should the nurse do? a. Use the package because it is dry at present. b. Consider the outer package contaminated, but the inner package sterile. c. Discard the entire package as contaminated. d. Open the package and consider the 1-inch border as contaminated. ANS: C
A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated. If there is any question or doubt of an item’s sterility, the item is considered to be unsterile. Once a sterile package has been opened, a 2.5-cm (1-inch) border around the edges is considered unsterile. DIF: Cognitive Level: Application REF: Text reference: p. 186 OBJ: Explain the importance of organization and caution when using surgical aseptic techniques. TOP: Principles of Surgical Asepsis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. A type I hypersensitivity to latex is evident if the nurse assesses: a. localized swelling. b. skin redness and itching. c. runny eyes and nose and cough. d. tachycardia, hypotension, and wheezing. ANS: D
NURSINGTB.COM
Type I allergic reaction is a true latex allergy that can be life threatening. Reactions vary on the basis of the type of latex protein and the degree of individual sensitivity, including local and systemic. Symptoms include hives, generalized edema, itching, rash, wheezing, bronchospasm, difficulty breathing, laryngeal edema, diarrhea, nausea, hypotension, tachycardia, and respiratory or cardiac arrest. Type IV hypersensitivity is a cell-mediated allergic reaction to chemicals used in latex processing. Reaction, including redness, itching, and hives, can be delayed up to 48 hours. Localized swelling, red and itchy or runny eyes and nose, and coughing may develop. Irritant dermatitis is a nonallergic response characterized by skin redness and itching. DIF: Cognitive Level: Comprehension REF: Text reference: p. 191 OBJ: Identify individuals at risk for latex allergy. TOP: Levels of Latex Reactions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. A nurse is preparing a sterile field for a dressing change using surgical aseptic technique. The
nurse gathers supplies to prepare the sterile field using a packaged drape. Which option correctly describes how the nurse should set up the field? a. Don sterile gloves before opening the packaged drape. b. Clean the bottle of irrigation solution with alcohol before placing the bottle on the field. c. Avoid dropping sterile supplies close to the 1-inch border around the drape. d. Leave the sterile field unattended to obtain needed supplies.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: C
The exterior border of the sterile drape is presumed contaminated, so all supplies must be kept within the sterile portion. Dropping supplies too close to the 1-inch border risks having them bounce off the sterile area. Nonsterile supplies are never to be placed on the sterile field. The sterile field is never to be out of the nurse's line of sight. Sterile gloves will not be applied until the sterile field is set up, and items needed to deliver care are ready for use. Applying them earlier in the process risks having them become contaminated. DIF: Cognitive Level: Application REF: Text reference: pp. 187-190 OBJ: Prepare a sterile field and use a sterile drape correctly. TOP: Using Surgical Asepsis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Nurses commonly use surgical asepsis in which of the following situations? (Select all that
apply.) a. In labor and delivery areas b. When inserting an intravenous catheter c. When treating patients with surgical incisions or burns d. When inserting a urinary catheter e. When dressing a MRSA-positive wound ANS: A, B, C, D
Although nurses commonly practice surgical asepsis in operating rooms, labor and delivery areas, and major diagnostic or special procedure areas, they use surgical aseptic techniques at the patient’s bedside in threeN prim aryIsitG uation.sC : (1)Mduring procedures that require intentional URSinsertion N TBof O perforation of a patient’s skin (e.g., intravenous [IV] catheters), (2) when the skin’s integrity is broken as the result of a surgical incision or burns, and (3) during procedures that involve insertion of devices or surgical instruments into normally sterile body cavities (e.g., insertion of a urinary catheter). DIF: Cognitive Level: Application REF: Text reference: p. 181 OBJ: Discuss settings in which you will use surgical aseptic techniques. TOP: Surgical Asepsis KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 2. The patient has just had a tracheostomy tube placed and is expectorating copious amounts of
sputum that he coughs forcefully from his tracheostomy tube. The patient also is suspected of having methicillin-resistant Staphylococcus aureus (MRSA) in his sputum. The nurse is preparing to suction the patient to clear his airway. Which of the following will the nurse need to wear if following standard precautions? (Select all that apply.) a. Mask b. Goggles c. Gown d. Sterile gloves ANS: A, B, C, D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Standard precautions are used for potential contact with blood and all body fluids. The use of standard precautions calls for the wearing of masks in combination with eye protection devices such as goggles or glasses with solid side shields whenever splashes, spray, splatter, or droplets of blood or other potentially infectious fluids may occur. These barriers keep the eyes, nose, and mouth free from exposure. Similarly, you wear gowns when there is risk of being splattered with blood or other infectious materials. All health care institutions need to provide to all employees at risk for exposure personal protective equipment and instructions for its use. DIF: Cognitive Level: Synthesis REF: Text reference: p. 182 OBJ: Identify principles of surgical asepsis. TOP: Standard Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. A sterile field consists of which of the following? (Select all that apply.) a. Sterile tray b. Work surface draped with a sterile towel c. Table covered by a large sterile drape d. Patient’s bedside table ANS: A, B, C
A sterile field may consist of a sterile kit or tray, a work surface draped with a sterile towel or wrapper, or a table covered with a large sterile drape. A patient’s bedside table is not sterile but can be a work surface where a sterile field can be applied. DIF: Cognitive Level: Application REF: Text reference: p. 186 OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a TOP: Sterile Field sterile field, applying a sterile dN rape rectl URcor SI NGy.TB.C OM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1.
is one practice designed to make and maintain objects and areas free from pathogenic microorganisms. ANS: Surgical asepsis
Surgical asepsis or aseptic techniques and practices are designed to make and maintain objects and areas free from pathogenic microorganisms. DIF: Cognitive Level: Comprehension REF: Text reference: p. 181 OBJ: Describe conditions when you use surgical asepsis. TOP: Surgical Asepsis KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 2. The minimum standard for infection control as established by the Centers for Disease Control
and Prevention (CDC) is ANS:
standard precautions
.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The Centers for Disease Control and Prevention has established standard precautions as the minimum standard for infection control. Standard precautions are used for potential contact with blood and all body fluids. DIF: Cognitive Level: Knowledge REF: Text reference: p. 182 OBJ: Discuss settings in which you will use surgical aseptic techniques. TOP: Standard Precautions KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 3. When performing sterile aseptic procedures, the nurse must create a
in which
objects can be handled with minimal risk for contamination. ANS:
sterile field When performing sterile aseptic procedures, the nurse must have a work area in which objects can be handled with minimal risk for contamination. A sterile field serves such a purpose. DIF: Cognitive Level: Application REF: Text reference: p. 186 OBJ: Perform the following skills: applying sterile gloves using open glove method, preparing a sterile field, applying a sterile drape correctly. TOP: Sterile Field KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity OTHER 1. Which is the appropriate sequence to use when applying sterile attire?
A. B. C. D. E. F.
Apply sterile gloves. NURSINGTB.COM Secure hair. Don protective eyewear. Apply hair cover. Wash hands. Apply mask.
ANS:
E, B, D, F, C, A The correct sequence is wash hands, secure hair, apply hair cover, apply mask, don protective eyewear, apply sterile gloves. DIF: Cognitive Level: Application REF: Text reference: pp. 183-184 OBJ: Don sterile attire. TOP: Sterile Attire KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 9: Safe Patient Handling, Transfer, and Positioning MULTIPLE CHOICE 1. A nurse should be aware of safety measures to prevent personal injury when lifting or moving
patients. An appropriate principle to follow is: a. bend at the waist for lifting. b. tighten the stomach muscles and pelvis. c. keep the weight to be lifted away from the body. d. carry or hold the weight 1 to 2 feet above the waist. ANS: B
Tighten the stomach muscles and tuck the pelvis; this provides balance and protects the back. Bend at the knees; this helps to maintain the nurse’s center of gravity and lets the strong muscles of the legs do the lifting. Keep the weight to be lifted as close to the body as possible; this action places the weight in the same plane as the lifter and close to the center of gravity for balance. DIF: Cognitive Level: Application REF: Text reference: p. 197 OBJ: Describe principles of safe patient transfer and positioning. TOP: Principles of Lifting KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop. b. pressure ulcers. c. musculoskeletal disorderN s. URSINGTB.COM d. contractures. ANS: C
Musculoskeletal disorders are the most prevalent and debilitating occupational health hazard among nurses. Little improvement has been noted in the incidence of musculoskeletal injuries among health care workers. In 1989, 4.2 lost-workday injury cases per 100 were reported; in 2000, 4.1 cases per 100 were reported. Plantar flexion contracture or footdrop is a complication seen in bedridden patients. Pressure ulcers and contractures are complications that can develop in patients who do not maintain correct body alignment. DIF: Cognitive Level: Comprehension REF: Text reference: p. 198 OBJ: Describe body mechanics and its importance in caring for patients. TOP: Risks for Nurses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The patient is an elderly male with severe kyphosis who is immobile from a stroke several
years earlier. He has been admitted for severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize? a. This patient should be turned onto his back for meals. b. This patient may have to be turned more frequently than every 2 hours. c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort. d. Skin breakdown is not an issue for this patient.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: B
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema may require more frequent position changes because patients are prone to skin breakdown. DIF: Cognitive Level: Application REF: Text reference: p. 198 OBJ: Describe principles of safe patient transfer and positioning. TOP: Repositioning KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. Why does a nurse move a patient who has been confined to bed for a few days slowly from a
sitting to a standing position? a. Fatigue b. Muscle injury c. Sensory disorientation d. Orthostatic hypotension ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop in blood pressure) when transferred. DIF: Cognitive Level: Comprehension REF: Text reference: p. 199 OBJ: Describe principles of safe patient transfer and positioning. TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IN ntegR rityI G B.C M
U S N T
O
5. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual
has the greatest potential for injury during transfers? a. Diabetes mellitus b. Myocardial infarction c. A cerebrovascular accident d. An upper extremity fracture ANS: C
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus, myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury. DIF: Cognitive Level: Application REF: Text reference: p. 198 OBJ: Describe procedures for safely lifting patients. TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the bed. b. Raise the head of the bed 30 degrees. c. Turn the patient onto the side facing away from the nurse. d. Move the patient’s legs over the side of the bed.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is raised and the patient is turned to face the nurse. DIF: Cognitive Level: Application REF: Text reference: p. 201 OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and transferring a patient from a bed to a chair. TOP: Assisting Patient to a Sitting Position on Side of Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a
chair, what should the nurse do? a. Grab the patient under the axilla to lift. b. Have the patient move forward with the weak side. c. Have the patient put on shoes with nonskid soles. d. Place the chair in a position 90 degrees opposite the bed. ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Always have the patient wear shoes during transfer; bare feet increase the risk for falls. A transfer belt allows the nurse to maintain stability of the patient during transfer and reduces the risk of falling. A transfer belt provides movement of the patient at the center of gravity. Patients should never be lifted by or under the arms. If the patient demonstrates weakness or paralysis of oneN siU deRoSfI thN eG boTdB y,.pC laO ceMa chair on the patient’s strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed. DIF: Cognitive Level: Application REF: Text reference: p. 203 OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and transferring a patient from a bed to a chair. TOP: Assisting Patient to a Sitting Position on Side of Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to
assist. Of the following, which would be the best technique for transferring the patient? a. Using three nurses and a slide board b. Using the three-person lift technique c. Raising the head 30 degrees d. Having the patient keeps arms to the side ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during transfer. DIF: Cognitive Level: Application REF: Text reference: pp. 205-206 OBJ: Describe principles of safe patient transfer and positioning. TOP: Normal Body Alignment for Sitting Position KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. An appropriate technique for the nurse to implement when moving a patient out of bed to a
chair with a mechanical lift is to: a. lower the height of the bed. b. lower the head of the bed. c. place the sling from shoulders to knees. d. deep the check valve open when the patient is seated in the chair. ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left open, the boom may continue to lower and injure the patient. DIF: Cognitive Level: ApplicN atiU onRSINGRT EB F:.C TeO xtMreference: pp. 207-208 OBJ: Describe principles of safe patient transfer and positioning. TOP: Normal Body Alignment for Sitting Position KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. When preparing to move a patient in bed, the nurse should: a. expect that the patient’s comfort level will decrease. b. make sure that all pillows used in the previous position stay in position. c. raise the bed to a comfortable working height. d. plan on moving the patient herself because other nurses are busy. ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety. DIF: Cognitive Level: Application REF: Text reference: p. 211 OBJ: Describe principles of safe patient transfer and positioning. TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 11. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed. b. start by flexing the patient’s knees and hips. c. place a pillow under the patient’s shoulders. d. instruct the patient to inhale and hold still. ANS: B
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out, thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver. DIF: Cognitive Level: Application REF: Text reference: p. 212 OBJ: Describe principles of safe patient transfer and positioning. TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished,
the patient is in a supported Fowler’s position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with pillows. G B.C M N R I b. place a large pillow behindUhisS heaN d toTprevenO t extension. c. place a pillow behind his upper back. d. avoid using pillows if the patient does not have use of the hands and arms. ANS: A
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment. Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion contractures of arms and wrists. DIF: Cognitive Level: Application REF: Text reference: p. 213 OBJ: Describe principles of safe patient transfer and positioning. TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. To position a patient with hemiplegia in Fowler’s position, the nurse should: a. elevate the head of the bed 15 to 30 degrees. b. place the patient in the prone position. c. position a spastic hand with the fingers extended using hand rolls.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. position the patient’s head with slight hyperextension of the neck. ANS: C
Position a spastic hand with the wrist in neutral position or slightly extended; fingers should be extended with the palm down or may be left in relaxed position with the palm up. Position the patient in supine position. Elevate the head of the bed 45 to 60 degrees. This increases comfort, improves ventilation, and increases the patient’s opportunity to relax. Adjust the head of the bed according to the patient’s condition. For example, those with increased risk for pressure ulcers will remain at a 30-degree angle. Position the head on a small pillow with the chin slightly forward. If the patient is totally unable to control head movement, avoid hyperextension of the neck. Too many pillows under the head may cause or worsen neck flexion contracture. DIF: Cognitive Level: Application REF: Text reference: p. 214 OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions. TOP: Supporting a Hemiplegic Patient in Fowler’s Position KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. In positioning the patient in the prone position, one way to improve breathing is to: a. support the arms in a flexed position level at the shoulders. b. place a pillow under the lower legs. c. place a small pillow under the patient’s abdomen. d. support the patient’s head with a small pillow. ANS: C
Placing a small pillow underN the R patiI ent’G s abBd. omenMbelow the level of the diaphragm reduces S Npatients T Cand O decreases hyperextension of the lumbar pressure on the breasts of someUfemale vertebrae and strain on the lower back; it also improves breathing by reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose. DIF: Cognitive Level: Application REF: Text reference: pp. 214-215 OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions. TOP: Hand Rolls KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. A postoperative patient has been instructed by a nurse about the importance of moving in bed
but is still avoiding movement. The nurse should: a. avoid moving the patient until he or she is motivated. b. have family members move the patient around. c. decrease the frequency of movement to be performed. d. medicate the patient with a prescribed analgesic before moving. ANS: D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving. Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility. DIF: Cognitive Level: Application REF: Text reference: p. 200 OBJ: Describe principles of safe patient transfer and positioning. TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The patient is an elderly man who has just been admitted for a probable cerebrovascular
accident. The patient is nonverbal and does not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on his right side continuously because he seems comfortable. b. prevent the patient from lying on his right side until he no longer wishes to lie on that side. c. frequently assess the patient and turn him more frequently. d. allow the patient to lie on his right side until a pressure ulcer develops and he can no longer lie on that side. ANS: C
Patients who have maintained bed rest for a long time may revert back to a favorite position. Ns, RanSdItuNrnGT B.CoreMoften as needed. Not turning them places Frequently assess these patientU them mO them at greater risk for complications of immobility. Not allowing the patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of assessment and turning is to prevent complications of immobility. DIF: Cognitive Level: Analysis REF: Text reference: p. 198 |Text reference: pp. 210-211 |Text reference: p. 218 OBJ: Describe principles of safe patient transfer and positioning. TOP: Turning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse is preparing to reposition the patient. Which of the following is a principle of safe
patient transfer and positioning? a. The wider the base of support, the greater the stability of the nurse. b. The higher the center of gravity, the greater the stability of the nurse. c. Facing in the opposite direction of movement prevents twisting. d. Using either the arms or the legs reduces the risk for back injury. ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs reduces the risk for back injury.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Comprehension REF: Text reference: p. 198 OBJ: Describe principles of safe patient transfer and positioning. TOP: Principles of Safe Patient Transfer and Positioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse
place the trochanter roll? a. Under the small of the back b. Behind the knees when supine c. Alongside the ilium to mid-thigh d. In the palm of the hand with fingers flexed ANS: C
The nurse should place the trochanter roll alongside the ilium to mid-thigh. The trochanter roll is a rolled wedge, pillow, or sandbag placed by the lateral aspect of the leg between the iliac crest and the knees to prevent external hip rotation. DIF: Cognitive Level: Application REF: Text reference: pp. 213-214 OBJ: Describe the use of the trochanter. TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Patients at risk for complications and/or injury from improper positioning include patients
with which of the following? (Select all that apply.) NURSINGTB.COM a. Poor nutrition b. Loss of sensation c. Impaired muscle development d. Poor circulation ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer. Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility, and impaired muscle development. DIF: Cognitive Level: Comprehension REF: Text reference: p. 198 OBJ: Describe body mechanics and its importance in caring for patients. TOP: Risks for Complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible.
This is because the nurse realizes that mobilization: (Select all that apply.) a. improves joint motion. b. decreases circulation. c. increases social activity. d. enhances mental stimulation. ANS: A, C, D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation. DIF: Cognitive Level: Analysis REF: Text reference: pp. 210-211 OBJ: Describe principles of safe patient transfer and positioning. TOP: Mobilization KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse prevents self-injury by using which of the following when transferring a patient?
(Select all that apply.) a. Correct posture b. Maximal muscle strength c. Effective body mechanics d. Effective lifting techniques ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting techniques. Consider individual patient problems during transfer. DIF: Cognitive Level: Comprehension REF: Text reference: p. 199 OBJ: Describe principles of safe patient transfer and positioning. TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
NURSINGTB.COM
4. Proper alignment for a patient in sitting position includes which of the following? (Select all
that apply.) a. Head erect b. Four-inch space between edge of seat and popliteal space c. Vertebrae straight d. Both feet elevated ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee. DIF: Cognitive Level: Application REF: Text reference: p. 205 OBJ: Describe normal body alignment for standing, sitting, and lying down. TOP: Normal Body Alignment for Sitting Position KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. Which of the following risk factors contribute to complications of immobility? (Select all that
apply.) a. Paralysis b. Traction c. Arterial insufficiency
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. Incontinence e. Constipation ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological changes associated with aging predispose older adults to greater risks for developing complications of immobility. DIF: Cognitive Level: Comprehension REF: Text reference: p. 211 OBJ: Describe principles of safe patient transfer and positioning. TOP: Risk Factors That Contribute to Complications of Immobility KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. Positioning of patients to maintain correct body alignment is essential to prevent which of the
following complications? (Select all that apply.) a. Thrombus b. Pressure ulcer c. Kyphosis d. Contractures ANS: B, D
Positioning of patients to maN inta inS cI orre ctT bB od.yCalig R G Mnment is essential in preventing U N O complications. These complications include pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. DIF: Cognitive Level: Comprehension REF: Text reference: p. 198 OBJ: Describe body mechanics and its importance in caring for patients. TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION 1. The coordinated effort of the musculoskeletal and nervous systems in maintaining balance,
posture, and body alignment is known as
.
ANS:
body mechanics Body mechanics is the coordinated effort of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment during lifting, bending, moving, and performing activities of daily living. Body mechanics also facilitates body movement so that a person can carry out a physical activity without using excessive muscle energy. DIF: Cognitive Level: Comprehension
REF: Text reference: p. 198
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Describe body mechanics and its importance in caring for patients. TOP: Body Mechanics KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Plantar flexion contracture, otherwise known as
, is caused when the force of gravity pulls an unsupported, weakened foot into a plantar-flexed position. ANS:
footdrop Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at walking. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 213-214 OBJ: Describe body mechanics and its importance in caring for patients. TOP: Footdrop KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility
to attain positions to regain optimal independence is known as
.
ANS:
transferring Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to regain optimal independence as quickly as possible. DIF: Cognitive Level: Comprehension REF: Text reference: p. 199 OBJ: Describe principles of saN feUpR atien trG ansf er. anC dO poMsitioning. SIt N TB TOP: Transferring KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. Awareness of posture and changes in equilibrium is known as
.
ANS:
proprioceptive function Assess the patient’s proprioceptive function (awareness of posture and changes in equilibrium). Determine the stability of the patient’s balance for transfer. DIF: Cognitive Level: Comprehension REF: Text reference: p. 200 OBJ: Assess for alterations in body alignment. TOP: Proprioceptive Function KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The term
_ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. ANS:
body alignment The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures. DIF: Cognitive Level: Knowledge
REF: Text reference: p. 210
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Describe principles of safe patient transfer and positioning. TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. Body balance is achieved when a wide
exists.
ANS:
base of support Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical line can be drawn from the center of gravity through the base of support. DIF: Cognitive Level: Comprehension REF: Text reference: p. 210 OBJ: Describe principles of safe patient transfer and positioning. TOP: Base of Support KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The patient is immobile and is being placed in the supine position. To reduce extension of the
fingers and abduction of the thumb, the nurse places hands.
in the patient’s
ANS:
hand rolls For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in opposition to the fingers. DIF: Cognitive Level: ApplicN ation F:.C Text URSINGRE TB OMreference: p. 214 OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and transferring a patient from a bed to a chair. TOP: Hand Rolls KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 10: Exercise and Ambulation MULTIPLE CHOICE 1. The patient has been admitted for hypertension. His blood pressure is normally in the 160/90
range. He has been on bed rest for the past few days, and the doctor has started him on a new blood pressure medication. The nurse is assisting the patient to move from the bed to the chair for breakfast, but when the patient tries to sit up on the side of the bed, he complains of being dizzy and nauseous. The nurse lays the patient down and takes his vital signs. His pulse is 124. His blood pressure is 130/80. This blood pressure is indicative of what? a. A normal blood pressure for this patient b. Orthostatic hypotension c. Orthostatic hypertension d. Effective baroreceptor function ANS: B
Orthostatic hypotension is a drop in blood pressure that occurs when the patient changes from a horizontal to a vertical position. It traditionally is defined as a drop in systolic or diastolic blood pressure of 20 or 10 mm Hg, respectively. Those at higher risk are immobilized patients, those undergoing prolonged bed rest, the older adult patient, those receiving antihypertensive medications, and those with chronic illness, such as diabetes mellitus or cardiovascular disease. Signs and symptoms of orthostatic hypotension include dizziness, light-headedness, nausea, tachycardia, pallor, and even fainting. Orthostatic hypertension would be an increase in blood pressure. Physiological changes associated with aging and prolonged bed rest may reduce the effectiveness of the baroreceptors. In these patients, moving to the dangling positN ion R mayIcauGse B a g.rC avitM y-induced drop in blood pressure; thus, it U of S the N bed T and O a few minutes before dangling. is recommended to raise the head allow DIF: Cognitive Level: Analysis REF: Text reference: p. 236 OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation. TOP: Orthostatic Hypotension KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The patient is an elderly gentleman who has been on bed rest for the past several days. When
getting the patient up, the nurse should: a. tell the patient not to move his legs when dangling. b. tell the patient to hold his breath while dangling. c. raise the head of the bed and allow a few minutes before dangling. d. have the patient stand without dangling. ANS: C
Physiological changes associated with aging and prolonged bed rest may influence the effectiveness of the baroreceptors. For these patients, moving to the dangling position may cause a gravity-induced drop in blood pressure; thus, it is recommended to raise the head of the bed and allow a few minutes before dangling. Interventions to minimize orthostatic hypotension include movement of the legs and feet in the dangling position to promote venous return via intermittent contraction and relaxation of the skeletal leg muscles, and asking the patient to take several deep breaths before and during dangling. Dangling a patient before standing is an intermediate step that allows assessment of the individual before changing positions to maintain safety and prevent injury to the patient.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Application REF: Text reference: p. 236 OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation. TOP: Dangling KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. An appropriate technique for the nurse to use when performing range of motion (ROM)
exercises is to: a. repeat each action five times during the exercise. b. perform the exercises quickly and firmly. c. support the proximal portion of the extremity being exercised. d. continue the exercise slightly beyond the point of resistance. ANS: A
Each movement should be repeated five times during an exercise period. Be sure that ROM exercises are performed slowly and gently. When performing active-assisted or passive ROM exercises, support the joint by holding the distal portion of the extremity, or by using a cupped hand to support the joint. Discontinue exercise if the patient complains of discomfort, or if you note resistance or muscle spasm. DIF: Cognitive Level: Application REF: Text reference: p. 223 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Range of Motion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. A patient is admitted to the mNediR cal I unitGfollB o. wiC ng M a cerebrovascular accident (CVA).
U Sis noted, N T and the O nurse will be following up on ROM and Evidence of left-sided hemiparesis other exercises performed in physical therapy. The nurse should correctly teach the patient and family members which of the following principles of ROM exercises? a. Flex the joint to the point of discomfort. b. Medicate the patient after the ROM exercise session. c. Move the joints quickly. d. Provide support for distal joints. ANS: D
When performing active-assisted or passive ROM exercises, support the joint by holding the distal portion of the extremity, or by using a cupped hand to support the joint. The joint should be flexed to the point of resistance, not to the point of discomfort. Assess the patient’s level of comfort (on a scale of 0 to 10, with 10 being the worst pain) before performing exercises. Before beginning ROM exercises, determine whether the patient would benefit from pain medication. Joints should be moved slowly through the ROM. Quick movement could cause injury. DIF: Cognitive Level: Application REF: Text reference: p. 222 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Range of Motion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 5. A nurse should be concerned when observing a patient performing isometric exercises if the
patient is: a. holding his or her breath while exerting. b. performing the exercises four times per day. c. tightening each muscle group for 8 seconds, then relaxing. d. repeating each exercise 8 to 10 times for each muscle group. ANS: A
Patients doing isometric exercises should be taught to exhale while exerting effort. Many persons hold their breath (Valsalva maneuver), which increases intrathoracic pressure, causing a decrease in venous return to the heart. Each exercise prescription is individualized according to the patient’s needs and limitations. Gradual buildup of exercise repetitions improves both muscle strength and endurance. Hold the muscles tightly contracted for 5 to 15 seconds, and then relax completely for several seconds. DIF: Cognitive Level: Application REF: Text reference: p. 228 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Isometric Exercises KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 6. A nurse encourages a patient to prevent venous stasis by: a. crossing the legs when sitting in a chair. b. wearing thigh-length nylon stockings or garters. c. elevating the legs on pillows while in bed. d. increasing early ambulation. ANS: D
NURSINGTB.COM
Prevention is the best method to reduce the risk for deep vein thrombosis (DVT) secondary to immobility. Early ambulation remains the most effective preventive measure. Discourage patients from activities that promote venous stasis (e.g., crossing legs, wearing garters, elevating legs on pillows). DIF: Cognitive Level: Comprehension REF: Text reference: p. 234 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Venous Stasis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. Antiembolic stockings (TEDs) are ordered for the patient on bed rest after surgery. The nurse
explains to the patient that the primary purpose for the elastic stockings is to: a. keep the skin warm and dry. b. prevent abnormal joint flexion. c. apply external pressure. d. prevent bleeding. ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The primary purpose of TEDs is to maintain external pressure on the muscles of the lower extremities and thus promote venous return. The primary purpose of TEDs is not to keep the skin warm and dry, prevent abnormal joint flexion, or prevent bleeding. They are used to prevent clot formation due to venous stasis. DIF: Cognitive Level: Comprehension REF: Text reference: p. 234 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Antiembolic Stockings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. When assessing the patient for risk for DVT, the nurse should consider which of the following
an indicator of increased risk? a. A positive Homans’ sign b. Pallor to the distal area c. Edema noted in the extremity d. Fever or dehydration ANS: D
Indicators in Virchow’s triad include clotting disorders, fever, and dehydration. Additionally, a swollen extremity, pain, and warm cyanotic skin, indicate an elevated risk. Less than 20% of patients exhibit a positive Homans’ sign. Edema of the extremity may or may not occur. DIF: Cognitive Level: Application REF: Text reference: p. 234 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, andNappR gs and SCD. U lyin SIg ela NGstic TBst.ocCkinOM TOP: DVT KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. An appropriate procedure for the nurse to use when applying an elastic stocking is to: a. remove the stockings every 24 hours. b. keep the tops of the stockings rolled down slightly. c. turn the stocking inside out to apply from the toes up. d. wash stockings daily and dry in a dryer. ANS: C
Turn elastic stocking inside out by placing one hand into the sock, holding the toe of the sock with the other hand, and pulling. This allows easier application of the stocking. Elastic stockings should be removed and reapplied at least twice a day. Instruct the patient not to roll the socks partially down. Rolling the socks partially down has a constricting effect and can impede venous return. Instruct the patient to launder elastic stockings every 2 days with mild detergent and lay flat to dry. DIF: Cognitive Level: Application REF: Text reference: pp. 234-235 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Applying Elastic Stockings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 10. When using an SCD, the nurse should: a. apply powder to the patient’s skin if redness and itching are present. b. leave a two-finger space between the patient’s leg and the compression stocking. c. keep the patient connected to the compression device when transferring into and
out of bed. d. remove the elastic stockings before putting on the sequential pneumatic
compression stockings. ANS: B
Check the fit of SCD sleeves by placing two fingers between the patient’s leg and the sleeve. Observe for signs, symptoms, and conditions that might contraindicate the use of elastic stockings or SCD: Elastic stockings and SCD sleeves may aggravate a skin condition or cause it to spread. Remove SCD sleeves when transferring the patient into and out of bed to prevent injury. If the patient is wearing elastic stockings, eliminate any wrinkles and folds before applying SCD sleeves. Wrinkles lead to increased pressure and alter circulation. DIF: Cognitive Level: Comprehension REF: Text reference: p. 235 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Applying SCD Sleeves KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The patient is a paraplegic who possesses good arm and hand strength. When the following
devices are compared, which would be most appropriate for this patient? a. Axillary crutch b. Platform crutch NURSINGTB.COM c. Lofstrand crutch d. Standard crook cane ANS: C
The Lofstrand crutch has a handgrip and a metal band that fits around the patient’s forearm. Both the metal band and the handgrip are adjusted to fit the patient’s height. This type of crutch is useful for patients with a permanent disability such as paraplegia. The axillary crutch frequently is used by patients of all ages on a short-term basis. The platform crutch is used by patients who are unable to bear weight on their wrists. It has a horizontal trough on which patients can rest their forearms and wrists and a vertical handle for the patient to grip. The standard crook cane provides the least support and is used by patients who require only minimal assistance to walk. DIF: Cognitive Level: Analysis REF: Text reference: p. 237 OBJ: Develop teaching plans for selected patients for safety precautions to use at home while using an ambulation aid, applying and monitoring effects of elastic stockings and SCDs, using the CPM, and performing ROM and isometric exercises. TOP: Crutches KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. An appropriate way for the nurse to measure a patient for crutches is to: a. have a flexion of 45 degrees at both of the patient’s elbows. b. have a space of two to three fingers between the top of the crutch and the axilla. c. place the crutch tips 1 foot to each side of the patient’s feet, and observe the
positioning of the crutches.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. place the crutch tips 1 foot to the front of the patient’s feet, and observe the
positioning of the crutches. ANS: B
Following correct crutch adjustment, two to three fingers should fit between the top of the crutch and the axilla. Following correct crutch adjustment, elbows should be flexed 15 to 30 degrees. Elbow flexion is verified with a goniometer. Position the crutches with the crutch tips at 6 inches (15 cm) to the side and 6 inches in front of the patient’s feet, and the crutch pads 2 inches (5 cm) below the axilla. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 239-240 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Crutches KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. The patient has been using crutches for the past 2 weeks. When she comes for her follow-up
examination, she complains of tingling and numbness in her hands and upper torso. Possible causes of these symptoms are: a. the patient’s elbows are flexed 15 to 30 degrees when using the crutches. b. crutch pad is approximately 2 inches below the patient’s axilla. c. patient holds the cane 4 to 6 inches to the side of her foot. d. handgrip does not allow for elbow flexion. ANS: D
Instruct the patient to report any tingling or numbness in the upper torso, which may mean that the crutches are being usN ed iR ncoI rrectly, B or that M they are the wrong size. If the handgrip is U occur S NG T if.C O crutch length is correct, because the too low, radial nerve damage can even overall extra length between the handgrip and the axillary bar can force the bar up into the axilla as the patient stretches down to reach the handgrip. After correct crutch adjustment, two to three fingers must fit between the top of the crutch and the axilla. Adequate space prevents crutch palsy. Proper fit is when the crutch pad is approximately 2 inches or two to three finger widths under the axilla, with the crutch tips positioned 6 inches (15 cm) lateral to the patient’s heel. DIF: Cognitive Level: Analysis REF: Text reference: p. 239 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Crutches KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. The patient has a leg injury and is being fitted for a cane. The patient should be taught to: a. hold the cane on the uninvolved side. b. hold the cane on the weaker side. c. extend the cane 15 inches from the foot when used. d. maintain approximately 60 degrees of elbow flexion. ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The patient holds the cane on the uninvolved side, 4 to 6 inches (10 to 15 cm) to the side of the foot. This offers the most support when the cane is placed on the stronger side of the body. The cane and the weaker leg work together with each step. The cane extends from the greater trochanter to the floor while the cane is held 6 inches (15 cm) from the foot. Allow approximately 15 to 30 degrees of elbow flexion. As weight is taken on by the hand and the affected leg is lifted off the floor, complete extension of the elbow is necessary. DIF: Cognitive Level: Comprehension REF: Text reference: p. 245 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Cane Measurement KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. While ambulating, the patient becomes light-headed and starts to fall. What should the nurse
do first? a. Call for help. b. Try to reach for a chair. c. Ease the patient down to the floor. d. Push the patient back toward the bed. ANS: C
If the patient begins to fall, gently ease the patient to the floor by holding firmly onto the gait belt; stand with the feet apart to provide a broad base of support, extend the leg, and let the patient gently slide to the floor. As the patient slides, the nurse bends the knees to lower the body. The nurse can cause more damage to self and patient by trying to catch the patient. The nurse certainly will call for help, but this is not the first priority. The nurse must ensure M to the floor. the patient’s safety before geN ttiU ngRhSeI lpNbG yT eaB si. ngChOim DIF: Cognitive Level: Application REF: Text reference: p. 240 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Patient Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. When the four gaits listed below are compared, which is the most stable of the crutch gaits? a. Four-point gait b. Three-point gait c. Two-point gait d. Swing-to gait ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Four-point gait is the most stable of crutch gaits because it provides at least three points of support at all times. The patient must be able to bear weight on both legs. Each leg is moved alternately with each opposing crutch, so that three points of support are on the floor all the time. This gait is often used when the patient has some form of paralysis, such as for spastic children with cerebral palsy. This is less stable than four-point gait because it requires the patient to bear all weight on one foot. Weight is borne on the uninvolved leg and then on both crutches. The affected leg does not touch the ground during the early phase of three-point gait. This gait may be useful for patients with a broken leg or a sprained ankle. This is less stable than four-point gait because it requires at least partial weight bearing on each foot. It is faster than four-point gait and requires better balance because only two points support the body at any one time. This is the easier of the two swinging gaits. It is less stable than four-point gait because it requires the ability to partially bear body weight on both legs. This gait is frequently used by patients whose lower extremities are paralyzed, or who wear weight-supporting braces on their legs. DIF: Cognitive Level: Analysis REF: Text reference: pp. 241-242 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Crutch Gaits KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse is caring for a patient who has just been treated for a broken leg. She needs to teach
the patient how to use crutches. Which crutch gait is most appropriate for this patient? a. Four-point gait b. Three-point gait c. Two-point gait NURSINGTB.COM d. Swing-to gait ANS: B
The three-point gait requires the patient to bear all weight on one foot. Weight is borne on the uninvolved leg and then on both crutches. The affected leg does not touch the ground during the early phase of three-point gait. It is useful for patients with a broken leg or a sprained ankle. The four-point gait is the most stable of crutch gaits because it provides at least three points of support at all times. The patient must be able to bear weight on both legs. Each leg is moved alternately with each opposing crutch, so that three points of support are on the floor all the time. The two-point is used when the patient has some form of paralysis, such as for spastic children with cerebral palsy. This gait requires at least partial weight bearing on each foot. It requires better balance because only two points support the body at one time. This is the easier of the two swinging gaits. It requires the ability to partially bear body weight on both legs. The swing-to gait is used by patients whose lower extremities are paralyzed, or who wear weight-supporting braces on their legs. DIF: Cognitive Level: Analysis REF: Text reference: pp. 241-242 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Crutch Gaits KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 18. When teaching the use of a three-point crutch gait, the nurse should instruct the patient to
move: a. both crutches and the affected leg first, then the stronger leg. b. the right crutch, left foot, left crutch, and right foot in sequence. c. the left crutch and right foot, then move the right crutch and left foot. d. both crutches, then lift and swing the legs forward as far as the crutches. ANS: A
The proper sequence for the three-point crutch gait is: begin in tripod position, advance both crutches and the affected leg, and then move the stronger leg forward, stepping on the floor. This is the proper sequence for the four-point gait, the two-point gait, and the swing-to gait. DIF: Cognitive Level: Comprehension REF: Text reference: p. 241 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Crutch Gaits KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. A patient with left hemiparesis is using a quad cane for ambulation. Which of the following is
the correct technique for the nurse to use in teaching the patient? a. Use the cane on the right side, with the cane moving forward first. b. Use the cane on the left side, with the left leg moving forward with the cane. c. Use the cane in either hand, with the right leg moving forward first. d. Use the cane in either hand, with the left leg moving beyond the forward placement of the cane. ANS: A
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To correctly use a quad cane, the patient places the cane on the side opposite the involved leg. This provides added support for the weak or impaired side. Ambulation then begins by moving the cane forward 6 to 10 inches (15 to 25 cm), keeping body weight on both legs. The weak leg is then brought forward even with the cane while the body weight is supported by the strong leg and the cane. The strong leg is then advanced past the cane. Moving a leg and the cane forward at the same time will compromise balance and increase risk of fall. DIF: Cognitive Level: Comprehension REF: Text reference: p. 245 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Ambulation With a Cane KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The patient had a stroke and is currently immobile. The nurse realizes that increasing mobility
is critical because immobility can result in alterations in which of the following? (Select all that apply.) a. Cardiovascular function b. Pulmonary function c. Skin integrity d. Elimination
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS: A, B, C, D
When mobility is altered, many body systems are at risk for impairment. Impaired mobility can result in altered cardiovascular functioning, disruption of normal metabolic functioning, increased risk for pulmonary complications, the development of pressure ulcers, and urinary elimination alterations. DIF: Cognitive Level: Comprehension REF: Text reference: p. 221 OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation. TOP: Complications of Immobility KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is caring for an immobile patient. Which of the following may help reduce the
hazards associated with immobility? (Select all that apply.) a. A high-fiber diet b. Frequent repositioning c. Muscle and joint exercises d. Increased fluid intake ANS: A, B, C, D
Frequent repositioning, deep breathing and coughing exercises, muscle and joint exercises, increased fluid intake, and dietary intake of foods containing fiber are examples of measures that help to reduce the hazards of immobility. DIF: Cognitive Level: Comprehension REF: Text reference: p. 221 OBJ: Discuss the hazards of immobility. TOP: Prevention of Complications of Immobility KEY: Nursing Process Step: Implementation G B.C M MSC: NCLEX: Physiological Integrity
N UR SI N T
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3. The nurse is applying a CPM machine to the patient’s leg. To do so, she must: (Select all that
apply.) a. provide analgesia 1 hour before starting the CPM. b. stop the CPM when in extension and place a sheepskin on the machine. c. align the patient’s joint with the CPM’s mechanical joint. d. secure the patient’s extremity tightly with Velcro straps. ANS: B, C
Provide analgesia 20 to 30 minutes before CPM is needed. Stop the CPM when in extension. Place sheepskin on the CPM to ensure that all exposed hard surfaces are padded to prevent rubbing and chafing of the patient’s skin. Align the patient’s joint with the mechanical joint of the CPM. DIF: Cognitive Level: Application REF: Text reference: p. 232 OBJ: Identify significant assessment data to be noted before and during the use of a machine. TOP: CPM Machine KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Factors that contribute to the development of DVT are: (Select all that apply.) a. elevated sodium (Na+) levels. b. hypercoagulability of the blood. c. venous wall damage. d. stasis of blood flow.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: B, C, D
Three elements (commonly referred to as Virchow’s triad) contribute to the development of DVT: hypercoagulability of the blood, venous wall damage, and stasis of blood flow. DIF: Cognitive Level: Comprehension REF: Text reference: p. 234 OBJ: Understand the pathophysiology of the development of DVTs. TOP: Deep Vein Thrombosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION
refers to an ability to move about freely.
1. ANS:
Mobility Mobility refers to an ability to move about freely. DIF: Cognitive Level: Knowledge REF: Text reference: p. 221 OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation. TOP: Mobility KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. A person’s inability to move about freely is known as
.
ANS:
immobility Immobility refers to a person’s inability to move about freely.
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DIF: Cognitive Level: Knowledge REF: Text reference: p. 221 OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation. TOP: Immobility KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. A drop in blood pressure that occurs when the patient changes position from a horizontal to a
vertical position is known as
.
ANS:
orthostatic hypotension Orthostatic hypotension is a drop in blood pressure that occurs when the patient changes position from a horizontal to a vertical position. DIF: Cognitive Level: Comprehension REF: Text reference: p. 236 OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation. TOP: Orthostatic Hypotension KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The patient is performing ROM exercises independently. These are known as
exercises. ANS:
active ROM
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ROM exercises may be active, passive, or active-assisted. They are active if the patient is able to perform the exercises independently and passive if the exercises are performed for the patient by the caregiver. The exercises are active-assisted if the patient is able to perform some of the actions independently with support and assistance from the caregiver. DIF: Cognitive Level: Knowledge REF: Text reference: p. 222 OBJ: Discuss indications for performing ROM and isometric exercises. TOP: Active Range of Motion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. Static exercises that involve tightening or tensing of muscles without moving a body part are
known as
.
ANS:
isometric exercises Isometric or static exercises involve tightening or tensing of muscles without moving body parts. DIF: Cognitive Level: Knowledge REF: Text reference: p. 227 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Isometric Exercises KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
increase muscle tension but do not change the length of muscle fibers.
6. ANS:
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Isometric contractions Isometric contractions increase muscle tension but do not change the length of muscle fibers. DIF: Cognitive Level: Knowledge REF: Text reference: p. 227 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Isometric Contractions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. Virchow’s triad (hypercoagulability of blood, venous wall damage, and stasis of blood flow)
has been found to contribute to
.
ANS:
deep vein thrombosis (DVT) Three elements (commonly referred to as Virchow’s triad) contribute to the development of DVT: hypercoagulability of the blood, venous wall damage, and stasis of blood flow. DIF: Cognitive Level: Comprehension REF: Text reference: p. 237 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Deep Vein Thrombosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
8. The nurse is concerned that the patient may fall while he is ambulating. To help her maintain
control while the patient walks, the nurse may apply a waist.
around the patient’s
ANS:
gait belt A gait belt encircles a patient’s waist and has space for the nurse to hold while the patient walks. This gives the nurse better control and helps to prevent injury. DIF: Cognitive Level: Application REF: Text reference: p. 240 OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD. TOP: Gait Belt KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 11: Orthopedic Measures MULTIPLE CHOICE 1. According to the National Association of Orthopaedic Nurses (NAON), which of the
following is possibly the most effective cleansing solution for pin-site care? a. Normal saline b. Hydrogen peroxide c. Chlorhexidine d. None of the above ANS: C
The second group to develop clinical practice guidelines is the United States–based NAON, which indicated that chlorhexidine 2 mg/mL solution is possibly the most effective cleansing solution for pin-site care. A British consensus group of orthopedic nurse experts recommends that pin sites be cleaned only with sterile normal saline or water to remove crusts around the pins (Walker, 2007). Walker found no definitive evidence to support a pin-site dressing containing an antimicrobial agent. Several studies have found that although hydrogen peroxide is a common cleansing agent, it may cause damage to the healthy tissue surrounding the pin. DIF: Cognitive Level: Comprehension REF: Text reference: p. 264 OBJ: Explain nursing measures for complications from traction. TOP: Pin-Site Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The patient has a broken leg N anU dR nS eeI dsNtG oT haB v. e aCcOaM st applied. When plaster of Paris is
compared and contrasted versus the newer synthetic casts, which of the following statements is true? a. Plaster of Paris can tolerate earlier weight bearing than synthetic casts. b. Plaster of Paris is more expensive than synthetic casts. c. Synthetic casts can withstand contact with water better than plaster of Paris. d. Synthetic casts are lighter but take longer to set than plaster of Paris. ANS: C
Although the newer synthetic casts are more expensive than plaster of Paris, they can withstand contact with water without crumbling. A plaster of Paris cast has multiple rolls of open-weave cotton saturated with calcium sulfate crystals. These casts are heavier than synthetic casts and take 24 to 72 hours with no weight bearing or application of pressure while drying. Synthetic casts are lightweight, set in 15 minutes, and can sustain weight bearing or pressure in 15 to 30 minutes. DIF: Cognitive Level: Analysis REF: Text reference: p. 251 OBJ: Explain nursing measures for complications from traction. TOP: Comparison of Cast Material KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 3. An expected outcome of cast application that the nurse evaluates is: a. skin irritation at the cast edges. b. decreased capillary refill and pallor.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank c. tingling and numbness distal to the cast. d. slight edema, soreness, and limited range of motion. ANS: D
Expected outcomes after completion of the procedure: Patient initially experiences only slight edema, soreness, mild pain, and some limitation of active range of joint motion (ROJM) from being in the cast. Expected outcomes after completion of the procedure: Skin around proximal and distal cast edges remains intact without irritation, is free of pressure and friction from the cast edges, and is warm and of normal color with capillary refill of 3 seconds or less; and the patient verbalizes no abnormal or unusual sensations and is able to move the fingers or toes below the casted part. Neurovascular function to the body part is maintained. DIF: Cognitive Level: Application REF: Text reference: p. 252 OBJ: Describe neurovascular assessments of a patient with an orthopedic injury. TOP: Expected Outcomes KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 4. The patient is admitted for a fractured tibia. The nurse is preparing for cast application and
expects to administer a(n) to the patient minutes before the procedure. a. oral analgesic 10 b. intramuscular (IM) analgesic 10 c. intravenous (IV) analgesic 2 to 5 d. muscle relaxant 10 ANS: C
Administer analgesic per order before cast application: IV, 2 to 5 minutes before the procedure. This is the most effective way to reduce pain during cast application. Alternately, you could adminN iste Rr an Ialge GsicTBby.m Cou Mth (PO), 30 to 40 minutes before cast U S N O application to obtain optimal analgesic effect. If administering analgesic via IM injection, give does 20 to 30 minutes before cast application for optimal analgesic effect. Administer muscle relaxant 30 minutes before cast application if spasms are present. Often, muscle spasms are treated more effectively with skeletal muscle relaxants than with opioids. DIF: Cognitive Level: Application REF: Text reference: p. 252 OBJ: Describe how to assist in application of casts. TOP: Preprocedure Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. An appropriate technique for the nurse to implement for the patient who is being casted is to: a. apply ice to the top of the cast. b. maintain the extremity below heart level. c. handle the wet cast with the fingertips. d. fold the stockinette or padding over the outer cast edges. ANS: D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Assist with “finishing” by folding the stockinette or other padding down over the outer edge of the cast to provide a smooth edge. Smooth edges lessen possible skin irritation. When the cast is finished with a stockinette, later “petaling” with tape is not required when the cast is dry. Elevation and ice can be ordered, but ice would not be applied to the top of the wet cast because the weight could change the shape of the cast, causing indentations that can lead to pressure areas. Maintain elevation at or above heart level; elevation enhances venous return and decreases edema. Handle the casted extremity with palms only until the cast is dry. Fingers can cause indentations that can lead to pressure areas. DIF: Cognitive Level: Application REF: Text reference: p. 254 OBJ: Describe how to assist in application of casts. TOP: Finishing the Cast KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. When teaching cast care, the nurse instructs the patient to: a. blow dry the wet cast on the “hot” setting. b. report changes in sensation or mobility to the area. c. use only soft objects to slide down the cast for scratching. d. cut away the edges of the cast if the skin becomes irritated. ANS: B
The patient must monitor neurovascular status, paying particular attention to blueness or paleness of the nails, pain, a feeling of tightness, numbness, or a tingling sensation. Caution the patient against drying a wet cast with a hair dryer; this can cause plaster to crack or the skin underneath to be damaged. The patient should avoid sticking objects down or into the cast to scratch because these objects can cause breaks in underlying skin and subsequent infection. Inform the patient to inspect the cast and petal rough edges to reduce the risk of NtheRS I G B.C M trauma to underlying skin and U needNforTcast chOanges. Small pieces (petals) of adhesive tape 2.5 to 5.0 cm (1 to 2 inches) are cut and taped smoothly over the edge of the cast. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 254-256 OBJ: Describe elements of education for the patient with a cast and after removal of a cast. TOP: Cast Care KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 7. For cast removal, which of the following instructions should the nurse provide to the patient? a. Discomfort will be felt from the cast saw. b. An enzyme wash may be applied to intact skin. c. The skin will be scrubbed very well after the removal. d. Aggressive range-of-motion exercises will be performed after removal. ANS: B
If the skin is intact, gently apply a cold water enzyme wash to the skin; let it stay on the skin 15 to 20 minutes. This helps dissolve or emulsify dead cells and fatty deposits on tissues and prevents injury to delicate tissue. A cast saw vibrates the cast loose; the patient will feel heat and vibration. Do not scrub the skin because this may traumatize delicate tissue and lead to skin breakdown. It may take several days before all residue is removed from the skin. Obtain a physician’s order to gently put joints through active and passive ROJM. Clarify the level of activity allowed. Joints and muscles will be stiff and weak. Activity is resumed slowly to avoid reinjury.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Comprehension REF: Text reference: pp. 257-258 OBJ: Describe elements of education for the patient with a cast and after removal of a cast. TOP: Cast Removal KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The patient is brought into the emergency department after falling on the ice in her driveway.
She is suspected of having a fractured hip. After comparing different available types of traction, she anticipates that which of the following will be used? a. Bryant’s traction b. Dunlop’s traction c. Buck’s extension d. Gallows traction ANS: C
Buck’s extension provides temporary immobilization of a hip fracture until open reduction and internal fixation (ORIF) can be performed. It also reduces muscle spasms, contractures, and dislocations and occasionally is used as an interim treatment for lumbosacral muscle spasms that cause low back pain. Bryant’s traction (called Gallows in England) is no longer used because of the risk for gravitational vascular draining of the extremities and the possible tourniquet effect of bandages, triggering vasospasms and avascular necrosis. Dunlop’s traction is a simultaneous horizontal form of Buck’s extension to the humerus with an accompanying vertical Buck’s extension to the forearm. DIF: Cognitive Level: Analysis REF: Text reference: p. 258 OBJ: Explain the purposes of placing a patient in skin or skeletal traction. TOP: Buck’s Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
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9. Which type of traction does the nurse anticipate will be used for an adult patient with a
fractured humerus? a. Bryant’s traction b. Dunlop’s traction c. Gallows traction d. Buck’s extension ANS: B
Dunlop’s traction is a simultaneous horizontal form of Buck’s extension to the humerus with an accompanying vertical Buck’s extension to the forearm. Bryant’s traction (called Gallows in England) is no longer used because of the risk for gravitational vascular draining of the extremities and the possible tourniquet effect of bandages, triggering vasospasms and avascular necrosis. Buck’s extension provides temporary immobilization of a hip fracture until ORIF can be performed. It also reduces muscle spasms, contractures, and dislocations and occasionally is used as an interim treatment for lumbosacral muscle spasms that cause low back pain. DIF: Cognitive Level: Analysis REF: Text reference: p. 258 OBJ: Explain the purposes of placing a patient in skin or skeletal traction. TOP: Dunlop’s Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. For a patient who is to be placed in Russell’s traction, the nurse prepares the:
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
occipital area. arm and forearm. back and abdomen. lower extremities.
ANS: D
Russell’s traction is a modification of Buck’s extension in which Newton’s third law of motion (for each force in one direction, there is an equal force in the opposite direction) is used to double the amount of pull through the arrangement of ropes, pulleys, and weights. DIF: Cognitive Level: Comprehension REF: Text reference: p. 258 OBJ: Explain the purposes of placing a patient in skin or skeletal traction. TOP: Russell’s Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The nurse places the patient in traction. Expected outcomes would include which of the
following? a. Alignment of fracture fragments with formation of callus within 24 hours b. Verbalization of pain level as a “4” on a scale of 0 to 10 c. Verbalization of immediate relief of symptoms d. Distal skin tissue becoming cooler, with capillary refill greater than 3 seconds ANS: B
Expected outcomes would include verbalization of increased comfort after traction application and rating of pain as 4 or lower on a scale of 0 to 10 since injured tissues and bone are stabilized. Evidence of callus may not become apparent for 7 to 10 days or longer. Sufficient time in traction (varying from 1 to 10 or more days) elicits symptom relief. It takes time for inflammation to decrease andNtis sues rega R ItoNG Bin.mCore Mnormal function. Neurovascular status U S T O should remain stable. Distal skin tissue remains warm and of a normal color with capillary refill of 3 seconds or less. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 261-262 OBJ: Explain the purposes of placing a patient in skin or skeletal traction. TOP: Expected Outcomes of Traction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. While in Buck’s extension traction, the patient may be positioned on the back: a. with the head of the bed elevated 45 degrees. b. turning to the unaffected side for 10- to 15-minute periods. c. with the buttocks slightly elevated off of the bed. d. with the bed tilted toward the side that is opposite the traction. ANS: B
Position varies with the part of the body to be placed in traction, plus effects of weight and gravity. Body parts are kept aligned anatomically. With Buck’s extension, the patient is primarily on his back but may be allowed to turn to the unaffected side for brief periods (10 to 15 minutes). With Buck’s extension, the patient is on his back with the head of the bed flat or elevated no more than 30 degrees. With Dunlop’s traction, the patient may be tilted on low-shock blocks toward the side opposite the traction. DIF: Cognitive Level: Application REF: Text reference: p. 261 OBJ: Explain the purposes of placing a patient in skin or skeletal traction.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Positioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. An appropriate technique for the nurse to implement for a patient who is being placed in
traction is to: a. apply a traction boot tightly. b. drop the weights after the traction is attached. c. assess neurovascular status every 1 to 2 hours for the first day. d. shave the hair off the area where traction is to be placed. ANS: C
Assess neurovascular status 15 minutes after application of skin traction and every 1 to 2 hours for 24 hours, and then extend to every 4 hours if the patient is stabilizing. Ensure that boot size is correct. A traction boot should fit snugly (not too tight or too loose). Too tight leads to pressure on skin, peroneal nerve, and vascular structures. When all traction materials and spreader bars are in place, weights are placed on weight holders and are attached to a loop in the rope. The weights then are lowered slowly and gently until the rope is taut. Traction is established slowly to avoid involuntary muscle spasms or pain for the patient. Shaving may create micro nicks that could become inflamed under traction strips. DIF: Cognitive Level: Application REF: Text reference: pp. 261-262 OBJ: Explain the purposes of placing a patient in skin or skeletal traction. TOP: Evaluation of Traction KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 14. For a patient in traction who has skeletal pins, the nurse should: a. use povidone-iodine to cleanse the pin site. b. apply antiseptic ointmentNaU ndRcS oI veN rG wT ithBa.sC plO itM dressing. c. use hydrogen peroxide as a rinse before a dressing is applied. d. do both pin sites at the same time, with the same swab and solution. ANS: B
Using a sterile applicator, apply a small amount of topical antibiotic ointment to the pin site and cover with a sterile 2 2 split gauze dressing. (Note: Some physicians leave the site uncovered.) Dip a sterile cotton-tipped applicator into a sterile container of chlorhexidine 2 mg/mL solution. Place a sterile applicator by the pin, and roll it along the skin, away from the insertion site. Clean outward in a circular fashion from the pin. Dispose of the applicator. Remove crusts from the pin site when signs of infection are present. Chlorhexidine 2 mg/mL is the most effective cleansing solution for pin-site care. Never touch one pin site with material used on another. This prevents cross-contamination. DIF: Cognitive Level: Application REF: Text reference: p. 266 OBJ: Describe steps for applying each form of skin or skeletal traction. TOP: Pin Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. For a patient with a fractured femur, a nurse is alert to the possibility of a fat embolus. What
should the nurse specifically watch for? a. Bradypnea b. Restlessness c. Bradycardia
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. Calf pain ANS: B
Assess for indicators of hypoxemia, such as restlessness or agitation. Recognize early signs of fat embolism syndrome. Signs of hypoxemia include tachypnea, not bradypnea. Signs of hypoxemia include tachycardia, not bradycardia. Calf pain would indicate a DVT, not a fat embolism. DIF: Cognitive Level: Application REF: Text reference: p. 267 OBJ: Explain nursing measures for complications from traction. TOP: Fat Embolism Syndrome KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 16. In planning nursing care, the nurse knows that she will need to provide an abduction pillow
for which patient? a. A patient who will be immobilized for a long time b. A patient who has undergone repair of a fractured right arm c. A patient who is post hip replacement surgery d. A patient who has a severely sprained ankle ANS: C
The abduction splint or pillow, used after hip replacement surgery, maintains the patient’s legs in an abducted position. This permits the patient to be turned without changing the position of the healing limb, and prevents dislocation of the hip prosthesis. DIF: Cognitive Level: Application REF: Text reference: p. 268 OBJ: Explain nursing measures for complications from immobilization. TOP: Abduction Pillows Y:.C NursM ing Process Step: Implementation N R I GKEB MSC: NCLEX: Physiological IntU egriS ty N
T
O
MULTIPLE RESPONSE 1. The nurse is caring for a patient who has had a new cast applied. The nurse is performing a
neurovascular assessment so as to detect signs of possible compartment syndrome. Which of the following are signs of compartment syndrome? (Select all that apply.) a. Inability to move body parts distal to the cast b. Pain on passive motion of distal body parts c. Hyperventilation d. Tachycardia ANS: A, B, C, D
Signs of development of compartment syndrome, cast syndrome, or severe claustrophobia may result from snugness of the cast, which is common for patients in a spica or body cast. Observe the patient for signs of pain or anxiety; ask the patient to rate pain on a scale from 0 to 10; observe for inability to move body parts distal to the cast, pain on passive motion of distal body parts, hyperventilation, swallowing of air (aerophagia), nausea and/or vomiting, tachycardia, and blood pressure elevation. DIF: Cognitive Level: Comprehension REF: Text reference: p. 255 OBJ: Describe neurovascular assessments of a patient with an orthopedic injury. TOP: Compartment Syndrome KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
2. The patient is in traction and is at risk for fat embolism syndrome. Signs and symptoms of fat
embolism include which of the following? (Select all that apply.) a. Chest pain b. Tachypnea c. Tachycardia d. Apprehension e. Altered LOC ANS: A, B, C, D
Symptoms of possible fat embolism include clinical manifestations of dyspnea, tachycardia, cyanosis, and circulatory collapse. DIF: Cognitive Level: Comprehension REF: Text reference: p. 267 OBJ: Explain nursing measures for complications from traction. TOP: Fat Embolism Syndrome KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 3. The patient has been in skeletal traction for external fixation of his femur for 2 days.
Suddenly, he calls the nurse complaining of chest pain and shortness of breath. The nurse notes that the patient appears anxious, and that his pulse and respirations are elevated. She should do which of the following? (Select all that apply.) a. Massage the lower extremity b. Elevate the head of the bed c. Administer oxygen d. Notify the physician ANS: B, C, D
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If symptoms of pulmonary embolus are evident, elevate the head of the bed (if conscious), administer oxygen, and notify the physician immediately. Do not massage the lower extremity. DIF: Cognitive Level: Application REF: Text reference: p. 267 OBJ: Explain nursing measures for complications from traction. TOP: Pulmonary Embolism KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Skeletal traction is implemented primarily for: (Select all that apply.) a. simple fracture. b. multiple trauma. c. fractured ankle. d. acetabular fracture. e. cervical fracture. ANS: B, C, D, E
Skeletal traction immobilizes fractures of the cervical spine, fractures of the femur below the trochanter, and some fractures of the bones of the arm or ankle. It is also used to immobilize the femoral head in an acetabular fracture. DIF: Cognitive Level: Comprehension REF: Text reference: p. 263 OBJ: Describe steps for applying each form of skin or skeletal traction. TOP: Evaluation of Traction KEY: Nursing Process Step: Assessment
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity COMPLETION 1.
involves monitoring for the five Ps (pain, pallor, pulselessness, paresthesia, and paralysis). ANS:
Neurovascular assessment It is essential to monitor for the five Ps (pain, pallor, pulselessness, paresthesia, and paralysis) of neurovascular status because permanent damage may result if circulation is not restored or pressure is not removed. DIF: Cognitive Level: Comprehension REF: Text reference: p. 256 OBJ: Explain nursing measures for complications from traction. TOP: Neurovascular Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The patient has fallen and broken her leg. To keep the leg bones aligned and to reduce muscle
spasms, the physician orders the patient to be placed in
.
ANS:
Buck’s traction Buck’s traction is the most common type of adult skin traction. It is applied to the legs to provide temporary immobilization of the hip while reducing muscle spasms, contractures, and dislocations.
N R I G B.C M
U S N REF: T Text O reference: pp. 258-259 DIF: Cognitive Level: Comprehension OBJ: Explain nursing measures for complications from traction. TOP: Traction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. A
is an externally applied structure that holds musculoskeletal tissues in a specific position to permit healing of injuries or fractures or to align malpositioned tissues. ANS:
cast A cast is an externally applied structure that holds musculoskeletal tissues in a specific position to permit healing of injuries or fractures or to align malpositioned tissues, as in clubfoot or congenital hip dislocation. DIF: Cognitive Level: Comprehension REF: Text reference: p. 250 OBJ: Explain nursing measures for complications from traction. TOP: Cast KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. After application of the cast, the nurse ensures that plaster crumbs are removed and rough
edges are ANS:
petaled
to prevent skin breakdown.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank After application of the cast, ensure that plaster crumbs are removed and rough edges are “petaled” to prevent skin breakdown. DIF: Cognitive Level: Comprehension REF: Text reference: p. 254 OBJ: Explain nursing measures for complications from traction. TOP: Petaling KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. When applying a plaster of Paris cast, it is important to keep the cast exposed for at least
minutes. ANS:
15 fifteen Explain that the patient may experience warmth during the cast application process. Plaster gives off heat from a chemical reaction when drying. Keep the cast exposed to permit maximum dissipation of the heat. Most casts cool in about 15 minutes. DIF: Cognitive Level: Comprehension REF: Text reference: p. 253 OBJ: Describe how to assist in application of casts. TOP: Heat Dissipation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. After applying a cast, the nurse should be able to insert
fingers between the cast and
the limb. ANS:
2 NURSINGTB.COM two Plaster must be of sufficient thickness to give strength to the cast. More than two fingers’ space in the cast indicates that the cast is too loose and will not support the limb; less than two fingers’ space indicates that the cast may be too tight and may inhibit circulation. DIF: Cognitive Level: Comprehension REF: Text reference: p. 255 OBJ: Describe how to assist in application of casts. TOP: Spacing Between Cast and Limb KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
may occur when pressure within a casted extremity increases.
7. ANS:
Compartment syndrome When pressure within a casted extremity increases, this may lead to compartment syndrome, which occurs when pressure within the muscle compartment increases as a result of edema, bleeding, or decreased venous return. The fascia covering the muscle group acts as a tourniquet on structures within the compartment such as nerves, blood vessels, and muscle tissue. DIF: Cognitive Level: Comprehension REF: Text reference: p. 255 OBJ: Describe neurovascular assessments of a patient with an orthopedic injury. TOP: Compartment Syndrome KEY: Nursing Process Step: Evaluation
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity
applies a pull indirectly to the bone via straps attached to the skin
8.
around the structure. ANS:
Skin traction Skin traction applies a pull indirectly to the bone via straps and a sling or boot applied to the skin around the structure. Skin traction typically applies between 5 and 7 lb and is commonly used for minor trauma or immediate immobilization before surgery. DIF: Cognitive Level: Comprehension REF: Text reference: p. 258 OBJ: Explain the purposes of placing a patient in skin or skeletal traction. TOP: Skin Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9.
consists of a metal frame that secures pins inserted through the bone above and below the fracture site. It stabilizes a fracture with hardware visible outside the body. ANS:
External fixation External fixation consists of a metal frame that secures pins inserted through the bone above and below a fracture site. External fixation stabilizes a fracture with hardware visible outside the body. It fosters the healing of complex fractured bones, usually in the lower extremities. DIF: Cognitive Level: Comprehension REF: Text reference: p. 263 GTofBsk.inCoOr M OBJ: Describe steps for applyN inU g eRaS chIfoNrm skeletal traction. TOP: Evaluation of Traction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. An immobilization device used to immobilize and protect a body part is known as a
. ANS:
splint Immobilization devices increase stability, support weak extremities, or reduce the load on weight-bearing structures such as hips, knees, or ankles. A splint immobilizes and protects a body part. DIF: Cognitive Level: Knowledge REF: Text reference: p. 268 OBJ: Explain nursing measures for complications from traction. TOP: Splints KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 12: Support Surfaces and Special Beds MULTIPLE CHOICE 1. The patient is admitted to the unit with a stage III pressure ulcer. When the different types of
support surfaces are compared, which would be most therapeutic for this patient? a. Foam mattress b. Gel overlay c. Air-fluidized bed d. Air mattress ANS: C
Air-fluidized beds are recommended for use for patients with stage III and stage IV pressure ulcers. Foam support surfaces are recommended to reduce the risk of the patient developing pressure ulcers. Gel overlay support surfaces are recommended for patients who are wheel chair dependent, as well as those who are at risk for developing pressure ulcers. Nonpowered air-filled mattress are recommended for patients who are able to reposition themselves. DIF: Cognitive Level: Analysis REF: Text reference: p. 275 OBJ: Identify the different types of support surfaces and specialty beds used for pressure redistribution. TOP: Pressure Ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. What is the most important factor in preventing and treating pressure ulcers? a. Proper use of foam or air mattresses b. Proper utilization of an air-fluidized bed c. Frequent repositioning ofNth ntGTB.COM UeRpSatIieN d. Proper use of a low-air-loss bed ANS: C
Frequent repositioning, which temporarily relieves pressure, is the backbone of preventive protocols. It is the nurse’s responsibility to use appropriate turning schedules for patients in bed or on a chair. No bed or mattress totally eliminates the need for competent nursing care. DIF: Cognitive Level: Comprehension REF: Text reference: p. 274 OBJ: Explain why preventive nursing care is still essential when support surfaces and specialty beds are used. TOP: Repositioning KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. What is the primary purpose for the use of a support surface? a. To reduce pressure b. To promote patient comfort c. To increase circulation d. To facilitate patient movement ANS: A
Support surfaces aid in reducing pressure on the patient’s skin. Promoting patient comfort may happen, but it is not the primary purpose of the support mattress. A support mattress does not increase patient circulation, nor does it facilitate patient movement. DIF: Cognitive Level: Comprehension
REF: Text reference: p. 274
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Describe guidelines to follow when placing patients on support surfaces and specialty beds. TOP: Patient Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. When working with a patient who is being placed on an air mattress/overlay, the nurse should: a. apply the preinflated overlay over the standard mattress. b. bring any plastic strips or flaps around the corners of the bed mattress. c. administer an analgesic after the patient is moved onto the mattress. d. keep clamps or pins attached to the sheets to keep them in place over the mattress. ANS: B
When preparing an air mattress/overlay, bring any plastic strips or flaps around the corners of the bed mattress. This secures the air mattress in place. Apply a deflated mattress flat over the surface of the bed mattress. The decision to administer analgesic would be based on the patient’s condition rather than on the procedure. Pins and other sharps should not be used, to avoid puncturing an air mattress. DIF: Cognitive Level: Application REF: Text reference: p. 281 OBJ: Describe guidelines to follow when placing patients on support surfaces and specialty beds. TOP: Air Mattress/Overlay KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The patient requires a support surface to help prevent pressure ulcers. He has a large open
wound on his leg that is dressed daily. The nurse must choose which support surface would be most appropriate. What does the nurse realize when comparing the different types of support surfaces? a. Water mattresses are better for patients with open wounds. b. Air surface beds cannot bN eU usReS dI if N thG eT paBti. enCt O neM eds CPR. c. Water mattresses make it hard to regulate patient body temperature. d. Air mattresses reduce shear and friction. ANS: D
Water mattresses are no longer used regularly because they harbor organisms in the water; leaks in the mattress are risky for patients with open wounds; and the structural integrity of the building does not always support the weight of the mattress. Air mattress reduce shear and friction and so are a good choice for this patient. Air surface beds are equipped with a cardiopulmonary resuscitation (CPR) switch to instantly lower the head section from an elevated position and to deflate the mattress to provide a firm surface for chest compressions. Follow the manufacturer’s directions regarding the temperature of the water. Proper water temperature prevents loss of body heat as the patient lies on the mattress. DIF: Cognitive Level: Analysis REF: Text reference: p. 275 OBJ: Describe guidelines to follow when placing patients on support surfaces and specialty beds. TOP: Comparison of Support Surfaces KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The patient is admitted with a large stage IV pressure ulcer on his coccyx. After comparing
the benefits of the following support surfaces, the nurse would choose which of the following as most appropriate for this patient? a. Water mattress b. Gel overlay
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank c. Foam overlay d. Air-fluidized bed ANS: D
If a patient has large stage III or stage IV pressure ulcers on multiple turning surfaces, a low-air-loss bed or air-fluidized bed may be indicated. The use of water mattresses has been reduced considerably because they harbor organisms in the water, and leaks in the mattress are risky for patients with open wounds. Gel overlays are used for moderate- to high-risk patients, not for patients who have stage IV ulcers. They are useful for patients who are wheelchair dependent. Foam overlays are used for moderate- to high-risk patients, not for those with stage IV ulcers. DIF: Cognitive Level: Analysis REF: Text reference: p. 275 OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Air-Fluidized Beds KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 7. An air-suspension bed is contraindicated for the patient with: a. burns. b. traction. c. osteoporosis. d. respiratory insufficiency. ANS: B
Changes in pressure and position from an air-suspension bed are contraindicated for patients with an unstable spine or traction who must remain in alignment. An air-suspension bed is not contraindicated for patients with burns, osteoporosis, and respiratory insufficiency.
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DIF: Cognitive Level: Application REF: Text reference: p. 276 OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Air-Suspension Beds KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 8. Of the following problems that may occur with the use of an air-fluidized bed, which is of
greatest concern to the nurse? a. Nausea b. Anxiety c. Slight disorientation d. Insensible fluid loss ANS: D
Diaphoresis often goes undetected, and thus insensible fluid loss is not always evident until a patient develops fluid and electrolyte imbalances. This individual often is already compromised in relation to hydration, fluids, and electrolytes; therefore, the nurse needs to carefully monitor the patient’s fluid balance status. Some nausea, disorientation, and anxiety can occur, but they are not as critical as insensible fluid loss. DIF: Cognitive Level: Evaluation REF: Text reference: p. 275 OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Air-Fluidized Beds KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 9. The nurse is caring for a patient who is in an air-fluidized bed. She places the patient in
semi-Fowler’s position using foam wedges, even though she realizes that: a. patients gain the greatest benefit from the prone position in an air-fluidized bed. b. for resuscitation, she may have to increase the air pressure of the bed to do CPR. c. she may have to increase the air pressure of the bed to turn the patient. d. the foam wedges may decrease the effects of the bed. ANS: D
Although the use of foam wedges as needed is recommended (e.g., elevating the head of the patient for position changes), areas supported by the foam wedges do not benefit from pressure relief of the bed’s surface. Do not position a patient in a prone (face-down) position on an air-fluidized bed. Suffocation may occur. In emergencies when resuscitation is required, press the CPR switch and unplug the unit to defluidize the bed immediately. To turn patients, position bedpans, or perform other therapies, stop fluidization. Once the procedure is complete, set to continuous fluidization. Stopping fluidization provides firm, molded support that facilitates turning and handling of the patient. Continuous fluidization provides permanent fluid support. DIF: Cognitive Level: Application REF: Text reference: p. 286 OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Use of Foam Wedges KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. A patient is on bed rest after sustaining injuries in a car accident. Which nursing action helps
prevent complications of immobility? a. Decreasing fluid intake to ease dependent edema b. Turning the patient everyN2UhR ouSrI s aNnG dT prB ov.idCinOgMa low-air-loss mattress c. Raising the head of the bed to maximize the patient’s lung inflation d. Bathing and feeding the patient to decrease energy expenditure ANS: B
To avoid pressure ulcers in an immobilized patient, the nurse must assess the skin thoroughly and use such preventive measures as regular turning, a low-air-loss mattress, and a trapeze (if the patient’s condition allows). The nurse should increase, not decrease, the patient’s fluid intake to help prevent renal calculi, which may result from immobility. To prevent atelectasis, another complication of immobility, having the patient cough, deep-breathe, and use an incentive spirometer would be more effective than raising the head of the bed. Instead of bathing and feeding the patient, the nurse should promote independent self-care activities whenever possible to prepare the patient for a return to the previous health status. DIF: Cognitive Level: Analysis REF: Text reference: p. 274|Text reference: p. 277 OBJ: Explain why preventive nursing care is still essential when support surfaces and specialty beds are used. TOP: Use of a Low-Air-Loss Mattress KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. After comparing the following support surfaces, the nurse realizes that an extremely obese
patient should benefit from the use of a(n): a. bariatric bed. b. foam mattress.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank c. water mattress. d. air-fluidized bed. ANS: A
A valuable resource in the care of the morbidly obese patient (a person who weighs more than 100 lb above ideal weight) is the bariatric bed, which provides a safe, adaptable surface. The foam or water mattress and the air-fluidized bed are not designed specifically for the obese patient. DIF: Cognitive Level: Analysis REF: Text reference: p. 275|Text reference: p. 287 OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Bariatric Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. Which of the following is a limitation of the bariatric bed? a. Lack of an in-bed scale b. The narrowness of the bed c. Lack of pressure reduction d. Increased liability to the institution ANS: C
A limitation of this bed is the lack of pressure reduction or relief in the mattress. The at-risk obese patient needs to have some type of pressure redistribution mattress placed on the bariatric bed. The bariatric bed possesses an in-bed scale that provides the nurse with a means of obtaining accurate weights and thus improves health care and patient dignity. The bed is slightly wider than a standard hospital bed, yet it is within the guidelines for standard door width, allowing movement inNto aRnd I of aBro.oC U SoutNG T mOwMithout difficulty. A full- or double-wide bariatric bed can accommodate a patient up to 1000 lb. However, when using a full- or double-wide bariatric bed, you must assemble it in the patient’s room and must not use it for transfers, because this bed is too large to fit through standard hospital doorways. Because the bariatric bed is capable of supporting weights up to 850 pounds, it provides a stable, balanced surface that limits hospital liability should the standard bed frame collapse or the electric motor burn out. DIF: Cognitive Level: Comprehension REF: Text reference: p. 287 OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Bariatric Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. After comparing the benefits of the following support surfaces, the nurse realizes that a patient
with multiple trauma and/or spinal cord injury is expected to be placed on a(n): a. Rotokinetic bed. b. bariatric bed. c. flotation mattress. d. air-fluidized mattress. ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The Rotokinetic bed provides skeletal alignment and constant rotation and is used for patients with multiple trauma and spinal cord injury. Use of the bariatric bed is contraindicated in patients with spinal cord injury. Flotation mattresses and air-fluidized mattresses are contraindicated for patients with an unstable spine. DIF: Cognitive Level: Analysis REF: Text reference: p. 289 OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Rotokinetic Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. When teaching about the use of the Rotokinetic bed, the nurse informs the patient that the: a. bed will be stopped in one position most of the time. b. amount of rotation will be greater in the beginning. c. patient may experience a sensation of falling or lightheadedness. d. bed is moved manually all of the time and will rotate head over feet. ANS: C
Inform the patient that there will be a sensation of lightheadedness or falling. However, reassure the patient that he or she will not fall because the pads will prevent this and are checked by two people to ensure proper placement. It is recommended that the Rotokinetic bed stay in rotation mode for 20 hours a day. The bed rotates constantly when set on rotation mode. The Rotokinetic bed rotates automatically from side to side. DIF: Cognitive Level: Application REF: Text reference: p. 276|Text reference: p. 289 OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Rotokinetic Bed KEY: Nursing Process Step: Im ple men tatio n NURSI NG TB.C OM MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Factors that contribute to pressure ulcer formation include which of the following? (Select all
that apply.) a. Friction b. Shear c. Turning every 2 hours d. Malnutrition e. Impaired mobility ANS: A, B, D, E
Factors that contribute to pressure ulcer formation are both extrinsic (e.g., moisture, friction, shear) and intrinsic (e.g., malnutrition, loss of sensation, impaired mobility, aging skin, impaired mental status, infection, incontinence, low arteriolar pressure). DIF: Cognitive Level: Comprehension REF: Text reference: p. 273 OBJ: Explain why preventive nursing care is still essential when support surfaces and specialty beds are used. TOP: Risk Factors for Pressure Ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 2. The patient is admitted to the hospital. Part of the patient assessment will include: (Select all
that apply.) a. Use of an appropriate pressure ulcer risk scale b. Assessment of the patient’s nutritional status c. Assessment of the patient’s mobility status d. Assessment of the patient’s fluid status ANS: A, B, C, D
A complete patient assessment includes the use of appropriate pressure ulcer risk scales, the presence of shear and friction, and the patient’s nutritional, fluid, mobility, and continence status. DIF: Cognitive Level: Application REF: Text reference: p. 274|Text reference: p. 276 OBJ: Describe guidelines to follow when placing patients on support surfaces and specialty beds. TOP: Patient Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Air-fluidized beds require the nurse to assess for which of the following? (Select all that
apply.) a. The patient’s fluid and electrolyte status b. The patient’s financial status c. The structural strength of the room where the bed will be d. The room temperature ANS: A, B, C, D
Air-fluidized beds provide continuous circulation of warm, dry air, which may increase patient risk for dehydration. The bed also may increase room temperature, making it uncomfortable for the patientNand ea. diC ngOtM o overheating of the equipment. Another Rpo Issib GlyTlB U S N concern is that the bed is heavy and expensive. Unless the patient has a physician order, third-party payment may not be available. DIF: Cognitive Level: Application REF: Text reference: p. 275|Text reference: p. 283 OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Air-Fluidized Beds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1.
are defined as localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. ANS:
Pressure ulcers The National Pressure Ulcer Advisory Panel defines pressure ulcers as localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. DIF: Cognitive Level: Comprehension REF: Text reference: p. 273 OBJ: Explain why preventive nursing care is still essential when support surfaces and specialty beds
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank are used. TOP: Pressure Ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The major cause of pressure ulcers is
.
ANS:
unrelieved pressure The major cause of pressure ulcers is unrelieved pressure. The greater the pressure and the longer the pressure is applied, the greater the likelihood that a pressure ulcer will develop. DIF: Cognitive Level: Comprehension REF: Text reference: p. 273 OBJ: Explain why preventive nursing care is still essential when support surfaces and specialty beds are used. TOP: Pressure Ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse understands that an
using foam, air, water, or gel can be
placed on top of the mattress to provide pressure relief. ANS:
overlay Support surfaces are categorized as mattress (or wheelchair) overlays, mattress replacements, or specialty beds. An overlay rests on top of the hospital mattress and uses foam, air, water, gel, or combinations of these products to provide pressure relief. DIF: Cognitive Level: Comprehension REF: Text reference: p. 278 OBJ: Compare and contrast mattress overlays and mattress replacements. TOP: Overlays KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological IN ntegR rityI G B.C M
U S N T
4. A
O
serves as an artificial layer of fat to protect bony surfaces.
ANS:
flotation pad A flotation pad is made of a silicone or polyvinyl chloride gel enclosed in a vinyl-covered square. The pad serves as an artificial layer of fat to protect bony surfaces such as the sacrum and the greater trochanters. These flotation pads are available for the bed or for wheelchair patients. DIF: Cognitive Level: Comprehension REF: Text reference: p. 278 OBJ: Compare and contrast mattress overlays and mattress replacements. TOP: Flotation Pads KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5.
beds are for patients who are immobile or otherwise are confined to the bed; they support a patient’s weight on air-filled cushions. ANS:
Air-suspension Air-suspension beds are for patients who are immobile or otherwise are confined to the bed. The air-suspension bed supports a patient’s weight on air-filled cushions. DIF: Cognitive Level: Knowledge
REF: Text reference: p. 283
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Air-Suspension Beds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The patient will be going home but still requires an air-fluidized bed. Before discharge, it will
be necessary for the company that is leasing the bed to inspect the home for accessibility and . ANS:
structural support Beds weigh between 1700 and 2100 lb; therefore the company that is leasing the bed needs to inspect the home for accessibility and structural support. DIF: Cognitive Level: Application REF: Text reference: p. 287 OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Home Care Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. A full or double-wide
can accommodate a patient up to 1000 lb.
ANS:
bariatric bed A full or double-wide bariatric bed can accommodate a patient up to 1000 lb. However, when using a full or double-wide bariatric bed, you must assemble it in the patient’s room and must not use it for transfers, because this bed is too large to fit through standard hospital doorways. DIF: Cognitive Level: ComprN ehen F:.C Text URsion SINGRE TB OMreference: p. 287 OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Bariatric Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. Use of the bariatric bed is contraindicated in patients with
.
ANS:
spinal cord injury Use of this bed is contraindicated in patients with spinal cord injury. DIF: Cognitive Level: Comprehension REF: Text reference: p. 288 OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Bariatric Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The
bed rotates and improves skeletal alignment with constant side-to-side rotation up to 90 degrees. ANS:
Rotokinetic This bed improves skeletal alignment with constant side-to-side rotation up to 90 degrees.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Comprehension REF: Text reference: p. 289 OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Rotokinetic Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. It is recommended that the Rotokinetic bed stay in the rotation mode for at least
hours a day. ANS:
20 twenty It is recommended that the Rotokinetic bed stay in the rotation mode for at least 20 hours a day. DIF: Cognitive Level: Comprehension REF: Text reference: p. 289 OBJ: Describe correct placement of a patient on an air-fluidized bed, an air-suspension bed, a bariatric bed, a Rotokinetic bed, or a support surface mattress. TOP: Rotokinetic Bed KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 13: Safety and Quality Improvement MULTIPLE CHOICE 1. The patient is admitted to the hospital with orders for activity as tolerated. He is
wheelchair-bound at home and has brought his own electric wheelchair and battery charger to help him maintain mobility. The nurse realizes that: a. patients are not allowed to bring in an electric wheelchair. b. electrical equipment is banned from all hospitals. c. the charger needs to be checked by hospital engineers. d. electrical devices are not a cause for concern. ANS: C
The third (longer) prong in an electrical plug is the ground. If a patient brings an electrical device to the hospital, an engineer inspects the device for safe wiring and function before use. Many patients with disabilities use battery chargers for mobility equipment function. These devices need to be inspected by hospital engineers. Fires in health care settings typically are electrical or anesthetic-related. DIF: Cognitive Level: Comprehension REF: Text reference: p. 313 OBJ: Describe methods used to evaluate interventions designed to maintain or promote a patient’s safety. TOP: Fire/Electrical Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. Upon entering the patient’s room, the nurse sees a fire burning in the trash can next to the bed.
M hat is the nurse’s next action? The nurse removes the patienNt U anR dS reIpN orG tsTthBe. fiC reO .W a. Extinguish the fire. b. Remove all other patients from the unit. c. Close all doors of patient rooms. d. Move the trash can into the bathroom. ANS: C
Using the “RACE” acronym, the next action the nurse should take is to confine the fire by closing doors and windows and turning off oxygen and electrical equipment (Rescue, Activate, Contain, and Evacuate). Extinguish the fire by using an extinguisher after ensuring patient and individual safety after closing the doors of patient rooms. After activating the alarm, the nurse should close all the doors, not remove all the other patients from the unit. Moving the trash can would not be an appropriate action, as the nurse could get burned in this attempt. DIF: Cognitive Level: Application REF: Text reference: p. 313 OBJ: Describe nursing interventions taken in the event of fire and electrical shock. TOP: Fire Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. In a long-term care facility, an elderly patient drops his burning cigarette into a trash can and
starts a fire. A Type _ fire extinguisher is the most appropriate type of fire extinguisher for the nurse to use in this situation. a. A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. B c. C d. D ANS: A
Type A fire extinguishers are used for ordinary combustibles such as wood, cloth, paper, and plastic. A trash can fire would require a type A fire extinguisher. Type B fire extinguishers are used for flammable liquids such as gasoline, grease, paint, and anesthetic gas. Type C fire extinguishers are used for electrical fires. There is no Type D fire extinguisher. DIF: Cognitive Level: Comprehension REF: Text reference: p. 314 OBJ: Describe nursing interventions performed in the event of fire and electrical shock. TOP: Fire Extinguishers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Given the most common causes of hospital fires, which of the following choices are most
appropriate in preventing patient injury? a. Assure that all electrical devices are checked by engineering. b. Assist patients who smoke to a safe area to smoke. c. Prop fire doors open for easier patient access. d. Educate patients on the importance of smoking cessation. ANS: A
Fires in health care settings are usually electrical or anesthetic-related, so ensuring all electrical devices are inspected will greatly reduce the risk of fire. Look for inspection labels verifying recent inspection for all electrical devices. Fire door should never be propped open. While educating patients on smoking cessation is a good idea, it will have little impact on immediate hospital safety. AN ltho ugh okin R Ism G Bg.isCnoOMlonger allowed in the hospital setting, U S N T smoking-related fires continue to pose a risk due to unauthorized smoking in bed or the bathroom. DIF: Cognitive Level: Analysis REF: Text reference: p. 312 OBJ: Describe nursing interventions performed in the event of fire and electrical shock. TOP: Fire Extinguishers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. After recognizing that a patient has received an electrical shock and removing the source of
the shock, what should the nurse do next? a. Call for assistance. b. Immediately start CPR. c. Obtain emergency equipment. d. Assess for the presence of a pulse. ANS: D
If the patient receives an electrical shock, immediately assess for the presence of a pulse. Electrical shock can cause cardiac arrest, asystole. Do not leave the patient. Only if the patient is pulseless will the nurse institute cardiopulmonary resuscitation. If the patient has a pulse and remains alert and oriented, obtain vital signs and assess the skin for signs of thermal injury. Electrical current will cause burn at points of entry and exit from the body. DIF: Cognitive Level: Application REF: Text reference: p. 314 OBJ: Describe nursing interventions performed in the event of fire and electrical shock.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Electrical Shock MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step: Implementation
6. The patient is an elderly gentleman who is admitted for a medical problem. While doing his
admission assessment, the nurse learns that the patient gets up two to three times a night to use the restroom. The institution has only beds with four side rails. Which of the following is the appropriate rationale for leaving one of the lower side rails down? a. Falls rarely happen in the inpatient setting. b. Having all side rails raised increases the occurrence of falling. c. Side rails have no bearing on whether or not a patient falls. d. Patient falls rarely result in physical injury. ANS: B
Having all four side rails raised often increases the occurrence of falling, because patients try to climb over the rails to reach a chair or bathroom and often fall farther as a result. Leaving three side rails up (two upper and one lower) on a bed with four side rails is safer for the patient. Leaving the lower side rail down on the side of the bed the patient will exit the bed from to access the bathroom reduces the risk of falls. DIF: Cognitive Level: Comprehension REF: Text reference: p. 297 OBJ: Discuss the importance of a nursing assessment in providing for patient safety. TOP: Falls Prevention KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 7. A patient is taking a medication that has the potential to cause orthostatic hypotension.
Which of the following nursing interventions is appropriate for this patient? a. Have the patient sit slowly and dangle. b. Refer the patient to physiN caU lR thS erI apNyG . TB.COM c. Keep the side rails up at all times. d. Obtain a walker or a cane for patient use. ANS: A
Dangling allows adjustment to orthostatic hypotension, permitting blood pressure to stabilize before ambulating. Have the patient dangle his or her feet for a few minutes before standing, walk slowly, and ask for help if dizzy or weak. The nurse would confer with physical therapy on the feasibility of gait training and muscle-strengthening exercise. Check agency policies regarding side rail use. Side rails are a restraint device if they immobilize or reduce the ability of a patient to move his or her arms, legs, body, or head freely. Keep one side rail up in a two-rail system, and keep three of four rails up (one lower rail down) in a four-rail system, with the bed in low position and wheels locked, when you are not administering patient care. This allows the patient to maneuver and get out of bed safely. Do not assume that the patient requires a walker or a cane. Evaluate the need for assistive devices such as walker, cane, or bedside commode. Assistive devices may provide greater stability and may help the patient to assume a more active role. DIF: Cognitive Level: Application REF: Text reference: p. 301 OBJ: Describe nursing interventions specific for reducing the risk for falls. TOP: Orthostatic Hypotension KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 8. What should the nurse do to promote patient understanding and security in the health care
setting? a. Restrain the patient as necessary. b. Explain all procedures to the patient. c. Allow the patient more time alone. d. Restrict activity as much as possible. ANS: B
Orient patient and family to surroundings, introduce to staff, and explain all treatments and procedures. This promotes patient understanding and cooperation. The use of restraints is one safety strategy that can protect patients from injury, but restraints must be used with extreme caution. Physical restraints should be the last resort and should be used only when reasonable alternatives have failed. Isolation may increase anxiety. Encourage family and friends to stay with the patient. Sitters or companions may be used. In some institutions, volunteers can be effective companions. Patient anxiety is reduced and safety is increased when one person provides care and supervision is constant. Constant activity may irritate the patient, yet the lack of activity may create anxiety and/or boredom. Meaningful diversional activities provide distraction, help to reduce boredom, and provide tactile stimulation. Minimize occurrences of wandering. DIF: Cognitive Level: Comprehension REF: Text reference: p. 299 OBJ: Describe steps in the design of a restraint-free environment. TOP: Alternatives to Physical Restraint KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 9. As part of an attempt to implement a restraint-free environment, the nurse: a. provides constant activity for the patient. NUs RanSdIdN GT b. covers or camouflages tube rain s.B.COM c. changes caregivers as often as possible. d. reduces visiting hours and times in therapy. ANS: B
Position intravenous (IV) catheters, urinary catheters, and tubes/drains out of patient view, or use camouflage by wrapping the IV site with bandage or stockinette, placing undergarments on patients with a urinary catheter, or covering abdominal feeding tubes/drains with a loose abdominal binder. This helps maintain medical treatment and reduces patient access to tubes/lines. Provide scheduled ambulation, chair activity, and toileting. Organize treatments so the patient has long uninterrupted periods throughout the day. Provide for sleep and rest periods. Constant activity may irritate the patient. Provide the same caregivers to the extent possible. This increases familiarity with individuals in the patient’s environment, decreasing anxiety and restlessness. Encourage family and friends to stay with the patient. Sitters or companions may be used. In some institutions, volunteers can be effective companions. Patient anxiety is reduced and safety is increased when one person provides care and supervision is constant. DIF: Cognitive Level: Application REF: Text reference: p. 305 OBJ: Describe steps in the design of a restraint-free environment. TOP: Alternatives to Physical Restraint KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 10. A patient is well known to the hospital staff from previous admissions and is prone to
wandering at night. For patient safety, the physician writes an order for “belt restraint prn.” What should the nurse do upon reviewing this order? a. Apply a belt restraint on the patient as needed. b. Have the patient sign an “informed consent” form. c. Inform the physician that “prn” restraint orders are unacceptable. d. Obtain a signed “informed consent” from a family member. ANS: C
The use of mechanical or physical restraints should be part of a patient’s prescribed medical treatment. A physician’s time-limited order is necessary. The patient’s or family member’s informed consent is necessary in the long-term care setting. DIF: Cognitive Level: Application REF: Text reference: p. 308 OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Applying Physical Restraints KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. To promote patient safety, government standards regarding mechanical and physical restraints
state that: a. alternative measures are to be implemented before restraints are used. b. the nurse’s judgment is all that is required for restraint use. c. restraints should be used immediately for all patients who may need them. d. restraints cannot be used except to prevent others from being harmed. ANS: A
The use of mechanical or physical restraints must be part of the prescribed medical treatment, all less-restrictive interventioN nsUm t be d. firC st,OoMther disciplines must be applied, and RusSI NGtrieTB supporting documentation must be provided. If the alternatives fail, the nurse may consider use of a restraint to prevent injury. Determine the patient’s need for restraint if other less-restrictive measures fail to prevent interruption of therapy or injury to self or others. Confer with the physician or primary health care provider, who must write the order for restraints. Restraints may be needed for the confused or combative patient to prevent interruption of therapy or injury to self or others. Confer with the physician or primary health care provider. DIF: Cognitive Level: Application REF: Text reference: p. 308|Text reference: p. 312 OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Applying Physical Restraints KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 12. When applying a belt restraint to a patient, it is important for the nurse to: a. apply the belt under the hospital gown. b. place the restraint around the abdomen. c. have the patient in a sitting position. d. apply the belt as tightly as possible. ANS: C
Have the patient in a sitting position. Remove wrinkles or creases in clothing. Bring ties through slots in a belt. Apply a belt over clothes, gown, or pajamas to prevent damage to the skin. Make sure to place the restraint at the waist, not at the chest or abdomen. Avoid applying the belt too tightly.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Application REF: Text reference: p. 309 OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Belt Restraints KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. When caring for a patient who has been restrained, how often will the nurse perform an
assessment? a. Every 15 minutes b. Every 30 minutes c. Every hour d. Every 2 hours ANS: A
After application, evaluate the patient’s condition every 15 minutes for signs of injury. Frequent assessments prevent injury to the patient and allow removal of the restraint at the earliest possible time. Observation and frequent assessments prevent complications such as suffocation, skin breakdown, and impaired circulation. The Joint Commission recommends that the patient’s condition be evaluated every 15 minutes. If the nurse restrains the patient in an emergency situation because of violent or aggressive behavior that presents an immediate danger, a face-to-face physician assessment within 1 hour is needed to determine the patient’s continued need for restraints. Restraints should be removed at least every 2 hours. If the patient is violent or noncompliant, remove one restraint at a time and/or have staff assistance while removing restraints. Removal provides an opportunity to change the patient’s position, offer nutrients, perform full range of joint motion (ROJM), and toilet and exercise the patient. DIF: Cognitive Level: Comprehension REF: Text reference: p. 311 OBJ: Discuss precautions usedNtU oR prS evI enN tG inT jurB y. inCpO atM ients who are restrained. TOP: Evaluation of Patient Condition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. When caring for a patient who has an arm or leg restraint in place, how often will the nurse
remove the restraint? a. Every 15 minutes b. Every 30 minutes c. Every hour d. Every 2 hours ANS: D
Restraints should be removed at least every 2 hours (Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 2004). If the patient is violent or noncompliant, remove one restraint at a time and/or have staff assistance while removing restraints. Removal provides an opportunity to change the patient’s position, offer nutrients, perform full ROJM, and toilet and exercise the patient. After application, evaluate the patient’s condition for signs of injury every 15 minutes. Frequent assessments prevent injury to the patient and allow removal of the restraint at the earliest possible time. If the patient shows no sign of impaired circulation or other complications, the restraint does not need to be removed at this time. If the nurse restrains a patient in an emergency situation because of violent or aggressive behavior, this presents an immediate danger; a face-to-face physician assessment is needed within 1 hour to determine the patient’s need for the restraint.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Comprehension REF: Text reference: pp. 311-312 OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Evaluation of Patient Condition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. When assessing a patient, a nurse notes that the skin distal to a restraint is pale and cool to the
touch. Which of the following interventions will the nurse perform first? a. Remove the restraint. b. Loosen the restraint. c. Obtain a larger restraint. d. Reapply the restraint with more padding. ANS: A
If a patient has altered neurovascular status of an extremity, such as cyanosis, pallor and coldness of skin, or complaints of tingling, pain, or numbness, remove the restraint immediately, and notify the physician. Loosening the restraint may not effectively restore adequate circulation. An improperly sized restraint may not provide the protection needed for the patient. DIF: Cognitive Level: Application REF: Text reference: p. 312 OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Altered Neurovascular Status of an Extremity KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. A nurse enters the room of a patient who is sitting in a chair and begins to have a seizure. To
promote patient safety, which nursing intervention will the nurse initially perform? a. Immediately call for assisNtanR Uce.SINGTB.COM b. Assist the patient to the floor. c. Put the patient back into the bed. d. Insert a padded tongue blade into the patient’s mouth. ANS: B
When the seizure begins, position the patient safely. If the patient is standing or sitting, guide the patient to the floor and protect the head by cradling in the nurse’s lap or placing a pillow under the head. Clear the surrounding area of furniture. If the patient is in bed, raise the side rails and pad, and put the bed in a low position. Stay with the patient, and observe the sequence and timing of seizure activity. Continued observation ensures adequate ventilation during and after a seizure and will assist in documentation, diagnosis, and treatment of a seizure disorder. If possible, turn the patient onto one side, with the head tilted slightly forward. This allows the tongue to fall away from the airway, permitting drainage of saliva and vomitus, and prevents aspiration. Do not force any objects such as fingers, medicine or tongue depressor, or airway into the patient’s mouth when the teeth are clenched. This could cause injury to the mouth and stimulate gagging, which could lead to aspiration. DIF: Cognitive Level: Application REF: Text reference: p. 316 OBJ: Describe nursing interventions for a patient who experiences generalized seizures. TOP: Seizures KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. What should the nurse do to prevent a patient from aspirating during a seizure? a. Insert an oral airway.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. Restrain the patient securely. c. Sit the patient upright. d. Turn the patient onto his/her side. ANS: D
If possible, turn the patient onto the side, with the head flexed slightly forward. This position prevents the tongue from blocking the airway and promotes drainage of secretions, thus reducing the risk for aspiration. Do not force any objects such as fingers, medicine or tongue depressor, or airway into the patient’s mouth when the teeth are clenched. This could cause injury to the mouth and could stimulate gagging, leading to possible aspiration. Do not restrain the patient. Loosen clothing to prevent musculoskeletal injury and airway obstruction. When a seizure begins, position the patient safely. If the patient is standing or sitting, guide the patient to the floor and protect the head by cradling in the nurse’s lap or placing a pillow under the head. Clear the surrounding area of furniture. If the patient is in bed, raise the side rails and pad, and put the bed in a low position. DIF: Cognitive Level: Application REF: Text reference: p. 316 OBJ: Describe nursing interventions for a patient who experiences generalized seizures. TOP: Aspiration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. A safe health care environment is one in which: (Select all that apply.) a. the patient’s basic needs are met. b. physical hazards are reduced. c. transmission of microorgN anis is N reGduc URmsSI TBed.. COM d. sanitary measures are carried out. ANS: A, B, C, D
A safe environment is one in which the patient’s basic needs are met, physical hazards are reduced or eliminated, transmission of microorganisms is reduced, and sanitary measures are carried out. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 295-296 OBJ: Describe methods used to evaluate interventions designed to maintain or promote a patient’s safety. TOP: Safe Environment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Effective fall prevention programs include which of the following? (Select all that apply.) a. Risk assessment b. Medication reviews c. Use of assistive devices d. Exercise and strength training ANS: A, B, C, D
Evidence shows that hospital-based fall prevention programs that focus on a multifactorial approach reduce fall rates (CDC, 2006). Effective fall prevention programs include risk assessment, medication reviews with necessary modifications, use of assistive devices, exercise and strength training, and education for home safety.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Comprehension REF: Text reference: pp. 296-297 OBJ: Discuss current evidence in the area of fall prevention. TOP: Fall Prevention Programs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Which of the following fall prevention strategies should the nurse perform on all hospitalized
patients? (Select all that apply.) a. Conduct hourly rounds. b. Provide the patient regular toileting. c. Assess the patient’s comfort needs. d. Evaluate the effectiveness of pain medication. ANS: A, B, C
A recent study shows that hourly nurse rounds are an effective strategy for reducing falls. Combining hourly rounds with activities such as regular toileting and assessing the patient’s comfort needs manages those factors that often prompt patients to get out of bed without assistance. In the hospital setting, a variety of fall risk factor screening tools are available. Because multiple risk factors for falls are known, no single assessment tool is sensitive and specific for analyzing fall risk. DIF: Cognitive Level: Comprehension REF: Text reference: p. 302|Text reference: p. 305 OBJ: Describe nursing interventions specific for reducing the risk for falls. TOP: Fall Prevention Programs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. Which of the following alternatives to physical restraints should the nurse use to promote
patient safety? (Select all that apply.) a. Environmental modifications b. Less frequent patient obsN erU vaR tiS onINGTB.COM c. Involvement of family during visitation d. Frequent reorientation of the patient ANS: A, C, D
Many alternatives to the use of restraints are available, and you should try all of them before using restraints. Modification of the environment is an effective alternative to restraints. More frequent observation of patients, involvement of family during visitation, and frequent reorientation are helpful measures. DIF: Cognitive Level: Application REF: Text reference: p. 304 OBJ: Describe steps in the design of a restraint-free environment. TOP: Alternatives to Physical Restraint KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The use of restraints has been associated with which of the following complications? (Select
all that apply.) a. Pressure ulcers b. Pneumonia c. Constipation d. Death ANS: A, B, C, D
The use of restraints is associated with several serious complications, including pressure ulcers, hypostatic pneumonia, constipation, incontinence, and death.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Comprehension REF: Text reference: p. 308 OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Applying Physical Restraints KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. When working with a patient who has a new seizure disorder, the nurse is alerted to the need
for further instruction when the patient tells the nurse: (Select all that apply.) a. “I will avoid over-the-counter medications that contain alcohol.” b. “I have the medications that I take listed on this card that I carry with me.” c. “I will be sure to take my medications as prescribed by my provider.” d. “I will visit my physician right after I return home from my next trucking job.” ANS: B, D
Patients should wear a medical alert bracelet or carry an identification card noting the presence of seizure disorder and listing medications taken. Without a medical alert bracelet or identification noting the presence of seizure disorder and medications taken, just having the medications at work or home will not necessarily mean that the appropriate treatment will be started. A seizure condition usually imposes driving limitations. It is recommended that a waiting period of 1 seizure-free year elapses before the patient attempts to drive or operate dangerous equipment. DIF: Cognitive Level: Application REF: Text reference: p. 318 OBJ: Describe nursing interventions for a patient who experiences generalized seizures. TOP: Teaching Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION
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1. It is important for nurses to understand what patients perceive as
so that patients
will become partners in programs to prevent them. ANS:
errors mistakes problems Patients consider falls, communication problems, and lack of nurse responsiveness as errors, along with medication errors and injury from medical equipment. It is important for nurses to understand what patients perceive as errors, so that patients will become partners in programs to prevent errors. DIF: Cognitive Level: Comprehension REF: Text reference: p. 296 OBJ: Describe methods used to evaluate interventions designed to maintain or promote a patient’s safety. TOP: Medical Errors KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. More than
United States. ANS:
one million
patients are injured in falls in inpatient settings annually in the
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 1 million Patient falls are the most common type of inpatient accidents in the United States. TJC recommends that all hospitals develop a fall prevention program and evaluate its effectiveness regularly. DIF: Cognitive Level: Knowledge REF: Text reference: p. 297 OBJ: Describe methods used to evaluate interventions designed to maintain or promote a patient’s safety. TOP: Medical Errors KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Health care facilities must provide employees access to information about the properties of
particular chemicals and information for handling substances in a safe manner. Facilities do this by providing . ANS:
material safety data sheets (MSDSs) Health care facilities provide employees access to a material safety data sheet (MSDS) for each hazardous chemical. An MSDS is a form that contains data about the properties of a particular chemical and information for handling a substance in a safe manner (e.g., storage, disposal, protective equipment, spill handling procedures). DIF: Cognitive Level: Comprehension REF: Text reference: p. 313 OBJ: Describe methods used to evaluate interventions designed to maintain or promote a patient’s safety. TOP: Material Safety Data Sheets (MSDS) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
are the most common type of inpatient accident.
4. ANS:
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Falls Falls are the most common type of inpatient accident. Approximately 30% of hospital patient falls result in physical injury. DIF: Cognitive Level: Comprehension REF: Text reference: p. 297 OBJ: Discuss current evidence in the area of fall prevention. TOP: Falls KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The use of physical restraints is one safety strategy that has been used to protect patients from
injury. However, physical restraints should be used as a when reasonable alternatives have failed.
and are used only
ANS:
last resort The use of physical restraints is one safety strategy that has been used to protect patients from injury. However, efforts have been in place for several years by the Centers for Medicare and Medicaid Services and The Joint Commission to reduce the use of restraints and to use them only under extreme caution. Physical restraints are the last resort and are used only when reasonable alternatives have failed. DIF: Cognitive Level: Application REF: Text reference: p. 307 OBJ: Describe steps in the design of a restraint-free environment.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Physical Restraint MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step: Assessment
6. An
maintains immobilization of the extremities to protect the patient from accidental removal of a therapeutic device. ANS: extremity restraint DIF: Cognitive Level: Comprehension REF: Text reference: p. 309 OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Extremity Restraints KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
7. A thumb-less device used to restrain patients’ hands to prevent them from dislodging invasive
equipment, removing dressings, or scratching is known as a
.
ANS:
mitten restraint A mitten restraint is a thumb-less mitten device that restrains patients’ hands and prevents patients from dislodging invasive equipment, removing dressings, or scratching, yet it allows greater movement than is permitted with a wrist restraint. DIF: Cognitive Level: Comprehension REF: Text reference: p. 309 OBJ: Discuss precautions used to prevent injury in patients who are restrained. TOP: Mitten Restraints KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8.
are sudN den , ab norm ndCex cessive electrical discharges from the brain R I Gal, Ba. M U S N T O that change motor or autonomic function, consciousness, or sensation. ANS:
Seizures Seizures are sudden, abnormal, and excessive electrical discharges from the brain that change motor or autonomic function, consciousness, or sensation. DIF: Cognitive Level: Knowledge REF: Text reference: p. 315 OBJ: Describe nursing interventions for a patient who experiences generalized seizures. TOP: Seizures KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. Continuous seizure activity that lasts longer than 10 minutes is known as ANS:
status epilepticus Continuous seizure activity that lasts longer than 10 minutes is status epilepticus, which is a medical emergency. DIF: Cognitive Level: Knowledge REF: Text reference: p. 315 OBJ: Describe nursing interventions for a patient who experiences generalized seizures. TOP: Status Epilepticus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 14: Disaster Preparedness MULTIPLE CHOICE 1. In addition to the Department of Homeland Security, which of the following agencies has a
mission to ensure that the nation is well prepared to respond to an act of terrorism? a. AMA b. Red Cross c. CDC d. Salvation Army ANS: C
The Centers for Disease Control and Prevention (CDC) is recognized as the leading federal agency designed to protect the health and safety of people at home and abroad. The mission of the CDC’s Coordinating Office for Terrorism Preparedness and Emergency Response (COTPER) is to protect the health and enhance the living of all people in terms of community preparedness and response. The CDC’s mission is to ensure that the nation is well prepared to respond to an act of terrorism (CDC, 2003). The American Medical Association has developed a series of National Disaster Life Support courses “designed to provide a uniform, coordinated approach to all-hazards disaster management,” but these courses are not designed specifically to combat terrorism. The CDC works with the American Red Cross because both are advocates of preparedness and coordination of prompt, effective emergency efforts. This preparedness coordination goes far beyond these individual agencies and includes outreach to other agencies or groups through mutual aid agreements. However, the CDC is the preeminent agency in this field. Other agencies (e.g., department stores, the Salvation Army, Goodwill) provide clothing. Their effortN s arR e noIt diG rectB ed.pCrimM arily toward terrorist activity.
U S N T
O
DIF: Cognitive Level: Comprehension REF: Text reference: p. 324 OBJ: Discuss guidelines for patient care in the event of mass casualty care. TOP: Centers for Disease Control and Prevention (CDC) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Personal protection equipment is categorized by the level of safety provided. Standard work
uniforms or work clothes offer what level of protection? a. Level A b. Level B c. Level C d. Level D ANS: D
Standard work uniforms or work clothes offer level D protection. There is no respiratory protection. Standard precautions are important to take when level D protection is used. Level A protection provides maximum protection because it offers self-contained breathing apparatus, fully encloses the individual, and includes chemical-resistant boots and gloves. Level B protection provides respiratory protection but less skin protection. Used by trained responders, this PPE includes self-contained breathing apparatus, a hooded chemical-resistant suit, and face, boot, and glove protection. First responders (those emergency personnel first on the scene) and hospital personnel are trained and fitted to use level C protection. As with level A and B protection, level C protection presents danger to the user, primarily for dehydration and hyperthermia.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Comprehension REF: Text reference: p. 327 OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure. TOP: Levels of Safety KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. The most recently labeled level of protection is BioPPE. The use of BioPPE requires which of
the following items? a. Self-contained breathing apparatus b. Respiratory protection but less skin protection c. Chemically resistant boots and gloves d. Standard work clothes, contact and respiratory protective devices ANS: D
The most recently labeled level of protection is BioPPE. BioPPE requires the use of standard work clothes, along with contact and respiratory protection. Double gloving and an N95 mask or a better respirator is recommended. Level A protection provides maximum protection in that it offers a self-contained breathing apparatus, fully encapsulates the individual, and includes chemically resistant boots and gloves. BioPPE protection is not adequate when caring for patients exposed to toxic chemicals; however, it provides adequate protection against radiological and biological agents. DIF: Cognitive Level: Application REF: Text reference: p. 327 OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure. TOP: BioPPE KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Upon arriving at a mass causN alityRsceIne,GheaB lt. hC careMproviders using the SALT approach will
U S N T
O
initiate triage by doing which of the following first? a. Assess b. Move c. Sort d. Send ANS: C
In the SALT process, the first step is to sort the affected individuals in to groups so that they may be assessed individually. Category 1 includes those who are not moving and have life-threatening injuries. Category 2 includes those who are able to wave or have purposeful movement. Category 3 consists of those able to walk on their own. DIF: Cognitive Level: Comprehension REF: Text reference: p. 327 OBJ: Discuss guidelines for patient care in the event of mass casualty care. TOP: Triage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. Disaster nursing differs from general nursing because when caring for patients during a
disaster: a. the focus is on caring for the sickest people first. b. using a color tag system reduces the amount of emotional stress on the nurse. c. the focus is no longer on airway, breathing, and circulation. d. the focus is on caring for those most likely to survive.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: D
Disaster nursing differs from general nursing in that the focus shifts from caring for the sickest people first to saving the greatest number of lives. Triage sorts the victims in to groups with color coded tags which identify status—black for the dead or mortally injured, red for those in need of immediate attention to survive, yellow for those seriously injured but more stable than individuals coded "red", and green for those with minimal injuries, This allows the rescue teams to direct resources in a most effective manner to save the greatest number of lives. DIF: Cognitive Level: Comprehension REF: Text reference: p. 328 OBJ: Discuss guidelines for patient care in the event of mass casualty care. TOP: Disaster Nursing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse has arrived at the scene of a natural disaster and is assigned to care for four patients.
To which patient should the nurse provide care first? a. Patient with a closed head injury with no changes in level of consciousness b. Patient with a 3-cm laceration to the forearm c. Patient who is breathing eight times per minute d. Patient with a displaced wrist fracture ANS: C
Nursing care should be prioritized when multiple patients are cared for at once. ABCs (airway, breathing, and circulation) should always take precedence. The patient who is breathing only eight times per minute is in need of immediate nursing care. The goal of triage is to sort, assess, and perform lifesaving measures as quickly as possible for large numbers of victims.
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DIF: Cognitive Level: Analysis REF: Text reference: p. 328 OBJ: Discuss guidelines for patient care in the event of mass casualty care. TOP: Disaster Nursing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The patient is brought into the emergency department as part of an MCI. The patient has white
powder on his clothes, and it is suspected that the patient has been exposed to anthrax. What should the nurse do first? a. Cut off the patient’s clothing and place it in a plastic bag. b. Have the patient remove his sweater by pulling it over his head. c. Avoid using oxygen that could decrease the patient’s oxygen drive. d. Provide the patient with appropriate antibiotics. ANS: A
If you suspect anthrax, remove the patient’s clothing and place it in a labeled plastic biohazard bag. Do not have the patient pull clothing off over the head, but rather cut off clothing. Administer oxygen therapy. Various biological agents (e.g., pulmonary anthrax) commonly cause respiratory symptoms that will result in an altered gas exchange. Exposure to these agents is commonly treated with ciprofloxacin and/or doxycycline, and botulism requires supportive care and use of an antitoxin. DIF: Cognitive Level: Application REF: Text reference: p. 334 OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Anthrax KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. Which of the following biological agent requires the use of an antitoxin if exposure occurs? a. Anthrax b. Plague c. Botulism d. Typhoid ANS: C
Botulism requires supportive care and use of an antitoxin. Attack with various biological agents (e.g., anthrax, plague, typhoidal tularemia) is commonly treated with ciprofloxacin and/or doxycycline. DIF: Cognitive Level: Application REF: Text reference: p. 331 OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure. TOP: Botulism KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The patient is admitted to the emergency department with possible smallpox exposure. The
patient has never had a smallpox immunization. The nurse prepares to administer a smallpox vaccination, realizing that vaccination: a. within 3 days of exposure will completely prevent the disease. b. is effective only if received before exposure. c. 4 to 7 days after exposure will completely prevent the disease. d. within 3 days will offer only some protection from disease. ANS: A
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In the event that smallpox is the biological weapon, the best treatment is prevention by immunization with vaccinia vaccine before the onset of symptoms. Vaccination within 3 days of exposure will completely prevent the disease or will significantly reduce its effect. Vaccination 4 to 7 days post exposure offers some protection from disease or will decrease the severity of disease. DIF: Cognitive Level: Application REF: Text reference: p. 334 OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure. TOP: Smallpox KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. If a patient is receiving radiation using gamma rays, the nurse would be watching for which of
the following? a. Severe pain during administration b. Development of an allergy to shellfish c. Severe burns or internal injury d. Confusion and lethargy ANS: C
Gamma rays pose the greatest health risk because the waves penetrate deeply, causing severe burns and internal injury. Radiation does not cause patients to develop an allergy to shellfish and is painless during administration. Confusion and lethargy are not known side effects of radiation.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Analysis REF: Text reference: p. 340 OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure. TOP: Gamma Rays KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. After a suspected radiological exposure, the initial scan of the patient’s extremities is positive.
What will be the next step in this patient’s care? a. Washing the skin with soap and water while taking care not to irritate or abrade the skin b. Removing clothing to eliminate 70% to 90% of the contamination c. Isolating and covering up any skin that is positive for radiation using a plastic wrap d. Conducting a thorough survey of the patient’s entire body with the radiation sensing equipment ANS: D
If the initial assessment of the patient’s face, hands, and feet is positive for radiation exposure the specially trained technician will a more thorough assessment of the patient’s entire body. Determining the amount and level of radiation is important in determining the level of danger to the caretaker and the level of care required for the patient. This determination precedes any other care. DIF: Cognitive Level: Application REF: Text reference: p. 341 OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure. TOP: Assessment of Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. How is a disaster best defined? a. Any event or situation thaNt U reR sult inGmu lti. plC eO caMsualties and/or deaths SIs N TB b. A catastrophic and/or destructive event that disrupts normal functioning c. An industrial accident and unplanned release of nuclear waste d. An event that results in human casualties that overwhelm available health care
resources ANS: B
A disaster is defined as a catastrophic and/or destructive event that disrupts normal functioning; it may include any anticipated or unexpected event whose effects lead to significant destruction and/or adverse consequences. Any event or situation that results in multiple casualties and/or deaths is called a mass casualty incident (MCI). An industrial accident with unplanned release of nuclear waste is classified as a technological disaster. A medical disaster is a catastrophic event that results in human casualties that overwhelm available health care resources. DIF: Cognitive Level: Comprehension REF: Text reference: p. 323 OBJ: Discuss the characteristics of different types of disasters. TOP: Disasters KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. Dispersal of biological agents is a real and psychological terrorist threat. Which of the
following organisms has the potential to cause the greatest harm? a. Anthrax b. Ricin c. Salmonella
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. Hantavirus ANS: A
Category A organisms are considered the greatest threat because they can be transmitted easily from person to person and can cause high mortality with a potential for major public health impact. Of the organisms listed here, only anthrax (Bacillus anthracis) is considered a Category A organism. Category B organisms are moderately easy to disseminate and cause moderate morbidity and low mortality. They are considered high-risk organisms. Ricin toxin and Salmonella are classified as Category B. Hantavirus is considered a Category C organism or a pathogen that could be engineered for mass dissemination. DIF: Cognitive Level: Comprehension REF: Text reference: p. 325 OBJ: Discuss the characteristics of different types of disasters. TOP: Potential Organisms for Bioterrorism by CDC Category KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Which of the following are goals of the Department of Homeland Security (DHS)? (Select all
that apply.) a. Prevention of terrorist attacks b. Response to disasters c. Recovery from disasters d. Coordination of efforts among agencies ANS: A, D
The DHS focuses on efforts to prevent terrorist attacks and coordination of efforts of multiple agencies to maintain the safeN tyUoR f tS heIU . NnGitTedBS.taCteOsM DIF: Cognitive Level: Comprehension REF: Text reference: p. 323 OBJ: Discuss guidelines for patient care in the event of mass casualty care. TOP: Department of Homeland Security (DHS) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Which of the following should make the nurse suspect a biological event? (Select all that
apply.) a. Large numbers of ill persons with unexplained similar symptoms b. Unexplained deaths among young and healthy populations c. A patient population with symptoms suggestive of a common agent d. An unusual geographical pattern associated with the symptoms ANS: A, B, D
You should suspect a biological event when large numbers of ill persons present who have unexplained yet similar symptoms; when unexplained deaths occur, particularly among young and healthy populations; when an unusual pattern (e.g., geographical, season, patient population) is associated with the symptoms; when the patient fails to respond to traditional therapy; and when a single patient presents with symptoms suggestive of an uncommon agent (e.g., anthrax, smallpox). Once you suspect a biological event, notify incident command immediately. DIF: Cognitive Level: Comprehension
REF: Text reference: p. 333
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure. TOP: Bioterrorism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Why are children particularly vulnerable to environmental toxins? (Select all that apply.) a. They have stronger immune systems. b. They take in proportionally larger doses of toxins from food, water, and the air. c. Their organ systems are less able to remove toxins than adult organs systems. d. They have a greater number of years of life expectancy. ANS: B, C, D
Children are particularly vulnerable to environmental toxins because they take in larger doses, pound-for-pound, of toxins than adults, their organ systems are less able to remove the toxins than those of adults, and they have a greater number of years of life expectancy over which to develop complications from the toxic exposure. DIF: Cognitive Level: Comprehension REF: Text reference: p. 335 OBJ: Discuss guidelines for patient care in the event of mass casualty care. TOP: Psychological Status KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The patient is admitted with exposure to an unknown chemical. His clothing appears to be
grossly contaminated. What should the nurse do? (Select all that apply.) a. Avoid touching contaminated parts of clothing. b. Pull the patient’s tee shirt off over his head. c. Cut the patient’s clothes off. d. Wash the patient with large amounts of soap and water. ANS: A, C, D
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Remove all of the patient’s clothing, but do not pull it over the patient’s head; instead, cut garments off. Act quickly, and avoid touching contaminated parts of clothing as much as possible. Decontaminate the patient using large amounts of soap and water to wash the patient thoroughly. DIF: Cognitive Level: Application REF: Text reference: p. 335 |Text reference: p. 338 |Text reference: p. 342 OBJ: Discuss guidelines for patient care in the event of mass casualty care. TOP: Decontamination KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. The government agency that coordinates the efforts of multiple organizations to secure and
maintain the safety of our nation is the
.
ANS:
Department of Homeland Security (DHS) The Department of Homeland Security (DHS) was established to provide a unifying core as the basis for efforts to prevent and discourage terrorist attacks. This governmental agency coordinates the efforts of multiple organizations to secure and maintain the safety of our nation.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Comprehension REF: Text reference: p. 323 OBJ: Discuss guidelines for patient care in the event of mass casualty care. TOP: Department of Homeland Security (DHS) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The strategic plan of the Centers for Disease Control and Prevention in the event of a disaster
first focuses on
.
ANS:
preparedness The CDC’s strategic plan in the event of a disaster first focuses on preparedness, which is key to the impact that any disaster has on the individuals or communities involved. Preparedness requires that nurses have a basic understanding of the science of a disaster and an understanding of the key components of any plan to deal with an MCI. DIF: Cognitive Level: Comprehension REF: Text reference: p. 324 OBJ: Describe elements of the CDC’s strategic plan for disasters. TOP: The Centers for Disease Control and Prevention (CDC) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. In the event of a mass casualty incident, part of the CDC’s disaster preparedness program
involves backup plans for maintaining public and intraagency/interagency _
.
ANS:
communication Traditional modes of communication will likely be interrupted in the event of an MCI; therefore part of disaster prepNaU reR dnSeI ssNinGvT olB ve.s C baOcM kup plans for maintaining public and intraagency/interagency communication (e.g., use of two-way radios and satellite phones). DIF: Cognitive Level: Comprehension REF: Text reference: p. 324 OBJ: Describe elements of the CDC’s strategic plan for disasters. TOP: The Centers for Disease Control and Prevention (CDC) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. An outbreak of influenza A in the same geographical location is known as an
.
ANS:
epidemic An epidemic is an infectious disease or condition that attacks many people at the same time in the same geographical area. DIF: Cognitive Level: Comprehension REF: Text reference: p. 323 OBJ: Discuss the characteristics of different types of disasters. TOP: Epidemic KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. An outbreak of an infectious disease such as SARS in many parts of the world is known as a
. ANS:
pandemic A pandemic is an epidemic that occurs in many parts of the world.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Comprehension REF: Text reference: p. 323 OBJ: Discuss the characteristics of different types of disasters. TOP: Pandemic KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. It is recommended that every household prepare a
.
ANS:
disaster supply kit Every household should prepare a disaster supply kit that includes basic items (water, can opener, utility knife, food, first-aid kit, identification, etc.) but items unique to members of the household, like hearing aid batteries or an extra pair of glasses. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 335-336 OBJ: Discuss the characteristics of different types of disasters. TOP: Disaster Supply Kit KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 7. An
provides a standard approach to managing emergencies in which multiple agencies are involved. ANS:
incident command system An incident command system (ICS), also referred to as the incident management system (IMS), provides a standard approach to managing emergencies in which multiple agencies are involved. DIF: Cognitive Level: Comprehension REF: Text reference: p. 325 OBJ: Identify actions to take iN n the bi ol. ogC ical , chemical, and radiation exposure. UReve SIntNoGfKEY: TB OM TOP: Incident Command Systems Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 8. Hurricane Zee has caused severe flooding and loss of power throughout the state. The local
community has a stockpile of supplies that will help it get through the next 72 hours. Beyond this, once local and federal authorities confirm the need, a “push package” of supplies will be issued within 12 hours of the confirmation. These supplies will come from the . ANS:
strategic national stockpile (SNS) The CDC has developed a strategic national stockpile (SNS) that contains large quantities of medical equipment in the event of a disaster. Most local communities will be prepared to provide essential resources for up to 72 hours (via hospitals, pharmacies, etc.) to support local needs. Once local and federal authorities confirm the need for the SNS, and upon request of the affected state’s governor’s office, the 12-hour push package is flown or transported within 12 hours to any state in the United States. The 12-hour push package contains approximately 100 steel containers that hold pharmaceuticals (prepackaged 10-day supplies of antibiotics, antidotes, narcotics, epinephrine, albuterol, prednisone, etc.), IV fluids and IV supplies, ventilators, suction equipment, airway supplies, tablet counting machines, and other emergency provisions. DIF: Cognitive Level: Application REF: Text reference: p. 327 OBJ: Discuss guidelines for patient care in the event of mass casualty care.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Strategic National Stockpile (SNS) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9.
is the sorting of individuals by the seriousness of their condition and the likelihood of their survival. ANS:
Triage Triage is the sorting of individuals by the seriousness of their condition and the likelihood of their survival. DIF: Cognitive Level: Knowledge REF: Text reference: p. 328 OBJ: Discuss guidelines for patient care in the event of mass casualty care. TOP: Triage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The terrorist act of releasing a biological agent into a specified environment is known as
. ANS:
bioterrorism biological attack Bioterrorism or a biological attack is the result of the release of a biological agent into a specified environment. DIF: Cognitive Level: Comprehension REF: Text reference: p. 330 OBJ: Identify actions to take iN n the ol. ogC ical , chemical, and radiation exposure. UReve SIntNoGf bi TB OM TOP: Bioterrorism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. The patient is being treated for biological agent exposure and is resting in the emergency
department bay. It is important that the nurse evaluate changes in airway, breathing, and circulation, as well as . ANS:
psychological status Observe for improved airway maintenance, breathing, circulation, level of consciousness, and neurological functioning. Evaluate vital signs, the condition of the patient’s skin, and changes that suggest improvement or deterioration of psychological status. Ask the patient, “How do you feel right now?” Check level of orientation and ability to conduct conversation. This evaluates the patient’s response to emotional trauma. DIF: Cognitive Level: Application REF: Text reference: p. 333 OBJ: Describe psychosocial effects of disasters on patients. TOP: Psychological Status KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. For safety reasons, rescue workers should be upwind and uphill from a toxic chemical disaster
scene to avoid exposure. The exception is when _ is lighter than air.
has been released, because it
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS:
cyanide gas For safety reasons, rescue workers should be upwind and uphill from a toxic chemical disaster scene to avoid exposure. The exception is when cyanide gas has been released. Cyanide is lighter than air and thus will travel uphill. It has the unique smell of bitter almonds. DIF: Cognitive Level: Comprehension REF: Text reference: p. 336 OBJ: Discuss guidelines for patient care in the event of mass casualty care. TOP: Cyanide Gas KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. A patient has been exposed to a toxic chemical. The nurse’s first priority is
. ANS:
decontamination Suspect a toxic chemical event when large numbers of ill persons present who have unexplained yet similar symptoms. The primary objective for initial care is decontamination, the process used to remove harmful contaminants from the surface of the skin. You achieve this by removing clothing, scrubbing the skin, and performing hydrolysis, a process of chemical dilution in which large volumes of water are used. DIF: Cognitive Level: Comprehension REF: Text reference: p. 336 OBJ: Discuss guidelines for patient care in the event of mass casualty care. TOP: Decontamination KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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14. The dispersal of radioactive material via a “dirty bomb” or by deliberate contamination of
food supplies or water supplies is known as a
.
ANS:
radiological event A radiological event is the dispersal of radioactive material via a “dirty bomb” or by deliberate contamination of food supplies or water supplies or over the terrain. DIF: Cognitive Level: Knowledge REF: Text reference: p. 340 OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure. TOP: Radiological Event KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. Releasing nuclear energy in an explosive manner as the result of a nuclear chain reaction is
known as a
.
ANS:
nuclear event A nuclear event involves a device that releases nuclear energy in an explosive manner as the result of a nuclear chain reaction. DIF: Cognitive Level: Knowledge REF: Text reference: p. 340 OBJ: Identify actions to take in the event of biological, chemical, and radiation exposure. TOP: Nuclear Event KEY: Nursing Process Step: Assessment
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 15: Pain Assessment and Basic Comfort Measures MULTIPLE CHOICE 1. The nurse is caring for a patient who is a devout Orthodox Jew. The patient is on a
patient-controlled analgesia (PCA) pump. What accommodations might the nurse have to make to conform to the patient’s cultural needs? a. Ask the patient whether he will need alternative forms of medication for the Sabbath. b. Ask the patient specific questions because Jews tend to be stoic regarding pain. c. Medicate the patient “around the clock” instead of as needed (“prn”). d. Understand that Jews believe that suffering is a consequence of actions in a previous life. ANS: A
Orthodox or Observant Jews may not use electrical equipment during the Sabbath and on Holy Days; therefore, the staff should program the PCA to achieve optimum pain relief. Alternative methods will be needed during these times. Cultures vary regarding when to recognize pain, what words to use in expressing pain, when to seek treatment, and what treatments are desirable. Russians, Asians, and Native Americans tend to be stoic, whereas Italians, Puerto Ricans, and Jews tend to be more expressive. The nurse should ask the patient about his preferences. Some Hindu patients believe that suffering is a consequence of actions in a previous life. For example, a belief in the concept of Karma motivates the patient to bear the pain, refuse pain medications, and suffer in silence. Some Jews view pain as a communal suffering that they should share with others to affirm their life experience.
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DIF: Cognitive Level: ComprehU ensiS on N RT EF: TeO xt reference: p. 348 OBJ: Assess a patient’s level of pain. TOP: Cultural Considerations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The patient is admitted with chronic pain. She states that nothing takes the pain away totally,
but that “Dilaudid works best.” The fact that the patient calls the medication by name should alert the nurse to: a. suspect that the patient is drug seeking. b. expect that the patient may need smaller doses than normal. c. assess the patient’s acceptable level of comfort. d. accept the fact that nothing will help this patient’s pain. ANS: C
It is important to assess the patient’s acceptable level of comfort so that both you and the patient are striving for the same outcome. Some patients with prior pain conditions can alert the nurse to pain-relieving measures that were successful. Patients with chronic/persistent pain are often familiar with the names and actions of medications, including opioid medications. This should not cause you to view the patient negatively or with suspicion. Patients currently receiving opioids for chronic pain often require higher doses of analgesics to alleviate new pain. Do not accept that “there is nothing that will help this patient’s pain.” Learn the institutional policy for how to proceed in this situation. DIF: Cognitive Level: Application OBJ: Assess a patient’s level of comfort.
REF: Text reference: pp. 348-349
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Assessment of Comfort Level MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step: Implementation
3. The nurse frequently must assess a patient who is experiencing pain. When assessing the
intensity of the pain, the nurse should: a. ask whether there are any precipitating factors. b. question the patient about the location of the pain. c. offer the patient a pain scale to objectify the information. d. use open-ended questions to find out about the sensation. ANS: C
Descriptive scales are an objective means of measuring pain intensity. Use a pain intensity scale appropriate to the patient’s age, developmental level, and comprehension, and ask the patient to rate the pain. An appropriate pain rating scale is reliable, easily understood, and easy to use, and it reflects changes in pain intensity. Asking the patient what precipitates the pain does not assess intensity, but rather assesses the pain pattern. Asking the patient about the location of pain does not assess the intensity of the patient’s pain. To determine the quality of the patient’s pain, the nurse may ask open-ended questions to find out about the sensation experienced (e.g., “Tell me what your pain feels like”). This approach assists in identifying the underlying pain mechanism (e.g., somatic or neuropathic pain), but it may not reveal intensity or changes in intensity. DIF: Cognitive Level: Application REF: Text reference: pp. 347-348|Text reference: pp. 362-363 OBJ: Assess a patient’s level of comfort. KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
TOP: Assessing Pain Intensity
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4. The nurse who is caring for a patient postoperatively notes that he is expressing discomfort
and is diaphoretic. Which of the following interventions is most appropriate? a. Straighten the bed linens. b. Change the saturated surgical dressing. c. Administer prescribed pain medications. d. Check for displaced equipment underneath the patient. ANS: C
Administer pain-relieving medications as ordered. Analgesics are the cornerstone of pain management. Smoothing wrinkles in bed linens may reduce pressure and irritation to the skin; however, pain-relieving medication should be given first. Changing a wet surgical dressing might not be needed if the patient has received a wet-to-dry dressing as treatment, or if not changing the dressing will reduce irritation to the skin but will not address the discomfort. Reposition underlying tubes, wires, or equipment that may apply pressure directly to dependent skin surfaces. Removing these stimuli may maximize the response to pain-relieving interventions such as medication, but pain-relieving medication should be administered first. DIF: Cognitive Level: Application REF: Text reference: p. 350 OBJ: Identify skills appropriate for relieving a patient’s reported pain. TOP: Treatment of Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 5. The patient’s family is concerned that the patient may get too much pain medication after
surgery and become addicted to the medication if he is placed on a PCA pump. They also voice concern about the effectiveness of the PCA. The nurse should instruct the family and the patient that: a. pain relief with the PCA pump is not as good as when the nurse provides it, but it does save on nursing time. b. pain relief is good when the medication peaks, but less so when the levels drop, and that is when the patient will know that he needs more. c. because the device provides medication as soon as the patient needs it, he will probably use less of the medication. d. the patient will be kept in bed for several days after surgery to make sure it is safe to ambulate. ANS: C
Because the device provides medication on demand as soon as the patient feels the need, the total amount of opioid use is reduced. Because the blood level stays within a narrow range of the minimum effective analgesia concentration for the individual, pain relief is enhanced, and the incidence of side effects, such as sedation and respiratory depression, is decreased. The PCA has several advantages. It allows more constant serum levels of the opioid and, as a result, avoids the peaks and troughs of a large bolus. An advantage of PCA is that when used postoperatively, fewer complications arise because earlier and easier ambulation occurs as a result of effective pain relief. DIF: Cognitive Level: Comprehension REF: Text reference: p. 353 OBJ: Teach a patient to use a PCA device. TOP: Patient-Controlled Analgesia (PCA) KEY: Nursing Process Step: Implementation B.C M N R I G MSC: NCLEX: Physiological IntU egriS ty N T O 6. The nurse caring for a patient who has a PCA knows that it: a. allows the family to participate in pain management for the patient. b. prevents mistakes in medication administration. c. can be used by all hospitalized patients. d. provides a more constant level of medication. ANS: D
PCA allows more constant serum levels of the opioid, and, as a result, it avoids the peaks and troughs of a large bolus. Because the blood level is maintained within a narrow range of the minimum effective analgesia concentration for the individual, pain relief is enhanced, and the incidence of side effects, such as sedation and respiratory depression, is decreased. Potential concerns involving PCA use are pump failure, and operator errors. Patients may misunderstand how PCA therapy works, may mistake the PCA button for the nurse call button, or may have family members who operate the demand button. Instruct the family not to push the timing device for the patient unless the patient is unable to push the button himself, and the nurse has instructed the family to do so. Use of a PCA pump does not prevent mistakes. The pump may fail to deliver drug on demand, may have a faulty alarm or a low battery, or may lack free-flow protection. Operators may incorrectly program the dose, concentration, or rate. Not all patients are candidates for PCA. Assess the patient’s cognitive ability to determine the appropriateness of PCA pain management. DIF: Cognitive Level: Comprehension
REF: Text reference: p. 353
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Teach a patient to use a PCA device. TOP: Patient-Controlled Analgesia (PCA) KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 7. When evaluating the effects of PCA, the nurse notes that the patient is sedated and is difficult
to arouse. What step should the nurse take next? a. Insert an airway. b. Turn patient to the side. c. Stop the PCA. d. Expect this as a patient outcome of the therapy. ANS: C
If the patient is sedated and is not readily arousable, stop the PCA. As long as the patient has spontaneous respirations, instruct him or her to take deep breaths. Apply oxygen at 2 L via nasal cannula. Elevate the head of the bed 30 degrees, unless contraindicated, to facilitate respirations. Heavy sedation is not an expected outcome of PCA therapy. Evaluate for the presence of analgesic side effects. Maintain a slightly drowsy, easily aroused patient. DIF: Cognitive Level: Application REF: Text reference: p. 357 OBJ: Evaluate the effectiveness of pain management techniques. TOP: Patient-Controlled Analgesia (PCA) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The patient is scheduled for surgery late in the afternoon. His postoperative orders include
PCA therapy. Which of the following nursing interventions is appropriate to perform? a. Teach the patient about PCA after the patient comes out of recovery. b. Teach the patient about PN CA ore ryCand URbef SI NGsurg TBe. OMbefore preoperative medication administration. c. Tell the patient not to use PCA unless he can no longer tolerate the pain. d. Inform the patient’s family to watch him carefully and to depress the PCA administration button whenever they think he needs it. ANS: B
Instruct surgical patients preoperatively. Encourage the patient to push the button on the timing unit whenever he feels pain. Tell the patient not to delay if he is experiencing pain. Pain is easier to prevent than to treat. Inform the patient and family that the patient cannot overdose with PCA if only the patient pushes the button. The family should not push the button unless instructed to do so by the nurse. DIF: Cognitive Level: Application REF: Text reference: p. 357 OBJ: Teach a patient to use a PCA device. TOP: Patient-Controlled Analgesia (PCA) Teaching Consideration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse knows that an advantage of intraspinal analgesia is the: a. smaller doses of epidural than intrathecal medication. b. lack of significant patient complications. c. systemic distribution of morphine faster than fentanyl. d. ability to achieve appropriate analgesia with smaller dosages.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: D
Because opioids are delivered close to their site of action, the central nervous system (CNS), they have greater bioavailability and thus require much smaller doses to achieve adequate pain relief. Epidural and intrathecal doses are not equivalent. Intrathecal doses are much smaller than epidural doses. As an example, the epidural dose of morphine is 10 to 20 times greater than that required for an intrathecal dose. The catheter poses a threat to patient safety because of its anatomical location, its potential for migration through the dura, and its proximity to spinal nerves and vessels. Migration of an epidural catheter into the subarachnoid space can produce medication levels too high for intrathecal use. Fentanyl and sufentanil are hydrolipid, which causes them to have a quicker onset and a shorter duration of action (2 hours). Morphine and hydromorphone are hydrophilic, resulting in a longer onset and a longer duration of action (up to 24 hours with a single bolus dose). DIF: Cognitive Level: Comprehension REF: Text reference: p. 358 OBJ: Monitor and manage the patient who is receiving epidural analgesia. TOP: Intraspinal Analgesia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. The patient is in the hospital undergoing major abdominal surgery. When the patient returns
from the recovery room, the nurse expects that he most likely will be receiving pain medication: a. by mouth. b. intramuscularly. c. via the epidural route. d. intravenously.
N R I G B.C M Research shows the epidural roU uteS to bN e mT ost effeO ctive in managing postoperative pain from ANS: C
thoracic and abdominal surgeries. DIF: Cognitive Level: Comprehension REF: Text reference: p. 358 OBJ: Monitor and manage the patient who is receiving epidural analgesia. TOP: Intraspinal Analgesia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 11. While reviewing a patient’s medication history, the nurse determines that intraspinal analgesia
is contraindicated as a result of: a. previous spinal anesthesia. b. recent administration of anticoagulants. c. a history of cardiac problems. d. a diagnosis of advanced cancer. ANS: B
Recent anticoagulants sometimes contraindicate the placement of an epidural catheter because of the risk for epidural hematoma at the insertion site. Certain conditions may make epidural analgesia the method of choice for pain control: following surgery, for patients with trauma or advanced cancer that is not responsive to other pain management modalities, and those predisposed to cardiopulmonary complications because of a preexisting medical condition or surgery. Previous spinal anesthesia is not a contraindication for receiving subsequent spinal anesthesia.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Analysis REF: Text reference: pp. 358-361 OBJ: Monitor and manage the patient who is receiving epidural analgesia. TOP: Intraspinal Analgesia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. A nurse checks the continuous IV infusion for the intraspinal analgesia. The IV setup should
be changed if: a. tubing with a Y-port is attached. b. an infusion pump is attached. c. the tubing connections are all taped. d. a diluted, preservative-free medication is used. ANS: A
Use tubing without Y-ports for continuous infusions. Use of tubing without Y-ports prevents accidental injection or infusion of another medication meant for vascular space into epidural space. Normal equipment used for intraspinal infusion includes an infusion pump and compatible tubing without Y-ports. Catheter and injection cap or infusion pump tubing should be securely taped and labeled. Closed, intact systems prevent entry of pathogens and disruption of the flow of medication. Medication should be prediluted, preservative-free opioid or local anesthetic as prescribed by the physician and prepared for use in an IV infusion pump (usually prepared by pharmacy). Preservatives may be toxic to nerve tissue. DIF: Cognitive Level: Application REF: Text reference: pp. 359-361 OBJ: Monitor and manage the patient who is receiving epidural analgesia. TOP: Intraspinal Analgesia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
ural nuMrse aspirates and suspects that the catheter 13. Before administering an epidN URme SIdica NGtion TB, .thCe O has migrated into the subarachnoid space when: a. clear drainage is noted. b. no drainage is noted. c. purulent drainage is noted. d. redness, warmth, and edema are noted. ANS: A
Aspiration of more than 1 mL of clear fluid or bloody return means that the catheter may have migrated into the subarachnoid space or into a vessel. Do not inject the drug. Notify the physician. Purulent drainage is a sign of infection, indicating that local inflammation and superficial skin infection at the insertion site have occurred. DIF: Cognitive Level: Analysis REF: Text reference: p. 362 OBJ: Monitor and manage the patient who is receiving epidural analgesia. TOP: Catheter Migration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. The nurse is preparing to administer a bolus of epidural medication. The nurse must remember
to: a. clean the injection cap of the epidural catheter with an anti-infective according to
agency policy. b. clean the injection cap of the epidural catheter with alcohol. c. inject opioids quickly and smoothly.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. flush with saline after the injection. ANS: A
Clean the injection cap of the epidural catheter with povidone-iodine, or substitute anti-infective according to agency policy. Alcohol causes pain and is toxic to neural tissue. Inject opioid at a rate of 1 mL over 30 seconds. Slow injection prevents discomfort by lowering the pressure exerted by fluid as it enters the epidural space. The catheter is in a space, not a blood vessel; thus flushing with saline is not required. DIF: Cognitive Level: Application REF: Text reference: p. 361 OBJ: Monitor and manage the patient who is receiving epidural analgesia. TOP: Injecting a Bolus of Epidural Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. A nurse is evaluating the epidural catheter insertion site and suspects that the intraspinal
catheter has punctured the dura when a. clear drainage is b. bloody drainage is c. purulent drainage is d. redness, warmth, and swelling are
noted.
ANS: A
Clear drainage may indicate puncture of the dura. Bloody drainage may indicate that the catheter has entered the blood vessel. Purulent drainage is a sign of infection. Redness, warmth, and swelling are signs of inflammation. Local inflammation and superficial skin infection can occur at the insertion site.
N R I G B.C M
T Text O reference: p. 360 DIF: Cognitive Level: AnalysisU S N REF: OBJ: Monitor and manage the patient who is receiving epidural analgesia. TOP: Evaluating Epidural Site KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. When assessing a local infusion pump site, the nurse notes that which of the following
requires an intervention? a. The device is labeled, indicating that an anesthetic is being used. b. The catheter connections are loose. c. Surgical dressings are dry and intact. d. No blood backup is present in the tubing. ANS: B
Assess the catheter connections; all should be firmly attached. If connections become detached, do not reattach because infection could occur. Notify the physician. The label on the device provides information regarding type of anesthetic, concentration, volume, flow rate, date and time prepared, and the name of the person who prepared it. The nurse should read this label. The dressing should be dry and intact. If not, stop the infusion and notify the physician. The catheter may not be placed properly. Assess for blood backing up in the tubing. If blood is present, stop the infusion and notify the physician. This indicates possible displacement of the catheter into a blood vessel. DIF: Cognitive Level: Analysis REF: Text reference: p. 364 OBJ: Monitor and manage the patient who is receiving a local anesthetic infusion pump.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Assessment of Local Anesthetic Infusion Pump KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. The patient had knee replacement surgery and has a local infusion pump to provide a local
anesthetic to the surgical site. The patient puts on the call light and complains that pain at the site is more intense than it has ever been and is getting worse. The nurse checks the site and finds that the dressing is damp but intact. The infusion pump is pumping, and there is medication in the bag. The most probable cause of the problem might be the: a. catheter may be clogged. b. pump may be releasing too much drug into the site. c. catheter may be displaced. d. patient may be exaggerating the pain. ANS: C
Assess the surgical dressing and the site of catheter insertion. The dressing should be dry and intact. Determine whether the catheter is properly placed. If the catheter is clogged, infusion of medication will stop. Pain levels will increase but the dressing will be dry, and the pump should alarm. If the pump is releasing too much medication, the nurse should expect to see symptoms of local anesthetic adverse reaction. It is not the patient’s responsibility to convince the nurse that he has pain; it is the nurse’s responsibility to believe the patient. DIF: Cognitive Level: Analysis REF: Text reference: p. 365 OBJ: Monitor and manage the patient who is receiving a local anesthetic infusion pump. TOP: Unexpected Outcomes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18. A nonpharmacological approach that the nurse may implement for patients who are
experiencing pain that focuseN sU onRdSivIeN rtG inT gB th. eC paO tiM ent’s attention away from the pain sensation by promoting pleasurable and meaningful stimuli is: a. massage. b. heat/cold. c. guided imagery. d. distraction. ANS: D
Distraction is a technique that diverts an individual’s attention away from the pain sensation. By introducing meaningful stimuli, the nurse helps the patient refocus attention. Distraction directs a patient’s attention to something else and thus can reduce awareness of pain and even increase tolerance. A proper massage not only blocks the perception of pain impulses but also helps relax muscle tension and spasm that otherwise might increase pain. Massage hastens the elimination of wastes stored in muscles, improves oxygenation of tissues, and stimulates the relaxation response in the nervous system. Heat produces vasodilation, reduced blood viscosity, reduced muscle tension, and increased tissue metabolism. Heat helps relieve muscle spasms and joint stiffness. Cold produces vasoconstriction, reduced cell metabolism, and increased blood viscosity. Cold is effective for inflamed joints and muscles. The goal of imagery is to have the patient use one or several of the senses to create an image of the desired result. This image creates a positive psychophysiological response. Guided imagery can be used as a distraction technique. DIF: Cognitive Level: Comprehension REF: Text reference: p. 367 OBJ: Monitor and manage the patient who is receiving nonpharmacological measures to relieve pain.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Distraction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The patient is unable to rest even after pain medication has been administered. The nurse
decides to give the patient a backrub. Which of the following strokes should the nurse use when finishing the backrub? a. Long firm stroking movements down the back b. Light strokes while moving up the back in a circular motion c. Kneading movements toward the sacrum d. Circular motion upward from buttocks to shoulders ANS: A
The nurse should end the backrub with long firm strokes down the back. This is the most soothing of massage movements. The backrub is not finished with light strokes while moving up the back in a circular motion. Kneading movements toward the sacrum are done before the backrub is ended with long firm strokes down the back. The nurse should begin a backrub by massaging in a circular motion upward from buttocks to shoulders. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 369-370 OBJ: Identify and discuss various nonpharmacological pain-relief measures. TOP: Ending Massage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. The patient is admitted for chronic pain. He states that morphine sulfate (Morphine) has been
used to relieve his pain, but recently he has been needing to use more of the medication to relieve pain. This patient’s plan of care will have to incorporate interventions to deal with which of the following? a. Addiction NURSINGTB.COM b. Pseudoaddiction c. Drug tolerance d. Physical dependence ANS: C
Drug tolerance is defined as a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug’s effects over time. Addiction is defined as a primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors that influence its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Pseudoaddiction is a term that describes patient behavior that may occur when pain is undertreated. Patients with unrelieved pain may focus on obtaining medications, may “clock watch,” or otherwise may seem inappropriately “drug seeking.” Even such behaviors as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that behaviors resolve when pain is effectively treated. Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreased blood level of the drug, and/or administration of an antagonist. DIF: Cognitive Level: Analysis REF: Text reference: p. 346 OBJ: Plan care on the basis of a patient’s history, including pain history, and physical assessment findings. TOP: Terminology Related to Drug Dependency
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. Which of the following patient conditions is categorized as a neurobiological disease? a. Physical dependence b. Addiction c. Pseudoaddiction d. Drug tolerance ANS: B
Addiction is defined as a primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors that influence its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreased blood level of the drug, and/or administration of an antagonist. Pseudoaddiction is a term that describes patient behavior that may occur when pain is undertreated. Patients with unrelieved pain may focus on obtaining medications, may “clock watch,” or otherwise may seem inappropriately “drug seeking.” Even such behaviors as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that behaviors resolve when pain is effectively treated. Drug tolerance is defined as a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug’s effects over time. DIF: Cognitive Level: Analysis REF: Text reference: p. 346|Text reference: p. 348 OBJ: Plan care on the basis of a patient’s history, including pain history, and physical assessment NUino RSlogy INRe GT B.C M Dependency findings. TOP: Term lated to O Drug KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. Which of the following statements about evaluating patients in pain is true? a. The best judge of the existence of pain is the nurse. b. Visible signs always accompany pain. c. Patients often are hesitant to report pain. d. Nonpharmacological interventions are better than pain medications. ANS: C
Patients often are hesitant to report pain for fear of being labeled as complainers, hypochondriacs, or addicts. The patient’s self-report is the most reliable indicator of the existence and intensity of pain. Even with severe pain, periods of physiological and behavioral adaptation occur, leading to periods of minimal or no observable signs of pain. Lack of pain expression does not necessarily mean lack of pain. Nonpharmacological interventions are synergistic with medications, but are not a substitute for pharmacological management of pain. DIF: Cognitive Level: Comprehension REF: Text reference: p. 347 OBJ: Assess a patient’s level of comfort. TOP: Misconceptions of Pain KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MULTIPLE RESPONSE 1. Which of the following are characteristics of cancer pain? (Select all that apply.) a. It may be acute. b. It may be chronic. c. It usually is related to tumor recurrence or treatment. d. It often is of less intensity than the patient reports. ANS: A, B, C
Cancer pain may be acute, chronic, or intermittent, and it usually is related to tumor recurrence or treatment. The patient is the only one who knows whether pain is present and what the experience is like. It is not the patient’s responsibility to convince the nurse that he has pain; it is the nurse’s responsibility to believe the patient. DIF: Cognitive Level: Comprehension OBJ: Assess a patient’s level of pain. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 346 TOP: Cancer Pain MSC: NCLEX: Physiological Integrity
2. The patient has morphine sulfate ordered for pain every 4 hours “prn.” The patient complains
of severe pain and usually requests more morphine an hour before it is due. The nurse should: (Select all that apply.) a. Request a “placebo order” from the physician. b. Offer the patient medication “around the clock” instead of “prn”. c. Offer the patient massage between medication doses. d. Offer the patient a nonopioid medication between morphine doses if ordered. ANS: B, C, D
Some patients exhibit drug-sN eekiR ng bIehaGvioB are seeking pain relief. SaN Trs.wtoChen OMin factathey Occasionally, a physician will U order placebo discredit patient’s report of pain. This is unethical and should be avoided. Timely administration before a patient’s pain becomes severe is crucial to ensure optimal relief. Pain is easier to prevent than to treat. In most circumstances, administration of pharmacological agents “around-the-clock” rather than on an “as-needed” (prn) basis is preferable. Often a combination of nonopioids and opioids is effective in managing pain. Using an integrated approach that considers both pharmacological and nonpharmacological therapies in managing pain is recommended. DIF: Cognitive Level: Application OBJ: Assess a patient’s level of pain. KEY: Nursing Process Step: Assessment
REF: Text reference: pp. 346-347 TOP: Pain Treatment Strategies MSC: NCLEX: Physiological Integrity
3. The patient voices concern to the nurse regarding his PCA pump. He states that he is afraid of
getting an overdose if he pushes the button too many times. The nurse reassures the patient that: (Select all that apply.) a. there is a time delay (lockout) between patient doses. b. there is a maximum dose the patient can receive. c. the patient has a right to be concerned and needs to be careful. d. the patient could be put on a continuous infusion instead, because it is safer. ANS: A, B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank PCA prevents overdosing by interposing a preprogrammed delay time or “lockout” (usually 6 to 16 minutes) between patient-initiated doses. In addition, the prescriber may limit the total amount of opioid that the patient may receive in 1 to 4 hours (Pasero, 1999). Use basal (continuous) infusions cautiously because studies have not shown superior analgesic benefit. Continuous infusion increases the risk for opioid overdose. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 353-355 OBJ: Teach a patient to use a PCA device. TOP: Patient-Controlled Analgesia (PCA) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The patient states that the PCA is not controlling his pain. The nurse checks the infusion setup
and IV site and then evaluates the patient’s ability to use the system. All looks in order. The nurse should notify the physician to: (Select all that apply.) a. report suspected drug-seeking behavior. b. possibly change the drug being used. c. adjust the dosage of the drug being used. d. request placebo medication to evaluate true pain. ANS: B, C
Instruct the patient to check with the nurse or physician with questions and concerns, or if medication is not controlling the pain. The drug may have to be changed, or the dosage may need to be adjusted. DIF: Cognitive Level: Application REF: Text reference: p. 348 OBJ: Teach a patient to use a PCA device. TOP: Patient-Controlled AnalgNesia UR(PC SIA)NG TB.C OM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. Drugs administered in the epidural space spread by: (Select all that apply.) a. diffusion through the dura mater. b. transport through blood vessels. c. absorption by fat. d. absorption through muscle. ANS: A, B, C
A drug administered in the epidural space spreads (1) by diffusion through the dura mater into the cerebrospinal fluid (CSF), where it acts directly on receptors in the dorsal horn of the spinal cord; (2) via blood vessels in the epidural space for systemic delivery; and/or (3) by means of absorption by fat in the epidural space, creating a depot where the drug is released slowly into the systemic circulation. DIF: Cognitive Level: Comprehension REF: Text reference: p. 358 OBJ: Monitor and manage the patient who is receiving epidural analgesia. TOP: Epidural Space KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. Pain is experienced differently by different people, because pain perception is based on which
of the following? (Select all that apply.) a. Past pain experiences
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. Personal values c. Cultural expectations d. Emotions ANS: A, B, C, D
Because higher centers in the brain influence perception greatly, the pain experience is a product of a person’s past pain experiences, values, cultural expectations, and emotions. DIF: Cognitive Level: Comprehension REF: Text reference: p. 347 OBJ: Monitor and manage the patient who is receiving nonpharmacological measures to relieve pain. TOP: Pain Perception KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION
has an identifiable cause and rapid onset and generally disappears with healing.
1. ANS:
Acute pain Acute pain or transient pain has an identifiable cause, has a rapid onset, varies in intensity, is of short duration, and generally disappears with healing. DIF: Cognitive Level: Knowledge OBJ: Assess a patient’s level of pain. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 346 TOP: Acute Pain MSC: NCLEX: Physiological Integrity
2. Pain that extends beyond the period of healing and often lacks an identified pathology is
known as
N . URSINGTB.COM
ANS:
chronic pain Chronic pain or persistent pain extends beyond the period of healing, often lacks identified pathology, rarely has autonomic signs, does not provide a protective function, disrupts sleep and activities of daily living, degrades the health and function of an individual, and may be cancer or noncancer/nonmalignant in origin. DIF: Cognitive Level: Knowledge OBJ: Assess a patient’s level of pain. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 346 TOP: Chronic Pain MSC: NCLEX: Physiological Integrity
is a method of preventing pain while reducing overall opioid use.
3. ANS:
Preemptive analgesia Preemptive analgesia is a method of preventing pain while reducing overall opioid use. DIF: Cognitive Level: Knowledge OBJ: Assess a patient’s level of pain. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 347 TOP: Preemptive Analgesia MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 4.
is an interactive method of pain management that permits patient control over pain through self-administration of analgesics. ANS:
Patient-controlled analgesia (PCA) Patient-controlled analgesia (PCA) is an interactive method of pain management that permits patient control over pain through self-administration of analgesics. DIF: Cognitive Level: Knowledge REF: Text reference: p. 353 OBJ: Describe delivery of medication through a patient-controlled analgesia (PCA) device. TOP: Patient-Controlled Analgesia (PCA) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The
is a potential space between the vertebral bones and the dura mater, the outermost meninges covering the brain and spinal cord. ANS:
epidural space The epidural space is a potential space between the vertebral bones and the dura mater, the outermost meninges covering the brain and spinal cord. DIF: Cognitive Level: Knowledge REF: Text reference: p. 358 OBJ: Monitor and manage the patient who is receiving epidural analgesia. TOP: Epidural Space KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. Catheter migration into the
oduce dangerously high medication levels. NURSINGTBc.anCpr OM
Only physicians and nurse anesthetists administer drugs in this space. ANS:
subarachnoid space Only physicians and nurse anesthetists administer spinal drugs due to the increased risk associated with them. DIF: Cognitive Level: Knowledge REF: Text reference: p. 358 OBJ: Monitor and manage the patient who is receiving epidural analgesia. TOP: Epidural Space KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The application of touch and movement to muscles, tendons, and ligaments without
manipulation of the joints is called
.
ANS:
massage A gentle massage, a form of cutaneous stimulation, is the application of touch and movement to muscles, tendons, and ligaments without manipulation of the joints. DIF: Cognitive Level: Comprehension REF: Text reference: p. 366 OBJ: Monitor and manage the patient who is receiving nonpharmacological measures to relieve pain. TOP: Massage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
8.
draws on internal experiences of memories, dreams, fantasies, and visions; explores the inner world of experience; protects the privacy of the patient; and fosters the imagination. ANS:
Guided imagery Guided imagery is a creative sensory experience that effectively reduces pain perception and minimizes reaction to pain. It draws on internal experiences of memories, dreams, fantasies, and visions; explores the inner world of experience; protects the privacy of the patient; and fosters the imagination. The goal of imagery is to have the patient use one or several of the senses to create an image of a desired result. DIF: Cognitive Level: Comprehension REF: Text reference: p. 367 OBJ: Monitor and manage the patient who is receiving nonpharmacological measures to relieve pain. TOP: Guided Imagery KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 9. Massaging upward and outward from the vertebral column and back again is known as
. ANS:
effleurage Effleurage is massaging upward and outward from the vertebral column and back again. Gliding strokes, used without manipulation of deep muscles, smooth and extend muscles, increase nutrient absorption, and improve lymphatic and venous circulation. DIF: Cognitive Level: ComprN ehU enRsiS onINGRT EB F:.C TeO xtMreference: p. 368|Text reference: p. 370 OBJ: Identify and discuss various nonpharmacological pain-relief measures. TOP: Effleurage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10.
is a massage technique used on tense muscles to “knead” muscles, promote relaxation, and stimulate local circulation. ANS:
Pétrissage Pétrissage is used on tense muscle groups to “knead” muscles, promote relaxation, and stimulate local circulation. DIF: Cognitive Level: Comprehension REF: Text reference: p. 369 OBJ: Identify and discuss various nonpharmacological pain-relief measures. TOP: Pétrissage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 16: Palliative Care MULTIPLE CHOICE 1. The patient has a history of terminal cancer but is being admitted for treatment of a pressure
ulcer. The patient’s wife has been caring for him at home and refuses to discuss admission to a nursing home. The wife looks extremely tired and is near the point of exhaustion. What could the nurse suggest? a. A consult for hospice care b. Continuing with the plan of care as is c. That the doctor order the patient into a nursing home d. That the wife stay away while the patient is hospitalized ANS: A
Hospice benefits include respite for family caregivers. The current plan of care may be the reason for the decubiti and may lead to the patient’s wife’s becoming ill. Palliative and hospice care place a primary focus on the patient’s values, quality of life, and care preferences. DIF: Cognitive Level: Application REF: Text reference: p. 375 OBJ: Describe hospice care. TOP: Respite Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The patient is being admitted to the hospital for injuries received when a hurricane destroyed
her home. She is upset from the loss of her home and possessions. What type of loss is this NURSINGTB.COM considered? a. Necessary loss b. Maturational loss c. Situational loss d. Perceived loss ANS: C
Situational losses include loss from sudden, unpredictable external events such as a hurricane that destroys one’s home or city. Necessary losses, such as leaving friends after high school graduation, are a natural part of life. Such losses usually are replaced by something different or better. Some necessary losses are more difficult and never seem acceptable, such as the loss of a loved one through death. Life goes on, but replacements for these losses do not appear. Maturational losses include changes that occur as a part of normal life development. For instance, a parent feels loss when a child marries and moves away from home. Perceived losses are interpreted uniquely by the individual and often are not obvious to others. For example, one person perceives failure to get into a preferred college as a loss of all opportunity, while another person views the same experience as a relief. DIF: Cognitive Level: Comprehension REF: Text reference: p. 378 OBJ: Discuss principles of palliative care. TOP: Loss KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. The nurse recognizes that anticipatory grieving can be most beneficial for a patient or family
because it can:
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
be done in a private setting. be discussed with other individuals. promote separation of the ill patient from the family. allow time for the process of grief.
ANS: D
The benefit of anticipatory grief is that it allows for a gradual disengagement from the loss. Anticipatory grief may help people move through the stages of grief, allowing time to grieve in private, to discuss the anticipated loss with others, and then to “let go” of the loved one. DIF: Cognitive Level: Comprehension REF: Text reference: p. 378 OBJ: Identify the nurse’s role in assisting patients and families in grief and at the end of life. TOP: Grief KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is preparing to assist the patient at the end stage of her life. To provide comfort for
the patient in response to anticipated symptom development, the nurse plans to: a. decrease the patient’s fluid intake. b. limit the use of pain medication. c. provide larger meals with more seasoning. d. determine patient wishes and select appropriate therapies. ANS: D
Have the patient identify what she wants to accomplish, and use strategies to conserve energy for meeting those goals. This provides the patient with a sense of well-being and purpose to meet important personal goals. Decreasing the patient’s fluid intake may make the terminally ill patient more prone to dehydration and constipation. The nurse should take measures to help maintain oral intake, such as N adm tics, applying topical analgesics to oral URinis SIteri NGngTaBn.tieCme OM lesions, and offering ice chips. The use of analgesics should not be limited. Controlling the terminally ill patient’s level of pain is a primary concern in promoting comfort. Nausea, vomiting, and anorexia may increase the terminally ill patient’s likelihood of inadequate nutrition. The nurse should serve smaller portions and bland foods, which may be more palatable. DIF: Cognitive Level: Analysis REF: Text reference: p. 373|Text reference: p. 376|Text reference: pp. 383-384 OBJ: Identify the nurse’s role in assisting patients and families in grief and at the end of life. TOP: Caring for the Dying Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. A nurse-initiated or independent activity for promotion of respiratory function in a terminally
ill patient is to: a. limit PO fluid intake. b. position the patient in semi-Fowler’s or Fowler’s position. c. reduce narcotic analgesic use. d. administer bronchodilators. ANS: B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Position the patient in semi-Fowler’s or Fowler’s position. This promotes maximal ventilation, lung expansion, and drainage of secretions. Limiting fluids may not promote respiratory function, and unless a patient is on a fluid-restricted diet, the nurse should not do so. Reducing narcotic analgesic use is not a nurse-initiated activity to promote respiratory function. Respiratory rate should be assessed before narcotics are administered, to prevent further respiratory depression. Management of air hunger involves judicious administration of morphine and anxiolytics for relief of respiratory distress. The administration of bronchodilators would require a physician’s order. It is not an independent nursing activity. DIF: Cognitive Level: Application REF: Text reference: p. 383 OBJ: Identify the nurse’s role in assisting patients and families in grief and at the end of life. TOP: Caring for the Dying Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. When caring for a patient who is an appropriate candidate for organ or tissue donation, the
nurse knows that requests for donation are: a. required by state law. b. the total responsibility of the survivors. c. a possible inclusion in the advance directive. d. made only by the physician. ANS: C
A patient’s choice regarding organ and tissue donation can be included in an advance directive. The 1986 Omnibus Budget Reconciliation Act (OBRA) requires that a patient’s significant others be offered the option of organ and tissue donation; however, organ donation is voluntary. It is important for persons to keep family members informed of their wishes regarding organ donation. Because of the sensitive nature of making requests for organ NUdRinSorg INan GTprocure B.COment M often assume that responsibility. They donation, professionals educate inform family members of their options for donation, provide information about costs (no cost to the family), and inform the family that donation does not delay funeral arrangements. DIF: Cognitive Level: Application REF: Text reference: p. 385 OBJ: Discuss the nurse’s role in facilitating autopsy and organ and tissue donation requests. TOP: Organ Donation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The patient is on a ventilator and has a heartbeat but has been declared “brain dead.” The
family has agreed to organ donation. The nurse realizes that which of the following organ donations would require that the patient be left on life support? a. Eyes b. Bone c. Kidney d. Skin ANS: C
In the case of vital organ donation (e.g., heart, lungs, liver, pancreas, kidneys), the patient must remain on life support until the organs are removed surgically. Tissues such as eyes, bone, and skin are commonly retrieved from deceased patients who are not on life support. DIF: Cognitive Level: Application REF: Text reference: p. 385 OBJ: Discuss the nurse’s role in facilitating autopsy and organ and tissue donation requests.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Organ Donation MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step: Implementation
8. An appropriate technique for the nurse to implement when caring for a patient’s body after
death is to: a. remove the patient’s ID band and put a new gown on the patient. b. cover the patient with a sheet and transfer him or her to the morgue. c. inquire about particular cultural or spiritual practices. d. remove tubes and lines if the patient is to be autopsied. ANS: C
Respect the individuality of the patient and family and support their right to have cultural or religious values and beliefs upheld. Identify and tag the body, leaving identification on the body as directed by agency policy to ensure proper identification of the body for delivery to the morgue or mortuary. After viewing, remove linens and gown, per agency policy. Place the body in a shroud provided by the agency. The shroud protects from injury to the skin, avoids exposure of the body, and provides a barrier against potentially contaminated body fluids. Removal of tubes and lines is contraindicated if an autopsy is planned. DIF: Cognitive Level: Application REF: Text reference: pp. 385-386 OBJ: Describe postmortem care. TOP: Postmortem Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. After the death of a patient and before other nursing interventions are implemented, the nurse
should: a. place the patient in a supine position and elevate the head of the bed 30 degrees. .iCngO. M b. wait an hour to prepare thNeU pR atiS enItN foGr T viB ew c. place the patient in a side-lying position to allow drainage. d. exclude the family while the body is being prepared. ANS: A
Immediately after death and before other activities are begun, place the body in supine position, and elevate the head of the bed 30 degrees to decrease rigor mortis. Ask family members if they have requests for preparation or viewing of the body (such as position of the body, special clothing, shaving). Determine whether they wish to be present or assist with care of the body. This provides closure for those who wish to assist with body preparation. DIF: Cognitive Level: Application REF: Text reference: pp. 385-386 OBJ: Describe postmortem care. TOP: Postmortem Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. Before allowing the family of a deceased patient to view the body, the nurse should: a. insert the patient’s dentures. b. lower the head of the bed. c. fold the arms and hands over the chest. d. leave all of the old dressings and tape in place. ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank If the person wore dentures, reinsert them. If the mouth fails to close, and if it is culturally appropriate to close the mouth, place a rolled-up towel under the chin. Dentures maintain the patient’s natural facial expression. Place a small pillow or a folded towel under the head. This prevents pooling of blood in the face and subsequent discoloration. Avoid placing one hand on top of the other. Placing one hand on top of the other can lead to discoloration of the skin. Remove soiled dressings and replace with clean gauze dressings. Use paper tape. Paper tape minimizes skin trauma. Changing dressings helps to control odors caused by microorganisms and creates a more acceptable appearance. DIF: Cognitive Level: Application REF: Text reference: p. 387 OBJ: Describe postmortem care. TOP: Postmortem Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. A new staff member is working with a patient who is dying. A nurse evaluates that this new
employee requires additional teaching when he or she is observed: a. limiting the family’s visiting hours. b. staying with the patient and family as much as possible. c. finding a quiet place for family members to gather. d. asking the family if they would like to help with preparing the body. ANS: A
Some cultures require silence at the time of death; others express grief with loud wailing, “falling out,” or hysteria. Do not rush any grieving process. Give family members and friends a private place to gather. Allow them time to ask questions. This creates a safe environment for the grieving family. Questions provide information about how they are coping with loss and their needs. Ask family members if they have requests for preparation or viewing of the Nody RS I Gl clothin B.COg,Mor shaving). Determine whether they body (such as position of the bU , speNciaT wish to be present or assist with care of the body. This may provide closure for those who wish to assist with body preparation. DIF: Cognitive Level: Application REF: Text reference: p. 387 OBJ: Describe postmortem care. TOP: Postmortem Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The patient was a practicing Hindu when he died. Knowing this, the nurse realizes that: a. the body should be covered with a cotton sheet. b. anointing of the sick is performed even after death. c. family members often prefer to wash the body after death. d. the body should be buried within 24 hours. ANS: C
With Hinduism, family members prefer to wash the body after death and are present to chant, pray, and use incense. In Buddhism, when the person has died, the body should be covered with a cotton sheet. Others should not touch the body, and the mouth and eyes of the deceased are left open. Christians in the Roman Catholic tradition often request sacraments of Penance and Anointing of the Sick and Holy Communion at the end of life. In Orthodox Judaism, a family member remains with the body until burial, which takes place within 24 hours, not on the Sabbath.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Application REF: Text reference: p. 377 OBJ: Describe postmortem care. TOP: Postmortem Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. For a patient in the final stages of dying, a nurse expects to: a. keep the patient’s room cool. b. avoid catheterizing the patient. c. elevate the head of the bed as tolerated. d. encourage the patient to eat and drink more. ANS: C
Poor circulation of body fluids, immobilization, and inability to expectorate secretions cause rattles and bubbling. Elevate the head with a pillow or raise the head of the bed; gently turn the head to the side to drain secretions. Coolness, color, and temperature change in the hands, arms, legs, and feet. Place socks on the feet. Cover with a light cotton blanket. Keep warm blankets on the patient. Decreased muscle tone and consciousness may lead to incontinence of urine and/or bowel. Change bedding as appropriate. Use an indwelling catheter for patient comfort. Do not force the patient to eat or drink; give ice chips, soft drinks, or juice, as possible. Provide mouth care. DIF: Cognitive Level: Application REF: Text reference: p. 383|Text reference: p. 388 OBJ: Identify the nurse’s role in assisting patients and families in grief and at the end of life. TOP: Physical Signs and Symptoms in the Final Stages of Dying KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE
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1. Hospice care can be provided in which of the following settings? (Select all that apply.) a. Home b. Free-standing hospice facilities c. Extended care facilities d. Acute care facilities ANS: A, B, C, D
Because hospice is a philosophy of care, not necessarily a place, the services are sometimes provided at home, in free-standing hospice facilities, or in nursing home, extended care, or acute care settings. DIF: Cognitive Level: Knowledge OBJ: Describe hospice care. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 375 TOP: Hospice MSC: NCLEX: Physiological Integrity
2. Hospice benefits include which of the following? (Select all that apply.) a. Respite for family caregivers b. Hospitalization for acute symptom management c. Emotional and psychological support d. Financial assistance and funeral arrangement ANS: A, B, C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Hospice benefits include respite for family caregivers, limited hospitalization for acute symptom management, and bereavement care after death. Hospice does not provide financial assistance or funeral arrangements. DIF: Cognitive Level: Knowledge OBJ: Describe hospice care. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 375 TOP: Hospice MSC: NCLEX: Physiological Integrity
COMPLETION
as an “approach that improves the quality of life of individuals and their families facing life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other physical, psychological, and spiritual problems.”
1. The World Health Organization (2002) defines
ANS:
palliative care The World Health Organization (2002) defines palliative care as an “approach that improves the quality of life of individuals and their families facing life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other physical, psychological, and spiritual problems.” DIF: Cognitive Level: Knowledge REF: Text reference: p. 375 OBJ: Discuss principles of palliative care. TOP: Palliative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
helps peopleNlivR e asIweG ll asBp. osCsibM le through the dying process.
2.
U S N T
O
ANS:
Hospice Hospice, an interdisciplinary, patient- and family-centered program of total palliative care, helps people live as well as possible through the dying process. DIF: Cognitive Level: Knowledge OBJ: Describe hospice care. KEY: Nursing Process Step: Assessment 3.
REF: Text reference: p. 375 TOP: Hospice MSC: NCLEX: Physiological Integrity
specify medical interventions that the patient does not want in certain situations, such as mechanical ventilation, and are used to communicate the care a patient wants, for example, pain relief to the fullest extent possible. ANS:
Advance directives In an advance directive, patients indicate in writing the types of treatments that are acceptable or unacceptable to them, describe their life values, or designate a person to speak for them as their durable power of attorney (DPOA) for health care decisions. Advance directives specify medical interventions that the patient does not want in certain situations, such as mechanical ventilation, and are used to communicate the care a patient wants, for example, pain relief to the fullest extent possible. DIF: Cognitive Level: Comprehension
REF: Text reference: p. 376
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Describe hospice care. KEY: Nursing Process Step: Planning
TOP: Advance Directives MSC: NCLEX: Physiological Integrity
4. Nurses provide
that is defined as care of the body after death in a manner consistent with the patient’s religious and cultural beliefs. ANS:
postmortem care Nurses provide postmortem care, care of the body after death, in a manner consistent with the patient’s religious and cultural beliefs. DIF: Cognitive Level: Comprehension OBJ: Describe postmortem care. KEY: Nursing Process Step: Planning 5. A person experiences an actual
REF: Text reference: p. 376 TOP: Postmortem Care MSC: NCLEX: Physiological Integrity
when an object or a person can no longer be felt,
heard, or experienced. ANS:
loss A person experiences an actual loss when an object or a person can no longer be felt, heard, or experienced. Examples include the loss of a person, a body part, or a home. DIF: Cognitive Level: Comprehension REF: Text reference: p. 378 OBJ: Discuss principles of palliative care. TOP: Loss KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
ll U brR aiS nI fuN nG ctiT oB n. is C teO rm 6. The irreversible absence of aN Med
.
ANS:
brain death Family members often need help understanding what “brain death,” the irreversible absence of all brain function (including the brainstem), means for the person who has died. DIF: Cognitive Level: Comprehension REF: Text reference: p. 385 OBJ: Discuss the nurse’s role in facilitating autopsy and organ and tissue donation requests. TOP: Brain Death KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. An
is the surgical dissection of a body after death.
ANS:
autopsy An autopsy, the surgical dissection of a body after death, helps determine the exact cause and circumstances of a death, discovers the pathway of a disease, or provides data for research purposes. DIF: Cognitive Level: Comprehension REF: Text reference: p. 385 OBJ: Discuss the nurse’s role in facilitating autopsy and organ and tissue donation requests. TOP: Autopsy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 8. The patient was brought into the emergency department with a cardiac arrest after suffering
multiple gunshot wounds. The patient did not survive even after multiple attempts at resuscitation. The nurse is preparing the body for transport to the morgue by completing hospital procedures for _ . ANS:
autopsy An autopsy is not performed in every death. State laws determine when autopsies are required, but they usually are performed in circumstances of unusual death (e.g., violent trauma, unattended or unexpected death in the home) and when death occurs within 24 hours of hospital admission. DIF: Cognitive Level: Application REF: Text reference: p. 385 OBJ: Discuss the nurse’s role in facilitating autopsy and organ and tissue donation requests. TOP: Autopsy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 17: Personal Hygiene and Bed Making MULTIPLE CHOICE 1. The nurse is aware that normal flora that does not cause disease but does prevent
disease-causing microorganisms from reproducing is known as: a. sebum. b. the epidermis. c. resident bacteria. d. the dermis. ANS: C
Bacteria reside on the skin’s outer surface. Resident bacteria constitute normal flora that does not cause disease but does prevent disease-causing microorganisms from reproducing. Sebum, secreted from hair follicles from sebaceous glands, provides an acidic coating. This acid coating protects the epidermis against penetration from chemicals and microorganisms. It also minimizes loss of water and plasma proteins. It is not alive, however, and is not considered flora. The epidermis, or outer skin layer, is the first line of defense from external injury and infection. It contains several thin layers of cells undergoing different stages of maturation. Resident bacteria live on its surface and protect it. Three primary layers make up the skin: the epidermis, the dermis, and subcutaneous tissue. The dermis lies underneath the epidermis and is not considered “flora.” DIF: Cognitive Level: Comprehension REF: Text reference: p. 392 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Resident Bacteria Y: Nursing Process Step: Assessment N R I GKEB .COM MSC: NCLEX: Physiological IntU egriS ty N T 2. In relation to hygiene and the acute care setting, the nurse knows that which of the following
statements is true? a. The disposable bath is a less desirable form of bathing than the traditional basin bath. b. The disposable bath is a more desirable form of bathing than the traditional basin bath. c. The disposable bath is more desirable for patients who can bathe independently. d. The disposable bath is not an acceptable form of bathing in the acute care setting. ANS: B
Prepackaged disposable bath products have been shown to decrease the spread of infection. The disposable bath is a desirable form of bathing for patients who are unable to bathe themselves in critical care and long-term care settings; it is even preferable to the traditional basin bath. DIF: Cognitive Level: Analysis REF: Text reference: pp. 394-395 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: The Disposable Bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 3. The nurse is caring for a ventilated patient in the ICU who has just undergone coronary artery
bypass. The nurse is concerned that the patient may be at risk for ventilator-acquired pneumonia (VAP). What step will she take to minimize this risk? a. Not provide oral hygiene because this may cause bacterial contamination of the airway. b. Be careful not to use chlorhexidine in oral care because it provides a medium for bacterial growth. c. Not use chlorhexidine in oral care because it enhances the rate at which VAP develops. d. Include the use of a chlorhexidine rinse as part of oral hygiene to delay the development of VAP. ANS: D
Guidelines for oral care in ventilator patients and those who need assistance with oral hygiene often include the use of a chlorhexidine rinse as a part of oral hygiene. Chlorhexidine early in the postintubation period may help delay the onset or development of VAP. Presently, chlorhexidine is recommended during the postoperative period for patients undergoing cardiac surgery. Ventilator-associated pneumonia results from the colonization of bacteria in the oral pharynx. These microorganisms then migrate from the mouth into the lungs. Dental plaque is also a reservoir for microorganisms causing VAP. Because of this evidence, guidelines for oral care in ventilator patients and those who need assistance with oral hygiene often include the use of a chlorhexidine rinse as a part of oral hygiene. DIF: Cognitive Level: Application REF: Text reference: p. 411 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Chlorhexidine KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity G B.C M
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4. The nurse plans to give the patient a therapeutic bath. Which of the following is considered
therapeutic? a. Bed bath b. Sponge bath at the sink c. Sitz bath d. Bag bath ANS: C
The Sitz bath cleanses and reduces pain and inflammation in perineal and anal areas. It is used for a patient who has undergone rectal or perineal surgery or childbirth or has local irritation from hemorrhoids or fissures. There are two categories of baths: cleansing and therapeutic. Cleansing baths include the bed bath, tub bath, sponge bath at the sink, shower, and bag bath. DIF: Cognitive Level: Analysis REF: Text reference: p. 395 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Therapeutic Baths KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. What should the nurse do before starting a patient’s bed bath? a. Lower the bed. b. Offer the bedpan or urinal. c. Partially undress the patient. d. Place the head of the bed in high-Fowler’s position.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS: B
The patient will feel more comfortable after voiding, and this will prevent interruption of the bath. The bed should be raised to a comfortable working height to aid the nurse’s access to the patient and to minimize strain on the nurse’s back muscles. The patient’s gown or pajamas are removed and the bath blanket is used to cover the patient. This provides full exposure of body parts during bathing. The head of the bed is raised 30 to 45 degrees if the patient’s condition allows. DIF: Cognitive Level: Application REF: Text reference: p. 397 OBJ: Administer a complete bed bath. TOP: Providing Comfort During the Bed Bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is preparing to provide a complete bed bath to a patient who has a running IV. She
places a bath blanket over the patient and: a. removes the gown from the arm with the IV first. b. removes the gown from the arm without the IV first. c. removes the gown after the bath to keep the patient warm. d. readjusts the IV rate before removing the gown. ANS: B
If the patient has an IV line, remove the gown from the arm without the IV first. Then remove the gown from the arm with the IV. Remove the IV from the pole, and slide the IV container and tubing through the arm of the patient’s gown. Rehang the IV container; check the flow rate and regulate if necessary. Removing the patient’s gown or pajamas before the bath provides full exposure of body parts during bathing. Rehang the IV container after changing the gown. Check the flow ratN e. ItRmaI haGve B U Sy N Tch.anCged OMwith all the manipulation of the gown change. Regulate if necessary. DIF: Cognitive Level: Application REF: Text reference: p. 398 OBJ: Administer a complete bed bath. TOP: Changing the Hospital Gown KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. While washing the patient’s face, the nurse should: a. wash the eyes using soap and warm water. b. wash the eyes from outer canthus to inner canthus. c. wash the eyes with plain warm water. d. use the same portion of the washcloth. ANS: C
Wash the patient’s eyes with plain warm water, using a clean area of cloth for each eye, bathing from inner to outer canthus. Soap irritates eyes. Use of separate sections of the mitt reduces infection transmission. Bathing the eye gently from inner to outer canthus prevents secretions from entering the nasolacrimal duct. DIF: Cognitive Level: Application REF: Text reference: p. 399 OBJ: Administer a complete bed bath. TOP: Washing the Eyes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 8. When bathing a patient, which sequence is the correct approach to use? a. Wash the feet after the legs. b. Wash the eyes after the face. c. Wash the legs before the abdomen. d. Wash the back area before the extremities. ANS: A
When washing the patient the nurse will try to work from the most soiled area to the least soiled area. Therefore, the legs are washed before the feet, the eyes are washed before the face, the abdomen is washed before the legs, and the back is washed after the extremities. DIF: Cognitive Level: Application REF: Text reference: pp. 399-401 OBJ: Administer a complete bed bath. TOP: Sequence of the Bed Bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. What should hygienic care of the patient with dry skin include? a. Use of moisturizers b. Use of ultraviolet light c. Application of antiseptic lotion d. Lowering of bath water temperature ANS: A
Apply body lotion to the skin as needed and topical moisturizing agents to dry, flaky, reddened, or scaling areas. Dry skin results in reduced pliability and cracking. Moisturizers help to prevent skin breakdown. Ultraviolet light and antiseptic lotion are not used to treat dry skin. Decreased bath water temperature causes chilling.
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DIF: Cognitive Level: Application REF: Text reference: p. 401 OBJ: Administer a complete bed bath. TOP: Dry Skin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. While giving the patient a bed bath, the nurse notices a reddened area on the patient’s coccyx.
The nurse should: a. decrease the temperature of the bath water. b. massage the reddened area to decrease the redness. c. apply topical moisturizing agents to the area. d. ignore the redness because it will return to normal soon. ANS: C
Apply body lotion to the skin as needed and topical moisturizing agents to dry, flaky, reddened, or scaling areas. Decreased bath water temperature causes chilling. Do not massage any reddened area on the patient’s skin. Reddened areas, especially over bony prominences, indicate localized injury to the skin and/or underlying tissue and cannot be ignored. DIF: Cognitive Level: Application REF: Text reference: p. 401 OBJ: Administer a complete bed bath. TOP: Reddened Areas KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The optimal position for a female patient for the provision of perineal care is:
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
prone. side-lying. high-Fowler’s. dorsal recumbent.
ANS: D
The dorsal recumbent position provides full exposure of the female genitalia. The side-lying, prone, and high-Fowler’s positions do not allow adequate exposure of the female genitalia. DIF: Cognitive Level: Comprehension REF: Text reference: p. 403 OBJ: Administer a complete bed bath. TOP: Perineal Care for the Female KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. While evaluating the hygienic care practices of a female patient, the nurse recognizes that
additional instruction is necessary if the patient: a. washes the perineal area from back to front. b. washes the labia majora before the labia minora. c. avoids tension on the indwelling catheter. d. uses separate sections of the washcloth for each cleansing stroke. ANS: A
The patient should wash downward from the pubic area toward the rectum in one smooth stroke. She should use a separate section of the cloth for each stroke. DIF: Cognitive Level: Application REF: Text reference: p. 403 OBJ: Identify principles of aseptic technique applied while administering a bed bath. TOP: Perineal Care for the Fem Y:.C NursM ing Process Step: Implementation NaleR I GKEB MSC: NCLEX: Physiological IntU egriS ty N
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13. In providing perineal care for a male patient, the nurse realizes that the patient has not been
circumcised. The nurse should: a. retract the foreskin after care has been completed. b. place the patient in prone position. c. replace the foreskin to its natural position after care has been provided. d. have the patient adduct his legs. ANS: C
After administering male perineal care for uncircumcised males, make sure that the foreskin is in its natural position. This is extremely important for those patients with decreased sensation in the lower extremities. Tightening of the foreskin around the shaft of the penis causes local edema, discomfort, and, if not corrected, permanent urethral damage. Assist the patient to a supine position and have him abduct his legs. DIF: Cognitive Level: Application REF: Text reference: p. 404 OBJ: Administer a complete bed bath. TOP: Perineal Care for the Male Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The home care nurse is getting ready to help the patient prepare a tub bath. What should the
nurse be sure to do? a. Instruct the patient to use safety bars.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. Use the patient’s favorite bath oil for aroma therapy. c. Instruct the patient to stay in the tub no longer than 30 minutes. d. Check on the patient every 20 minutes. ANS: A
Instruct the patient to use safety bars when getting into and out of the tub or shower. Caution the patient against the use of bath oil in tub water. This could lead to falls. Instruct the patient not to remain in the tub longer than 20 minutes. Check on the patient every 5 minutes. DIF: Cognitive Level: Application REF: Text reference: pp. 403-404 OBJ: Explain precautions to take when assisting patients with a tub bath or shower. TOP: Preparing for a Tub Bath KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. When teaching parents how to provide oral care to their child, the nurse instructs them to: a. give bottles with juice at bedtime. b. begin dental visits after the child is 8 years old. c. allow the preschool child to floss his teeth without parental supervision. d. limit snacks to three or four per day. ANS: D
Limit snacks to three or four per day. Avoid sugary snacks and drinks and sticky candy. Teach parents that the infant should not be put to bed with a bottle; this causes tooth decay as well as ear infection. Children should have their first dental examination at 1 year or sooner if needed. Then children need to have a dental examination every 6 months. Young children will need parenteral assistance and supervision to learn to floss correctly. DIF: Cognitive Level: ApplicN ationR I GREB F: TextMreference: p. 409 S administering N T .C Ooral OBJ: Identify guidelines to followUwhen hygiene. TOP: Pediatric Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is about to provide oral hygiene to an unconscious patient. To do so, she places the
patient in which position? a. Fowler’s b. Semi-Fowler’s c. Sims’ d. Supine ANS: C
Unless contraindicated (e.g., head injury, neck trauma), lower the side rail and position the patient on the side (Sims’ position) with the head turned well toward the dependent side and the head of the bed lowered. Raise the side rail. This allows secretions to drain from the mouth instead of collecting in the back of the pharynx and prevents aspiration. This position allows secretions to drain toward the lungs as a result of gravity. DIF: Cognitive Level: Application REF: Text reference: p. 412 OBJ: Explain differences in providing oral hygiene to dependent versus unconscious patients. TOP: Oral Hygiene for an Unconscious Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 17. A nurse recognizes that a shampoo may be contraindicated for a bed-bound patient with: a. heart disease. b. diabetes mellitus. c. a neck injury. d. a bleeding disorder. ANS: C
Caution is needed with patients who have suffered neck injuries because flexion and hyperextension of the neck could cause further injury. Heart disease does not mean that a shampoo is contraindicated. A shampoo is not contraindicated for patients with diabetes mellitus or a bleeding disorder. DIF: Cognitive Level: Comprehension REF: Text reference: p. 418 OBJ: Identify guidelines for administering hair, nail, and foot care. TOP: Washing the Hair of Patients With Neck Injuries KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 18. Shaving with a disposable razor is contraindicated for a patient with: a. heart disease. b. diabetes mellitus. c. a head injury. d. a bleeding disorder. ANS: D
Before shaving, assess whether the patient has a bleeding tendency. Review medical history or laboratory values (e.g., platelet counts, prothrombin time). Determine the need to use an electric razor for the patient’s safety because of the potential for bleeding. Shaving with a disposable razor is not contraN ind icate at. ieC ntsOw Mith heart disease, diabetes mellitus, or a UR SIdNfoGrTpB head injury. DIF: Cognitive Level: Analysis OBJ: Shave a male or female patient. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 415|Text reference: p. 418 TOP: Shaving a Male Patient MSC: NCLEX: Physiological Integrity
19. When evaluating the shaving of a patient done by a family member, the nurse determines that
the technique is done appropriately when: a. long strokes are used. b. the razor is held at a 45-degree angle to the skin. c. shaving is done against the direction of hair growth. d. a cool cloth is used on the skin before the shave. ANS: B
The razor should be held in the dominant hand at a 45-degree angle to the patient’s skin. Begin by shaving across one side of the patient’s face using short, firm strokes in the direction the hair grows. Use the nondominant hand to gently pull the skin taut while shaving. Check with the patient, and ask whether he feels comfortable. Use a warm cloth. A warm cloth helps soften the skin and beard, and the sensation of warmth can be relaxing. DIF: Cognitive Level: Application REF: Text reference: p. 417 OBJ: Shave a male or female patient. TOP: Shaving a Male Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
20. The nurse is providing nail care for the patient who wants his fingernails “done.” The nurse
should: a. clip the fingernails gently to prevent injury. b. clean under the nails using an orange stick. c. soak the fingernails no longer than 10 minutes. d. clean under the nails using the end of a cotton swab. ANS: C
Unless the patient has diabetes, allow the patient’s feet and fingernails to soak no longer than 10 minutes. The goal is to soften the skin and debris beneath the nails, without causing excessive dryness. Obtain a physician’s order for cutting the nails (required by most agencies). The patient’s skin may be cut accidentally. Certain patients are more at risk for infection, depending on their medical condition. Check agency policy for appropriate process for cleaning beneath the nails. Do not use an orange stick or the end of a cotton swab; both of these splinter and can cause injury. DIF: Cognitive Level: Application REF: Text reference: p. 423 OBJ: Safely administer nail care. TOP: Nail Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse assesses the patient’s skin and notices an abrasion. Which of the following best
describes this type of skin abnormality? a. A papulopustular skin eruption b. Rough texture on the skin surface c. Erythema and scaly, oozing areas d. A scraping away of the eN piU deR rm s NGTB.COM SiI ANS: D
An abrasion is a scraping or rubbing away of the epidermis; it may result in localized bleeding and later weeping of serous fluid. Acne is defined as a papulopustular skin eruption. Rough texture may indicate dry skin, not an abrasion. Scaly, oozing erythematous areas may indicate contact dermatitis. DIF: Cognitive Level: Comprehension REF: Text reference: p. 393 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Skin Problems KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22. The nurse is caring for a gentleman who has dry skin. When the following interventions are
compared, which would be most appropriate for this patient? a. Limiting the frequency of bathing b. Using a fat-free soap for washing c. Using warm water and moisturizers d. Bathing with hot water to increase blood flow ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Effective treatment for dry skin does not include limiting the frequency of bathing but lies in bathing with warm, not hot, water and using moisturizers. Superfatted soap (e.g., Dove) should be used for cleansing. The body should be rinsed well of all soap, because residue left can cause irritation and breakdown. Moisture should be added to the air through the use of a humidifier. Fluid intake should be increased when the skin is dry. DIF: Cognitive Level: Application REF: Text reference: p. 393|Text reference: p. 401|Text reference: p. 424 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Treatment for Dry Skin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The patient confides in the nurse that she is bothered by the fact that she has alopecia. How
should the nurse respond to this information? a. Shave hair off of the affected area. b. Use permethrin (Nix). c. Offer the patient access to scarves or wigs. d. Place a drop of oil on the area. ANS: C
Alopecia is balding patches in the periphery of the hairline. Offer patients access to scarves, hairpieces, or wigs. Stop hair care practices that damage hair. Shaving hair off of the affected area is the treatment for pediculosis pubis (crab lice). Permethrin is the treatment for pediculosis capitis (head lice). Ticks are removed by placing a drop of oil or ether on the tick, causing it to suffocate. DIF: Cognitive Level: Application REF: Text reference: p. 415 R I G OBJ: Identify guidelines for aN dmin iste ring hair naC il, O anMd foot care. U S N TB, . TOP: Alopecia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. The patient requires postural drainage three times a day. Which of the following bed positions
would be most appropriate for this task? a. Fowler’s position b. Trendelenburg’s position c. Reverse Trendelenburg’s position d. Semi-Fowler’s position ANS: B
With Trendelenburg’s position, the entire bed frame is tilted, with the head of the bed down. This position facilitates postural drainage and venous return in patients with poor peripheral perfusion. In Fowler’s position, the head of the bed is raised to an angle of 45 to 90 degrees or more. This position is preferred while the patient eats, is used during nasogastric tube insertion and nasotracheal suction, and promotes lung expansion. In reverse Trendelenburg’s position, the entire bed frame is tilted, with the foot of the bed down. It is used infrequently, promotes gastric emptying, and prevents esophageal reflux. In semi-Fowler’s position, the head of the bed is raised approximately 30 to 45 degrees. This promotes lung expansion and relieves strain on abdominal muscles. DIF: Cognitive Level: Application REF: Text reference: p. 427 OBJ: Identify guidelines for administering hair, nail, and foot care.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Bed Positions MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step: Implementation
MULTIPLE RESPONSE 1. The skin, the largest human body organ, protects us from heat, light, injury, and infection and
does which of the following? (Select all that apply.) a. Helps regulate body temperature b. Stores water, vitamin D, and fat c. Helps to sense pain d. Prevents the entry of bacteria ANS: A, B, C, D
Skin, the largest human body organ, protects us from heat, light, injury, and infection and serves to (1) help regulate body temperature; (2) store water, vitamin D, and fat; (3) help sense pain and other stimuli; and (4) prevent the entry of bacteria. DIF: Cognitive Level: Comprehension REF: Text reference: p. 439 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Skin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Critically ill patients on a ventilator are at risk for ventilator-associated pneumonia (VAP).
Sources of VAP include: (Select all that apply.) a. bacteria in the oral pharynx. b. dental plaque. c. chlorhexidine rinses. NURSINGTB.COM d. frequent oral hygiene. ANS: A, B
VAP results from the colonization of bacteria in the oral pharynx. These microorganisms then translocate from the mouth into the lungs. Dental plaque is also a reservoir for microorganisms causing VAP. Because of this, guidelines for oral care in ventilator patients and in those who need assistance with oral hygiene often include the use of a chlorhexidine rinse as part of oral hygiene. Chlorhexidine early in the postintubation period may help delay the onset or development of VAP. DIF: Cognitive Level: Comprehension REF: Text reference: p. 394|Text reference: p. 411 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Oral Hygiene KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. When taking a shower in the home setting, the patient at risk for falls may benefit from:
(Select all that apply.) a. installation of grab bars. b. adhesive strips applied to the tub floor. c. addition of a shower chair or stool. d. a hydraulic lift. ANS: A, B, C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Patients at risk for falls may benefit from the installation of grab bars in the shower, the application of adhesive strips to the shower or tub floor, and the addition of a shower chair or placement of a chair or stool. Hydraulic lifts are useful in bathtubs. DIF: Cognitive Level: Application REF: Text reference: p. 403 OBJ: Explain precautions to take when assisting patients with a tub bath or shower. TOP: Preparing for a Shower KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Patients at greatest risk for developing serious foot problems include those with: (Select all
that apply.) a. peripheral neuropathy. b. peripheral vascular disease. c. pancreatitis. d. diabetes. ANS: A, B, D
Patients at greatest risk for developing serious foot problems are those with peripheral neuropathy and peripheral vascular disease. These two disorders, commonly found in patients with diabetes, cause reduction in blood flow to the extremities and loss of sensory, motor, and autonomic nerve function. As a result, the patient is unable to feel heat and cold, pain, pressure, and the position of the foot. This reduction in blood flow impairs healing and promotes risk for infection. DIF: Cognitive Level: Analysis REF: Text reference: p. 420 OBJ: Identify risk factors for foot and nail problems. TOP: Foot Problems KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
NURSINGTB.COM
5. The development of diabetic foot ulcers is dependent on which of the following? (Select all
that apply.) a. Peripheral neuropathy b. Tissue ischemia c. Trauma to the foot d. Pain in the affected extremity ANS: A, B, C
The development of diabetic foot ulcers is multifactorial; three contributing factors are (1) peripheral neuropathy (changes in the function and efficiency of the nerves), (2) ischemia (decrease in blood flow related to plaque formation in the arteries), and (3) a pivotal event (e.g., trauma caused by banging the toe or stepping on a foreign object). DIF: Cognitive Level: Comprehension REF: Text reference: p. 420 OBJ: Identify risk factors for foot and nail problems. TOP: Diabetic Foot Ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. A patient is admitted with the diagnosis of pediculosis capitis (head lice). Proper treatment for
this condition would include which of the following? (Select all that apply.) a. Use of medicated shampoo or permethrin (Nix) b. Use of products containing lindane c. Combing the hair with a nit comb for 2 to 3 days after treatment d. Washing linens in cold water for 30 minutes
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: A, C
Use medicated shampoo available as a crème rinse for eliminating lice, or permethrin (Nix). Caution against the use of products containing lindane, because this ingredient is toxic and is known to cause adverse reactions. Remove the patient’s clothing before treatment, and apply new clothing after treatment. Repeat treatment according to product directions. Check the hair for nits, and comb with a nit comb for 2 to 3 days until you are sure all lice and nits have been removed. Manual removal of lice is the best option when treatment has failed. Vacuum infested areas of the home. Wash linens in hot water, and dry for at least 30 minutes. DIF: Cognitive Level: Analysis REF: Text reference: p. 415 OBJ: Identify guidelines for administering hair, nail, and foot care. TOP: Lice KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. The
is the largest human organ.
ANS:
skin Skin, the largest human body organ, protects us from heat, light, injury, and infection, and serves to (1) help regulate body temperature; (2) store water, vitamin D, and fat; (3) help sense pain and other stimuli; and (4) prevent the entry of bacteria. DIF: Cognitive Level: Knowledge REF: Text reference: p. 392 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Skin KEY: NN ursinRg PI rocess Step: Assessment U S NGTB.COM MSC: NCLEX: Physiological Integrity 2. The first line of defense against external injury and infection contains several thin layers of
cells undergoing different stages of maturation. This first line of defense is known as the . ANS:
epidermis The epidermis, or outer skin layer, is the first line of defense against external injury and infection. It contains several thin layers of cells undergoing different stages of maturation. DIF: Cognitive Level: Comprehension REF: Text reference: p. 392 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: The Epidermis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3.
provides an acidic coating to protect the epidermis against penetration from chemicals and microorganisms; it also minimizes loss of water and plasma proteins. ANS:
Sebum Sebum, secreted from hair follicles from sebaceous glands, provides an acidic coating. This acidic coating protects the epidermis against penetration from chemicals and microorganisms. It also minimizes loss of water and plasma proteins.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Comprehension REF: Text reference: p. 392 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Sebum KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
removes sweat, oil, dirt and bacteria and helps maintain skin integrity.
4. ANS:
Bathing Bathing removes sweat, oil, dirt and microorganisms and helps maintain skin integrity. DIF: Cognitive Level: Comprehension REF: Text reference: p. 395 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Bathing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The act of chewing is also known as
.
ANS:
mastication The teeth are organs of chewing, or mastication. DIF: Cognitive Level: Comprehension REF: Text reference: p. 392 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Mastication KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6.
N R I G B.C M
UemSbraNnesTwith unOderlying supportive tissue that encircle the are mucous m neck of erupted teeth to hold them in place. ANS:
Gingivae The gums, or gingival tissue, are mucous membranes with underlying supportive fibrous tissue. They encircle the neck of erupted teeth to hold them firmly in place. The gums normally are pink, moist, firm, and relatively inelastic. DIF: Cognitive Level: Comprehension REF: Text reference: p. 392 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Gingivae KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. Regular oral hygiene is necessary to maintain the integrity of tooth surfaces and to prevent
gum inflammation known as
.
ANS:
gingivitis Regular oral hygiene is necessary to maintain the integrity of tooth surfaces and to prevent gingivitis, or gum inflammation. DIF: Cognitive Level: Comprehension REF: Text reference: p. 392 OBJ: Discuss guidelines used to provide personal hygiene to patients.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Gingivitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. Tissue that surrounds the fingernail, slowly grows over the nail, and must be regularly pushed
back with a soft nail brush is known as the
.
ANS:
cuticle The nail is surrounded by a cuticle, which slowly grows over the nail and must be regularly pushed back with a soft nail brush. Take care to avoid breaking the skin around the nail. Breaks in the skin allow the entry of bacteria. DIF: Cognitive Level: Comprehension REF: Text reference: p. 394 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: The Cuticle KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. Many foot ulcers are due to repeat trauma over time, often caused by
.
ANS: poorly fitting shoes DIF: Cognitive Level: Comprehension REF: Text reference: p. 422 OBJ: Identify risk factors for foot and nail problems. TOP: Foot Ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
is defined as excessive growth of body and facial hair.
10. ANS:
N R I G B.C M
U S N T O Hirsutism Hirsutism is defined as excessive growth of body and facial hair, especially in women. DIF: Cognitive Level: Knowledge REF: Text reference: p. 393 OBJ: Discuss guidelines used to provide personal hygiene to patients. TOP: Hirsutism KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
is balding patches in the periphery of the hairline.
11. ANS:
Alopecia Alopecia is balding patches in the periphery of the hairline. Hair becomes brittle and broken. Alopecia can be caused by diseases, as a medication side effect, or after improper use of hair care products and hair styling devices. DIF: Cognitive Level: Knowledge REF: Text reference: p. 415 OBJ: Identify guidelines for administering hair, nail, and foot care. TOP: Alopecia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 18: Pressure Ulcer Care MULTIPLE CHOICE 1. The nurse is turning a patient when she notices an area with nonblanchable redness over the
patient’s coccyx. The patient complains of pain at the site, and the site does feel cooler than the areas immediately around the site. The nurse recognizes that this patient has developed: a. a stage I pressure. b. a stage II pressure. c. an unstageable pressure. d. deep tissue injury. ANS: A
The hallmarks of a stage I pressure ulcer are intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, and warmer or cooler as compared with adjacent tissue. Stage II pressure ulcers are defined by partial-thickness loss that presents as a shallow open ulcer with a red or pink wound bed, without slough. They also may present as intact or open/ruptured serum-filled blisters. They usually present as shiny or dry shallow ulcers without sloughing or bruising. Unstageable pressure ulcers are characterized by full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore the stage, cannot be determined. Deep tissue injury usually is characterized by purple or maroon localized areas of discolored intact skin or blood-filled blisters caused by damage to underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is N painR shC y, bM U ful, SIfirm NG,TmBu. O oggy, and warmer or cooler as compared with adjacent tissue. The wound may further evolve and become covered by thin eschar. DIF: Cognitive Level: Analysis REF: Text reference: p. 435 OBJ: Describe patient characteristics, as well as characteristics of the pressure ulcer itself, that should be included in an assessment. TOP: Stage I Pressure Ulcer KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. In a patient with a stage II pressure ulcer, the nurse describes the wound as: a. superficial blistering. b. nonblanchable redness. c. loss of skin without bone exposure. d. loss of skin with exposed muscle. ANS: A
A stage II pressure ulcer is defined by partial-thickness loss presenting as a shallow open ulcer with a red to pink wound bed, without slough. It also may present as an intact or open/ruptured serum-filled blister. It usually presents as a shiny or dry shallow ulcer without sloughing or bruising. The hallmarks of a stage I pressure ulcer are intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, and warmer or cooler as compared with adjacent tissue. Stage III pressure ulcers involve full-thickness skin loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present in some parts of the wound bed.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Analysis REF: Text reference: p. 435 OBJ: Describe patient characteristics, as well as characteristics of the pressure ulcer itself, that should be included in an assessment. TOP: Stage II Pressure Ulcer KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is caring for four patients during a shift. Which of the following patients is at
greatest risk for developing a pressure ulcer? a. The patient who is bedridden, but who turns himself randomly b. The patient whose Braden Scale score is 8 c. The patient who can ambulate to the bathroom independently d. The patient whose Braden Scale score is 18 ANS: B
Given the overall score on the Braden Scale, the patient will fall within one of these categories: mild risk, 16 to 18; moderate risk, 13 to 14; or high risk, 9 or less. Use these risk scores to plan care by looking at the individual risk factors that place the patient at risk and developing a care plan to decrease or eliminate the identified risk factors. Immobility often restricts the patient’s ability to change and control body position, thus increasing pressure over bony prominences. Patients who can turn themselves are at less risk than those who cannot. DIF: Cognitive Level: Analysis REF: Text reference: pp. 438-439 OBJ: Discuss the risk assessment tools commonly used in assessment of pressure ulcer risk. TOP: Braden Scale KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. Aggressive prevention measuNresR shoI uld G be iB m. plC emeMnted for a patient in the general
U S N T
O
population with a pressure ulcer risk on the Braden Scale of less than or equal to: a. 16. b. 18. c. 20. d. 24. ANS: A
Less than or equal to 16 is the risk cut score for the general population when the Braden Scale is used. Less than or equal to 18 is the risk cut score for older adults and black or Latino patients when the Braden Scale is used. DIF: Cognitive Level: Comprehension REF: Text reference: p. 439 OBJ: Discuss the risk assessment tools commonly used in assessment of pressure ulcer risk. TOP: Braden Scale KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. A patient with anemia is at risk for developing pressure ulcers as a result of which of the
following? a. Increased sedation b. Edematous tissues c. Reduced tensile strength d. Diminished oxygen to the tissues ANS: D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Decreased hemoglobin reduces the oxygen-carrying capacity of the blood and the amount of oxygen available to the tissues, thus increasing the risk for pressure ulcers. Anemia does not cause increased sedation, edematous tissue, or reduced tensile strength. DIF: Cognitive Level: Comprehension REF: Text reference: p. 439 OBJ: Identify risk factors for the development of pressure ulcers. TOP: Anemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. In a long-term care facility, how often should the nurse reassess a patient for risk of a pressure
ulcer? a. Every 1 to 2 days b. Every time the nurse sees the patient c. Weekly for the first few weeks of stay d. Monthly for the first 4 months of stay ANS: C
In a long-term care facility, the patient is assessed every week for 4 weeks and then quarterly, or whenever the patient’s condition changes. An assessment schedule of every 1 to 2 days would be more appropriate for acute care than in the long-term care setting. The patient is not reassessed for risk in the long-term setting every time the nurse sees the patient. The new patient in long-term care is reassessed weekly rather than monthly after he is admitted. DIF: Cognitive Level: Knowledge REF: Text reference: p. 441 OBJ: Describe guidelines for the prevention of pressure ulcers. TOP: Reassessment of Pressure Ulcer Risk KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
NURSINGTB.COM
7. The patient with a nasogastric (NG) tube in place may experience skin breakdown: a. in the nose. b. on the tongue. c. behind the ears. d. around the lips. ANS: A
NG and oxygen cannulas can cause pressure on the nares, leading to pressure ulcers. Skin breakdown around the lips and tongue may result from oral airways or endotracheal (ET) tubes. Skin breakdown behind the ears may result from pressure from the oxygen cannula or the patient’s pillow. DIF: Cognitive Level: Knowledge REF: Text reference: p. 440 OBJ: Describe guidelines for the prevention of pressure ulcers. TOP: Reassessment of Pressure Ulcer Factors KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. The nurse is caring for a darkly pigmented patient who is immobile and needs turning every 2
hours. While turning the patient, to what should the nurse who is performing the assessment pay particular attention? a. Edema in the sacrum b. Skin texture c. Skin temperature d. Pallor or mottling of the skin
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS: C
Darkly pigmented skin does not always have visible blanching. Its color differs from that of surrounding skin. Skin temperature changes may be an important early indicator of a stage I pressure ulcer. Edema is not an initial indication of a pressure ulcer. Do not massage any reddened or discolored pressure points. Areas of nonblanchable erythema or discolored areas may indicate that deeper tissue damage is present. Massage in this area may worsen the inflammation by further damaging underlying damaged blood vessels. Pallor or mottling will be difficult or impossible to see in a patient with darkly pigmented skin. DIF: Cognitive Level: Application REF: Text reference: p. 441 OBJ: Describe guidelines for the prevention of pressure ulcers. TOP: Reassessment of Pressure Ulcer Factors KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The patient is admitted with an open pressure ulcer with necrotic tissue around the base of the
wound. How would the nurse classify this ulcer? a. Stage III pressure ulcer b. Stage IV pressure ulcer c. Wound that cannot be staged d. Stage II pressure ulcer ANS: C
To correctly stage a pressure ulcer, the nurse must be able to see the base of the wound. Therefore, pressure ulcers that are covered with necrotic tissue cannot be staged until the eschar has been debrided and the base of the wound is visible. Until debridement occurs, the ulcer should be documented N as uR nstaI geaG ble.B.C M
U S N T
O
DIF: Cognitive Level: Application REF: Text reference: p. 445|Text reference: p. 448 OBJ: Describe patient characteristics, as well as characteristics of the pressure ulcer itself, that should be included in an assessment. TOP: Staging Pressure Ulcers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. A nurse classifies a pressure ulcer according to the type of tissue in the wound bed. What does
it indicate if the wound bed has granulation in it? a. Wound needs debridement b. The presence of significant infection c. Colonization by bacteria d. Movement toward healing ANS: D
The presence of granulation tissue signifies a movement toward wound healing. Black tissue is necrotic tissue. A wound with a high percentage of black tissue will require debridement. Yellow tissue or slough tissue indicates the presence of infection or colonization. DIF: Cognitive Level: Comprehension REF: Text reference: p. 445 OBJ: Describe patient characteristics, as well as characteristics of the pressure ulcer itself, that should be included in an assessment. TOP: Color Typing of Tissue KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
11. When evaluating a patient, the nurse observes an unexpected outcome of treatment when the
surrounding skin of an ulcer becomes macerated. The nurse should: a. obtain a wound culture. b. apply pressure-reducing devices. c. use dressings with increased moisture absorption. d. monitor the patient for systemic signs and symptoms. ANS: C
Select a dressing that has increased moisture-absorbing capacity. Dressings that increase moisture absorption will result in dryer skin that is less macerated. A wound culture is not indicated for macerated skin unless an increase in drainage or development of necrotic tissue occurs. Pressure-reducing devices are not indicated for macerated skin. Macerated skin is a local reaction; the patient would not need systemic monitoring unless the pressure ulcer extended beyond the original margins. DIF: Cognitive Level: Comprehension REF: Text reference: p. 450 OBJ: Discuss indications for the use of topical agents in the treatment of pressure ulcers. TOP: Unexpected Outcomes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. After teaching a home caregiver how to manage a pressure ulcer, the nurse realizes that
further education is needed when the caregiver says: a. “I will be sure to reposition her frequently and keep her off of the pressure ulcer.” b. “I will wash the pressure ulcer with saline and report any changes in the drainage.” c. “I know that a thick, black covering will protect the pressure ulcer from getting worse.” N R I G B.C M d. “I will let you know if the pUresS sureNulcT er startsOto smell rotten.” ANS: C
Black tissue in a pressure ulcer is eschar, a necrotic tissue that covers a section of the ulcer and prevents effective assessment. If the caregiver makes this statement additional education is needed. The other statements indicate that the caregiver understands how to care for pressure ulcers. DIF: Cognitive Level: Analysis REF: Text reference: p. 436|Text reference: p. 445 OBJ: Discuss teaching needs of the patient and family regarding pressure ulcers. TOP: Teaching Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is aware that pressure ulcers can occur: (Select all that apply.) a. from any position that causes soft tissue compression. b. because of lack of blood flow (ischemia). c. only in bedbound patients. d. in as little as 90 minutes. ANS: A, B, D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Pressure ulcers occur from any position that causes soft tissue compression. Compression of soft tissue interferes with blood flow to the tissue; if this compression continues for a prolonged time, the tissue dies from lack of blood flow, also known as ischemia. This pressure, if not relieved, can cause irreversible tissue damage in as little as 90 minutes. It is quite possible for an individual to develop a pressure ulcer even if not confined to bed. DIF: Cognitive Level: Knowledge REF: Text reference: p. 433 OBJ: Identify risk factors for the development of pressure ulcers. TOP: Pressure Ulcer Etiology KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Patients are at risk for developing pressure ulcers on which areas of the body? (Select all that
apply.) a. Coccyx b. Nares c. Ears d. Genitalia ANS: A, B, C, D
The most common sites of pressure ulcers are the sacrum, coccyx, ischial tuberosities, greater trochanters, elbows, heels, scapulas, iliac crests, and lateral and medial malleoli (Pieper, 2007). Pressure ulcers can occur on any area of skin subjected to pressure. Nonbony locations in which pressure ulcers can occur include the nares, usually related to pressure caused by nasogastric (NG) tubes or oxygen cannulas; the ears, resulting from an oxygen cannula; and the genitalia, with ulcers resulting from Foley catheter tension. DIF: Cognitive Level: Comprehension REF: Text reference: p. 433 OBJ: Identify risk factors for tN heUdR evSeI lopNmGeT ntB of.pC reO ssM ure ulcers. TOP: Pressure Ulcer Sites KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse knows that which of the following factors contribute to the development of pressure
ulcers? (Select all that apply.) a. Friction and shear b. Immobility c. Poor nutrition d. Moisture and ammonia e. Uncontrolled pain ANS: A, B, C, D
Factors such as incontinence, friction and shear, immobility, loss of sensory perception, reduced level of activity, and poor nutrition contribute to pressure ulcer formation. Moisture and ammonia from incontinence soften the skin, allowing the skin to become susceptible to breakdown. Uncontrolled pain does not contribute to the development of pressure ulcers. DIF: Cognitive Level: Comprehension REF: Text reference: p. 433 OBJ: Identify risk factors for the development of pressure ulcers. TOP: Pressure Ulcer Sites KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is planning care for her patient who has a stage II pressure ulcer. Care should
include which of the following? (Select all that apply.)
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
A heat lamp to dry the wound Application of topical antibiotics Nutritional assessment Maintaining moisture in the wound
ANS: B, C, D
The treatment plan for a patient with a pressure ulcer must include elimination or reduction of the factors that have caused the pressure ulcer. A moist wound environment supports the growth of new tissue. If the wound is not free of necrotic tissue, you need to choose topical wound care that will cleanse the wound bed of devitalized tissue. Treat infection both systematically and topically. Wound healing in a patient with a pressure ulcer progresses if the patient has adequate nutritional status as well as control over preexisting conditions such as diabetes and cardiovascular and pulmonary disease. DIF: Cognitive Level: Application REF: Text reference: p. 444 OBJ: Identify outcome criteria for patients at risk for pressure ulcers or impaired skin integrity. TOP: Treatment for Pressure Ulcer KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. A
is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. ANS:
pressure ulcer NURSINGTB.COM A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. DIF: Cognitive Level: Knowledge REF: Text reference: p. 433 OBJ: Describe patient characteristics, as well as characteristics of the pressure ulcer itself, that should be included in an assessment. TOP: Pressure Ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. When skin layers adhere to the linens and deeper tissue layer move downward,
damage occurs. ANS:
shear Shear damage is caused when pressure holds one layer of skill in place while the deeper layer is forced downward as may happen when turning or moving in bed. This force causes reduced blood flow to the tissues. DIF: Cognitive Level: Comprehension REF: Text reference: p. 434 OBJ: Identify risk factors for the development of pressure ulcers. TOP: Shear KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The removal of devitalized tissue in a wound is known as
_.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS:
debridement If the tissue in the wound is devitalized, consider debridement, which is the removal of devitalized tissue. Debridement is accomplished by selecting a dressing and using enzyme preparations or surgical or laser techniques. DIF: Cognitive Level: Comprehension REF: Text reference: p. 444 OBJ: Discuss indications for the use of topical agents in the treatment of pressure ulcers. TOP: Debridement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 19: Care of the Eye and Ear MULTIPLE CHOICE 1. The nurse decides that assistive personnel can provide care to a patient with contact lenses
when the assistive personnel states: a. “If I am in a hurry, I will use tap water for rinsing the lenses.” b. “Gloves aren’t necessary; the eye is a clean organ.” c. “I will check with the patient to see if the lenses are disposable.” d. “It is normal for contact lens wearers to have red, teary eyes.” ANS: C
Let the patient be a resource in the care of each device. Although it is the nurse’s responsibility to ensure that patients do not damage their devices or injure themselves, patients familiar with their devices are likely to have an established routine and helpful tips. The replacement schedule is determined by the type of lenses the patient wears; the patient can provide that information. Tap water can contain microorganisms and may be absorbed into the lens, making it uncomfortable to wear. Clean, powder-free gloves are used to prevent the spread of microorganisms during care of contact lenses. Pain, tearing, discomfort, and redness can indicate conjunctivitis and should be referred to the patient’s provider if symptoms persist. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 456-457 OBJ: Identify guidelines used in caring for eye and ear prostheses. TOP: Contact Lenses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity G B.C M
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2. When providing eye care for the comatose patient, the nurse should: a. place the patient in a prone position for easier access. b. use a different corner of the washcloth for each eye. c. wipe each eye from outer to inner canthus. d. use a sterile medicine cup to instill lubricant. ANS: B
Use a separate, clean cotton ball or corner of the washcloth for each eye. Place the patient in supine position. Gently wipe each eye from inner to outer canthus. Use an eyedropper to instill the prescribed lubricant (e.g., saline, methylcellulose, liquid tears) as ordered. DIF: Cognitive Level: Application REF: Text reference: p. 455 OBJ: Identify guidelines used in caring for eye and ear prostheses. TOP: Eye Care for a Comatose Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. In caring for a patient with contact lenses, the nurse should be aware that: a. rigid gas-permeable (RGP) lenses are no longer used. b. soft contact lenses are smaller than the cornea. c. all lenses must be removed periodically. d. extended wear lenses can be used for only 6 nights. ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank It is important to remember that all lenses must be removed periodically to prevent infection and corneal damage, and that proper cleaning is necessary before a lens is reinserted. Two basic types of contact lenses are used today: RGP and soft. Rigid contact lenses are made of firm, durable plastic and are smaller than the cornea. Soft contact lenses are made of a flexible hydrogel plastic and cover the entire cornea and a small rim of the sclera. Although the limit for extended wear lenses is usually 6 nights, certain soft lenses have been approved for continuous wear up to 30 nights. DIF: Cognitive Level: Application REF: Text reference: p. 455 OBJ: Identify guidelines used in caring for eye and ear prostheses. TOP: Contact Lenses KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Which of the following nursing interventions would the nurse perform first after a patient
sustained a chemical splash injury to the eye? a. Assess visual acuity. b. Flush the eye with large amounts of irrigation fluid. c. Assess level of pain. d. Determine whether the pupils are PERRLA. ANS: B
The first thing the nurse should do when caring for a patient who has sustained a chemical injury to the eye is flush the eye with large amounts of irrigation fluid. Assessing visual acuity, pain, and PERRLA will be performed after the eye has been irrigated appropriately. DIF: Cognitive Level: Application REF: Text reference: p. 460 OBJ: Identify nursing care for a patient with a chemical splash to the eye. NURSINGKTEB TOP: Splash to Eye Y. : C NuOrsM ing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse caring for a comatose patient determines that he is wearing contact lenses. Which of
the following nursing interventions will the nurse use when removing the contact lenses? a. Put on snug, powdered, clean gloves. b. Ask the patient to look down to expose the lower eyeball. c. Use the fingernail to slide the lens off of the cornea. d. Inspect the eye after the lenses have been removed. ANS: D
After the lenses have been removed, inspect the eye for redness, pain, swelling of the eyelids or conjunctivae, discharge, or excess tearing. Perform hand hygiene. Don snug, powder-free, clean gloves, and place a towel just below the patient’s face. Ask the patient to look up to expose the lower eyeball to which the lens will be displaced. With the pad of the index finger of the same hand, slide the lens off the cornea down onto the lower sclera. Use of the pad rather than the fingernail prevents injury to the cornea and damage to the lens. DIF: Cognitive Level: Application REF: Text reference: p. 456 OBJ: Correctly remove, store, clean, and insert a contact lens. TOP: Removal of Contact Lenses KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. When removing a soft contact lens, the nurse finds that it is sticking together. What should the
nurse do next?
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
Rub the lens briskly. Soak the lens in saline. Place cleansing solution on the lens. Pry the lens apart with the fingertips.
ANS: B
If the lens edges stick together, place the lens in the palm and soak thoroughly in saline; gently roll the lens back and forth with the index finger. If this is unsuccessful in restoring the shape of the lens, placing the lens in cleansing solution would be the next step. Brisk rubbing may damage the lens. Prying the lens apart could damage it. DIF: Cognitive Level: Application REF: Text reference: p. 456 OBJ: Correctly remove, store, clean, and insert a contact lens. TOP: Removal of Contact Lenses KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. When caring for the patient with an artificial eye, the nurse realizes that: a. the prosthesis must be cleansed daily. b. implants are always visible. c. modern implants move as the companion eye moves. d. the prosthesis always is made of glass. ANS: C
The muscles and other tissues of the eye are sewn around the implant, holding it in place. The implant, therefore, is not visible. Modern implants are made of glass or plastic and are porous so that the tissues of the eye grow into the sphere. Like a healthy eye, this integrated implant moves as the companion eye moves. Cleansing with sterile saline or soap and water is done at intervals of up to a year on thN eU baRsis heToB cu.laCrist IofNtG M’s recommendations and patient S O preference. DIF: Cognitive Level: Comprehension REF: Text reference: p. 458 OBJ: Explain the rationale for maintaining aseptic technique during care of an artificial eye. TOP: Eye Implants KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. The nurse is caring for an unconscious patient who has an artificial eye. To determine which
eye is artificial, she shines a light into the patient’s eyes. Why does the nurse do this? a. The light will cause the eye to move differently than the natural eye. b. An artificial eye pupil does not react to changes in light. c. It is essential to remove the prosthesis for cleaning. d. The implant can be seen only by shining a light. ANS: B
An artificial eye pupil does not react to changes in light. Modern implants are made of glass or plastic and are porous so that the tissues of the eye grow into the sphere. Like a healthy eye, this integrated implant moves as the companion eye moves. Unless advised by the patient’s eye care practitioner, the prosthesis usually is not removed unless the patient experiences discomfort, because excessive handling may cause irritation and increased secretions. The muscles and other tissues of the eye are sewn around the implant, holding it in place. The implant, therefore, is not visible. DIF: Cognitive Level: Application
REF: Text reference: p. 458
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Explain the rationale for maintaining aseptic technique during care of an artificial eye. TOP: Eye Implants KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. When removing and cleansing a patient’s eye prosthesis, the nurse: a. places the patient in a prone position. b. retracts the upper eyelid with her thumb and forefinger. c. cleans the prosthesis using an alcohol solution. d. cleans the prosthesis using mild soap and water. ANS: D
Clean the prosthesis by washing it with mild soap and warm water or plain saline solution by rubbing well between the thumb and index finger. Position the patient in sitting or supine position with the head elevated. Provide privacy. With the thumb or forefinger of the dominant hand, gently retract the lower eyelid against the lower orbital ridge. Never use alcohol or other products because they are harmful to the prosthesis. DIF: Cognitive Level: Application REF: Text reference: pp. 458-459 OBJ: Explain proper care of eye and ear prostheses. TOP: Removing Eye Prosthesis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The patient is brought to the emergency department after receiving a chemical burn to his
eyes. The doctor orders immediate eye irrigations. Of the following solutions, which would be the most beneficial for this patient? a. Lactated Ringer’s solution b. Normal saline c. Tap water NURSINGTB.COM d. Dextrose and water ANS: A
Controversy continues over the best solution for irrigating the eye in a health care setting. When a choice of normal intravenous (IV) solutions is available, lactated Ringer’s solution is more effective than normal saline in restoring pH after a chemical burn to the eye. Often cool tap water is recommended for emergency eye flushing because it is effective and immediately available for first aid. Nevertheless, controversy continues over the best solution for irrigating the eye in a health care setting. Dextrose and water usually are not used for eye irrigation. DIF: Cognitive Level: Analysis REF: Text reference: p. 460 OBJ: Explain differences in irrigation procedures for removing exudates and chemicals from the eyes. TOP: Eye Irrigation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. When providing care to a patient who has splashed bleach into his eye, the nurse will: a. remove the patient’s contacts immediately. b. flush the eye from the outer to the inner canthus. c. reinsert contacts as soon as irrigation is done. d. irrigate toward the lower conjunctival sac. ANS: D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Ask the patient to look toward the brow. Gently irrigate with a steady stream toward the lower conjunctival sac. This will minimize the force of the stream on the cornea and will flush irritant out of the eye and away from the other eye and nasolacrimal duct. In an emergency such as first aid for a chemical burn, do not delay flushing by removing the patient’s contact lens before irrigation. Do not remove the contact unless rapid swelling is occurring. Flush the eye from the inner to the outer canthus. Advise the patient to consult the prescriber before reusing the contact lens. DIF: Cognitive Level: Application REF: Text reference: p. 461 OBJ: Explain differences in irrigation procedures for removing exudates and chemicals from the eyes. TOP: Eye Irrigation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The patient is found to have impacted cerumen in his ear canal. The nurse most likely will: a. instill 1 to 2 drops of mineral oil. b. instill the irrigation under pressure. c. occlude the ear canal when irrigating. d. straighten the ear canal. ANS: A
If the patient is found to have impacted cerumen, instill 1 to 2 drops of mineral oil or over-the-counter softener into the ear twice a day for 2 to 3 days before irrigation, to loosen cerumen and ensure easier removal during irrigation. The greatest danger during administration of ear irrigation is rupture of the tympanic membrane. Fluids must not be instilled under pressure or with the irrigating device occluding the ear canal. Always attempt to remove foreign objects in the ear by first simply straightening the ear canal. Cerumen, however, is wax buildup and is not a foreign object.
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DIF: Cognitive Level: Application REF: Text reference: p. 464 OBJ: Correctly perform eye and ear irrigations. TOP: Ear Irrigation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. How should the nurse position the ear when performing ear irrigation for a 2-year-old patient? a. Instill the irrigating solution quickly and forcefully. b. Pull the pinna up and back. c. Direct the fluid toward the anterior aspect of the ear canal. d. Pull the pinna down and back. ANS: D
In children age 3 or younger, pull the pinna down and back. Slowly instill irrigating solution by holding the tip of the syringe 1 cm ( inch) above the opening to the ear canal. Allow fluid to drain out during instillation into the basin. Continue until the canal is cleansed or the solution is used. Slow instillation prevents buildup of pressure in the ear canal and ensures contact of the solution with all canal surfaces. For adults and children older than age 3, gently pull the pinna up and back. Direct the fluid toward the superior aspect of the ear canal. DIF: Cognitive Level: Application REF: Text reference: p. 464 OBJ: Correctly perform eye and ear irrigations. TOP: Ear Irrigation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
14. How does the nurse assess that a hearing aid is operating correctly? a. Speaking very softly behind the patient b. Covering the patient’s unaffected ear and speaking c. Determining the patient’s response to a normal tone of voice d. Removing the hearing aid and sending it to be checked by an audiologist ANS: C
To determine whether the patient can hear clearly using the hearing aid, turn your back to the patient and ask a question slowly and clearly in a normal tone of voice. Depending on your position, the patient may be able to read your lips. The prostheses are limited by the function of the ear structures. The hearing aid may not be the problem in this case. DIF: Cognitive Level: Comprehension REF: Text reference: p. 466 OBJ: Describe techniques that determine whether a hearing aid functions properly. TOP: Assessing the Function of the Hearing Aid KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. The nurse is preparing to clean the patient’s hearing aid. The nurse realizes that she must: a. make sure the hearing aid volume is turned on before removing the hearing aid. b. hold the hearing aid over the sink when cleansing. c. insert a paper clip into the receiver port to cleanse cerumen buildup. d. make sure the pressure equalization channel is clear. ANS: D
The pressure equalization channel is a tiny hole through the entire length of the ear mold; it should be clear for the entire length. Before removing the hearing aid, turn the volume off to prevent feedback (whistling)N durR l. . HC old M UingSIrem NGova TB Othe hearing aid over a towel, and wipe the exterior with tissue to remove the cerumen. This prevents breakage if dropped. The receiver port is easily damaged. Never insert anything into the receiver port. DIF: Cognitive Level: Application REF: Text reference: p. 468 OBJ: Correctly remove, clean, and reinsert a hearing aid. TOP: Cleaning the Hearing Aid KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. When instructing a patient on correct technique for inserting a hearing aid into the ear, the
nurse will include which of the following instructions? a. Pull the outer ear up and out. b. Hold the aid with the long portion upright. c. Fit the aid snugly in the midline of the canal. d. Turn the aid to the desired sound level before insertion. ANS: C
Hold the hearing aid in the dominant hand and insert the pointed end of the ear mold into the ear canal while following the natural contours of the canal. Pulling up and out on the outer ear has little effect on hearing aid insertion. Instead, hold the hearing aid in the dominant hand and insert the pointed end of the ear mold into the ear canal while following the natural contours of the canal. Turn the volume slowly to high to prevent damage to the hearing aid. DIF: Cognitive Level: Application REF: Text reference: p. 469 OBJ: Correctly remove, clean, and reinsert a hearing aid. TOP: Inserting the Hearing Aid
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The elderly patient is instructed to store his hearing aid in a(n): a. cold place. b. container that keeps out moisture. c. easy to reach place. d. a cup of water. ANS: B
Hearing aids and batteries should be stored in a dry container with desiccant or in an electronic dryer to prolong life, minimize repairs, and preserve batteries. Advise the patient to avoid exposing the hearing aid to extremes of temperature. Batteries are toxic if swallowed; keep them away from pets and children. Advise the patient to protect the hearing aid from water, alcohol, hair spray or cologne, perspiration, rain, and snow. DIF: Cognitive Level: Application REF: Text reference: p. 470 OBJ: Correctly remove, clean, and reinsert a hearing aid. TOP: Storage of Hearing Aid KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is preparing to provide eye care for a comatose patient. The nurse realizes that
comatose patients do not have natural protective mechanisms to protect the cornea. These protective mechanisms include: (Select all that apply.) a. blinking. NURSINGTB.COM b. squinting. c. lubrication. d. dilation. ANS: A, C
Comatose patients do not have the natural protective mechanisms to protect the cornea. These protective mechanisms include blinking and lubrication of the eye. When patients are in a coma, the nurse is responsible for providing this care. DIF: Cognitive Level: Comprehension REF: Text reference: p. 455 OBJ: Identify guidelines used in caring for eye and ear prostheses. TOP: Protective Mechanisms KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. In teaching a patient with a new eye prosthesis on how to care for his eye, the nurse informs
the patient that: (Select all that apply.) a. the artificial eye should be checked at least twice a year. b. the artificial eye should be cleansed daily using an alcohol product. c. an artificial eye usually is replaced every 5 years. d. if the prosthesis is not to be reinserted, it should be wrapped in a dry sterile towel. ANS: A, C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Patients are instructed to have the artificial eye checked and polished at least twice a year to avoid unnecessary discomfort to the patient as a result of protein deposits or scratches on the surface of the artificial eye. An artificial eye usually is replaced every 5 years. DIF: Cognitive Level: Application REF: Text reference: p. 458 OBJ: Explain proper care of eye and ear prostheses. TOP: Removing Eye Prosthesis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. The patient is brought into the emergency department after a motor vehicle accident. The
patient is unresponsive. The nurse is concerned about whether or not the patient wears contact lenses because contact lenses that are not removed can cause . ANS:
corneal injury It is extremely important to determine whether patients wear contact lenses, particularly when patients are admitted to hospitals or agencies in an unresponsive or confused state. If a seriously ill patient is wearing contact lenses, and this fact goes undetected, severe corneal injury can result. DIF: Cognitive Level: Application REF: Text reference: p. 456 OBJ: Identify guidelines used in caring for eye and ear prostheses. TOP: Contact Lenses KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
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is the completeUsurS gicaN l reT moval oO f the eyeball.
2. ANS:
Enucleation As a result of tumor, infection, congenital blindness, or severe trauma to the eye, patients may undergo enucleation, the complete surgical removal of the eyeball. DIF: Cognitive Level: Knowledge REF: Text reference: p. 458 OBJ: Explain the rationale for maintaining aseptic technique during care of an artificial eye. TOP: Enucleation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The substance found in the ear canal that has an antibacterial effect and maintains an acid pH
is called
.
ANS:
cerumen Cerumen has an antibacterial effect and maintains an acid pH in the auditory canal. DIF: Cognitive Level: Comprehension REF: Text reference: p. 465 OBJ: Correctly perform eye and ear irrigations. TOP: Ear Irrigation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. A
is a small, battery-powered, electronic device that amplifies sound.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS:
hearing aid A hearing aid is a small, battery-powered, electronic device that amplifies sound. DIF: Cognitive Level: Comprehension REF: Text reference: p. 466 OBJ: Describe techniques that determine whether a hearing aid functions properly. TOP: Hearing Aid KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 20: Safe Medication Preparation MULTIPLE CHOICE 1. The prescribed dose of Tylenol is given to a patient. The nurse recognizes the name Tylenol
as which of the following? a. Chemical name b. Trade name c. Generic name d. United States Pharmacopeia ANS: B
A medication trade name or brand name is used to market the medication. The trade name has the symbol ™ at the upper right of the name, indicating a manufacturer’s trademark for the name (e.g., Panadol™, Tempra™, Tylenol™). The chemical name describes the medication’s composition and molecular structure, such as N-acetyl-para-aminophenol, commonly known as Tylenol. The chemical name rarely is used in clinical practice. A manufacturer who first develops a medication gives the generic name of a medication. Acetaminophen is the generic name for Tylenol. The generic name is the official name that is listed in official publications such as the United States Pharmacopeia (USP). The USP is a drug book that lists all drugs by generic name. DIF: Cognitive Level: Remembering REF: Text reference: p. 474 OBJ: Discuss factors that contribute to medication errors. TOP: Medication Names KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
enUtR wS itI hN livGeT r dBis. eaCsO e aMnd a decreased albumin level may develop 2. The nurse is aware that a patiN which of the following effects? a. Toxicity on normal doses of medication b. Less active medication available in the body c. Reduction in therapeutic effect d. Accelerated biotransformation of the medication ANS: A
Most medications bind to albumin to some extent. When medications bind to albumin, they are unable to exert pharmacological activity. Only the unbound or “free” medication is active. Older adults and patients with liver disease or malnutrition have reduced albumin, which increases their risk for medication toxicity. With less albumin to bind with the medication, more “free” or active medication is present in the body. This would result in an increase in therapeutic effect and possibly in toxicity. Most biotransformation occurs in the liver, although the lungs, kidneys, blood, and intestines also play a role. Patients (e.g., elderly, those with chronic disease) are at risk for medication toxicity if their organs that metabolize medications do not function correctly. DIF: Cognitive Level: Applying REF: Text reference: p. 474 OBJ: Discuss the types of medication actions. TOP: Protein Binding KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. During the admission process, the patient states that he stopped taking daily aspirin because of
nausea. The nurse documents the nausea as which of the following?
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
Noncompliance Toxic effects of the medication Side effects of the medication Allergic reaction to the medication
ANS: C
Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. For example, some antihypertensive medications cause impotence in male patients. Noncompliance is almost an accusatory name given to patients who do not follow their medical regimen such as by not taking their medications. Usually, however, there is a reason for noncompliance, and in this case, the reason is the side effect of the medication. Be careful with this term because it carries a negative connotation. Toxic effects develop after prolonged intake of a medication, when a medication accumulates in the blood because of impaired metabolism or excretion, or when too high a dose is given. Allergic reactions are unpredictable responses to a medication. Exposure to an initial dose of a medication causes a patient to become sensitized immunologically. The medication acts as an antigen, and this causes antibodies to be produced. Nausea is not an antigen-antibody response. DIF: Cognitive Level: Applying REF: Text reference: p. 475 OBJ: Discuss the types of medication actions. TOP: Side Effects KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. An 80-year-old patient who complains of feeling “anxious” is given lorazepam (Ativan). The
patient becomes agitated and delirious. The nurse documents this reaction to Ativan as which of the following? a. Toxicity b. Side effect c. Idiosyncratic reaction NURSINGTB.COM d. Allergic reaction ANS: C
Medications often cause unpredictable effects such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction different from normal. Predicting which patients will have an idiosyncratic response is impossible. For example, Ativan, an antianxiety medication, when given to an older adult, may cause agitation and delirium. Toxic effects develop after prolonged intake of a medication, when a medication accumulates in the blood because of impaired metabolism or excretion, or when too high a dose is given. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. Allergic reactions are unpredictable responses to a medication. The medication acts as an antigen, and this causes antibodies to be produced. With repeated administration, the patient develops an allergic response. Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, severe wheezing, and shortness of breath are characteristic of severe or anaphylactic reactions. Some patients become severely hypotensive, necessitating emergency resuscitation measures. Anaphylaxis is potentially fatal. DIF: Cognitive Level: Applying REF: Text reference: p. 476 OBJ: Discuss the types of medication actions. TOP: Idiosyncratic Reactions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 5. A patient admitted to the hospital with pneumonia has IV antibiotics ordered. He receives the
first dose with no problem, but during the second dose, he begins to complain of shortness of breath and difficulty breathing. The nurse notes wheezes throughout the lung fields. The nurse documents these symptoms as which of the following? a. Idiosyncratic reaction b. Toxic effect of the antibiotic c. Side effect of the medication d. Anaphylactic reaction ANS: D
An allergic reaction ranges from mild to severe, depending on the patient and the medication. Among the different classes of medications, antibiotics cause a high incidence of allergic reactions. Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, severe wheezing, and shortness of breath are characteristic of severe or anaphylactic reactions. Some patients become severely hypotensive, necessitating emergency resuscitation measures. Anaphylaxis is potentially fatal. Medications often cause unpredictable effects, such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction that is different from normal. However, the symptoms displayed by this patient are classic anaphylactic symptoms. Toxic effects develop after prolonged intake of a medication, when a medication accumulates in the blood because of impaired metabolism or excretion, or when too high a dose is given. Two doses of a medication usually are not enough to develop toxic effects. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. Anaphylaxis is usually unpredictable initially and is avoided after the first reaction by listing the cause of the anaphylaxis in the allergy alert section of the patient record. DIF: Cognitive Level: ApplyiN ng R I GREB F: Text reference: p. 476 U Sactions. N T .C OM OBJ: Discuss the types of medication TOP: Allergic Reactions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. A patient with chronic back pain has been taking oral morphine sulfate (MS Contin) for the
past 2 years. Upon admission to the hospital, the patient receives morphine sulfate for back pain but reports no pain relief. The nurse notifies the health care provider, recognizing that the reason for the lack of pain relief is which of the following? a. Side effect of the morphine b. Drug dependence c. Idiosyncratic response to the morphine d. Medication tolerance ANS: D
Medication tolerance is a decreased physiological response that occurs after repeated administration of a medication. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. Drug dependence can be physical or psychological. In psychological dependence, patients have an emotional desire for a drug to maintain an effect. A person believes that a desirable effect will result when taking the medication. Physical dependence is a physiological adaptation to a medication that manifests itself by intense physical disturbance when the medication is withdrawn. Medications often cause unpredictable effects, such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction that is different from normal. DIF: Cognitive Level: Analyzing
REF: Text reference: pp. 476-477
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Discuss the types of medication actions. TOP: Medication Tolerance KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. A patient is receiving vancomycin IV every 8 hours at 0800, 1600, and 2400. A serum peak
and trough level is ordered after the third dose, which will be given at 1600. When should the nurse order the trough level? a. 1630 b. 1800 c. 2330 d. 2400 ANS: C
The point at which the lowest amount of drug is in the serum is the trough concentration. Some medication doses (e.g., vancomycin, gentamicin) are based on peak and trough serum levels. A patient’s trough level is drawn as a blood sample 30 minutes before the drug is administered, and the peak level is drawn whenever the drug is expected to reach its peak concentration. The third dose will be given at 1600, which means that the lowest level of drug will be present 30 minutes before the fourth dose at midnight. A patient’s trough level is drawn as a blood sample 30 minutes before the drug is administered. 1630 is 30 minutes after the drug is administered. 1800 is 2 hours after the drug is administered. If the medication reaches its peak concentration in 2 hours, this could be a peak concentration, because the peak level is drawn whenever the drug is expected to reach its peak concentration. 2400 is the time that the next dose is due. A patient’s trough level is drawn as a blood sample 30 minutes before the drug is administered. DIF: Cognitive Level: Applying REF: Text reference: p. 477 TOP: Trough Concentration OBJ: Discuss the types of medication actions. N R I G B.C M KEY: Nursing Process Step: ImpU lemS entaN tionT O MSC: NCLEX: Physiological Integrity 8. The hospital uses a unit-dose system for medication distribution. The nurse recognizes that
this system includes which safety feature? a. All medications are kept in the patient’s drawer. b. Liquids are kept in multi-dose containers to prevent spillage. c. Narcotics are kept in an area separate from the patient’s regular medications. d. The nurse is responsible for restocking the medication drawers daily. ANS: C
Controlled substances are not kept in the individual patient drawer; they are kept in a larger locked drawer to keep them secure. The unit dose is the ordered dose of medication that the patient receives at one time. Each tablet or capsule is wrapped in a foil or paper container. Liquid doses come in prepackaged foil or paper cups. At a designated time each day, the pharmacist or a pharmacy technician refills the drawers in the cart with a fresh supply. DIF: Cognitive Level: Understanding REF: Text reference: pp. 478-479 OBJ: Discuss factors that contribute to medication errors. TOP: Unit Dose KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 9. The nurse is calculating a medication dosage using the metric system. A vial contains 1 mL of
fluid, and the nurse calculates the correct dosage to be half of the medication in the vial. How should the nurse document the correct dosage? a. mL b. .5 mL c. 0.5 mL d. 0.50 mL ANS: C
When writing medication dosages in metric units, convert fractions to decimals. Always include a zero before a decimal point (e.g., 0.1 mL is correct). Never use a trailing zero (e.g., 1.0 mL is incorrect). DIF: Cognitive Level: Applying REF: Text reference: p. 480 OBJ: Identify the system of measurement for a given prescribed medication. TOP: The Metric System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse is teaching a patient how to measure medication dosages at home. The prescription
is written for 30 mL of the medication. Which household measurement will the nurse teach the patient to use? a. Drops b. Teaspoon c. Tablespoon d. Cup ANS: C
The equivalents of measuremNeU ntRaS reI asNfG olT loB w. s:C1O 5M drops = 1 mL, 1 teaspoon = 5 mL, 1 tablespoon = 15 mL, and 1 cup = 240 mL; therefore, a tablespoon is most appropriate, with 2 tablespoons = 30 mL. DIF: Cognitive Level: Applying REF: Text reference: p. 480 |Text reference: p. 486 OBJ: Identify the system of measurement for a given prescribed medication. TOP: Household Measurement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The patient is complaining of severe leg pain. No pain medication is ordered, so the nurse
calls the health care provider. An order for Tylenol with Codeine prn is given, in addition to a one-time order for morphine sulfate to be given stat. Which action by the nurse is most appropriate? a. Give the morphine sulfate and Tylenol with Codeine immediately. b. Give the Tylenol with Codeine now. c. Give the morphine sulfate immediately. d. Ask the patient which medication he would like first. ANS: C
Types of orders based on frequency and/or urgency of medication administration include prn orders (given only when a patient requires it) and stat orders (given immediately and only once). DIF: Cognitive Level: Applying REF: Text reference: p. 481 OBJ: List and discuss the six rights of medication administration.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Medication Orders MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step: Implementation
12. The nurse is preparing to administer medication to a patient who is alert and oriented. When
medications are reviewed with the patient, the patient states that he does not take metoprolol. Which action by the nurse is most appropriate? a. Ignore the patient’s statement and give the medication. b. Withhold the medication. c. Convince the patient that the doctor ordered it, and he should take it. d. Give the medication and check the order afterward. ANS: B
If a patient questions the medication a nurse prepares, it is important not to ignore these concerns. An alert patient will know whether a medication is different from those received before. Withhold the medication until you are able to recheck the preparation against the order. If a medication order seems incorrect or inappropriate, always consult the prescriber. DIF: Cognitive Level: Applying REF: Text reference: p. 481 OBJ: List and discuss the six rights of medication administration. TOP: Medication Orders KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. The nurse is preparing a liquid medication. Which action is most appropriate? a. Pour the liquid medication toward the label. b. Draw the liquid quickly into a syringe. c. Place the medication cup on a flat surface at eye level. d. Measure the poured liquid to the top of the meniscus. ANS: C
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Pour liquid medication into a medication cup with the cup on a flat surface at eye level, so you can accurately see the desired amount. The amount of poured liquid should be even with the base of the meniscus. Pour liquid medications away from a label to ensure that liquid will not run down a label, making it difficult to read. Draw liquid medication into a syringe (without a needle) slowly, to prevent air bubbles from entering the syringe. Air displaces medications, which leads to inaccurate measurement of doses. DIF: Cognitive Level: Applying REF: Text reference: p. 481 OBJ: List and discuss the six rights of medication administration. TOP: Right Dose KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse enters the patient’s room to give medications. Which action is most appropriate to
identify the “right patient”? a. Ask the patient to state his name. b. Ask the patient to state his name and birth date. c. Ask the primary nurse to identify the patient. d. Say the patient’s name and date of birth and request patient validation. ANS: B
Before giving a medication to a patient, always use at least two patient identifiers (TJC, 20121a). Acceptable patient identifiers include the patient’s name, an identification number assigned by the health care agency, and the date of birth.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Applying REF: Text reference: p. 483 |Text reference: p. 489 OBJ: List and discuss the six rights of medication administration. TOP: Right Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. When medications are administered, which action by the nurse is appropriate? a. Administering medications prepared by another nurse b. Using sterile technique for nonparenteral medications c. Leaving medication at the bedside when the patient is in the bathroom d. Documenting the reason for medication refusal in the nurse’s notes ANS: D
When a patient refuses a medication, determine the reason for it, and take action. Document refusal of medications, and notify the prescriber. Never administer a medication prepared by another nurse. Use good medical aseptic technique and perform hand hygiene before preparing a dose of medication. Avoid touching tablets and capsules. Use sterile technique for parenteral medications. Remain with the patient as the patient takes the medication. Provide assistance if necessary (e.g., for the patient who is weak and unable to administer eyedrops). Do not leave medications at a patient’s bedside without a prescriber’s order to do so. DIF: Cognitive Level: Applying REF: Text reference: p. 488 OBJ: Identify guidelines for safe administration of medications. TOP: Medication Preparation/Medication Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. When controlled substances aNre aRdmI d,.wChic h action is required by the nurse? U S inis NGtere TB OM a. Discard and sign for unused quantities. b. Count the amount of medication daily. c. Keep narcotics to be given with other patient medications. d. Have a second nurse witness disposal of unused portions and sign the record. ANS: D
If you give only part of a premeasured dose of a controlled substance, a second nurse must witness disposal of the unused portion. Both nurses sign their names on the required form. Store all narcotics in a locked, secure cabinet separate from the patient’s routine medications. (Computerized, locked cabinets are preferred.) The computerized dispensing system should maintain the inventory of medications. DIF: Cognitive Level: Applying REF: Text reference: p. 489 OBJ: Identify guidelines for safe administration of medications. TOP: Controlled Substances KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. To prevent medication errors, which action should be taken by the nurse? a. Clarify illegible orders with the prescriber. b. Document the medication before administration. c. Read medication labels 2 times when preparing. d. Prepare all of the client’s medications for the shift at the same time. ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Do not interpret illegible handwriting; clarify illegible orders with the prescriber. Document all medications as soon as they are given. Be sure to read labels at least 3 times (comparing MAR with label): before, during, and after administering the medication. Prepare medications at the time ordered, and document all medications as soon as they are given. DIF: Cognitive Level: Applying REF: Text reference: p. 485 |Text reference: pp. 488-489 OBJ: Identify guidelines for safe administration of medications. TOP: Medication Orders/Right Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The patient is to receive a medication via the sublingual route. Which action by the nurse is
appropriate? a. Placing the medication under the tongue b. Crushing the medication before administration c. Offering the client a glass of orange juice after administration d. Using sterile technique to administer the medication ANS: A
Administering a medication by the sublingual route involves placing the solid medication in the mouth under the tongue until the medication dissolves. Crushing the medication is not necessary because it is designed to dissolve under the tongue. Patients are not to take any liquids with medications given by sublingual administration or immediately afterward. The mouth is not sterile. Sterile technique is not necessary for sublingual administration. DIF: Cognitive Level: Applying REF: Text reference: pp. 478-479 OBJ: Identify guidelines for safe administration of medications. TOP: Routes of Medication AN dmin ation URistr SI NG TB.C OM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The nurse is caring for several patients. The patient in which situation can safely receive oral
medications? a. Nausea with frequent episodes of vomiting b. Taking a daily dose of vitamins c. Nasogastric tube connected to suction d. Diagnosed with an esophageal stricture ANS: B
Avoid giving oral medications to patients with alterations in gastrointestinal function (e.g., nausea and vomiting), reduced motility (after general anesthesia or inflammation of the bowel), or surgical resection of a portion of the gastrointestinal tract. Oral medications cannot be given when the patient has gastric suctioning and are contraindicated in patients before some tests or surgery. Oral administration is contraindicated in patients who are NPO and unable to swallow (e.g., patients with neuromuscular disorders, esophageal strictures, or lesions of the mouth). DIF: Cognitive Level: Applying REF: Text reference: p. 479 OBJ: Identify guidelines for safe administration of medications. TOP: Factors Influencing Choice of Administration Routes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
20. The nurse receives an order to give a drug parenterally. The nurse will administer this
medication by which route? a. Oral b. Topical c. Sublingual d. Intramuscular ANS: D
Parenteral medications can be intramuscular, subcutaneous, intradermal, epidural, or intravenous. Medications given orally are given by mouth. Topical medications are applied on the skin (as a cream or patch) and as eye/eardrops. Sublingual medications are given under the tongue. DIF: Cognitive Level: Applying REF: Text reference: p. 484 OBJ: Identify guidelines for safe administration of medications. TOP: Routes of Medication Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. A patient with a history of renal failure and liver disease has been receiving morphine sulfate
every 4 hours for the past 2 weeks. The nurse finds the patient lethargic with a respiratory rate of 6 breaths per minute. The health care provider orders naloxone (Narcan). The nurse anticipates which effects when naloxone (Narcan) is given? (Select all that apply.) a. Increase in alertness N R I G B.COM b. Decrease in urine output U S N T c. Complaints of pain d. Increase in respiratory rate ANS: A, C, D
Toxic effects develop after prolonged intake of a medication, when a medication accumulates in the blood as the result of decreased clearance by the liver and/or kidneys (because of impaired metabolism or excretion), or when too high a dose is given. Respiratory depression and sedation are known effects of opioid toxicity. Naloxone reverses the effects of opioids, including pain relief. DIF: Cognitive Level: Applying REF: Text reference: p. 476 OBJ: Discuss the types of medication actions. TOP: Toxic Effects KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. When do most medication errors occur? (Select all that apply.) a. During hospital admission b. During transfer from one unit to another c. During discharge home d. During discharge to another facility ANS: A, B, C, D
Most medication errors occur at patient care transition points such as during hospital admission, transfer from one unit to another, and discharge to home or another facility.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Remembering REF: Text reference: p. 473 OBJ: Discuss factors that contribute to medication errors. TOP: Safe Medication Administration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse recognizes that patients with which conditions will have a reduction in the
distribution of drugs? (Select all that apply.) a. Peripheral vascular disease b. Heart failure c. Liver disease d. Obesity ANS: A, B
The rate and extent of distribution depend on circulation, cell membrane permeability, and protein binding. Peripheral vascular disease and heart failure result in a decrease in circulation, which reduces distribution. Liver disease causes a reduction in plasma proteins, which results in more free active drug that is distributed more readily. Obesity does not affect distribution. DIF: Cognitive Level: Applying REF: Text reference: p. 474 OBJ: Discuss the types of medication actions. TOP: Pharmacokinetics KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4. The hospital has implemented a computerized physician order entry system (CPOE) to
eliminate the need for written orders. The benefits of this system include which of the following? (Select all that apply.) a. Automatic drug allergy cN heck URsSINGTB.COM b. Automatic dosage indications c. Identification of potential drug interactions d. Reduced number of medical errors ANS: A, B, C, D
Decision support software, integrated into a CPOE system, allows for automatic drug allergy checks, dosage indications, and identification of potential drug interactions. Use of CPOE systems may significantly reduce medication errors by as much as 55% to 83%. DIF: Cognitive Level: Understanding REF: Text reference: pp. 477-478 |Text reference: p. 480 OBJ: Describe the safety features of medication delivery systems. TOP: Computerized Provider Order Entry KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The nurse reviews a medication administration record for an anticoagulant that is ordered at
0900 daily. The medication record indicates that the drug was given at the following times over the past 4 days. Which times follow the “right time” of medication administration? (Select all that apply.) a. 0800 b. 0830 c. 0930 d. 1000 ANS: B, C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Time-critical medications such as anticoagulants must be administered within 30 minutes of the scheduled time. Non–time-critical medications can be given 1 to 2 hours before or after the scheduled time. DIF: Cognitive Level: Applying REF: Text reference: p. 484 OBJ: List and discuss the six rights of medication administration. TOP: Right Time KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. Medication errors include which of the following? (Select all that apply.) a. Administration of the wrong medication b. Administration via the wrong route c. Inaccurate prescribing d. Failing to administer a medication ANS: A, B, C, D
Medication errors include inaccurate prescribing and administering the wrong medication, by the wrong route, and in the wrong time interval, as well as administering extra doses or failing to administer a medication. DIF: Cognitive Level: Understanding REF: Text reference: p. 473 OBJ: Identify guidelines for safe administration of medications. TOP: Reporting Medication Errors KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse administers a medication to the wrong patient but the patient suffers no harm from
the medication error. What actions should the nurse take? (Select all that apply.) a. Prepare a written incidenN t rep URort. SI NG TB.C OM b. Document in the nurses’ notes that an incident report was completed. c. Report the incident to a manager only if the patient is harmed. d. Notify the prescriber. ANS: A, D
When a medication error occurs, the nurse assesses the patient and notifies the prescriber as soon as possible. When the patient is stable, the nurse notifies the appropriate person in the institution (e.g., manager, supervisor). The nurse is responsible for preparing a written incident report usually within 24 hours of the incident. To legally protect the nurse and the institution, the incident report is not referred to in the nurses’ notes. All medication errors, including those that do not cause obvious or immediate harm, should be reported. DIF: Cognitive Level: Applying REF: Text reference: p. 489 OBJ: Identify steps to take in reporting medication errors. TOP: Reporting Medication Errors KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. A patient receives the usual dose of a medication for the first time and develops severe
hypotension and bradycardia. The nurse reports this event as an medication action.
_ type of
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS:
adverse drug effect (ADE) Adverse drug effects are unintended, undesirable, and often unpredictable. They occur at doses normally used. DIF: Cognitive Level: Applying REF: Text reference: p. 475 OBJ: Discuss the types of medication actions. TOP: Adverse Drug Effect KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Medication safety is always one of the
set by The Joint Commission.
ANS:
National Patient Safety Goals Medication safety has consistently been one of the National Patient Safety Goals. DIF: Cognitive Level: Remembering REF: Text reference: p. 473 |Text reference: p. 482 OBJ: Discuss National Patient Safety Goals for medication administration. TOP: National Patient Safety Goals KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The intended or desired physiological response to a medication is known as its
. ANS:
therapeutic effect Each medication has a therapeutic effect—the intended or desired physiological response to a medication. For example, the nurse administers morphine sulfate, an analgesic, to relieve a patient’s pain. NURSINGTB.COM DIF: Cognitive Level: Remembering REF: Text reference: p. 474 OBJ: Discuss the types of medication actions. TOP: Therapeutic Effects KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4.
are predictable and often unavoidable secondary effects of a medication produced at a usual therapeutic drug dose. ANS:
Side effects Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. For example, some antihypertensive medications cause impotence in male patients. DIF: Cognitive Level: Remembering REF: Text reference: p. 475 OBJ: Discuss the types of medication actions. TOP: Side Effects/Adverse Effects KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The patient reports taking an opioid medication in large dosages for the past several years.
While in the hospital, the patient is not prescribed the medication and develops tachycardia, hypertension, sweating, and tremors. He becomes confused and experiences visual hallucinations. The nurse recognizes these signs as indicative of . ANS:
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank physical dependence Drug dependence can be physical or psychological. Physical dependence is manifested by intense physical disturbance when the medication is withdrawn. DIF: Cognitive Level: Applying REF: Text reference: p. 477 OBJ: Discuss the types of medication actions. TOP: Medication Tolerance and Dependence KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. A drug interaction in which the combined effect of drugs is greater than the sum of the effects
of each individual agent acting independently is known as a
.
ANS:
synergistic effect A synergistic effect is a drug interaction in which the combined effect of two drugs is greater than the sum of the effects of each individual agent acting independently. In other words, 1+1 = 3 or more. The use of a combination of drugs to treat hypertension is an example of synergism. Each drug lowers blood pressure but in a different way; the summed effect produces a greater reduction in hypertension than is produced by the effects of each medication. DIF: Cognitive Level: Remembering REF: Text reference: p. 477 OBJ: Discuss the types of medication actions. TOP: Medication Interactions KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The prescriber orders an IV antibiotic every 8 hours. The nurse administers the medication at
0900. The medication’s onset of action is 5 minutes, peak action is 30 minutes, and duration is 6 to 24 hours. An order for pN eaU kR anSdItrN ouGgT hB le. veClsOiM s written. The nurse will have the peak level drawn at . ANS:
0930 The highest level is called the peak concentration. The peak level is drawn whenever the drug is expected to reach its peak concentration. DIF: Cognitive Level: Applying REF: Text reference: p. 477 OBJ: Discuss the types of medication actions. TOP: Medication Dose Responses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. The nurse administers 100 mg of a drug at 0800. The drug’s biological half-life is 4 hours. A
serum drug level is drawn at 1600. The nurse should anticipate be left in the body at 1600?
milligrams will
ANS:
25 mg Biological half-life is the time it takes for excretion processes to lower the serum medication concentration by half. After the first half-life (1200), 50 mg will be left in the body. After the second half-life (1600), 25 mg will be left in the body. Each half-life lowers the amount of drug in the body by half. DIF: Cognitive Level: Applying
REF: Text reference: p. 477
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Discuss the types of medication actions. TOP: Medication Dose Responses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. A patient reports a pain level of 7 out of 10 and receives 10 mg of morphine IV. The nurse
knows that IV morphine has an onset of 1 to 2 minutes, a peak of 20 minutes, and a duration of 4 to 5 hours. The patient asks when he will start to feel some pain relief. The nurse should respond that relief should begin in . ANS:
1 to 2 minutes The period of time it takes after a medication is administered for it to produce a therapeutic effect is known as the onset of medication action. DIF: Cognitive Level: Applying REF: Text reference: pp. 474-475 |Text reference: p. 477 OBJ: Discuss the types of medication actions. TOP: Onset of Medication Action KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. The nurse administers 650 mg of acetaminophen (Tylenol) orally to a patient with a pain level
of 4 out of 10. The nurse is aware that the onset of action is 30 minutes to 1 hour, the peak action is 1 to 3 hours, and the duration of action is 3 to 8 hours. After hours, the nurse should assess the patient to determine the maximum effectiveness of the drug. ANS:
1 to 3 Peak action is the time it takes for a medication to reach its highest effective peak concentration. DIF: Cognitive Level: ApplyiN ngURSINGRT EB F:.C TeO xtMreference: p. 477 OBJ: Discuss the types of medication actions. TOP: Peak Action KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. A patient is prescribed diltiazem tablets, which have an onset of 30 minutes, a peak of 2 to 3
hours, and a duration of 6 to 8 hours. The nurse anticipates that the medication will be prescribed _ per day. ANS:
3 to 4 times Duration of action is the length of time during which the medication is present in a concentration great enough to produce a therapeutic effect. A medication with a duration of action of 6 to 8 hours will usually be given 3 to 4 times daily to maintain therapeutic effects. DIF: Cognitive Level: Applying REF: Text reference: p. 477 OBJ: Discuss the types of medication actions. TOP: Duration of Action KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. The
_ of a drug is the blood serum concentration reached and maintained after repeated, fixed doses. ANS:
plateau
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The plateau of a drug is the blood serum concentration reached and maintained after repeated, fixed doses. DIF: Cognitive Level: Remembering REF: Text reference: p. 477 OBJ: Discuss the types of medication actions. TOP: Plateau KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. A medication distribution system that uses individual patient drawers and whereby medication
is packaged according to what the patient would receive at one time is known as the system. ANS:
unit-dose The standard for medication distribution is the unit-dose system. The system uses automated medication dispensing systems or carts containing a drawer with a 24-hour supply of medications for each patient. Each drawer has a label with the name of the patient in the designated room. The unit dose is the ordered dose of medication the patient receives at one time. DIF: Cognitive Level: Remembering REF: Text reference: p. 478 OBJ: Describe the safety features of medication delivery systems. TOP: Unit Dose KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. The patient is to receive 200 mg of a medication. There are 100-mg scored tablets available.
The nurse prepares ANS:
tablets.
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2 The dose ordered is the amount of medication prescribed (e.g., 200 mg). The dose on hand is the dose (e.g., mg, mL, units) of medication supplied by the pharmacy (in this case, 100-mg tablets). The amount on hand is the weight or volume of medication available and supplied by the pharmacy. It appears on the medication label as the contents of a tablet or capsule, or as the amount of medication dissolved per unit volume of liquid. The amount on hand is the basic quantity of the medication that contains the dose on hand. For solid medications, the amount on hand is often one capsule; the amount of liquid on hand is often 1 mL or 1 L (in this case, it is 1 tablet). The amount to be administered (e.g., mL, mg) is always expressed in the same measure as the amount on hand. Dose ordered Amount on hand = Amount to administer Dose on hand 200 mg 1 tab = 200 mg = 2 tablets 100 mg 100 mg DIF: Cognitive Level: Applying REF: Text reference: pp. 486-487 OBJ: Accurately calculate medication doses. TOP: Dosage Calculations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 15. The dose ordered for a patient is 75 mg IM. The medication is available in a 50-mg/mL
solution. The nurse prepares
mL.
ANS:
1.5 The dose ordered is the amount of medication prescribed (e.g., 75 mg). The dose on hand is the dose (e.g., mg, mL, units) of medication supplied by the pharmacy (in this case, a 50-mg solution). The amount on hand is the weight or volume of medication available and supplied by the pharmacy. It appears on the medication label as the contents of a tablet or capsule, or as the amount of medication dissolved per unit volume of liquid. The amount on hand is the basic quantity of the medication that contains the dose on hand. The amount of liquid on hand is often 1 mL or 1 L (in this case, it is 1 mL). The amount to administer (e.g., mL, mg) is always expressed in the same measure as the amount on hand. Dose ordered Amount on hand = Amount to administer Dose on hand 75 mg 1 mL = 75 mg = 1.5 mL 50 mg 50 mg DIF: Cognitive Level: Applying REF: Text reference: pp. 486-487 OBJ: Accurately calculate medication doses. TOP: Dosage Calculations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The prescriber orders 3 mg/kg/d of a medication to be given in 3 equal doses. The patient
weighs 44 pounds. The nurseNcalR culaItes G thatBth.eCproM per amount per dose is
U S N T
O
.
ANS:
20 mg Convert pounds to kilograms. 44 pounds 1 kg/2.2 lb = 20 kg Solve the equation for how many mg/d. 20 kg 3 mg/kg = 60 mg/d Solve the equation for how many mg/dose. 60 mg divided by 3 equal doses = 20 mg/dose DIF: Cognitive Level: Applying REF: Text reference: p. 480 |Text reference: pp. 485-487 OBJ: Accurately calculate medication doses. TOP: Pediatric Doses KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse calculates that the proper dosage of a medication is 2 tsp. The nurse prepares
mL to administer to the patient. ANS:
10 Conversion: 1 tsp = 5 mL; 2 tsp = 10 mL.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Applying REF: Text reference: p. 480 OBJ: Accurately calculate medication doses. TOP: Equivalents of Measurement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
NURSINGTB.COM
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 21: Oral and Topical Medications MULTIPLE CHOICE 1. The nurse is administering a buccal medication. Which instruction should be given to the
patient? a. Hold the medication under the tongue. b. Swallow the medication after 30 seconds. c. Chew the medication before swallowing. d. Hold the medication against the cheek membranes. ANS: D
Buccal medication is placed between the upper or lower molar teeth and the cheek area and is allowed to dissolve. The sublingual route is used to administer medication under the tongue. Medication is dissolved rather than swallowed using the buccal route. DIF: Cognitive Level: Applying REF: Text reference: p. 493 |Text reference: p. 499 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Buccal Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is preparing to administer a medication. Which of the following is the most critical
to assess before medication administration? a. Diet history b. Allergy history c. Surgical history NURSINGTB.COM d. Drug tolerance ANS: B
Drug allergies should be listed on each page of the MAR, prominently displayed on the patient’s medical record, and the patient should be wearing the facility’s allergy bracelet. Assessment for drug allergies is necessary before medication is administered. A patient’s diet, surgical, and drug histories are important to assess, but they are not as critical as allergy history, which can reveal life-threatening conditions. DIF: Cognitive Level: Applying REF: Text reference: p. 495 OBJ: Identify guidelines for administering oral, enteral, and topical medications. TOP: Allergy History KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is preparing oral medications for administration. Which action by the nurse is
appropriate? a. Using a cutting device to cut scored tablets b. Unwrapping all of the medications to be given and placing them together in a cup c. Crushing capsules and enteric-coated medication for easier swallowing d. Holding the medication cup at eye level to pour a liquid dosage ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank If you have to break a medication to administer half the dosage, use a clean, gloved hand to break the tablet or cut it with a cutting device. Tablets that are to be broken in half must be pre-scored by a manufactured line that transverses the center of the tablet. Tablets that are not pre-scored cannot be broken into equal halves, and the result will be an inaccurate dose. Using a cutting device results in a more even split of the tablet. Wrappers maintain the cleanliness of medications and identify drug name and dose. Not all drugs can be crushed (e.g., capsules, enteric-coated, long-acting/slow-release drugs). The coating of these drugs protects the stomach from irritation or protects the drug from destruction by stomach acids. Liquid medications poured from a stock bottle should be poured into a medication cup that is placed at eye level on a flat surface. DIF: Cognitive Level: Applying REF: Text reference: p. 496 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Cutting Tablets KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse is caring for four patients who require medications at 0900. Which action by the
nurse adheres to the six rights of medication administration? a. Prepare medications for all of the patients at once and keep the cups separate. b. Ask the supervisor to clarify an unclear medication order. c. Give the prescribed anticonvulsant between 0830 and 0930. d. Leave each patient’s medications at the bedside and return within 30 minutes to make sure they have been taken. ANS: C
Time-critical medications such as anticonvulsants must be given within 30 minutes of the prescribed time. Prepare medications for one patient at a time. Keep all pages of the MAR for Nents RSpre INpara GTtion B.C M one patient together. This prevU errOors. Unclear orders should be clarified with the prescriber before administration. Stay with each patient until the medication is swallowed completely or is taken by the prescribed route. DIF: Cognitive Level: Applying REF: Text reference: p. 498 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Administering Oral Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. What should the nurse do to assist a patient who is having difficulty swallowing tablets? a. Administer the medication with less fluid. b. Insert a nasogastric tube and instill the medication. c. Crush the medications and administer with a small amount of food. d. Administer the tablets one at a time with plenty of water. ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank If the patient has difficulty swallowing, use a pill-crushing device to crush the tablets. Mix the ground tablet in a small amount of soft food (custard or applesauce). Large tablets are often difficult to swallow. A ground tablet mixed with palatable soft food is usually easier to swallow. Not all drugs can be crushed (e.g., capsules, enteric-coated, long-acting/slow-release drugs). The coating of these drugs protects the stomach from irritation or protects the drug from destruction by stomach acids. Administration of medication with less fluid could make it more difficult for the patient to swallow. Insertion of a nasogastric tube requires an order from the health care provider. A patient who is having difficulty swallowing may not be safe when swallowing large capsules or tablets even one at a time. Thin liquids such as water are more readily aspirated than thickened liquids. DIF: Cognitive Level: Applying REF: Text reference: p. 496 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Crushing MedicationsKEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is preparing to administer a pediatric dose of liquid medication to an infant. Which
action by the nurse is appropriate? a. Empty the unit-dose container into a plastic cup. b. Gently shake the multi-dose bottle before pouring the medication. c. Draw the medication into a syringe with a needle. d. Use an oral syringe to measure liquid dosages greater than 25 mL. ANS: B
If the liquid medication is in a multi-dose bottle, gently shaking the bottle ensures that the correct amount of medication, not just the solvent, is measured for the dose. If the medication is in a unit-dose container in the correct amount to be administered, no further preparation is GTuid B.C M use an oral syringe. Do not use a necessary. If giving less thanN 1U 0R mS LI oN f liq medOication, syringe with a needle. The medication may be accidentally given parenterally, or the needle may become dislodged and aspirated during administration. DIF: Cognitive Level: Applying REF: Text reference: p. 496 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Pediatric Liquid Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The patient is unable to sit upright for medication administration. The nurse should assist the
patient to which position to decrease the risk for aspiration? a. Prone b. Supine c. Side-lying d. Dorsal recumbent ANS: C
Assist the patient to a side-lying position if sitting is contraindicated by the patient’s condition. This decreases the risk for aspiration during swallowing. Swallowing is difficult or impossible in the prone position. The risk for aspiration is increased when the patient is swallowing in the supine position or in the dorsal recumbent position. DIF: Cognitive Level: Applying REF: Text reference: p. 498 OBJ: Correctly administer a medication by oral, enteral, and topical routes.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Positioning of Patient MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step: Implementation
8. The nurse is preparing to give sublingual nitroglycerin to a patient complaining of chest pain.
The nurse instructs the patient not to swallow the medication. Why is this instruction important? a. The effects of the medication will be nullified if swallowed. b. Sublingual drugs begin to dissolve when placed on the tongue. c. The medication needs to be held against the cheek membranes until dissolved. d. The patient may aspirate on the water used for these medications. ANS: A
If swallowed, the drug is destroyed by gastric juices or is detoxified so rapidly by the liver that therapeutic blood levels are not attained. Orally disintegrating formulations begin to dissolve when placed on the tongue. Sublingually administered medications are placed under the tongue and are allowed to dissolve completely. Water is not needed with these medications. DIF: Cognitive Level: Applying REF: Text reference: p. 498 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Sublingual Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse is preparing a medication for a small child. The medication comes in pill or liquid
form, but the liquid preparation has a bitter taste. Which action by the nurse is most appropriate? a. Give the pill form. N.URSINGTB.COM b. Mix the liquid with honey c. Mix the liquid in milk. d. Mix the liquid in applesauce. ANS: D
Children will refuse bitter or distasteful oral preparations. Mix the drug with a small amount (about 1 tsp) of a sweet-tasting substance such as jam, applesauce, sherbet, ice cream, or fruit puree. Offer the child juice or a flavored ice pop after medication administration. Liquid forms of medication are safer to swallow to avoid aspiration of small pills. Do not use honey in infants because of the risk for botulism. Do not place medication in an essential food item such as milk or formula; the child may refuse the food at a later time. DIF: Cognitive Level: Applying REF: Text reference: p. 500 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Pediatric Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse is preparing to administer aspirin to a patient via an enteral feeding tube. Which
form is appropriate for the nurse to administer? a. Crushed chewable aspirin b. Liquid aspirin c. Enteric-coated aspirin d. Sustained-release aspirin capsule ANS: B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Preferably, medications administered by enteral tubes should be given in liquid form. If liquid form is not available, you will have to modify the form of the medication tablet by crushing or dissolving it. However, you cannot crush sustained-release, chewable, long-acting, or enteric-coated tablets and capsules. Therefore, do not administer these medications by enteral tubes. Consult with the hospital pharmacy when in doubt. DIF: Cognitive Level: Understanding REF: Text reference: p. 500 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Enteral Feeding Tubes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The nurse is preparing to administer a medication via a jejunostomy tube to a patient who is
receiving continuous tube feedings. The medication needs to be given on an empty stomach and comes only in tablet form. What action should the nurse take first? a. Add the medications directly to the tube feeding. b. Flush the tubing before the medication is given. c. Stop the feeding 30 minutes before medication administration. d. Dissolve the medication in cold water. ANS: C
If the patient needs to take the medication on an empty stomach, stop the feeding 30 minutes before medication administration to facilitate absorption of the medication. Never add crushed medications directly to the tube feeding. Whenever possible, use liquid medications instead of crushed tablets, but if you have to crush tablets, the tubing must be flushed before and after the medication is given to prevent the drug from adhering to the inside of the tube. Dissolve in at least 30 mL of warm water. Cold water causes gastric cramping. DIF: Cognitive Level: ApplyiN ngURSINGRT EB F:.C TeO xtMreference: p. 502 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Instilling Crushed Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse is to administer several medications to a patient via a nasogastric (NG) tube. What
should the nurse do first? a. Add the medications to the tube feeding being given. b. Crush all tablets and capsules before administration. c. Administer all of the medications mixed together. d. Check for placement of the NG tube. ANS: D
Check the placement of the feeding tube by observing gastric contents and checking the pH of aspirated contents. Gastric pH should be 4 or less. This ensures proper tube placement and reduces the risk of introducing fluids into the respiratory tract. Never add medications directly to the tube feeding. Not all tablets can be crushed, such as sustained-release tablets, nor should all capsules be opened. Medications should be reviewed carefully before a tablet is crushed or a capsule is opened. To administer more than one medication, give each separately, and flush between medications with 10 mL of water. Keeping the medications separate allows for accurate identification of medication if a dose is spilled. In addition, some medications are not compatible with each other, and this may cause clogging of the tube. DIF: Cognitive Level: Applying
REF: Text reference: p. 500 |Text reference: p. 502
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Administering Several Medications via NG Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. When preparing to administer medication via a nasogastric tube, the nurse aspirates 275 mL
of gastric residual. What is the first action the nurse should take? a. Wait 1 hour and recheck the residual. b. Administer the medication with more fluid. c. Return the aspirate and withhold the medication. d. Attach the nasogastric tube to suction to remove additional volume. ANS: C
Return aspirated contents to the stomach unless a single volume exceeds 500 mL or two measurements taken 1 hour apart each exceed 250 mL. When gastric residual is greater than 250 mL, the medication is withheld and the residual is rechecked in 1 hour. Large-volume aspirates indicate delayed gastric emptying and place the patient at risk for aspiration. Additional fluid would not be administered if the patient had a large residual. Use of suction would require an order from the health care provider. DIF: Cognitive Level: Applying REF: Text reference: p. 502 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Gastric Residual KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The patient is to receive three different medications via a nasogastric tube. What is the total
amount of water the nurse should prepare to administer? a. 30 mL of water NURSINGTB.COM b. 60 mL of water c. 90 mL of water d. 250 mL of water ANS: C
30 mL of water is administered before the medications, 15 to 30 mL of water is administered after each of the first two medications, and 30 to 60 mL is administered after the third medication, so 90 to 150 mL of water is needed. DIF: Cognitive Level: Analyzing REF: Text reference: p. 504 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Flushing the NG Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is applying a new nitroglycerin transdermal patch. Which action by the nurse is
appropriate? a. Instructing the patient to wear the patch 24 hours a day every day b. Applying the new patch to the same site as the previous patch c. Cutting the patch in half when a change of dose is ordered d. Instructing the patient to avoid heat sources over the patch ANS: D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Heat sources over a transdermal patch can increase the rate of absorption, leading to potentially serious adverse effects. It is recommended to have a daily “patch-free” interval of 10 to 12 hours because tolerance develops if patches are used 24 hours a day every day. The patch should not be applied to previously used sites for at least 1 week. Transdermal patches are never to be cut in half. A change in dosage requires a new prescription. DIF: Cognitive Level: Applying REF: Text reference: p. 508 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Applying Topical Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is teaching a patient how to use a topical medication. Which statement indicates an
understanding of the procedure? a. “If the patch starts to come off, I can secure it with tape.” b. “If the patch falls off, I will put a new one on in the same place.” c. “If my skin is irritated, I will cleanse it using water only.” d. “I can dispose of used materials in the household trash as usual.” ANS: C
If skin is inflamed, instruct patients to use only warm water rinse without soap for cleansing. Instruct the patient on how to manage a transdermal patch that begins to peel off before the next dose is due. Rather than tape the patch or cover it, instruct the patient to remove the patch, clean the skin, and apply a new patch to a different area. Instruct the patient to wrap applicators, used patches, and similar materials and dispose of them into cardboard or plastic disposable containers. Careful disposal is necessary to ensure the safety of the patient, other adults, pets, and children. DIF: Cognitive Level: ApplyiN ngURSINGRT EB F:.C TeO xtMreference: p. 509 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Applying Topical Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The patient is prescribed an ophthalmic medication via an intraocular disc. Which action by
the nurse is appropriate when administering the medication? a. Place the disc in the conjunctival sac. b. Apply sterile gloves before placing the disc. c. Pull on the patient’s upper eyelid and ask the patient to look up. d. Instruct the patient that the disc will be changed daily. ANS: A
Medications delivered by disc resemble a contact lens, but the disc is placed in the conjunctival sac, not on the cornea. Clean gloves are used to place and remove the disc. The lower eyelid is pulled down and the patient is asked to look up. The disc remains in place for up to 1 week. DIF: Cognitive Level: Applying REF: Text reference: p. 513 OBJ: Correctly administer medications for irrigation and instillation. Differentiate types of topical administration that require sterile technique from those that require medical aseptic technique. TOP: Instilling Eye and Ear Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 18. The patient has eyedrops ordered daily to both eyes. Which action by the nurse is appropriate
when administering the medication? a. Carefully place the drop on the cornea. b. Wipe the eye with a tissue after placing the eyedrop. c. Hold the eyedropper about 1 to 2 cm above the eye. d. Instruct the patient to squeeze the eye shut after instillation. ANS: C
Holding the eyedropper approximately 1 to 2 cm ( to inch) above the conjunctival sac of the eye prevents accidental contact of the eyedropper with the eye and reduces risk for injury and transfer of microorganisms to the dropper. The cornea is very sensitive. If drops were instilled onto the cornea, this would stimulate the blink reflex. The tissue should be placed just below the lower eyelid so medication that escapes the eye is absorbed. Wiping the eye removes too much of the medication. Squinting or squeezing the eyelids after instillation forces the medication from the conjunctival sac. DIF: Cognitive Level: Applying REF: Text reference: p. 512 OBJ: Correctly administer medications for irrigation and instillation. TOP: Instilling Eye and Ear Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The nurse is preparing to administer an eye ointment to the patient. Which action by the nurse
is appropriate? a. Clean away drainage or crusts by wiping from the outer to the inner canthus. b. Instruct the patient to keep the eye open for 2 minutes after instillation. c. Apply a thin ribbon evenly along the inner edge of the lower eyelid. d. Instruct the patient to avoid wiping the eye after instillation. N R I G B.C M ANS: C
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While holding the ointment applicator above the lower lid margin, apply a thin ribbon of ointment evenly along the inner edge of the lower eyelid on the conjunctiva from the inner canthus to the outer canthus. This distributes medication evenly across the eye and lid margin. Eyes are cleansed from the inner to the outer canthus to avoid entry of microorganisms into the lacrimal duct. After instillation, the patient is instructed to close the eye and rub the lid lightly in a circular motion, if not contraindicated, to distribute the medication. If excess medication is on the eyelid, it can be gently wiped from the inner to the outer canthus. DIF: Cognitive Level: Applying REF: Text reference: p. 513 OBJ: Correctly administer medications for irrigation and instillation. TOP: Instilling Eye and Ear Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. A patient is experiencing a systemic effect from eyedrops. Which assessment finding by the
nurse is indicative of this? a. Headache b. Reddened eyes c. Darkened conjunctiva d. Elevated pulse and blood pressure ANS: D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank An unexpected outcome is noted when the patient experiences systemic effects from drops (e.g., increased heart rate and blood pressure from epinephrine, decreased heart rate and blood pressure from timolol). Local side effects include headache, bloodshot eyes, and local eye irritation. DIF: Cognitive Level: Analyzing REF: Text reference: p. 515 OBJ: Correctly administer medications for irrigation and instillation. TOP: Unexpected Outcomes of an Eye Medication KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. A nurse is preparing to administer eardrops to an adult patient. Which action should be taken
by the nurse? a. Warm the medication to room temperature using warm water. b. Pull the pinna down and back to straighten the ear canal. c. Apply gentle pressure or massage to the pinna of the ear. d. Remove cerumen from the inner ear canal with a cotton-tipped applicator. ANS: A
Internal ear structures are very sensitive to temperature extremes. Failure to instill a solution at room temperature can cause vertigo (severe dizziness) or nausea and can debilitate a patient for several minutes. Pulling the pinna down and back is the procedure for children aged 3 and younger. Do not massage the pinna of the ear; instead massage the tragus. Gentle pressure or massage to the tragus of the ear moves medication inward. Cerumen is removed from the outer canal only. DIF: Cognitive Level: Applying REF: Text reference: p. 510 OBJ: Correctly administer medications for irrigation and instillation. TOP: Instilling Eye and Ear MN edic Y. : C NuOrsM ing Process Step: Implementation URatio SInsNGKE TB MSC: NCLEX: Physiological Integrity 22. The nurse administers eardrops in the patient’s left ear. Which of the following positions is
appropriate after instillation of the drops? a. Prone b. Upright c. Right lateral d. Dorsal recumbent with hyperextension of the neck ANS: C
The patient should remain in the side-lying position, with the treated ear upward for a few minutes. Upright, prone, and dorsal recumbent positions are not recommended after administration of eardrops. The eardrops would run out of the ear canal. DIF: Cognitive Level: Applying REF: Text reference: p. 515 OBJ: Correctly administer medications for irrigation and instillation. TOP: Administering Eye and Ear Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. How should the nurse position the patient to administer nose drops to the maxillary sinus? a. Sitting upright with the head tilted backward toward the side to be treated b. Supine with a small pillow under the shoulders and the head tilted backward c. Supine with the head tilted backward and turned to the unaffected side
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. Head tilted back over the edge of the bed and turned toward the side to be treated ANS: D
For access to the frontal and maxillary sinus, tilt the head back over the edge of the bed or pillow with the head turned toward the side to be treated. This position allows medication to drain into the affected sinus. For access to the posterior pharynx, tilt the patient’s head backward. For access to the ethmoid or sphenoid sinus, tilt the head back over the edge of the bed or place a small pillow under the patient’s shoulder and tilt the head back. DIF: Cognitive Level: Applying REF: Text reference: p. 518 OBJ: Correctly administer medications for irrigation and instillation. TOP: Positioning to Administer Nose Drops to Maxillary Sinus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. The nurse is teaching a mother how to administer nasal drops to her infant. What should be
included in the teaching plan? a. Over-the-counter nasal drops can be saved and used later. b. Nasal decongestants are safe and have no serious side effects. c. Infants should receive nose drops 20 to 30 minutes before feedings. d. Infants are mouth breathers, so nasal medications are well tolerated. ANS: C
Infants are nose breathers, and the possible congestion caused by nasal medications may inhibit their sucking. Administer nose drops 20 to 30 minutes before feedings. Over-the-counter nasal sprays or nose drops should be used for only one illness; bottles become easily contaminated with bacteria. Nasal decongestants can enter the systemic circulation by way of the nasN al mRucoIsa oGr thB U S N T e .gaCstro OMintestinal tract if swallowed, causing restlessness, nervousness, tremors, or insomnia in some patients. Long-term use can worsen nasal congestion through a rebound effect. DIF: Cognitive Level: Applying REF: Text reference: p. 519 OBJ: Prepare a teaching plan regarding medication use for a selected patient. TOP: Teaching and Pediatric Considerations Relative to Nasal Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. Several patients have been prescribed inhalation medications. The nurse is aware that a spacer
will be beneficial for which patient? a. A young child using a dry powder inhaler b. An elderly patient who uses a metered-dose inhaler c. A teenager who has just started using a nebulizer d. A young child who needs medication several times per day ANS: B
Because use of a metered-dose inhaler (MDI) requires coordination during the breathing cycle, many patients spray only the back of their throat and fail to receive a full dose. The inhaler must be depressed to expel medication just as the patient inhales. This ensures that the medication reaches the lower airways. Poor coordination can be solved by the use of spacer devices. Coordination is not necessary with dry powder inhalers or nebulizers. The use of a spacer is not dependent on the schedule of administration.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Applying REF: Text reference: p. 520 OBJ: Instruct patients in the proper use of a metered-dose inhaler (MDI), a dry powder inhaler (DPI), and a small-volume nebulizer. TOP: Using Metered-Dose Inhalers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. The nurse is teaching a patient how to use a metered-dose inhaler without a spacer. Which
action by the patient demonstrates correct use of the device? a. Being careful not to shake the canister b. Positioning the mouthpiece in front of the mouth while not touching the lips c. Depressing the canister fully, waiting 3 to 5 seconds, then inhaling slowly and deeply d. Taking another puff of the medication within 10 seconds ANS: B
The best way to deliver medication without a spacer is to position the mouthpiece 2 to 4 cm in front of a widely opened mouth with the opening of the inhaler toward the back of the throat. The lips should not touch the inhaler. Shaking the inhaler before administration is the correct procedure; it mixes the medication within the canister. The correct procedure is to depress the canister fully while inhaling slowly and deeply through the mouth for 3 to 5 seconds. A wait of 20 to 30 seconds is advised between doses of the same medication; 2 to 5 minutes is the standard time between doses of different medications. DIF: Cognitive Level: Applying REF: Text reference: p. 522 OBJ: Instruct patients in the proper use of a metered-dose inhaler (MDI), a dry powder inhaler (DPI), and a small-volume nebulizer. TOP: Metered-Dose Inhalers KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
inha 27. The patient has a bronchodilaNtor URand SIanNG TBle.dCster OMoid scheduled for the same time. What teaching should the nurse provide to the patient about administering these medications? a. Inhale the bronchodilator, wait 20 to 30 seconds, then inhale the steroid. b. Inhale the bronchodilator, wait 2 to 5 minutes, then inhale the steroid. c. Inhale the steroid, wait 20 to 30 seconds, then inhale the bronchodilator. d. Inhale the steroid, wait 2 to 5 minutes, then inhale the bronchodilator. ANS: B
Drugs must be inhaled sequentially. If bronchodilators are administered with inhaled steroids, the bronchodilators should be given first to dilate the airway passages for the second medication. The patient is instructed to wait 2 to 5 minutes between inhalations when different medications are being given. The patient is instructed to wait 20 to 30 seconds between inhalations if the same medication is being taken. DIF: Cognitive Level: Applying REF: Text reference: p. 523 OBJ: Prepare a teaching plan regarding medication use for a selected patient. TOP: Bronchodilators and Steroids KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 28. The nurse is administering a beta-adrenergic medication via a small-volume nebulizer. Which
assessment finding requires the nurse to withhold the medication immediately? a. Episodes of coughing b. Rapid and shallow respirations c. Wheezing noted on auscultation of the lungs
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. Irregular pulse with light-headedness ANS: D
If the patient experiences cardiac dysrhythmias (light-headedness, syncope), especially if receiving beta-adrenergics, withhold all additional doses of medication, assess vital signs, and notify the prescriber regarding reassessment of the type of medication and delivery method. Coughing, rapid and shallow respirations, and wheezing would be assessed and recorded, but this would not necessarily require discontinuation of treatment. The prescriber would be notified to reassess the type of medication and/or delivery system. DIF: Cognitive Level: Applying REF: Text reference: p. 524 |Text reference: p. 528 OBJ: Identify conditions contraindicating the administration of medications by various oral and topical routes. TOP: Dysrhythmias KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 29. The patient is receiving vaginal suppositories for a vaginal infection. Which assessment
finding by the nurse indicates a desired outcome of the treatment? a. The patient reports pruritus and burning. b. The vaginal walls are bright red in color. c. White curdlike patches appear on the vaginal walls. d. Vaginal discharge the same color of the medication is noted. ANS: D
Some vaginal discharge that is the same color as the medication is an expected outcome after vaginal instillation. Local pruritus and burning indicate inflammation or infection and is an unexpected outcome. Bright red vaginal walls or white curdlike patches are signs of a possible yeast infection.
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DIF: Cognitive Level: Applying REF: Text reference: pp. 530-532 OBJ: Correctly administer medications for irrigation and instillation. TOP: Vaginal Instillations KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 30. The nurse is preparing to administer a rectal suppository to a patient. The patient should be
assisted to which position for insertion of the rectal suppository? a. Prone b. Supine c. Dorsal recumbent d. Left Sims’ position ANS: D
Left side-lying Sims’ position exposes the anus and helps the patient to relax the external anal sphincter, while lessening the likelihood that the suppository or feces will be expelled. Supine and dorsal recumbent positions would make access to the anus difficult and would allow the suppository to slip out. The prone position would make inserting the suppository difficult. DIF: Cognitive Level: Applying REF: Text reference: p. 534 OBJ: Correctly administer medications for irrigation and instillation. TOP: Inserting a Suppository KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 31. The nurse is preparing to administer a rectal suppository to an adult patient. Which action
should be taken by the nurse? a. Apply sterile gloves before handling the suppository. b. Apply extra lubricant to the suppository if there is active rectal bleeding. c. Insert the suppository past the internal sphincter, against the rectal wall, about 6 to 10 inches. d. Instruct the patient to remain lying flat or on the side for 5 minutes after insertion of the suppository. ANS: D
Lying flat or on the side for 5 minutes after the suppository is inserted prevents it from being expelled. Administering a suppository is not a sterile procedure; clean examination gloves are used. A suppository is contraindicated in the presence of active bleeding. The suppository is inserted 4 inches (10 cm). DIF: Cognitive Level: Applying REF: Text reference: p. 535 OBJ: Correctly administer medications for irrigation or instillation. Differentiate types of topical administration that require sterile technique from those that require medical aseptic technique. TOP: Inserting a Suppository KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse receives orders on several patients for oral medications. The nurse will question the
order on patients with which conditions? (Select all that apply.) a. History of asthma and difficulty breathing b. Inability to swallow foodN R I G B.C M U S N T O c. Decreased level of consciousness d. Use of gastric suction ANS: B, C, D
Certain situations contraindicate receiving medications by mouth, such as nausea/vomiting, inability to swallow, bowel inflammation, reduced peristalsis, recent gastrointestinal surgery, gastric suction, and decreased level of consciousness. Alterations in GI function can interfere with absorption, distribution, and excretion of the drug. Impaired swallowing and decreased level of consciousness increase the risk for aspiration. A history of asthma and difficulty breathing is not a contraindication to oral medications. DIF: Cognitive Level: Applying REF: Text reference: p. 494 OBJ: Describe factors to assess before administering medications. TOP: Oral Route of Drug Administration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is preparing several topical medications for a patient. The nurse identifies which of
the following as ways to administer a topical medication? (Select all that apply.) a. Administering through an enteral tube placed in the jejunum b. Inhaling an aerosol spray into the lungs c. Spraying a mist into the nose d. Dissolving a medication under the tongue ANS: B, C, D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Topical medications can be applied by direct application of liquid (eyedrops, gargling, swabbing the throat), insertion of a drug into a body cavity (rectal or vaginal suppositories, vaginal creams or foams), instillation of fluid into a body cavity (fluid is retained) (eardrops, nose drops, bladder and rectal instillation), irrigation of a body cavity (fluid is not retained) (flushing eye, ear, vagina, bladder, or rectum with medicated fluid), spraying (instillation into nose or throat or under the tongue), and inhalation of medicated aerosol spray or dry powder medication (distributes medication throughout the nasal passages and the tracheobronchial airway). Medication may be directly applied to the skin or mucosa (lotion, ointment, cream, powder, foam, spray, patch, and disc), or it may be given by the sublingual (medication placed under the tongue and allowed to dissolve) or buccal (medication placed between the upper or lower molar teeth and cheek area and allowed to dissolve) route. Medications placed in the gastrointestinal tract via an enteral tube are not topical medications. DIF: Cognitive Level: Understanding REF: Text reference: p. 493 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Topical Medications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is preparing to administer medications to a patient with an enteral tube. The nurse
can safely give the medications through which types of enteral tube? (Select all that apply.) a. Nasogastric feeding tube b. Percutaneous endoscopic gastrostomy tube c. Jejunostomy tube d. Nasogastric decompression tube ANS: A, B, C
A nasogastric feeding tube, a percutaneous endoscopic gastrostomy (PEG) tube, and a N Rniste INr GenTteral B.C M jejunostomy tube are used to adUmiS feO edings and can also be used to administer medications. Do not administer medications into nasogastric tubes that are inserted for decompression. DIF: Cognitive Level: Applying REF: Text reference: p. 500 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Enteral Feeding Tubes KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4. The nurse is teaching a patient with asthma about using a metered-dose inhaler to administer
albuterol (Proventil). Which statements should the nurse include in the teaching plan? (Select all that apply.) a. This medication can produce systemic effects such as tachycardia and tremors. b. After inhaling the medication, hold your breath for about 10 seconds. c. After inhaling the medication and holding your breath, exhale slowly through an open mouth. d. After the last dose, do not rinse your mouth or drink any water for at least 1 hour. ANS: A, B
Inhaled medications are designed to produce local effects; for example, bronchodilators open narrowed bronchioles. However, because these medications are absorbed rapidly through the pulmonary circulation, some have the potential for producing systemic side effects. Holding the breath for 10 seconds after inhalation allows the aerosol to penetrate deeper areas of the lung.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Exhalation should occur slowly through the nose or pursed lips to keep the small airways open during exhalation. About 2 minutes after the last dose, the mouth should be rinsed with warm water because inhaled bronchodilators may cause dry mouth and taste alterations. DIF: Cognitive Level: Applying REF: Text reference: p. 526 OBJ: Prepare a teaching plan regarding medication use for a selected patient. TOP: Metered-Dose Inhalers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. The easiest and most desirable way to administer medications is via the
route.
ANS:
oral The oral route is the easiest and most desirable way to administer medications. Patients usually ingest or self-administer oral medication with few problems. DIF: Cognitive Level: Knowledge REF: Text reference: p. 492 OBJ: Describe factors to assess before administering medications. TOP: Oral Route of Drug Administration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Medications in the form of drops or ointments will have the word
on the
container to identify them as eye medications. ANS:
NURSINGTB.COM ophthalmic Common eye (ophthalmic) medications used by patients are drops and ointments, including over-the-counter preparations such as artificial tears and vasoconstrictors (e.g., Visine, Murine). DIF: Cognitive Level: Knowledge REF: Text reference: p. 509 OBJ: Correctly administer a medication by oral, enteral, and topical routes. TOP: Applying Ophthalmic Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. Handheld devices that disperse medications through an aerosol spray or mist to penetrate lung
airways are known as
.
ANS:
metered-dose inhalers (MDIs) MDIs are handheld devices that disperse medications through an aerosol spray or mist to penetrate lung airways. DIF: Cognitive Level: Knowledge REF: Text reference: p. 520 OBJ: Instruct patients in the proper use of a metered-dose inhaler (MDI), a dry powder inhaler (DPI), and a small-volume nebulizer. TOP: Using Metered-Dose Inhalers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 4. Handheld devices that deliver inhaled medication in a fine powder to penetrate lung airways
are known as
.
ANS:
dry powder inhalers (DPIs) DPIs are handheld devices that deliver inhaled medication in a fine powder formulation to the respiratory tract. DIF: Cognitive Level: Knowledge REF: Text reference: p. 520 OBJ: Instruct patients in the proper use of a metered-dose inhaler (MDI), a dry powder inhaler (DPI), and a small-volume nebulizer. TOP: Using Dry Powdered Inhaled Medications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
NURSINGTB.COM
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 22: Parenteral Medications MULTIPLE CHOICE 1. The nurse is preparing an injection of 0.45 mL of medication for a pediatric patient. Which
syringe is most appropriate? a. Tuberculin syringe b. Insulin syringe c. 3-mL syringe d. 10-mL syringe ANS: A
The tuberculin syringe is calibrated in hundredths of a milliliter and has a capacity of 1 mL. It is used to prepare small amounts of medication such as small, precise doses for infants or young children. It is also used for intradermal and subcutaneous injections. An insulin syringe is used to administer insulin and is calibrated in units. A 3-mL syringe and a 10-mL syringe are calibrated in 0.2 of a milliliter and are not accurate for small volumes. DIF: Cognitive Level: Applying REF: Text reference: p. 542 OBJ: Explain the importance of selecting the proper size syringe and needle for an injection. TOP: Syringes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is preparing to administer an intramuscular (IM) injection to a 6-month-old infant.
Which injection site is the most appropriate for this patient? a. Deltoid muscle b. Dorsogluteal injection sitN e URSINGTB.COM c. Vastus lateralis d. Abdomen 2 inches away from the umbilicus ANS: C
On the basis of the evidence, the vastus lateralis is the recommended site for pediatric IM injections for infants up to 12 months of age. The deltoid is the recommended site for children 18 months of age and older. The dorsogluteal site should not be used as an IM injection site. The abdomen is used for subcutaneous injection, not for IM injection. DIF: Cognitive Level: Applying REF: Text reference: p. 539 OBJ: Discuss factors to consider when selecting injection sites. TOP: Intramuscular Injection Sites in Children KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. The nurse is administering a parenteral medication to the patient. Which action by the nurse
demonstrates proper technique? a. Using strict aseptic technique b. Using work-arounds to administer medications in a timely manner c. Injecting the medication smoothly but rapidly d. Inserting the needle into the patient’s skin smoothly and slowly ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Strict aseptic technique is used during all steps of preparation and administration of parenteral medications. Work-arounds bypass a procedure, policy, or protocol and should not be used. Medication should be injected slowly and smoothly. The needle should be inserted smoothly and quickly. DIF: Cognitive Level: Applying REF: Text reference: p. 540 OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP: Aseptic Technique in Injections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse is preparing a medication that comes in an ampule. Which action by the nurse is
appropriate? a. Tapping the ampule so fluid moves from the bottom of the ampule to the neck b. Avoiding inversion of the ampule after opening to prevent spillage of the medication c. Using a filter needle long enough to reach the bottom of the ampule d. Guiding the needle against the rim of the ampule to access the medication ANS: C
Filter needles filter out any fragments of glass, and reaching the bottom of the ampule allows the medication to be completely withdrawn. The top of the ampule is tapped to move the fluid from the neck into the bottom of the ampule, where it is withdrawn. The ampule is held upside down or is set on a flat surface for withdrawal of the medication. The medication will not spill from the ampule after opening unless the needle tip or shaft touches the rim. The rim is considered contaminated and should not be touched by the needle. DIF: Cognitive Level: ApplyiN ngURSINGRT EB F:.C TeO xtMreference: p. 544 OBJ: Correctly prepare injectable medications from a vial and an ampule. TOP: Preparing Injections: Ampules and Vials KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is teaching a patient how to mix 5 units of regular insulin and 15 units of NPH
insulin in the same syringe. The nurse determines that further instruction is needed if the patient does which of the following? a. Injects 5 units of air into the regular insulin vial first and withdraws 5 units of regular insulin b. Injects 15 units of air into the NPH insulin vial but does not withdraw the medication c. Withdraws 5 units of regular insulin before withdrawing 15 units of NPH insulin d. Calculates the combined total insulin dose as 20 units after withdrawing the regular insulin from the vial ANS: A
When rapid- or short-acting insulin is mixed with intermediate- or long-acting insulin, air should be injected into the intermediate- or long-acting insulin vial first without withdrawal of the medication. Regular insulin is withdrawn first, and then the combined total insulin dose is calculated before the NPH insulin is withdrawn from the vial. DIF: Cognitive Level: Applying
REF: Text reference: pp. 549-551
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Mixing Insulin KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 6. A patient has orders for 10 units of glargine (Lantus) insulin and 5 units of regular insulin to
be given at the same time. Which action by the nurse is appropriate? a. Injecting 10 units of air into the glargine insulin vial first and not withdrawing the medication b. Injecting 5 units of air into the regular insulin vial first and then 10 units of air into the glargine insulin vial c. Giving two separate injections using different needles and syringes d. Withdrawing 5 units of regular insulin first and then calculating the total dose of regular and glargine insulin combined ANS: C
If long-acting insulin glargine (Lantus) is ordered, it should not be mixed with other insulin preparations, so two separate injections are prepared. Air is injected into one vial, and this is followed by withdrawal of the medication. It doesn’t matter which one is drawn up first because they are in separate syringes. DIF: Cognitive Level: Applying REF: Text reference: p. 550 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Mixing Insulin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The nurse is preparing several medications that are administered parenterally. The patient
receiving which medication will have an intradermal injection? a. Opioid NURSINGTB.COM b. Medication for allergy testing c. Low-molecular-weight heparin d. Glargine insulin ANS: B
The nurse typically gives intradermal injections for skin testing, for example, in tuberculin screening and allergy tests. Opioid pain medications, low-molecular-weight heparin, and insulin are administered subcutaneously, not intradermally. DIF: Cognitive Level: Applying REF: Text reference: p. 552 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Intradermal Injections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse is preparing to administer an intradermal injection to an adult patient. Which action
should be taken by the nurse? a. Use a tuberculin syringe with a 1-inch 25-gauge needle. b. Inject no more than 1 mL of solution at one site. c. Insert the needle at a 5- to 15-degree angle 3 finger widths below the antecubital space. d. Expect a bleb and a small amount of bleeding after injection. ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The angle of insertion for an intradermal injection is 5 to 15 degrees. If possible, the site should be 3 to 4 finger widths below the antecubital space and one hand width above the wrist. To administer an injection intradermally, use a tuberculin or small syringe with a short (3/8 to 5/8 inch), fine-gauge (25 to 27) needle. Inject only small amounts of medication (0.01 to 0.1 mL) intradermally. If a bleb does not appear, or if the site bleeds after needle withdrawal, the medication may have entered subcutaneous tissue. In this situation, skin test results will not be valid. DIF: Cognitive Level: Applying REF: Text reference: p. 540 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Intradermal Injections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse administers a tuberculin screening test to a patient who has no known risk factors
for tuberculosis. When the test site is read 48 hours later, which result is considered positive? a. Induration of 2 mm or more b. Induration of 5 mm or more c. Induration of 10 mm or more d. Induration of 15 mm or more ANS: D
A raised, reddened, or hard zone around the test site indicates a positive tuberculin skin test. An induration of 15 mm or more indicates a positive reaction in patients with no known risk factors for TB. An induration that measures 5 mm or more in diameter indicates a positive TB reaction in patients who are human immunodeficiency virus (HIV) positive, have fibrotic changes on chest radiograph consistent with previous TB infection, have had organ transplants, or are immunosuppressed. An induration of 10 mm or more indicates a positive N R I GTigrants B.CO; M TB reaction in patients who areUrecSentNimm injection drug users; residents and employees in high-risk settings; patients with certain chronic illnesses; children younger than 4 years of age; and infants, children, and adolescents exposed to high-risk adults. DIF: Cognitive Level: Applying REF: Text reference: p. 554 OBJ: Evaluate the effectiveness and outcomes of administering medications by each injection route. TOP: Positive TB Test Results KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 10. The nurse is teaching a family member of an obese patient how to administer a subcutaneous
U-100 insulin injection to the patient. Which instruction should be included in the teaching plan? a. Carefully massage the site after the injection to aid absorption. b. Draw the medication into a tuberculin syringe with a 27-gauge needle. c. Insert the needle quickly and firmly at a 90-degree angle. d. Rotate injection sites between the abdomen, thighs, and upper arms. ANS: C
For an obese patient, the skin is pinched and the needle is inserted quickly and firmly at a 90-degree angle. Massage can damage underlying tissue. Subcutaneous U-100 insulin is given using an insulin syringe with a preattached needle of 28 to 31 gauge. Injection site rotation is no longer necessary because newer human insulins carry a lower risk for hypertrophy. Patients choose one anatomical area (e.g., the abdomen) and systematically rotate sites within that region—a practice that maintains consistent insulin absorption from day to day.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Applying REF: Text reference: p. 556 |Text reference: p. 560 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Insulin Injection KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 11. The nurse is teaching a patient how to inject low-molecular-weight heparin. What instruction
should be included in the teaching plan? a. The injection can be given in the abdomen or the upper thighs. b. Before injecting the medication, be sure to expel the air bubble in the syringe. c. After inserting the needle, pull back on the plunger of the syringe before injecting the medication. d. After injecting the medication, apply gentle pressure to the injection site for 30 to 60 seconds. ANS: D
Gentle pressure for 30 to 60 seconds prevents bleeding at the site. To minimize the pain and bruising associated with low-molecular-weight heparin (LMWH), it is given subcutaneously on the right or left side of the abdomen, at least 2 inches away from the umbilicus; this area is commonly referred to as a patient’s “love handles.” LMWH comes in a prefilled syringe, and the air bubble should not be expelled before administration. Aspiration after a subcutaneous injection is not necessary. Aspiration after an LMWH injection is not recommended. DIF: Cognitive Level: Applying REF: Text reference: p. 560 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Low-Molecular-Weight Heparin Injections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IN ntegR rityI G B.C M
U S N T
O
12. The nurse is preparing an intramuscular injection for a thin elderly patient. The nurse is aware
that the maximum volume most likely tolerated by this patient is which amount? a. 1 mL b. 2 mL c. 3 mL d. 5 mL ANS: B
Elderly adults and thin patients often tolerate only 2 mL in a single injection. A normal, well-developed adult can safely tolerate 2 to 5 mL of medication in larger muscles such as the ventrogluteal. However, clinically, it is unusual to administer more than 3 mL of medication in a single injection because the body does not absorb it well. DIF: Cognitive Level: Applying REF: Text reference: p. 562 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Volume of Medication That Can Be Given Safely IM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. The nurse is preparing to administer an intramuscular injection via the Z-track method. Which
action should be taken by the nurse? a. Pinch the skin between the thumb and the first finger. b. Insert the needle at a 90-degree angle.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank c. Immediately remove the needle after injecting the medication. d. Release the skin before removing the needle from the site. ANS: B
For an intramuscular injection, the needle is inserted perpendicular to the patient’s body as close to 90 degrees as possible. In using the Z-track method, the overlying skin and subcutaneous tissues are pulled approximately 2.5 to 3.5 cm (1 to inches) laterally to the side with the ulnar side of the nondominant hand. Keep the needle inserted for 10 seconds after injection to allow the medication to disperse evenly. Release the skin after withdrawing the needle. DIF: Cognitive Level: Applying REF: Text reference: p. 566 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Z-Track Method KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. A student nurse is preparing to administer an intramuscular injection into the ventrogluteal
muscle. The nursing instructor should question which action by the student? a. Asking the patient to assume a sitting position b. Placing the heel of the hand over the patient’s greater trochanter c. Asking the patient to flex the knee and hip d. Using the right hand to locate the injection site on the patient’s left side ANS: A
The patient should lie in either the supine or the lateral position while the ventrogluteal muscle is located. To locate the ventrogluteal site, the heel of the hand is placed over the greater trochanter of the patient’s hip with the wrist almost perpendicular to the femur. The right hand is used for the leftNhU ipR , aSnI dN thG eT leB ft . haCnO dM is used for the right hip. To relax the muscle, the patient lies on the side or back with the knee and hip flexed. DIF: Cognitive Level: Applying REF: Text reference: p. 563 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Ventrogluteal Injection Site KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is preparing to administer an immunization to a toddler. Which action by the nurse
is appropriate? a. Grasp the body of the muscle during injection. b. Place one hand above the knee and one below the knee to find the site. c. Have the patient’s knee flexed with the foot internally rotated. d. Ask the mother to hold the toddler on his side. ANS: A
The vastus lateralis is the preferred injection site for administration of immunizations to infants, toddlers, and children. With young children, it helps to grasp the body of the muscle during injection to be sure the medication is deposited in muscle tissue. The muscle is located on the anterior lateral aspect of the thigh. In an adult, one hand is placed above the knee and one below the greater trochanter to locate the muscle. To relax the muscle, the patient lies flat with the knee slightly flexed and the foot externally rotated or assumes a sitting position. A side-lying position would not be appropriate for this immunization.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Applying REF: Text reference: p. 563 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Vastus Lateralis Injection Site KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. After insertion of the needle into the patient’s ventrogluteal muscle, the nurse aspirates and
notices a very small amount of blood in the syringe. What action should the nurse take? a. Inject the medication slowly but smoothly. b. Withdraw the needle, expel the blood from the syringe, reinsert the needle, and inject the medication. c. Withdraw the needle, change the needle, insert the needle, and inject the medication. d. Withdraw the needle, dispose of the medication and syringe, and prepare another dose of medication. ANS: D
Aspiration of blood into the syringe indicates possible placement into a vein. If blood appears in the syringe, remove the needle, dispose of the medication and syringe properly, and prepare another dose of medication for injection. DIF: Cognitive Level: Applying REF: Text reference: p. 566 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Aspiration of Blood KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse is preparing to give a medication by IV bolus. When assessing the patient’s IV
insertion site, the nurse notes that it is warm, reddened, and tender. What action should the nurse take first? NURSINGTB.COM a. Slow the infusion rate and slowly inject the medication. b. Discontinue the IV infusion. c. Inject a local anesthetic to relieve the tenderness. d. Apply warm compresses over the insertion site. ANS: B
Swelling, warmth, redness, and tenderness indicate infiltration or phlebitis. Stop the IV infusion, remove the IV catheter, treat the IV site as indicated by institutional policy, and insert a new IV catheter if therapy continues. DIF: Cognitive Level: Applying REF: Text reference: pp. 572-573 |Text reference: p. 579 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. TOP: Phlebitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 18. A patient with a continuous IV infusion has an order for ciprofloxacin to be given IV
piggyback. Which action by the nurse is appropriate for administering the medication? a. Hang the bag with ciprofloxacin higher than the continuous infusion bag. b. Stop the continuous infusion while running the ciprofloxacin. c. Connect the piggyback tubing into the Y-port on the tubing of the continuous infusion that is closest to the patient. d. Occlude the tubing of the continuous infusion just above the injection port while injecting the medication.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: A
The set is called a “piggyback” because the small bag or bottle is set higher than the primary infusion bag or bottle. In the piggyback setup, the main line does not infuse when a compatible piggybacked medication is infusing. The port of the primary IV line contains a back-check valve that automatically stops the flow of the primary infusion once the piggyback infusion flows. After the piggyback solution infuses and the solution within the tubing falls below the level of the primary infusion drip chamber, the back-check valve opens, and the primary infusion starts to flow again. The piggyback is connected to a short tubing line that connects to the upper Y-port of a primary infusion line or to an intermittent venous access. The tubing is occluded to check for blood return or to give an IV bolus, but not for a piggyback medication. DIF: Cognitive Level: Applying REF: Text reference: p. 574 |Text reference: p. 576 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. TOP: Piggyback Infusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The nurse is preparing to administer an intravenous (IV) antibiotic using a mini-infusion
pump. Which action should the nurse do first? a. Place the syringe into the mini-infusion pump. b. Hang the pump on an IV pole. c. Connect the end of the mini-infusion tubing to the main IV line. d. Apply pressure to the syringe plunger to fill the tubing with medication. ANS: D
After connecting the prefilled syringe to the mini-tubing, the nurse carefully applies pressure GiT to the syringe plunger to fill N thU e tR ubSiI ngNw thBfl. uiC dO anMd to ensure that the tubing is free of air bubbles to prevent air embolus. After the tubing is filled with fluid, the syringe is placed into the mini-infusion pump and is hung on an IV pole. Then the mini-infusion tubing is connected to the main IV line. DIF: Cognitive Level: Applying REF: Text reference: p. 578 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. TOP: Mini-infusion Pump KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. The nurse is preparing to administer a medication using a volume-controlled administration
set or Volutrol. Which action should the nurse do first? a. Open the clamp between the Volutrol and the main IV bag. b. Open the air vent on the Volutrol. c. Inject the medication into the Volutrol. d. Clean the injection port on top of the Volutrol. ANS: A
The Volutrol is filled with the desired amount of IV fluid (50 to 100 mL) by opening the clamp between the Volutrol and the main IV bag. After the Volutrol is filled with the desired amount of fluid, the clamp is closed and the clamp on the air vent of the Volutrol is checked and opened if necessary. The injection port on the Volutrol is cleaned, and the medication is injected through the port.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Applying REF: Text reference: p. 577 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. TOP: Volume-Control Administration Sets KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. The student nurse is preparing to administer an IV bolus medication through a small-gauge IV
catheter. The student notes that there is no blood return on aspiration. Which action by the student should the nursing instructor question? a. Checking the IV site for redness and swelling b. Immediately stopping the IV infusion and removing the IV catheter c. Checking to see if the IV is infusing without difficulty d. Injecting the IV medication if no signs of infiltration ANS: B
The student should stop the IV, remove the catheter, and start a new one only if the line is not patent. In some cases, especially with a smaller-gauge IV catheter, blood return is not always aspirated, even if the IV is patent. Confirm patency. If the IV site does not show signs of infiltration and the IV fluid is infusing without difficulty, give the IV bolus medication. DIF: Cognitive Level: Applying REF: Text reference: p. 571 OBJ: Compare the risks of three different intravenous routes. TOP: IV Bolus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The nurse is teaching a patienNt abRoutIconGtinuBo. usCsubMcutaneous infusion with an insulin pump.
S teaching N T plan? O What should the nurse include U in the a. Rotate the site every 1 to 2 days. b. Place a gauze dressing over the insertion site. c. Select an insertion site in the abdomen away from the waistline. d. Pull the skin laterally before inserting the needle. ANS: C
Insulin is absorbed most consistently in the abdomen, so a site should be chosen in the abdomen away from the waistline. The site is changed every 2 to 7 days unless erythema or leaking occurs. An occlusive transparent dressing is used over the site. The skin should be gently pinched or lifted up to ensure that the needle will enter subcutaneous tissue. DIF: Cognitive Level: Applying REF: Text reference: p. 580 OBJ: Initiate, maintain, and discontinue a continuous subcutaneous infusion. TOP: Continuous Subcutaneous Infusion (CSQI) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. A patient has medication ordered to be given by IV bolus. The nurse recognizes which
advantage of this type of administration? a. There is a slower onset of medication effects. b. Medications are given over a longer time frame. c. Medications given by IV bolus are less irritating to the veins. d. Small volumes are used, so fluid overload can be avoided.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS: D
An IV bolus usually requires small volumes of fluid, which is an advantage for patients who are at risk for fluid overload. With IV bolus medications, rapid onset of medication effects occurs, which is useful for patients who are experiencing critical or emergent health problems. Medications can be prepared quickly and given over a shorter time frame rather than by IV piggyback. Medications given by IV bolus may cause direct irritation to the lining of the blood vessel. DIF: Cognitive Level: Analyzing REF: Text reference: p. 568 OBJ: Compare the risks of three different intravenous routes. TOP: Intravenous Bolus Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse follows practice guidelines when administering injections to a patient to avoid
which possible complications? (Select all that apply.) a. Drug response that is too rapid or too slow b. Nerve injury with possible pain or paralysis c. Death of tissue surrounding the injection site d. Death of the patient ANS: A, B, C, D
Failure to inject a medication correctly will result in complications such as an inappropriate drug response (e.g., too rapid, too slow), nerve injury with associated pain or paralysis, localized bleeding, tissue necrosis, and sterile abscess. Administration of an IV push medication too quickly can cN auU seRdSeI atN h.GTB.COM DIF: Cognitive Level: Understanding REF: Text reference: p. 539 OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP: Choosing Correct Injection Method KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is preparing to administer an intramuscular medication. In determining which size
needle and syringe to use to administer the medication, the nurse must consider which of the following? (Select all that apply.) a. The volume of medication b. The viscosity of the medication c. The size and weight of the patient d. Whether or not the syringe has a safety needle ANS: A, B, C
The nurse needs to determine the appropriate size of syringe and needle to be used. The smallest syringe possible for the volume of medication should be used to improve the accuracy of medication preparation. The needle length is chosen by the patient’s size and weight, the type of tissue to be injected, and the route of administration. The needle gauge is determined by the viscosity of the medication. DIF: Cognitive Level: Applying REF: Text reference: p. 562 OBJ: Explain the importance of selecting the proper size syringe and needle for an injection.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Choosing Correct Syringe and Needle Size KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is preparing a subcutaneous injection for a patient. The nurse is careful not to touch
which part of the syringe or needle? (Select all that apply.) a. The needle hub b. The needle shaft c. The syringe outer barrel d. The needle bevel ANS: A, B, D
The needle hub, shaft, and bevel must remain sterile at all times. DIF: Cognitive Level: Applying REF: Text reference: p. 542 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Maintaining Needle Sterility KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse is teaching a patient how to give a subcutaneous injection. The nurse includes
which sites as acceptable for this route of administration? (Select all that apply.) a. Ventrogluteal area between the greater trochanter and the iliac crest b. Outer aspect of the upper arms c. Abdomen from below the costal margins to the iliac crests d. Anterior thighs ANS: B, C, D
The best subcutaneous injection sitesIinclude the outer N toR G crests, B.C M aspect of the upper arms, the abdomen from below the costal margins U tS he ilN iac T aOnd the anterior aspects of the thighs. These areas are easily accessible and are large enough that you can rotate multiple injections within each anatomical location. The ventrogluteal area is used for intramuscular injections. DIF: Cognitive Level: Applying REF: Text reference: p. 580 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Subcutaneous Injection Sites KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse administers an injection of iron to a patient using the Z-track method. The nurse
recognizes which of the following as advantages of this method? (Select all that apply.) a. Provides faster absorption of the medication b. Reduces discomfort from the needle c. Prevents leakage of the medication into subcutaneous tissue d. Prevents the drug from irritating sensitive tissue ANS: C, D
The Z-track method is recommended for IM injections. The Z-track technique, which pulls the skin laterally before injection, prevents leakage of medication into subcutaneous tissue, seals medication in the muscle, and minimizes irritation. DIF: Cognitive Level: Understanding REF: Text reference: p. 562 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Z-Track Method KEY: Nursing Process Step: Implementation
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity 6. The nurse is preparing to administer an IV medication that must be diluted in 60 mL of fluid
and then given over 45 minutes. Which of the following methods can the nurse use to give this medication? (Select all that apply.) a. Piggyback infusion b. Volume-control device c. Mini-infusion pump d. IV bolus injection ANS: A, B, C
Piggyback infusions contain 25 to 250 mL, volume-control devices contain 50 to 150 mL, and mini-infusion pumps contain 5 to 60 mL. All three can be set to deliver the medication over a specific time frame. IV bolus injections are smaller volumes that are delivered quickly, usually over a few minutes. DIF: Cognitive Level: Applying REF: Text reference: p. 574 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. TOP: Administration of IV Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. The health care provider orders 4 units of regular insulin and 10 units of NPH insulin
subcutaneous before breakfast. The nurse draws the regular insulin into the syringe and is preparing to draw the NPH inNsulR in inIto tG he sB am ringe. When finished, the syringe should .eCsyM contain units. U S N T O ANS:
14 The combined units of insulin are determined by adding the number of units of both insulins together (4 units of regular + 10 units of NPH = 14 units). DIF: Cognitive Level: Applying REF: Text reference: p. 551 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Subcutaneous Insulin Injection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse injects the medication into the loose connective tissue just under the dermis when
giving a
injection.
ANS:
subcutaneous A subcutaneous injection involves depositing medication into the loose connective tissue underlying the dermis. DIF: Cognitive Level: Remembering REF: Text reference: p. 529 |Text reference: p. 555 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Subcutaneous Injection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
3. The nurse informs the patient that the medication will be absorbed rapidly because it was
injected into tissue with a rich blood supply. The patient has just received a injection. ANS:
intramuscular (IM) The intramuscular (IM) injection route deposits medication into deep muscle tissue, which has a rich blood supply, allowing the medication to be absorbed faster than by the subcutaneous or intradermal route. DIF: Cognitive Level: Applying REF: Text reference: p. 562 OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP: Intramuscular (IM) Injection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The patient is receiving allergy testing. The nurse is using the inner forearm to inject the
allergen into the
.
ANS:
dermis Intradermal (ID) injections are used for allergy testing. They are injected into the dermis, usually in the inner forearm or upper back. DIF: Cognitive Level: Applying REF: Text reference: p. 552 OBJ: Correctly administer intradermal, subcutaneous, and intramuscular injections. TOP: Intradermal (ID) Injection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IN ntU egR riS tyINGTB.COM 5. A patient with multiple intravenous lines has blood infusing in the right antecubital space,
parenteral nutrition infusing through a right subclavian line, and normal saline with potassium infusing in the left forearm. An intravenous medication is ordered stat. The nurse will use the line in the to administer the medication. ANS:
left forearm Never administer IV medications through tubing that is infusing blood, blood products, or parenteral nutrition solutions. DIF: Cognitive Level: Applying REF: Text reference: p. 570 |Text reference: p. 575 OBJ: Correctly administer an intravenous infusion by intravenous piggyback, intermittent infusion, or bolus through a hanging intravenous line or saline lock. TOP: Intravenous (IV) Injection or Infusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is preparing to give an intramuscular injection to a toddler. To decrease pain,
EMLA cream is applied to the injection site at least the injection. ANS:
hour(s) before administration of
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 1 EMLA cream should be applied to the injection site at least 1 hour before IM injection to decrease pain. DIF: Cognitive Level: Applying REF: Text reference: pp. 566-567 OBJ: Discuss ways to promote patient comfort while administering an injection. TOP: Pediatric Considerations for Intramuscular Injections KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The most frequent route of exposure to bloodborne disease for health care workers is
needlestick injury. The nurse recognizes that implementation of prevent needlestick injury.
can
ANS:
safe needle devices The Needlestick Safety and Prevention Act is a federal law that mandates health care facilities to use safe needle devices to reduce the frequency of needlestick injury. DIF: Cognitive Level: Understanding REF: Text reference: p. 574 OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP: Needlestick Injuries KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. An experienced nurse recognizes that the dorsogluteal injection site is no longer used for
intramuscular injections because of the risk of damaging the
.
ANS:
NURSINGTB.COM sciatic nerve Recent evidence supports avoiding the traditional dorsogluteal route in favor of the ventrogluteal site. Therefore, the dorsogluteal site should not be used as a site for IM injection. Studies have demonstrated that the exact location of the sciatic nerve varies from one person to another. If a needle hits the sciatic nerve, the patient may experience permanent or partial paralysis of the involved leg. DIF: Cognitive Level: Understanding REF: Text reference: p. 562 OBJ: Identify advantages, disadvantages, and risks of administering medication by each injection route. TOP: Complications of IM Injections KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 9. The nurse is preparing to draw up a medication using a filter needle and a syringe. This
equipment is necessary when the medication is being withdrawn from an
.
ANS:
ampule Filter needles must be used when medication is withdrawn from a glass ampule. Filter needles prevent glass particles from being drawn into the syringe. DIF: Cognitive Level: Understanding REF: Text reference: p. 580 OBJ: Correctly prepare injectable medications from a vial and an ampule. TOP: Filter Needle KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 10. The patient is complaining of tenderness at his intravenous (IV) insertion site. The nurse
examines the site and notices that the site is swollen, warm, and reddened. The nurse stops the intravenous infusion, realizing that the patient has . ANS:
phlebitis The patient has an unexpected outcome when his intravenous site becomes swollen, warm, reddened, and tender to touch, indicating phlebitis. DIF: Cognitive Level: Analyzing REF: Text reference: p. 544 |Text reference: pp. 546-547 OBJ: Evaluate the effectiveness and outcomes of administering medications by each injection route. TOP: Phlebitis KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 11. While checking the patient’s intravenous (IV) site, the nurse notices that the site is cool, pale,
and swollen. She immediately stops the IV infusion, realizing that these are signs indicating . ANS:
infiltration The patient has an unexpected outcome when his intravenous site becomes cool, pale, and swollen, indicating infiltration. DIF: Cognitive Level: Analyzing REF: Text reference: p. 572 OBJ: Evaluate the effectiveness and outcomes of administering medications by each injection route. TOP: Infiltration KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 23: Oxygen Therapy MULTIPLE CHOICE 1. A patient diagnosed with chronic obstructive pulmonary disease (COPD) is on oxygen
therapy at 3 L per nasal cannula. Which assessment finding should alert the nurse to a potential problem with this patient? a. Respiratory rate of 26 b. Low carbon dioxide levels c. Arterial oxygen saturation level of 99% d. Lower oxygen saturation levels at night than during the day ANS: C
In the patient with COPD, high levels of oxygen can extinguish the stimulus to breathe. In the individual with healthy lungs, the chemoreceptors are sensitive to small changes in carbon dioxide levels and effectively regulate ventilation. In patients with COPD who retain carbon dioxide, the chemoreceptors are not sensitive to small changes in carbon dioxide and regulate ventilation poorly. In these patients, it is the change in the oxygen level that stimulates changes in ventilation. Patients with COPD are at risk of retaining carbon dioxide and developing carbon dioxide narcosis induced by administration of high levels of oxygen. Uncontrolled oxygen administration may cause acute hypoventilation and carbon dioxide retention with dire consequences. Arterial oxygen saturation levels should be at 88% to 92% and no higher. Some patients with COPD have normal oxygen levels during the day but oxygen desaturation during sleep. DIF: Cognitive Level: Analyzing F: Tex t reference: p. 588 N R I GREB . C M UgenStheN O OBJ: Discuss indications for oxy rapyT . TOP: Carbon Dioxide Retention and Oxygen Drive KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 2. A patient with pneumonia is receiving supplemental oxygen. Which assessment finding(s) by
the nurse should be reported as an early indication of hypoxia? a. Cyanosis around the lips and oral mucosa b. Anxiety and restlessness c. Decrease in the level of consciousness d. Decreased blood pressure and respiratory rate ANS: B
Anxiety, confusion, and restlessness are early signs of hypoxia. Cyanosis around the lips and mouth is a sign of hypoxia, but it is a late sign. Decreased level of consciousness, decreased respiratory rate, and decreased blood pressure are also late signs of hypoxia. The respiratory rate will increase as the body attempts to compensate for the decreased level of oxygen. As hypoxia worsens, the respiratory rate may decline. During early stages of hypoxia, blood pressure is elevated unless the condition is caused by shock. DIF: Cognitive Level: Applying REF: Text reference: p. 588 OBJ: Discuss indications for oxygen therapy. TOP: Early Signs of Hypoxia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 3. A patient with COPD has carbon dioxide retention and is ordered oxygen therapy. The nurse
anticipates the use of which oxygen delivery system? a. Face tent b. Face mask c. Nasal cannula d. Nonrebreathing mask ANS: C
Oxygen can be delivered via the nasal cannula at flow rates of 1 to 2 L per minute, which deliver 24% to 28% FiO2 and are useful for patients with chronic lung disease. The face tent is used primarily for humidification and for oxygen only when the patient cannot or will not tolerate a tight-fitting mask. The FiO2 cannot be controlled, and there is no way to estimate how much oxygen is delivered. The simple face mask is used for short-term oxygen therapy. It fits loosely and delivers oxygen concentrations from 40% to 60%. The mask is contraindicated for patients with carbon dioxide retention because it will make the retention worse. When used as a nonrebreather, the plastic face mask with a reservoir bag delivers 60% to 100% oxygen at appropriate flow rates. This oxygen mask maintains a high-concentration oxygen supply in the reservoir bag. If the bag deflates, the patient breathes in large amounts of exhaled carbon dioxide. DIF: Cognitive Level: Analyzing REF: Text reference: pp. 590-591 OBJ: Demonstrate applying a nasal cannula and an oxygen mask. TOP: Nasal Cannulas KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4. The nurse is caring for several patients receiving oxygen by various delivery systems. Which
assessment finding by the nurse indicates proper use of the oxygen device? Nent. RSINGTB.C OM a. No mist is noted in a face tU b. The reservoir of the rebreathing mask collapses on inhalation. c. The flow rate is between 1 and 6 L/min for a nasal cannula. d. The flow rate for an oxygen hood is set at 3 L/min. ANS: C
The nasal cannula is used with an oxygen flow rate of 1 to 6 L/min. The face tent provides high humidity, and mist is expected. The reservoir of the rebreathing mask remains partially inflated when operating effectively to avoid rebreathing of carbon dioxide. The flow rate for an oxygen hood may be 5 L/min or more to prevent CO2 narcosis. DIF: Cognitive Level: Knowledge REF: Text reference: pp. 590-591 OBJ: Demonstrate applying a nasal cannula and an oxygen mask. TOP: Nasal Cannulas KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. A patient in respiratory distress enters the emergency department. The patient denies a history
of COPD. The nurse anticipates an order for oxygen delivered by which method to achieve the highest possible concentration of oxygen? a. Simple face mask at 15 L/min b. Nonrebreathing face mask at 15 L/min c. Venturi mask at 15 L/min d. Oxygen tent at 15 L/min ANS: B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank When used as a nonrebreather, the face mask with a reservoir bag delivers 60% to 90% oxygen at 15 L/min. The simple face mask delivers oxygen concentrations from 40% to 60% when set at 5 to 8 L/min. It is not used at 15 L/min. A Venturi mask delivers oxygen concentrations from 24% to 60% when set at 4 to 12 L/min. It is not used at 15 L/min. An oxygen tent is usually for pediatric use and delivers up to 50% oxygen concentration at 10 to 15 L/min. DIF: Cognitive Level: Analyzing REF: Text reference: pp. 590-591 OBJ: Discuss methods for administering oxygen therapy. TOP: Oxygen Mask KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 6. A patient with a nasal cannula at 5 L/min has skin irritation around the nares and complains of
a dry mouth and nose. Which action by the student nurse should be questioned by the nursing instructor? a. Using humidification b. Applying petroleum-based gel to the nares c. Providing frequent oral care d. Asking the physician for an order for sterile nasal saline ANS: B
Petroleum-based gel should not be used around oxygen because it is flammable. If the oxygen flow rate is greater than 4 L/min, humidification should be used. Frequent oral care and sterile nasal saline will help when there is drying of the nasal and oral mucosa. DIF: Cognitive Level: Applying REF: Text reference: p. 590 |Text reference: p. 594 OBJ: Discuss methods for administering oxygen therapy. TOP: Unexpected Outcomes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IN ntU egR riS tyINGTB.COM 7. A patient with a tracheostomy tube has an order for oxygen. Which action by the nurse is
appropriate? a. Apply sterile gloves to connect the oxygen to the tracheostomy tube. b. Check the oxygen tubing frequently to make sure water is present in the tubing. c. Attach the T tube to a humidified oxygen source. d. Monitor the response to oxygen with hourly arterial blood gas levels. ANS: C
The T tube connects an oxygen source to an artificial airway such as a tracheostomy tube. Humidification is necessary because the artificial airway bypasses the normal humidification process of the nose and mouth. Clean gloves, not sterile gloves, are used to connect oxygen to the artificial airway. Fluid should be drained from the tubing so that it does not provide a medium for bacterial growth. Hourly ABGs are not the standard for monitoring patients with artificial airways and oxygen. DIF: Cognitive Level: Applying REF: Text reference: pp. 595-597 OBJ: Demonstrate administering oxygen therapy to a patient with an artificial airway. TOP: Attaching a T Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse is caring for several patients postoperatively following abdominal surgery. Which
patient will benefit the least from the use of incentive spirometry?
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
Middle-aged male with a history of smoking since high school Elderly female with type 2 diabetes Middle-aged female with a history of chronic respiratory disease Adolescent female with atelectasis
ANS: B
Incentive spirometry (IS) assists the patient in deep breathing. It is used most often following abdominal or thoracic surgery to help reduce the incidence of postoperative pulmonary atelectasis. It is especially beneficial in patients with a history of smoking, pneumonia, chronic respiratory disease, or atelectasis. DIF: Cognitive Level: Applying REF: Text reference: pp. 597-598 OBJ: Demonstrate proper use of incentive spirometry. TOP: Incentive Spirometry KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse is teaching a patient how to use a flow-oriented incentive spirometer (IS) the night
before abdominal surgery. Which statement by the patient indicates an understanding of the procedure? a. “I need to get the balls to the top as quickly as possible.” b. ”Quick rapid breaths are the most effective when the incentive spirometer is used.” c. “I need to keep the balls elevated as long as possible.” d. “The balls must be elevated to be effective.” ANS: C
The goal is to keep the balls elevated for as long as possible to ensure maximal sustained inhalation, not to snap the balls to the top of the chamber quickly with a rapid, brief, low-volume breath. Even if vNery Rslow INinGspir Bat.ioCn OdoMes not elevate the balls, this pattern helps U S T to improve lung expansion. DIF: Cognitive Level: Applying REF: Text reference: p. 597 OBJ: Demonstrate proper use of incentive spirometry. TOP: Incentive Spirometry KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. A patient is planning to perform incentive spirometry after abdominal surgery. The nurse
should encourage the patient to do which of the following? a. Get comfortable in a semi-reclined position. b. Inhale as deeply as possible and then exhale into the incentive spirometry device. c. Hold the breath for at least 3 seconds before exhaling. d. Exhale as quickly as possible. ANS: C
The patient should hold his breath for at least 3 seconds after inhalation. The patient should be positioned in the most erect position (e.g., high-Fowler’s position), if tolerated. This promotes optimal lung expansion during respiratory maneuvers. The patient should exhale completely through the mouth and place the lips around the mouthpiece, and then he should take a slow, deep breath, hold it for at least 3 seconds, and exhale normally. DIF: Cognitive Level: Applying REF: Text reference: p. 597 |Text reference: p. 599 OBJ: Demonstrate proper use of incentive spirometry. TOP: Incentive Spirometry KEY: Nursing Process Step: Implementation
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity 11. A patient has been using continuous positive airway pressure (CPAP), and now the health care
provider is recommending bi-level positive airway pressure (BiPAP). The patient is asking the nurse to explain the difference again. Which response is appropriate? a. “CPAP maintains a set positive airway pressure during inspiration only.” b. “CPAP opens the airways during inspiration and allows them to close during expiration.” c. “BiPAP maintains a set pressure that is the same for inspiration and expiration.” d. “BiPAP delivers sufficient expiratory pressure to keep the airways open.” ANS: D
BiPAP uses two modes of pressure: one for inspiration and one for expiration. During expiration, BiPAP delivers sufficient pressure to keep the airways open. CPAP maintains a set positive airway pressure during inspiration and expiration. It keeps the airways open and prevents upper airway collapse. DIF: Cognitive Level: Applying REF: Text reference: pp. 600-601 OBJ: Demonstrate use of noninvasive positive-pressure ventilation using continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). TOP: CPAP/BiPAP KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. A patient is admitted to the emergency department following a motor vehicle accident. The
patient is unconscious and has a broken jaw, a broken nose, and facial lacerations. The patient’s breath sounds are diminished, and the health care provider suspects atelectasis. Frequent suctioning is required to clear the airway. Oxygen saturation levels range from 70% to 75%. The nurse recognizeN s tU haRt S thI isNpG atT ieB nt.mCoO stM likely will have which type of ventilatory device ordered? a. CPAP b. BiPAP c. Nasal cannula d. Mechanical ventilation ANS: D
Noninvasive ventilation, including CPAP and BiPAP, is contraindicated in cardiac or respiratory arrest, nonrespiratory organ failure, facial surgery or trauma, inability to protect the airway and/or high risk for aspiration, and inability to clear secretions. A nasal cannula cannot be used with nasal obstruction from a broken nose. DIF: Cognitive Level: Analyzing REF: Text reference: p. 601 |Text reference: p. 604 OBJ: Demonstrate use of noninvasive positive-pressure ventilation using continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). TOP: CPAP/BiPAP, Noninvasive Positive-Pressure Ventilation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. A patient is admitted with a diagnosis of COPD and the health care provider orders BiPAP.
Which action by the nurse is appropriate? a. Set the initial BiPAP settings at 4 to 8 cm H2O for inspiration and expiration. b. Draw arterial blood gas (ABG) levels after the first hour. c. Make sure the mask does not have quick-release straps.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. Set the initial BiPAP settings at 4 to 10 cm H2O for inspiration and at 10 to 15 cm
H2O for expiration. ANS: B
When BiPAP is initiated, especially in patients with underlying COPD, it is important to obtain ABG levels after the first hour and then per agency policy (usually every 2 to 6 hours) during the first day because these patients may retain carbon dioxide. BiPAP initial settings are 10 to 15 cm H2O for inspiratory pressure and 4 to 10 cm H2O for expiratory pressure. It is imperative that the mask have quick-release straps. In the case of an emergency (e.g., vomiting, respiratory arrest), quick-release straps allow the mask to be removed quickly. This system also allows the patient to remove the mask quickly as needed. DIF: Cognitive Level: Applying REF: Text reference: p. 602 OBJ: Demonstrate use of noninvasive positive-pressure ventilation using continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). TOP: Initiation of Noninvasive Positive-Pressure Ventilation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse is caring for a patient on a mechanical ventilator and the low-pressure alarm
sounds. Which action by the nurse is most appropriate? a. Assess for secretions in the airway and suction the patient. b. Administer a sedative to the patient to prevent coughing. c. Assess the endotracheal tube cuff to make sure it is deflated. d. Check the ventilator tubing and reconnect if disconnected. ANS: D
The low-pressure alarm sounN ds w henIthG e veB ntilatorM has no resistance to inflating the lung. The UR S T .Cor O a leak may have developed in the patient may be disconnected from the N ventilator, ventilator circuit. The high-pressure alarm sounds when the ventilator has met resistance to delivery of the tidal volume. This may result from coughing, increased secretions, or biting on the endotracheal tube. The cuff of the endotracheal tube is inflated to create a seal for positive-pressure ventilation. A cuff that is leaking could cause the low-pressure alarm to sound. DIF: Cognitive Level: Applying REF: Text reference: p. 606 OBJ: Demonstrate care of a patient receiving mechanical ventilation. TOP: Ventilator Alarms KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. The nurse is caring for a patient on mechanical ventilation. The nurse determines that the
endotracheal tube is properly placed by which assessment? a. Auscultating both lungs and watching the rise and fall of both sides of the chest b. Monitoring and comparing the blood pressure in both arms c. Observing and measuring inspiratory and expiratory rates d. Checking the settings on the ventilator and the low-pressure and high-pressure alarm settings ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Verify placement of the endotracheal tube by auscultating the lungs and assessing chest wall symmetry. This ensures that the tube has not migrated into the right main stem bronchus. Many factors can cause blood pressure fluctuations and fluctuations in respiratory rate. Always assess the patient first. Once the patient is determined to be safe, the settings for the ventilator alarm can be checked as well. DIF: Cognitive Level: Applying REF: Text reference: p. 609 OBJ: Demonstrate care of a patient receiving mechanical ventilation. TOP: Artificial Airway Placement KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. A patient on mechanical ventilation has an FiO2 setting of 38%. The nurse is reviewing
arterial blood gas results and pulse oximetry readings. The nurse is aware that the desired level of oxygen is which of the following? a. PaO2 greater than 90 mm Hg b. SpO2 greater than 60% c. PaO2 greater than 60 mmHg d. SpO2 greater than 95% ANS: C
A patient on mechanical ventilation ideally has an FiO2 setting less than 40% to maintain PaO2 levels greater than 60 mm Hg and SpO2 levels greater than 90%. DIF: Cognitive Level: Analyzing REF: Text reference: p. 606 OBJ: Demonstrate care of a patient receiving mechanical ventilation. TOP: Care of the Patient on a Ventilator KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
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MULTIPLE RESPONSE 1. The nurse is reviewing lab results for a patient with hypoxemia. The nurse is aware that which
of the following results may worsen the patient’s hypoxemia? (Select all that apply.) a. Low sodium levels b. Low hemoglobin levels c. Increased blood pH d. Decreased blood pH ANS: B, C
Hypoxemia is a deficiency of arterial blood oxygen. Decreased hemoglobin levels reduce the amount of oxygen transported to the cells. Acidemia (decreased blood pH) increases the ability of hemoglobin to release oxygen to the tissues. Alkalemia (increased blood pH) decreases the ability of hemoglobin to release oxygen to the tissues. DIF: Cognitive Level: Applying REF: Text reference: p. 587 OBJ: Discuss indications for oxygen therapy. TOP: Hemoglobin and Acid-Base Status KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is assessing a patient for hypoxia and observes a bluish discoloration in the
following areas. Which areas indicate hypoxia? (Select all that apply.) a. Oral mucosa
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. Conjunctiva of the eye c. Around the lips d. On the nail beds ANS: A, B, C
Cyanosis caused by hypoxia is observed in the oral mucosa, in the conjunctiva of the eye, and around the lips, known as circumoral cyanosis. Nail bed cyanosis may be caused by peripheral vascular disease or cold temperatures. DIF: Cognitive Level: Applying REF: Text reference: p. 588 OBJ: Discuss indications for oxygen therapy. TOP: Cyanosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. A patient will be using a nasal cannula continuously to deliver oxygen at home, and the nurse
is instructing the patient and family about important safety guidelines. Which of the following should be included in the teaching plan? (Select all that apply.) a. Smoking is allowed if it is not done in the same room in which the oxygen device is placed. b. If you feel short of breath, increase your oxygen by 2 to 3 L per minute. c. Avoid using an electric razor. d. Keep the oxygen tank at least 5 feet away from the stove. ANS: C, D
Items that create a spark such as an electric razor should not be used while a nasal cannula is in use. Oxygen delivery systems should be at least 5 feet from any heat source. No smoking is allowed on the premises. Oxygen is a medication. Increasing the oxygen liter flow for shortness of breath is similar to doubling heart, asthma, or other medications.
NURSINGTB.COM
DIF: Cognitive Level: Applying REF: Text reference: p. 589 OBJ: Discuss indications for oxygen therapy. TOP: Oxygen Therapy Safety Guidelines KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is checking the oxygen flow rate on several patients. All flow meters are set at 2
L/min. The nurse should question this flow rate for which delivery system(s)? (Select all that apply.) a. Nasal cannula b. Simple face mask c. Oxymizer d. Venturi mask ANS: B, D
Flow rates for a nasal cannula are 1 to 6 L/min, and flow rates for an oxymizer are 1 to 15 L/min, so 2 L/min is appropriate for either device. Flow rates for a simple face mask are 5 to 8 L/min to prevent rebreathing of CO2. Flow rates for a Venturi mask are 4 to 12 L/min, and a specific rate is necessary to deliver a specific FiO2. DIF: Cognitive Level: Applying REF: Text reference: p. 591 OBJ: Discuss methods for administering oxygen therapy. TOP: Flow Rates for Oxygen Delivery Systems KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 5. The nurse is caring for several patients who require oxygen therapy. The nurse anticipates an
order for noninvasive positive-pressure ventilation (NIPPV) for the patients with which diagnoses? (Select all that apply.) a. Pulmonary edema b. Obstructive sleep apnea c. Stroke with dysphagia d. Congestive heart failure ANS: A, B, D
In the cardiac patient, NIPPV reduces pulmonary edema because the increased alveolar pressure forces interstitial fluid out of the lungs and back into the pulmonary circulation. In patients who retain carbon dioxide, such as with obstructive sleep apnea, NIPPV keeps the airway open and prevents upper airway collapse. In selected patients, such as those with postpolio syndrome and other neuromuscular diseases, congestive heart failure, sleep disorders, and pulmonary diseases, NIPPV is often the treatment of choice in supporting ventilation without the hazards associated with endotracheal intubation. NIPPV is contraindicated in patients at high risk for aspiration, as after a stroke with dysphagia. DIF: Cognitive Level: Applying REF: Text reference: p. 600 OBJ: Demonstrate use of noninvasive positive-pressure ventilation using continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). TOP: Noninvasive Ventilation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse is teaching a patient with asthma how to measure peak expiratory flow rate (PEFR).
What should be included in the teaching plan? (Select all that apply.) a. Assume a recumbent position before measuring PEFR. b. Take a deep breath in, exhale, then place the mouthpiece in the mouth and form a firm seal with the lips. NURSINGTB.COM c. After placing the mouthpiece in the mouth, blow out as hard and as fast as possible through the mouth in only one single breath. d. Measure PEFR 3 times and record the highest number. ANS: C, D
To measure PEFR, the patient should be standing. If the patient is unable to stand, high-Fowler’s position or any other position that promotes optimum lung expansion should be used. The patient should take in a deep breath, place the mouthpiece in the mouth, and form a tight seal. Then the patient should blow out as hard and as fast as possible through the mouth in only one single breath. Two additional measurements are taken, and the highest number is recorded. DIF: Cognitive Level: Applying REF: Text reference: p. 604 OBJ: Demonstrate proper peak expiratory flow rate (PEFR) measurements. TOP: Use of a Peak Flow Meter KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The patient is placed on mechanical ventilation. After the initial settings have been applied,
the nurse should watch for which of the following complications? (Select all that apply.) a. Signs of decreased cardiac output b. Tension pneumothorax c. Pneumonia d. Failure to wean
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS: A, B, C
Multiple complications are associated with positive-pressure ventilation: decreased cardiac output, aspiration, tension pneumothorax, bronchospasm, laryngeal trauma, sinusitis, and ventilator-associated pneumonia. Failure to wean is not a major factor in starting the use of a ventilator; however, as the length of time needed for mechanical ventilation increases, the risk for failure to wean from the ventilator is increased. DIF: Cognitive Level: Analyzing REF: Text reference: p. 604 OBJ: Demonstrate care of a patient receiving mechanical ventilation. TOP: Initiation of Mechanical Ventilation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. The patient is on mechanical ventilation. Which actions by the nurse are appropriate? (Select
all that apply.) a. Keep the patient in a supine position. b. Note and mark the level of the endotracheal (ET) tube at the lips or nares. c. Have suction equipment available for immediate use. d. Perform mouth care at least twice daily. ANS: B, C
The patient should be positioned with the head of bed elevated 30 to 45 degrees to reduce gastric reflux, thereby decreasing the risk for aspiration and ventilator-associated pneumonia. Note and mark the level of the ET tube at the lips or nares. This provides a baseline for depth of tube placement and ensures that the tube is not too close to the carina or in the right main stem bronchus. Set up suction equipment, including oral suctioning, to provide airway care and suctioning as needed of the ET or tracheostomy tube, to prevent plugging of the airway, and to reduce the risk for infeNctioRn. PIerfG U S Norm TBm.oCuthOMcare at least 4 times per 24 hours. Use a toothbrush and a solution such as chlorhexidine, which is effective in reducing oral bacteria and the risk for ventilator-associated pneumonia. DIF: Cognitive Level: Applying REF: Text reference: pp. 608-609 OBJ: Demonstrate care of a patient receiving mechanical ventilation. TOP: Care of the Patient on a Ventilator KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. A condition in which oxygen is insufficient to meet the metabolic demands of the tissues and
cells is known as
.
ANS:
hypoxia Hypoxia is a condition in which oxygen is insufficient to meet the metabolic demands of the tissues and cells. DIF: Cognitive Level: Remembering REF: Text reference: p. 587 OBJ: Discuss indications for oxygen therapy. TOP: Hypoxia KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 2. The
, also called a Briggs adaptor, connects an oxygen source to an artificial airway such as an endotracheal tube. ANS:
T tube The T tube, also called a Briggs adaptor, is a T-shaped device with a 15-mm (3/5-inch) connection that connects an oxygen source to an artificial airway such as an endotracheal (ET) tube or tracheostomy. DIF: Cognitive Level: Remembering REF: Text reference: p. 595 OBJ: Demonstrate administering oxygen therapy to a patient with an artificial airway. TOP: The T Piece KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. A curved oxygen delivery device with an adjustable strap that fits around the patient’s neck is
known as a
.
ANS:
tracheostomy collar A tracheostomy collar is a curved device with an adjustable strap that fits around the patient’s neck. DIF: Cognitive Level: Remembering REF: Text reference: p. 595 OBJ: Demonstrate administering oxygen therapy to a patient with an artificial airway. TOP: The Tracheostomy Collar KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. In noninvasive ventilation,
NURSINGTB.CkeOeM ps the terminal airways (alveoli) partially
inflated, reducing the risk for atelectasis. ANS:
positive airway pressure Continuous positive airway pressure keeps the alveoli partially inflated, reducing the risk for atelectasis; if atelectasis has occurred, positive pressure assists in reinflation. DIF: Cognitive Level: Remembering REF: Text reference: p. 600 OBJ: Demonstrate use of noninvasive positive-pressure ventilation using continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). TOP: Positive Airway Pressure KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The amount of air inspired and expired with each breath while a patient is on mechanical
ventilation is known as the
.
ANS:
tidal volume The tidal volume, the amount of air per breath, is usually set by the patient’s ideal body weight (5 to 8 mL/kg). DIF: Cognitive Level: Remembering REF: Text reference: p. 605 OBJ: Demonstrate care of a patient receiving mechanical ventilation. TOP: Tidal Volume KEY: Nursing Process Step: Assessment
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity
NURSINGTB.COM
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 24: Performing Chest Physiotherapy MULTIPLE CHOICE 1. The nurse receives orders on several patients for chest percussion, vibration, and shaking. The
nurse is aware that chest physiotherapy maneuvers are indicated for which patient? a. 18-year-old who sustained thoracic trauma from a motor vehicle accident b. 75-year-old with osteoporosis who is underweight c. 15-year-old with cystic fibrosis d. 20-year-old with a fractured clavicle ANS: C
Chest physiotherapy (CPT) and coughing maneuvers assist with airway clearance of mucus in patients with retained tracheobronchial secretions. Secretions accumulate in the airways of patients with bronchitis, asthma, cystic fibrosis (CF), pneumonia, and bronchiectasis. Thoracic trauma, osteoporosis, and fracture of rib cage structures such as the clavicle contraindicate percussion, vibration, and shaking. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 613-614 |Text reference: p. 617 OBJ: Determine the need to modify or discontinue CPT maneuvers, including contraindications and individual variations. TOP: Indications for CPT KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse auscultates the patients’ lung fields and notes congestion in several patients. The
nurse anticipates that postural drainage may be used for the patient with which condition? a. Congestive heart failure with pulmonary edema CoOpMtysis b. History of cigarette smokN inU gR wS itI hN reG ceT ntBh. em c. Chronic bronchitis with frequent coughing d. Pulmonary embolism after a long international flight ANS: C
Secretions accumulate in patients with bronchitis, asthma, cystic fibrosis, pneumonia, and bronchiectasis. Contraindications for postural drainage include pulmonary edema associated with congestive heart failure, active hemoptysis, and pulmonary embolism. DIF: Cognitive Level: Analyzing REF: Text reference: pp. 613-614 OBJ: Determine the need to modify or discontinue CPT maneuvers, including contraindications and individual variations. TOP: Contraindications and Indications for Postural Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is teaching family members how to perform postural drainage at home for a patient
with chronic bronchitis. What instruction should the nurse provide? a. Plan to perform postural drainage 3 times a day about 1 hour after meals. b. Don’t give any pain medication within 2 hours of performing postural drainage. c. Perform postural drainage 20 minutes after the patient uses the inhaler. d. Encourage the patient to remain in each position for 30 minutes to adequately drain the area. ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Patients receiving inhaled bronchodilators, nebulizers, or aerosol treatments should have postural drainage performed 20 minute after such therapy. If a patient’s pain is 4 or greater, analgesics should be administered 20 minutes before CPT maneuvers. Pain control is essential for the patient to actively participate and cough forcefully to clear the airways. Treatments should not overlap with meals. Avoid postural drainage 1 to 2 hours before and after meals. The patient should maintain each position for 10 to 15 minutes. DIF: Cognitive Level: Applying REF: Text reference: p. 618 OBJ: Explain how to prepare the patient and the family for the performance of each CPT maneuver. TOP: Teaching Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse receives orders for an Acapella device on several patients. The nurse should
question the order on the patient with which condition? a. Chronic bronchitis b. Asthma c. Cystic fibrosis (CF) d. Pleural effusion ANS: D
The Acapella device is a respiratory rehabilitation device designed to aid sputum clearance. Patients with chronic conditions such as cystic fibrosis, chronic bronchitis, and asthma appear to receive the greatest benefit from this type of treatment. CPT is contraindicated in patients with pleural effusion. DIF: Cognitive Level: Applying REF: Text reference: p. 614 OBJ: Perform the outlined CPT maneuvers, including standard and modified versions. NURSINGKTEB TOP: Acapella Device Y. : C NuOrsM ing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The nurse is teaching a patient how to use an Acapella device. What instruction should the
nurse give to the patient? a. Take a full deep breath in and fill your lungs. b. Hold your breath for 5 to 10 seconds after placing the mouthpiece in your mouth. c. Cough forcefully to clear your lungs while maintaining a tight seal on the mouthpiece. d. Exhale slowly for 3 to 4 seconds through the device while it vibrates. ANS: D
Instruct the patient to try not to cough and to exhale slowly for 3 to 4 seconds through the device while it vibrates. The patient should be instructed to take in a breath that is larger than normal, but not to fill the lungs completely—about 75% of inspiratory capacity. Hold the breath for 2 to 3 seconds, and try not to cough. DIF: Cognitive Level: Applying REF: Text reference: p. 620 OBJ: Describe discharge teaching and planning related to the use of each CPT maneuver in the home setting. TOP: Acapella Device KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. A patient has received instructions on the use of an Acapella device. Which action by the
patient indicates an understanding of the teaching?
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
Complains of not being able to use an aerosol drug with the device Turns the frequency adjustment dial to medium resistance After completing one cycle, repeats for 2 more breaths After removing the mouthpiece, performs 1 to 2 forceful exhalations and “huff” coughs
ANS: D
When the cycles are completed, the mouthpiece is removed and 1 to 2 forceful exhalations and “huff” coughs are performed. If aerosol drug therapy is ordered, a nebulizer is attached to the end of the Acapella device. For the initial setting, the frequency adjustment dial should be set at the lowest resistance setting. The cycle should be repeated for 5 to 10 breaths as tolerated. DIF: Cognitive Level: Applying REF: Text reference: p. 620 OBJ: Describe discharge teaching and planning related to the use of each CPT maneuver in the home setting. TOP: Acapella Device KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The health care provider orders percussion on a patient to help clear airway secretions. Which
action by the nurse is appropriate? a. Performing percussion over the ribs, while avoiding the clavicles and sternum b. Administering pain medication before performing the percussion because the vibrations will be painful c. Performing percussion during exhalation only with the flat part of the palm d. Creating a rocking motion by slightly leaning on the patient’s chest ANS: A
NURSINGTB.COM
Percussion is performed by clapping the chest wall with cupped hands over the ribs only. The clavicles, breast tissue, sternum, spine, waist, and abdomen should not be used. If done correctly, percussion painlessly sets up vibrations in the chest to dislodge retained secretions. Vibration is done during exhalation only with the flat part of the palm. Shaking requires the caregiver to slightly lean on a patient’s chest and create a rocking motion. DIF: Cognitive Level: Applying REF: Text reference: p. 620 OBJ: Perform the outlined CPT maneuvers, including standard and modified versions. TOP: Percussion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. A patient who is very frail and thin with osteoporosis has just undergone abdominal surgery.
The nurse anticipates that which technique will be used to control respiratory secretions in this patient? a. Forceful coughing b. Percussion c. Vibration d. Shaking ANS: A
Thin, frail patients with osteoporosis are most susceptible to injury and are taught other secretion control measures (e.g., forceful coughing, humidification). Percussion, vibration, and shaking are contraindicated with rib fracture; fracture of other rib cage structures such as clavicle or sternum; pain; severe dyspnea; and severe osteoporosis.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Analyzing REF: Text reference: p. 615 |Text reference: p. 621 OBJ: Describe expected and unexpected outcomes of each CPT maneuver. TOP: Percussion, Shaking, and Vibration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. Percussion and vibration is ordered on a patient with retained pulmonary secretions. Which
action by the student nurse should the nursing instructor question? a. Performs percussion for 3 to 5 minutes in each position as tolerated b. Uses the wrist and elbow to create movement when performing percussion c. While the patient inhales, gently pushes down and vibrates the chest wall with the flat part of the hand d. Repeats the vibration 3 times and then instructs the patient to take a deep breath and cough while exhaling ANS: C
Vibration is performed while the patient is exhaling, not inhaling. Percussion is performed for 3 to 5 minutes in each position. When clapping, most arm movement comes from the elbow and wrist joints. Vibration is repeated 3 times and then the patient cascade coughs by taking a deep breath and doing a series of small coughs until the end of the breath. DIF: Cognitive Level: Applying REF: Text reference: p. 620 OBJ: Perform the outlined CPT maneuvers, including standard and modified versions. TOP: Percussion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. A patient has retained secretions in the right and left lower lobe superior bronchi. A nurse is
demonstrating to family memNber hoIwNtG oT peB rf. orC mOpM ercussion and vibration. Which action by URs S the nurse is appropriate? a. Positioning the patient in a chair leaning forward on a table b. Asking the patient to lie flat on the stomach with a pillow under the stomach c. Assisting the patient to the right side with the arm overhead and the feet elevated d. Asking the patient to lie on the left side with the head elevated ANS: B
Have the patient lie flat on the stomach with a pillow under the stomach. Percuss and vibrate below the scapula on either side of the spine. Sitting up and leaning forward is the position for drainage of the left and right upper lobe posterior apical branch. Having the patient lying on the right side in Trendelenburg’s position with the arm overhead facilitates drainage of the left upper lobe lingular bronchi. On the left side with the head elevated is not a correct position for any drainage procedure. DIF: Cognitive Level: Applying REF: Text reference: p. 616 OBJ: Explain how to prepare the patient and the family for the performance of each CPT maneuver. TOP: Patient Positioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 1. The nurse is teaching the family of a patient with cystic fibrosis how to use a high-frequency
chest wall oscillation (HFCWO) vest. The nurse informs the family that this device will do which of the following? (Select all that apply.) a. Allow patient to perform other tasks while receiving therapy. b. Improve patient adherence to chest physiotherapy. c. Assist in the removal of secretions from the lungs. d. Decrease the viscosity of mucus so coughing it up will be easier. ANS: A, C, D
The use of HFCWO such as the Vest airway clearance system often improves patient attitude toward chest physiotherapy Because the patient is able to perform other tasks while receiving therapy. The HFCWO therapy assists with the removal of secretions from the lungs and decreases the viscosity of mucus, making it easier to cough productively. DIF: Cognitive Level: Applying REF: Text reference: p. 614 |Text reference: p. 617 |Text reference: p. 621 OBJ: Assess the need to perform chest physiotherapy (CPT) maneuvers. TOP: Mechanical Devices KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is planning to perform postural drainage on a patient who is receiving continuous
tube feedings. What should the nurse do before performing the treatment? (Select all that apply.) a. Stop the tube feedings for 1 to 2 hours before and after postural drainage. b. Check for residual feeding in the patient’s stomach and hold treatment if greater than 100 mL. c. Give the prescribed inhaled bronchodilator 20 minutes before the procedure. d. Auscultate all lung fieldsN , aU ssResSsI vN itaG lT sigBn. s,CaO ndMdraw arterial blood gas levels (ABG). ANS: B, C
Stop all continuous gastric tube feedings for 30 to 45 minutes before postural drainage. Check for residual feeding in the patient’s stomach; if greater than 100 mL, hold treatment. If the patient is receiving inhaled bronchodilator, nebulizer, or aerosol treatment, postural drainage is performed 20 minutes after such therapy is provided. Assessing lung sounds and vital signs, but not blood gas levels, is routinely done. Instead, pulse oximetry readings can be assessed. DIF: Cognitive Level: Applying REF: Text reference: p. 617 OBJ: Determine the need to modify or discontinue CPT maneuvers, including contraindications and individual variations. TOP: Preparation for CPT KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is reviewing medical records on several patients. Which findings reported in the
chart indicate the need for postural drainage? (Select all that apply.) a. Atelectasis reported on chest x-ray b. Thick, sticky, tenacious, green secretions noted in the nurse’s notes c. Multiple rib fractures noted on chest x-ray d. Chest x-ray report indicating pneumonia with collapse of right lower lobe ANS: A, B, D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Chest x-ray film changes consistent with atelectasis, lobar collapse pneumonia, or bronchiectasis indicate a need for postural drainage. Other signs are ineffective coughing and thick, sticky, tenacious, discolored secretions that are difficult to cough up. Rib fractures are a contraindication for postural drainage. DIF: Cognitive Level: Applying REF: Text reference: p. 617 OBJ: Assess the need to perform chest physiotherapy (CPT) maneuvers. TOP: Indications for Postural Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse receives orders for postural drainage using Trendelenburg’s position. On which
patients should the nurse question the order? (Select all that apply.) a. Patient with a history of gastroesophageal reflux disease (GERD) b. Postsurgical patient with a distended abdomen c. Patient with blood pressure of 180/100 d. Patient with bronchiectasis on chest x-ray ANS: A, B, C
Trendelenburg’s position is contraindicated for uncontrolled hypertension, distended abdomen, esophageal surgery, recent gross hemoptysis, and uncontrolled airway at risk for aspiration. When patients have a risk for or history of GERD, the head-down position should not be used. Bronchiectasis is an indication for postural drainage. DIF: Cognitive Level: Applying REF: Text reference: p. 617 OBJ: Determine the need to modify or discontinue CPT maneuvers, including contraindications and individual variations. TOP: Contraindications to Trendelenburg’s Position KEY: Nursing Process Step: AN ssU esR sm ntNGMTSB C. : C NC SeI OLMEX: Physiological Integrity COMPLETION 1. The nurse positions the patient flat on the back with a small pillow under the knees to drain
the right and left
.
ANS:
anterior upper lobe bronchi The patient is positioned flat on the back with a small pillow under the knees for the right and left anterior upper lobe bronchi. DIF: Cognitive Level: Applying REF: Text reference: p. 616 OBJ: Explain how to prepare the patient and the family for the performance of each CPT maneuver. TOP: Positions for CPT KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The patient is complaining of feeling congested. After assessing the patient, the nurse places
the patient in the proper position and claps her cupped hands against the patient’s thorax. She does this because she is aware that assists in loosening retained secretions from the airway. ANS:
percussion
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Percussion involves clapping the chest wall with cupped hands. It sets up vibrations in the chest to dislodge retained secretions from the airway. DIF: Cognitive Level: Comprehension REF: Text reference: p. 620 OBJ: Assess the need to perform chest physiotherapy (CPT) maneuvers. TOP: Percussion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. To move secretions from small distal airways into larger central airways, the nurse would use
and
.
ANS:
vibration; shaking Vibration and shaking move secretions from small distal airways into larger central airways. Vibration is a fine, shaking pressure applied to the chest wall only during exhalation. Shaking is a stronger, bouncing maneuver that supplies a concurrent, compressive force to the chest wall. DIF: Cognitive Level: Comprehension REF: Text reference: p. 613 OBJ: Assess the need to perform chest physiotherapy (CPT) maneuvers. TOP: Vibration and Shaking KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4.
is positioning the patient so that the position of the lung segment to be drained allows gravity to have its greatest effect. ANS:
NURSINGTB.COM Postural drainage (PD) Postural drainage is the use of positioning techniques to drain specific segments of the lungs and bronchi into the trachea. DIF: Cognitive Level: Comprehension REF: Text reference: p. 613 OBJ: Describe expected and unexpected outcomes of each CPT maneuver. TOP: Postural Drainage (PD) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The system that lines the internal lumen of the tracheobronchial tree and consists of a thin
layer of mucus that constantly is propelled toward the larynx by cilia is called the . ANS:
mucociliary transport system In the normal lung, the mucociliary transport system clears the airways of excessive mucus and inhaled particles. This system lines the internal lumen of the entire tracheobronchial tree and consists of a thin layer of mucus that is constantly being propelled toward the larynx by cells that have hairlike projections called cilia. DIF: Cognitive Level: Comprehension REF: Text reference: p. 614 OBJ: Assess the need to perform chest physiotherapy (CPT) maneuvers. TOP: Mucociliary Transport System KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 6. The
provides positive expiratory pressure (PEP) with oral airway
oscillations. ANS:
Acapella device The Acapella is a handheld airway clearance device. It provides positive expiratory pressure (PEP) with oral airway oscillations. Positive expiratory pressure stabilizes airways and improves aeration of the distal lung areas. During exhalation, pressure from the airways is transmitted to the Acapella device, which helps mucus dislodge from the airway walls and as a result prevents airway collapse, accelerates expiratory flow, and moves mucus toward the trachea. DIF: Cognitive Level: Comprehension REF: Text reference: p. 619 OBJ: Perform the outlined CPT maneuvers, including standard and modified versions. TOP: Acapella Device KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
NURSINGTB.COM
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 25: Airway Management MULTIPLE CHOICE 1. A patient with a tracheostomy tube has thick, tenacious mucus that is difficult to remove. The
nurse should choose which technique to suction the airway? a. Normal saline instillation (NSI) before suctioning b. Dry suctioning 1 time followed by NSI with suctioning 2 more times c. Dry suctioning as long as the heart rate is above 60 beats/min d. Dry suctioning ANS: D
Normal saline instillation (NSI) into artificial airways is no longer recommended as standard practice. Clinical studies show that suctioning with or without NSI produces similar amounts of secretions and significant decreases in oxygen saturation. Potential side effects include increases in heart rate for 4 to 5 minutes after suctioning using NSI as opposed to dry suctioning. NSI has the potential to increase ventilator-associated pneumonia because bacteria from the upper airway can be dislodged to the lower airway. DIF: Cognitive Level: Applying REF: Text reference: p. 625 OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care. TOP: Normal Saline Instillation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. A patient using a nasal cannula has gurgling on inspiration. The nurse notes a productive
cough but the inability to cleN arU thReS seIcN reG tioTnB s f.roCmOtM he mouth. Which action should the nurse take first to prepare for oropharyngeal suctioning? a. Apply clean gloves and a mask. b. Insert the suction device to the back of the throat. c. Remove the patient’s nasal cannula. d. Connect the tubing to a standard suction catheter. ANS: A
Perform hand hygiene and apply clean gloves. Apply a mask or face shield if splashing is likely. Insert the device into the mouth along the gum line to the pharynx. Remove the patient’s oxygen mask, if present. A nasal cannula may remain in place. Connect one end of the connecting tubing to the suction machine and the other to a Yankauer suction catheter. DIF: Cognitive Level: Applying REF: Text reference: p. 627 OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care. TOP: Oropharyngeal Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. After oropharyngeal suctioning of a patient, the nurse notes bloody secretions in the suction
catheter and tubing. What should the nurse do next? a. Increase the suction pressure. b. Provide additional oxygen. c. Reduce the frequency of oral hygiene.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. Check the suction catheter for nicks. ANS: D
Observe the catheter tip for nicks, which can cause mucosal trauma. The nurse should assess the oral cavity for trauma or lesions, reduce the amount of suction pressure used, provide supplemental oxygen only if respiratory distress occurs, and increase the frequency of oral hygiene. DIF: Cognitive Level: Applying REF: Text reference: p. 628 OBJ: Describe the nursing interventions for airway management. TOP: Oropharyngeal Suctioning KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 4. The nurse is caring for an infant who has been vomiting and is having difficulty breathing.
What actions by the nurse are appropriate for suctioning the infant? a. Place the infant in a supine position. b. Suction only when a large amount of mucus is present. c. Suction for only 30 seconds. d. Compress the bulb syringe after it is placed in the nostril. ANS: A
Position infants with breathing problems or excessive vomitus in a supine or side-lying position. Airways of infants and children are smaller than those of an adult; even small amounts of mucus can cause airway obstruction. Suction should be completed for only 5 seconds with 30 to 60 seconds in between for the patient to reoxygenate. Compress the bulb syringe before insertion to prevent forcing secretions into the infant’s bronchi. DIF: Cognitive Level: ApplyiN ng R I GREB F: TextMreference: p. 629 U S for N airway T .C O OBJ: Describe the nursing interventions management. TOP: Pediatric Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. A patient on mechanical ventilation with an endotracheal tube requires suctioning. A closed
in-line catheter is in place. Which action by the nurse is appropriate? a. Use manual ventilation to hyperoxygenate the patient with 100% oxygen via Ambu bag. b. Push the catheter and slide the plastic sleeve back when the patient exhales. c. Push the catheter in until resistance is felt or the patient coughs. d. Apply suction for no longer than 30 seconds as you remove the catheter. ANS: C
The catheter is pushed in while the plastic sleeve is slid back between the thumb and forefinger until resistance is felt or the patient coughs. Hyperoxygenation is done by adjusting the FiO2 setting on the ventilator. Manual ventilation is not recommended. The catheter is pushed in when the patient inhales. Suction is applied for no longer than 15 seconds. DIF: Cognitive Level: Applying REF: Text reference: p. 635 |Text reference: p. 638 OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care. TOP: Closed (In-line) Suction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 6. The nurse is assessing several patients who have returned from surgery. Which finding most
likely indicates a need for suctioning? a. Complaint of pain when breathing b. Cough producing thick yellow mucus c. Oxygen saturation level of 88% d. Drowsiness and respiratory rate of 8 ANS: C
When a patient’s oxygen saturation falls below 90%, this is a good indicator of the need for suctioning. Pain with breathing is probably related to the surgery. If a cough is productive, suctioning is not necessary. Drowsiness and a decreased respiratory rate may be due to administration of pain medications such as opioids. DIF: Cognitive Level: Applying REF: Text reference: p. 629 OBJ: Discuss the indications for airway suctioning. TOP: Indications for Suctioning KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. A patient with head trauma following a motor vehicle accident is on mechanical ventilation
with an endotracheal tube. Which action by the nurse will reduce the risk for elevations in intracranial pressure during suctioning? a. Avoid hyperoxygenating the patient before suctioning. b. Insert the suction catheter just to the end of the endotracheal tube. c. Apply suction while inserting the catheter. d. Limit suctioning to 2 times with each suctioning procedure. ANS: D
Suctioning can cause elevations in intracranial pressure in patients with head injury. To reduce the risk, the nurse shoN uld xyg en. atC eO thM e patient before suctioning and should URhyp SIero NG TB suction only twice with each suctioning procedure. The catheter is inserted past the end of the endotracheal tube until resistance is met to adequately remove secretions from the airway. Suction should be applied while the catheter is removed. DIF: Cognitive Level: Applying REF: Text reference: p. 625 |Text reference: p. 635 OBJ: Describe the nursing interventions for airway management. TOP: Increased Intracranial Pressure With Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The student nurse is preparing to perform nasotracheal suctioning on an adult patient wearing
a face mask. Which action by the student should the nursing instructor question? a. Increasing the oxygen flow rate for the face mask and asking the patient to deep-breathe slowly before suctioning b. Inserting the catheter into the nares slanting slightly downward c. Asking the patient to swallow while the catheter is being inserted d. Inserting the catheter about 8 inches without applying suction ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The suction catheter should not be inserted during swallowing because it will most likely enter the esophagus. Insert during inhalation because the epiglottis is open. The patient should be hyperoxygenated before suctioning. The oxygen flow rate can be increased on the face mask, and the patient can deep-breathe slowly to accomplish this. The catheter should be inserted along the natural course of the nares—slightly slanted downward. In adults, the catheter is inserted about 20 cm or 8 inches. DIF: Cognitive Level: Applying REF: Text reference: p. 633 OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care. TOP: Nasotracheal Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse is providing nasotracheal suctioning for a 13-year-old patient with secretions in the
throat and trachea. Which action by the nurse demonstrates proper technique? a. Applying sterile petroleum jelly to the distal tip of the suction catheter b. Applying clean gloves to both hands c. Inserting the suction catheter 6 to 8 inches during inspiration d. Suctioning the pharynx first and then the trachea ANS: C
In older children, the suction catheter is inserted about 16 to 20 cm or 6 to 8 inches. The catheter is always inserted during inspiration. The catheter should be lubricated with water-soluble lubricant to avoid lipid aspiration pneumonia from a petroleum-based gel. The procedure requires sterile gloves, at least on one hand. The trachea should be suctioned before the pharynx because the mouth and the pharynx contain more bacteria than the trachea. DIF: Cognitive Level: ApplyiN ngURSINGRT EB F:.C TeO xtMreference: p. 634 OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care. TOP: Nasotracheal Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse is performing nasotracheal suctioning for a patient. Which action by the nurse is
appropriate? a. Applying intermittent suctioning while slowly withdrawing the suction catheter b. Carefully pushing the suction catheter in and out while applying suction c. Applying suction for 15 seconds or less d. Asking the patient to deep-breathe for 15 seconds before passing the catheter a second time ANS: C
Suction should be applied for 15 seconds or less to avoid cardiopulmonary compromise from hypoxemia or vagal overload. Continuous suction and back and forth rotation of the catheter are now recommended because studies show that tracheal damage from intermittent and continuous suctioning was similar. The catheter should be rotated back and forth, not pushed in and out. At least 1 minute should be allowed between suction passes for ventilation and oxygenation. DIF: Cognitive Level: Applying REF: Text reference: p. 634 OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care. TOP: Nasotracheal Suctioning
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The nurse is performing nasotracheal suctioning on a patient. The nurse should discontinue
the suctioning if which of the following occurs? a. The patient coughs as the catheter is inserted. b. The heart rate decreases from 84 beats per minute to 60 beats per minute. c. An increase in pulse occurs from 74 beats per minute to 94 beats per minute. d. Oxygen saturation levels decrease from 97% to 94%. ANS: B
If the patient’s pulse drops by more than 20 beats per minute, suctioning should be discontinued. The patient should cough, and this is expected. If the patient’s pulse increases by more than 40 beats per minute or pulse oximetry falls below 90% or 5% from baseline, suctioning should be discontinued. DIF: Cognitive Level: Analyzing REF: Text reference: p. 634 OBJ: Identify guidelines for managing a patient’s airway. TOP: Discontinuation of Suction KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 12. The nurse is suctioning a patient with an endotracheal tube. Which action should the nurse
take when the patient develops respiratory distress? a. Quickly remove the catheter and carefully reinsert it. b. Continue to apply intermittent suction to remove thick secretions. c. Administer oxygen directly through the suction catheter. d. Withdraw the catheter and encourage the patient to cough and deep-breathe. ANS: C
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If the patient develops respiratory distress during suctioning, the catheter should be immediately withdrawn and supplemental oxygen and breaths supplied as needed. In an emergency, disconnect suction and attach oxygen at the prescribed flow rate through the catheter. DIF: Cognitive Level: Applying REF: Text reference: p. 635 OBJ: Describe the nursing interventions for airway management. TOP: Respiratory Distress While Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. The nurse has completed suctioning a patient’s airway. Which action should the nurse take
first? a. Reduce the suction level to medium. b. Remove the face shield and save for future suctioning. c. Reposition the patient and assist with oral hygiene using sterile gloves. d. Pull the gloves off over the rolled catheter and discard. ANS: D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank When suctioning is completed, disconnect the catheter from the connecting tubing. Roll the catheter around the fingers of the dominant hand. Pull the glove off inside out so that the catheter remains coiled in the glove. Pull off the other glove over the first glove in the same way. Discard in an appropriate receptacle. The suction device should be turned off when suctioning is complete. There is no further need for suction. Remove the face shield and discard into an appropriate receptacle. Apply clean gloves to give personal care. DIF: Cognitive Level: Applying REF: Text reference: p. 636 OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care. TOP: Completing Airway Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse is preparing to suction an infant with a tracheostomy tube. Which action by the
nurse follows appropriate procedure? a. Using a suction catheter that is half the diameter of the tracheostomy tube b. Suctioning 0.2 to 0.5 inches beyond the tip of the tracheostomy tube c. Hyperoxygenating with 90% oxygen to avoid oxygen toxicity d. Using less than 150 mm Hg negative pressure ANS: A
Suction catheters for pediatrics should be half the diameter of the child’s tracheostomy tube. The distance suctioned should be no greater than 0.5 cm (0.2 inches) beyond the tip of the artificial airway. To determine distance, the catheter is placed near a sample artificial airway. Hyperoxygenate with 100% oxygen in pediatric patients. Negative pressure for suctioning should not exceed 100 mm Hg. DIF: Cognitive Level: ApplyiN ngURSINGRT EB F:.C TeO xtMreference: p. 637 OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care. TOP: Pediatric Considerations for Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. A patient has been on mechanical ventilation with an endotracheal tube for 1 week. Which
intervention by the nurse will help prevent ventilator-associated pneumonia (VAP)? a. Providing oral care with a toothbrush at least twice daily b. Changing the ventilator circuits at least every 72 hours c. Removing subglottal secretions before every position change d. Maintaining endotracheal cuff pressures at 10 cm H2O ANS: C
Subglottal secretions should be removed every 4 to 6 hours or before position changes. Oral care should be provided with a chlorhexidine swab or toothbrush (if chlorhexidine is contraindicated) every 8 hours. The ventilator circuits should be changed every 48 hours because of potential bacteria within the tubing condensation. The endotracheal cuff pressures should be maintained at 20 cm H2O to decrease movement of secretions into the lower airways. DIF: Cognitive Level: Applying REF: Text reference: p. 639 OBJ: Describe the nursing interventions for airway management. TOP: Ventilator-Associated Pneumonia (VAP) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
16. The nurse is caring for a patient with an oral endotracheal tube in place. Which intervention
by the nurse demonstrates proper procedure when providing endotracheal tube care? a. Determining proper endotracheal tube depth by noting the length of tube beyond the gum line b. Instructing the assistant to hold the tube away from the lips while changing the tape c. Removing the oral airway if the patient is actively biting down after the tape is removed from the endotracheal tube d. Repositioning the tube on the opposite side or at the center of the mouth at least every 24 to 48 hours ANS: D
The endotracheal tube should be repositioned to the opposite side or at the center of the mouth every 24 to 48 hours to prevent formation of pressure sores at the sides of the mouth. The proper depth of the endotracheal tube is determined by noting the centimeter mark at the lip or gum line. This line is marked on the tube and is recorded in the patient’s record at the time of intubation. The tube should not be held away from the lips because this allows too much “play” in the tube and increases the risk for tube movement and accidental extubation. The oral airway should not be removed if the patient is actively biting down until tape partially or completely secures the tube. DIF: Cognitive Level: Applying REF: Text reference: p. 641 OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care. TOP: Endotracheal Tube Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
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17. The nurse is assessing a patient who is intubated and on a ventilator. When listening above the
sternal notch with a stethoscope, the nurse notes a minimal amount of air leak at the end of inspiration. Which action by the nurse is appropriate? a. Remove all air from the cuff and reinflate the cuff until no air leak is present. b. Note that the cuff is properly inflated. c. Notify the health care provider. d. Suction the patient. ANS: B
The cuff should be inflated to minimal leak. If the air leak is audible with the ear, it is too large. A properly inflated cuff should have a minimal air leak that is heard only with a stethoscope. The air should not be removed, the health care provider does not need to be notified, and the patient does not need to be suctioned because the cuff is properly inflated. DIF: Cognitive Level: Applying REF: Text reference: p. 652 OBJ: Correctly inflate a cuff on an endotracheal or tracheostomy tube. TOP: Checking Air Leak KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 18. The student nurse is providing tracheostomy care to a patient who has intratracheal secretions
and a damp tracheostomy dressing and ties. Which action by the student should the nursing instructor question? a. Suctioning the tracheostomy tube before removing the soiled tracheostomy
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank dressing b. Assisting the patient to semi-Fowler’s position c. Placing new tracheostomy ties before cutting the old ties d. Cutting gauze pads to place around the tracheostomy tube ANS: D
Do not use scissors to cut gauze pads as they may shed fibers that could be inhaled by the patient. Use a manufactured pad with a slit. Suctioning the tube removes secretions to avoid occluding the outer cannula while the inner cannula is removed. Usually a supine or semi-Fowler’s position is used to promote patient comfort and prevent muscle strain for the nurse. If changing ties without an assistant, the old ties are not cut until the new ties are securely in place. DIF: Cognitive Level: Applying REF: Text reference: p. 648 OBJ: Discuss the indications for tracheostomy care. TOP: Tracheostomy Tube Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The nurse is providing care to a patient with a tracheostomy tube that has an inner cannula.
Which intervention by the nurse follows proper procedure for tracheostomy tube care? a. Carefully removes the inner cannula and places it in a basin of 1:10 bleach solution b. Scrubs the inner cannula on the inside and outside with a 1:10 bleach solution c. After scrubbing the inner cannula, rinses it with normal saline d. Uses a wet 4 4 gauze and cleans the inside of the outer cannula ANS: C
After the inner cannula is thoroughly cleaned, it is rinsed with normal saline. The inner cannula is removed and is plaNcedRin I a baG sin B of.nC ormMal saline to loosen secretions. It is U S N T O scrubbed and then rinsed with normal saline. The outer cannula is not cleaned on the inside. The exposed outer cannula surfaces at the stoma are dried with a 4 4 gauze to prevent a moist environment and prohibit microorganism growth and skin excoriation. DIF: Cognitive Level: Applying REF: Text reference: p. 647 OBJ: Change a tracheostomy tube or inner cannula. TOP: Tracheostomy Tube Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. A patient with a tracheostomy tube is accidentally extubated. What should the nurse do
immediately? a. Call the health care provider. b. Mechanically ventilate the patient. c. Insert a new tracheostomy tube. d. Hold the stoma open with the fingertips. ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Replace the old tracheostomy tube with a new tube. Some experienced nurses or respiratory therapists may be able to quickly reinsert the tracheostomy tube. A spare tracheostomy tube of the same size and kind should be kept at the bedside in the event of emergency replacement. Notify the health care provider after reestablishing the airway. Be prepared to manually ventilate the patient with an Ambu bag if respiratory distress develops until the tracheostomy is replaced. An endotracheal tube of the same size can be inserted in the stoma in an emergency. DIF: Cognitive Level: Applying REF: Text reference: p. 650 OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care. TOP: Accidental Decannulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. When assessing a patient’s tracheostomy site, the nurse notes redness and inflammation
around the stoma. Which intervention can the nurse provide to address this problem? a. Decrease the frequency of tracheostomy care. b. Apply a dry gauze dressing just under the stoma. c. Remove the ties at frequent intervals. d. Apply a topical antibacterial solution and allow it to dry. ANS: D
Apply a topical antibacterial solution and allow it to dry. Increase the frequency of tracheostomy care. Apply a hydrocolloid or transparent dressing just under the stoma to protect the skin from breakdown. Consult with a skin care specialist. Adjust the ties or apply new ones when the ties are loose or tight. Never remove the ties. DIF: Cognitive Level: ApplyiN ngURSINGRT EB F:.C TeO xtMreference: p. 650 OBJ: Describe the nursing interventions for airway management. TOP: Stomal Inflammation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The nurse is assessing a patient with an endotracheal tube on mechanical ventilation. Which
assessment finding indicates a partially deflated cuff? a. Increased exhaled tidal volume b. Spasmodic coughing c. Tense test balloon on the endotracheal tube d. Vocalizations by the patient ANS: D
A partially deflated cuff allows secretions to enter the trachea and permits vocalization. Other signs of an underinflated cuff are decreased exhaled tidal volume, a flaccid test balloon on the tube, and gurgling on expiration. An overinflated cuff can cause spasmodic coughing and a tense test balloon on the tube. DIF: Cognitive Level: Analyzing REF: Text reference: p. 651 OBJ: Correctly inflate a cuff on an endotracheal or tracheostomy tube. TOP: Underinflated Cuff KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 23. The nurse is assessing a patient with an endotracheal tube and notes an audible air leak when
standing by the patient. Which intervention should the nurse perform first to address this problem? a. Deflating the cuff of the endotracheal tube b. Repositioning the patient or tube c. Inserting a new endotracheal tube d. Notifying the health care provider ANS: B
If an air leak is audible with the ear, it is too large. Repositioning the patient or the tube may correct the problem. Reinflation of the cuff may be necessary. Prepare for insertion of a new tube by the health care provider or trained personnel if the cuff ruptures. Repositioning and reinflating the cuff are performed before the health care provider is notified. DIF: Cognitive Level: Analyzing REF: Text reference: p. 652 OBJ: Correctly inflate a cuff on an endotracheal or tracheostomy tube. TOP: Air Leak KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is assessing the risk for aspiration of gastric contents into the lungs resulting in
airway obstruction. The nurse identifies patients with which conditions as having increased risk? (Select all that apply.) a. Presence of a gastrostomy feeding tube b. History of smoking 2 packs per day for 30 years c. Head injury with a decreaNsedRlevI U S elNoGf co TBns.ciCous OMness d. Stroke with dysphagia ANS: A, C, D
Conditions that increase the patient’s risk for aspiration include enteral feeding tubes or other nasal or oral gastric tubes, a decreased level of consciousness, and a decreased swallowing ability. DIF: Cognitive Level: Applying REF: Text reference: p. 625 |Text reference: p. 651 OBJ: Identify guidelines for managing a patient’s airway. TOP: Risk for Aspiration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. A patient with increased secretions may develop airway obstruction. The nurse can promote a
patent airway by using which of the following techniques? (Select all that apply.) a. Limiting fluid intake b. Positioning c. Deep breathing d. Humidity ANS: B, C, D
Hydration, positioning, deep breathing, and humidity are techniques that are helpful in maintaining a patent airway. DIF: Cognitive Level: Applying REF: Text reference: p. 624 OBJ: Describe the nursing interventions for airway management.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Airway Management MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step: Implementation
3. The nurse performing nasotracheal suctioning should be assessing the patient for which
possible unexpected outcomes? (Select all that apply.) a. Severe reduction in heart rate b. Wheezing and inability to breathe c. Reduction in oxygen saturation d. Nasal bleeding ANS: A, B, C, D
Nasotracheal suctioning has many risks associated with it. The most serious relate to hypoxemia, which often results in cardiac dysrhythmias, laryngeal spasm, and bradycardia (due to stimulation of the vagus nerve). Nasal trauma and bleeding can develop as the result of trauma from the suction catheter. DIF: Cognitive Level: Applying REF: Text reference: p. 637 OBJ: Describe the nursing interventions for airway management. TOP: Risks of Nasotracheal Suctioning KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is providing care to a patient on mechanical ventilation with an endotracheal tube.
The nurse carefully inflates the cuff of the endotracheal tube using the minimal leak method, knowing that a properly inflated cuff provides which benefits to the patient? (Select all that apply.) a. Prevents aspiration of gastric contents b. Promotes accumulation of secretions below the epiglottis c. Prevents air from escapinN gU beRtw nG thT eB tu. beCaO ndMthe tracheal wall SeIeN d. Promotes lung inflation for mechanical ventilation ANS: A, C, D
A cuff on an endotracheal tube prevents the escape of air between the tube and the walls of the trachea and reduces aspiration when a patient is receiving mechanical ventilation. The goals of correctly inflating the cuff on an artificial airway are to promote lung inflation for mechanical ventilation, prevent aspiration of gastric contents, and at the same time allow drainage of secretions that accumulate between the epiglottis and the cuff. DIF: Cognitive Level: Understanding REF: Text reference: p. 650 OBJ: Correctly inflate a cuff on an endotracheal or tracheostomy tube. TOP: Endotracheal (ET) Tube Cuffs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a patient who has a tracheostomy. To prevent the patient from
developing an airway obstruction, the nurse assesses which of the following? (Select all that apply.) a. Patient’s nutritional status b. Environmental humidity c. Existing respiratory infection d. Patient’s ability to cough ANS: A, B, C, D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The patient’s hydration and nutritional status, humidity delivered to the tracheostomy tube, the status of an existing infection, and the ability to cough are all factors that affect the amount and consistency of secretions in the tracheostomy tube and the patient’s ability to clear the airway. DIF: Cognitive Level: Understanding REF: Text reference: p. 646 OBJ: Discuss the indications for tracheostomy care. TOP: Preventing Airway Obstruction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. A nurse is preparing to suction a patient via the nasotracheal route. Which conditions should
the nurse recognize as contraindications to nasotracheal suctioning? (Select all that apply.) a. Motor vehicle accident with acute head injuries b. History of hemophilia c. Epiglottitis or croup d. Environmental allergies with sinus drainage ANS: A, B, C
Contraindications to nasotracheal suctioning include facial or neck trauma/surgery, acute head injuries, bleeding disorders, nasal bleeding, epiglottitis or croup, laryngospasm, irritable airway, and gastric surgery. These conditions are contraindications because the passage of a catheter through the nasal route causes additional trauma, increases nasal bleeding, or causes severe bleeding in the presence of bleeding disorders. In the presence of epiglottitis, croup, laryngospasm, or irritable airway, the entrance of a suction catheter via the nasal route causes intractable coughing, hypoxemia, and severe bronchospasm; this may necessitate emergency intubation or tracheostomy. Allergies with sinus drainage will increase the volume of secretions in the pharynx and may require suctioning.
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DIF: Cognitive Level: Applying REF: Text reference: p. 631 OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care. TOP: Contraindications to Nasotracheal Suctioning KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse is caring for a patient on mechanical ventilation with an endotracheal tube. Which
nursing interventions will help prevent ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Changing the patient’s position every 2 hours b. Keeping the head of the bed elevated 30 to 45 degrees c. Providing oral care with a toothette every 8 hours d. Keeping the head flat during and for 30 minutes after enteral feedings ANS: A, B
Best practice guidelines indicate that the following interventions are advantageous in preventing VAP: elevating the head of the bed at 30 to 45 degrees to prevent aspiration, changing patient position every 2 hours to decrease risk for atelectasis and pulmonary infection, providing oral care with a toothbrush every 8 hours to remove dental plaque organisms (toothettes are not adequate to clean dental plaque, but they may be used between brushings for comfort), maintaining the endotracheal cuff pressures at 20 cm H2O to decrease movement of secretions to the lower airways, and carefully monitoring the patient for aspiration when enteral feedings are infusing.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Applying REF: Text reference: p. 639 OBJ: Describe the nursing interventions for airway management. TOP: Ventilator-Associated Pneumonia (VAP) Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse is evaluating a patient to determine whether the endotracheal tube cuff is properly
inflated. Which findings indicate proper inflation? (Select all that apply.) a. Exhaled tidal volume is 50 mL less than the tidal volume set on the ventilator. b. Air leak is heard with a stethoscope only at the end of inspiration. c. The patient is able to vocalize. d. Gastric contents are noted in airway secretions. ANS: A, B
The exhaled tidal volume from mechanical ventilation should not be less than 50 mL of the delivered tidal volume to ensure appropriate ventilation of the lungs. The air leak should be audible only with a stethoscope at the end of inspiration. Excessive phonation and gastric secretions in the airway indicate a partially deflated cuff. DIF: Cognitive Level: Applying REF: Text reference: pp. 652-653 OBJ: Correctly inflate a cuff on an endotracheal or tracheostomy tube. TOP: Inflating the Cuff on an Artificial Airway KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity COMPLETION 1. Too much oxygen reduces the drive to breathe in patients with chronic ANS:
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.
hypercapnia Too much oxygen reduces the drive to breathe in patients with chronic hypercapnia (elevated arterial carbon dioxide tension). DIF: Cognitive Level: Understanding REF: Text reference: p. 625 OBJ: Identify guidelines for managing a patient’s airway. TOP: Hypercapnia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. A patient has extremely copious and thick oral secretions. The nurse provides oropharyngeal
suctioning using a
suction device.
ANS:
Yankauer or tonsillar tip A Yankauer, or tonsillar tip, suction device is used for oropharyngeal suctioning. This catheter is used instead of a standard suction catheter when oral secretions are extremely copious and thick, because it can handle large volumes of secretions better than a standard suction catheter can. The Yankauer suction catheter is angled to facilitate removal of secretions through a patient’s mouth. DIF: Cognitive Level: Applying REF: Text reference: p. 626 OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care. TOP: Yankauer Suction
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
3. A plastic or rubber tube that is inserted through the nares or mouth past the epiglottis and
vocal cords to maintain an airway is known as an
.
ANS:
endotracheal (ET) tube An ET tube is inserted through the nares (nasal ET tube) or the mouth (oral ET tube) past the epiglottis and vocal cords, into the trachea. ET tubes usually are made of plastic or rubber. DIF: Cognitive Level: Understanding REF: Text reference: p. 629 OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care. TOP: Endotracheal (ET) Tubes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. A
is inserted directly into the trachea through a small incision made in the
patient’s neck. ANS:
tracheostomy tube A tracheostomy tube is inserted directly into the trachea through a small incision made in the patient’s neck. DIF: Cognitive Level: Knowledge REF: Text reference: p. 630 OBJ: Correctly perform oropharyngeal suctioning, tracheal suctioning, endotracheal care, and tracheostomy tube care. TOP: Tracheostomy Tube KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 26: Closed Chest Drainage Systems MULTIPLE CHOICE 1. The nurse is caring for a patient who is comatose and on a ventilator. When she enters the
room, she notices that the patient’s trachea has shifted toward the left side of the patient’s neck, and he has become tachycardic. She assesses the patient’s blood pressure and notes that it is 84/38. The nurse calls for help, having recognized that the patient has developed which of the following conditions? a. Hemothorax b. Pneumothorax on the left side c. Pneumothorax on the right side d. Myocardial infarction ANS: C
A tension pneumothorax occurs from rupture in the pleura when air accumulates in the pleural space more rapidly than it is removed. If left untreated, the lung on the affected side collapses, and the mediastinum and the trachea shift to the opposite (unaffected) side. The patient has sudden chest pain, a fall in blood pressure, and tachycardia, and cardiopulmonary arrest can occur. Patients with chest trauma, fractured ribs, and invasive thoracic bedside procedures (such as insertion of central lines) and those on high-pressure mechanical ventilation are at risk for tension pneumothorax. A hemothorax is a collapse of the lung caused by an accumulation of blood and fluid in the pleural cavity between the chest wall and the lung, usually as a result of trauma. Nothing in this scenario would suggest myocardial infarction. F:.TexC tMreference: p. 656 I GREB OBJ: List three conditions requiU ringS cheN st tuT be insertO ion. TOP: Pneumothorax DIF:
Cognitive Level: SyntheN sis R
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. For a patient with a pneumothorax, where does the nurse anticipate that the chest tube will be
located? a. Second to third intercostal space (apical), anterior b. Fifth to sixth intercostal space, posterior c. Fifth to sixth intercostal space, lateral d. Mediastinal area ANS: A
Apical (second or third intercostal space) and anterior chest tube placement promotes removal of air, which is necessary in the case of a pneumothorax. Chest tubes are placed low (usually in the fifth or sixth intercostal space) and posterior or lateral to drain fluid. A mediastinal chest tube is placed in the mediastinum, just below the sternum. This tube drains blood or fluid, preventing its accumulation around the heart. A mediastinal tube commonly is used after open heart surgery. DIF: Cognitive Level: Analysis REF: Text reference: p. 656 OBJ: List three common sites for chest tube placement. TOP: Chest Tube Position KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The patient’s chest tube is attached to a one-way flutter valve that allows air to escape the
chest cavity and prevents air from reentering. How does the nurse document this finding?
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
Heimlich chest drain valve Pneumovax Water seal Pleurovac
ANS: A
The device described is a Heimlich chest drain valve. Pneumovax is a pneumococcal vaccine that is effective against 23 common strains of Pneumococcus. A Pleurovac is the brand name of a water-seal set. DIF: Cognitive Level: Knowledge REF: Text reference: p. 657 OBJ: Define the key terms used in the care of patients with chest tubes. TOP: Type of Chest Tube KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is caring for a patient who has a chest tube connected to a water seal. The patient is
not on a ventilator. Which of the following would the nurse consider normal? a. The fluid level in the water seal rises with inspiration. b. The fluid level in the water seal falls with inspiration. c. Constant bubbling occurs in the water seal. d. The fluid level in the water seal falls with expiration 3 days after insertion. ANS: A
Observe the water seal for intermittent bubbling from its U tube or for a rise and fall of fluid that is synchronous with respirations. (For example, in a nonmechanically ventilated patient, the fluid rises during inspiration, and the fluid level falls during expiration. When a patient is on a mechanical ventilator, the opposite occurs.) In a nonmechanically ventilated patient, the fluid rises during inspiration,Nand URthe SIflu NGidTleBv.elCfall OMs during expiration. Constant bubbling in the water seal or a sudden, unexpected stoppage of water-seal activity is considered abnormal and requires immediate attention. After 2 to 3 days, tidaling or bubbling on expiration is expected to stop, indicating that the lung has reexpanded. DIF: Cognitive Level: Analysis REF: Text reference: p. 658 OBJ: Discuss the nursing principles involved in caring for patients with chest tubes. TOP: Water-Seal Tidaling KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a patient with a chest tube that was inserted 4 days earlier. She notices
that the drainage contains a large amount of pus. What does the presence of the pus indicate? a. Malignancy b. Pulmonary infarction c. Empyema d. Hemothorax ANS: C
Pus indicates an empyema, which is a collection of pus in the pleural cavity, and the drainage is pus colored. Blood-tinged fluid usually indicates malignancy, pulmonary infarction, or severe inflammation. Frank blood indicates a hemothorax. DIF: Cognitive Level: Knowledge REF: Text reference: p. 658 OBJ: Discuss the nursing principles involved in caring for patients with chest tubes. TOP: Pleural Drainage KEY: Nursing Process Step: Assessment
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity 6. What is indicated by continuous bubbling in the water-seal chamber with no bubbles noted in
the suction control chamber of the drainage system? a. A leak in the system b. Normal functioning c. A drainage obstruction d. Insufficient suction pressure ANS: A
Continuous bubbling in the water-seal chamber with an absence of bubbles in the suction control chamber indicates that there is a leak in the system. Normal functioning is indicated by gentle, continuous bubbling in the suction chamber and occasional bubbling in the water seal, with fluctuations on inspiration and expiration. Constant bubbling in the water seal or a sudden, unexpected stoppage of water-seal activity is considered abnormal and requires immediate attention. Insufficient suction pressure has little to no bubbling in the suction chamber. DIF: Cognitive Level: Analysis REF: Text reference: p. 659 OBJ: Describe methods of troubleshooting chest tube systems. TOP: Bubbling in Suction Control Chamber KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. What condition is indicated when a patient with a chest tube experiences sharp, stabbing chest
pain without a change in pulse or blood pressure? a. Pneumonitis b. Tube displacement c. A myocardial infarction NURSINGTB.COM d. A tension pneumothorax ANS: D
Sharp, stabbing chest pain with or without decreased blood pressure and increased heart rate may indicate a tension pneumothorax. A chest tube is not an expected treatment for pneumonitis. Tube displacement is an unexpected outcome and can lead to increased pneumothorax. Immediately apply pressure over the chest tube insertion site. Myocardial infarction pain is expressed as “crushing” or “pressure” over the sternal area. DIF: Cognitive Level: Analysis REF: Text reference: p. 662 OBJ: Describe methods of troubleshooting chest tube systems. TOP: Tension Pneumothorax KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 8. Which of the following is an expected outcome of chest tube insertion? a. Mild chest pain is maintained. b. Breath sounds are auscultated in all lobes. c. Drainage from the pleural cavity increases over time. d. Lung expansion is increased beyond the unaffected side. ANS: B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank When breath sounds are auscultated in all lobes, lung expansion is symmetrical, oxygen saturation (SaO2) is stable or improved, and respirations are nonlabored. Chest pain is not an expected outcome. Treatment is effective when the patient reports no chest pain. Drainage from the pleural cavity decreases over time with reexpansion of the lung. Lung expansion would be equal to preinjury status. DIF: Cognitive Level: Knowledge REF: Text reference: p. 663 OBJ: Describe methods of troubleshooting chest tube systems. TOP: Expected Outcomes of Chest Tube Insertion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. What should the nurse do to establish a two-chamber waterless chest tube system? a. Add sterile water to the suction chamber b. Add sterile solution to the water seal c. Set the float ball to the correct drainage pressure d. Connect directly to the chest tube and add nothing ANS: D
The waterless two-chamber system is ready for connecting to the patient’s chest tube after the wrappers have been opened. The waterless system’s principles are similar to those of the water-seal system, except that fluid is not required for setup. Because water is not used, accidentally tipping over the system does not compromise the patient’s condition. The suction chamber does not depend on water. Instead, it contains a float ball, which is set by a suction control dial after the suction source is turned on. DIF: Cognitive Level: Application REF: Text reference: p. 660 OBJ: Describe closed chest drainage systems: water-seal and waterless systems. TOP: Two-Chamber WaterlesN s Ch ste. mC OM URestSTIube NGSy TB KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. Which of the following represents appropriate technique when providing care for a patient
with chest tubes? a. Applying an occlusive dressing over the site b. “Stripping” the tube on a regular basis c. Assessing the patient hourly after insertion d. Keeping excess loops of tubing from hanging over the side of the bed ANS: D
Lay excess tubing horizontally on the mattress next to the patient. Secure with a rubber band and safety pin or with the system’s clamp. This prevents excess tubing from hanging over the edge of the mattress in a dependent loop. Drainage could collect in the loop and occlude the drainage system. Physician responsibility in chest tube placement includes covering the insertion site with sterile petroleum gauze, 4 4-inch gauze, and a large dressing to form an occlusive dressing supported with an elastic bandage. Strip or milk the chest tube only if indicated (this means compressing the tube to encourage clots to press through the tube). Stripping may cause complications because it creates excessive negative intrapleural pressure. Check agency policy. Monitor vital signs, SaO2, and the insertion site every 15 minutes for the first 2 hours. DIF: Cognitive Level: Application
REF: Text reference: p. 658
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Discuss the nursing principles involved in caring for patients with chest tubes. TOP: Providing Care to the Patient Who Has a Chest Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. Which of the following is the correct positioning for a patient after a chest tube has been
inserted for a hemothorax? a. Supine b. Side-lying c. Semi-Fowler’s d. High-Fowler’s ANS: D
After the tube is placed, assist the patient to a comfortable position. Supine does not facilitate drainage or removal of air or fluid, and side-lying does not facilitate lung expansion. The high-Fowler’s position is used to evacuate air (pneumothorax). DIF: Cognitive Level: Application REF: Text reference: p. 665 OBJ: Discuss the nursing principles involved in caring for patients with chest tubes. TOP: Positioning the Patient Who Has a Chest Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. What is the expected amount of drainage for an adult patient with a mediastinal chest tube? a. Less than 100 mL/hr during the immediate postoperative period b. Less than 10 mL/hr during the immediate postoperative period c. 1000 mL/hr during the first 24-hour period d. 200 mL/hr during the firsN t 24R -hoI ur pG erioB d .C M
U S N T
O
ANS: A
In the adult, less than 50 to 200 mL/hr is drained immediately after surgery in a mediastinal chest tube. No standard is known for 10 mL/hr in the immediate postoperative period. Expected drainage in the adult with a mediastinal chest tube is approximately 500 mL in the first 24 hours. DIF: Cognitive Level: Comprehension REF: Text reference: p. 666 OBJ: Discuss the nursing principles involved in caring for patients with chest tubes. TOP: Postoperative Drainage From a Mediastinal Chest Tube KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. What is the expected amount of drainage for an adult patient with a posterior chest tube? a. 100 to 300 mL during the first 3 hours b. 10 to 50 mL during the first 2 hours c. 200 mL during the first 24 hours d. 400 to 500 mL during the first 24 hours ANS: A
In the adult, between 100 and 300 mL of fluid may drain from a posterior tube during the first 3 hours after insertion. The 24-hour rate is 500 to 1000 mL. DIF: Cognitive Level: Comprehension REF: Text reference: p. 666 OBJ: Discuss the nursing principles involved in caring for patients with chest tubes.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Drainage from a Pleural Chest Tube KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. A nurse determines that there may be a leak in the chest tube system. Clamps are applied near
the patient’s chest, and the nurse finds that the bubbling stops. What should the nurse do next? a. Change the tubing. b. Change the drainage container. c. Move the clamps farther down the chest tube. d. Reinforce the dressing and notify the physician. ANS: D
Assess for the location of the air leak by clamping the chest tube close to the chest wall with two shodded hemostats. If the bubbling stops, the leak is inside the thorax or insertion site. Unclamp the tube, reinforce the dressing, and notify the physician immediately. If bubbling continues with the clamps near the chest wall, gradually move one clamp at a time down the tubing toward the patient. If bubbling stops, replace the tubing or secure the connections. If bubbling continues, replace the drainage system. DIF: Cognitive Level: Application REF: Text reference: p. 667 OBJ: Discuss the nursing principles involved in caring for patients with chest tubes. TOP: Detecting Air Leak in a Chest Tube System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. During assessment of a patient, the chest tube becomes dislodged. What should the nurse do
first? a. Have an assistant apply an occlusive gauze dressing and tape on all four sides. b. Clamp the chest tube. NURSINGTB.COM c. Attempt to gently reinsert the tube. d. Apply pressure over the insertion site. ANS: D
If the chest tube becomes dislodged, immediately apply pressure over the chest tube insertion site. The nurse should first stabilize the patient to the best of his or her ability before calling the physician. Applying gauze to all four sides of an occlusive dressing would not allow for the escape of any air from the pleural space and could lead to a tension pneumothorax. Because the chest tube has become dislodged, it is outside of the body. Clamping the tube at this point would be useless. Nurses are not allowed to reinsert chest tubes. Immediately apply pressure over chest tube insertion site. Have an assistant apply gauze dressing and tape three sides. Notify the health care provider. DIF: Cognitive Level: Application REF: Text reference: p. 667 OBJ: Discuss the nursing principles involved in caring for patients with chest tubes. TOP: Dislodged Chest Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What does the expected role of the nurse include during chest tube removal? a. Prepares an occlusive dressing b. Performs clipping of the sutures c. Provides support and assessment of the patient d. Removes the chest tube firmly and quickly
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: C
The nurse supports the patient physically and emotionally while the physician or an advanced practice nurse (APN) removes the dressing and clips the sutures. A physician or an APN prepares an occlusive dressing of petroleum gauze on a pressure dressing, sets it aside on a sterile field, and applies sterile gloves; removes the dressing and clips the sutures; and pulls out the chest tube. DIF: Cognitive Level: Application REF: Text reference: p. 668 OBJ: Discuss the nursing principles involved in caring for patients with chest tubes. TOP: Chest Tube Removal KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. Appropriate intervention for the patient who is having a reinfusion of chest tube drainage is
noted when the nurse: a. Hangs the reinfusion lower than the usual intravenous (IV) bag b. Uses a microaggregate filter on the reinfusion bag c. Maintains 500 mm Hg pressure in the gravity blood cuff d. Keeps the clamps open on the drainage tubing during bag transfer ANS: B
Use a new microaggregate filter to reinfuse each autotransfusion bag. Hang the bag on an IV pole and continue to prime the tubing until all air is gone. Clamp the tubing, attach it to the patient’s IV access, and adjust the clamp to deliver the reinfusion at the appropriate rate. Reinfusion is delivered by gravity or by application of a blood cuff (not to exceed 150 mm Hg pressure) or a blood-compatible IV pump. Connect the red and blue connectors on top of the initial collection bag, and remove it by lifting it from the side hook and then from the foot hook. This maintains a closed system within the bag and removes it for use in autotransfusion.
NURSINGTB.COM
DIF: Cognitive Level: Application REF: Text reference: p. 672 OBJ: Describe autotransfusion. TOP: Autotransfusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. Of the following nursing assessments, which should be reported to the primary care provider
immediately by the nurse? a. Bloody drainage from a patient with a hemothorax b. Subcutaneous emphysema is noted on assessment c. Bubbling in the water seal stops on a patient with a pneumothorax d. Over 300 mL of drainage has been collected in the system in the past hour ANS: D
Drainage exceeding 100 mL/hr should be reported immediately because this would be considered abnormal. Drainage would be expected to be bloody if the patient has a hemothorax. Cessation of bubbling in the water seal indicates that the air has been evacuated in the patient with a pneumothorax. Although the finding of subcutaneous emphysema should be reported, documented, and monitored, it is not an emergency. DIF: Cognitive Level: Analysis REF: Text reference: p. 658 OBJ: Demonstrate appropriate documentation and reporting of chest tube care. TOP: Chest Tube Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 19. The nurse is providing care for a patient with a pneumothorax. She anticipated removal of the
chest tube because of the absence of an air leak for the past a. 6 to 8 b. 12 to 16 c. 18 to 24 d. 48 to 72
hours.
ANS: C
One of the signs that indicate that the chest tube may be removed is lack of an air leak for 24 to 48 hours. Lack of an air leak for less than 24 hours is usually not long enough, and there is no need to wait 4 days. Other findings that indicate that the chest tube may be removed include a chest x-ray showing lung reexpansion, minimal tube drainage, and lack of water-seal tidaling. DIF: Cognitive Level: Analysis REF: Text reference: p. 658 OBJ: Verbalize the steps used in assisting with chest tube removal. TOP: Chest Tube Removal KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 20. The nurse is caring for a patient with blood collecting in the pleural space. The nurse
documents this as: a. pleural effusion. b. hemothorax. c. pulmonary hemorrhage. d. pneumothorax. ANS: B
A hemothorax is a collectionNofUbRloo Id NinGthe Bp.leCural Mspace. A pneumothorax is the collection S T O of air in the pleural space. A pulmonary hemorrhage is bleeding inside the lung. A pleural effusion is the collection of fluid within the pleura. DIF: Cognitive Level: Knowledge REF: Text reference: p. 656 OBJ: Define the key terms used in the care of patients with chest tubes. TOP: Chest Tubes DrainageKEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
is the proper term to describe that the patient’s water seal is fluctuating up and down with each breath. a. bubbling b. tidaling c. fluttering d. alternating
21. The nurse knows that
ANS: B
The term for the fluctuation of the water-seal chamber when the patient breathes is tidaling. Bubbling is different from tidaling, because bubbling is the presence of gas moving through the chamber, whereas tidaling is an up and down movement that correlates with the patient’s breathing. Fluttering and alternating reflect incorrect terminology. DIF: Cognitive Level: Knowledge REF: Text reference: p. 661 OBJ: Define the key terms used in the care of patients with chest tubes. TOP: Chest Tube Functioning KEY: Nursing Process Step: Assessment
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity 22. The nurse is caring for a patient with a chest tube connected to water-seal drainage. The nurse
may delegate which of the following tasks to nursing assistive personnel (NAP)? a. Changing the chest tube drainage system b. Milking the chest tube c. Measuring chest tube output d. Turning and positioning the patient ANS: D
The NAP may turn and position the patient as long as the nurse ensures that the NAP understands how to manipulate the tubing safely and what signs and symptoms should be reported immediately. Care of the chest tube, including milking the tube if ordered, measuring chest tube output, and changing the chest tube drainage system, should never be delegated to unlicensed assistive personnel. DIF: Cognitive Level: Application REF: Text reference: p. 661 OBJ: Recognize when it is appropriate to delegate aspects of the care of patients with chest tubes to unlicensed assistive personnel. TOP: Chest Tube Assessment KEY: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment 23. The patient has a chest tube for a pneumothorax. Assessment revealed no continuous bubbling
in the water-seal chamber. The nurse finds no loose connections. After the chest tube near the patient is clamped, the bubbling stops. The nurse’s first action should be to: a. apply pressure to the dressing around the chest tube insertion site. b. move the clamp farther down the tube and note whether bubbling resumes. c. replace the entire collection tubing and system. d. increase suction control uN nU tilRbS ubIbN linGgTdB oe.sC nO otMresume when the clamp is removed. ANS: A
If bubbling stops when the chest tube is clamped between the collecting system and the body, the leak is at the insertion site or inside the patient. Applying pressure to the dressing will determine which of the sites is leaking. If bubbling continues after the chest tube is clamped, the leak is below the clamp, and the next step would be to move the clamp farther away from the patient and reassess. Only if the bubbling never stops after the clamp is moved all the way down the tubing should the collection system be replaced. Turning the suction device higher will increase bubbling in the suction chamber and will not affect bubbling in the water-seal chamber. DIF: Cognitive Level: Application REF: Text reference: p. 667 OBJ: Verbalize the steps used in maintaining chest tube drainage. TOP: Chest Tube Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. A pneumothorax can be caused by which of the following? (Select all that apply.) a. Trauma b. Rupture of a blister c. Emphysema
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. Dyspnea ANS: A, B, C
A variety of mechanisms can cause a pneumothorax. A traumatic pneumothorax develops as a result of penetrating chest trauma, such as a stabbing or a case of the chest striking the steering wheel in an automobile accident. A spontaneous or primary pneumothorax sometimes occurs from the rupture of a small bleb (blister) on the surface of the lung or from an invasive procedure, such as insertion of a subclavian IV line. Secondary pneumothorax occurs because of underlying disease, such as emphysema. A patient with a pneumothorax usually feels pain as atmospheric air irritates the parietal pleura. Dyspnea is a symptom of pneumothorax, not a cause. DIF: Cognitive Level: Comprehension OBJ: Describe causes of pneumothorax. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 657 TOP: Pneumothorax MSC: NCLEX: Physiological Integrity
2. The nurse is caring for a patient with a chest tube connected to wall suction. To keep the tube
patent, the nurse should implement which of the following? (Select all that apply.) a. Routinely “milk” the drainage tubing. b. Avoid dependent loops of the drainage tubing. c. Lift and clear the tube every 15 minutes. d. Coil the drainage tubing to prevent dependent loops. ANS: B, C
Chest tube milking or stripping usually is contraindicated because it does not improve catheter patency. Careful management of chest tube drainage prevents the need to milk the chest tube. Institute nursing interventions to maintain tube patency. These interventions include avoiding dependent loops of the drainaNge tube , wh nC thes UR SI, or NG TBe. OMe loops cannot be avoided, such as when the patient is sitting, lifting and clearing the tube every 15 minutes. If the tubing is coiled, looped, or clotted, drainage is impeded, and this can result in a tension pneumothorax. DIF: Cognitive Level: Application REF: Text reference: p. 658 OBJ: Discuss the nursing principles involved in caring for patients with chest tubes. TOP: Chest Tube Patency KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient with a chest tube that was inserted 4 days earlier. She notices
that the drainage is blood-tinged. What might this indicate to the nurse? (Select all that apply.) a. Malignancy b. Pulmonary infarction c. Empyema d. Hemothorax ANS: A, B
Blood-tinged fluid usually indicates malignancy, pulmonary infarction, or severe inflammation. Pus indicates an empyema, which is a collection of pus in the pleural cavity, and the drainage is pus-colored. Frank blood indicates a hemothorax. DIF: Cognitive Level: Analysis REF: Text reference: p. 658 OBJ: Discuss the nursing principles involved in caring for patients with chest tubes. TOP: Pleural Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
4. The nurse is preparing to assist the physician in removal of a chest tube. What should the
nurse do to prepare the patient? (Select all that apply.) a. Assess the patient’s need for pain medication. b. Instruct the patient about the process. c. Teach the patient to take a deep breath and hold it. d. Clamp the chest tubes. ANS: A, B, C
The nurse should prepare the patient for chest tube removal by (1) assessing the need for pre-removal analgesia and obtaining the required medication orders, and (2) instructing the patient about the process and what will be requested of the patient. During removal of the chest tube, it is important to instruct the patient to take a deep breath and hold it until the tube is removed. This maneuver prevents air from being sucked into the chest as the tube is pulled out and an occlusive dressing is applied. Although clamping of the chest tubes is done to determine whether the chest tube can be eliminated, this is not part of the immediate chest tube removal procedure. DIF: Cognitive Level: Application REF: Text reference: p. 668 OBJ: Discuss the nursing principles involved in caring for patients with chest tubes. TOP: Chest Tube Removal KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a patient who has a chest tube. Attached to the top of the patient’s bed
are two shodded hemostats. In which situations would these be used? (Select all that apply.) a. To assess an air leak b. To quickly empty or change disposable systems c. To quickly seal off the luN ngUsR ifSthIeNsyGsT teB m.bC ecO oM mes disconnected d. To assess whether the patient is ready to have the chest tube removed ANS: A, B, D
Chest tubes are clamped only under the following specific circumstances, per health care provider order or nursing policy and procedure: to assess air leak, to quickly empty or change disposable systems, or to assess whether the patient is ready to have the chest tube removed (which is done by a health care provider’s order). Clamping an open system could lead to a tension pneumothorax. DIF: Cognitive Level: Application REF: Text reference: p. 665 |Text reference: p. 667 OBJ: Describe methods of troubleshooting chest tube systems. TOP: Two-Chamber Waterless Chest Tube System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is performing an initial assessment of a patient with a chest tube placed in the
eighth intercostal space. Which of the following findings would the nurse need to assess further? (Select all that apply.) a. Respiratory rate of 18 breaths per minute b. Continuous bubbling in the water-seal chamber c. The presence of subcutaneous emphysema d. Complaints of pain at the insertion site e. Serous drainage on the chest tube dressing the size of a bean
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: B, C, D
Continuous bubbling in the water-seal chamber could indicate a leak in the system and should be assessed further. The presence of subcutaneous emphysema must be assessed further because it can be caused by a poor seal at the chest tube insertion site. Complaints of pain at the insertion site can be expected but should be fully assessed before analgesics are administered. A respiratory rate of 18 breaths per minute falls within the normal range and does not, by itself, indicate a need for further assessment. A small amount of drainage on the chest tube dressing can be expected and serous drainage would be normal; however, it should be monitored for any change in appearance. DIF: Cognitive Level: Analysis REF: Text reference: pp. 666-667 OBJ: Demonstrate appropriate documentation and reporting of chest tube care. TOP: Chest Tube Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse is caring for a patient who has had a chest tube in place for 2 days. As the nurse
begins her shift assessment, she should ensure that what equipment is at the bedside? (Select all that apply.) a. Two rubber-tipped clamps b. Plain gauze 4 4 c. Sterile petroleum gauze d. Extra drainage system e. A sterile chest tube of the same size as the one inserted in the patient ANS: A, B, C, D
The nurse should ensure that two rubber-tipped clamps are at the bedside to clamp the tubing in case of emergency, as well as a plain gauze 4 4 and sterile petroleum gauze to make an N hes RS I Gecome B.CdOislodged, M occlusive dressing should the cU t tubNe bT and an extra drainage system, should the current system become full. There is no need to keep a spare chest tube in most instances because it could be obtained while waiting for the primary care provider to arrive and reinsert. DIF: Cognitive Level: Application REF: Text reference: p. 667 OBJ: Demonstrate appropriate documentation and reporting of chest tube care. TOP: Chest Tube Assessment KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 27: Emergency Measures for Life Support MULTIPLE CHOICE 1. The nurse is providing CPR to an unresponsive patient according to the 2010 American Heart
Association (AHA) resuscitation guidelines. The nurse is performing chest compressions correctly when she performs them at which rate? a. 60 to 80 per minute b. 120 per minute c. 100 per minute d. 40 to 60 per minute ANS: C
The 2010 AHA resuscitation guidelines recommend performing chest compressions at a rate of 100 per minute. DIF: Cognitive Level: Application OBJ: Discuss code management. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 685 TOP: Chest Compressions MSC: NCLEX: Physiological Integrity
2. The nurse is working in the emergency department when an 8-year-old patient is brought in
with respiratory distress. The nurse is preparing to insert an oral airway. Which of the following is the appropriate size for this patient? a. Size 1 b. Size 2 c. Size 3 NURSINGTB.COM d. Size 7 ANS: C
Oral airways vary in length and width. Pediatric sizes are 000, 00, 0, 1, 2, and 3 centimeters. School-age children are usually size 3 or 4. Adult sizes are 4 through 10 or small, medium, and large. The nurse chooses the size of an oral airway on the basis of the patient’s age and the width and length of the patient’s mouth. DIF: Cognitive Level: Application REF: Text reference: p. 678 OBJ: Demonstrate the following in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR). TOP: Oral Airway KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. While measuring an oral airway for proper fit, the nurse places the airway so that the flange is
held parallel to the front teeth with the airway against the patient’s cheek. Where is the end of the curve? a. At the angle of the jaw b. Above the ear c. To the level of the nose d. Upside down ANS: A
Size is correct if, when the flange is held parallel to the front teeth with the airway against the patient’s cheek, the end of the curve reaches the angle of the jaw.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Application REF: Text reference: p. 677 OBJ: Demonstrate the following in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR). TOP: Oral Airway KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Which sign or symptom of airway compromise may require insertion of an oral airway? a. Ability of the patient to speak b. Ability of the patient to cough forcefully c. Presence of wheezing between coughs d. Presence of gurgling with the respiratory cycle ANS: D
Identify the need to insert an oral airway. Signs and symptoms include upper airway gurgling with breathing, absence of a gag reflex, increased oral secretions, excessive drooling, grinding of teeth, clenched teeth, biting of the orotracheal or gastric tube, labored respirations, and increased respiratory rate. These conditions place the patient at risk for obstruction of the upper airway. Normal response shows no evidence of airway obstruction or compromise. Wheezing may be present as a symptom of allergy but not necessarily of airway obstruction. DIF: Cognitive Level: Application REF: Text reference: p. 678 OBJ: Demonstrate the following in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR). TOP: Oral Airway KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The nurse is preparing to inseNrt aR n orI al aG irwB ay.iC n a pMatient who is exhibiting signs of potential
S that N Tcandidates O for oral airway placement are those: respiratory distress. The nurse U knows a. with oral trauma. b. with loose teeth. c. who are unconscious. d. who have had recent oral surgery. ANS: C
Never insert an oral airway in a conscious patient or a patient with recent oral trauma, oral surgery, or loose teeth. Use oral airways only in unconscious patients. Oral airways may stimulate vomiting or laryngospasm if inserted in the semiconscious or conscious patient. DIF: Cognitive Level: Application REF: Text reference: p. 678 OBJ: Demonstrate the following in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR). TOP: Oral Airway KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. Which of the following is the appropriate technique for a nurse to implement when inserting
an oral airway? a. Insert the airway with the curved end up, then rotate it 180 degrees at the back of the throat. b. Insert the airway with the curved end down along the curve of the tongue. c. Use a tongue blade to insert and push the airway into position. d. Insert the airway sideways, then rotate it with the curved end up.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS: A
Hold the oral airway with the curved end up, insert the distal end until the airway reaches the back of the throat, then turn the airway more than 180 degrees, and follow the natural curve of the tongue. Never push the airway into position. The nurse may also hold the airway sideways, insert it halfway, and then rotate it 90 degrees while gliding it over the natural curvature of the tongue (curved end down). DIF: Cognitive Level: Application REF: Text reference: p. 679 OBJ: Demonstrate the following in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR). TOP: Oral Airway Insertion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The nurse is providing an educational seminar to a group of nursing students on the
advantages of using an automated external defibrillator (AED). She knows that her teaching has been effective when the students reply: a. “Health care providers do not need to learn CPR to use the AED.” b. “The health care provider is given a printout of the rhythm change.” c. “The health care provider can safely use both CPR skills and AED skills.” d. “The health care provider can adjust the level of shock administered.” ANS: C
The advantage of the AED is that laypeople or health care providers trained in basic life support, who have less training than ACLS personnel, can defibrillate. AEDs eliminate the need for training in rhythm interpretation and make early defibrillation practical and achievable. The AED is an automated external defibrillator that incorporates a rhythm analysis system. Upon rhythm idR entiI ficaG tionB , s.oC me M AEDs will automatically provide the NU S N(fully T automated). O electrical shock after a verbal warning Other AEDs will recommend a shock, if needed, and then will prompt the responder to press the shock button. The provider does not need to adjust anything. DIF: Cognitive Level: Application REF: Text reference: p. 680 OBJ: Identify the need for automated external defibrillator (AED) application and indications for use. TOP: Advantages of an Automated External Defibrillator (AED) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The nurse finds a patient lying on the bathroom floor. The patient is unresponsive and has a
pulse but is not breathing. What is the nurse’s first action? a. Give two breaths using mouth-to-mouth without a barrier device. b. Give two breaths using mouth-to-mouth without a barrier device and watch for chest movement. c. Give two breaths using a bag-mask device. d. Start chest compressions until an AED is available. ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Give two breaths using mouth-to-mouth with a barrier device or a mouth-to-mask device or a bag-mask device. Watch for chest rise and fall. In a hospital setting where protected methods of artificial ventilation are available, mouth-to-mouth without a barrier device is not recommended because of the risk for microbial contamination. Watch for chest rise and fall. Motion, by itself, could be caused by fasciculation and is not indicative of air moving into and out of the chest. DIF: Cognitive Level: Application REF: Text reference: p. 687 OBJ: State the end points for CPR. TOP: Mouth-to-Mouth With a Barrier Device KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The patient is brought to the emergency department after a motor vehicle accident. The patient
has head and neck trauma and has stopped breathing. What should the nurse do? a. Open the airway using the head tilt–chin lift method. b. Open the airway using the jaw-thrust method. c. Give two breaths using mouth-to-mouth and a barrier device. d. Give two breaths using a bag-mask device. ANS: B
First determine whether the patient has spontaneous respirations by opening the airway. Consider spinal cord injury in patients with trauma. In these situations, a rescuer must use the jaw-thrust maneuver. Prevention of head extension and neck movement is very important to prevent paralysis or spinal cord injury. Apply a rigid cervical collar as soon as possible to reduce cervical spine motion. DIF: Cognitive Level: Analysis REF: Text reference: p. 685 NPURR. SINGTTOB OBJ: State the end points for C P:.C JaO w-M Thrust Maneuver KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. During the secondary survey of the code event, the nurse realizes that the patient is not
breathing on his own. What should the nurse do next? a. Immediately intubate the patient. b. Have a laryngoscope handle and curved blades available. c. Ensure that the light source on the laryngoscope is functional. d. Have a laryngoscope handle and straight blades available. ANS: C
Ensure that the light source on the laryngoscope is functional. Light is necessary on the laryngoscope to visualize the vocal cords and intubate the trachea. Batteries may have to be changed. If respirations are absent, assist the code team with endotracheal intubation. Have available a laryngoscope handle, curved and straight blades, endotracheal (ET) tubes, a stylet, suction and tape, or an ET tube holder. DIF: Cognitive Level: Application REF: Text reference: p. 690 OBJ: Discuss code management. TOP: Intubation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The nurse is performing CPR on an adult patient who has an endotracheal tube in place. At
what rate does the nurse, who is alone, administer breaths?
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
8 per minute 12 per minute 20 per minute 24 per minute
ANS: A
Rescue breaths for CPR with an advanced airway (endotracheal tube/tracheotomy) are given at 8 to 10 breaths/min. DIF: Cognitive Level: Application REF: Text reference: p. 685 OBJ: Discuss code management. TOP: Rescue Breathing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse enters her patient’s room to find him unresponsive. She begins CPR according to
protocol. How deep should the nurse do chest compressions in this pulseless adult? a. 1 to inches in depth b. to 3 inches in depth c. to 1 inch in depth d. to 2 inches in depth ANS: D
Chest compressions for an adult are done on the lower half of the sternum between the nipples, with the heel of one hand and with the other hand on top compressing to 2 inches. One half to 1 inch or 1 to inches is no longer recommended. For children and infants, the recommendation is to the depth of the chest. to 3 inches is too deep for NURSINGTB.COM the average adult. DIF: Cognitive Level: Application REF: Text reference: p. 685 OBJ: Discuss code management. TOP: Chest Compressions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. The nurse observes a person collapse and stop breathing. The nurse would establish an airway
by: a. b. c. d.
inserting an endotracheal tube. inserting a finger to pull the tongue forward. using the head tilt–chin lift maneuver. using a modified jaw-thrust maneuver.
ANS: C
The nurse would establish an airway by tilting the head back and lifting the chin. An endotracheal tube should not be inserted by the nurse. It is not necessary to put tension on the tongue because proper head tilt with chin thrust will remove the tongue from obstructing the airway. A modified jaw thrust would be used if a neck injury was suspected, but because this patient collapsed in front of the nurse, that would not be a concern in this scenario. DIF: Cognitive Level: Application REF: Text reference: p. 687 OBJ: State the end points for CPR. TOP: Steps Used in Performing Rescue Breathing KEY: Nursing Process Step: Implementation
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity 14. The nurse is performing cardiac compressions on a 4-year-old child with the assistance of
another nurse. The nurses would deliver breaths and compressions at a ratio of compressions for breaths. a. 30; 2 b. 5; 1 c. 15; 2 d. 5; 2 ANS: C
The correct ratio of compressions to breaths is 15 chest compressions followed by 2 breaths if there are two rescuers for a child. A ratio of 30:2 would be used in adult CPR; if there are two rescuers, 1 breath is interspersed after 15 compressions but the ratio remains 30:2. Ratios of 5:1 and 5:2 are always incorrect when CPR is performed on a child. DIF: Cognitive Level: Application REF: Text reference: p. 685 OBJ: State the end points for CPR. TOP: Steps Used in Administering External Cardiac Compressions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. When applying an automated external defibrillator, the nurse would: a. connect the cable to the machine, apply the pads, and turn on the power. b. turn on the power, apply the pads, and connect the cable. c. turn on the power, connect the cable, and apply the pads. d. connect the cable, turn on the power, and apply the pads. ANS: B
NURSINGTB.COM
As soon as the cable is connected, the machine begins to attempt to analyze the rhythm, so the power should be turned on and the pads should be applied to the chest wall before the cable is connected to the machine. Connecting the cable, applying the pads, and then turning on the power would cause the machine to malfunction or would delay analysis while it cycles on. Connecting the cable before applying the pads could result in the rescuer being shocked. DIF: Cognitive Level: Application REF: Text reference: p. 681 OBJ: State the end points for CPR. TOP: Steps Used in Administering Automated External Defibrillation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. When using an automated external defibrillator, it is important for the nurse to ensure that no
one is touching the patient: a. after connecting the cable to the machine. b. when the machine is plugged in. c. while the pads are applied. d. while the machine analyzes the rhythm. ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The nurse needs to ensure that no one is touching the patient while the machine is analyzing because this may interfere with correct interpretation of the patient’s rhythm and could put anyone touching the patient at risk of being shocked. CPR may be continued up until the machine is ready to analyze, although CPR may need to be momentarily stopped for placement of the chest pad, and when the AED instructs the user to resume CPR. There is no risk in touching the patient while the machine is plugged in, and it is not possible to apply the pads without touching the patient. CPR should be performed until an AED is brought to the patient and the cable is ready to be inserted into the machine with the pads already in place. DIF: Cognitive Level: Application REF: Text reference: p. 682 OBJ: State the end points for CPR. TOP: Steps Used in Administering Automated External Defibrillation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse sees on the cardiorespiratory monitor that the patient’s cardiac rhythm has changed
from normal sinus rhythm to ventricular fibrillation. The nurse knows that the most effective means of converting this rhythm is: a. CPR. b. defibrillation. c. oxygen. d. precordial thump. ANS: B
CPR should be performed until the defibrillator patches are applied, but it is not the most effective means of converting the electrical rhythm; rather it supports life until defibrillation can be performed. Oxygen should be administered during CPR, but it is not the means of converting the rhythm. PrecoN rdU iaR lS thI um trM oversial at best and would not be the most NpGsTarBe .coCnO effective means of converting the rhythm. DIF: Cognitive Level: Application REF: Text reference: p. 676 |Text reference: p. 680 OBJ: State the end points for CPR. TOP: Key Terms Used in the Skills of Hospital Emergency Measures and Cardiopulmonary Resuscitation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse would call the code team for which of the following patients? a. A patient with blood pressure of 60/28 b. A patient experiencing severe dyspnea secondary to asthma c. A patient in atrial fibrillation d. An unconscious patient in ventricular tachycardia ANS: B
A patient who becomes unconscious while in ventricular tachycardia requires the rapid intervention of the cardiac/respiratory arrest team. A hypotensive patient or a patient experiencing dyspnea requires the intervention of the rapid response team. A patient in atrial fibrillation requires notification of the primary care provider. DIF: Cognitive Level: Application REF: Text reference: p. 684 OBJ: Identify indications for requesting a rapid response or cardiac/respiratory arrest team. TOP: Oral Airway KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
19. The nurse enters the patient’s room and finds that the patient is not breathing and has no
pulse. The patient does not have a do-not-resuscitate order. What would the nurse’s most immediate action be? a. Call the cardiac/respiratory arrest team. b. Begin CPR. c. Call a co-worker for help. d. Get the crash cart. ANS: A
The nurse’s first action should be to summon the cardiac/respiratory arrest team because it will take them a few minutes to arrive, and the patient’s best outcome depends on their rapid arrival. As soon as the team has been called, the nurse should begin CPR. If the arrest is not called over the public address system, the nurse should call a co-worker for help while performing CPR or after initiating CPR. If the code is called over the public address system, co-workers will hear the call and will come to the room without being summoned. Once co-workers have been alerted, they can obtain the crash cart and summon additional support. DIF: Cognitive Level: Application REF: Text reference: p. 681 OBJ: Describe the role of the nurse in initiating and participating in a cardiopulmonary arrest situation in a hospital. TOP: Oral Airway KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. For which of the following patients would the nurse request the rapid response team’s
immediate intervention? a. A patient complaining of severe postoperative incisional pain b. A patient with no pulse wNhU oR isS nI otN bG reT atB hi. ngCOM c. A patient complaining of chest pain, hypotension, and shortness of breath d. A patient with blood pressure of 164/96 ANS: C
The nurse would request the rapid response team’s immediate intervention for the patient with chest pain, hypotension, and shortness of breath to prevent a potentially life-threatening situation. A patient with postoperative pain can be successfully treated by the nurse on the unit and does not require the rapid response team. If the patient has no pulse and no respirations, the nurse should call the arrest team, not the rapid response team. The nurse should call the primary care provider for the patient who is hypertensive. DIF: Cognitive Level: Application REF: Text reference: p. 676 OBJ: Identify indications for requesting a rapid response or cardiac/respiratory arrest team. TOP: Oral Airway KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 21. A patient has been found with no pulse or respirations. The cardiopulmonary arrest team has
been called. What should the nurse do while awaiting the team’s arrival? a. Gather the patient’s medical record and medication administration record. b. Obtain the crash cart. c. Notify the patient’s primary care provider. d. Perform CPR. ANS: D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The nurse’s responsibility while awaiting the arrest team is to perform CPR, with or without assistance as available. Other team members can collect the patient’s records, obtain the crash cart, and notify the primary care provider. The nurse assigned to the patient should stay with the patient to provide the history when the team arrives. DIF: Cognitive Level: Application REF: Text reference: p. 685 OBJ: State the end points for CPR. TOP: The Nurse's Role in Initiating and Participating in a Cardiopulmonary Arrest Situation in a Hospital KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse in the ICU is caring for a newly admitted patient with chest pain. She is aware that
dysrhythmia may be caused by which of the following? (Select all that apply.) a. Electrolyte disturbances b. Heart damage c. Medications d. Respiratory arrest ANS: A, B, C, D
Causes of dysrhythmia may include electrolyte disturbances (potassium, magnesium, calcium), heart damage, and certain prescribed or recreational medications. Early intervention for a respiratory arrest usually prevents a cardiac arrest. DIF: Cognitive Level: Knowledge REF: Text reference: p. 676 OBJ: State indications for cardiopulmonary resuscitation (CPR). NUR SI NG TB.C OM KEY: Nursing Process Step: Assessment TOP: Cardiac Arrest MSC: NCLEX: Physiological Integrity 2. The nurse walks into her patient’s room to find him unresponsive. She begins CPR, knowing
that during a “code” situation, chest compressions should be interrupted for which of the following situations? (Select all that apply.) a. Ventilation b. Pulse checks c. Intubation d. Defibrillation ANS: A, B, C, D
The 2010 AHA resuscitation guidelines recommend performing chest compressions at a rate of 100 per minute with few and very brief interruptions for ventilation, pulse checks, intubation, and defibrillation. DIF: Cognitive Level: Application OBJ: Discuss code management. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 690 TOP: Chest Compressions MSC: NCLEX: Physiological Integrity
3. The nurse is caring for an unconscious patient who has an oral airway in place, and who has
copious amounts of oral secretions. What may the nurse have to do while caring for this patient? (Select all that apply.) a. Cleanse the mouth frequently using lemon glycerin swabs.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. Replace or clean the oral airway. c. Suction the oral cavity frequently. d. Keep the airway in place for extended periods. ANS: B, C
Do not use lemon glycerin swabs for oral care because they are drying to mucosal tissues and promote bacterial growth. The oral airway will have to be removed, cleaned or discarded, and replaced in patients with excessive oral secretions. Frequent suctioning of the oral cavity may be required. Oral airways are not a long-term solution. They can cause significant lip and tongue erosion. DIF: Cognitive Level: Application REF: Text reference: p. 679 OBJ: Demonstrate the following in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR). TOP: Oral Airway Maintenance KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. What is the nurse’s responsibility for the patient after he has been intubated during a code
event? (Select all that apply.) a. Ventilate using a bag-mask device at a rate of 22 breaths per minute. b. Auscultate the epigastric area. c. Auscultate both lungs. d. Call for a chest radiograph. ANS: B, C
Assist in confirmation of endotracheal tube placement by auscultating the epigastric area for lack of breath sounds and then the lungs for bilateral breath sounds. Intubation personnel usually perform secondary coNnfirRmaI us. inC g aM U Stion NGbyTB O carbon dioxide detector. Ventilate using a bag-mask device upon intubation at a rate of 8 to 10 breaths per minute. Avoid hyperventilation. Increased intrathoracic pressure due to incomplete exhalation results in reduced cardiac output. A chest radiograph usually is obtained after the patient has been stabilized to confirm placement of the endotracheal tube and central venous catheters. DIF: Cognitive Level: Application REF: Text reference: p. 690 OBJ: Discuss code management. TOP: Intubation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. Many cardiac arrests are caused by irregular heart rhythms known as ANS:
dysrhythmias Many cardiac arrests are caused by irregular heart rhythms known as dysrhythmias. DIF: Cognitive Level: Knowledge REF: Text reference: p. 676 OBJ: State indications for cardiopulmonary resuscitation (CPR). TOP: Cardiac Arrest KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 2. In the event of cardiopulmonary arrest, all patients receive CPR unless otherwise indicated in
the patient’s
.
ANS:
advance directive Unless otherwise indicated within a patient’s advance directive or a do-not-resuscitate (DNR) physician’s order, all patients receive CPR in the event of an arrest. DIF: Cognitive Level: Knowledge REF: Text reference: p. 677 OBJ: State indications for cardiopulmonary resuscitation (CPR). TOP: Advance Directives KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. A semicircular, minimally flexible, curved piece of hard plastic that is inserted into the mouth
so it extends from just outside the lips to the pharynx is known as an
.
ANS:
oral airway An oral airway is a semicircular, minimally flexible, curved piece of hard plastic. When inserted, it extends from just outside the lips, over the tongue, and to the pharynx. Oral airways enable the nurse to suction through a central core or along the side of the airway and to maintain airway patency in the unconscious patient. DIF: Cognitive Level: Knowledge REF: Text reference: p. 677 OBJ: Discuss indications for oral airway insertion. TOP: Oral Airway KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The most common cause of aN irU wR aySoIbN strGuT ctB io. nC inOaM n unresponsive patient is the ANS:
tongue The tongue is the most common cause of blocked airway in an unresponsive patient. DIF: Cognitive Level: Knowledge OBJ: State the end points for CPR. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 678 |Text reference: p. 687 TOP: Airway Obstruction MSC: NCLEX: Physiological Integrity
.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 28: Intravenous and Vascular Access Therapy MULTIPLE CHOICE 1. The nurse is caring for a patient receiving antineoplastic medications intravenously. The nurse
discovers that the intravenous site is red, edematous, and painful. The nurse knows that antineoplastic medications are vesicant medications and documents that the patient has experienced which of the following events? a. Occlusion b. Extravasation c. Phlebitis d. Thrombophlebitis ANS: B
When a vesicant medication infiltrates the tissue, this is called an extravasation. Occlusion refers to a thrombus or fibrin sheath that impedes the flow of IV fluids. Phlebitis occurs with redness surrounding the vein, and extravasation leads to trauma within the vein DIF: Cognitive Level: Application REF: Text reference: p. 735 OBJ: Define the key terms used in the skills of intravenous therapy. TOP: Assessment of IV Site KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 2. Established standards for routine replacement of peripheral IV catheters and intravenous
administration sets have recommended a maximum of contamination and prevent catheter site complications. NURSINGTB.COM a. 24 b. 48 c. 72 d. 96
hours to reduce IV fluid
ANS: D
Established standards for routine replacement of peripheral IV catheters and intravenous administration sets have recommended a maximum of 96 hours to reduce IV fluid contamination and prevent catheter site complications. DIF: Cognitive Level: Comprehension REF: Text reference: p. 695 |Text reference: p. 716 OBJ: Discuss complications of IV therapy. TOP: Replacement of IV Catheters and Administration Sets KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. While assessing the patient, the nurse recognizes that special caution should be taken with the
IV infusion because of fluid volume excess when the nurse notes the presence of which condition? a. Poor skin turgor b. Crackles in the lungs c. Decreased blood pressure d. Dry skin and mucous membranes ANS: B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Auscultation of crackles or rhonchi in the lungs may signal fluid buildup in the lungs caused by fluid volume excess. Poor skin turgor is common with fluid volume deficit. The pinched skin stays elevated for several seconds (tenting). This may be an indication of the need for IV therapy. Decreased blood pressure may indicate fluid volume deficit caused by a decrease in stroke volume. This may indicate the need for IV therapy. Dry skin and mucous membranes may indicate dehydration. DIF: Cognitive Level: Comprehension REF: Text reference: p. 698 |Text reference: p. 707 OBJ: Discuss complications of IV therapy. TOP: Fluid Volume Excess KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse needs to specifically prevent air emboli that may result from IV therapy. What
should the nurse make sure to do to prevent air emboli? a. Use a needleless system. b. Prime the tubing completely. c. Check for medication compatibility. d. Select a larger-gauge needle or catheter. ANS: B
Prime the infusion tubing by filling it with IV solution. Be certain that the tubing is clear of air and air bubbles. Large air bubbles can act as emboli. A needleless system does not specifically prevent the introduction of air emboli. Medication incompatibility may lead to crystallization of the medication and may cause emboli to form from precipitate. It will not lead, however, to air embolism. Catheter size does not contribute to emboli formation. DIF: Cognitive Level: Application REF: Text reference: p. 700 OBJ: Discuss complications of IV therapy. TOP: Air Embolism
KEY: Nursing Process Step: AN ssU esR sm ntNGMTSB C. : C NC SeI OLMEX: Physiological Integrity 5. Which of the following steps is necessary when a patient is prepared for IV insertion? a. Shaving the hair from the site b. Selecting a proximal site in an extremity c. Applying a tourniquet 4 to 6 inches above the selected site d. Vigorously taping and massaging the selected vein ANS: C
Apply a flat tourniquet around the arm, above the antecubital fossa or 4 to 6 inches (10 to 15 cm) above the proposed insertion site. Do not shave the area. Shaving may cause microabrasions and may predispose to infection. Use the most distal site in the nondominant arm, if possible. Vigorous friction and multiple taping of the veins, especially in older adults, may cause hematoma and/or venous constriction. DIF: Cognitive Level: Application REF: Text reference: p. 701 OBJ: Explain how to prepare the patient and the family for IV therapy. TOP: Applying a Tourniquet KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. What should be the next action by the nurse, once an over-the-needle catheter (ONC) has been
inserted through the skin and into the vein? a. Loosen the stylet for removal b. Check for blood return in the flashback chamber
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank c. Stabilize the catheter and release the tourniquet d. Advance the catheter until the hub rests at the insertion site ANS: B
Observe for blood return through the flashback chamber of the catheter or the tubing of the winged cannula, indicating that the bevel of the needle has entered the vein. Lower the needle until almost flush with the skin. Advance the catheter another to inch into the vein, and then loosen the stylet site on the ONC. Only after the catheter is advanced and is in its final position is the catheter stabilized with one hand while the tourniquet is released. Only after the blood and the needle are observed to advance another to inch into the vein is the stylet loosened. At that point, continue to hold the skin taut, and advance the catheter into the vein until the hub rests at the venipuncture site. DIF: Cognitive Level: Application REF: Text reference: p. 703 OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV. TOP: Inserting the Over-the-Needle Catheter KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. What should the nurse do once she recognizes that the patient has phlebitis at his IV site? a. Reduce the IV flow rate. b. Elevate the affected extremity. c. Place a moist warm compress over the site. d. Adjust the additive in the current IV. ANS: C
CpOerMature, and erythema along the path of the Phlebitis is indicated by painN , iU ncRreSaI seN dG skT inBt. em vein. Stop the infusion and discontinue the IV. Start a new IV if continued therapy is necessary. Place a moist warm compress over the area of phlebitis. Document the degree of phlebitis and nursing interventions per agency policy and procedure. The extremity is elevated for an infiltration to reduce edema. DIF: Cognitive Level: Application REF: Text reference: p. 707 OBJ: Discuss complications of IV therapy. TOP: Phlebitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. What should the nurse do upon noting bleeding around a dressing at an IV insertion site? a. Discontinue the IV. b. Assess the insertion site. c. Leave the dressing intact, but reinforce it. d. Elevate and apply warm compresses to the extremity. ANS: B
When blood appears on the dressing, verify that the system is intact, and change the dressing. The IV should be discontinued in the event of infiltration or phlebitis. If bleeding occurs around the venipuncture site and the catheter is within the vein, gauze dressing may be applied over the site. Be aware that if gauze dressing is used, it must be removed to accurately assess the insertion site. Elevation is used in cases of infiltration to reduce edema. Warm compresses are used in cases of phlebitis.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Application REF: Text reference: p. 707 OBJ: Discuss complications of IV therapy. TOP: Bleeding at Venipuncture Site KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. Which patient would a nurse anticipate would be a candidate for a peripherally inserted
central catheter (PICC)? a. An older adult who is having cataracts removed b. A perinatal patient who is having prolonged labor c. A neonate requiring blood therapy d. An adolescent who is having surgery for reduction of a fracture ANS: C
When a child is critically ill or when long-term IV access is anticipated, a PICC catheter, a Broviac catheter, or an implanted port may be used to access a larger vein. PICCs can be used to infuse IV fluids, parenteral nutrition, blood and blood products, and medications such as antibiotics. Gerontological veins are very fragile, with less subcutaneous support tissue and with thinning of the skin. In older patients, use the smallest gauge possible. For example, a 22-gauge needle is adequate for fluid and medication therapy. PICC lines are not inserted routinely. PICCs are used when long-term IV is needed. DIF: Cognitive Level: Comprehension REF: Text reference: p. 695 |Text reference: pp. 724-725 OBJ: Explain how to prepare the patient and the family for IV therapy. TOP: Pediatric Considerations KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 10. The nurse is caring for a patiN ent R receI ivinG g inB tr. avCenoM us therapy. The nurse should report which
U S N T
of the following to the primary care provider? a. Completion of each liter of fluid b. Initiation of IV fluids c. Small infiltration d. Extravasation
O
ANS: D
If a patient suffers an extravasation, the primary care provider should be notified as soon as possible because complications of some vesicants can be reduced by injection of specific medications, whereas others require rapid medical intervention. It is not necessary to report when you routinely initiate or complete IV therapy. Primary care providers do not need to be notified of a small infiltrate, but it should be documented in the patient’s medical record, and your facility may require completion of an event reporting form. DIF: Cognitive Level: Application REF: Text reference: p. 707 |Text reference: p. 735 OBJ: Demonstrate appropriate documentation and reporting of intravenous therapy. TOP: Assessment of IV Therapy Access Devices KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 11. The patient has an IV ordered to infuse at 1000 mL over 10 hours. The infusion set has a
calibration of 15 gtt/mL. At which rate does the nurse regulate the infusion? a. 20 gtt/min b. 25 gtt/min c. 30 gtt/min
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. 32 gtt/min ANS: B
Select one of the following formulas to calculate drop rate based on drops per minute: mL/hr/60 min = mL/min followed by Drop factor mL/min = Drops/min, or mL/hr Drop factor/60 min = Drops/min. DIF: Cognitive Level: Analysis REF: Text reference: pp. 710-711 OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV. TOP: IV Rate Calculation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The order is for the patient to receive 500 mL over 4 hours. The nurse has an electronic
infusion device (EID) in place that provides for the regulation of hourly infusion. The IV tubing available is 10 gtt/mL. What is the setting for the infusion device? a. 125 mL/hr b. 500 mL/hr c. 21 gtt/min d. 32 gtt/min ANS: A
For use of EID for infusion, turn on the power button, select the required drops per minute or volume per hour, close the door to the control chamber, and press the start button. In this case, 500 mL/4 hr = 125 mL/hr. DIF: Cognitive Level: Analysis REF: Text reference: pp. 710-711 OBJ: Demonstrate initiation of N IV therapy, regulation ofMIV flow rate, changing of IV solutions, R I ssin GTgs,B.C changing of IV tubing, changing oUf IVSdreN and O discontinuation of a peripheral IV. TOP: IV Rate Regulation via EID KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. A pediatric patient has an IV with a microdrip. The order is for 40 mL/hr to infuse. At what
rate does the nurse set the microdrip? a. 10 gtt/min b. 20 gtt/min c. 40 gtt/min d. 80 gtt/min ANS: C
Select one of the following formulas to calculate drop rate based on drops per minute: mL/hr/60 min = mL/min followed by Drop factor mL/min = drops/min, or mL/hr Drop factor/60 min = drops/min. In this case, 40 mL/hr 60 gtt/mL = 240 gtt/hr 1 hr/60 min = 40 gtt/min. When microdrip is used, mL/hr always equals gtt/min. DIF: Cognitive Level: Analysis REF: Text reference: p. 711 OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV. TOP: IV Rate Regulation via Microdrip KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 14. While assessing the patient’s IV infusion, the nurse notes that it is infusing more slowly than
it should be. What should the nurse do first? a. Discontinue the IV. b. Increase the rate of infusion. c. Observe for fluid overload. d. Check the position of the IV fluid and extremity. ANS: D
Check the patient for positional changes that might affect infusion rate, height of the IV container, and tubing obstruction. Check the condition of the site. The most likely cause of a slow-running IV is positioning. An infiltrated or clotted IV line probably will not be running at all. Discontinue the IV if it is determined that it is infiltrated or clotted off. Position will affect flow even if rate is increased. Fluid overload is not associated with slowing of the infusion rate. Often it occurs when an IV is running too quickly. DIF: Cognitive Level: Application REF: Text reference: p. 712 OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV. TOP: Slow-Running IV KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse caring for a patient receiving IV fluids knows that the current recommendation for
changing the tubing on a continuously running IV is: a. at least every 48 hours. b. every 24 hours. c. no more often than every 96 hours. d. with each IV solution bag change. ANS: C
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Intravenous tubing administration sets remain sterile for 96 hours. Thus, the INS recommends changing tubing no more frequently than every 96 hours. When possible, schedule tubing changes when it is time to hang a new IV container. DIF: Cognitive Level: Application REF: Text reference: p. 695 |Text reference: p. 716 OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV. TOP: IV Tubing Change for Continuous Infusions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is caring for a patient diagnosed with pneumonia who receives IV antibiotics every
8 hours. How often should the nurse change the primary intermittent IV sets? a. No more often than every 72 hours b. At least every 72 hours c. With each IV bag change d. Every 24 hours ANS: D
You should change primary intermittent sets every 24 hours because the IV system becomes interrupted, which increases the risk for contamination. DIF: Cognitive Level: Application
REF: Text reference: p. 716
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV. TOP: IV Tubing Change for Intermittent Infusions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. What is an appropriate technique for the nurse to implement when changing the dressing at a
peripheral IV site? a. Wear sterile gloves to remove the old dressing. b. Keep one finger over the IV catheter until the tape is replaced. c. Cleanse with an antiseptic solution in a circular manner toward the site. d. Tape the connection between the IV catheter port and the tubing. ANS: B
Keep one finger over the catheter at all times until the tape or dressing secures placement. If the patient is restless or uncooperative, it is helpful to have another staff member assist with the procedure. Perform hand hygiene. Apply disposable gloves. Apply the final swab in a circular pattern, moving outward from the insertion site. Do not tape over the connection of the access tubing or port to the IV catheter. DIF: Cognitive Level: Application REF: Text reference: p. 721 OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV. TOP: IV Dressing Change KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. What should the nurse do when discontinuing a peripheral IV? a. Withdraw the catheter quN ickl URy.SINGTB.COM b. Keep the hub perpendicular to the skin. c. Apply pressure to the site for 1 minute. d. Inspect the catheter for intactness after removal. ANS: D
Inspect the catheter for intactness after removal, noting tip integrity and length. Place clean sterile gauze above the site, and withdraw the catheter, using a slow, steady motion. Keep the hub parallel to the skin. Do not raise or lift the catheter before it is completely out of the vein, to avoid trauma or hematoma formation. Apply pressure to the site for 2 to 3 minutes, using a dry, sterile gauze pad. Secure with tape. Note: Apply pressure for 5 to 10 minutes if the patient is taking anticoagulants. DIF: Cognitive Level: Application REF: Text reference: p. 724 OBJ: Demonstrate initiation of IV therapy, regulation of IV flow rate, changing of IV solutions, changing of IV tubing, changing of IV dressings, and discontinuation of a peripheral IV. TOP: Discontinuing a Peripheral IV KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The patient is expected to require intravenous therapy for several years as treatment for a
chronic disease process. Which of the following would be the best choice for venous access in this patient? a. Peripherally inserted central catheter (PICC) b. Nontunneled percutaneous central venous catheter c. Subcutaneous implanted port
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. Peripheral IV ANS: C
Implanted infusion ports are used for long-term and complex IV therapy. When not in use, no external catheter is present, and port manufacturers recommend that the port be heparinized every 4 weeks to maintain patency. No other care is required for an unused port. PICCs provide alternative IV access when the patient requires intermediate-length venous access (>7 days to several months). These catheters are used for shorter placements (e.g., 5 to 10 days). Use of peripheral IV therapy increases the risk for patients to develop infection, vein sclerosis, phlebitis, and infiltration. DIF: Cognitive Level: Synthesis REF: Text reference: pp. 724-725 OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Subcutaneous Implanted Ports KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 20. The nurse is assisting the physician during the insertion of a central line into the subclavian
vein. How should the nurse cleanse the area? a. With chlorhexidine in a back and forth scrubbing motion b. With chlorhexidine followed by alcohol in a back and forth scrubbing motion c. With alcohol in a circular motion for 5 minutes d. With antimicrobial solution that must be dabbed dry with a sterile towel ANS: A
Antiseptics such as chlorhexidine remove resident and transient bacteria. Alcohol should not be applied after the application of iodophor solution. Chlorhexidine is scrubbed in a back and forth motion for 30 seconds. Allow the antimicrobial solution to air-dry completely. This ensures maximum antimicrobNial R effeI ct. G B.C M
U S N T
O
DIF: Cognitive Level: Application REF: Text reference: p. 728 OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Inserting a Central Venous Access Device KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse is preparing to draw blood from a central venous access device for blood cultures.
Which of the following steps is part of that process? a. Apply sterile gloves. b. Flush the port with 5 to 10 mL of 0.9% sodium chloride. c. Slowly aspirate 5 mL of blood and discard the syringe. d. Use the distal lumen to draw blood. ANS: D
Use the distal (red or brown) lumen to draw blood if the device has more than one lumen. The distal (red or brown) lumen typically is the largest-gauge lumen. Apply clean gloves to prevent transfer of body fluids. Do not flush before drawing blood for blood cultures. If blood cultures have been ordered, do not discard any blood. Use the initial specimen for blood cultures. DIF: Cognitive Level: Application REF: Text reference: p. 730 OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Blood Sampling
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. What should the nurse do to decrease the potential for infection related to IV therapy? a. Use the clean technique for dressing changes. b. Change the IV tubing every 12 hours. c. Palpate the insertion site daily through the intact dressing. d. After cleansing the skin, dab it dry with a sterile gauze pad. ANS: C
Palpate the catheter insertion site for tenderness daily through the intact dressing. Perform hand hygiene before and after palpating, inserting, replacing, or dressing any intravascular device. Maintain use of sterile dressings. Replace IV tubing no more frequently than at 72-hour intervals unless clinically indicated. Allow the site to air-dry before proceeding with the procedure. DIF: Cognitive Level: Application REF: Text reference: p. 696 OBJ: Explain techniques for preventing transmission of infection for a patient receiving IV therapy. TOP: Standards to Decrease Intravascular Infection Related to IV Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse is caring for a patient with a continuous intravenous infusion of 0.9% normal saline
with 40 mEq of potassium chloride added to each liter. During a routine hourly check of the infusion, the nurse discovers that 4 hours of fluid has infused in the past 1 hour. The nurse’s first action should be to: a. notify the primary care provider. b. assess the patient. NURSINGTB.COM c. reduce the infusion rate. d. notify the charge nurse. ANS: C
If the intravenous fluid is infusing 4 times faster than ordered, the first intervention should be to reduce the rate. Notification of the primary care provider and the charge nurse would occur after the flow rate is reduced and an assessment of the patient is performed. Although assessing the patient is vitally important, you do not want to allow the fluid to continue infusing at a rapid rate while you are performing the assessment. DIF: Cognitive Level: Analysis REF: Text reference: p. 712 OBJ: Identify interventions required to prevent complications associated with TOP: IV Administration Rates KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. The nurse is caring for a patient who has experienced hypovolemia secondary to acute
vomiting and diarrhea. The nurse anticipates what type of intravenous fluid to be ordered by the health care provider? a. Hypotonic or isotonic solutions b. Hypertonic or isotonic solutions c. Hypertonic solutions only d. Whole blood ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Hypotonic solutions are administered for cellular dehydration, whereas isotonic solutions replace intravascular fluid, so both of these might be appropriate for this patient. Hypertonic solutions pull fluid from extravascular spaces and would not be appropriate for this patient. Whole blood is not indicated because there is no evidence of blood loss. DIF: Cognitive Level: Analysis REF: Text reference: p. 694 OBJ: Identify common types of intravenous fluids. TOP: Different IV Fluids KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 25. Which of the following patients would the nurse anticipate requiring the placement of a
central venous catheter? a. A patient in same-day surgery who might require blood transfusions b. A patient in the intensive care unit requiring multiple simultaneous intravenous medications c. A patient in the cardiac care unit diagnosed with possible myocardial infarction d. A patient on the surgical unit recovering from hernia repair ANS: B
The most likely candidate for a central venous catheter is the patient in intensive care requiring the administration of multiple medications. The central venous catheter will simplify the administration of multiple medications to this critically ill patient. Because same-day surgery patients are expected to go home at the end of the day, it would be unlikely this patient would need a central catheter. A patient diagnosed with myocardial infarction would be unlikely to need a central line unless his condition deteriorated. A patient post hernia repair would be unlikely to require a central venous line unless complications arose, which is not indicated in this scenario. DIF: Cognitive Level: ApplicN atiU onRSINGRT EB F:.C TeO xtMreference: p. 725 OBJ: Identify indications and contraindications for intravenous therapy and central venous lines. TOP: Tunneled Central Venous Catheters KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 26. The nurse assigns nursing assistive personnel (NAP) to care for several patients with
continuous IV infusions. Which of the following can NAP assist with? a. Changing empty IV solution containers b. Confirming the correct IV drip rate c. Assessing the patient for response to IV therapy d. Informing the nurse if they notice anything abnormal ANS: D
If UAP notice anything they consider abnormal, they should notify the nurse. It is the nurse’s responsibility to inform the UAP of specific things to look for. Changing empty IV solution containers cannot be delegated to UAP because the procedure requires knowledge of sterile technique. Confirming the correct IV drip rate is the nurse’s responsibility. Assessment is not the responsibility of UAP; it is the responsibility of the nurse. DIF: Cognitive Level: Application REF: Text reference: p. 697 OBJ: Recognize when it is appropriate to delegate aspects of intravenous therapy to unlicensed assistive personnel. TOP: Intravenous Devices KEY: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MULTIPLE RESPONSE 1. The patient is on daily weights and is receiving intravenous therapy. The nurse notices that the
patient has gained 2 kg since the previous morning. What else would the nurse expect to observe? (Select all that apply.) a. Dry skin and mucous membranes b. Distended neck veins c. Tenting of the skin d. Crackles or rhonchi in the lungs ANS: B, D
A change in body weight of 1 kg corresponds to 1 L of fluid retention or loss. Dry skin and mucous membranes suggest fluid volume deficit (FVD). Distended neck veins suggest fluid volume excess (FVE). Poor skin turgor is seen when after pinching, the skin fails to return to normal position within 3 seconds. With FVD, the pinched skin stays elevated for several seconds. This is called tenting. Auscultation of crackles or rhonchi in the lungs may signal fluid buildup in the lungs caused by FVE. DIF: Cognitive Level: Analysis REF: Text reference: p. 698 |Text reference: p. 707 OBJ: Discuss complications of IV therapy. TOP: Fluid Volume Excess KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. What should the nurse do upon noting that the patient’s IV site is pale, cool, and edematous?
(Select all that apply.) a. Stop the infusion. b. Elevate the extremity. c. Start a new IV. d. Flush the IV site.
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ANS: A, B, C
Infiltration is indicated by swelling and possible pitting edema, pallor, coolness, pain at the insertion site, and a possible decrease in flow rate. The nurse should stop the infusion and should discontinue the IV, elevate the affected extremity, start a new IV if continued therapy is necessary, and document the degree of infiltration and nursing intervention. Flushing the IV site is not recommended. DIF: Cognitive Level: Application REF: Text reference: p. 707 OBJ: Discuss complications of IV therapy. TOP: Infiltration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is preparing to start an IV on a 92-year-old patient. The nurse realizes that she may
need to take which of the following actions? (Select all that apply.) a. Avoid using veins in the hand. b. Avoid using veins in the dominant arm. c. Use the largest-gauge catheter possible for maximum flow. d. Avoid using a tourniquet. ANS: A, B, D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank In older patients, use the smallest gauge possible. For example, a 22-gauge needle is adequate for fluid and medication therapy; use a 24-gauge in frail, older adults. Smaller-gauge catheters are less traumatizing to the vein but still allow blood flow to provide increased hemodilution of IV fluids or medications. If possible, avoid the back of the older adult’s hand or the dominant arm for venipuncture because they interfere with the older adult’s independence. Minimize pressure from tourniquets, or avoid them if possible. Apply a blood pressure cuff in place of a tourniquet. DIF: Cognitive Level: Application REF: Text reference: p. 701 |Text reference: p. 708 OBJ: Explain how to prepare the patient and the family for IV therapy. TOP: Starting IVs in Older Patients KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. For which patients are electronic infusion devices (EIDs) used? (Select all that apply.) a. Those who require low hourly rates b. Those who are at risk for volume overload c. Those who have impaired renal clearance d. Those who are receiving fluids that require a specific hourly volume ANS: A, B, C, D
Infusion pumps are necessary for patients requiring low hourly rates, at risk for volume overload, with impaired renal clearance, or receiving medications or fluids that require a specific hourly volume. DIF: Cognitive Level: Knowledge REF: Text reference: p. 709 OBJ: Explain how to prepare the patient and the family for IV therapy. TOP: Electronic Infusion Device (EID) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IN ntU egR riS tyINGTB.COM 5. Central venous access devices (CVADs) can be used in the home, in the hospital, and in
long-term care facilities for patients who require which of the following? (Select all that apply.) a. Supplemental nutrition b. Blood and blood products c. Hemodynamic monitoring d. Blood sampling ANS: A, B, C, D
CVADs can be used in the home, in the hospital, and in long-term care facilities for patients who require supplemental nutrition, blood and blood products, continuous fluids, medications, hemodynamic monitoring, and blood sampling. DIF: Cognitive Level: Comprehension REF: Text reference: p. 716 |Text reference: pp. 724-725 OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Central Venous Access Devices (CVADs) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. Which of the following are CVADs? (Select all that apply.) a. Implanted subcutaneous ports b. Peripherally inserted central catheter (PICC) lines c. Saline locks
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. Heparin locks ANS: A, B
Four types of CVADs are available: nontunneled percutaneous central venous catheters, tunneled central venous catheters, PICCs, and implanted subcutaneous ports. DIF: Cognitive Level: Comprehension REF: Text reference: p. 724 OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Central Venous Access Devices (CVADs) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. Fluids that have the same osmolality as body fluids are used most often to replace
extracellular volume and are known as
fluids.
ANS:
isotonic Isotonic fluids have the same osmolality as body fluids and are used most often to replace extracellular volume (e.g., prolonged vomiting). Isotonic fluids effectively mimic the body’s fluid loss in the absence of an electrolyte imbalance. DIF: Cognitive Level: Knowledge REF: Text reference: p. 694 OBJ: Discuss patient conditions requiring intravenous (IV) therapy. TOP: Isotonic Fluids KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2.
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pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that possibly will result in pulmonary edema. ANS:
Hypertonic solutions Hypertonic solutions pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that possibly will result in pulmonary edema. DIF: Cognitive Level: Knowledge REF: Text reference: p. 694 OBJ: Discuss complications of IV therapy. TOP: Hypertonic Fluids KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient who will be on long-term antibiotic therapy. The patient has
had numerous IVs in the past, but because the upcoming therapy will be given on a long-term basis, the nurse suggests that a be inserted. ANS:
central venous access device (CVAD) CVADs, which include nontunneled and tunneled catheters, PICCs, and implanted ports, are designed for long-term use. DIF: Cognitive Level: Comprehension REF: Text reference: p. 724 OBJ: Discuss patient conditions requiring intravenous (IV) therapy.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Central Venous Access Devices (CVADs) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is caring for a patient who has a peripheral IV. While performing her routine
assessment, she notes that the insertion site is pale, cool, and edematous. The patient indicates that the site is also painful to the touch. The nurse recognizes these symptoms as revealing a possible . ANS:
infiltration Infiltration is indicated by swelling and possible pitting edema, pallor, coolness, pain at the insertion site, and a possible decrease in flow rate. DIF: Cognitive Level: Analysis REF: Text reference: p. 707 OBJ: Discuss complications of IV therapy. TOP: Infiltration KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 5.
is manifested by decreased urine output, dry mucous membranes, decreased capillary refill, a disparity in central and peripheral pulses, tachycardia, hypotension, and shock. ANS:
Fluid volume deficit (FVD) FVD is manifested by decreased urine output, dry mucous membranes, decreased capillary refill, a disparity in central and peripheral pulses, tachycardia, hypotension, and shock. DIF: Cognitive Level: Knowledge REF: Text reference: p. 707 N R I G OBJ: Discuss complications of IU V thS erapNy. TB.C TO Fluid Volume Deficit OPM: KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 6. The nurse is caring for a patient who is receiving IV fluids at a rate of 150 mL per hour.
During her assessment, the nurse notes that the patient is having more labored respirations, and that crackles have developed in the patient’s lungs. The nurse reduces the IV rate and notifies the physician. She does this while recognizing that the patient is experiencing signs of . ANS:
fluid volume excess (FVE) FVE is manifested by crackles in the lungs, shortness of breath, and edema. DIF: Cognitive Level: Analysis REF: Text reference: p. 707 OBJ: Discuss complications of IV therapy. TOP: Fluid Volume Excess KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 7. While assessing the patient’s IV site, the nurse notes that the site is reddened and warm. The
patient states that it is “sore.” The nurse recognizes these as signs of
.
ANS:
phlebitis Phlebitis is indicated by pain, increased skin temperature, and erythema along the path of the vein.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Application REF: Text reference: p. 707 OBJ: Discuss complications of IV therapy. TOP: Phlebitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. An electronic device that delivers a measured amount of intravenous fluid over a specified
period (e.g., 100 mL/hr) using positive pressure is called an
.
ANS:
electronic infusion device (EID) An EID delivers a measured amount of fluid over a specified period (e.g., 100 mL/hr) using positive pressure. EIDs use an electronic sensor and an alarm that signals if the pressure in the system changes and the desired flow rate is altered. DIF: Cognitive Level: Knowledge REF: Text reference: p. 709 OBJ: Explain how to prepare the patient and the family for IV therapy. TOP: Electronic Infusion Device (EID) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. Intravenous pumps that have built-in software programmed from health care pharmacy
databases with unit-specific profiles are known as
.
ANS:
smart pumps A new generation of IV infusion safety systems reduce medication administration errors. Known as smart pumps, they are designed to serve as a final step in preventing errors that relate directly to administratiN onUoRf S IVIm edT icB at. ioC nsO. M They have built-in software programmed NG from health care pharmacy databases with unit-specific profiles. DIF: Cognitive Level: Knowledge REF: Text reference: p. 709 OBJ: Explain how to prepare the patient and the family for IV therapy. TOP: Smart Pumps KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. An intravenous catheter that is inserted through a large arm vein and is advanced until the tip
enters the central venous system is known as a
.
ANS:
peripherally inserted central catheter (PICC) A PICC is inserted through a large arm vein (e.g., cephalic or basilic vein) and is advanced until the tip enters the central venous system in the lower third of the superior vena cava. DIF: Cognitive Level: Knowledge REF: Text reference: p. 724 OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Peripherally Inserted Central Catheter (PICC) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. Intravenous catheters that are inserted directly through the skin and into the internal or
external jugular, subclavian, or femoral vein for up to several weeks are known as .
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS:
nontunneled percutaneous venous access devices Nontunneled percutaneous venous access devices are inserted directly through the skin and into the internal or external jugular, subclavian, or femoral vein. The tip of the catheter rests in the superior vena cava. These catheters may be left for anywhere from several days up to several weeks. DIF: Cognitive Level: Knowledge REF: Text reference: p. 724 OBJ: Identify common types of central vascular access devices (CVADs), and describe their care and maintenance. TOP: Nontunneled Percutaneous Central Venous Catheters KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12.
are surgically inserted through a tunnel into subcutaneous tissue, usually between the clavicle and the nipple, into the internal jugular or subclavian vein, with the catheter tip resting in the distal end of the superior vena cava. The subcutaneous tunnel allows the catheter to remain in place for months to years. ANS:
Tunneled central venous catheters Tunneled central venous catheters are surgically inserted through a tunnel into subcutaneous tissue, usually between the clavicle and the nipple (Figure 28-7), into the internal jugular or subclavian vein, with the catheter tip resting in the distal end of the superior vena cava. The subcutaneous tunnel allows the catheter to remain in place for months to years. DIF: Cognitive Level: Knowledge REF: Text reference: pp. 724-725 OBJ: Identify common types oNf U ceR ntS raI l vNaG scT ulaBr . acC ceO ssMdevices (CVADs), and describe their care and maintenance. TOP: Tunneled Central Venous Catheters KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 29: Blood Transfusions MULTIPLE CHOICE 1. For how long may blood preserved with CPD be stored (unfrozen) before use? a. 21 days b. 35 days c. 42 days d. 3 months ANS: A
When preserved with citrate, phosphate, and dextrose a unit of blood has a shelf life of 21 days (unfrozen). DIF: Cognitive Level: Knowledge REF: Text reference: p. 738 OBJ: Discuss indications for blood therapy. TOP: Packed Red Cells KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is caring for a patient who needs a blood transfusion. The patient has been tested
and was found to have blood type O. The nurse knows this means that which antigen is present on the surface of the red blood cells? a. The type A antigen is present. b. The type B antigen is present. c. Neither type A nor type B antigens are present. d. Both type A and type B antigens are present. ANS: C
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When neither A nor B antigens are present, the blood group is type O. When the type A antigen is present, the blood group is type A. When the type B antigen is present, the blood group is type B. When both A and B antigens are present, the blood group is type AB. DIF: Cognitive Level: Application REF: Text reference: p. 758 OBJ: Describe various transfusion reactions. TOP: Blood Type KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. A nurse is concerned about the type of blood that a patient is to receive. A patient with an O
blood type may safely receive which type of blood? a. Type A blood b. Type B blood c. Type AB blood d. Type O blood ANS: D
People with type O blood have both A and B antibodies and therefore can receive only type O blood. People with type A blood have anti-B antibodies and therefore can receive only type A blood. People with type B blood have anti-A antibodies and therefore can receive only type B blood. People with type AB blood have neither antibody and therefore can receive all blood types. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 738-739 OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Type O Blood KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The patient is brought to the emergency department after a motor vehicle accident and has lost
a large volume of blood. The patient’s blood type is AB. Which blood type may this patient safely receive in transfusion? a. Only type AB blood b. Only type O blood c. All blood types d. Only type A blood ANS: C
People with type AB blood have neither antibody and therefore can receive all blood types. DIF: Cognitive Level: Application REF: Text reference: pp. 738-739 OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Type AB Blood KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The patient is scheduled to receive a blood transfusion. Preadministration laboratory tests are
run to assess the level of which component in the patient’s blood? a. Sodium (Na) b. Calcium (Ca) c. Potassium (K) d. Iron (Fe) ANS: C
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When blood is stored, there is continual destruction of RBCs, which releases potassium from the cells into the plasma. If blood is transfused rapidly, transient elevated potassium levels may occur before the potassium is reabsorbed and put the patient at risk. DIF: Cognitive Level: Application REF: Text reference: p. 738 |Text reference: p. 740 OBJ: Describe various transfusion reactions. TOP: Hypocalcemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The patient has received a total of 7 units of blood over the past 8 hours. The nurse assesses
the patient’s laboratory test results. Which of the following would be an expected complication? a. Hypokalemia b. Hyperkalemia c. Hypercalcemia d. Iron deficiency ANS: B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank When blood is stored, there is continual destruction of RBCs, which releases potassium from the cells into the plasma. If blood is transfused rapidly, transient hyperkalemia may occur before the potassium is reabsorbed. Blood that is preserved with citrate phosphate dextrose (CPD) contains a high concentration of citrate ions. The excess citrate may combine with the ionized calcium in the recipient’s blood, resulting in transient low ionized calcium levels. Patients receiving multiple transfusions should be assessed for iron overload. DIF: Cognitive Level: Application REF: Text reference: p. 748 OBJ: Describe various transfusion reactions. TOP: Hyperkalemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The patient is to receive 2 units of packed RBCs. The units are cold, and the nurse is
concerned that this could lead to dysrhythmias and/or a reduction in core temperature. What action may the nurse take to prevent this? a. Warm the blood in a microwave. b. Warm the blood using hot water. c. Warm the blood using a blood warmer. d. Allow the blood to warm to room temperature before administering. ANS: C
In emergency situations, rapid transfusion of cold blood may lead to dysrhythmias and a reduction in core temperature. Sometimes a blood warmer machine is used for large transfusions of greater than 50 mL/kg/hr or in patients with cold agglutinins. Heating blood products in a microwave or with hot water is dangerous and may destroy blood cells. Blood must be given within a prescribed time frame. Allowing the blood to come to room temperature before administration would decrease the time available for administration.
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DIF: Cognitive Level: Application REF: Text reference: p. 742 OBJ: Describe various transfusion reactions. TOP: Blood Warmer KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The patient is scheduled to receive 1 unit of packed RBCs. She has small, fragile veins, and a
22-gauge intravenous (IV) patent catheter is in place. What should the nurse do? a. Cancel the blood transfusion. b. Insert a 16-gauge IV catheter into the antecubital fossa. c. Use the IV catheter that is in place. d. Transfuse the blood over 6 hours. ANS: C
In emergency situations that require rapid transfusions, a large-gauge cannula is preferred; however, transfusions for therapeutic indications may be infused with cannulas ranging from 20 to 24 gauge. Large-gauge cannulas (18 or 20 gauge) promote rapid flow of blood components. 16-Gauge catheters are used frequently in surgery, but not usually on acute care units. Blood must be transfused within 4 hours. Use of smaller-gauge cannulas, such as 24 gauge, often requires the blood bank to divide the unit so that each half can be infused within the allotted time or requires the use of pressure-assisted devices. DIF: Cognitive Level: Application REF: Text reference: p. 744 OBJ: Describe various transfusion reactions. TOP: IV Catheter Size
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. What primary intervention should a nurse who is preparing a blood transfusion perform? a. Set up the Y tubing. b. Obtain 0.9% saline. c. Verify the blood product and the patient. d. Have the patient void or empty the urine drainage container. ANS: C
Correctly verify the product and identify the patient with a person considered qualified by your agency. Strict adherence to verification procedures before administration of blood or blood components reduces the risk of administering the wrong blood to the patient. Clerical errors are the cause of most hemolytic transfusion reactions. Y tubing is used to facilitate maintenance of IV access in case a patient will need more than 1 unit of blood. However, the focus here is on prevention of possible blood reactions. Use of Y tubing will not prevent a blood reaction. Normal saline is compatible with blood products, unlike solutions that contain dextrose, which causes coagulation of donor blood. However, strict adherence to verification procedures before administration of blood or blood components reduces the risk of administering the wrong blood to the patient. Empty the urine drainage collection container or have the patient void. If a transfusion reaction occurs, a urine specimen containing urine produced after initiation of the transfusion will be sent to the laboratory. DIF: Cognitive Level: Application REF: Text reference: p. 746 OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Pretransfusion Procedure KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IN ntU egR riS tyINGTB.COM 10. The patient is to receive 1 unit of packed RBCs. The nurse obtains the blood from the blood
bank and returns to the unit to find that the patient has been taken to radiology for a CT scan and is expected to return in about an hour. What should the nurse do? a. Go to radiology and administer the blood. b. Keep the blood refrigerated until the patient returns. c. Return the blood to the blood bank. d. Hang the blood in the patient’s room and start it when the patient returns. ANS: C
Initiate the blood transfusion within 30 minutes of the time of release from the blood bank. If you cannot do this because the patient is in the bathroom or the physician has to be notified of an elevated temperature, immediately return the blood to the blood bank, and retrieve it when you can administer it. DIF: Cognitive Level: Application REF: Text reference: p. 745 OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Delayed Start of Transfusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 11. The nurse is preparing to administer a unit of blood to a patient using blood tubing. On the
blood product side of the Y tubing, she will hang blood. What will she hang on the other side of the Y tubing? a. Dextrose 5% b. Normal saline c. Dextrose 10% d. Dextrose 5%/normal saline ANS: B
Normal saline is compatible with blood products, unlike solutions that contain dextrose, which causes coagulation of donor blood. DIF: Cognitive Level: Application REF: Text reference: p. 747 OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Normal Saline and Blood Products KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse is administering blood. What should the nurse do to detect a blood reaction as
quickly as possible? a. Remain with the patient during the first 15 minutes. b. Transfuse the blood at 10 mL/min. c. Monitor vital signs q 1 hour. d. Transfuse blood at 50 gtt/min. ANS: A
Remain with the patient during the first 15 minutes of a transfusion. Most transfusion reactions occur within the firN st 15RmI es oB U Sinut NG T f a.tCrans OMfusion. The initial flow rate during this time should be 2 mL/min, or 20 gtt/min. Initially infusing a small amount of blood component minimizes the volume of blood to which the patient is exposed, thereby minimizing the severity of a reaction. Monitor the patient’s vital signs at 5 minutes, at 15 minutes, and every 30 minutes until 1 hour after transfusion or per agency policy. Frequent monitoring of vital signs will help to quickly alert the nurse to a transfusion reaction. DIF: Cognitive Level: Application REF: Text reference: p. 748 OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Early Detection of Blood Reaction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. An appropriate technique for the nurse to implement for a blood transfusion is to: a. provide medication through the IV line with the blood. b. regulate the flow of blood so that it infuses over 8 hours. c. clear the IV tubing with normal saline after the blood infuses. d. administer a blood product with clots through a filter line. ANS: C
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank After the blood has infused, clear the IV line with 0.9% normal saline and discard the blood bag according to agency policy. Medication should never be injected into the same IV line as a blood component because of the risk of contaminating the blood product with pathogens and the possibility of incompatibility. A separate IV line must be maintained if the patient requires IV infusion (total parenteral nutrition, pain control) during the transfusion. A unit of blood should not hang for longer than 4 hours because of the danger of bacterial growth. Check the appearance of blood product for leaks, bubbles, clots, or a purplish color. Do not transfuse blood if its integrity is compromised. Blood serves as a medium for bacteria. DIF: Cognitive Level: Application REF: Text reference: p. 748 OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Blood Product Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. When a patient’s adverse reaction to a blood transfusion is differentiated, which of the
following signs/symptoms indicates the presence of an anaphylactic response? a. Wheezing and chest pain b. Headache and muscle pain c. Hypotension and tingling of the extremities d. Crackles in the lungs and increased central venous pressure ANS: A
Observe the patient for wheezing, chest pain, and possible cardiac arrest. All of these are indications of an anaphylactic reaction. Be alert to patient complaints of headache or muscle pain in the presence of a fever. Both may be indicative of a febrile nonhemolytic reaction. Observe patients receiving massive transfusions for mild hypothermia, cardiac dysrhythmias, hypotension, and hypocalcemNiaU. R CS olI dN blG ooTdBp. roC duOcM ts can affect the cardiac conduction system, resulting in ventricular dysrhythmias. Other cardiac dysrhythmias, hypotension, and tingling may indicate hypocalcemia, which occurs when citrate (used as a preservative for some blood products) combines with the patient’s calcium. Crackles in the bases of lungs and rising central venous pressure (CVP) are indications of circulatory overload. DIF: Cognitive Level: Analysis REF: Text reference: p. 750 OBJ: Describe various transfusion reactions. TOP: Anaphylactic Response KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 15. The patient is receiving a unit of packed RBCs. Fifteen minutes into the procedure, he
complains of severe kidney pain, and his temperature increases by 3° F. The nurse stops the transfusion immediately, suspecting that which of the following reactions is occurring? a. Delayed hemolytic transfusion reaction b. Nonhemolytic febrile reaction c. Acute hemolytic transfusion reaction d. Severe allergic reaction ANS: C
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Symptoms of an acute hemolytic reaction usually begin within 15 minutes of transfusion initiation and include severe pain in the kidney area and chest, increased temperature (up to 105 F), increased heart rate, and a sensation of heat and pain along the vein receiving blood, as well as chills, low back pain, headache, nausea, chest or back pain, chest tightness, dyspnea, bronchospasm, anxiety, hypotension, vascular collapse, disseminated intravascular coagulation, and possibly death. Symptoms of a delayed hemolytic reaction usually begin 2 to 14 days after the transfusion and include unexplained fever, an unexplained decrease in hemoglobin/hematocrit (Hgb/Hct), increased bilirubin levels, and jaundice. Symptoms of a nonhemolytic febrile reaction begin between 30 minutes after initiation and 6 hours after completion of transfusion and include fever greater than 1 C above baseline, flushing, chills, headache, and muscle pain; they occur most frequently in immunosuppressed patients. Symptoms of an acute severe allergic reaction usually begin within 5 to 15 minutes of initiation of transfusion and include coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of consciousness, and possible cardiac arrest. DIF: Cognitive Level: Analysis REF: Text reference: p. 740 OBJ: Describe various transfusion reactions. TOP: Acute Hemolytic Reaction KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 16. The patient has been home from the hospital for 10 days. On the last day of his
hospitalization, he received 2 units of packed RBCs. This morning, he noticed that his skin had a yellow tint to it and his temperature was elevated. Which reaction might this patient be experiencing? a. Delayed hemolytic transfusion reaction b. Acute hemolytic transfusion reaction c. Nonhemolytic febrile reaction d. Severe allergic transfusioN nU reR acStiI onNGTB.COM ANS: A
Symptoms of a delayed hemolytic reaction usually begin 2 to 14 days after the transfusion and include unexplained fever, unexplained decrease in Hgb/Hct, increased bilirubin levels, and jaundice. Symptoms of an acute hemolytic reaction usually begin within 15 minutes of transfusion initiation and include severe pain in the kidney area and chest, increased temperature (up to 105 F), increased heart rate, and increased sensation of heat and pain along the vein receiving blood, as well as chills, low back pain, headache, nausea, chest or back pain, chest tightness, dyspnea, bronchospasm, anxiety, hypotension, vascular collapse, disseminated intravascular coagulation, and possibly death. Symptoms of a nonhemolytic febrile reaction begin between 30 minutes after initiation and 6 hours after completion of transfusion and include fever greater than 1 C above baseline, flushing, chills, headache, and muscle pain; they occur most frequently in immunosuppressed patients. Symptoms of an acute severe allergic reaction usually begin within 5 to 15 minutes of initiation of transfusion and include coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of consciousness, and possible cardiac arrest. DIF: Cognitive Level: Analysis REF: Text reference: p. 741 OBJ: Describe various transfusion reactions. TOP: Delayed Hemolytic Reaction KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 17. The specific blood product used for replacement of clotting factors and fibrinogen is: a. whole blood.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. packed RBCs. c. cryoprecipitate. d. albumin, 25% pooled. ANS: C
Cryoprecipitate replaces factors VIII and XIII, von Willebrand’s factor, and fibrinogen. It also replaces red cell mass and plasma volume and is expected to raise hemoglobin by 1 g/100 mL and hematocrit by 3% in a nonhemorrhaging adult. Using cryoprecipitate is the preferred method of replacing red blood cell mass. DIF: Cognitive Level: Knowledge REF: Text reference: p. 743 OBJ: Discuss indications for blood therapy. TOP: Cryoprecipitate KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 18. The nurse is administering 1 unit of packed red blood cells as ordered by the primary care
provider. While the nurse is measuring vital signs 15 minutes after starting the transfusion, the patient complains of chills and back pain. What is the nurse’s first action? a. Stop the blood transfusion and keep the vein patent by administering saline to infuse from the other side of the Y tubing. b. Slow the blood transfusion and notify the charge nurse. c. Disconnect the blood tubing from the catheter and replace it with an infusion of normal saline. d. Stop the blood transfusion and notify the primary care provider. ANS: C
The nurse’s first priority is to stop the blood transfusion. To keep the intravenous site patent, normal saline can be infused at a keep-open rate, but the tubing must be changed to avoid administering more blood as N the neNfG lush heObMlood from the tubing. If the tubing is not URsali SI TBes.tC changed, additional blood will be administered, and the possible transfusion reaction will increase. The charge nurse or the primary care provider should be notified only after the patient has been assessed. DIF: Cognitive Level: Application REF: Text reference: p. 748 |Text reference: p. 751 OBJ: Verbalize the skills used in administering blood transfusions. TOP: Transfusion Reaction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Transfusion therapy is the intravenous (IV) administration of which of the following? (Select
all that apply.) a. Whole blood b. Plasma products c. Red blood cells (RBCs) d. Platelets ANS: A, B, C, D
Transfusion therapy or blood replacement is the IV administration of whole blood, its components, or plasma-derived product for therapeutic purposes. DIF: Cognitive Level: Comprehension
REF: Text reference: p. 737
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Discuss indications for blood therapy. TOP: Transfusion Therapy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. What is the purpose of administering a transfusion? (Select all that apply.) a. Restore intravascular volume. b. Restore the oxygen-carrying capacity of blood. c. Provide clotting factors. d. Improve blood pressure. ANS: A, B, C
Transfusions are used to restore intravascular volume with whole blood or albumin, to restore the oxygen-carrying capacity of blood with RBCs, and to provide clotting factors and/or platelets. Although increasing blood volume may increase blood pressure, increasing blood pressure is not a primary objective of transfusion. DIF: Cognitive Level: Comprehension REF: Text reference: p. 737 OBJ: Discuss indications for blood therapy. TOP: Transfusion Therapy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. The patient is to receive 2 units of packed RBCs. Before administering the blood, what does
the nurse need to do? (Select all that apply.) a. Insert an 18-gauge IV cannula. b. Have the patient complete a consent form. c. Obtain pretransfusion vital signs. d. Notify the physician for a temperature of 37° C. ANS: B, C
In emergency situations that N requRire I rapiG d transfusioMns, a large-gauge cannula is preferred; U S indications N TB.C O however, transfusions for therapeutic may be infused with cannulas ranging from 20 to 24 gauge. Check that the patient has properly completed and signed transfusion consent before retrieving blood. Most agencies require patients to sign consent forms before receiving blood component therapy because of the inherent risks. Obtain and record pretransfusion vital signs, including temperature, immediately before initiation of the transfusion. If the patient is febrile (temperature greater than 100 F [37.8 C]), notify the physician or the health care provider before initiating the transfusion. Change from baseline vital signs during infusion will alert the nurse to a potential transfusion reaction or adverse effect of therapy. DIF: Cognitive Level: Application REF: Text reference: p. 744 OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Pretransfusion Procedure KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The patient is receiving blood when he suddenly complains of low back pain and develops
diaphoresis and chills. The nurse should: (Select all that apply.) a. stop the transfusion. b. start normal saline connected to the Y tubing. c. notify the physician. d. start normal saline using new IV tubing. ANS: A, C, D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank If signs of a transfusion reaction occur, stop the transfusion, start normal saline with new primed tubing directly to the ventricular assist device (VAD) at the keep-vein-open rate (KVO), and notify the physician immediately. DIF: Cognitive Level: Application REF: Text reference: pp. 748-749 |Text reference: p. 751 OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Blood Reaction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. Symptoms that indicate an adverse reaction to blood products include which of the following?
(Select all that apply.) a. Fever b. Skin rash c. Hypotension d. Cardiac arrest ANS: A, B, C, D
Symptoms that indicate an adverse reaction range from fever, chills, and skin rash to hypotension and cardiac arrest. DIF: Cognitive Level: Knowledge REF: Text reference: p. 750 OBJ: Describe various transfusion reactions. TOP: Symptoms of a Blood Product Reaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION
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1. A transfusion in which the donor is the patient is known as an
transfusion or
autotransfusion. ANS:
autologous In autologous transfusion, or autotransfusion, the donor is the patient. DIF: Cognitive Level: Knowledge REF: Text reference: p. 737 OBJ: Discuss indications for blood therapy. TOP: Autologous Transfusion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The presence or absence of specific antigens on the surface of red blood cells determines
in the ABO system. ANS:
blood type The presence or absence of specific antigens on the surface of red blood cells determines blood type in the ABO system. DIF: Cognitive Level: Knowledge REF: Text reference: p. 738 OBJ: Describe various transfusion reactions. TOP: Blood Type KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 3. Antibodies that react against the A and B antigens are naturally present in the plasma of
people whose red blood cells do not carry the antigen. These antibodies react against the foreign antigens. Incompatible red blood cells clump together or , which results in a life-threatening hemolytic transfusion reaction. ANS:
agglutinate Antibodies that react against the A and B antigens are naturally present in the plasma of people whose red blood cells do not carry the antigen. These antibodies (agglutinins) react against the foreign antigens (agglutinogens). Incompatible red blood cells agglutinate (clump together), which results in a life-threatening hemolytic transfusion reaction. DIF: Cognitive Level: Knowledge REF: Text reference: p. 738 OBJ: Describe various transfusion reactions. TOP: Agglutination KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is caring for a patient who is receiving blood while monitoring the patient for
potential complications. The nurse knows that a systemic response to administration of a blood product that is incompatible with the blood of the recipient, contains allergens to which the recipient is sensitive or allergic, or is contaminated with pathogens is known as a . ANS:
hemolytic reaction A hemolytic reaction is a systemic response to the administration of a blood product that is incompatible with the blood of the recipient, contains allergens to which the recipient is sensitive or allergic, or is conNtamRinaI ted G withBp. atC hogM ens.
U S N T
O
DIF: Cognitive Level: Knowledge REF: Text reference: p. 740 |Text reference: p. 750 OBJ: Describe various transfusion reactions. TOP: Hemolytic Reaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The patient has received blood within the past 6 hours. The patient begins to feel short of
breath and calls for the nurse. The nurse finds that the patient is dusky in color with crackles throughout his lungs and is coughing up pink frothy sputum. The nurse calls the physician immediately, knowing that the patient is showing signs of . ANS:
transfusion-related acute lung injury (TRALI) Possible adverse outcomes that result from transfusion therapy include transmission of diseases, circulatory overload, and TRALI characterized by noncardiogenic pulmonary edema with onset within 6 hours of transfusion. DIF: Cognitive Level: Analysis REF: Text reference: p. 750 OBJ: Describe various transfusion reactions. TOP: Transfusion-Related Acute Lung Injury (TRALI) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. Under the ABO system, the blood type
known as the “Universal Donor.”
can be given to any individual and is
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS:
O negative O negative can be given to people of any blood type and is known as the “Universal Donor.” DIF: Cognitive Level: Knowledge REF: Text reference: p. 739 OBJ: Demonstrate the following skills on selected patients: initiating blood therapy, implementing autotransfusion, and monitoring for adverse reactions to transfusion. TOP: Universal Donor KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 30: Oral Nutrition MULTIPLE CHOICE 1. The nurse is admitting a person to the unit and is assessing the patient’s nutritional status. In
assessing the patient’s nutritional status, the nurse realizes that: a. body mass index (BMI) is the main indicator of obesity. b. ideal body is the standard gauge for nutritional status. c. clinical judgment is required, along with other indicators. d. the amount of weight change is the main nutritional indicator. ANS: C
Use clinical judgment when evaluating muscular patients or patients with large amounts of edema or ascites, because these physiological states will lead to false overestimation of the degree of fatness. BMI alone is not a perfect predictor of overweight or obesity. You gather weight information in several ways, including usual body weight (UBW), ideal body weight (IBW), actual body weight (ABW), and BMI. A thorough nutritional assessment usually requires the collection of all of these weight measures. The magnitude and direction of weight change are more meaningful than standardized weight references when one is dealing with sick or debilitated patients. DIF: Cognitive Level: Application REF: Text reference: p. 761 OBJ: Perform accurate nutritional screening. TOP: Anthropometrics/Body Weight KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is assessing the paN tieUnR t fS orInN uG triT tioBn. alCsO taM tus. Which laboratory value may indicate
compromised protein status? a. Serum albumin level of 4.0 g/dL b. Prealbumin level of 12 g/dL c. Total lymphocyte count of 1600 cells/mm3 d. Prealbumin level of 35 g/dL ANS: B
Prealbumin normally ranges from 20 to 50 mg/dL. This test is useful for monitoring short-term changes in visceral protein (Grodner et al, 2004). It has a short half-life of 2 days. A patient has compromised protein status when levels are between 10 and 15 g/dL. Normal serum albumin values are between 3.5 and 5.0 g/dL. For nutritional analysis, values between 2.8 and 3.5 g/dL indicate compromised protein status. Total lymphocyte count (TLC) is a useful measure of immune function. A normal TLC is greater than 1500 cells/mm3. You must assess a measure of TLC along with other diagnostic indicators. A count of less than 1500/mm3 indicates possible immunocompromise associated with protein-energy malnutrition. DIF: Cognitive Level: Comprehension REF: Text reference: p. 762 OBJ: Perform accurate nutritional screening. TOP: Prealbumin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient diagnosed with severe dehydration. She notes that the
patient’s albumin level is 4.0. What may this indicate?
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
The patient is in a compromised protein state. The level may be falsely high. An acute nutritional deficiency. A long-term nutritional deficiency.
ANS: B
In patients who are dehydrated or who have received infusions of albumin, fresh frozen plasma, or whole blood, serum albumin levels will appear normal. Normal serum albumin values are between 3.5 and 5.0 g/dL. Albumin is a useful test for monitoring long-term nutrition changes because normal values still may be found among patients who are malnourished. For nutritional analysis, values between 2.8 and 3.5 g/dL indicate compromised protein status. Normal serum albumin values are between 3.5 and 5.0 g/dL. DIF: Cognitive Level: Analysis REF: Text reference: p. 762 OBJ: Perform accurate nutritional screening. TOP: Albumin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is caring for a patient who requires assistance with eating. The patient repeatedly
apologizes to the nurse, saying, “I’m so sorry. I’m like a baby. I’m such a burden since I can’t even feed myself.” What is the most appropriate strategy for the nurse to use? a. Feed all of the solid foods first, and then offer liquids. b. Feed the patient quickly so as not to make the patient feel like it is taking a great deal of time out of the nurse’s day. c. Minimize conversation so that the patient can eat faster. d. Appear unhurried, sit at the bedside, and encourage the patient to feed himself/herself as much as possible. ANS: D
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Meals should be a pleasant event for the patient. Conversation promotes socialization. Adults who need help to eat need compassion and understanding. Given the importance of nutrition in the healing process the nurse should use common sense to provide a socially meaningful mealtime. Feeding the patient quickly is likely to accentuate his belief that he is a burden. It is best to offer fluids after every 3 or 4 bites of solid food, or whenever the patient requests a drink. DIF: Cognitive Level: Application REF: Text reference: p. 764 |Text reference: p. 767 OBJ: Verbalize the steps used in assisting an adult to eat. TOP: Assisting the Patient with Oral Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 5. What must the nurse do before assisting the patient with feeding? a. Assess the patient’s gag reflex. b. Make sure that the consistency of the food is thin. c. Remove the patient’s dentures to prevent gagging. d. Prepare the patient to be fed by a staff member. ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Assess the patient’s ability to swallow and the patient’s gag reflex. Some patients (those who have neurological diseases or who are handicapped) have a reduced gag reflex and/or dysphagia, increasing the risk for aspiration. Changes in the consistency of the diet (thickened liquids, pureed, soft), swallow training, or alternative means of nutrition are often necessary and require a speech therapist or a registered dietitian. If the patient wears dentures, check to ensure that they fit well and are clean. This ensures that the patient is able to chew food and swallow more normally. Patients with any level of independence should not be totally fed by hospital staff. A thorough understanding of the patient’s physical and cognitive limitations alerts the nurse to the type of assistance the patient needs. DIF: Cognitive Level: Application REF: Text reference: p. 765 OBJ: Perform accurate nutritional screening. TOP: Assisting the Patient with Oral Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is caring for an infant who is 3 months old and is being bottle-fed human milk. Will
the nurse need to provide the infant with any additional sources of nutrition or fluids? a. The infant will need extra water in between feedings. b. The infant will need juice in between feedings. c. No additional fluids will be needed between meals. d. The child will need to start on infant cereal. ANS: C
Human milk is the most desirable complete diet for infants during the first 6 months. Infants who are breast- or bottle-fed human milk do not require additional fluids, especially water or juice, during the first 4 months of life. Excessive intake of water causes water intoxication, IyNpG failure to thrive, and hyponatN reU mR iaS .T icT allB y. , iC nfO anMts do not consume solid foods until 4 to 6 months of age. Iron-fortified infant cereal is usually the first solid food to be offered. DIF: Cognitive Level: Application REF: Text reference: p. 768 OBJ: Perform accurate nutritional screening. TOP: Pediatric Considerations with Oral Feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. What is an appropriate technique for the nurse to use to prevent aspiration when assisting a
patient with meals? a. Keep the patient’s head back and straight. b. Offer thin-consistency foods. c. Provide large amounts of fluids. d. Have the patient sit up for 30 minutes after eating. ANS: D
Ask the patient to remain sitting upright for at least 30 minutes after the meal to reduce the risk for gastroesophageal reflux, which can cause aspiration. The patient must be sitting upright for passage of food through the pharynx and esophagus. Observe the patient’s ability to ingest foods of various textures and thicknesses to indicate whether aspiration risk is increased with thin liquids. Observe the patient with various consistencies of liquids. Difficulty managing certain foods may indicate dysphagia, and referral to a dietitian is appropriate if a patient has difficulty with a particular consistency.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Application REF: Text reference: p. 772 OBJ: Identify risk factors for aspiration related to dysphagia. TOP: Preventing Aspiration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. The patient is admitted with a diagnosis of stroke. The nurse attempts to feed the patient, but
the patient coughs and gags when food is placed in his mouth. What should the nurse do to assist this patient? a. Feed the patient more slowly. b. Feed the patient more quickly. c. Contact the speech pathology department. d. Ignore the cough and try again later. ANS: C
If the patient coughs, gags, complains of food “stuck in the throat,” or has pockets of food in the mouth, the patient may require a swallowing evaluation by a licensed speech pathologist or by videofluoroscopy. Consider consultation with a speech therapist for swallowing exercises and techniques to improve swallowing and reduce risk for aspiration. Notify the physician of any symptoms that occurred during the meal and which foods caused the symptoms. DIF: Cognitive Level: Application REF: Text reference: p. 769 OBJ: Identify risk factors for aspiration related to dysphagia. TOP: Suspected Dysphagia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. The nurse is caring for a patient who is 6 feet 2 inches tall and weighs 250 pounds. What is
the patient’s body mass index (BMI)? a. 18.5 kg/m2 NURSINGTB.COM b. 30.2 kg/m2 c. 32.13 kg/m2 d. 40.11 kg/m2 ANS: C
BMI = Weight (lb)/Height (inches) Height (inches) 703. In this case, 250/(74 74) 703 250/5476 703 .0457 703 = 32.13 kg/m2. DIF: Cognitive Level: Analysis REF: Text reference: p. 762 OBJ: Perform accurate nutritional screening. TOP: BMI KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 10. The nurse is caring for a patient who is believed to be suffering from malnutrition. The nurse
calculates that the patient’s body mass index (BMI) is 16.4 kg/m2. What does this indicate about the patient’s weight? a. The patient is underweight. b. The patient’s weight is normal. c. The patient is overweight. d. The patient is obese (class 1). ANS: A
Underweight is defined as a BMI 18.5 kg/m2. Normal weight is classified as a BMI between 18.5 and 24.9 kg/m2. Overweight is defined as a BMI between 25 and 29.9 kg/m2. Obesity (class 1) is defined as a BMI between 30 and 34.9 kg/m2.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Analysis REF: Text reference: p. 761 OBJ: Perform accurate nutritional screening. TOP: Underweight KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. A patient is admitted to the hospital for evaluation for sleep apnea. The nurse calculates his
body mass index (BMI) at 42 kg/m2. What does this indicate about the patient’s weight? a. The patient is overweight. b. The patient falls into the class 1 range of obesity. c. The patient falls into the class 2 range of obesity. d. The patient falls into the class 3 range of extreme obesity. ANS: D
Extreme obesity (class 3) is defined as a BMI equal to or greater than 40 kg/m2. Overweight is defined as a BMI between 25 and 29.9 kg/m2. Class 1 obesity is defined as a BMI between 30 and 34.9 kg/m2. Class 2 obesity is defined as a BMI between 35 and 39.9 kg/m2. DIF: Cognitive Level: Analysis REF: Text reference: p. 762 OBJ: Perform accurate nutritional screening. TOP: Extreme Obesity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse is caring for a patient 2 days after surgery. The ordered diet is a mechanical soft
diet. Which of the following foods may the patient choose to eat? a. Salad b. Baked potato without skin c. Cooked cereal d. Soft peeled apples ANS: C
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Mechanically altered diets consist of chopped, ground, mashed, or pureed foods for patients who have problems with chewing or swallowing. Consistency can be varied according to the patient’s own ability to chew or swallow. Small amounts of liquids added to foods contribute to an appropriate consistency. Liquids that are added should complement the food and should not conceal the food’s original flavor. Butter, margarine, and honey can be added to increase caloric density. A regular diet with no restrictions could include a salad. A baked potato without the skin or soft peeled apples would be allowed on a dysphagia advanced diet that uses regular food, with the exception of very hard, sticky, or crunchy foods. DIF: Cognitive Level: Application REF: Text reference: p. 765 OBJ: Perform accurate nutritional screening. TOP: Types of Therapeutic Diets KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. The patient is placed on a clear liquid diet after surgery. Which of the following foods may
the patient select? a. Coffee with milk and sugar b. Gelatin, popsicles, apple juice c. Water, orange juice, Jell-O d. Black coffee, popsicles, ice cream ANS: B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank A clear liquid diet consists of foods that are clear and liquid at room or body temperature (e.g., water, clear fruit juice, gelatin, popsicles). Caution should be exercised with regard to the amount of caffeine received by patients on clear liquids. Coffee with milk, orange juice, and ice cream are not clear liquids. DIF: Cognitive Level: Application REF: Text reference: p. 765 OBJ: Perform accurate nutritional screening. TOP: Clear Liquid Diet KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. Which of the following is a sign of vitamin C deficiency? a. Cheilosis (redness/swelling of the lips) b. Glossitis c. Spongy, bleeding, abnormal redness of the gingiva d. Spoon-shaped, brittle, ridged fingernails ANS: C
Spongy, bleeding gingiva is indicative of inadequate vitamin C intake. Cheilosis, glossitis, and spoon-shaped, brittle, ridged nails are symptoms of iron deficiency. DIF: Cognitive Level: Knowledge REF: Text reference: p. 760 OBJ: Perform accurate nutritional screening. TOP: Vitamin C Deficiency KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. The patient is on the dysphagia puree stage of the national dysphagia diet. Which of the
following foods may the patient select? a. Mashed potatoes b. Dry cereals moistened with milk c. Well-cooked noodles in gNraUvR y SINGTB.COM d. Well-moistened cereals ANS: A
The dysphagia puree stage requires foods that are uniform, pureed, and cohesive with a pudding-like texture. Examples include mashed potatoes, pureed meat, pureed pasta, yogurt, and cooked cereals. Dry cereals moistened with milk and well-cooked noodles in gravy are allowed in the dysphagia mechanically altered stage. Well-moistened cereals are allowed in the dysphagia advanced stage. DIF: Cognitive Level: Analysis REF: Text reference: p. 770 OBJ: Perform accurate nutritional screening. TOP: National Dysphagia Diet KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse is preparing to assess the nutritional status of an 80-year old patient in a long-term
care facility. What screening tool would best suit this purpose? a. The Malnutrition Universal Screening Tool (MUST) b. Mini Nutritional Assessment (MNA) c. Anthropometric measurements d. A daily nutrition intake log ANS: B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The Mini Nutritional Assessment (MNA) is specifically designed to meet to the needs of geriatric patients in long term care facilities. The MUST tool is particularly designed for assessing older adults in clinical settings, including acute care. Including anthropomorphic measurements might be part of an assessment as might information from the nutrition intake log , but neither would provide a complete picture in this case. DIF: Cognitive Level: Application REF: Text reference: p. 755 |Text reference: p. 760 OBJ: Discuss the components and purposes of nutritional assessments and screenings. TOP: Nutritional Screening Tools KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The nurse is admitting a patient to the medical unit. Which of the following are reasons the
nurse may perform a nutritional screening on this patient? (Select all that apply.) a. To assess risk for malnutrition b. To assist with feeding c. To identify risk for aspiration d. To determine body weight ANS: A, B, C
A nurse’s role includes performing nutritional screening to assess a patient’s risk status for malnutrition, assessing and assisting an adult patient with feeding, and identifying patients at risk for aspiration during oral feeding. Although determining body weight is one aspect of assessing nutritional status, it is not the focus of a nutritional screening. DIF: Cognitive Level: ApplicN ationR I GREB F:.TexC tMreference: pp. 754-755 OBJ: Identify and refer patients U apprS oprN iate T for nutriO tional assessment. TOP: Nutritional Screening KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The NCP provides structure for the provision of nutritional care to all patients and provides a
framework for the RD to make decisions regarding medical nutrition therapy. The steps involved in this process include which of the following? (Select all that apply.) a. Nutrition assessment b. Nutrition diagnosis c. Nutrition intervention d. Nutrition evaluation ANS: A, B, C, D
In 2003, the American Dietetic Association published the Nutrition Care Process (NCP) and model. This process provides structure for the provision of nutritional care to all patients and provides a framework for the RD to think critically and make decisions regarding medical nutrition therapy. This process consists of four steps: nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation. DIF: Cognitive Level: Knowledge REF: Text reference: p. 755 OBJ: Perform accurate nutritional screening. TOP: Nutrition Care Process KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 3. Biochemical indices help the clinician to determine the effects of nutritional factors or of
medical conditions on the health status of patients. No single test is available for evaluating short-term response to medical nutritional therapy. Laboratory tests conducted over time will give more accurate information than a single test. Which of the following are the most important biochemical measures? (Select all that apply.) a. Ideal body weight b. Visceral protein status c. Immune function d. Percent of weight gain ANS: B, C
Laboratory tests conducted over time will give more accurate information than a single test. The most important biochemical measures are visceral protein status and immune function. Ideal body weight and percent of weight gain are not biochemical measures. DIF: Cognitive Level: Comprehension REF: Text reference: p. 762 OBJ: Perform accurate nutritional screening. TOP: Biochemical Indices KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. A stroke patient has residual dysphagia. The nurse notes that the ordered diet is the national
dysphagia diet. She knows this diet comprises which of the following? (Select all that apply.) a. Dysphagia puree diet b. Dysphagia mechanically altered diet c. Dysphagia advanced diet d. Regular diet ANS: A, B, C, D
In October 2002, the AmericN anUDRiete SIticNGAss TBoc.iaCtion OMpublished the National Dysphagia Diet Task Force (NDDTF) National Dysphagia Diet (National Dysphagia Diet Task Force, 2002). The diet consists of four levels: dysphagia puree, dysphagia mechanically altered, dysphagia advanced, and regular. DIF: Cognitive Level: Knowledge REF: Text reference: p. 770 OBJ: Identify risk factors for aspiration related to dysphagia. TOP: National Dysphagia Diet KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. Which of the following are signs of iron (Fe2+) deficiency? (Select all that apply.) a. Pale eye membranes b. Cheilosis (redness/swelling) of the lips c. Spongy, bleeding gingiva d. Glossitis ANS: A, B, D
Pale eye membranes, cheilosis, and glossitis are all signs of iron deficiency. Spongy, bleeding gingiva is indicative of inadequate vitamin C intake. DIF: Cognitive Level: Knowledge REF: Text reference: p. 760 OBJ: Perform accurate nutritional screening. TOP: Iron Deficiency KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
1. A nurse’s role includes performing
to assess a patient’s risk status for malnutrition, assessing and assisting an adult patient with feeding, and identifying patients at risk for aspiration during oral feeding. ANS:
nutritional screening A nurse’s role includes performing nutritional screening to assess a patient’s risk status for malnutrition, assessing and assisting an adult patient with feeding, and identifying patients at risk for aspiration during oral feeding. DIF: Cognitive Level: Knowledge REF: Text reference: pp. 754-755 OBJ: Identify and refer patients appropriate for nutritional assessment. TOP: Nutritional Screening KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Patients who have a cancer diagnosis, infected or draining wounds, burns, or an elevated
temperature for more than 2 days are at elevated
risk.
ANS:
nutritional Risk factors for potential nutritional problems include cancer diagnoses, infected or draining wounds, burns, and elevated body temperature for more than 2 days. Patients exhibiting these conditions should be assessed for their nutritional status. DIF: Cognitive Level: Knowledge REF: Text reference: p. 755 OBJ: Identify and refer patients appropriate for nutritional assessment. NURSINGKTEB TOP: Nutritional Risk NuOrsM ing Process Step: Assessment Y. : C MSC: NCLEX: Physiological Integrity 3. The nurse will collaborate with a
to develop a nutritional plan for a patient
identified as being at nutritional risk. ANS:
registered dietitian A registered dietitian is a vital member of the health care team. An RD will assess the patient's nutritional status and recommend the intervention that will best address the patient's unique nutrition diagnosis. DIF: Cognitive Level: Knowledge REF: Text reference: p. 755 OBJ: Identify and refer to a registered dietitian patients appropriate for nutritional assessment. TOP: Registered Dietitian KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4.
are measures of height; weight; head, arm, and muscle circumferences; and skinfold thickness. ANS:
Anthropometrics Anthropometrics are measures of height; weight; head, arm, and muscle circumferences; and skinfold thickness.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Knowledge REF: Text reference: p. 760 OBJ: Perform accurate nutritional screening. TOP: Anthropometrics KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
is useful for monitoring short-term changes in visceral protein.
5. ANS:
Prealbumin Prealbumin normally ranges from 20 to 50 mg/dL. This test is useful in monitoring short-term changes in visceral protein. It has a short half-life of 2 days. DIF: Cognitive Level: Knowledge REF: Text reference: p. 726 OBJ: Perform accurate nutritional screening. TOP: Prealbumin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse recognizes that the patient is exhibiting signs of
when she notices that he has difficulty holding food and fluid in his mouth and experiences difficulty moving it to his esophagus. ANS:
dysphagia Classic signs of dysphagia include inability to hold food and fluid in the mouth or difficulty moving food into the esophagus. Any condition that produces muscle weakness may result in impairment of the swallowing mechanism. Early recognition of the patient's difficulty will allow the nurse to implement aspiration precautions to protect the patient from complications of dysphagia.
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DIF: Cognitive Level: Knowledge REF: Text reference: p. 764 OBJ: Define aspiration. TOP: Aspiration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity OTHER 1. The nurse is caring for a patient who is 48 hours post bowel resection with creation of a
colostomy. This morning, the nurse assessed the return of bowel sounds. In what order would this patient’s diet progress? a. Full liquid diet b. Regular diet c. Clear liquid diet d. NPO e. Soft diet ANS:
D, C, A, E, B The patient has most likely been kept NPO until bowel sounds returned. Once bowel sounds resume, the initial diet will be clear liquids. If clear liquids are tolerated, the patient will advance to a full liquid diet, then to a soft diet, and finally to a regular diet. DIF: Cognitive Level: Analysis
REF: Text reference: p. 760
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: State types of and reasons for special or modified diets. TOP: Types of Diets KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 31: Enteral Nutrition MULTIPLE CHOICE 1. Of the patients listed below, which would be a candidate for nasoenteric feeding tube
placement? a. Post–motor vehicle accident victim with a broken nose and jaw b. Patient with a bleeding ulcer and possible esophageal varices c. Elderly patient with a diagnosis of failure to thrive and an inability to chew d. Patient with an esophageal tumor ANS: C
Enteral nutrition, commonly called tube feeding, is the administration of nutrients through the gastrointestinal tract when a patient cannot ingest, chew, or swallow, but can digest and absorb nutrients. Nasoenteric tubes are contraindicated in patients with facial trauma, prolonged bleeding, and upper gastrointestinal (GI) blockage (as is seen in cases of solid cancer). DIF: Cognitive Level: Analysis REF: Text reference: p. 775 OBJ: Assess the patient who is to receive enteral tube feedings. TOP: Indications/Contraindications for Nasoenteric Tube Insertion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse has just inserted a nasogastric (NG) feeding tube into a patient. What should the
nurse do to definitely ascertain that the tube is in the stomach or in the intestine? a. Test the pH of the contents. b. Use a carbon dioxide senN soU r.RSINGTB.COM c. Lower the head of the bed to 15 degrees. d. Obtain an order for a chest radiograph. ANS: D
The most reliable method of feeding tube verification is a chest radiograph (chest x-ray). Gastric and intestinal pH measurements have been shown to differentiate tube placement, with the stomach having a lower pH than the intestines. This helps to ensure that the tube is beyond the pylorus, theoretically reducing the risk for aspiration. This method is helpful before and after radiological confirmation. Carbon dioxide sensors are helpful in determining tube placement between the stomach and the lung. A small plastic piece with an embedded yellow sensor is attached to the end of the feeding tube; the sensor changes color when carbon dioxide is present. Investigators have shown that this reduces the incidence of inadvertent pulmonary placement. This method is helpful before and after radiological confirmation. Elevation of the head of the bed to a minimum of 30 degrees is a simple method used to keep the risk for aspiration at a minimum. The nurse is instrumental in achieving this goal. This method does not ascertain placement but may be useful in preventing aspiration. DIF: Cognitive Level: Application REF: Text reference: p. 776 |Text reference: p. 781 OBJ: Demonstrate ability to correctly insert a small-bore feeding tube. TOP: Determining Position of NG Tubes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 3. The nurse is checking gastric residual on a patient who has a continuously running tube
feeding. She finds that the patient has a 600-mL residual volume. How should the nurse respond? a. Stop the tube feeding. b. Slow the tube feeding. c. Continue the tube feeding at the same rate. d. Increase the rate of the tube feeding. ANS: A
Tube feedings are stopped if the patient has high gastric residual (more than 500 mL). DIF: Cognitive Level: Application REF: Text reference: p. 776 |Text reference: p. 790 OBJ: Assess the patient who is to receive enteral tube feedings. TOP: Residual Volume KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Before insertion of a nasogastric (NG) tube, of which finding should the physician be
notified? a. Patent nares b. Absent bowel sounds c. Evident gag reflex d. Impaired swallowing ANS: B
Absent bowel sounds may indicate decreased or absent peristalsis and increased risk for aspiration. A finding of patent nares rules out obstruction or irritated nares, septal defect, or facial fracture and does not need to be reported to the physician because it is a “normal” finding. The nurse should assN ess aO gaM g reflex to determine the patient’s ability URthe SIpati NGentTBfo.r C to swallow and to discern whether a greater risk for aspiration exists. An evident gag reflex is a normal finding and does not need to be reported to the physician. Impaired swallowing is the probable reason for insertion of the NG tube. DIF: Cognitive Level: Application REF: Text reference: p. 777 |Text reference: p. 789 OBJ: Demonstrate ability to correctly insert a small-bore feeding tube. TOP: Absent Bowel SoundsKEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. An appropriate technique for nasogastric (NG) tube insertion is for the nurse to: a. position the patient supine. b. apply oil-based lubricant to the plastic tube. c. advance the tube while the patient swallows. d. measure the tube length from the nose to the sternum. ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Encourage the patient to swallow by giving small sips of water or ice chips. Advance the tube as the patient swallows. Rotate the tube 180 degrees while inserting. Swallowing facilitates passage of the tube past the oropharynx. Position the patient sitting with the head of the bed elevated at least 30 degrees. If the patient is comatose, place him in semi-Fowler’s position with the head propped forward using a pillow. If the patient is forced to lie supine, place him in reverse Trendelenburg’s position. This reduces the risk for pulmonary aspiration in the event that the patient should vomit. Apply water-soluble lubricant. The tip of the tube must reach the stomach. Measure the distance from the tip of the nose to the earlobe to the xiphoid process of the sternum. Add 20 to 30 cm (8 to 12 inches) for a nasoenteric tube. DIF: Cognitive Level: Application REF: Text reference: p. 779 OBJ: Demonstrate ability to correctly insert a small-bore feeding tube. TOP: NG Tube Insertion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. Which technique is appropriate for the nurse to implement during nasogastric (NG) tube
insertion? a. Use sterile gloves. b. Have the patient mouth-breathe. c. Advance the tube quickly when the patient coughs. d. Bend the patient’s head backward after the tube is through the nasopharynx. ANS: B
Emphasize the need to mouth-breathe and swallow during the procedure. This facilitates passage of the tube and alleviates the patient’s fears during the procedure. Put on clean gloves. Do not force the tube. If resistance is met, or if the patient starts to cough or choke, or becomes cyanotic, stop advancing the tube, pull the tube back, and start over. Have the patient N R I G e B.C M flex his head toward his chest aUfterStheNtubT has pO assed through the nasopharynx. This closes off the glottis and reduces the risk that the tube may enter the trachea. DIF: Cognitive Level: Application REF: Text reference: p. 779 OBJ: Demonstrate ability to correctly insert a small-bore feeding tube. TOP: NG Tube Insertion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The nurse has inserted a nasogastric (NG) feeding tube. The feeding tube has a stylet in place
to aid insertion. What should the nurse do once the tube is in place? a. Remove the stylet immediately. b. Reinsert the stylet if the radiograph determines incorrect placement. c. Fasten the end of the NG tube to the patient’s gown using tape and a safety pin. d. Leave the stylet in place and obtain a chest/abdomen radiograph. ANS: D
Leave the stylet in place (if used) until correct position has been verified by x-ray film. Never attempt to reinsert a partially or fully removed stylet while the feeding tube is in place. This can cause perforation of the tube and can injure the patient. Do not use safety pins to pin the tube to the patient’s gown. Safety pins become unfastened and can cause injury to the patient. DIF: Cognitive Level: Application REF: Text reference: p. 781 OBJ: Demonstrate ability to correctly insert a small-bore feeding tube. TOP: NG Tube Insertion KEY: Nursing Process Step: Implementation
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity 8. The nurse is caring for a patient who is receiving continuous tube feedings. What must the
nurse do to care for this patient? a. Verify tube position every 4 to 6 hours. b. Obtain a radiograph every 4 to 12 hours. c. Instill air into the stomach via the tube and listen for bubbles. d. Do not worry about tube placement because the tube has already been determined to be in the right place. ANS: A
After initial radiographic verification that a tube is positioned in the desired site (either the stomach or the small intestine), the nurse is responsible for ensuring that the tube has remained in the intended position before administering formula or medications through the tube. Therefore, the nurse must verify tube position every 4 to 6 hours and as needed. Because it is not practical to do radiographic checks at this frequency, other methods of determining placement have been investigated. Insufflation of air into the tube while the abdomen is auscultated is not a reliable means of determining the position of the feeding tube tip. It is possible for the tip of a feeding tube to move into a different location (from the stomach to the intestine, or from the intestine into the stomach) without any external evidence that the tube has moved. The risk for aspiration of regurgitated gastric contents into the respiratory tract increases when the tip of the tube accidentally dislocates upward into the esophagus. DIF: Cognitive Level: Application REF: Text reference: p. 782 OBJ: Discuss the rationale for methods used to determine nasogastric or nasoenteric feeding tube placement. TOP: NG Tube Placement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IN ntU egR riS tyINGTB.COM
9. The home health nurse evaluates the provision of intermittent tube feedings by the patient’s
family member. The nurse notes that additional teaching is required when she notices that the family member: a. keeps the formula refrigerated between feedings. b. keeps the feeding tube capped between feedings. c. begins the feeding before checking tube placement. d. irrigates the tube with 30 to 60 mL of water before and after feedings. ANS: C
For intermittent tube-fed patients, test placement immediately before each feeding and before each administration of medication. Each administration of feeding/medication can lead to aspiration if the tube is displaced. For intermittent feeding, have a syringe ready and be sure that the formula is at room temperature. When tube feedings are not being administered, cap or clamp the proximal end of the feeding tube. Draw up in the syringe 30 mL of normal saline or tap water. This amount of solution will flush the length of the tube. DIF: Cognitive Level: Application REF: Text reference: pp. 784-785 OBJ: Demonstrate three appropriate techniques for administering enteral formulas. TOP: Beginning Tube Feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. Which evaluation indicates that placement of a nasogastric or enteric tube is correct?
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
Nasointestinal aspirate with a pH of less than 6 Pleural fluid pH of less than 6 Gastric aspirate with a pH of 5 or less after patient fasting Gastric aspirate with a pH of 4 and continuous tube feedings
ANS: C
Gastric fluid from a patient who has fasted for at least 4 hours usually has a pH of 5 or less. Fluid from an enteric tube of a fasting patient usually has a pH greater than 6. The pH of pleural fluid from the tracheobronchial tree is generally greater than 6. Patients with continuous tube feeding may have a pH of 5 or greater. DIF: Cognitive Level: Analysis REF: Text reference: p. 784 OBJ: Discuss the rationale for methods used to determine nasogastric or nasoenteric feeding tube placement. TOP: NG Tube Placement KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 11. The nurse is checking the residual volume on a patient who is getting intermittent tube
feedings via his NG tube. Which of the following may indicate that the patient has started to bleed again? a. The nurse obtains brown aspirate. b. The nurse notices that the abdomen is distended. c. The nurse obtains red aspirate. d. The nurse notices severe respiratory distress. ANS: C
Red or brown coloring (coffee-grounds appearance) of fluid aspirated from a feeding tube indicates new blood or old blood, respectively, in the gastrointestinal tract. If the color is not related to medications recentN lyUaR dmi nist ered I G B, n.oCtify Mthe physician. Abdominal distention S N T O usually indicates that the tube feeding is not progressing through the GI tract. This could be a sign of paralytic ileus. Stop the tube feeding and notify the physician. If the patient develops severe respiratory distress (e.g., dyspnea, decreased oxygen saturation, increased pulse rate), this may be a result of aspiration or tube displacement into the lung. Stop any enteral feedings. Notify the physician. Obtain chest radiographs as ordered. DIF: Cognitive Level: Analysis REF: Text reference: p. 785 OBJ: Discuss the risk for pulmonary complications during insertion and maintenance of a feeding tube. TOP: NG Tube Placement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse determines that a nasogastric (NG) tube needs irrigation when she: a. obtains more than 200 mL of residual volume. b. obtains a small amount of thin watery residual. c. does not encounter resistance when aspirating the residual. d. obtains a unusually thick secretions. ANS: D
Thick secretions indicate the need to irrigate the tube. Note the ease with which tube feeding infuses through the tubing. Excess volume of secretions (more than 200 mL) indicates delayed gastric emptying. Irrigating the NG tube will not help. Failure of the formula to infuse as desired may indicate a developing obstruction.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Analysis REF: Text reference: p. 786 OBJ: Demonstrate the appropriate technique for irrigating a feeding tube. TOP: NG Tube Irrigation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. What is an appropriate amount of nasogastric irrigant for an adult patient? a. 1 or 2 mL b. 30 mL c. 5 to 15 mL d. 250 mL ANS: B
Draw up 30 mL of normal saline or tap water in a syringe. This amount of solution will flush the length of the tube. Irrigation of a tube requires a smaller volume of solution in children: 1 to 2 mL for small tubes to 5 to 15 mL or more for large ones. DIF: Cognitive Level: Knowledge REF: Text reference: p. 786 OBJ: Demonstrate the appropriate technique for irrigating a feeding tube. TOP: NG Tube Irrigation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. Which technique is appropriate for providing intermittent tube feeding once placement of the
tube has been checked? a. Cooling the formula b. Lowering the head of the bed c. Allowing the bag to empty gradually over 30 to 45 minutes d. Adding food coloring to detect aspiration ANS: C
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Allow the bag to empty gradually over 30 to 45 minutes. Gradual emptying of tube feeding by gravity from the feeding bag reduces the risk for abdominal discomfort, vomiting, or diarrhea induced by bolus or too-rapid infusion of tube feedings. Cold formula causes gastric cramping. Place the patient in high-Fowler’s position, or elevate the head of the bed at least 30 degrees to prevent aspiration. Do not add food coloring or dye to formula to assist in detecting aspiration, presumably by staining tracheobronchial secretions. This is associated with increased risk for contamination and may cause patient deaths. DIF: Cognitive Level: Application REF: Text reference: p. 790 OBJ: Demonstrate three appropriate techniques for administering enteral formulas. TOP: Administering Tube Feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is preparing to administer an enteral feeding for the patient. The patient has been on
enteral feedings for 2 days. The nurse knows that the most appropriate technique for implementing enteral feeding is: a. weighing the patient weekly. b. measuring the gastric residual every hour. c. changing the formula every 12 hours in an open system. d. leaving the formula in place in an open system for up to 24 hours. ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Maximum hang time for formula is 12 hours in an open system, and 24 to 48 hours in a closed, ready-to-hang system (if it remains closed). Weigh the patient daily until the maximum administration rate is reached and maintained for 24 hours, and then weigh the patient 3 times per week. Check the gastric residual volume. Residual volume should be assessed before each feeding for intermittent feedings. DIF: Cognitive Level: Comprehension REF: Text reference: p. 791 OBJ: Demonstrate three appropriate techniques for administering enteral formulas. TOP: Administering Tube Feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. The nurse is initiating a continuous tube feeding for a patient who has a gastrostomy tube.
Which of the following procedures indicates proper practice? a. Allow the container to empty gradually over 60 minutes. b. Change the bag every 24 hours. c. Do not use water to flush the tube. d. Quickly increase the rate of administration. ANS: B
Rinse the bag and tubing with warm water whenever feedings are interrupted. Use a new administration set every 24 hours. Allowing the container to empty over 30 to 45 minutes is the method used for intermittent administration of tube feedings. Administer water via a feeding tube as ordered or between feedings. This provides the patient with a source of water to help maintain fluid and electrolyte balance and clears the tubing of formula. Gradually advancing the rate of concentration of the tube feeding helps to prevent diarrhea and gastric intolerance to formula. DIF: Cognitive Level: ComprN ehU enRsiS onINGRT EB F:.C TeO xtMreference: p. 791 OBJ: Demonstrate three appropriate techniques for administering enteral formulas. TOP: Gastrostomy Tube Feedings KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 17. The nurse would anticipate the need for an enteral access device in which of the following
patients? a. Patient whose bowel sounds have not yet returned after abdominal surgery b. Patient who recently suffered a cerebrovascular accident (CVA) c. Patient who dislikes the taste of facility meals d. Patient who suffers from severe acute dysphagia ANS: D
A patient who is unable to swallow because of severe acute dysphagia will require an enteral access device to provide adequate nutrition. The patient who suffered a CVA may require an enteral access device if the ability to swallow is affected, but more information would be needed before this option is chosen. A patient whose bowel sounds have not yet returned will remain NPO and may have no need for an enteral access device. Less invasive strategies can be used for the patient who does not like the taste of food provided by the facility. DIF: Cognitive Level: Evaluation REF: Text reference: pp. 788 -789 OBJ: Identify indications for enteral access devices. TOP: Enteral Access Devices KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MULTIPLE RESPONSE 1. The nurse is caring for a patient with an enteral feeding tube in place. She assesses for
pulmonary aspiration as the main complication related to feeding tubes. She is aware of other complications, including which of the following? (Select all that apply.) a. Infection b. Diarrhea c. Tube clogging d. Tube dislodgment ANS: A, B, C, D
The main complication related to feeding tubes is pulmonary aspiration with possible lung compromise. Other complications include misplaced tubes, infection, diarrhea, tube clogging, and tube dislodgment. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 782-783 |Text reference: p. 786 |Text reference: pp. 791-792 OBJ: Discuss the rationale for methods used to determine nasogastric or nasoenteric feeding tube placement. TOP: Complications Related to Feeding Tubes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse, physician, and dietitian collaborate to select an enteral feeding formula for the
patient. Their decision should be based on which of the following? (Select all that apply.) a. Protein requirements of the patient b. Digestive ability of the patient c. Amount of lactose required d. The patient’s disease process ANS: A, B
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The nurse, dietitian, and physician collaborate to select an enteral feeding formula based on the patient’s protein and calorie requirements and digestive ability. Formulas in the United States are sterile and lactose free. Disease-specific formulas are available, but research has not always supported their efficacy. DIF: Cognitive Level: Comprehension REF: Text reference: p. 775 OBJ: Assess the patient who is to receive enteral tube feedings. TOP: Enteral Feeding Formulas KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Conditions that increase the risk for spontaneous tube dislocation include which of the
following? (Select all that apply.) a. Retching/vomiting b. Nasotracheal suction c. Coughing d. Cyanosis ANS: A, B, C
Conditions that increase the risk for spontaneous tube dislocation include retching/vomiting, nasotracheal suction, and severe bouts of coughing. Cyanosis may be an indicator of displacement but is not a cause. DIF: Cognitive Level: Comprehension
REF: Text reference: p. 783
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Discuss the rationale for methods used to determine nasogastric or nasoenteric feeding tube placement. TOP: Dislocation of NG Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse is caring for a patient with a nasogastric tube in place. What interventions would
the nurse perform to reduce the risk of clogging the feeding tube? (Select all that apply.) a. Use the smallest barrel syringe possible to reduce the pressure in the tube. b. Mix medication with feedings to thoroughly dilute the medication. c. Flush the tube liberally with water before, between, and after each medication instillation. d. Use the largest barrel syringe possible to reduce the pressure in the tube. e. Crush solid medications thoroughly and mix them in water before administration. ANS: C, D, E
Flushing the tube liberally with water before, between, and after each medication instillation will reduce the risk of clogging, as will crushing solid medications thoroughly and mixing them in water before administration. The largest barrel, not the smallest barrel, syringe exerts less pressure and reduces the risk of clogging. Mixing medications with formula is contraindicated because it increases the risk of clogging. DIF: Cognitive Level: Application REF: Text reference: p. 784 |Text reference: p. 786 OBJ: List strategies to help prevent clogged feeding tubes. TOP: NG Tube Clogging KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION
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1. A tube passed through the nose or mouth with the end terminating in the stomach or the small
bowel, and used in feeding the patient for short periods is known as a
.
ANS:
nasogastric feeding tube NG feeding tube A nurse passes a nasogastric (NG) tube through the nose or mouth with the end terminating in the stomach or the small bowel for use in delivering supplemental nutrition or facilitating gastric decompression. DIF: Cognitive Level: Knowledge REF: Text reference: p. 777 |Text reference: p. 779 OBJ: Assess the patient who is to receive tube feedings. TOP: Nasogastric Feeding Tube KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is caring for a patient in a chronic vegetative state with inadequate gastric
emptying. The nurse would anticipate finding in a patient’s nutritional needs. ANS:
jejunostomy
tube placed to assist with this
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank A jejunostomy tube would be appropriate for this patient. A nasally inserted tube would be inappropriate for long-term use; this fact rules out nasogastric and nasoenteric tubes. A tube placed into the stomach would be inappropriate for a patient with inadequate gastric emptying; this fact rules out gastrostomy and nasogastric tubes. DIF: Cognitive Level: Analysis REF: Text reference: p. 793 OBJ: Compare and contrast use of the nasogastric tube, nasoenteric tube, gastrostomy tube, and jejunostomy tube for nutritional support. TOP: Types of Access Devices KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 32: Parenteral Nutrition MULTIPLE CHOICE 1. A 72-year-old patient is admitted to the hospital with a medical diagnosis of intestinal failure.
Which intervention should the nurse include in the plan of care to deliver nutritional needs? a. Enteral b. Parenteral c. A combination of enteral and parenteral d. Oral ANS: B
In situations where partial or complete intestinal failure has occurred and oral nutrition or enteral tube feeding is not possible, parenteral nutrition (PN) is the therapy of choice. When a patient’s gastrointestinal (GI) tract is functional, clinicians assess the patient and choose the best method of delivering nutritional needs, which may include enteral feeding, parenteral feeding, or a combination of both. DIF: Cognitive Level: Analysis REF: Text reference: pp. 796-797 OBJ: Identify patients who are candidates for parenteral nutrition. TOP: Parenteral Nutrition KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The patient has been ordered to receive parenteral nutrition but will require the nutritional
therapy to continue for several months. Which route is most important for the nurse to consider? a. Second intravenous line NURSINGTB.COM b. Enteral feeding tube c. Central venous access device d. Parenteral feeding tube ANS: C
The ideal method to administer PN over an extended period is through a central venous catheter, which allows for higher concentration of nutrients. DIF: Cognitive Level: Analysis REF: Text reference: p. 800 OBJ: Describe factors influencing the selection of appropriate sites for administering parenteral nutrition. TOP: Central Lines KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient who is receiving PN. As part of therapy, the patient
undergoes routine bedside glucose monitoring that reveals which expected outcome? a. Lower than normal blood glucose to determine adequate tolerance for PN b. Slightly higher than normal blood glucose to meet increased cellular needs c. Slightly higher than normal blood glucose to prevent infection or systemic sepsis d. Normal blood glucose to prevent associated complications ANS: D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank For PN to be used safely, its administration must be closely monitored. Special care is necessary to maintain blood glucose levels in the normal range. Higher glucose levels are often associated with cardiovascular events, general infection, systemic sepsis, acute renal failure, and death. DIF: Cognitive Level: Analysis REF: Text reference: pp. 798-799 OBJ: Discuss risks associated with parenteral nutrition. TOP: Blood Sugar Control KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 4. A patient had surgery 1 week ago, has not been eating his meals, and states that he has no
appetite. The nurse assesses that the patient has been progressively losing weight. Which intervention has the highest priority? a. Encouraging the patient to eat b. Force-feeding the patient c. Consulting with the nutritional support team d. Being aware that the patient will come around when hungry ANS: C
Frequently, the nurse will be the first to identify risk factors, such as progressive weight loss, restricted or limited fluid intake, intolerance to enteral feedings, increased energy need (burns, sepsis, and trauma), and being NPO (nothing by mouth) for 3 or more days. The first sign of a developing problem is a pattern of a decline in oral food intake and reduced appetite. Assessment provides information for consulting with the nutritional support team and the physician in an effort to initiate appropriate PN. Force-feeding the patient may only lead to worse issues, especially if the patient has a nonfunctioning intestinal system. DIF: Cognitive Level: Analysis REF: Text reference: pp. 799-801 N R I G OBJ: Identify patients who are cU andS idateN s foT r pBa. reC nteOraMl nutrition. TOP: Nutritional Support Team KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 5. The patient has been receiving PN but has not been given lipid emulsion therapy. The nurse
notices that the patient is developing dry, scaly skin, his wound is healing more slowly than expected, and he is anemic. Which condition should the nurse anticipate as a potential problem? a. Excess linoleic acid b. Omega-6 fatty acid excess c. Essential fatty acid deficiency d. Electrolyte instability ANS: C
A nutritional regimen without adequate fatty acids leads to essential fatty acid deficiency (EFAD), characterized by dry, scaly skin, sparse hair growth, impaired wound healing, decreased resistance to stress, increased susceptibility to respiratory tract infection, anemia, thrombocytopenia, and liver function abnormalities. DIF: Cognitive Level: Analysis REF: Text reference: p. 799 OBJ: Identify complications of PN without adequate fatty acids. TOP: Essential Fatty Acid Deficiency (EFAD) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 6. During IV administration of fat (lipid) emulsions, the patient voices complaints. Which
complaint indicates to the nurse that the patient is experiencing a complication associated with the administration? a. Fever, chills, and malaise b. Low temperature, chills, and headache c. Fever, flushing, and muscle relaxation d. Low temperature, muscle aches, and dyspnea ANS: A
Fever, chills, and malaise are symptoms of catheter-related sepsis. DIF: Cognitive Level: Analysis REF: Text reference: p. 804 OBJ: Identify complications r/t intolerance to fat emulsion. TOP: Lipid Infusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. Which assessment should a nurse expect to see for a patient receiving PN? a. Weight gain of 1 to 2 pounds per week b. Serum calcium level of 10 mEq/L c. Serum potassium level of 2.8 mEq/L d. Serum glucose level of more than 200 mg/100 mL ANS: A
The patient’s ideal weight gain is usually between 1 and 2 pounds per week. Serum electrolytes are out of normal range. This may indicate movement of electrolytes in response to infusion of fluids and glucose. The electrolyte levels in the solution may need to be adjusted. Serum glucose levels should be less than 200 mg/100 mL.
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DIF: Cognitive Level: Analysis REF: Text reference: p. 802 OBJ: Demonstrate appropriate nursing care for the patient receiving parenteral nutrition. TOP: Weight Gain KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 8. A patient on PN has gained 4 lbs over a 24-hour period. Given this weight gain, which
interpretation by the nurse is most accurate? a. Increased nutrition from the patient’s parenteral infusions b. Decreased linoleic acid intake c. Increased fluid loss d. Fluid retention ANS: D
Weight gain greater than 1 lb/day indicates fluid retention. The patient’s ideal weight gain is usually between 1 and 2 lb/wk. Weight is an indicator of the patient’s nutritional status and determines fluid volume. A nutritional regimen without adequate fatty acids leads to EFAD, characterized by dry, scaly skin, sparse hair growth, impaired wound healing, decreased resistance to stress, increased susceptibility to respiratory tract infection, anemia, thrombocytopenia, and liver function abnormalities. DIF: Cognitive Level: Analysis REF: Text reference: p. 803 OBJ: Demonstrate appropriate nursing care for the patient receiving parenteral nutrition. TOP: Fluid Retention KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
9. To detect a common untoward effect of interrupting a PN infusion, the nurse should assess the
patient for development of which symptom? a. Fever b. Chest pain c. Erythema and induration d. Shaking and dizziness ANS: D
Do not interrupt a PN infusion. This infusion maintains a continuous supply of nutrients and prevents a hypoglycemic reaction. Fever could be caused by systemic infection. Chest pain could be caused by air embolism. Localized infection can occur at the exit site or tunnel. DIF: Cognitive Level: Application REF: Text reference: p. 803 OBJ: Demonstrate appropriate nursing care for the patient receiving parenteral nutrition. TOP: Complications of Parenteral Nutrition KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 10. The nurse is managing the care of a patient receiving PN. Which assessment finding indicates
potential septicemia? a. Shakiness and dizziness b. Chest pain/hypotension c. Increased thirst d. Increased temperature ANS: D
Know the patient’s recent temperature range. Patients with peripheral or central intravenous (IV) lines are susceptible to sN eptiR elevBat. edCtem can be an early indicator of a U cem SIia;NG T patient OMtoperature bacterial process. Hypoglycemia causes the be shaky, dizzy, nervous, and anxious; the patient senses hunger and has a blood sugar level less than 80 mg/100 mL. Air embolism results in sudden respiratory distress, shortness of breath, coughing, chest pain, and decreased blood pressure. Hyperglycemia leads to excessive thirst. DIF: Cognitive Level: Analysis REF: Text reference: p. 803 OBJ: Demonstrate appropriate nursing care and use of safety precautions when caring for a patient receiving PN. TOP: Complications of Parenteral Nutrition KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 11. The nurse has been caring for a patient who has had a central venous catheter in place. The
patient complains of sudden chest pain and difficulty breathing. Which assessment finding warrants immediate intervention by the nurse? a. Exit site infection b. Catheter-related sepsis c. Pneumothorax d. Hyperglycemia ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Symptoms of pneumothorax include sudden chest pain, difficulty breathing, decreased breath sounds, cessation of normal chest movement on the affected side, and tachycardia. Symptoms of exit site infection include erythema, tenderness, induration, or purulence within 2 cm of the skin at the exit site. Symptoms of catheter-related sepsis include isolation of the same microorganism from a blood culture and catheter segment, with the patient showing fever, chills, malaise, and elevated white blood cell count. Symptoms of hyperglycemia include excessive thirst, urination, blood glucose greater than 160 mg/100 mL, and confusion. DIF: Cognitive Level: Application REF: Text reference: p. 798 OBJ: Discuss risks associated with parenteral nutrition. TOP: Complications of Central Parenteral Nutrition KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse is caring for a patient receiving PN. In planning the patient’s care for the day,
which nursing assessment is most essential? a. Electrolyte levels b. Weight c. Temperature d. Condition of insertion site ANS: A
Since the need for PN is usually associated with conditions that result in electrolyte instability, maintaining electrolyte balance during therapy is crucial. Monitor the patient’s electrolyte levels (potassium, magnesium, and phosphorus) for low serum levels which may indicate a risk for arrhythmias and muscle weakness, Patient’s at risk may require having electrolyte panels done several times a day. While it is necessary to monitor the patient’s weight and temperature and be alert for signs of infection at the insertion site, the biggest risk to the N R I G B.C M patient is electrolyte instabilityU . S N T O DIF: Cognitive Level: Application REF: Text reference: pp. 799-800 OBJ: Discuss risks associated with parenteral nutrition. TOP: Assessment/Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is caring for a patient who is receiving parenteral nutrition (PN). The nurse realizes
that PN is associated with which of the following risks? (Select all that apply.) a. Decreased mortality b. Bloodstream infection c. Pneumothorax d. Decreased length of stay e. Liver disease ANS: B, C, E
Use of PN in the perioperative patient is controversial, and although benefits are more likely in the severely malnourished, evidence has shown little effect of PN in preventing mortality. PN creates risks. It has been associated with catheter-related bloodstream infection, noninfective complications such as pneumothorax, increased hospital length of stay, and liver disease.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Comprehension REF: Text reference: p. 796 |Text reference: p. 798 OBJ: Discuss risks associated with parenteral nutrition. TOP: Parenteral Nutrition Complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The patient will be going home on PN. The patient and his family education will need to
perform which of the following care steps? (Select all that apply.) a. Monitor the patient’s weight. b. Monitor the patient’s serum glucose levels. c. Measure the patient’s intake and output. d. Perform catheter care. e. Limit the patient’s activity. ANS: A, B, C, D
The patient and family caregiver will need to learn to monitor the patient’s weight, blood glucose levels, and intake and output. They will also need to know how to perform catheter care and dressing changes. Home-based PN can be managed to allow the patient a reasonable amount of mobility and limiting activity should not be required. DIF: Cognitive Level: Comprehension REF: Text reference: p. 804 OBJ: Discuss risks associated with parenteral nutrition. TOP: Quality of Life KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION 1. For patients receiving PN,
provide supplemental kilocalories and prevent
N R I G B.C M U S N T O
essential fatty acid deficiencies. ANS:
lipids Lipids provide supplemental kilocalories and prevent essential fatty acid deficiencies. DIF: Cognitive Level: Knowledge REF: Text reference: p. 797 |Text reference: p. 799 OBJ: Identify measures used to prevent complications of central parenteral nutrition. TOP: Lipids KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. If PN must be discontinued suddenly, hang
in water at the same infusion rate to
prevent hypoglycemia. ANS:
5% dextrose The 5% dextrose solution will maintain the fluid and electrolyte balance of the patient until either the PN therapy may be restarted or gradually withdrawn. DIF: Cognitive Level: Knowledge REF: Text reference: p. 802 OBJ: Identify measures used to prevent complications of central parenteral nutrition. TOP: Lipids KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 33: Urinary Elimination MULTIPLE CHOICE 1. The nurse is assessing a patient whose 24-hour output is 2400 mL. Which finding reflects the
nurse’s understanding of urine output? a. Increased output b. Decreased output c. Normal output d. Balanced output ANS: C
Know the average output range for a patient. Adult urinary output averages 2200 to 2700 mL in 24 hours. DIF: Cognitive Level: Comprehension REF: Text reference: p. 811 OBJ: Identify factors that alter normal voiding. TOP: Normal Urinary Output KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 2. On the basis of the nurse’s assessment of kidney function for an adult patient, which finding is
normal? a. 10 mL/hr b. 20 mL/hr c. 30 mL/hr d. 100 mL/hr ANS: C
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Minimum average hourly output is 30 mL.
DIF: Cognitive Level: Knowledge REF: Text reference: p. 811| Text reference: p. 815 OBJ: Identify factors that alter normal voiding. TOP: Normal Urinary Output KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 3. Which activities related to urinary elimination may be delegated to a nursing assistant? a. Catheterization b. Positioning the patient c. Evaluating alternatives to catheter use d. Assessing urinary drainage ANS: B
NAP may assist with positioning the patient, focusing lighting for the procedure, and enhancing the patient’s comfort during the procedure through measures such as holding the patient’s hand or keeping the patient warm. The nurse uses sterile asepsis when inserting an indwelling or straight catheter to reduce the risk for bladder infection. The nurse evaluates possible alternatives to catheter use, and assessment is the responsibility of the nurse. DIF: Cognitive Level: Application REF: Text reference: p. 813 OBJ: Describe devices used to promote urinary elimination. TOP: Delegation Considerations for Inserting a Urinary Catheter KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 4. The nurse is planning care for a 12-year-old female patient who needs a Foley catheter
inserted. It is most important for the nurse to use a catheter of which size? a. 5 to 6 French (Fr) b. 8 to 10 Fr c. 12 Fr d. 14 to 16 Fr ANS: C
Gender and age determine catheter size. A 12 Fr catheter may be considered for use in young girls. The prescriber may order a larger size. For infants, 5 to 6 Fr is generally used; for children, 8 to 10 Fr with a 3-mL balloon is used; and 14 to 16 Fr is indicated for adult women. DIF: Cognitive Level: Analysis REF: Text reference: p. 812 OBJ: Perform the following skills: insert a urinary catheter, and provide care for an indwelling urinary catheter. TOP: Size of Urinary Catheter KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 5. The nurse notes that urine does not flow after a female patient is catheterized. The nurse
believes that the catheter has been placed into the vagina. Which action should the nurse take? a. Remove the catheter and reinsert it. b. Irrigate the catheter with saline. c. Leave the catheter in place and insert another one. d. Insert the catheter 9 to 10 inches farther into the patient to verify that it is in the vagina. ANS: C
If no urine appears, check whether the catheter is in the vagina. If misplaced, leave the catheter in the vagina as a lanNdm re not to insert it, and insert another URarkSIindi NGcati TBng.wChe OM catheter into the meatus. Reinserting a catheter that has already been contaminated by vaginal exposure could lead to urinary tract infection. DIF: Cognitive Level: Application REF: Text reference: p. 819 |Text reference: p. 822 OBJ: Perform the following skills: place and remove a urinal, insert a urinary catheter, and provide care for an indwelling urinary catheter. TOP: Inserting Catheter Into a Female Patient KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 6. Resistance is encountered during urinary catheterization of a male patient. Which action
should the nurse take? a. Remove the catheter immediately. b. Apply force to insert the catheter farther. c. Ask the patient to breathe quickly through the mouth. d. Ask the patient to take slow, deep breaths. ANS: D
If resistance to catheter insertion is encountered, have the patient take slow, deep breaths to promote relaxation while the catheter is slowly inserted. If resistance persists the patient may have an enlarged prostate or some other obstruction of the urethra. DIF: Cognitive Level: Application REF: Text reference: p. 820 OBJ: Perform the following skills: place and remove a urinal, insert a urinary catheter, and provide care for an indwelling urinary catheter. TOP: Inserting Catheter Into a Male Patient KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
7. When the balloon on an indwelling urinary catheter is inflated and the patient expresses
discomfort, it is essential for the nurse to take which action? a. Remove the catheter. b. Continue to blow up the balloon because discomfort is expected. c. Aspirate the fluid from the balloon and advance the catheter. d. Pull back on the catheter slightly to determine tension. ANS: C
If resistance to inflation is noted, or if the patient complains of pain, the balloon may not be entirely within the bladder. Stop inflation, aspirate any fluid injected into the balloon, and advance the catheter a little farther before attempting again to inflate. DIF: Cognitive Level: Application REF: Text reference: p. 820 OBJ: Perform the following skills: place and remove a urinal, insert a urinary catheter, and provide care for an indwelling urinary catheter. TOP: Inflating the Balloon KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 8. The nurse is caring for a patient who has an indwelling urinary catheter. Which intervention is
most important to include in this patient’s plan of care? a. Maintaining tension on the tubing b. Emptying the urinary collection bag every 24 hours c. Cleaning in a circular motion from the meatus down the catheter d. Keeping the drainage bag on the bed or attached to the side rails ANS: C
Using a clean washcloth, wipe in a circular motion along the length of the catheter for about 10 cm (4 inches). Allow slacN k inRtheI r s.oCmoM U S cath NGete TB Ovement does not create tension on it. Empty the drainage bag, and record amounts at least every 3 to 6 hours. The drainage bag must be below the level of the bladder; do not place the bag on the side rails of the bed. DIF: Cognitive Level: Application REF: Text reference: p. 825 OBJ: Perform the following skills: place and remove a urinal, insert a urinary catheter, and provide care for an indwelling urinary catheter. TOP: Catheter Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse has been ordered to perform closed intermittent irrigation of a patient’s indwelling
urinary catheter. Which intervention is indicative of safe practice? a. Applies sterile gloves b. Instills 100 mL of irrigant c. Leaves the drainage tubing unclamped irrigation d. Determines the amount of urinary drainage by subtracting the amount of irrigant from the total output ANS: D
Calculate the fluid used to irrigate the bladder and catheter, and subtract from the volume drained to determine accurate urinary output. Closed intermittent irrigation does not require the use of sterile gloves. The typical amount of irrigant used is 30 to 50 mL and the tubing is clamped during the process. DIF: Cognitive Level: Application
REF: Text reference: pp. 830- 832
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Perform the following skills: irrigate a catheter. TOP: Catheter Irrigation KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 10. When evaluating the health care team member’s ability to apply a condom catheter, it is most
important for the nurse to provide further instruction for which intervention? a. Clipping of hair at the base of the penis b. Applying skin prep to the penis before catheter placement c. Using regular adhesive tape to hold the catheter in place d. Leaving 1 to 2 inches of space between the tip of the penis and the end of the catheter ANS: C
Use of an adhesive strip not designed for sheath application may be inflexible and may impede circulation to the penis. Clip hair at the base of the penis. Hair adheres to the condom and is pulled during condom removal or may get caught in rubber as the condom catheter is applied. Apply skin preparation to the penis and allow it to dry. Leave 1 to 2 inches of space between the tip of the glans penis and the end of the condom. DIF: Cognitive Level: Application REF: Text reference: p. 835 OBJ: Perform the following skills: apply a condom catheter. TOP: Condom Catheter KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 11. When providing care for a patient with a suprapubic catheter who has acquired a UTI, which
intervention is most important for the nurse to implement? a. Using clean technique b. Securing the tube to the inner thigh c. Cleansing the insertion site in a direction toward the drain d. Promoting intake of 2200Nm uiG dT peBr . daCyOM ULRoSfIflN ANS: D
Encourage the patient with a UTI to drink at least 2200 mL of fluid per day. The insertion site is cleansed in a circular swabbing pattern so as not to disturb the tubing. Standard care requires the use of clean gloves and securing the catheter to the abdomen. DIF: Cognitive Level: Application REF: Text reference: pp. 838-839 OBJ: Perform the following skills: care for a patient with a suprapubic catheter. TOP: Suprapubic Catheterization KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. Which symptom is the patient with fluid overload likely to exhibit? a. Oliguria b. Distended neck veins c. Increased skin temperature d. Increased urine specific gravity ANS: B
Cardiovascular signs of fluid volume excess include bounding pulse rate, normal blood pressure with or without orthostatic changes, third heart sound (S3), and distended neck veins. Oliguria is a renal sign of fluid volume deficit. Increased skin temperature is a sign of fluid volume deficit. Increased urine specific gravity is a renal sign of fluid volume deficit. DIF: Cognitive Level: Application
REF: Text reference: p. 810
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Discuss the relationship between fluid balance and urinary elimination. TOP: Fluid Volume Excess KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. When observing a patient for symptoms of dehydration, the nurse should observe which
assessment? a. Increased salivation b. Diuresis c. Periorbital edema d. Decreased capillary filling ANS: D
Cardiovascular signs of fluid volume deficit include increased pulse rate, weak pulse, hypotension, decreased pulse volume/pressure, decreased capillary filling, and increased hematocrit. Increased salivation and periorbital edema are signs of fluid volume excess. Diuresis is a renal sign of fluid volume excess. DIF: Cognitive Level: Application REF: Text reference: p. 810 OBJ: Discuss the relationship between fluid balance and urinary elimination. TOP: Fluid Volume Deficit KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. When providing care for a patient in need of an indwelling catheter, the nurse understands that
which of the following is an indication for this need? a. Presence of stage III and IV pressure ulcers b. Presence a yeast infection c. Need for inaccurate measurement of urinary output d. Need to manage urinary eNliU mR inS atI ioN nGTB.COM ANS: A
Indications for an indwelling catheter include (1) the presence of stage III and IV pressure ulcers that cannot heal because of continual incontinence, and (2) the need for accurate measurement of urinary output in critically ill patients. The incidence of catheter-associated UTI significantly decreases when the nurse gives the prescriber daily reminders to remove unnecessary catheters and suggests the use of alternative noninvasive treatments to manage urinary elimination. DIF: Cognitive Level: Comprehension REF: Text reference: p. 810 OBJ: Describe devices used to promote urinary elimination. TOP: Foley Catheter KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. The nurse receives an order to insert a Foley catheter. In obtaining a catheter of the right size,
the nurse is aware that large catheters can lead to which complication? a. Urethral damage b. Bladder relaxation c. Obstruction of urinary flow d. Decreased risk for infection ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Large catheters (larger than 16 Fr) can distend the urethra and permanently damage the urethra and bladder neck, as well as cause bladder spasms and leaking around the catheter. Use a catheter of the smallest size possible to minimize trauma and promote adequate drainage of the periurethral glands. This will decrease the risk for infection. DIF: Cognitive Level: Analysis REF: Text reference: p. 812 |Text reference: p. 814 OBJ: Perform the following skills: place and remove a urinal, insert a urinary catheter, and provide care for an indwelling urinary catheter. TOP: Size of Urinary Catheter KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 16. The nurse is caring for a patient who has an indwelling catheter attached to a drainage bag; to
achieve the desired outcome of this procedure, which nursing action should be taken? a. Make sure the tubing has dependent loops to gather urine. b. Make sure the tubing is coiled and secured to the bed. c. Make sure the tubing is kinked. d. Make sure the collection bag is higher than the bladder. ANS: B
Check the drainage tubing and the bag to make sure that the tubing does not have dependent loops and the bag is not positioned above the level of the bladder. Check to make sure that the tubing is coiled and is secured to the bed linen, is free of kinks, and is not clamped, and that the patient is not lying on it. DIF: Cognitive Level: Application REF: Text reference: p. 821 OBJ: Perform the following skills: place and remove a urinal, insert a urinary catheter, and provide care for an indwelling urinary catheter. TOP: Catheter Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IN ntegR rityI G B.C M
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17. The nurse is caring for a patient who is experiencing inadequate bladder emptying. To
determine postvoid residual, which technique is most important for the nurse to implement? a. Bladder scanner b. Indwelling catheterization c. Straight/intermittent catheterization d. Foley catheterization ANS: A
The bladder scan is most commonly used to measure postvoid residual (PVR); it is the least invasive method of making this determination. DIF: Cognitive Level: Analysis REF: Text reference: p. 827 OBJ: Perform the following skills: obtain a residual urine. TOP: Residual Urine KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse is preparing the patient for a bladder scan to determine PVR. Which of the
following is part of the preparation? a. Limit food intake for 2 hours before the scan. b. Begin scan 10 minutes after the patient has voided. c. Limit liquid intake for 30 minutes before the scan. d. Administer an analgesic 30 minutes before the scan.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: B
The nurse will assist the patient to void, then wait 10 minutes before administering the bladder scan. There is no need to limit either food or fluids before the test. Since the test is completely noninvasive, there is no need to administer an analgesic beforehand. DIF: Cognitive Level: Knowledge REF: Text reference: p. 827 OBJ: Perform the following skills: determine PVR. TOP: Residual Urine KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. In assisting a male patient in using a urinal, which of the following actions should the nurse
take? (Select all that apply.) a. Assess for orthostatic hypotension. b. Assess the patient’s normal elimination habits. c. Assess for periods of incontinence. d. Prop the urinal in place if the patient is unable to hold it. e. Always stay with the patient during urinal use. ANS: A, B, C
To assist the patient in using a urinal, the nurse should assess the patient’s normal urinary elimination habits and look for periods of incontinence. Always determine mobility status before having a patient stand to void, and assess for orthostatic hypotension if the patient has been on prolonged bed rest. If the patient is able to handle the urinal himself, allow him privacy. If the patient is unable to handle the urinal the nurse will assist by holding it.
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DIF: Cognitive Level: KnowledU ge S N RT EF: TeO xt reference: p. 811 OBJ: Perform the following skills: place and remove a urinal. TOP: Assisting the Male Patient in Using a Urinal KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse has inserted an indwelling catheter and secured the catheter to the patient’s thigh,
making sure that there is enough slack that movement will not create tension on the catheter. The nurse understands that the chief purpose of properly securing Foley catheters is to obtain which outcome? (Select all that apply.) a. Minimized risk for bleeding b. Reduced risk for bladder spasm c. Reduced risk for meatal necrosis d. Reduced risk for trauma e. Increased bladder relaxation ANS: A, B, C, D
Securing the catheter will minimize accidental dislodgment. It also will minimize risks for bleeding, trauma, meatal necrosis, and bladder spasms from pressure and traction. DIF: Cognitive Level: Analysis REF: Text reference: pp. 820-821 |Text reference: p. 825 OBJ: Perform the following skills: place and remove a urinal, insert a urinary catheter, and provide care for an indwelling urinary catheter. TOP: Securing the Catheter KEY: Nursing Process Step: Implementation
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity COMPLETION 1. Antimicrobial catheters coated with silver or antibiotics have been shown to reduce the
incidence of
.
ANS:
catheter associated urinary tract infection (CAUTI) Silver coated antimicrobial catheters have been effective in reducing incidences of CAUTI in short term catheter use. DIF: Cognitive Level: Knowledge REF: Text reference: p. 812 OBJ: Identify factors that increase risk for urinary infection. TOP: Urinary Tract Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Catheter use in older adults has been associated with increased
.
ANS:
mortality Older adults are at greater risk of death after the development of CAUTI. They face a greater risk of the bacteria entering the bloodstream and causing a systemic infection. DIF: Cognitive Level: Knowledge REF: Text reference: p. 822 OBJ: Identify factors that increase risk for urinary infection. TOP: Urosepsis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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3. The risk for catheter-associatedUuriS narN y traTct infecO tion can be reduced by using
when inserting the catheter. ANS:
aseptic technique Numerous studies has confirmed the effect of the use of aseptic technique in the insertion of urinary catheters in reducing the rate of catheter associated infections. DIF: Cognitive Level: Knowledge REF: Text reference: p. 810 OBJ: Identify factors that decrease risk for urinary infection. TOP: Aseptic Technique during Catheter Insertion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. A single-lumen catheter that is inserted into the bladder through the urethra only to empty the
bladder and then is removed is known as a
catheter.
ANS:
straight or intermittent A straight or intermittent catheter is a single-lumen catheter that is inserted into the bladder through the urethra only to empty the bladder, and then is removed. Use this type of catheter on a one-time basis, for example, to determine the amount of residual urine in the bladder, or intermittently, when the patient cannot urinate because of a urinary obstruction or a neurological disorder such as spinal cord injury.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Knowledge REF: Text reference: p. 812 OBJ: Describe devices used to promote urinary elimination. TOP: Straight or Intermittent Catheters KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. An
has a separate lumen that is used to inflate a balloon so the catheter remains in the bladder for short- or long-term use. ANS:
indwelling catheter An indwelling catheter has a separate lumen that is used to inflate a balloon so the catheter remains in the bladder for short- or long-term use. DIF: Cognitive Level: Knowledge REF: Text reference: pp. 812-813 OBJ: Describe devices used to promote urinary elimination. TOP: Indwelling Catheter KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
is the volume of urine in the bladder after a normal voiding.
6. ANS:
Residual urine Residual urine, also referred to as postvoid residual (PVR), is the volume of urine in the bladder after a normal voiding. DIF: Cognitive Level: Knowledge REF: Text reference: p. 827 OBJ: Perform the following skills: obtain a residual urine. TOP: Residual Urine KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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7. A noninvasive device that is used to provide accurate determination of a patient’s bladder
volume by first creating an ultrasound image of the patient’s bladder and then calculating the urine volume in the bladder is known as a . ANS:
bladder scanner The bladder scanner is noninvasive, so there is no risk for nosocomial UTI and possible trauma associated with urinary catheterization. It provides accurate determination of a patient’s bladder volume by first creating an ultrasound image of the patient’s bladder and then calculating the urine volume in the bladder. DIF: Cognitive Level: Knowledge REF: Text reference: p. 827 OBJ: Perform the following skills: obtain a residual urine, and measure a bladder scan. TOP: Bladder Scanner KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. A
is a noninvasive alternative for management of male urinary incontinence. Because it is noninvasive, the risk for UTI is decreased. The device fits over the penis and connects to a small collection bag that attaches to the leg with a strap, or to a standard urinary collection bag that hangs on the bed frame below the level of the bladder. ANS:
condom catheter
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank A condom catheter, also referred to as an external catheter or a penile sheath, is a noninvasive alternative for management of male urinary incontinence. Because it is noninvasive, the risk for UTI is decreased. The device is a soft, flexible, condom-like sheath that fits over the penis and connects to a small collection bag that attaches to the leg with a strap, or to a standard urinary collection bag that hangs on the bed frame below the level of the bladder. DIF: Cognitive Level: Knowledge REF: Text reference: p. 833 OBJ: Perform the following skills: apply a condom catheter. TOP: Condom Catheter KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9.
involves the insertion of a urinary catheter directly into the bladder through the lower abdominal wall. Urine drains from the catheter into a urinary drainage bag. ANS:
Suprapubic catheterization Suprapubic catheterization involves the insertion of a urinary catheter directly into the bladder through the lower abdominal wall. Urine drains from the catheter into a urinary drainage bag. Suprapubic catheters are inserted with local or general anesthetic for short- or long-term use. DIF: Cognitive Level: Knowledge REF: Text reference: p. 837 OBJ: Perform the following skills: care for a patient with a suprapubic catheter. TOP: Suprapubic Catheterization KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 34: Bowel Elimination and Gastric Intubation MULTIPLE CHOICE 1. The nurse is caring for a patient who has been on bed rest for several weeks. The nurse notes
that the patient is continually seeping liquid stool rectally. The nurse should take which action? a. Hold the patient’s antibiotics. b. Put the patient on a bran diet. c. Perform a digital rectal examination. d. Increase the dosage of the patient’s antibiotics. ANS: C
Continual seepage of diarrhea may occur with an impaction, and a digital rectal examination can verify its presence. Diarrhea is often due to diet or antibiotic use, which alters the normal flora in the gastrointestinal tract. However, a physician’s order is required to change these, and continual seepage of stool is more likely the result of impaction; this should be ruled out first. DIF: Cognitive Level: Application REF: Text reference: p. 849 OBJ: Discuss methods used to relieve constipation or impaction. TOP: Digital Rectal Examination KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The patient is a 74-year-old man who has been in the hospital for 4 days following an
orthopedic surgical procedure. He is concerned because he has not moved his bowels every Mhich response made by the nurse is day as he did before surgery,NbU utReS veI ryNoGthTeB r d.aC y.OW appropriate? a. Tells the patient to put himself on over-the-counter laxatives b. Tells the patient that daily bowel movements are not always necessary c. Tells the patient that with increasing age, his bowel movements should increase in frequency d. Tells the patient that she will call to get a laxative to get him back on track ANS: B
Reinforce with older adult patients that as long as the consistency of the stool remains normal and bowel movements occur with regularity. As long as he is able to move his bowels at least 3 times a week, he shouldn’t worry about not having a daily movement. Since there is no indication of constipation the patient should not place himself on laxatives. However, since the patient is most likely less mobile and receiving strong pain medication following his orthopedic surgery (both likely to cause constipation) the nurse should monitor the situation. DIF: Cognitive Level: Application REF: Text reference: pp. 842-843 OBJ: Discuss methods used to relieve constipation or impaction. TOP: Gerontological Considerations KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 3. The nurse assesses that a patient has a severe fecal impaction. Which action taken by the nurse
addresses this problem? a. Administering laxatives
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. Providing a high-fiber diet c. Performing a digital removal d. Administering an enema ANS: C
Prevention is the key to fecal impaction. However, once it occurs, digital removal of stool is the only alternative. Once the impaction is cleared, a high-fiber diet, increased activity, and adequate hydration may all reduce the likelihood of recurrence. DIF: Cognitive Level: Application REF: Text reference: p. 849 OBJ: Describe factors that promote and impede normal bowel elimination. TOP: Digital Removal of Fecal Impaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse prepares to exercise a digital removal of feces. To detect an untoward effect of this
procedure, the nurse should assess the patient history for which condition? a. Heart disease b. Abdominal pain c. Urinary infection d. Diabetes mellitus ANS: A
Because of the potential to stimulate the vagus nerve, patients with a history of dysrhythmia or heart disease are at greater risk for changes in heart rhythm. Be sure to monitor the patient’s pulse before and during the procedure. This procedure may be contraindicated in cardiac patients; if in doubt, verify with the physician. Symptoms of fecal impaction include constipation, rectal discomfort, anorexia, nausea, vomiting, abdominal pain, diarrhea (around the impacted stool), and urinN ary freq cy.TB A. bdC om inal pain by itself is not indicative of the UR SIuen NG OM need for extra caution. Symptoms of fecal impaction include urinary frequency, not infection. There is no correlation between the two. DIF: Cognitive Level: Analysis REF: Text reference: pp. 849-850 OBJ: Describe factors that promote and impede normal bowel elimination. TOP: Digital Removal of Fecal Impaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. When evaluating a health care team member’s ability to digitally remove feces, the nurse
determined that further teaching is required in which of the following situations? a. Staff member provides perianal skin care. b. Staff member continues the procedure if bleeding starts. c. Staff member follows the procedure by offering the patient the bedpan. d. Staff member discontinues the procedure in the presence of bradycardia. ANS: B
If the patient experiences bleeding from the rectum, the anal and perianal regions should be assessed to locate the source of the bleeding. Observe for the presence of perianal skin irritation. The presence of such indicates the need for postprocedure skin care to the perianal region to reduce pain during subsequent bowel elimination. After the procedure, assist the patient to the toilet or onto a clean bedpan. Removal of impaction stimulates the defecation reflex. The sacral branch of the vagus nerve is stimulated during digital stimulation; this may result in reflex slowing of the heart rate. Stop the procedure and retake vital signs.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Analysis REF: Text reference: p. 851 OBJ: Implement the following skills: digital removal of stool. TOP: Digital Removal of Fecal Impaction KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 6. The nurse is preparing to administer an enema to a patient. Which type of enema is most
likely to lead to circulatory overload? a. Hypertonic solution b. Soapsuds c. Tap water d. Harris flush ANS: C
A tap water (hypotonic) enema should not be repeated after first instillation because water toxicity or circulatory overload can develop. Hypertonic solution is useful for patients who cannot tolerate large volumes of fluid. Only 120 to 180 mL (4 to 6 ounces) is usually effective (e.g., commercially prepared Fleet enema). A soapsuds enema (SSE) consists of pure castile soap added to tap water or normal saline, depending on the patient’s condition and the frequency of administration. Use only castile pure soap. The recommended ratio of pure soap to solution is 5 mL (1 teaspoon) to 1000 mL (1 quart) warm water or saline. Add soap to the enema bag after water is in place to reduce excessive suds. The Harris flush enema is a return-flow enema that helps to expel intestinal gas. Fluid alternately flows into and out of the large intestine. This stimulates peristalsis in the large intestine and assists in expelling gas. DIF: Cognitive Level: Analysis REF: Text reference: p. 852 OBJ: Implement the following skills: enema administration. TOP: Tap Water Enema KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
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7. When preparing an infant for an enema, the nurse understands that which solution is the
safest? a. Tap water enema solution b. Hypertonic enema solution c. Oil retention d. Physiological normal saline ANS: D
Physiological normal saline is safest. Infants and children can tolerate only this type because of their predisposition to fluid imbalance. If solution is prepared at home, mix 500 mL (1 pt) of tap water with 1 teaspoon of table salt. None of the other types of enemas are safe to use for infants and children. DIF: Cognitive Level: Analysis REF: Text reference: p. 852 OBJ: Implement the following skills: enema administration. TOP: Saline Enema KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 8. The patient is being prepped for surgery and has an order for “enemas until clear.” The nurse
realizes that she will be giving a maximum of how many enemas? a. One b. Two c. Three d. Four
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: C
The “enemas until clear” order means that you repeat enemas until the patient passes fluid that is clear of fecal matter. Check agency policy, but usually a patient should receive a maximum of three consecutive enemas to avoid disruption of fluid and electrolyte balance. If more are required, notify the physician before administering. DIF: Cognitive Level: Application REF: Text reference: p. 853 OBJ: Implement the following skills: enema administration. TOP: Enemas Until Clear KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse is preparing to administer an enema to an adult patient who has normal sphincter
control. For administration of the enema, the patient is placed in which position? a. Right side-lying b. Dorsal recumbent c. Sims’ d. Prone ANS: C
Assist the patient into left side-lying (Sims’) position with the right knee flexed. Additionally, place a child in dorsal recumbent position. This allows enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum, thus improving retention of solution. DIF: Cognitive Level: Application REF: Text reference: p. 854 OBJ: Implement the following skills: enema administration. TOP: Enema Process: Positioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IN ntegR rityI G B.C M
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10. The nurse has been directed to provide an enema for an elderly female patient who has very
poor rectal sphincter control. Which position is most appropriate for this patient? a. Sims’ position b. Dorsal recumbent position on the bedpan c. Sitting on the toilet d. Right lateral position ANS: B
If the patient has poor sphincter control, position the patient on the bedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control cannot retain all of the enema solution. Administering an enema with the patient sitting on the toilet is unsafe because curved rectal tubing can abrade the rectal wall. DIF: Cognitive Level: Application REF: Text reference: p. 853 OBJ: Implement the following skills: enema administration. TOP: Dorsal Recumbent Position on the Bedpan KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. When preparing an adult patient for an enema, the nurse understands that the tube or nozzle
should be inserted how far? a. 1 to inches
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. 2 to 3 inches c. 3 to 4 inches d. 4 to 5 inches ANS: C
Insert the nozzle of the container gently into the anal canal—for adults, 7.5 to 10 cm (3 to 4 inches). If administering to an infant, insert the tip of the tube 2.5 to 3.75 cm (1 to inches). If administering to a child, insert the tip of the tube 5 to 7.5 cm (2 to 3 inches). However, children and infants usually do not receive prepackaged hypertonic enemas because hypertonic solutions cause rapid fluid shift. Inserting the tip of the tube more than 4 inches is not appropriate at any age. DIF: Cognitive Level: Application REF: Text reference: p. 854 OBJ: Implement the following skills: enema administration. TOP: Insertion of Tubing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. While the nurse is administering an enema with a standard enema bag, which intervention is
important to implement? a. Keeping the solution at room temperature b. Positioning the patient on the right side c. Raising the enema bag to 12 inches above the patient d. Instructing the patient to release the enema solution as soon as possible ANS: A
Maintaining a the correct temperature for the solution is a critical safety precaution. If the solution is too hot it will burn the intestinal mucosa. Cold water can cause abdominal cramping. Solution dripped oN nU inR nS erIwN riG stTshBo. ulC dO beMcomfortable. Unless patient condition requires a different position, the patient will lay on his/her left side with the top leg flexed (left lateral Sims’) and the bag of solution will be hung 18 inches above the rectum. The patient will be instructed to retain the solution as long as possible for maximum therapeutic effect. DIF: Cognitive Level: Application REF: Text reference: pp. 854-855 OBJ: Implement the following skills: enema administration. TOP: Temperature of Solution KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. While the nurse is administering an enema, the patient complains of some cramping. Which
action should the nurse take next? a. Discontinue the procedure completely. b. Increase the height of the solution. c. Slow the rate of infusion. d. Have the patient roll into a supine position. ANS: A
If abdominal cramping develops, decrease the height of the enema bag and slow the rate of instillation. Changing the patient position will not be helpful. Sometimes, temporarily stopping the solution (taking a break) minimizes cramping. DIF: Cognitive Level: Application REF: Text reference: pp. 855-856 OBJ: Implement the following skills: enema administration. TOP: Abdominal Cramping
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. When providing care for a patient who is disoriented during a nasogastric (NG) tube
placement, which intervention is important for the nurse to implement? a. Halt the procedure. b. Request assistance with insertion. c. Administer a hypnotic medication. d. Continue the procedure as with any other patient. ANS: B
If the patient is confused, disoriented, or unable to follow commands, obtain assistance from another staff member to insert the tube. DIF: Cognitive Level: Application REF: Text reference: p. 858 OBJ: Implement the following skills: insertion of an NG tube. TOP: Disoriented Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. When developing a plan of care for a patient requiring an NG tube, the nurse recognizes that it
is essential to implement which technique in measuring the length of the tube? a. Measure from the nose to the ear to the patient’s navel. b. Measure from the nose to the middle of the sternum. c. Measure and mark a point 30 inches from the end. d. Mark the 50-cm point on the tube, measure in the traditional way, and insert halfway between the two spots. ANS: D
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Hanson method: First, mark the 50-cm point on the tube, and then do traditional measurement. Tube insertion should be to the midway point between 50 cm (20 inches) and the traditional mark. DIF: Cognitive Level: Application REF: Text reference: p. 859 OBJ: Implement the following skills: insertion of an NG tube. TOP: Measuring Tube for Placement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. In advancing the NG tube, which technique provides the safest outcome? a. Rotate the tube if resistance is felt. b. Advance the tube in between swallows. c. Start with the patient’s head flexed. d. Check the tube placement by instilling air and auscultating over the stomach. ANS: A
If resistance is met, try to rotate the tube and see whether it advances. If there is still resistance, withdraw the tube, allow the patient to rest, relubricate the tube, and insert it into the other naris. Advance the tube 2.5 to 5 cm (1 to 2 inches) with each swallow of water. If the patient is not allowed fluids, instruct him to dry swallow or suck air through a straw. Initially, instruct the patient to extend his neck back against the pillow; insert the tube slowly through the naris with the curved end pointing downward. Verify tube placement. Check agency policy for preferred methods.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Application REF: Text reference: p. 859 OBJ: Implement the following skills: insertion of an NG tube. TOP: Insertion of NG Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. When care is provided for a patient with an NG tube in place, which intervention is safest for
the nurse to implement? a. Tape the tube up and around the ear on the side of insertion. b. Secure the tubing to the bed by the patient’s head. c. Mark the tube where it exits the nose. d. Change the tubing daily. ANS: C
Once placement is confirmed, a red mark should be made or place tape on the tube to indicate where the tube exits the nose. The mark or the tube length is to be used as a guide to indicate whether displacement may have occurred. The tube should be taped to the nose, not to the ear. The tubing should be secured to the patient’s gown, not to the bed, and should not be changed daily, but it may be irrigated daily. DIF: Cognitive Level: Application REF: Text reference: p. 862 OBJ: Implement the following skills: insertion of an NG tube. TOP: Marking NG Tube Placement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. A patient is admitted for constipation. When planning care for this patient, the nurse
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recognizes that which intervenU tionS s woNuldThelp coOntrol constipation? (Select all that apply.) a. Increases in activity level b. Elimination of laxative use c. Decreased dietary fiber d. Increased fluids e. Timely response to urge to move bowels ANS: A, B, D, E
Changes in lifestyle that will be helpful to eliminate constipation cycles include increased dietary fiber, increased fluids, moderate exercise, and elimination of laxative use. It is also important to encourage patients to respond to the urge to move bowels when the urge first occurs, since delay may promote constipation. DIF: Cognitive Level: Analysis REF: Text reference: p. 843 OBJ: Describe factors that promote and impede normal bowel elimination. TOP: Interventions to Control Constipation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The patient has increased his fluid and dietary fiber intake and has started a supervised
exercise program. However, he is still having problems with constipation. Which of the following would be an effective intervention? (Select all that apply.) a. Metamucil b. Milk of magnesia
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank c. Dulcolax d. Mineral oil e. Colace ANS: A, B, C
Use the following stepwise levels of interventions. Bulk-forming laxatives (e.g., psyllium [Metamucil], methylcellulose [Citrucel]) are safe, add bulk to the fecal material, and are used in combination with a saline laxative (e.g., magnesium hydroxide [milk of magnesia]) or an osmotic laxative (e.g., lactulose [Chronulac]). The patient should increase water intake to enhance the effectiveness of bulk-forming laxatives. If constipation continues, stimulant laxatives (e.g., bisacodyl [Dulcolax], senna [Senokot]) usually provide relief. Avoid emollient laxatives, such as mineral oil and Colace, because they are associated with lipoid aspiration pneumonia. DIF: Cognitive Level: Analysis REF: Text reference: p. 843 OBJ: Discuss methods used to relieve constipation or impaction. TOP: Laxatives KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The patient is receiving a soapsuds enema but is having a difficult time retaining the fluid.
What action should the nurse take? (Select all that apply.) a. Give the enema slowly. b. Place the patient in the dorsal recumbent position on a bedpan. c. Give the enema with the patient on the toilet. d. Give the enema in the right lateral position. e. Give the enema faster. ANS: A, B
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Give the enema slowly to aid absorption. If the patient is full of stool, retention is difficult. As stool is evacuated, there is more room in the colon for additional fluid. If the patient has poor sphincter control, position the patient on the bedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control cannot retain all of the enema solution. Administering an enema with the patient sitting on a toilet is unsafe because curved rectal tubing can abrade the rectal wall. Enemas are not given to patients in the right lateral position. DIF: Cognitive Level: Application REF: Text reference: pp. 854-856 OBJ: Implement the following skills: enema administration. TOP: Inability to Retain Enema Fluid KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The Levin tube and the Salem sump tube are used most commonly for stomach
decompression. Which of the following statements about these tubes is true? (Select all that apply.) a. Levin tubes have a blue “pigtail” that functions as an air vent. b. These tubes are inserted as a sterile procedure. c. The blue air vent should not be used for irrigation. d. The Salem sump tube has a blue “pigtail” that functions as an air vent. e. The Salem sump is preferred for stomach decompression. ANS: C, D, E
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The Levin tube is a single-lumen tube with holes near the tip. You connect the tube to a drainage bag or to an intermittent suction device to drain stomach secretions. The Salem sump tube has two lumina: one for removal of gastric contents and one to provide an air vent, which prevents suctioning of gastric mucosa into eyelets at the distal tip of the tube. A blue “pigtail” is the air vent that connects with the second lumen. Never clamp off the air vent, connect it to suction, or use it for irrigation. NG tube insertion does not require sterile technique. Clean technique is adequate. The Salem sump is preferred for gastric decompression. DIF: Cognitive Level: Comprehension REF: Text reference: p. 857 OBJ: Implement the following skills: insertion of an NG tube. TOP: Nasogastric (NG) Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. What should the nurse do to verify nasogastric (NG) tube placement? (Select all that apply.) a. Ask the patient to speak. b. Inspect the posterior pharynx. c. Aspirate back on the syringe. d. Obtain an x-ray of the placement. e. Auscultate the lung fields. ANS: A, B, C, D
While an x-ray examination is the gold standard to verify NG tube placement, there are several steps the nurse can take to gauge correct placement. Ask the patient to speak. If the patient is unable to speak, the NG tube may have passed through the vocal cords. Inspect the posterior pharynx for the presence of a coiled tube. The tube is pliable and will coil up behind the pharynx instead of advancing into the esophagus. Aspirate gently back on the syringe to obtain gastric contents, observing color. Gastric contents are usually cloudy and green but NlooRS IorGbT B.C M sometimes are off-white, tan, bU dy, N rown. AOspiration of contents provides the means to measure fluid pH and thus determine tube tip placement in the GI tract. DIF: Cognitive Level: Application REF: Text reference: p. 860 OBJ: Implement the following skills: insertion of an NG tube. TOP: Verifying Position of NG Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. Infrequent bowel movements (less often than every 3 days), difficulty in evacuating feces,
inability to defecate, and hard feces are signs of
.
ANS:
constipation Constipation is a symptom, not a disease. Signs of constipation usually include infrequent bowel movements (less often than every 3 days), difficulty in evacuating feces, inability to defecate, and hard feces. DIF: Cognitive Level: Knowledge REF: Text reference: p. 842 OBJ: Describe factors that promote and impede normal bowel elimination. TOP: Constipation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 2. The
system is an intrarectal catheter that has a retention cuff, an intraluminal balloon, three pilot balloons, anchor straps, and a port for sampling stool. The purpose of this system is to divert feces away from wounds while providing access for administering rectal medications and irrigations. ANS:
Actiflo bowel management One strategy by which to manage diarrhea is the Actiflo Bowel Management system, which diverts feces away from wounds and administers rectal medications and irrigations. This system consists of an intrarectal catheter that has a retention cuff, an intraluminal balloon, three pilot balloons, anchor straps, and a port for sampling stool. DIF: Cognitive Level: Knowledge REF: Text reference: pp. 843-844 OBJ: Describe factors that promote and impede normal bowel elimination. TOP: Zassi Bowel Management KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. A bedpan that is designed for patients with body or leg casts or for patients restricted from
raising their hips (e.g., following total joint replacement) is known as a
.
ANS:
fracture pan A fracture pan, designed for patients with body or leg casts or for those restricted from raising their hips (e.g., following total joint replacement), has a shallow end approximately 1.3 cm ( inch) deep that slips easily under a patient. The open end of the regular pan fits just under the upper thighs, and the back of the pan fits under the patient’s buttocks toward the sacrum. For the fracture pan, the handle isNjusR unIderGtheBth.igChs,M UtS N T O and the smaller portion is toward the buttocks. DIF: Cognitive Level: Knowledge REF: Text reference: p. 844 OBJ: Implement the following skills: assisting the patient in using a bedpan. TOP: Fracture Pan KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4.
is defined by a number of signs including infrequent bowel movements, difficulty evacuating, hard stools, and inability to defecate. ANS:
Constipation Constipation is a symptom with a number of signs including infrequent bowel movements, difficulty evacuating, hard stools, and inability to defecate. DIF: Cognitive Level: Knowledge REF: Text reference: p. 842 OBJ: Describe factors that promote and impede normal bowel elimination. TOP: Obstipation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The inability to pass a hard collection of stool is known as ANS:
fecal impaction
_.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Fecal impaction, the inability to pass a hard collection of stool, occurs in all age groups. DIF: Cognitive Level: Knowledge REF: Text reference: p. 849 OBJ: Describe factors that promote and impede normal bowel elimination. TOP: Fecal Impaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. An
is the instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis. ANS:
enema An enema is the instillation of a solution into the rectum and sigmoid colon. Enemas promote defecation by stimulating peristalsis. DIF: Cognitive Level: Knowledge REF: Text reference: p. 852 OBJ: Describe precautions that should be followed in administering an enema. TOP: Enema KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 35: Ostomy Care MULTIPLE CHOICE 1. The nurse is caring for a patient with an ostomy. The nurse notes that the ostomy is putting
out watery effluent. The nurse recognizes that this is indicative of which location? a. Descending colon b. Sigmoid colon c. Ileal portion of the small intestine d. transverse colon ANS: C
An opening in the ileal portion of the small intestine is an ileostomy, and the fecal effluent will be watery to thick liquid that will contain some digestive enzymes. A colostomy in the descending or sigmoid colon generally results in a stool similar to that normally passed through the rectum. If the opening is in the transverse or ascending colon, the effluent will vary from thick liquid to semi-formed stool. DIF: Cognitive Level: Analysis REF: Text reference: p. 866 OBJ: Explain differences in the color and consistency of effluent based on the type of ostomy. TOP: Position of the Ostomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is caring for a patient who has an ostomy. The nurse notices that the effluent ranges
from a thick liquid to a semi-formed stool. The nurse recognizes that this is indicative of which location? NURSINGTB.COM a. Descending colon b. Ileal portion of the small intestine c. Sigmoid colon d. Transverse or ascending colon ANS: D
If the opening is in the transverse or ascending colon, the effluent will vary from thick liquid to semi-formed stool. A colostomy in the descending or sigmoid colon generally results in a stool similar to that normally passed through the rectum. An opening in the ileal portion of the small intestine is an ileostomy, and the fecal effluent will be watery to thick liquid that will contain some digestive enzymes. DIF: Cognitive Level: Analysis REF: Text reference: p. 866 OBJ: Explain differences in the color and consistency of effluent based on the type of ostomy. TOP: Position of the Ostomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient who had a colostomy placed 5 days earlier. The nurse notes
that the stoma is red and moist. Which action should the nurse take? a. Notify the physician immediately. b. Apply pressure. c. Note the condition of the stoma in her notes. d. Change the appliance pouch. ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The stoma should be red or pink and moist. After assessment the nurse will note the appearance of the stoma in the patient HER. If it is gray, purple, or black, report this to the charge nurse or physician immediately. Pressure is applied to control active bleeding. The information given in the question does not indicate that there is a need to change the appliance at this time. DIF: Cognitive Level: Application REF: Text reference: p. 870 OBJ: Describe methods used to maintain the integrity of the peristomal skin. TOP: Condition of Ostomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. In caring for a patient who had a fecal surgical diversion, which nursing intervention is
essential? a. Place a pouch over the newly created stoma. b. Place a dressing over the stoma. c. Wait several days before placing a pouch. d. Prepare several pouches in advance. ANS: A
Immediately after a fecal surgical diversion, it is necessary to place a pouch over the newly created stoma to contain effluent when the stoma begins to function. The pouch will keep the patient clean and dry, will protect the skin from drainage, and will provide a barrier against odor. Dressings would obstruct the opening and would become saturated with fecal material. Preparing multiple pouches in advance would be counterproductive; in the immediate postoperative period, the stoma may be edematous and the abdomen distended. These symptoms eventually resolve, but during this time, it will be necessary to revise the pouching system to meet the changing size of the stoma and the changes in body contours.
NURSINGTB.C OM
DIF: Cognitive Level: Application REF: Text reference: p. 868 OBJ: Describe methods used to maintain the integrity of the peristomal skin. TOP: Immediate Postsurgical Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. When planning care for a patient who has a colostomy, which intervention is important for the
nurse to perform when pouching the colostomy ? a. Leave an intact skin barrier in place for 3 to 7 days. b. Use soap and water to cleanse the peristomal skin. c. Empty the pouch when it is two-thirds full. d. Use tape to secure pouches that have minor leaks. ANS: A
Observe the existing skin barrier and pouch for leakage and length of time in place. The pouch should be changed every 3 to 7 days, not daily. To minimize skin irritation, avoid unnecessary changing of the entire pouching system, but if the effluent is leaking under the wafer, change it, because skin damage from the effluent will cause more skin trauma than will be caused by early removal of the wafer. Cleanse the peristomal skin gently with warm tap water using a washcloth; do not scrub the skin. Pat the skin dry. Avoid soap; it leaves residue on the skin, which interferes with pouch adhesion. Pouches must be emptied when they are one-third to one-half full, because the weight of the pouch may disrupt the seal of the adhesive on the skin. If the ostomy pouch is leaking, change it. Taping or patching it to contain effluent leaves the skin exposed to chemical or enzymatic irritation.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Application REF: Text reference: p. 870 OBJ: Pouch a fecal or urinary diversion. TOP: Pouching a Colostomy or Ileostomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. When providing care for a patient with a colostomy or an ileostomy, the nurse recognizes that
which is an expected assessment finding? a. A moist, reddish-pink stoma b. A dry, purplish stoma c. Erythema on the skin around the stoma d. No drainage noted from the stoma when washed ANS: A
Normal findings in a patient with a postoperative ostomy that is healing include a stoma that is moist and reddish-pink, skin that is intact and free of irritation, and sutures that are intact. The stoma is edematous initially and shrinks over the next 4 to 6 weeks. A necrotic stoma is manifested by a purple or black color and a dry instead of moist texture. The stoma is functioning normally when the stoma drains a moderate amount of liquid or soft stool and flatus in the pouch. Flatus indicates the return of peristalsis after surgery. Flatus is noted by bulging of the pouch. (Flatus may not be observable if the pouch has a gas filter.) DIF: Cognitive Level: Application OBJ: Pouch a fecal or urinary diversion. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 870 TOP: Pouching a Colostomy or Ileostomy MSC: NCLEX: Physiological Integrity
7. The nurse is caring for a preterm infant in the neonatal intensive care unit who has multiple
stomas. Given the uniquenesN s of on is essential for the nurse to take? URinfa SInts, NGwh TBic.h Cacti OM a. Apply an ostomy pouch using standard sealants. b. Use a pouch that can accommodate increased amounts of flatus. c. Use multiple pouches (one for each stoma). d. Be aware that the stoma size will remain the same as the baby grows. ANS: B
Because babies swallow large amounts of air while sucking, it is normal to expect flatus. Make sure that the pouch can accommodate increased amounts of flatus after feeding, or be prepared to release flatus frequently. The skin of a preterm infant is not fully developed and is more absorbent than the skin of a full-term infant. Do not use skin sealants and adhesive removers unless they are approved for preterm infant use. Neonates may have multiple stomas on their tiny abdomens that are the result of corrective bowel surgeries. Select a cut-to-fit pouch that allows multiple stoma openings in the skin barrier yet still fits on the neonate’s abdomen. Usually, a baby triples its birth weight in the first year. As a baby grows in size, so does the stoma. DIF: Cognitive Level: Application REF: Text reference: p. 873 OBJ: Pouch a fecal or urinary diversion. TOP: Pediatric Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. In caring for a patient who has a pouching for a noncontinent urinary diversion, which nursing
intervention is essential?
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
Empty the pouch when it is one-third to one-half full. Remove the ureteral stents after 2 days. Pouch the stoma with the patient sitting up. Dispose of used pouches in the toilet.
ANS: A
Empty pouches when they are one-third to one-half full so that the weight of the pouch does not disrupt the seal. A surgeon places the stents; these will be removed during the hospital stay or at the first postoperative visit with the surgeon. Place the patient in a semi-reclining position. If possible, provide the patient a mirror for observation. Properly dispose of used pouches and soiled equipment according to facility policy. DIF: Cognitive Level: Application REF: Text reference: p. 874 OBJ: Pouch a fecal or urinary diversion. TOP: Pouching a Urostomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. When assessing the patient with a noncontinent urinary diversion, the nurse finds that the
urine has mucous shreds. Which action should the nurse take? a. Culture any drainage. b. Instruct the patient to consume less water. c. Note the characteristics of the urine in her notes. d. Cleanse the stoma with soap and water. ANS: C
Mucous shreds are normal when urine flows through an intestinal segment. Obtain a urine specimen for culture and sensitivity to test for possible infection when ordered by the physician if urine output is leN ssUtR han I30Nm GL/ Bhr., oCrOifMthe urine has a foul odor. Teach patients S T the significance and importance of drinking 1.5 to 2 quarts of fluid daily to prevent urinary tract infection. Avoid soap; it leaves residue on the skin, which interferes with pouch adhesion. DIF: Cognitive Level: Analysis REF: Text reference: p. 875 OBJ: Pouch a fecal or urinary diversion. TOP: Mucous Shreds KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse has removed the patient’s old urostomy pouch and is attempting to measure the
stoma opening for placement of a new pouch. Which action should the nurse take next? a. Place the patient in a prone position. b. Cleanse the peristomal skin with warm soap and water. c. Remove any stents that are in place. d. Place rolled gauze at the stoma opening. ANS: D
Wick the stoma continuously during pouch measurement and change. Place a rolled gauze wick at the stomal opening. Using a wick at the stoma opening prevents the peristomal skin from becoming wet with urine during a pouching-change procedure. Position the patient in a semi-reclining position. Avoid soap when cleansing the area. In the immediate postoperative period, urinary stents extend out from the stoma. A surgeon places the stents to prevent stenosis of the ureters at the site where the ureters are attached to the conduit. The stents will be removed during the hospital stay or at the first postoperative visit with the surgeon.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Application REF: Text reference: p. 878 OBJ: Pouch a fecal or urinary diversion. TOP: Wicking the Stoma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. A patient who has a urostomy is being discharged to home. Which instruction will the nurse to
provide to the patient? a. Restrict fluid intake to reduce urine output. b. Report any mucus in his urine. c. Keep unused pouches in the refrigerator. d. Shower without covering the pouch. ANS: D
The patient may shower without covering the pouch. Teach patients the significance and importance of drinking 1.5 to 2 quarts of fluid daily to prevent urinary tract infection. Patients should avoid storing pouches in extremely hot or cold locations like the refrigerator. Teach patients that some mucus in the urine is expected, but that they should report to their physician any blood in the urine, excessively cloudy urine, chills, fever (101 F or higher), or back (flank) pain. DIF: Cognitive Level: Application REF: Text reference: p. 876 OBJ: Describe methods used to maintain the integrity of the peristomal skin. TOP: Patient Education KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The nurse is caring for a patient who has a urinary diversion. She notices that the patient has a
temperature of 102 F and foN ulU -sR mS elI linNgGuT riB ne. .C WO haMt action should the nurse take? a. Obtain a urine culture from the patient’s pouch. b. Catheterize the patient to obtain a sterile urine specimen. c. Notify the physician. d. Realize that these are normal findings. ANS: C
Common symptoms of a UTI include fever and foul-smelling odor. The Nurse will need to contact the physician immediately. The physician will order a catheterization so that a urine sample may be obtained. Although the nurse realizes the need for catheterization, it is an invasive procedure, and an invasive procedure requires a physician’s order. Obtaining a specimen of urine in a pouch does not result in an accurate finding because of the likely risk of contamination by microorganisms. Some mucus in the urine is expected. DIF: Cognitive Level: Analysis OBJ: Catheterize a urinary diversion. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 878 TOP: Urinary Infection MSC: NCLEX: Physiological Integrity
13. The nurse is preparing to catheterize a patient who has a urostomy and uses a two-piece pouch
system. The nurse should take which action? a. Place the patient in a semi-recumbent position. b. Remove both pieces of the pouch system. c. Remove the pouch and leave the barrier attached. d. Use sterile gloves to remove the system.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: C
Remove the pouch. If the patient uses a two-piece system, remove the pouch but leave the barrier attached to the skin. Position the patient sitting, if possible; gravity facilitates the flow of urine. Sterile gloves are used for the actual catheterization. Clean gloves are all that are necessary for removing the pouch. DIF: Cognitive Level: Application REF: Text reference: p. 877 OBJ: Catheterize a urinary diversion. TOP: Removing the Pouch KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is caring for a patient who will have surgery in the morning to have a colostomy
placed. The nurse is aware of the physical and emotional stresses that the patient will experience. These include which of the following? (Select all that apply.) a. Body image changes b. Fear of social rejection c. Sexual function and intimacy issues d. Loss of independence e. Heightened immunity ANS: A, B, C, D
In addition to the stresses of illness and surgical recovery, patients with ostomies face body image changes, fear of social rejection, concern about sexual function and intimacy, and the need for help with personal care. It is very important to provide an effective pouching system to facilitate the emotional adjN ustm . A supportive nurse makes the initial RenIt to Gthe Bos.toCmy OM period of adjustment easier. U S N T DIF: Cognitive Level: Analysis REF: Text reference: p. 868 OBJ: Identify types of fecal and urinary diversions. TOP: Physical and Emotional Stressors Related to Ostomy Placement KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION 1. The opening created into the abdominal wall for fecal or urinary elimination is known as a
. ANS:
stoma Certain diseases or conditions require surgical intervention to create an opening into the abdominal wall for fecal or urinary elimination. This opening is called a stoma and is constructed from a section of colon or small intestine. DIF: Cognitive Level: Knowledge REF: Text reference: p. 866 OBJ: Identify types of fecal and urinary diversions. TOP: Stoma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The output from a urinary or fecal stoma is called the
.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS:
effluent The output from the stoma is called the effluent. DIF: Cognitive Level: Knowledge REF: Text reference: p. 866 OBJ: Identify types of fecal and urinary diversions. TOP: Effluent KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. A
is an opening in the large intestine or colon for elimination of fecal
material. ANS:
colostomy An opening in the large intestine or colon is a colostomy, and the fecal effluent will vary in consistency depending on where the opening in the colon is surgically created. DIF: Cognitive Level: Knowledge REF: Text reference: p. 866 OBJ: Identify types of fecal and urinary diversions. TOP: Colostomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. An opening that is in the ileal portion of the small intestine is an
.
ANS:
ileostomy An opening in the ileal portion of the small intestine is an ileostomy, and the fecal effluent will be watery to thick liquid that will contain some digestive enzymes.
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DIF: Cognitive Level: Knowledge REF: Text reference: p. 866 OBJ: Identify types of fecal and urinary diversions. TOP: Ileostomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. An ostomy that is created from a portion of the ileum to form a stoma through which urine
can exit the body is called a(n)
.
ANS:
urostomy or ileal conduit A urostomy or ileal conduit is created from a 6- to 8-inch portion of the intestine that is resected from the ileum. One end of the conduit is sutured closed, and the ureters are implanted through the mucosa. The other end is brought out of the abdominal wall, and a stoma is formed through which urine can exit the body. DIF: Cognitive Level: Knowledge REF: Text reference: p. 866 OBJ: Identify types of fecal and urinary diversions. TOP: Urostomy or Ileal Conduit KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 36: Preoperative and Postoperative Care MULTIPLE CHOICE 1. When planning care for a surgical patient, the nurse recognizes that surgical site infections
account for what percentage of hospital-acquired infection? a. 22% to 40% b. 5% to 10% c. 45% to 70% d. 75% to 100% ANS: A
The National Nosocomial Infections Surveillance (NNIS) system of the Centers for Disease Control and Prevention (CDC) reports that surgical site infections (SSIs) account for up to 16% of hospital-acquired infections. Current research indicates that 38% of hospital-acquired infections are surgical site infections. DIF: Cognitive Level: Application REF: Text reference: p. 881 OBJ: Explain the rationale for preoperative procedures. TOP: Hospital-Acquired Infections KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The goal of prophylactic antibiotic therapy is to protect the patient from infection with as little
risk as possible. To achieve this goal, the nurse recognizes that antibiotics should be administered when they will be most beneficial. When would that be? a. Twenty-four hours before surgery b. For 2 weeks after surgery c. For no longer than 24 houNrU s aRftS erIsN urG geTrB y .COM d. When signs of infection first appear ANS: C
Overall, it is recommended that prophylactic antibiotics be given as close to the time of incision as possible (within 30 to 60 minutes) and not be given for longer than 24 hours postoperatively. However, vancomycin and fluoroquinolones may be given up to 2 hours before incision because of their longer infusion times. The goal of prophylactic antibiotic therapy is to protect the patient from infection with as little risk as possible. To achieve this goal, antibiotics must be administered when they will be most beneficial. DIF: Cognitive Level: Application REF: Text reference: pp. 881-882 OBJ: Describe the activities needed to prepare a patient for surgery. TOP: Hospital-Acquired Infections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. While planning care for a surgical patient, the nurse recognizes that which of the following
effects of hyperglycemia is seen in the immediate postoperative period? a. Increases risk for infection in the diabetic patient only b. Decreases risk for surgical site infection c. Increases risk for infection in diabetic and nondiabetic patients d. Has no effect on the body’s ability to fight infection ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The presence of hyperglycemia in the immediate postoperative period increases the risk for infection in both diabetic and nondiabetic patients. The higher the serum glucose, the greater the potential for infection in both patient groups. Hyperglycemia has been shown to inhibit the body’s ability to fight infection. Immediate postoperative glucose control also has been correlated with a reduction in surgical infection. DIF: Cognitive Level: Application REF: Text reference: p. 882 OBJ: Explain the rationale for preoperative procedures. TOP: Hyperglycemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse is to obtain an informed consent for a patient before surgery is performed. The
nurse recognizes that which of the following statements is true? a. Informed consent is required by law to protect the surgeon in case of an adverse outcome. b. Only the patient can sign a surgical consent. c. The nurse’s legal responsibility is to ensure that the patient understands the information presented. d. The surgeon should give the patient information about the surgery. ANS: D
The surgeon should give the patient information about the extent and type of surgery, alternative therapies, usual risks and benefits, and consequences of not having surgery in a nonthreatening manner, as outlined in The Patient Care Partnership developed by the American Hospital Association (AHA). Informed consent is required by law to help protect patients’ rights, their autonomy, and their privacy. The patient or the patient’s legal guardian must sign a surgical consent form that includes this information. If the patient’s cultural N R I G band, B.CfO M practices include male dominanUce,StheNhusT ather, or oldest brother of a female patient also may need to sign the consent form. It is the nurse’s ethical (not legal) responsibility, acting as the patient’s advocate, to ensure that the patient understands the information. See institutional policy regarding consent. DIF: Cognitive Level: Application REF: Text reference: p. 883 OBJ: Explain the rationale for preoperative procedures. TOP: Informed Consent KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is planning care for a preoperative patient. Which intervention is implemented to
ensure safe nursing care? a. Allowing the patient to have ice chips b. Always keeping the patient NPO for 12 to 14 hours before c. Allowing the patient to brush teeth and swallow water d. Allowing the patient to take specifically ordered oral medications with small amounts of water ANS: D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Patients may take oral medications with sips of water (30 mL) if they are specially ordered to be taken preoperatively (e.g., antiarrhythmic or seizure medications). All other oral medications are withheld. The nurse must later check postoperative orders to ensure that scheduled medications unrelated to surgery are not forgotten. In general, food and fluids are withheld for 4 to 8 hours before surgery requiring general anesthesia, to minimize the risk for aspiration. Patients may brush their teeth but should not swallow water. DIF: Cognitive Level: Application REF: Text reference: p. 886 OBJ: Adequately prepare a patient for surgery. TOP: Preoperative Medication Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is providing the patient with preoperative education. When the nurse informs the
patient that she will not be able to wear makeup, the patient states, “But I never go anywhere without my makeup.” The nurse’s response is based on what rationale? a. She will speak with the surgeon to see if he will make an exception. b. The patient may wear makeup if she insists. c. Makeup makes it difficult for the surgeon to assess the patient. d. Makeup impedes circulation. ANS: C
Instruct the patient to remove hairpins, clips, wigs, hairpieces, jewelry, including rings used in body piercings, and makeup (including nail polish and acrylic nails). Makeup, nail polish, and false nails impede the assessment of skin and oxygenation. In addition, acrylic nails harbor pathogenic organisms. Makeup does not impede circulation. DIF: Cognitive Level: ApplicN atiU onRSINGRT EB F:.C TeO xtMreference: p. 886 OBJ: Adequately prepare a patient for surgery. TOP: Makeup KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The patient is in the hospital awaiting surgery. When asked to remove her jewelry, the patient
asks why she needs to remove her navel ring. What explanation should the nurse provide? a. The navel ring may impede assessment of the skin. b. The navel ring may decrease circulation. c. She may leave it in place if she chooses. d. The navel ring may cause injury. ANS: D
Hair appliances and jewelry anywhere on the body may become dislodged and cause injury during positioning and intubation. Navel rings probably would not impede assessment or decrease circulation. Due to the risk of injury if left in place, allowing the patient to leave the ring in place is not an option. DIF: Cognitive Level: Analysis REF: Text reference: p. 886 OBJ: Adequately prepare a patient for surgery. TOP: Jewelry KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. A patient who is scheduled for colon surgery is wearing a simple wedding band that he cannot
remove. Which intervention is implemented to provide safe patient care?
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
Get the ring cutter from the emergency department and cut the ring off. Call the physician and cancel the surgery. Tape the wedding ring in place. Call the physician for an order for extra antibiotics.
ANS: C
Tape in place wedding rings that cannot be removed. Be careful not to create a tourniquet effect with tape around the finger. DIF: Cognitive Level: Application REF: Text reference: p. 886 OBJ: Adequately prepare a patient for surgery. TOP: Jewelry KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse is helping the patient prepare for surgery. The patient has removed her jewelry and
glasses. Which action should the nurse take to keep the jewelry safe? a. Put these items in the patient’s bedside stand. b. Inventory the items and give them to the family. c. Place the items in a plastic bag and send them to the OR with the patient. d. Keep these items with her until the patient returns. ANS: B
Inventory the items and give them to family members, or have security lock them up. Document a list of items and their locations in a preoperative checklist and/or in the nurses’ notes per agency policy. Valuables left in the patient’s room may be lost or stolen. Items not secured could be misplaced or lost. Keeping the items with the nurse creates a liability for the nurse.
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DIF: Cognitive Level: Application REF: Text reference: p. 886 OBJ: Adequately prepare a patient for surgery. TOP: Jewelry KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. In planning care for a surgical patient, the patient asks the nurse what may be “left on” during
the surgery. Understanding patient safety, the nurse tells the patient that which item may remain in place? a. Hearing aid b. Artificial limb c. Pair of eyeglasses d. Pair of contact lenses ANS: A
The only item the might be left in place is a hearing aid. If the patient will be required to follow instructions in the operating room, allow the patient to keep the hearing aid in place. Otherwise remove prostheses, including dentures and oral appliances, glasses and contact lenses, artificial limbs and eyes, and artificial eyelashes. Prostheses can be lost or damaged during surgery and could cause injury. Oral appliances may occlude the airway. DIF: Cognitive Level: Application REF: Text reference: p. 886 OBJ: Adequately prepare a patient for surgery. TOP: Hearing Aids KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
11. In planning surgical care for an older adult patient, the nurse recognizes which of the
following as causing the greatest risk for surgery? a. Increased tactile sense b. Decreased glomerular filtration rate c. Increased numbers of red blood cells d. Decreased rigidity of arterial walls ANS: B
Reduced glomerular filtration rate and excretory times limit the ability to remove drugs or toxic substances. Assess for adverse effects of medications. Older adults usually will have sensory losses, reduced numbers of red blood cells, and increased rigidity of the arterial walls. DIF: Cognitive Level: Application REF: Text reference: p. 889 OBJ: Adequately prepare a patient for surgery. TOP: Gerontological Consideration KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 12. When providing care for an ambulatory surgical patient, the nurse recognizes that which
assessment indicates that the patient meets discharge criteria? a. The patient is able to drive home alone. b. Some respiratory depression is evident. c. The oxygen saturation level is at 85%. d. No intravenous (IV) narcotics have been given in the past 30 minutes. ANS: D
An ambulatory surgical patient meets discharge criteria when no IV narcotics have been administered for the past 30 m utesI adult is present to accompany the patient Nin UR S, aNrGespo TBn.siCbleOM home, respiratory depression is not present, and oxygen saturation is greater than 90%. DIF: Cognitive Level: Application REF: Text reference: p. 888 OBJ: Discuss the differences in nursing assessment during the immediate postoperative period and the convalescent phase of recovery. TOP: Discharge From Ambulatory Care Surgery KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. As a patient is prepared for surgery, which finding indicates that the nurse should inform the
surgeon that the surgery may need to be postponed? a. The patient has a history of smoking. b. The patient is experiencing calf pain, redness, and swelling. c. The patient has an increased hemoglobin level. d. The patient experienced an upper respiratory infection a month ago. ANS: B
Observe the calves for redness, warmth, and tenderness. Palpate pedal pulses. If a thrombus is suspected, notify the physician and refrain from manipulating the extremity any further. Surgery usually will be postponed. Any condition that affects chest wall movement such as obesity, advanced pregnancy, thoracic or abdominal surgery, history of smoking, or presence of reduced hemoglobin level can increase the risk for postoperative complications but will not necessarily require postponement of surgery. Assess and report to the physician and/or the anesthesiologist if the patient has had a cold or an upper respiratory infection within the past week.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Analysis REF: Text reference: p. 891 OBJ: Discuss the differences in nursing assessment during the immediate postoperative period and the convalescent phase of recovery. TOP: Possible DVT KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. The patient has been taught how to use diaphragmatic breathing. When the patient returns
from surgery, however, he cannot be placed upright and must remain flat. What does the nurse tell the patient about performing the diaphragmatic exercises? a. Diaphragmatic breathing cannot be done in this position. b. Alternative breathing exercises need to be found. c. Diaphragmatic breathing exercises still can be performed. d. Diaphragmatic breathing exercises may be postponed. ANS: C
Although performing the diaphragmatic exercises in the upright position is ideal, the patient can still benefit from performing the exercises while laying flat. The upright position is preferred because it facilitates diaphragmatic excursion by using gravity to keep abdominal contents away from the diaphragm. It prevents tension on the abdominal muscles, which allows for greater diaphragmatic excursion. DIF: Cognitive Level: Application REF: Text reference: p. 892 OBJ: Successfully instruct a patient in performing postoperative exercises. TOP: Diaphragmatic Breathing Exercises KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 15. When teaching the patient about positive expiratory pressure therapy (PEP) and “huff”
coughing, the nurse incorporates which of the following in the plan of care? a. Instruct the patient to remNain URflat SIinNbGed. TB.COM b. Place a nose clip on the patient’s nose. c. Instruct the patient to breathe through his nose. d. Instruct the patient to exhale with long slow breaths. ANS: B
Instruct the patient to assume semi-Fowler’s or high-Fowler’s position, and place a nose clip on the patient’s nose. Have the patient place his lips around the mouthpiece. Instruct the patient to exhale in quick, short, forced “huffs.” “Huff” coughing, or forced expiratory technique, promotes bronchial hygiene by increasing expectoration of secretions. DIF: Cognitive Level: Application REF: Text reference: p. 893 OBJ: Successfully instruct a patient in performing postoperative exercises. TOP: Teaching Positive Expiratory Pressure Therapy (PEP) and “Huff” Coughing KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 16. When providing teaching to a patient, which action is important to help the patient in
performing controlled coughing? a. Repeat the breathing exercises twice. b. Cough two to three times and inhale between coughs. c. Place a pillow over the incisional site for splinting. d. Use the chest and shoulder muscles while inhaling during diaphragmatic breathing. ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank If the surgical incision is to be thoracic or abdominal, teach the patient to place a pillow over the incisional area and to place his hands over the pillow to splint the incision. The patient should begin by taking two or three slow, deep breaths inhaling through the nose and exhaling through the mouth. On the third inhale he should hold the breath to a count of 3. The patient will then cough fully for two to three consecutive coughs without inhaling between coughs. Teach the patient to avoid using chest and shoulder muscles while inhaling.. The patient will do this 2 to 3 times every hour he is awake. DIF: Cognitive Level: Application REF: Text reference: p. 893 OBJ: Successfully instruct a patient in performing postoperative exercises. TOP: Teaching Controlled Coughing and Splinting KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 17. When providing care for a postoperative patient, it is important for the nurse to include which
postoperative exercise? a. Turning every 4 hours b. Completing leg exercises once daily c. Repeating individual leg exercises 20 times d. Performing exercises with the unaffected extremities ANS: D
A leg unaffected by surgery can be exercised safely unless the patient has preexisting phlebothrombosis (blood clot formation) or thrombophlebitis (inflammation of the vein wall). Instruct the patient to turn every 2 hours from side to back to the other side while awake. Have the patient continue to practice exercises at least every 2 hours while awake and repeat exercises 5 times. Instruct the patient to coordinate turning and leg exercises with diaphragmatic breathing, incentive spirometry, and coughing exercises.
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DIF: Cognitive Level: Application REF: Text reference: pp. 894-895 OBJ: Successfully instruct a patient in performing postoperative exercises. TOP: Teaching Postoperative Exercises KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 18. When planning care for a PACU or recovery room patient, how often should the nurse plan to
assess the patient? a. Every 5 minutes b. Every 15 minutes c. Every 30 minutes d. Hourly ANS: B
Conduct complete assessment of all vital signs. Compare findings with the patient’s normal baseline. Continue assessing vital signs at least every 15 minutes until the patient’s condition stabilizes. DIF: Cognitive Level: Application REF: Text reference: p. 898 OBJ: Discuss the differences in nursing assessment during the immediate postoperative period and the convalescent phase of recovery. TOP: Assessment of Patient in PACU KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 19. When providing care for a patient who has received spinal anesthesia, the nurse recognizes
that which position prevents spinal headaches? a. Prone b. Lying on the side c. Supine, with the head flat d. Trendelenburg’s position ANS: C
Position patients with spinal anesthetic supine, without elevation of the head, for up to 24 hours to prevent spinal headache from loss of cerebrospinal fluid. Increased IV or PO fluids aid the body in replacing cerebrospinal fluid. DIF: Cognitive Level: Application REF: Text reference: p. 900 OBJ: Discuss the differences in nursing assessment during the immediate postoperative period and the convalescent phase of recovery. TOP: Positioning of Patient in PACU KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. While providing care for a postsurgical patient who has not received spinal anesthesia, the
nurse recognizes that which position is required to maintain a patent airway in the recovery phase? a. On his side with head facing down and neck slightly extended b. On his side with head facing down and neck slightly flexed c. On his back with hands over the chest d. On his side with head facing up and neck slightly extended ANS: A
Position the patient on his sidNe wR headGfacBin.gCdow n and neck slightly extended. Extension I U ith T AOM prevents occlusion of the airway atStheNpharynx. downward position of the head moves the tongue forward, and mucus or vomitus can drain out of the mouth, preventing aspiration. Never position the patient with hands over the chest (reduces chest expansion). DIF: Cognitive Level: Application REF: Text reference: p. 900 OBJ: Discuss the differences in nursing assessment during the immediate postoperative period and the convalescent phase of recovery. TOP: Positioning of Patient in PACU KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse is providing care for a patient who is recovering in the postanesthesia care unit
(PACU). Given that the patient is restricted to the supine position, which intervention provides the patient with adequate chest expansion? a. Keeping the bed flat during recovery b. Positioning the patient’s hands over his chest c. Flexing the neck and turning the head to the side d. Extending the neck and turning the head to the side ANS: D
If the patient is restricted to a supine position, elevate the head of the bed approximately 10 to 15 degrees, extend the neck, and turn the head to the side. Never position the patient with his hands over his chest (reduces chest expansion). DIF: Cognitive Level: Application
REF: Text reference: p. 900
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Discuss the differences in nursing assessment during the immediate postoperative period and the convalescent phase of recovery. TOP: Positioning of Patient in PACU KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. A patient is being transferred to a room from the PACU. What should the nurse do upon
transfer? a. Remove the indwelling urinary catheter. b. Turn off the nasogastric tube suction. c. Use a black pen to note drainage on the dressing. d. Change the dressing immediately when the patient reaches the room. ANS: C
Mark the dressing with a circle around the drainage using a black pen. Never use a felt tip marker to mark the dressing because ink can bleed into the gauze, contaminating the incision site. Once the patient is transferred to the bed, immediately attach any existing oxygen tubing, hang IV fluids, check the IV flow rate, attach a nasogastric (NG) tube to suction, and place an indwelling catheter in drainage position. Reinforce the pressure dressing, or change a simple dressing as ordered and needed. First dressing changes most often occur 24 hours postoperatively and usually are done by the physician. DIF: Cognitive Level: Application REF: Text reference: p. 901 OBJ: Conduct an assessment of a postoperative patient. TOP: Assessing Dressing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. The nurse explains to the patient that the incentive spirometer is used to promote which of the
following outcomes? NURSINGTB.COM a. Lung expansion b. Reduce likelihood of vascular complications c. Incisional healing d. Expectoration of mucus ANS: A
The use of the incentive spirometer promotes lung expansion. The visual incentive provided by the device encourages the patient to breathe as deeply as possible. Huff coughing is used to promote expectoration of mucus. Repositioning the patient regularly reduces the risk for vascular complications. While adequate oxygenation is needed for wound healing, the use of the incentive spirometer is not recommended for that outcome. DIF: Cognitive Level: Application REF: Text reference: p. 893 OBJ: Conduct an assessment of a postoperative patient. TOP: Incentive Spirometry KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 24. When assessing a postoperative patient, the nurse notes tenderness, redness, and swelling in
the left calf. What should the nurse do next? a. Massage the lower leg. b. Contact the surgeon and prepare for heparin therapy. c. Keep the leg in a dependent position. d. Have the patient exercise that extremity.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: B
Calf tenderness, redness, and edema in the lower extremity are signs and symptoms of venous thrombosis or thrombophlebitis. Notify the surgeon and anticipate orders for bed rest, leg elevation, and initiation of anticoagulation (e.g., heparin intravenous drip). Do not massage the affected leg. Continue to have the patient do leg exercises with the unaffected leg, not the affected leg. DIF: Cognitive Level: Analysis REF: Text reference: p. 905 OBJ: Conduct an assessment of a postoperative patient. TOP: DVT KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 25. The nurse understands that paralytic ileus is a possible postoperative complication. Which
assessment provides the nurse with information about this postoperative complication? a. Auscultating for bowel sounds every 4 hours b. Checking blood pressure while sitting and standing c. Observing the patient’s performance of leg exercises d. Palpating the suprapubic region for distention ANS: A
Paralytic ileus can develop as a common complication after bowel or abdominal surgery. Intestinal motility may return slowly, depending on anesthetic effects. Assess for bowel sounds and flatus every 4 hours. A blood pressure check has little to do with paralytic ileus and is an assessment done before ambulation. Leg exercises may help prevent venous stasis and thrombosis, but observing them will not help you to detect a paralytic ileus. Palpation of the suprapubic region is part of the assessment for bladder distention. DIF: Cognitive Level: Application REF: Text reference: p. 905 OBJ: Conduct an assessment oNf U aR poS stI opN erG atT ivB e p.aC tieO ntM . TOP: Paralytic Ileus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 26. Upon entering a patient’s room, the nurse finds that the abdominal surgical wound has
eviscerated. Which intervention is safest for the nurse to implement? a. Cover the site with dry sterile dressings. b. Report the incident to the oncoming shift. c. Attempt to replace the organs. d. Cover the site with saline-soaked sterile gauze. ANS: D
Report wound dehiscence and/or evisceration to the surgeon immediately because it could be life threatening. If evisceration has occurred, cover abdominal contents with sterile gauze saturated with sterile normal saline, and prepare the patient for emergency surgery. DIF: Cognitive Level: Application REF: Text reference: p. 905 OBJ: Conduct an assessment of a postoperative patient. TOP: Wound Evisceration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Which of the following have been identified as evidence-based guidelines to reduce surgical
site infections (SSIs)? (Select all that apply.)
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d. e.
Prepping the surgical site with a razor followed by an antiseptic scrub Giving antibiotics immediately after the procedure Maintaining blood glucose levels Maintaining normal body temperatures Maintaining proper positioning
ANS: C, D
Four evidence-based guidelines have been identified to reduce SSIs: Do not remove hair unless it will interfere with the operation, and remove it with electrical clippers if possible; give the correct antibiotic preoperatively and at the appropriate time; maintain blood glucose postoperatively, especially for patients undergoing cardiac surgery; and maintain normothermia. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 881-882 OBJ: Explain the rationale for preoperative procedures. TOP: Hospital-Acquired Infections KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Therapies and regimens designed to prevent venous thromboembolism (VTE) include which
of the following? (Select all that apply.) a. Pneumatic compression stockings b. Venous foot pump c. Low-molecular-weight heparin d. Fondaparinux e. Elspar ANS: A, B, C, D
Mechanical therapies include the use of graduated compression stockings along with intermittent pneumatic compN ress RionSI(IPC G)ToBr a.vCeno Mus foot pump (VFP). The VFP is limited U N O primarily to when IPC cannot be used, as when surgery or injury occurs to the affected lower extremity. Pharmacological regimens that include the administration of low-dose unfractionated heparin, low-molecular-weight heparin, factor Xa inhibitor (fondaparinux), or warfarin are recommended. Elspar is a chemotherapeutic drug used to treat which can increase the risk for clot formation. DIF: Cognitive Level: Analysis REF: Text reference: p. 882 OBJ: Explain the rationale for preoperative procedures. TOP: Venous Thromboembolism (VTE) Therapies KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Being overweight or obese increases the risk for many diseases and health conditions,
including which of the following? (Select all that apply.) a. Hypertension b. Coronary heart disease c. Sleep apnea d. Respiratory problems e. Hypotension ANS: A, B, C, D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Being overweight or obese increases the risk for many diseases and health conditions, including hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, sleep apnea, and respiratory problems. These conditions increase risks for postoperative complications. Hypotension is not a complication of obesity. DIF: Cognitive Level: Analysis REF: Text reference: p. 882 OBJ: Explain the rationale for preoperative procedures. TOP: Obesity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 37: Intraoperative Care MULTIPLE CHOICE 1. The charge nurse is assigning duties in the surgical arena. Which member of the surgical team
should be assigned to the role of circulating nurse? a. Registered nurse (RN) b. Licensed practical nurse (LPN) c. Certified surgical technologist (CST) d. Licensed nursing assistant ANS: A
The circulating nurse is always an RN who is the charge nurse in the operating room. DIF: Cognitive Level: Application REF: Text reference: p. 908 OBJ: Describe the roles of a registered nurse in the operating room. TOP: The Circulating Nurse KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. Which of the following is true about the circulating nurse’s primary responsibility? a. She is a “sterile” member of the surgical team. b. She provides the surgeon with instruments. c. She is a “nonsterile” member of the surgical team. d. She performs delegated medical functions or skills. ANS: C
The circulating nurse is a “noNnstR erileI ” mG ember of thMe surgical team who assumes U for S maintaining N TB.CO responsibility and accountability patient safety and continuity of quality care. This includes supervising the conduct of the scrub technician and delegating tasks to licensed and unlicensed nursing assistive personnel (NAP) as appropriate. The circulating nurse is also an assistant to the first assistant, the scrub nurse/technician, and the surgeon. The scrub nurse/technician provides the surgeon with instruments and supplies. The registered nurse first assistant (RNFA) performs a combination of nursing and delegated medical functions and/or skills. DIF: Cognitive Level: Application REF: Text reference: p. 908 OBJ: Describe the roles of a registered nurse in the operating room. TOP: The Circulating Nurse KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. The scrub nurse’s hands are being washed in preparation for a surgical procedure. As the
nurse finishes, the scrub nurse accidentally touches the faucet with one hand. Which action should the nurse take next? a. Apply sterile gloves. b. Apply a sterile gown. c. Apply a sterile mask. d. Wash her hands. ANS: D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The scrub nurse/technician who accidentally touches the faucet with one hand while rinsing will rescrub. This is an example of following a sterile conscience and being committed to safe, quality patient care. DIF: Cognitive Level: Application REF: Text reference: pp. 908-909 OBJ: Describe the meaning of a sterile conscience. TOP: Sterile Conscience KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse recognizes that evidence-based care is appropriate when the nurse witnesses the
surgeon take which step? a. Washing hands for a minimum of 15 minutes with soap and water b. Using alcohol hand scrub for 15 minutes c. Using alcohol combined with chlorhexidine gluconate hand scrubs d. Using a combination of soap and alcohol as a scrub ANS: C
Recent research demonstrates that hand scrub preparations containing 50% to 90% alcohol combined with chlorhexidine gluconate are just as effective as the traditional scrubbing method in preventing SSI. DIF: Cognitive Level: Analysis REF: Text reference: p. 910 OBJ: Identify guidelines for the use of sterile technique in the operating room. TOP: Hand Scrub KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 5. When planning care for a surgical patient, the nurse implements which technique to maintain
sterility in the operating roomN?URSINGTB.COM a. Keeps the hands below the waist b. Tucks the hands under the axilla c. Uses sterile gloved hands to move a sterile drape under a table d. Has anyone who is unscrubbed stay at least 1 foot away from the sterile field ANS: D
Unscrubbed persons should always stay at least 1 foot away from the sterile field while keeping it in constant view and should contact only unsterile areas. Sterile persons must keep their hands in view, above waist level and below the neckline, to avoid contamination. When wearing a sterile gown, do not fold the arms with hands tucked in the axillary region. This area is not considered sterile once operating room personnel have donned gowns. Sterile-draped tables are sterile only at table level. The sides of the drape extending below table level are unsterile. DIF: Cognitive Level: Application REF: Text reference: p. 911 OBJ: Identify guidelines for the use of sterile technique in the operating room. TOP: Principles of Sterile Technique KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 6. When one prepares to enter the operating room, which technique demonstrates the safest
outcome? a. Keeping the hands below the elbows b. Applying surgical gloves before the scrub c. Scrubbing for at least 3 to 5 minutes with an antimicrobial
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. Drying the hands and arms, starting at the elbow and moving toward the fingers ANS: C
The Association of periOperative Registered Nurses (AORN) recommends a 3- to 5-minute hand and arm scrub with an approved antimicrobial agent for all surgical procedures. Rinse hands and arms thoroughly under running water. Grasp one end of the sterile towel to dry one hand thoroughly, moving from fingers to elbow in a rotating motion. Use the opposite end of the towel to dry the other hand. DIF: Cognitive Level: Application REF: Text reference: p. 911 OBJ: Correctly perform surgical hand antisepsis. TOP: The Surgical Hand Scrub KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. When evaluating a health care team member’s ability to put on a sterile gown and perform
closed gloving, it is most important for the nurse to assess for which outcome? a. Opening the sterile gown pack on a sterile surface b. Holding the gown close to the body before applying c. Having the circulating nurse tie the gown at the hip d. Keeping the hands inside the sleeves of the gown until the gloves are applied ANS: D
Apply gloves using the closed-glove method, with hands covered by gown cuffs and sleeves. Open the sterile gown and glove package on a clean, dry, flat surface. This can be done by the scrub nurse (before scrubbing hands) or the circulating nurse. While keeping it at arm’s length away from the body, allow the gown to unfold with the inside of the gown toward the body. Do not touch the outside of the gown, and do not allow it to touch the floor. Have the circulating nurse tie the gownNat neck . If the gown is wraparound style, the URtheSI NGan TBd .wCaist OM sterile front flap is not touched until the scrub nurse has gloved. DIF: Cognitive Level: Application REF: Text reference: p. 916 OBJ: Correctly apply sterile gloves using the closed technique. TOP: Applying Gloves Via Closed Technique KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. The charge nurse is assigning members of the surgical team; the nurse recognizes that which
member is responsible for ensuring preoperative and postoperative patient management in collaboration with other health care providers? a. RN b. LPN c. Circulating RN d. RNFA ANS: D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The role of the RNFA is an expansion of the traditional perioperative nursing role, and areas of responsibility will overlap. Responsibilities specific to the practice of first assisting include participating in “time out” procedures with other surgical team members (safety measures taken to ensure correct patient, correct procedure, correct site and side, correct patient position, and correct implants/equipment present), providing surgical exposure (assisting in retraction of tissues and suctioning of surgical field), providing hemostasis (control of bleeding), handling and/or cutting tissue, using surgical instruments/medical devices and suturing, performing wound closure, applying human anatomical and physiological considerations in practice, recognizing structure, function, and location of tissues and organs, manipulating tissues accordingly to avoid injury, and ensuring preoperative and postoperative patient management in collaboration with other health care providers. The scrub nurse gowns and gloves surgeons and assistants as they enter the operating room, provides the surgeon with instruments and supplies, disposes of soiled sponges, and accounts for sponges, needles, and instruments in the surgical field. DIF: Cognitive Level: Application REF: Text reference: p. 909 OBJ: Describe the roles of a registered nurse in the operating room. TOP: Role of the Registered Nurse First Assistant KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 9. When planning care for a surgical patient, which nursing diagnosis has the highest priority? a. Risk for infection b. Risk for constipation c. Risk for falls d. Risk for knowledge deficit ANS: A
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Surgical patients are at risk for surgical site infection from the stress of surgery and their procedure. Studies have found that surgical staff may transmit pathogens via contact with patients and contaminated items. DIF: Cognitive Level: Application REF: Text reference: p. 910 OBJ: Describe the meaning of a sterile conscience. TOP: Evidence-Based Practice Trends KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 10. While supervising the surgical team, the charge nurse notices that a team member’s nails are
long and chipped. Which action should the nurse take next? a. Allow the team member to complete the task. b. Remove the team member to have the nails cut. c. Turn the team member in to the RNFA. d. Ask the team member why the nails are long and chipped. ANS: B
The team member must be removed immediately to allow cutting of the nails. Long nails and chipped or old polish harbor greater numbers of bacteria. Long fingernails can puncture gloves, causing contamination. DIF: Cognitive Level: Application REF: Text reference: pp. 910-911 OBJ: Describe the meaning of a sterile conscience. TOP: Surgical Hand Antisepsis KEY: Nursing Process Step: Implementation
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Who of the following can assume the role of the scrub nurse/assistant? (Select all that apply.) a. RN b. LPN c. CST d. Licensed nursing assistant e. Medical transcriptionist ANS: A, B, C
RNs, LPNs, and CSTs may assume the scrub nurse role. DIF: Cognitive Level: Comprehension REF: Text reference: p. 908 OBJ: Describe the roles of a registered nurse in the operating room. TOP: The Scrub Nurse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The consequences of double gloving during surgery include which of the following? (Select
all that apply.) a. Decreased need for handwashing b. Decreased risk for exposure to bloodborne pathogens c. Increased perforations to the innermost glove d. Decreased risk for surgical wound infection e. Increased patient cost ANS: B, D
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Benefits of double gloving during surgery include decreasing the risk for exposure to bloodborne pathogens for surgical team members and decreasing the risk for surgical wound infection for the patient. Double gloving significantly reduces perforations to the innermost glove. Handwashing remains the cornerstone of surgical asepsis. DIF: Cognitive Level: Comprehension REF: Text reference: p. 915 OBJ: Identify guidelines for the use of sterile technique in the operating room. TOP: Double Gloving KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. Which of the following are principles of sterile procedure? (Select all that apply.) a. Gowns are sterile from the chest and shoulder to table level. b. Sterile persons must keep hands in view and above the waist and below the neck. c. Sterile persons must fold arms across chest with hands tucked into the axillary
region. d. Unscrubbed persons must stay at least 6 inches away from the sterile field. e. Sterile persons may position themselves with their back to the sterile field. ANS: A, B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Once in place, gowns are sterile from the front chest and shoulders to table level and on the sleeves to 2 inches (5 cm) above the elbow. Sterile persons must keep their hands in view, above waist level and below the neckline, and must not turn their back to the sterile field to avoid contamination. When wearing a sterile gown, do not fold arms with hands tucked into the axillary region. This area is not considered sterile once operating room personnel have donned gowns. Perspiration can lead to strike through, or contamination that occurs when moisture permeates a sterile barrier. Unscrubbed persons always stay at least 1 foot away from the sterile field while keeping it in constant view; they touch only unsterile areas. DIF: Cognitive Level: Application REF: Text reference: pp. 910-911 OBJ: Identify guidelines for the use of sterile technique in the operating room. TOP: Principles of Sterile Technique KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4. Through the use of an antimicrobial agent and sterile brushes or sponges, which of the
following occurs? (Select all that apply.) a. Debris and transient microorganisms are removed from the nails, hands, and forearms. b. The resident microbial count is reduced to a minimum. c. The skin is sterilized. d. Rapid/rebound growth of microorganisms is inhibited. e. The need to wash between patients is reduced. ANS: A, B, D
Although the skin cannot be sterilized, operating room personnel can greatly reduce the number of microorganisms by chemical, physical, and mechanical means. Through the use of an antimicrobial agent and sterile brushes or sponges, the surgical hand scrub removes debris RSthe INnai GTls,B.C and transient microorganismsNfU rom handOs,Mand forearms, and inhibits rapid/rebound growth of microorganisms. DIF: Cognitive Level: Comprehension REF: Text reference: pp. 911-912 OBJ: Correctly perform surgical hand antisepsis. TOP: The Surgical Hand Scrub KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 5. Which of the following are sources of contamination in the operating room? (Select all that
apply.) a. A wristwatch b. Chipped nail polish c. Artificial fingernails d. Abrasions on the hands e. Tattoos to the arms ANS: A, B, C, D
Jewelry harbors and protects microorganisms from removal. Allergic skin reactions may occur as a result of scrub agent or glove powder accumulating under jewelry. Long nails and chipped or old polish harbor great numbers of bacteria. Long fingernails can puncture gloves, causing contamination. Artificial nails harbor gram-negative microorganisms and fungus. Cuts, abrasions, exudative lesions, and hangnails tend to ooze serum, which may contain pathogens. Broken skin permits microorganisms to enter various layers of the skin, providing deeper microbial breeding.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Comprehension REF: Text reference: pp. 911-912 OBJ: Identify guidelines for the use of sterile technique in the operating room. TOP: Sources of Contamination KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The surgeon is about to finish surgery and requests a sponge count. Who would normally
perform this task? (Select all that apply.) a. Scrub nurse b. Registered nurse first assistant c. Circulating nurse d. Certified registered nurse anesthetist e. Surgical technician ANS: A, C
Part of the role of the scrub nurse is to perform sponge, sharps, and instrument counts with the circulating nurse before an incision is made, at the beginning of wound closure, and at the end of the surgical procedure. DIF: Cognitive Level: Comprehension REF: Text reference: p. 909 OBJ: Describe the roles of a registered nurse in the operating room. TOP: Role of the Scrub Nurse and Circulating Nurse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. While the patient is in the OR and the OR team is gowned and gloved, the nurse recommends
completion of a safety checklist. The nurse understands that the checklist verifies which of the following? (Select all that apply.) a. Patient identity b. Patient allergies NURSINGTB.COM c. Accurate marking of surgical site d. Patient cultural preferences e. Questions posed by the patient ANS: A, B, C
While the patient is in the OR and the OR team is gowned and gloved, it is recommended that a surgical safety checklist or the World Health Organization (WHO) checklist be conducted. The WHO checklist verifies the patient’s identity, ascertains whether the patient has any allergies, checks if the surgical site is marked and reverifies the site marking, and asks the patient if he or she has any questions. DIF: Cognitive Level: Application REF: Text reference: pp. 909-910 OBJ: Describe the roles of a registered nurse in the operating room. TOP: Role of the Checklist Coordinator KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1. The
phase begins when the patient enters the operating room suite and ends with admission to the postanesthesia care unit (PACU). ANS:
intraoperative
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The intraoperative phase begins when the patient enters the operating room suite and ends with admission to the PACU. DIF: Cognitive Level: Knowledge REF: Text reference: p. 908 OBJ: Describe the roles of a registered nurse in the operating room. TOP: The Intraoperative Phase KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The
_ is a nurse with advanced education who assists the surgeon with the surgical procedure, performing a combination of nursing and delegated medical functions and/or skills. ANS:
registered nurse first assistant (RNFA) The RNFA is a nurse with advanced education who assists the surgeon with the surgical procedure, performing a combination of nursing and delegated medical functions and/or skills. DIF: Cognitive Level: Knowledge REF: Text reference: p. 908 OBJ: Describe the roles of a registered nurse in the operating room. TOP: The Registered Nurse First Assistant KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
is a “sterile” team member who provides the surgeon with instruments and supplies, disposes of soiled sponges, and accounts for sponges, sharps, and instruments in the surgical field.
3. The
ANS:
NURSINGTB.COM scrub nurse/technician The scrub nurse/technician is a “sterile” team member who provides the surgeon with instruments and supplies, disposes of soiled sponges, and accounts for sponges, sharps, and instruments in the surgical field. DIF: Cognitive Level: Knowledge REF: Text reference: pp. 908-909 OBJ: Describe the roles of a registered nurse in the operating room. TOP: The Scrub Nurse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 38: Wound Care and Irrigations MULTIPLE CHOICE 1. When is healing by primary intention expected? a. When the wound is left open and is allowed to heal b. When a surgical wound is left open for 3 to 5 days c. When connective tissue development is evident d. When the edges of a clean incision remain close together ANS: D
Healing by primary intention occurs when the edges of a clean surgical incision remain close together. The wound heals quickly, and tissue loss is minimal or absent. The skin cells quickly regenerate, and the capillary walls stretch across under the suture line to form a smooth surface as they join. Wounds that are left open and are allowed to heal by scar formation are classified as healing by secondary intention. Connective tissue development is evident during healing by secondary intention. Healing by tertiary intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish. DIF: Cognitive Level: Comprehension REF: Text reference: p. 922 OBJ: Differentiate between primary and secondary intention wound healing. TOP: Primary Intention KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse is caring for a patient who has a dressing over a surgical wound created the night
before. The dressing has nevN erU bR eeS nI chNaG ngTeB d.. HC ow OMshould the nurse proceed? a. Change the dressing so she can assess the wound. b. Administer an analgesic 30 to 45 minutes before a dressing change. c. Culture the wound if wound exudate is present. d. Administer an analgesic 30 minutes after a dressing change. ANS: B
To promote patient comfort, administer an analgesic as ordered, usually 30 to 45 minutes before changing the dressing. However, you will need to assess to determine the best time for analgesic administration before providing wound care. Do not remove an initial surgical dressing for direct wound inspection until a physician writes a medical order for removal. The presence of wound exudate is an expected stage of epithelial cell growth. DIF: Cognitive Level: Application REF: Text reference: p. 922 OBJ: Perform a wound assessment. TOP: Medicating the Patient Before Dressing Changes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient with a large stasis ulcer. She has just changed the wound
dressing and is using a negative-pressure wound system. What can the nurse tell the patient about the functioning of this system? a. Decreases the amount of angiogenesis b. Reduces mechanical stretch of tissue c. Dressing should not need to be changed for 48 hours
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. Helps create a dry environment ANS: C
The dressing is changed on a scheduled basis, usually no earlier than 48 hours. Researchers believe that blood flow increases because of the removal of wound fluid and angiogenesis (development of new blood vessels), and that this stimulates the production of new blood vessels via mechanical stretch of the tissue. The dressing placed into the wound maintains a moist environment to facilitate healing. A suction device is placed over the dressing, and the dressing, suction, and wound area are covered with a transparent dressing, which provides the air-tight seal necessary for negative-pressure wound therapy (NPWT). DIF: Cognitive Level: Application OBJ: Perform a wound assessment. KEY: Nursing Process Step: Planning
REF: Text reference: p. 923 TOP: Negative-Pressure Wound Therapy (NPWT) MSC: NCLEX: Physiological Integrity
4. The nurse is in the process of irrigating the wound for a patient who has a large pressure ulcer
on his buttock. How should the nurse proceed? a. Use irrigation pressures of less than 4 psi. b. Cleanse in a direction from most contaminated to least contaminated. c. Irrigate so that the solution flows from least contaminated to most contaminated. d. Irrigate with clean irrigation solution only. ANS: C
When one is irrigating, all the solution flows from the least contaminated to the most contaminated area. The pressure needed to irrigate wounds is between 4 and 15 psi. Irrigating solutions are sterile. DIF: Cognitive Level: ApplicN ationR I GREB TextMreference: p. 923 TF:.C O OBJ: Perform wound irrigation.U S N TOP: Irrigation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is changing a surgical dressing and is cleansing the wound. She knows that: a. the incision line should be cleansed last. b. she should start at one end of the incision line and swab the entire length. c. she should start at the center of the incision line and swab toward one end. d. she should work in a circular motion around the incision line. ANS: C
The center is the most important part of the suture line; therefore, using a sterile swab or gauze, clean the suture line by starting at the center of the suture line and working toward one end. With another sterile swab or gauze, start at the center of the incision and work toward the other end. All other cleansing involves moving from one end to the other on each side of the incision. Work in straight lines, moving away from the suture line with each successive stroke. DIF: Cognitive Level: Application REF: Text reference: p. 923 OBJ: Explain factors that impair or promote normal wound healing. TOP: Cleansing an Incision KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 6. The nurse answers the patient’s call light to find the patient agitated and stating that she “felt
something pop.” The nurse finds that the patient’s abdominal surgical wound has eviscerated. What should the nurse do? a. Try to reinsert the abdominal contents. b. Cover the wound with a dry sterile dressing. c. Notify the surgeon when he makes rounds. d. Cover the wound with a moist saline dressing. ANS: D
This is a surgical emergency, and the nurse needs to cover the wound with a moist saline dressing, immediately notify the surgeon, and prepare the patient for emergency surgery. DIF: Cognitive Level: Application REF: Text reference: p. 924 OBJ: Explain factors that impair or promote normal wound healing. TOP: Evisceration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The nurse prepares to irrigate the patient’s wound. What is the primary reason for this
procedure? a. Decrease scar formation. b. Remove debris from the wound. c. Improve circulation from the wound. d. Decrease irritation from wound drainage. ANS: B
Wound irrigations promote wound healing by removing debris from a wound surface, decreasing bacterial counts, and loosening and removing eschar. The primary purposes of wound irrigation do not incluN deUdRecr arCfor Mation, improving circulation, or SIeasi NGngTsBc. Om decreasing irritation. DIF: Cognitive Level: Application REF: Text reference: p. 926 OBJ: Explain factors that impair or promote normal wound healing. TOP: Irrigation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. Which of the following approaches is correct technique when wound irrigation is performed? a. Placing the patient in supine position b. Placing the syringe directly into the wound c. Using sterile technique for a chronic wound d. Selecting a soft catheter for deep wounds with small openings ANS: D
If the patient has a deep wound with a narrow opening, attach a soft catheter to the syringe to permit the fluid to enter the wound. Position the patient comfortably to permit gravitational flow of irrigating solution through the wound and into the collection receptacle. Hold the syringe tip 2.5 cm (1 inch) above the upper end of the wound and over the area being cleansed; this prevents syringe contamination. Wound cleansing and irrigation are accomplished using sterile technique (surgical wounds) or clean technique (some chronic wounds). DIF: Cognitive Level: Application OBJ: Perform wound irrigation.
REF: Text reference: p. 926 TOP: Irrigation
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. On which types of wounds may the nurse use a pulsatile high-pressure lavage for irrigation? a. Graft sites b. Wounds with exposed blood vessels c. Necrotic tissue d. Wounds with exposed muscle or tendons ANS: C
Pulsatile high-pressure lavage is often the irrigation of choice for necrotic wounds. The amount of irrigant is wound size dependent. Pressure settings on the device need to remain between 4 and 15 psi. Do not use this type of irrigation with graft sites or exposed blood vessels, muscle, tendon, or bone. DIF: Cognitive Level: Application REF: Text reference: p. 926 OBJ: Perform wound irrigation. TOP: Pulsatile High-Pressure Lavage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. When should a nurse consider culturing a wound? a. When the tissue is clean and dry b. When exudate is not present c. When the patient is afebrile d. When the surrounding area shows inflammation ANS: D
Consider culturing a wound if it R hasI a foul, purulentModor; inflammation surrounds the wound; NU GTB.C S N a nondraining wound begins to drain; or the patieO nt is febrile. DIF: Cognitive Level: Application REF: Text reference: p. 929 OBJ: Explain factors that impair or promote normal wound healing. TOP: Wound Culture KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 11. When teaching about wound care in the home environment, the nurse instructs the patient and
caregiver to: a. make normal saline with 8 teaspoons of salt and .1 gallon of distilled water. b. use normal saline for 1 week and then discard it. c. not apply topical anesthetics before wound care. d. call the physician’s office to have someone come to the home and complete the wound care. ANS: A
Teach the patient and caregiver how to make normal saline, especially if cost is an issue. They can make normal saline by using 8 teaspoons of salt in 1 gallon of distilled water and keeping it refrigerated for 1 month. The saline solution should be allowed to reach room temperature before use. Commonly used topical anesthetic solutions include 2% and 4% lidocaine jelly, which inactivates exposed wound pain receptors. Some patients need to receive wound care management in an outpatient wound care clinic. Be sure the patient has directions to the clinic and knows where to park and where to obtain dressing supplies.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Application REF: Text reference: p. 930 OBJ: Explain factors that impair or promote normal wound healing. TOP: Teaching Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. Which situation noticed during evaluation would determine that the staples or sutures should
remain in place? a. The wound edges are separated. b. No drainage or erythema is present. c. The patient is anxious about their removal. d. A cosmetically aesthetic result would not be achieved. ANS: A
Assess healing ridge and skin integrity of the suture line for uniform closure of wound edges, normal color, and absence of drainage and inflammation that indicates adequate wound healing for support of internal structures without continued need for sutures or staples. If wound edges are separated or signs of infection are present, the wound has not healed properly. Notify the health care provider because sutures or staples may need to remain in place. Absence of drainage and erythema would indicate that sutures are ready for removal. Steps could be taken to relieve the patient’s anxiety, but suture removal is based on the condition of the wound. Timing of suture removal is based on adequate wound healing. DIF: Cognitive Level: Application REF: Text reference: p. 931 OBJ: Remove sutures or staples. TOP: Wound Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
enUrR emo 13. What should the nurse do whN Ivin GgTinBte.rmCitte Mnt sutures? S N O a. Snip both sides of the suture before removing. b. Snip the suture as close to the knot as possible. c. Snip the suture as close to the skin as possible. d. Pull up the knot to apply as much tension as possible. ANS: C
Snip the suture as close to the skin as possible at the end distal to the knot. Never snip both ends of the suture; there will be no way to remove the part of the suture situated below the surface. Grasp the knot of the suture with forceps, and gently pull up the knot while slipping the tip of the scissors under the suture near the skin. DIF: Cognitive Level: Application REF: Text reference: p. 933 OBJ: Remove sutures or staples. TOP: Removing Sutures KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. What should the nurse do when performing suture or staple removal? a. Snip both ends of the sutures. b. Apply tension to the suture line to remove the sutures. c. Pull the exposed surface of the suture through the tissue below the epidermis. d. Apply Steri-Strips if any separation greater than the width of two stitches is
present. ANS: D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Apply Steri-Strips if any separation greater than two stitches or two staples in width is apparent, to maintain contact between wound edges. This supports the wound by distributing tension across the wound and eliminates closure technique scarring. Never snip both ends of the suture; there will be no way to remove the part of the suture situated below the surface. Grasp the knotted end with forceps, and in one continuous smooth action, pull the suture through from the other side; this smoothly removes the suture without additional tension to the suture line. Tension on the suture line is not required. Never pull the exposed surface of any suture into tissue below the epidermis. The exposed surface of any suture is considered contaminated. DIF: Cognitive Level: Application REF: Text reference: p. 934 OBJ: Remove sutures or staples. TOP: Removing Sutures KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The physician reports that he is expecting that the patient’s wound will have an output of
close to 500 mL per day. The nurse anticipates placement of which of the following? a. Dry sterile dressing b. Jackson-Pratt (JP) drain c. Hemovac drain d. No drain ANS: C
If drainage accumulates in the wound bed, wound healing is delayed. Drainage is removed by using a closed or an open drain system, even if the amount of drainage is small. A JP drain collects fluid that is in the 100 to 200 mL per 24-hour range; the Hemovac drain accommodates more drainage, usually up to 500 mL in 24 hours.
NURSINGTB.COM
DIF: Cognitive Level: Application REF: Text reference: p. 935 OBJ: Demonstrate care of a wound drainage system. TOP: Drainage Systems KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 16. What is an appropriate technique for the nurse to implement for drainage evacuation? a. Replace the Hemovac drain fully expanded. b. Attach the drainage tubing to the patient’s gown. c. Tilt the evacuator of the Hemovac away from the plug. d. Complete the dressing change before the drainage evacuation. ANS: B
Pinning drainage tubing to the patient’s gown will prevent tension or pulling on the tubing and the insertion site. Check the evacuator for reestablishment of the vacuum, patency of drainage tubing, and absence of stress on the tubing. The Hemovac needs to be flattened (compressed) to create a vacuum. Tilt the evacuator in the direction of the plug. Drainage evacuation may be done at times other than dressing change times. DIF: Cognitive Level: Application REF: Text reference: p. 936 OBJ: Demonstrate care of a wound drainage system. TOP: Drainage Systems KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. What should the nurse do to reestablish the vacuum of the Hemovac system after emptying?
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
Place a safety pin on the part of the drain outside the body. Replace the cap immediately after emptying. Pin the drainage tubing to the patient’s gown. Place the Hemovac on a flat surface.
ANS: D
Place the evacuator on a flat surface with the open outlet facing upward; continue pressing downward until the bottom and the top are in contact; hold the surfaces together with one hand, quickly cleanse the opening and the plug with the other hand, and immediately replace the plug; and then secure the evacuator to the patient’s bed. Compression of the surface of the Hemovac creates a vacuum. Cleansing of the plug reduces transmission of microorganisms into the drainage evacuation. Be sure the Penrose drain has a sterile safety pin in place. This pin prevents the drain from being pulled below the skin’s surface. Compress the bulb of a JP drain over the drainage container. Cleanse the ends of the emptying port with an alcohol sponge while continuing to compress the container. Replacing the cap immediately prevents tension on the drainage tubing, but does not help to reestablish the vacuum. DIF: Cognitive Level: Application REF: Text reference: p. 937 OBJ: Demonstrate care of a wound drainage system. TOP: Reestablishing Vacuum of Drainage Systems KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse is explaining wound healing to a patient. Which of the following statements
explains the healing that occurs during the inflammatory stage of wound healing in a full-thickness wound? a. A reduction in the size of the wound is noted. b. The epithelial cells duplicNaU teR . SINGTB.COM c. Synthesis of collagen occurs at the site. d. Blood flow to the wound and arrival of white blood cells are increased. ANS: D
Vasodilatation occurs, allowing plasma and blood cells to leak into the wound, noted as edema, erythema, and exudate. Leukocytes (white blood cells) arrive in the wound to begin wound cleanup. Macrophages, a type of white blood cell, appear and begin to regulate wound repair. The result of the inflammatory phase is a clean wound bed in the patient with an uncomplicated wound. It is during the proliferative stage, not the inflammatory stage, that contraction causes a reduction in the size of the wound, duplication of epithelial cells occurs, and collagen is synthesized. DIF: Cognitive Level: Application REF: Text reference: p. 921 OBJ: Discuss the body’s response during each stage of the wound-healing process. TOP: Phases of Wound Healing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. For absorption of heavy exudate from a wound, a nurse selects which of the following
dressings? a. Alginates b. Hydrogel c. Hydrocolloid d. Transparent film
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: A
Alginates are used for absorption of heavy to moderate wound exudate. Hydrogels are used for dry wounds to wounds with minimal exudate. Hydrocolloids are used to absorb minimal to moderate exudate. Transparent film has no absorption quality. DIF: Cognitive Level: Application REF: Text reference: p. 927 OBJ: Discuss the body’s response during each stage of the wound-healing process. TOP: Dressings KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 20. The nurse is educating a patient about his role in wound healing. Which of the following
factors, if modified by the patient, can support adequate oxygenation at the tissue level? a. Age b. Smoking c. Underlying cardiopulmonary conditions d. Hemoglobin ANS: B
Factors that decrease oxygenation include decreased hemoglobin level, smoking, and underlying cardiopulmonary conditions. Smoking is the only one of these factors that can be modified by the patient alone. Age causes vascular changes. DIF: Cognitive Level: Application REF: Text reference: p. 924 OBJ: Explain factors that impair or promote normal wound healing. TOP: Skin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. The nurse is caring for a patiN ent R withIa pG ostsB u. rgC icalMwound dehiscence who is being treated
U Sof the N following T O can be appropriately delegated to the nurse with a wet-to-dry dressing. Which assistant? a. Performing a sterile dressing change b. Observing for any drainage on the dressing c. Performing wound assessment during the dressing change d. Notifying the physician of drainage present on the dressing ANS: B
Wound assessment and sterile dressing changes cannot be delegated to nursing assistive personnel (NAP). The nurse can direct the NAP to report any drainage from the wound that is present on the sheets or as strike-through from the dressing. The NAP should not be reporting this to a physician. DIF: Cognitive Level: Application REF: Text reference: p. 925 OBJ: Perform a wound assessment. TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Management of Care 22. You are irrigating a wound and are trying to make sure you get the wound adequately
cleansed. Which of the following should you avoid? a. Inserting the tip of a soft catheter into a deep wound b. Using a 19-gauge angiocatheter c. Pushing the tip inside a deep wound that has a small opening d. Using a large syringe
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS: C
Do not force a catheter into a wound because this will cause tissue damage. Using a 19-gauge angiocatheter and a 35-cc syringe is acceptable. If you need to irrigate a deep wound with a small opening, use a soft catheter and insert it 1.3 cm to avoid touching the fragile inner wall of the wound. DIF: Cognitive Level: Application REF: Text reference: p. 929 OBJ: Perform wound irrigation. TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1. How does the skin defend the body? (Select all that apply.) a. Skin serves as a sensory organ for pain. b. Skin serves as a sensory organ for touch. c. Skin serves as a sensory organ for temperature. d. Skin has an acid pH. ANS: A, B, C, D
The skin defends the body by serving as a sensory organ for pain, touch, and temperature, and it has an acid pH, which is often called the “acid mantle.” DIF: Cognitive Level: Comprehension REF: Text reference: p. 920 OBJ: Explain factors that impair or promote normal wound healing. TOP: Skin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological IN ntegR rityI G B.C M
U S N T
O
2. Physiologically, wound healing occurs in the same way for all patients, with some tissues
(including the vascular tissues) regenerating quickly and others regenerating slowly or not at all. The latter group includes which of the following cells? (Select all that apply.) a. Liver cells b. Skin cells c. Renal tubules d. Central nervous system neurons ANS: A, C, D
Physiologically, wound healing occurs in the same way for all patients, with skin cells and some tissues (including the vascular tissues) regenerating quickly and others regenerating slowly or not at all. The latter group includes cells of the liver, renal tubules, and central nervous system neurons. DIF: Cognitive Level: Comprehension REF: Text reference: p. 921 OBJ: Explain factors that impair or promote normal wound healing. TOP: Wound Healing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. You are explaining wound healing to your patient. You are trying to explain the healing
process in a full-thickness wound. Which of the following phases should you include in your explanation? (Select all that apply.) a. Hemostasis
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. Inflammation c. Proliferation d. Maturation ANS: A, B, C, D
In a full-thickness wound, the phases include hemostasis, inflammation, proliferation, and maturation. DIF: Cognitive Level: Application REF: Text reference: p. 921 OBJ: Discuss the body’s response during each stage of the wound-healing process. TOP: Phases of Wound Healing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. You are explaining negative-pressure wound therapy (NPWT) to a patient. Which of the
following statements will help reassure the patient that this type of therapy will support wound healing? (Select all that apply.) a. NPWT optimizes blood flow. b. NPWT will remove wound fluid. c. NPWT will maintain a moist environment. d. NPWT will apply positive pressure to the wound. ANS: A, B, C
NPWT supports wound healing by optimizing blood flow, removing wound fluid, and maintaining a moist environment. DIF: Cognitive Level: Application OBJ: Perform a wound assessment. KEY: Nursing Process Step: PN lannR ing I
REF: Text reference: p. 923 TOP: Negative-Pressure Wound Therapy (NPWT) MS NCLMEX: Physiological Integrity G BC:.C
U S N T
O
5. Wounds that have been approved for treatment using NPWT include which of the following?
(Select all that apply.) a. Pressure ulcers b. Diabetic ulcers c. Traumatic wounds d. Venous stasis ulcers ANS: A, B, C, D
Chronic wounds such as pressure ulcers, diabetic ulcers, traumatic wounds, and venous stasis ulcers are approved for NPWT. DIF: Cognitive Level: Application OBJ: Perform a wound assessment. KEY: Nursing Process Step: Planning
REF: Text reference: p. 923 TOP: Negative-Pressure Wound Therapy (NPWT) MSC: NCLEX: Physiological Integrity
6. The nurse is caring for a patient who has had major abdominal surgery. She is concerned
about the possibility of dehiscence. During her assessment, she makes sure she assesses for which of the following contributing factors? (Select all that apply.) a. Age b. Malnutrition/obesity c. Gender d. Use of steroids
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: B, D
Factors that contribute to surgical wound dehiscence include anemia, malnutrition, obesity, and use of steroids. DIF: Cognitive Level: Application REF: Text reference: p. 924 OBJ: Explain factors that impair or promote normal wound healing. TOP: Dehiscence KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity COMPLETION 1. The
is composed of newly formed collagen, and the nurse can usually feel it along a healing wound. It is usually present directly under the suture line between days 5 and 9. ANS:
healing ridge The healing ridge is composed of newly formed collagen, and you can usually feel it along a healing wound. It is usually present directly under the suture line between days 5 and 9. Lack of a ridge is cause for concern, and you will need to begin interventions promptly to reduce mechanical strain on the wound. DIF: Cognitive Level: Knowledge REF: Text reference: p. 921 OBJ: Discuss the body’s response during each stage of the wound-healing process. TOP: The Healing Ridge KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
N R I G B.C M
intentionUoccSursNwhT en surgO ical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.
2. Healing by
ANS:
tertiary Healing by tertiary intention is sometimes called delayed primary intention or closure. It occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish. Then the wound edges are sutured or stapled closed. Scarring is usually minimal. DIF: Cognitive Level: Knowledge OBJ: Perform a wound assessment. KEY: Nursing Process Step: Assessment 3.
REF: Text reference: p. 922 TOP: Tertiary Intention MSC: NCLEX: Physiological Integrity
is black, brown, or tan tissue in the wound that should be removed before wound healing can begin. ANS:
Eschar Black, brown, or tan tissue in the wound is eschar that should be removed before wound healing can begin. DIF: Cognitive Level: Knowledge OBJ: Perform a wound assessment.
REF: Text reference: p. 922 TOP: Eschar
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Assessment 4.
MSC: NCLEX: Physiological Integrity
uses the mechanical force (high or low) of a stream of solution to remove debris, bacteria, and necrotic tissue from a wound. ANS:
Irrigation Irrigation uses the mechanical force (high or low) of a stream of solution to remove debris, bacteria, and necrotic tissue from a wound. DIF: Cognitive Level: Knowledge OBJ: Perform wound irrigation. KEY: Nursing Process Step: Planning
REF: Text reference: p. 923 TOP: Irrigation MSC: NCLEX: Physiological Integrity
5. A failure of wound healing in which the surgical wound breaks, separates, and opens to the
fascial level is known as
.
ANS:
dehiscence Dehiscence, a failure of wound healing in which the surgical wound breaks, separates, and opens to the fascial level. It occurs fairly early after surgery (5 to 8 days after surgery) in patients in whom the normal healing response lags. DIF: Cognitive Level: Knowledge REF: Text reference: p. 924 OBJ: Explain factors that impair or promote normal wound healing. TOP: Dehiscence KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
NURSINGTB.COM
are threads of wire or other materials used to sew body tissues together.
6. ANS:
Sutures Sutures are threads of wire or other materials used to sew body tissues together. DIF: Cognitive Level: Knowledge OBJ: Remove sutures or staples. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 930 TOP: Sutures MSC: NCLEX: Physiological Integrity
7. The Jackson-Pratt (JP) drain relies on the presence of a vacuum to withdraw drainage and is
considered a
_ drainage system.
ANS:
closed A closed drainage system such as the JP drain (Figure 38-8) or Hemovac drain relies on the presence of a vacuum to withdraw accumulated drainage from around the wound bed into the collection device. DIF: Cognitive Level: Comprehension REF: Text reference: p. 935 OBJ: Demonstrate care of a wound drainage system. TOP: Closed Drain Systems KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 39: Dressings, Bandages, and Binders MULTIPLE CHOICE 1. The nurse is caring for a patient who is bleeding. To control bleeding, she would apply a a. b. c. d.
dressing. pressure alginate foam hydrocolloid
ANS: A
Apply a pressure dressing to control bleeding, but when wound drainage is present, use a highly absorbent dressing. Use an alginate, foam, or hydrocolloid dressing in a noninfected wound that is draining a moderate to large amount of exudate. DIF: Cognitive Level: Application REF: Text reference: p. 943 OBJ: Choose the correct dressing for a wound. TOP: Pressure Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is changing a dry, woven gauze dressing when she notices that the gauze has
inadvertently stuck to the wound. What should the nurse do? a. Pull the dressing off to aid in debridement. b. Recover the dressing and leave in place. c. Moisten the gauze to minimize trauma. d. Ensure that the shiny sideNoU fR thS eI drN yG gaTuB ze.dC reOssMing does not stick. ANS: C
When a dry dressing inadvertently adheres to the wound, moisten the dressing with sterile normal saline or sterile water before removing the gauze to minimize wound trauma. Moistening the gauze applies only to dry dressings and is not applicable for moist-to-dry dressings. A dry dressing is not used for debriding wounds. Telfa gauze dressings (not dry woven gauze dressings) contain a shiny, nonadherent surface on one side that does not stick to the wound. DIF: Cognitive Level: Application REF: Text reference: p. 946 OBJ: Understand the technique of a dressing, bandage, or binder application. TOP: Dry Woven Gauze Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient who has a wound healing by primary intention that has little
to no drainage. Which dressing is most appropriate for this type of wound? a. Moist-to-dry dressing b. Hydrocolloid dressing c. Dry dressing d. Hydrogel dressing ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Dry dressings are used for wound healing by primary intention with little drainage. These dressings protect the wound from injury, prevent the introduction of bacteria, reduce discomfort, and speed healing. The primary purpose of moist-to-dry dressings is to mechanically debride a wound. Hydrocolloid dressings provide a moist environment for wound healing while facilitating softening and subsequent removal of wound debris. Hydrogel dressings (e.g., Curasol, IntraSite Gel, Vigilon) have a high moisture content (95%), causing them to swell and retain fluid. They are useful over clean, moist, or macerated tissues. DIF: Cognitive Level: Analysis REF: Text reference: p. 946 OBJ: Choose the correct dressing for a wound. TOP: Dry Dressings KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse would consider a dry dressing appropriate for a wound that requires which of the
following? a. Protection b. Debridement c. Absorption of heavy exudate d. Healing by second intention ANS: A
A dry dressing may be chosen for management of a wound healing by primary intention with little drainage. The dressing protects the wound from injury, reduces discomfort, and speeds healing. The dry dressing does not interact with wound tissues and causes little wound irritation. A dry dressing is not appropriate for an open wound that is healing by secondary intention. DIF: Cognitive Level: Application REF: Text reference: p. 946 N R I G OBJ: Choose the correct dressinU g foS r a wNounT dB . .COM TOP: Dry Dressings KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 5. What should the nurse do for a patient who is having a wet-to-dry dressing applied? a. Moisten the old inner dressing to remove it. b. Pack the gauze in flat pieces into the wound. c. Wet the new inner dressing with a cytotoxic solution. d. Apply a secondary dressing over the inner wet packing. ANS: D
The primary purpose of wet-to-dry dressings is to mechanically debride a wound. The moistened contact layer of the dressing (primary dressing) increases the absorptive ability of the dressing to collect exudate and wound debris. As the dressing dries, it adheres to the wound and debrides the wound of tissue when the dressing is removed. The moistened gauze must be covered with a secondary dressing layer that is dry. It is incorrect technique and a common error by some clinicians to moisten the dried gauze before removing it. This defeats the purpose of using this type of dressing and reduces the amount of debris that the dressing will remove. Open or “fluff” the woven gauze that will be placed directly against the wound bed. Moisten the packing material with a noncytotoxic solution such as normal saline. Never use cytotoxic solutions. DIF: Cognitive Level: Application REF: Text reference: p. 946 OBJ: Choose the correct dressing for a wound. TOP: Wet-to-Dry Dressings KEY: Nursing Process Step: Implementation
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity 6. Moist-to-dry dressings consist of gauze moistened with an appropriate solution. What should
the nurse do when caring for a patient who has a pressure wound that requires debridement? a. Saturate the primary dressing with saline or lactated Ringer’s solution. b. Moisten the primary dressing with saline or lactated Ringer’s solution. c. Moisten the primary dressing with acetic acid. d. Moisten the primary dressing with povidone-iodine. ANS: B
Moist-to-dry dressings consist of gauze moistened with an appropriate solution. Commonly used wetting agents include normal saline and lactated Ringer’s solution, which are isotonic solutions that aid in mechanical debridement. A dressing that is too wet causes tissue maceration and bacterial growth. It also does not dry out and therefore does not remove necrotic tissue when it is being removed from the wound. Acetic acid is effective against Pseudomonas aeruginosa but is toxic to fibroblasts in standard dilutions. Povidone-iodine is a rapid-acting antimicrobial agent for cleansing intact skin and is never used on a healthy granulating wound bed. DIF: Cognitive Level: Application REF: Text reference: p. 946 OBJ: Choose the correct dressing for a wound. TOP: Wet-to-Dry Dressings KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The patient has a large, deep wound on the sacral region. The nurse correctly packs the wound
by: a. filling two thirds of the wound cavity. b. leaving saline-soaked folded gauze squares in place. c. putting the dressing in veN ryUtR igS htI lyN . GTB.COM d. extending only to the upper edge of the wound. ANS: D
Apply moist, fine-mesh, open-weave gauze as a single layer directly onto the wound surface. If the wound is deep, gently pack the gauze into the wound with a sterile gloved hand or forceps until all wound surfaces are in contact with the moist gauze. Be sure that the gauze does not touch periwound skin. Moisture that escapes the dressing often macerates the periwound area. The gauze should be saturated with the prescribed solution, wrung out, unfolded, and lightly packed into the wound. Overpacking the wound may cause pressure on tissue in the wound bed. DIF: Cognitive Level: Application REF: Text reference: p. 950 OBJ: Apply dry, moist-to-dry, pressure, transparent, and synthetic dressings correctly. TOP: Packing the Wound KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. What should the nurse do for a patient with a sudden severe hemorrhage? a. Go for help. b. Drape the patient. c. Apply direct pressure. d. Put on clean or sterile gloves. ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Apply direct pressure immediately. Seek assistance after pressure is applied. Maintaining asepsis and privacy is considered only if time and severity of blood loss permit inclusion of these activities. DIF: Cognitive Level: Application REF: Text reference: p. 953 OBJ: Choose the correct dressing for a wound. TOP: Hemostasis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. What should the nurse anticipate might happen to a patient if bleeding cannot be controlled? a. Skin dryness b. Bradycardia c. Hypovolemic shock d. Hypertension ANS: C
Findings of tachycardia, hypotension, diaphoresis, restlessness, and diminished urinary output indicate impending hypovolemic shock. Bradycardia is a decreased pulse rate. Dry skin is not an indicator of hypovolemic shock. Hypertension is an increase in blood pressure. DIF: Cognitive Level: Application OBJ: Assess a wound correctly. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 955 TOP: Hypovolemic Shock MSC: NCLEX: Physiological Integrity
10. How should the nurse proceed when applying a pressure bandage? a. Elevate the extremity or area of bleeding. b. Wrap pressure-bandage gauze in a proximal-to-distal direction. c. Apply pressure to diminiN shUthReSpI ulse th. e dCista NGtoTB OMl body part. d. Wrap tape around the circumference of the site to secure the gauze padding. ANS: A
As soon as possible, elevate the extremity or area of bleeding. Elevation assists in decreasing the rate of blood loss. Start the pressure bandage from distal to proximal, working toward the heart. Secure tape on the distal end, pull tape across the dressing, and maintain firm pressure as the proximate end of the tape is secured. To ensure blood flow to distal tissues and to prevent a tourniquet effect, adhesive tape must not be continued around the entire extremity. DIF: Cognitive Level: Application REF: Text reference: p. 954 OBJ: Understand the technique of a dressing, bandage, or binder application. TOP: Pressure Bandage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. Serious hemorrhaging has resulted in the patient experiencing a fluid and electrolyte
imbalance. How should the nurse respond? a. Initiate intravenous (IV) therapy. b. Order blood for transfusions. c. Remove and reapply any dressings. d. Monitor vital signs every 15 minutes. ANS: D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Monitor vital signs every 5 to 15 minutes (apical, distal rate, blood pressure). IV therapy and blood transfusions require a provider’s order. Reinforce the dressing with tape as needed to prevent seepage. If the dressing is saturated, replace only the top layers so as not to disturb any clot formation at the wound site. DIF: Cognitive Level: Application REF: Text reference: p. 955 OBJ: Understand the technique of a dressing, bandage, or binder application. TOP: Hemorrhage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. The patient is being sent home from the hospital after a cardiac catheterization. What should
the nurse instruct the patient to do first if bleeding should occur at the femoral artery puncture site? a. Call the physician. b. Call 9-1-1. c. Apply pressure to the site. d. Apply a new bandage. ANS: C
Wounds to the groin area can result in a large amount of blood loss, which is not always visible. If bleeding should occur at the femoral artery puncture site, the patient should apply direct pressure immediately. At home, the patient may apply pressure with clean towels or linen. The patient should call the physician as soon as possible after homeostasis is established. The patient should call 9-1-1 as soon as possible after applying pressure to the site. DIF: Cognitive Level: Application REF: Text reference: p. 956 OBJ: Assess a wound correctlN y.URSINGTT OB P:.C HeO mM orrhage KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 13. The patient is brought from a construction site to the emergency department with a pipe
puncturing his abdomen. The pipe is still in place. The patient is triaged and is scheduled for the operating room. What should the nurse do while waiting for the surgeon? a. Pull the pipe out in the direction of entry. b. Push the pipe through to the other side, then out. c. Leave the pipe in place. d. None of the above. ANS: C
If a puncture wound occurs from a penetrating object (e.g., knife, toy, building materials), do not remove the object. Removal of the object will cause more rapid blood loss and may damage underlying structures. DIF: Cognitive Level: Application REF: Text reference: p. 956 OBJ: Assess a wound correctly. TOP: Penetrating Objects KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. For a patient with a transparent film dressing, the nurse assesses that there is white, opaque
fluid accumulation and the surrounding tissue is inflamed. How should the nurse respond? a. Culture the wound.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. Leave the current dressing in place. c. Apply gauze over the top of the dressing. d. Remove and stretch the film more tightly over the wound. ANS: A
Accumulation of fluid with a white, opaque appearance and erythema of the surrounding tissue usually indicate an infectious process; the dressing should be removed and a wound culture obtained. DIF: Cognitive Level: Application REF: Text reference: p. 956 OBJ: Assess a wound correctly. TOP: Film Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is changing a film dressing over a wound that is showing a large amount of
drainage. How should the nurse proceed? a. Apply a film dressing after culturing the wound. b. Apply a film dressing after cleansing the area. c. Choose another type of dressing for this wound. d. Keep the wound open to air. ANS: C
If the wound has a large amount of drainage, choose another dressing that can absorb this amount of wound drainage, rather than transparent film dressing, which can absorb only light to moderate amounts of drainage. Explain to the patient and family that collection of wound fluid under the dressing is not “pus,” but rather is a result of normal interaction of body fluids with the dressing.
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DIF: Cognitive Level: Application REF: Text reference: p. 957 OBJ: Choose the correct dressing for a wound. TOP: Film Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. In what type of wound is a foam dressing contraindicated? a. Shallow stage II ulcer b. Exudative stage II ulcer c. Wound that has tunneling d. Wound that is infected ANS: C
Foam dressings are not appropriate when there is wound tunneling because the dressing expands, which can enlarge the tunnels. International pressure ulcer guidelines recommend foam for use on exudative stage II and shallow stage II pressure ulcers. Foam dressings are also used to dress infected wounds. DIF: Cognitive Level: Application REF: Text reference: p. 959 OBJ: Choose the correct dressing for a wound. TOP: Foam Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 17. When assessing a patient with a hydrocolloid dressing, the nurse finds the formation of a soft,
white-yellow gel that is adherent to the wound and has a very slight odor. The nurse evaluates this outcome as: a. an expected occurrence. b. a wound infection requiring a culture. c. an adverse reaction to the hydrocolloid components. d. excessive exudate requiring a different type of dressing. ANS: A
Hydrocolloid dressings interact with wound fluids and form a soft whitish-yellowish gel that is hard to remove and may have a faint odor. These are normal occurrences and should not be confused with pus or purulent exudate, wound infection, or deterioration of the wound. DIF: Cognitive Level: Application REF: Text reference: p. 961 OBJ: Apply dry, moist-to-dry, pressure, transparent, and synthetic dressings correctly. TOP: Hydrocolloid Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. What should the nurse remember to do when applying a hydrocolloid dressing? a. Apply granules after applying the wafer. b. Never use a secondary dressing. c. Hold the dressing in place. d. Use silk tape to hold the dressing in place. ANS: C
Hold the dressing in place for 30 to 60 seconds after application. Hydrocolloid dressings are most effective at body temperature. Holding the dressing in place for a short time facilitates dressing action. In the case oN f aUdReep colloid granules or paste is applied before Iwo Gund B, h.yCdro M S N T O the wafer. Hydrocolloid granules/paste assists in absorbing drainage to increase the wearing time of the dressing. Apply a secondary dressing (e.g., ABD pad) if needed. When a secondary dressing is not used, apply nonallergic, paper tape around the edges of the hydrocolloid dressing. DIF: Cognitive Level: Application REF: Text reference: p. 962 OBJ: Apply dry, moist-to-dry, pressure, transparent, and synthetic dressings correctly. TOP: Hydrocolloid Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. Which of the following is an appropriate procedure for the nurse to implement during the
application of an absorption or alginate dressing? a. Never cut the dressing to fit the wound. b. Irrigate the wound gently to remove residual gel. c. Fill the wound cavity entirely with the dressing material. d. Never use a secondary dressing. ANS: B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Cleanse the area gently with moist 4 4 sterile gauze pads, swabbing exudate away from the wound, or spray with a wound cleanser. Cleansing effectively removes any residual dressing gel without injuring newly formed delicate granulation tissue formed in the healing wound bed. With some brands, dressings can be trimmed to fit wound size, whereas other brands of dressings cannot be cut. Fill the wound cavity only one-half to two-thirds full to allow for expansion with absorption. Apply a secondary dressing, such as transparent film, hydrogen, foam, or hydrocolloid. DIF: Cognitive Level: Application REF: Text reference: p. 961 OBJ: Apply dry, moist-to-dry, pressure, transparent, and synthetic dressings correctly. TOP: Alginate Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. The nurse is caring for a patient who had a negative-pressure wound dressing. The nurse
realizes that the system is working properly when the vacuum setting is set at which of the following levels? a. –40 mm Hg b. –210 mm Hg c. –125 mm Hg d. –25 mm Hg ANS: C
The target negative pressures for wound healing range from –50 mm Hg to –175 mm Hg, but a setting of –125 mm Hg is most common. DIF: Cognitive Level: Application REF: Text reference: p. 965 OBJ: Change a negative-pressure wound therapy dressing correctly. BT.)COM TOP: Negative-Pressure WounNdU TR heS raI pyN(G NT PW KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. The nurse is caring for a patient who has a negative-pressure dressing. The nurse realizes that
typically the dressing should be changed: a. every shift. b. daily. c. every 8 hours. d. every 48 hours. ANS: D
You will typically change an entire NPWT dressing and wound filler every 48 hours or 3 times per week. The schedule for changing NPWT dressings varies and is based on the type and condition of the wound. An infected wound may need a dressing change every 24 hours, whereas a clean wound can be changed 3 times a week. DIF: Cognitive Level: Application REF: Text reference: p. 965 OBJ: Change a negative-pressure wound therapy dressing correctly. TOP: Negative-Pressure Wound Therapy (NPWT) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The nurse is preparing to apply a gauze bandage to a dressing on the patient’s wrist. How
should the nurse proceed? a. Use a 3-inch bandage.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. Use a 2-inch bandage. c. Apply from the elbow toward the wrist. d. Secure the bandage with a safety pin. ANS: B
When applying a gauze or elastic bandage, you select a type of bandage and bandage width depending on the size and shape of the body part to be bandaged. For example, 3-inch bandages are used most commonly for the adult leg. A smaller, 2-inch bandage normally is used for the upper extremity. When applying an elastic bandage to an extremity, start the bandage at the site farthest from the heart (distal) and proceed toward the heart (proximal). Use adhesive tape or special clips rather than safety pins to fasten the bandage. DIF: Cognitive Level: Application REF: Text reference: pp. 969-971 OBJ: Demonstrate the technique for applying turned bandages correctly. TOP: Applying a Bandage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. Which of the following tasks might be delegated to nursing assistive personnel (NAP)? a. Pressure dressing to an actively bleeding wound b. Chronic wound that needs a nonsterile moist-to-dry dressing change c. Hydrogel dressing change d. Wound assessment during the dressing change ANS: B
The task of applying dry and moist-to-dry dressings may sometimes be delegated to nursing assistive personnel (NAP) if the wound is chronic (see facility policy and Nurse Practice Act). Wound assessments, care of acute new wounds, and wound care requiring sterile technique cannot be delegated. The appN lica hyd ro. geCl dr URtion SIofNG TB OMessings or pressure dressings cannot be delegated. DIF: Cognitive Level: Application REF: Text reference: p. 959 OBJ: Assess a wound correctly. TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Dressings serve several functions. Which of the following is a function of a dressing? (Select
all that apply.) a. Maintains a moist environment b. Prevents the spread of microorganisms c. Increases patient comfort d. Controls bleeding ANS: A, B, C, D
Dressings serve several functions such as maintaining a moist environment, protecting from outside contaminants, protecting from further injury, preventing the spread of microorganisms, increasing patient comfort, and controlling bleeding. DIF: Cognitive Level: Comprehension REF: Text reference: p. 942 OBJ: Discuss the purposes of dressings, bandages, and abdominal binders.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: Functions of Dressings MSC: NCLEX: Physiological Integrity
KEY: Nursing Process Step: Assessment
2. Which of the following are examples of wounds that heal by secondary intention? (Select all
that apply.) a. Burns b. Surgical incisions c. Infected wounds d. Deep pressure ulcers ANS: A, C, D
Healing by secondary intention occurs when a wound is left open. Healing results in the formation of granulation tissue from the bottom of the wound and eventual epithelialization from the sides of the wound to close the defect. During the process of epithelialization, epithelial cells migrate and proliferate from the wound edges to cover the wound surface. Burns, infected wounds, and deep pressure ulcers heal in this manner. DIF: Cognitive Level: Comprehension OBJ: Assess a wound correctly. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 943 TOP: Secondary Intention MSC: NCLEX: Physiological Integrity
3. Hydrocolloid dressings are used for which of the following? (Select all that apply.) a. Maintaining a moist wound environment b. Autolytic debriding of necrotic wounds c. Absorption of moderately draining wounds d. Protecting from friction ANS: A, B, C
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Hydrocolloid dressings comprise elastometric, adhesive, and gelling agents. They facilitate autolytic debridement of wounds through rehydration. They absorb exudate and encourage healing by maintaining a moist wound healing environment. Transparent dressings are more suitable for preventing friction. DIF: Cognitive Level: Comprehension REF: Text reference: p. 959 OBJ: Choose the correct dressing for a wound. TOP: Hydrocolloid Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Negative-pressure wound therapy (NPWT) would be contraindicated in which of the
following? (Select all that apply.) a. Dehisced wounds b. Pressure ulcers c. Malignancies d. Necrotic tissue with eschar ANS: C, D
NPWT is a type of therapy that speeds wound healing by applying localized negative pressure to draw the edges of a wound together. It is commonly used for acute, chronic, traumatic, and dehisced wounds; pressure ulcers; and partial-thickness burns and as a bolster for skin grafts. Contraindications for NPWT for chronic wounds are exposed vital organs, inadequately debrided wounds, untreated osteomyelitis or sepsis near a wound, untreated coagulopathy, necrotic tissue with eschar, and malignancy within a wound.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Comprehension REF: Text reference: pp. 964-965 OBJ: Choose the correct dressing for a wound. TOP: Negative-Pressure Wound Therapy (NPWT) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. In caring for a patient who has an abdominal binder, it is expected that the nurse will do which
of the following? (Select all that apply.) a. Remove the binder and assess the skin and wound every 8 hours. b. Evaluate the patient’s ability to breathe deeply and cough effectively every 4 hours. c. Evaluate the patient’s pulmonary function every 8 hours. d. Remove the binder at least daily. ANS: A, B
Remove the binder and surgical dressing to assess the skin and wound characteristics every 8 hours to determine that the binder has not resulted in complications (e.g., rubbing or abrasion of skin, disruption of wound). Evaluate the patient’s ability to ventilate properly, including deep breathing and coughing, every 4 hours to help identify any impaired ventilation. A properly applied binder will have no impact on pulmonary function. DIF: Cognitive Level: Knowledge REF: Text reference: p. 973 OBJ: Apply an abdominal binder correctly. TOP: Abdominal Binder KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. The nurse is demonstrating a dressing change to a nursing student. What key safety features
should she emphasize duringNthe (SBe. leC ct O aM ll that apply.) Rpro Icess G? T U S N a. Knowing the type of wound b. Knowing the expected amount of drainage c. Knowing the patient’s blood type d. Knowing whether drainage tubes are present ANS: A, B, D
It is important to: 1. Know the cause or type of wound. Wounds caused by vascular insufficiency, diabetes mellitus, pressure, trauma, and surgery are all very different and must have an individualized treatment plan. Not knowing the cause of a wound can have serious negative effects if treatments that are contraindicated for certain types of wounds are used. 2. Know the expected amount and type of wound exudate or drainage. Wounds with large amounts of drainage require more frequent dressing changes or need an absorptive dressing. 3. Determine whether wound drainage tubes are present to prevent their accidental dislocation when you remove the old dressing. Knowing the patient’s blood type is not necessary for the purposes of changing the dressing unless you are expecting a bleeding complication, and then it would be important for the patient to have a blood type and screen done. DIF: Cognitive Level: Application REF: Text reference: pp. 945-946 OBJ: Assess a wound correctly. TOP: Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
COMPLETION 1. A
dressing comes in direct contact with the wound bed.
ANS:
primary A primary dressing comes in direct contact with the wound bed. DIF: Cognitive Level: Knowledge REF: Text reference: p. 943 OBJ: Discuss the purposes of dressings, bandages, and abdominal binders. TOP: Primary Dressing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
dressings cover or hold primary dressings in place.
2. ANS:
Secondary Secondary dressings cover or hold primary dressings in place. DIF: Cognitive Level: Knowledge REF: Text reference: p. 943 OBJ: Discuss the purposes of dressings, bandages, and abdominal binders. TOP: Secondary Dressing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3.
healing takes place when tissue is cleanly cut and the margins are reapproximated.
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ANS:
Primary Primary healing takes place when tissue is cleanly cut and the margins are reapproximated. DIF: Cognitive Level: Knowledge OBJ: Properly assess a wound. KEY: Nursing Process Step: Assessment
REF: Text reference: p. 943 TOP: Primary Healing MSC: NCLEX: Physiological Integrity
dressings are used for wounds that require debridement.
4. ANS:
Moist-to-dry Moist-to-dry dressings are used for wounds that require debridement. DIF: Cognitive Level: Knowledge REF: Text reference: p. 946 OBJ: Choose the correct dressing for a wound. TOP: Moist-to-Dry Dressing KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. A
is a clear, adherent, nonabsorptive, polyurethane moisture- and vapor-permeable dressing that often is used for protection over high-friction areas and over intravenous (IV) catheters. ANS:
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank transparent dressing A transparent dressing is a clear, adherent, nonabsorptive, polyurethane moisture- and vapor-permeable dressing. These dressings manage superficial, minimally draining wounds and often are used for protection over high-friction areas and over IV catheters. DIF: Cognitive Level: Knowledge REF: Text reference: p. 956 OBJ: Choose the correct dressing for a wound. TOP: Film Dressings KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6.
is a type of therapy that speeds wound healing by applying localized negative pressure to draw the edges of a wound together. ANS:
Negative-pressure wound therapy (NPWT) NPWT is a type of therapy that speeds wound healing by applying localized negative pressure to draw the edges of a wound together. DIF: Cognitive Level: Knowledge REF: Text reference: p. 964 OBJ: Choose the correct dressing for a wound. TOP: Negative-Pressure Wound Therapy (NPWT) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 40: Therapeutic Use of Heat and Cold MULTIPLE CHOICE 1. The nurse is using cryotherapy for a patient with a sprained ankle. She is explaining the
benefits to her patient. Which of the following statements made about the benefits of cryotherapy is correct? a. It causes vasodilatation. b. It provides local anesthesia. c. It increases nerve conduction velocity. d. It increases blood flow. ANS: B
The reduction in temperature creates positive physiological and biological effects such as pain relief, reduced muscle spasms, decreased nerve conduction velocity, and decreased inflammation edema caused by constriction of blood vessels. DIF: Cognitive Level: Application REF: Text reference: p. 977 OBJ: Identify the effects of heat and cold on the patient. TOP: Cryotherapy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 2. You are developing evidence-based guidelines for the OR. Of the following methods of
warming patients undergoing major surgery, which has been shown to be most beneficial? a. Placing warm blankets on the patient b. Using a circulating water device c. Using a forced air warming system d. None of the above
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ANS: B
A study examining the best method to prevent hypothermia during surgery tested a variety of warming devices. This study noted that circulating warming devices were most effective in maintaining body temperature control during surgery. DIF: Cognitive Level: Application REF: Text reference: p. 977 OBJ: Correctly apply heat and cold applications. TOP: Prevention of Intraoperative Hypothermia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. What procedure should the nurse follow when applying hot therapy to a patient with muscle
spasm in response to an acute injury? a. Apply the source for 20- to 30-minute periods. b. Allow the patient to adjust the temperature for comfort. c. Encourage the patient to move the application. d. Position the patient so that he or she cannot move away from the temperature source. ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank When areas are prone to muscle spasm in response to an acute injury, you apply heat for 20 to 30 minutes. Do not allow the patient to adjust temperature settings. It is common for the patient to adapt to a temperature extreme and then think that the temperature should be adjusted. Discourage the patient from moving an application. This may cause injury to an unprotected area of the body and may decrease the effectiveness of therapy. Never position the patient so that the patient cannot move away from the temperature source. DIF: Cognitive Level: Application REF: Text reference: p. 985 OBJ: Correctly apply heat and cold applications. TOP: Applying Heat KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. When reviewing the documentation of patients on the unit, a nurse determines that one of the
patients is at higher risk for injury from a local heat application to an extremity. Which condition poses this risk? a. Arthritis b. Renal calculi c. Pulmonary disease d. Peripheral neuropathy ANS: D
Patients with diabetes, victims of stroke or spinal cord injury, and patients with peripheral neuropathy and rheumatoid arthritis are particularly at risk for thermal injury. Arthritis, renal calculi, and pulmonary disease do not increase the patient’s risk for thermal injury. DIF: Cognitive Level: Analysis REF: Text reference: p. 978 OBJ: Correctly apply heat and cold applications. TOP: Risk for Heat Injury KEY: Nursing Process Step: AN ssU esR sm ntNGMTSB C. : C NC SeI OLMEX: Physiological Integrity 5. What procedure should the nurse follow when applying hot compresses to an open wound? a. Apply clean gloves. b. Cover all wound surfaces. c. Leave the application in place for 30 to 40 minutes. d. Apply an electrical heating unit directly over the compress. ANS: B
Pack gauze snugly against the wound. Be sure that all wound surfaces are covered by a warm compress. Packing of compresses prevents rapid cooling from underlying air currents. Sterile gloves are used to contact an open wound. You apply heat for 20 to 30 minutes every 2 hours. Cover the moist compress with dry sterile dressing and a bath towel. Apply an aquathermia pad or a waterproof heating pad over the towel. DIF: Cognitive Level: Application REF: Text reference: p. 981 OBJ: Correctly apply heat and cold applications. TOP: Sterile Warm Compress KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. A new staff nurse is assigned to the unit. The charge nurse evaluated that the new staff
member knows proper use of the aquathermia pad when the: a. temperature was set between 95° F and 98° F. b. water in the reservoir was allowed to run out.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank c. pad was covered with a towel or a pillowcase. d. patient was positioned to lie directly over the pad. ANS: C
Aquathermia pads and heating pads are common forms of dry heat therapy. Both are covered and applied directly to the skin’s surface; for this reason, the nurse needs to take extra precautions to prevent burns. In most health care institutions, the central supply department sets the temperature regulators to the recommended temperature, approximately 40.5° C to 43° C (105° F to 109.4° F). Never position the patient so that the patient is lying directly on the pad. This position prevents dissipation of heat and increases risk for burns. DIF: Cognitive Level: Application REF: Text reference: p. 984 OBJ: Correctly apply heat and cold applications. TOP: Aquathermia Pads KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. The nurse is removing a heating pad when she notices that the skin beneath the pad is pink
and warm to touch. How should the nurse respond? a. Keep the pad in place the next time by pinning it with a safety pin. b. Position the patient next time so that the patient is lying directly on the pad. c. Note the findings because this is a normal finding. d. Put the pad back on for an additional 20 to 30 minutes. ANS: C
Vasodilation from heat exposure increases blood flow to the affected part. Do not pin the wrap to the pad because this may cause a leak in the device. Never position the patient so that patient is lying directly on the pad. This position prevents dissipation of heat and increases risk for burns. After 20 to 30Nmin s (o r tim Rute I G Be.oCrder Med by the physician), remove the pad and U S N T O store. Continued exposure will result in burns. DIF: Cognitive Level: Analysis REF: Text reference: p. 984 OBJ: Correctly apply heat and cold applications. TOP: Heat Application KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. Assessment of a patient reveals that the area directly under the heating pad is slightly red.
How should the nurse respond? a. Continue the therapy. b. Apply a cold compress. c. Reduce the amount of heat. d. Remove the pad and reassess in 5 minutes. ANS: D
If skin is reddened and sensitive to touch, the symptoms indicate first-degree burn. Remove the pad and reassess in 5 to 10 minutes. DIF: Cognitive Level: Application REF: Text reference: p. 985 OBJ: Correctly apply heat and cold applications. TOP: Heat Application KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 9. For which patient should the nurse consider an application of cold? a. Menstrual cramping
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. Infected wound c. Fractured ankle d. Degenerative joint disease ANS: C
Cold exerts a profound physiological effect on the body, reducing inflammation caused by injury to the musculoskeletal system. Application of cold is not indicated for the patient with an infected wound, as it reduces blood flow to the area. Application of heat to reduce muscle tension and pain would be more appropriate for the patient with menstrual cramping. The effects of heat application would also be more beneficial for the patient with degenerative joint disease. DIF: Cognitive Level: Application REF: Text reference: p. 986 OBJ: Correctly apply heat and cold applications. TOP: Cold Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. If a patient is to receive a cold application for a sprain, he or she should have: a. a prolonged application time. b. the body part carefully aligned. c. a colder temperature applied. d. extra packing under the cooling device. ANS: B
Keep the injured part immobilized and in alignment. Movement can cause further injury to strains, sprains, or fractures. Cold should be applied directly over the injury. Extreme temperatures can cause tissue damage. After 15 to 20 minutes (or as ordered by the physician), apply clean gloveN s, reRmoI ve tG he cBo. mC presM s or pad, and gently dry off any moisture.
U S N T
O
DIF: Cognitive Level: Application REF: Text reference: p. 987 OBJ: Correctly apply heat and cold applications. TOP: Cold Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The nurse is applying an ice pack to the patient’s knee. She notices moisture on the outside of
the bag. How should the nurse respond? a. Discard the ice pack because it is leaking. b. Refill the ice pack to the top. c. Continue to apply the ice pack. d. Open the ice pack to allow air inside. ANS: C
Moisture may form on the outside of the bag if room temperature is warm. This does not indicate a leak. Fill the bag two-thirds full with small ice chips. The bag is easier to mold over a body part when it is not full. Excess air in the bag interferes with cold conduction. DIF: Cognitive Level: Application REF: Text reference: p. 988 OBJ: Correctly apply heat and cold applications. TOP: Cold Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 12. The nurse removes an ice pack and notices that the area underneath the ice pack is blue. What
action should the nurse take? a. Reapply the ice pack. b. Discontinue the use of ice packs. c. Refill the ice pack to the top. d. Reapply the ice pack without the wrapping. ANS: B
Do not reapply the ice pack to red or bluish areas; continual use of the ice pack makes ischemia worse. When filling an ice pack, fill the bag two-thirds full with small ice chips. The bag is easier to mold over a body part when it is not full. However, in this case, do not reapply the ice pack. DIF: Cognitive Level: Application REF: Text reference: p. 988 OBJ: Correctly apply heat and cold applications. TOP: Cold Therapy on Red or Bluish Areas KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. The patient is receiving cold therapy and complains to the nurse that the area being treated is
numb. How should the nurse respond? a. Continue application of therapy. b. Stop cold therapy. c. Apply more ice to the ice pack. d. Check for moisture on the ice pack, indicating leakage. ANS: B
Stop cold therapy when the pN atieR f a bMurning sensation or when skin begins to U ntScIomp NGlain TBs.oC O feel numb. DIF: Cognitive Level: Application REF: Text reference: p. 989 OBJ: Correctly apply heat and cold applications. TOP: Numbness KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. When applying a hypothermia or hyperthermia blanket, the nurse should: a. wrap the patient’s hands and feet. b. monitor the patient’s axillary temperature every hour. c. put the patient directly onto the heating or cooling blanket. d. place the patient onto the blanket and then start the heating or cooling process. ANS: A
Wrap the patient’s hands and feet in gauze. This reduces the risk for thermal injury to the body’s distal areas. Monitor the patient’s temperature and vital signs every 15 minutes during the first hour and after every 30 minutes of therapy thereafter. Cover the hypothermia or hyperthermia blanket with a thin sheet or bath blanket. Precool or prewarm the blanket, setting the pad temperature to the desired level. DIF: Cognitive Level: Application REF: Text reference: p. 991 OBJ: Explain common guidelines used to protect patients who receive heat and cold applications. TOP: The Hypothermia-Hyperthermia Blanket KEY: Nursing Process Step: Implementation
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity 15. If a patient on a hypothermia blanket starts to shiver, what action should the nurse take? a. Discontinue treatment. b. Place more padding around the patient. c. Discuss with the physician the use of a metabolic stimulant. d. Increase the temperature to a more comfortable range. ANS: D
Adjust the temperature to a more comfortable range and assess whether shivering decreases. If shivering continues, stop treatment and notify the physician. DIF: Cognitive Level: Application REF: Text reference: p. 992 OBJ: Correctly apply heat and cold applications. TOP: The Hypothermia-Hyperthermia Blanket KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. Which of the following would require using caution in applying cold therapy? a. Chronic pain b. Joint trauma c. Circulatory insufficiency d. Sprains ANS: C
Conditions that require caution with cold therapy include circulatory insufficiency, cold allergy, and advanced diabetes. Cold therapy is used immediately after direct trauma such as sprains, strains, fractures, or N muscle after superficial lacerations or puncture wounds; RSIspasms; GTB.C M U N O after minor burns; with chronic pain of arthritis and joint trauma; with delayed-onset muscle soreness; and with inflammation. DIF: Cognitive Level: Application REF: Text reference: p. 977 OBJ: Correctly apply heat and cold applications. TOP: Cold Therapy Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. You are explaining to the patient the reason why you are using dry heat. Which of the
following statements indicates understanding of the advantage of dry heat application for the patient? a. It maintains temperature changes longer. b. It reduces drying of the skin. c. It penetrates tissue layers deeply. d. It conforms better to body surfaces. ANS: A
Dry heat maintains temperature changes longer than moist heat treatments. Moist heat reduces the drying of skin and softens wound exudate. Moist heat also penetrates more deeply into tissue layers and conforms better to the body area being treated. DIF: Cognitive Level: Application REF: Text reference: p. 977 OBJ: Correctly apply heat and cold applications. TOP: Advantages of Dry Heat KEY: Nursing Process Step: Implementation
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. When the skin is exposed to warm or hot temperatures, which of the following occurs? (Select
all that apply.) a. Vasodilatation b. Vasoconstriction c. Perspiration d. Piloerection ANS: A, C
Systemically, when the skin is exposed to warm or hot temperatures, vasodilatation and perspiration occur to promote heat loss. As perspiration evaporates from the skin, cooling occurs. In cryotherapy, when the skin is exposed to cool or cold temperatures, the systemic response includes vasoconstriction and piloerection to conserve heat. Shivering occurs in response to cooler temperatures, producing heat through skeletal muscle contraction. DIF: Cognitive Level: Comprehension REF: Text reference: p. 976 OBJ: Identify the effects of heat and cold on the patient. TOP: The Hypothalamus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The use of cold (cryotherapy) to treat certain injuries is beneficial because of which of the
following effects? (Select all that apply.) a. Relief of pain b. Decreased muscle spasm c. Increased nerve conductiN on R I G B.C M U S N T O d. Decreased edema ANS: A, B, D
The reduction in temperature creates positive physiological and biological effects, such as pain relief, reduction in muscle spasm, decreased nerve conduction velocity, and decreased inflammation edema, caused by constriction of blood vessels. DIF: Cognitive Level: Comprehension REF: Text reference: p. 977 OBJ: Identify the effects of heat and cold on the patient. TOP: Cryotherapy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. Which of the following conditions are best treated with cold therapy? (Select all that apply.) a. Localized inflammatory responses b. Hemorrhage c. Muscle spasm d. Pain ANS: A, B, C, D
Cold therapy treats localized inflammatory responses that lead to edema, hemorrhage, muscle spasm, or pain. DIF: Cognitive Level: Comprehension REF: Text reference: p. 986 OBJ: Differentiate the types of injuries or conditions that benefit from heat and cold applications. TOP: Cold Application KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
4. Hot applications are used with caution in which of the following conditions? (Select all that
apply.) a. Pregnancy b. Laminectomy sites c. Malignancy d. Spinal cord injury ANS: A, B, C, D
Caution is used with heat therapy in cases of pregnancy, at laminectomy sites, with spinal cord injury, malignancy, or vascular insufficiency, and near the eyes or testes. DIF: Cognitive Level: Comprehension REF: Text reference: p. 977 OBJ: Correctly apply heat and cold applications. TOP: Heat Therapy Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. Advantages of moist heat over dry heat include which of the following? (Select all that
apply.) a. Reduces drying of skin b. Softens wound exudate c. Does not cause skin maceration d. Penetrates deeply into tissue layers ANS: A, B, D
Advantages of moist heat include reduced drying of skin and softening of wound exudate, conforming well to the body area being treated, penetration deeply into tissue layers, and decreased sweating and insenNsibR uid G ver, moist heat can cause maceration of the Ule SflI Nloss TB. H.oCwe OM skin with prolonged exposure. DIF: Cognitive Level: Comprehension REF: Text reference: p. 977 OBJ: Correctly apply heat and cold applications. TOP: Advantages of Moist Heat KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity COMPLETION 1.
exerts a profound physiological effect on the body, reducing inflammation caused by injury to the musculoskeletal system. ANS:
Cold Cold exerts a profound physiological effect on the body, reducing inflammation caused by injury to the musculoskeletal system. DIF: Cognitive Level: Knowledge REF: Text reference: p. 986 OBJ: Correctly apply heat and cold applications. TOP: Cold Application KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The
blanket raises, lowers, or maintains body temperature through conductive heat or cold transfer between the blanket and the patient.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS:
hypothermia-hyperthermia The hypothermia-hyperthermia blanket raises, lowers, or maintains body temperature through conductive heat or cold transfer between the blanket and the patient. DIF: Cognitive Level: Knowledge REF: Text reference: p. 989 OBJ: Correctly apply heat and cold applications. TOP: The Hypothermia-Hyperthermia Blanket KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Besides monitoring the controls on the hypothermia blanket every 30 minutes, the nurse will
need to assess the patient’s
every 4 hours.
ANS:
rectal temperature The patient’s core body temperature must be monitored by taking a rectal temperature reading every 4 hours to assess the effectiveness of the treatment and to indicate when it may be discontinued. DIF: Cognitive Level: Application REF: Text reference: p. 991 OBJ: Correctly apply heat and cold applications. TOP: The Hypothermia-Hyperthermia Blanket KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 41: Home Care Safety MULTIPLE CHOICE 1. Patients who require home care often experience physical alterations that require changes in
their home environment. In the case of older adults, what is the best way to make these changes? a. Make changes quickly to prevent problems. b. Make changes to limit the patient’s need to move around. c. Make changes to complement the patient’s strengths. d. Make changes regardless of the patient’s previous sense of personal space. ANS: C
In the case of older adults, the progressive physical changes of aging create the same type of need. Changes made should complement the patient’s remaining strengths. Making changes too rapidly without the patient’s consent will cause more problems than benefits. Appreciate the arrangement of the patient’s space within the home, and do not move things or suggest modifications without permission. You also need to respect the concept of personal space. DIF: Cognitive Level: Comprehension REF: Text reference: p. 995 OBJ: Identify interventions that modify the home environment for physical safety. TOP: Modifying Safety Risks KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 2. The nurse is assessing a patient for mobility problems that could lead to falls. She has the
patient perform a Timed Up and Go (TUG) test. The nurse uses this test to gauge: RSadIvNanGcT a. the patient’s ability to perN foUrm edBa. mC bO ulM ation maneuvers. b. whether the patient can walk 30 feet without fatiguing. c. whether the patient can tolerate the activity for longer than 30 seconds. d. how quickly the patient can perform the test. ANS: D
Conduct a TUG for basic mobility. Instruct the patient to rise from a standard chair, walk approximately 10 feet (3 meters), turn around, walk back to the chair, and sit in the chair again. Have patient perform the test 3 times, and then calculate the mean score. Time the patient while he or she performs the activity. The normal time required to finish the test is less than 13.5 seconds. Individuals who cannot complete the test probably have mobility problems, especially if the time is greater than 20 seconds. This is not a test for tolerance of activity. DIF: Cognitive Level: Application REF: Text reference: p. 997 OBJ: Perform a geriatric fall risk assessment. TOP: Timed Up and Go (TUG) Test KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 3. When teaching an elderly patient about safety in the bathroom, which of the following
recommendations should the nurse make? a. Use bath oils to maintain skin integrity and suppleness. b. Hang towels on grab bars for easy access. c. Make sure the bathroom door can be locked from the inside only for privacy. d. Shower using a shower stool and a handheld sprayer.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: D
A shower stool allows the patient to sit while showering. Use of bath oils makes the tub surface slippery and increases the risk for falls. Do not hang towels on grab bars. Some patients accidentally grab the towel instead of the bar when needing support. Be sure that bathroom doors can be unlocked from both sides of the door. Functional locks prevent the person from becoming trapped in the bathroom. DIF: Cognitive Level: Analysis REF: Text reference: p. 998 OBJ: Perform a home safety risk assessment. TOP: Home Safety KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 4. Which of the following is a safety measure that the patient should implement in the home
environment? a. Using fluorescent lighting b. Wearing extra clothing for padding c. Obtaining a large fire extinguisher d. Installing additional towel bars for support in the shower ANS: B
Have the patient use padding or types of clothing that will cushion bony prominences, especially high-risk bony prominences (e.g., hips). Specially designed hip protectors are available; they help to absorb the impact of a falling body. Provide a direct light source in areas where the patient reads, cooks, uses tools, or conducts hobby work. Avoid fluorescent lighting because it creates excessive glare. Have the patient select a fire extinguisher that is easy to handle and manipulate. Have a grab bar installed into wall studs at the tub, toilet, and/or shower. Towel bars are not designed to support the weight of the patient. DIF: Cognitive Level: ApplicN atiU onRSINGRT EB F:.C TeO xtMreference: p. 1001 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Padded Clothing KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. Of what should the nurse remind the patient when discussing safety measures for the home
environment? a. Set the hot water heater to only 160° F. b. Turn on the cold water faucet first. c. Use small throw rugs on slippery wood floors. d. Put high-wattage bulbs into all lamps. ANS: B
Instruct the patient to always turn cold water on first to prevent direct exposure to hot water. Have the setting on the hot water heater adjusted to 120° F or lower. Secure all carpeting, mats, and tile; place nonskid backing under small rugs and door mats. Have the patient check light bulb wattage in all fixtures; this ensures that proper wattage is being used. DIF: Cognitive Level: Application REF: Text reference: p. 1002 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Preventing Scalding KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 6. The patient has been brought to the emergency department by a family member, who states
that she just “doesn’t know what to do.” The patient often forgets where he is and refuses to bathe or change clothes. He will put things on the stove and forget that he has something cooking. She is obviously concerned for her loved one’s safety. The nurse is likely to interpret these symptoms as signs of: a. depression. b. amnesia. c. aphasia. d. Alzheimer’s disease. ANS: D
Alzheimer’s disease is a form of dementia that causes problems with memory, thinking, or behavior. There is also a risk for wandering, where patients repeatedly try to carry out tasks or leave the place of residence. Depression is a chronic, insidious emotional disorder characterized by feelings of sadness, melancholy, dejection, and worthlessness that are inappropriate and out of proportion to reality. Amnesia is loss of memory. This is only one symptom of Alzheimer’s disease. The patient has several symptoms. Aphasia is the loss of language skills. This is only one symptom of Alzheimer’s disease, and it is not one that the patient’s family member has identified. DIF: Cognitive Level: Analysis REF: Text reference: p. 1004 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Alzheimer’s Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. While performing a home visit with an elderly patient, the nurse notices that the patient’s
dress is less tidy than in previous visits, and she finds an open orange juice container in the RS IN M paper towels in the refrigerator. How pantry cabinet instead of the N reU frig erat orGaT ndB.C a rolO l of should the nurse respond? a. Begin rearranging the patient’s storage, and show her how it needs to be done. b. Raise her voice, and tell the patient that this is not acceptable. c. Complete a Mini-Mental State Examination (MMSE) or Short Geriatric Depression Scale (GDS). d. Realize that elderly patients do things differently. ANS: C
Behavioral changes associated with cognitive dysfunction are evident in a disorderly home and inappropriate placement of objects (e.g., carton of orange juice placed inside kitchen cabinet instead of in refrigerator). If you suspect a cognitive or mental status change, complete an MMSE (e.g., Folstein’s examination) for dementia and/or complete a short GDS for depression. Speak clearly and in a normal tone of voice. DIF: Cognitive Level: Application REF: Text reference: p. 1005 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Cognitive Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 8. A patient with a cognitive deficit becomes agitated and upset about not being able to
remember daily activities. How should the nurse respond to this agitation? a. Tell the patient not to worry about it. b. Provide an easy-to-follow calendar and reinforce the information.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank c. Explain that becoming upset is not going to help the situation. d. Remind the patient that now is the time to rest and relax. ANS: B
If the patient has difficulty remembering when to perform tasks (e.g., paying bills, taking medicines), help the patient to create a list, or post reminder notes in a conspicuous location (e.g., bulletin board, front of refrigerator), provide a medication container organized by days of the week, and recommend a wristwatch with alarm to signal medication administration times. Memory function in older adults tends to be preserved for relevant, well-learned material. Lists and organizers will help the patient cope with memory loss and safely perform activities. Telling the patient not to worry negates the patient’s feelings. Reminding the patient that it is his or her “time to rest and relax” may be seen as a dismissal. False reassurance is not helpful to the patient. Focus on the patient’s abilities, and modify approaches used to perform daily activities. DIF: Cognitive Level: Application REF: Text reference: p. 1007 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Cognitive Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. When communicating with a patient with a cognitive deficit, what is the best way for the
nurse to respond? a. “You managed all of your medications very well today.” b. “Your family should really take over the cooking. It’s too hard for you to do.” c. “I don’t see how you will be able to shop for yourself anymore. Someone will have to do it for you.” N R I G B.C M d. “This schedule will be too U diffiS cultNforTyou to O remember. I better write it all down.” ANS: A
Focus on the patient’s abilities rather than disabilities; this retains the patient’s autonomy and sense of self-worth. DIF: Cognitive Level: Application REF: Text reference: p. 1007 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Patient Autonomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 10. The nurse is visiting an elderly patient who lives with his wife and daughter. He takes several
daily medications, including antihypertensives, antiarrhythmics, diuretics, and pain medication. The patient’s wife states that he takes all of the pills in the morning and some at night. The nurse should examine the pills and suggest which of the following? a. Take the antiarrhythmics and antihypertensives together in the morning to prevent hypotension during sleep. b. Take the diuretics at bedtime. c. Increase the different types of pain medication to prevent addiction to one. d. Administer at bedtime medications that are likely to cause confusion. ANS: D
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Administer at bedtime medications that are likely to cause confusion to reduce the risk for confusion during waking hours, which contributes to disorientation and the risk for falling. However, do not recommend this if the patient has nocturia. Space antihypertensives and antiarrhythmics at different times to minimize side effects. Have diuretics taken early in the day and not at night, so that the diuretic effect occurs during the day, while the patient is awake. Reduce the number of pain medications used when possible. Drugs create sedative effects, increasing the risk for falls. DIF: Cognitive Level: Application REF: Text reference: p. 1007 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Medication Changes KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 11. Which assistive device would most benefit a patient with a neuromuscular weakness? a. Large-print labels b. A syringe with a magnifier c. Screw-top medication containers d. Color-coded tops for medications ANS: C
For patients with a weakened grasp or pain in the hands and fingers, have the local pharmacist place medications in a screw-top container. Larger labels and syringe magnifiers are used for patients with visual alterations. Color-coding systems are designed for patients taking multiple medications. DIF: Cognitive Level: Application REF: Text reference: p. 1011 OBJ: Recommend strategies tN o en sure UR SIsafe NGdru TBg .adCmin OMistration within the home. TOP: Medication Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 12. The patient is on neutral protamine Hagedorn (NPH) insulin and regular insulin at home. How
should the nurse teach the patient and the patient’s caregiver to store the insulin? a. In the refrigerator and removed only for administration b. In a warm place such as in a cabinet above the stove c. In the dairy bin of the refrigerator with the cheese and eggs d. At room temperature for up to 30 days ANS: D
Insulin may be stored in the refrigerator, but this is not necessary. Patients can store insulin at room temperature for up to 30 days without losing potency as per the manufacturer’s guidelines. Insulin should be kept in a cool place and away from very warm temperatures. If insulin is stored in the refrigerator, be sure that the drug is in a bin or container away from food. DIF: Cognitive Level: Application REF: Text reference: p. 1011 OBJ: Recommend strategies to ensure safe drug administration within the home. TOP: Insulin Storage KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 13. When teaching about medication use in the home, what instructions should the nurse provide
to the patient?
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
Always keep insulin in the refrigerator. Put used needles in double paper bags. Put all of the medication to be taken in one bottle. Discard unused or expired medication in a bag containing coffee grounds.
ANS: D
Discard unused portions of drugs or outdated drugs in a bag containing coffee grounds or kitty litter. This ensures that no one in the household uses a drug not prescribed for their use or that will be ineffective pharmacologically. Insulin may be stored in the refrigerator, but this is not necessary. Discard sharps in puncture-resistant sharps containers or in a 2-liter soda bottle with a cap. Do not place different medicines in the same container. DIF: Cognitive Level: Application REF: Text reference: p. 1012 OBJ: Recommend strategies to ensure safe drug administration within the home. TOP: Disposal of Outdated Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Common causes of falls in older patients include which of the following? (Select all that
apply.) a. Gait disturbances b. Muscle weakness c. Visual impairments d. Environmental hazards
N R I G B.C M Environmental hazards, gait diU sturS banN ces,T muscleOweakness, and visual impairments are some ANS: A, B, C, D
of the causes of falls in older patients. Polypharmacy adds to the risk. DIF: Cognitive Level: Comprehension REF: Text reference: p. 994 OBJ: Describe factors within a home environment that create risks for patient injury. TOP: Causes of Falls KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. In determining the causes of falls or other injuries within the home, the nurse should assess for
which of the following? (Select all that apply.) a. Symptoms at time of fall and history of previous falls b. Location of fall and activity at the time of the fall c. Time of fall d. Trauma post fall ANS: A, B, C, D
Key symptoms are helpful in identifying causes of falls. Onset, location, and activity associated with falls provide additional details on causative factors and how to prevent future falls. Determine whether the patient has had a history of falls or other injuries within the home. Be specific in your assessment. Use the mnemonic SPLATT: Symptoms at time of fall, Previous fall, Location of fall, Activity at time of fall, Time of fall, and Trauma post fall. DIF: Cognitive Level: Analysis REF: Text reference: p. 996 OBJ: Identify interventions that modify the home environment for physical safety.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank TOP: SPLATT Mnemonic KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 3. The nurse is assessing the home of an elderly patient for safety issues. Which of the following
would reassure the nurse? (Select all that apply.) a. Cleaning the stove top b. Putting a shower chair in the bathroom c. Installing adequate lighting in all living areas d. Placing emergency numbers close to the telephone ANS: A, B, C, D
The kitchen is one of the most hazard-oriented rooms in a home and poses serious hazards for fire. Grease is highly flammable. Stove tops and ovens should be kept clean and grease free. A shower stool allows patients to sit while showering. Adequate lighting helps persons to see any barriers or uneven walking surfaces. Emergency numbers near the phone are important for all home care patients. DIF: Cognitive Level: Analysis REF: Text reference: p. 998 OBJ: Perform a home safety risk assessment. TOP: Home Safety KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 4. When a caregiver is communicating with a patient, which of the following may facilitate
communication? (Select all that apply.) a. Face the patient who has a hearing impairment. b. Avoid eye contact. c. Use simple words. d. Be aware of nonverbal gestures. ANS: A, C, D
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Instruct the caregiver on how to use simple and direct communication: Sit or stand in front of the patient in full view. This promotes reception of verbal and nonverbal messages. Face the patient who has a hearing impairment while speaking so that the patient can see the speaker’s lips. Use a calm and relaxed approach. Use eye contact and touch to help reinforce messages. Speak slowly, in simple words and short sentences, to enhance understanding of messages. Use nonverbal gestures that complement verbal messages. DIF: Cognitive Level: Application REF: Text reference: p. 1007 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1.
is a generalized impairment of intellectual functioning, with the most common form being Alzheimer’s disease. ANS:
Dementia Dementia is a generalized impairment of intellectual functioning, with the most common form being Alzheimer’s disease.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Knowledge REF: Text reference: p. 1004 OBJ: Identify patients at risk for safety problems and possible accidents in the home. TOP: Dementia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Activities of daily living (ADLs) include the patient’s ability to bathe, dress, go to the toilet,
transfer, maintain continence, and feed himself; include the ability to use a telephone, prepare meals, travel, do housework, take medication, and shop. ANS:
independent activities of daily living (IADLs) ADLs include the patient’s ability to bathe, dress, go to the toilet, transfer, maintain continence, and feed himself; IADLs include the ability to use a telephone, prepare meals, travel, do housework, take medication, and shop. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1004 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: ADLs/IADLs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Dementia is characterized by a gradual, progressive, irreversible
dysfunction.
ANS:
cerebral Dementia is characterized by a gradual, progressive, irreversible cerebral dysfunction. DIF: Cognitive Level: KnowlN edge F:.C Text URSINGRE TB OMreference: p. 1004 OBJ: Identify interventions used to reduce safety risks for patients with sensory, cognitive, and mental status alterations. TOP: Dementia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 42: Home Care Teaching MULTIPLE CHOICE 1. Of the following types of thermometers available, which is not recommended for home use? a. Digital b. Tympanic c. Mercury d. Disposable single-use ANS: C
If a mercury thermometer breaks, and it is not disposed of properly, the mercury gets into the air, posing a major health risk in the home (EPA, 2007). Educate patients about the environmental hazards associated with mercury in the home, and encourage patients to purchase mercury-free thermometers. DIF: Cognitive Level: Analysis REF: Text reference: p. 1017 OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Mercury Thermometers KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 2. Which of the following is essential in teaching the patient how to use a thermometer? a. Reading a digital thermometer b. Shaking down the thermometer before use c. Using the axillary thermometer d. Selecting the most appropriate thermometer ANS: D
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Help a patient choose the most appropriate thermometer to use in the home based on the patient’s dexterity, vision, and financial resources. For example, a patient with visual changes from glaucoma or retinopathy is able to read more easily a thermometer with a large digital display. The need for an oral, rectal, or axillary temperature depends on the patient’s age and health status. DIF: Cognitive Level: Analysis REF: Text reference: p. 1017 OBJ: Identify factors that influence patients’ abilities to learn and care for themselves at home. TOP: Choosing the Right Thermometer KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 3. What should the nurse first assess when preparing to teach a patient and/or family member
how to read a thermometer? a. Patient’s actual temperature b. Patient’s ability to manipulate the thermometer c. Family member’s temperature d. Patient’s ability to take a pulse and respiratory rate as well ANS: B
Assess the patient’s ability to manipulate and read the thermometer. Physical restrictions in handling or reading the thermometer prevent patients from being able to read the thermometer and often require instruction of a family member or significant other instead of the patient.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Analysis REF: Text reference: p. 1017 OBJ: Identify factors that influence patients’ abilities to learn and care for themselves at home. TOP: Choosing the Right Thermometer KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 4. Which of the following is an appropriate step when teaching temperature monitoring in the
home? a. Suggest aspirin to decrease fevers. b. Recommend using only tympanic membrane sensors. c. Encourage the use of alcohol rubs to reduce fevers. d. Demonstrate the technique and have the client/caregiver perform it. ANS: D
Demonstration is the best technique for teaching psychomotor skills. It allows for correction of errors in technique as they occur and for discussion of potential consequences of errors. Provide rationale for steps to the patient or caregiver. Use caution in recommending aspirin or any other over-the-counter drug or antipyretic medicine for patients whose conditions contraindicate their use. The type of thermometer needed is determined on the basis of the patient’s age and health status. Instruct the patient or caregiver to never use sponging with isopropyl alcohol to lower fever because of the neurotoxic effects that have been reported. DIF: Cognitive Level: Application REF: Text reference: p. 1017 OBJ: Implement and evaluate appropriate learning strategies that support clients’ ability to care for themselves in the home. TOP: Teaching How to Use the Thermometer KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. What should the nurse instruN ct thR e paItienGt toBd. oC wheMn teaching the patient how to take a
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O
temperature? a. Wait at least 30 minutes after smoking or ingesting hot or cold foods. b. Take the temperature immediately upon seeing chills or shivering. c. Wear sterile rubber gloves when taking a rectal temperature. d. Lubricate an oral thermometer with water-soluble lubricant only. ANS: A
Instruct the patient to take the temperature at least 30 minutes after smoking or ingesting hot or cold liquids or foods. This improves the accuracy of temperature readings. To ensure accuracy, teach the patient to take the temperature after chills or shivering subsides. If taking rectal temperature, instruct the patient to lubricate the thermometer tip with water-soluble lubricant, to wear clean, disposable gloves, and to use only a rectal thermometer. Lubrication normally is not needed when one is taking an oral temperature. DIF: Cognitive Level: Application REF: Text reference: p. 1018 OBJ: Implement and evaluate appropriate learning strategies that support clients’ ability to care for themselves in the home. TOP: Teaching How to Use the Thermometer KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 6. What should the nurse instruct the parents to do when teaching them about temperature
monitoring for a child? a. Use only a glass mercury thermometer. b. Take the temperature after shivering subsides.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank c. Avoid the use of tepid water sponging for fever. d. Take the temperature, but adjust the reading if the child has eaten a popsicle. ANS: B
Teach the patient to take the temperature after chills or shivering subsides to obtain an accurate temperature. Nurses in home care need to encourage their patients to purchase mercury-free thermometers. Applying cool, moist compresses to the skin is a common therapy for temperature reduction that is safe to perform at home. Wait 30 minutes to take the temperature after the patient has ingested a popsicle. DIF: Cognitive Level: Application REF: Text reference: p. 1018 OBJ: Implement and evaluate appropriate learning strategies that support clients’ ability to care for themselves in the home. TOP: Utilizing the Thermometer KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 7. In teaching the patient how to take his own blood pressure, which of the following is true? a. Blood pressure cuffs that are too small will give a falsely low reading. b. Blood pressure cuffs that are too large will give a falsely high reading. c. Electronic blood pressure cuffs are just as accurate as other methods. d. The cuff should be placed directly over the skin and not over clothing. ANS: D
Have clients place the cuff directly on the skin, not over clothing. Blood pressure cuffs that are too small tend to overestimate blood pressure, and cuffs that are too large tend to underestimate blood pressure. Although electronic monitors are easier to use, their accuracy is still a focus of debate.
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U S N REF: T Text O reference: p. 1020 DIF: Cognitive Level: Application OBJ: Choose appropriate teaching strategies to use in the home setting. TOP: Blood Pressure Devices. KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 8. The patient is taking Synthroid (a thyroid medication) for hypothyroidism. What should the
nurse instruct the patient to do when teaching the patient how to assess her own blood pressure and pulse? a. Withhold the medication if her blood pressure is above the normal range or if her pulse is over 100 beats per minute. b. Withhold the medication if her blood pressure is below the normal range or if her pulse is less than 60 beats per minute. c. Never withhold her medication. Have the patient take it and notify the physician at the next office visit. d. Withhold her medication only if both her blood pressure and pulse rate are too high. ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Instruct patients taking thyroid medications to withhold medications when blood pressure is above the normal range or when pulse is above 100 beats per minute. Confirm with the prescriber specific guidelines for blood pressure and pulse, document information in the home care record, and provide clear, written instructions for the patient. Beta blockers (e.g., propranolol), calcium channel blockers (e.g., verapamil hydrochloride), or cardiac glycosides (e.g., digoxin) often are withheld if blood pressure is below normal range and/or pulse is below 60 beats per minute. DIF: Cognitive Level: Analysis REF: Text reference: p. 1024 OBJ: Choose appropriate teaching strategies to use in the home setting. TOP: Teaching Considerations KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 9. In teaching the patient how to perform intermittent self-catheterization, the nurse instructs
which of the following? a. Only strict aseptic technique should be used. b. All hospitals use strict aseptic technique. c. Clean intermittent self-catheterization increases the chance for infection. d. Clean intermittent self-catheterization is a safe and effective method. ANS: D
Clean intermittent self-catheterization (CISC) is a safe and effective way to empty the bladder. Current practice supports CISC for use in the home to provide a means to completely empty the bladder, prevent urinary tract infection, and prevent further bladder and kidney damage. Today, some hospital policies recommend sterile technique; others recommend clean technique. DIF: Cognitive Level: ApplicN atiU onRSINGRT EB F:.C TeO xtMreference: p. 1024 OBJ: Choose appropriate teaching strategies to use in the home setting. TOP: Clean Intermittent Catheterization KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 10. When teaching the patient and family about CISC, why is it important for the nurse to teach
about the signs and symptoms of complications? a. Although rare, complications are always severe. b. It is part of the process; complications almost never occur. c. Urinary complications are common with CISC. d. The only major complication is infection. ANS: C
Urinary complications are common in patients who use CISC. Verbalization of signs and symptoms of complications helps patients identify potential problems early and seek appropriate care. Signs and symptoms of complications of CISC include urinary tract infection (UTI) and urethral trauma and bleeding. DIF: Cognitive Level: Application REF: Text reference: p. 1025 OBJ: Choose appropriate teaching strategies to use in the home setting. TOP: Clean Intermittent Catheterization KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 11. When being taught CISC, at what interval should the patient be taught to replace the catheter? a. With each use
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. Daily c. Weekly d. Monthly ANS: D
Teach the patient to replace the catheter every 2 to 4 weeks, or when it becomes cracked or brittle, has any buildup of sediment, or loses its form. DIF: Cognitive Level: Comprehension REF: Text reference: p. 1026 OBJ: Choose appropriate teaching strategies to use in the home setting. TOP: Replacing the Catheter KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. What is the principal difference in tracheostomy care between care given in the acute care
setting and care given in the home care environment? a. In the acute care setting, the inner cannula is cleaned. b. In the home care setting, dressings are not necessary. c. In the acute care setting, hydrogen peroxide is used for cleaning. d. In the home care setting, the procedure may be done with clean technique. ANS: D
The indications for performing tracheostomy care and suctioning in the home are similar to those for tracheostomy care and suctioning in the hospital, except for one key variable: the use of medical asepsis or clean technique. In the hospital, principles of surgical asepsis are used because the patient is more susceptible to infection, and because the hospital contains more virulent or pathogenic microorganisms than are usually present in the home setting. In the home setting, most patients use clean technique. Inner cannula care is performed both at home and in the acute care setting. N The Rinn IerNcGann Bul.a CisOavMailable in both disposable and U S T nondisposable forms. Fresh trach dressings protect the skin around the stoma from pressure breakdown and collect secretions; they are necessary in both acute care and home care settings. Hydrogen peroxide may be used in both home care and acute care settings. DIF: Cognitive Level: Comprehension REF: Text reference: p. 1034 OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Differences in Trach Care Between Home Care and Acute Care Settings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. What is an expected outcome after tracheostomy care is successfully performed? a. A stoma site that is hard to the touch b. An inner cannula that is free of secretions c. Copious secretions obtained from suctioning d. Bloody secretions that have been suctioned ANS: B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank A stoma site that is clean and free of infection and transesophageal fistula and an inner cannula that is free of secretions indicate that tracheostomy care is successful. If the stoma site is reddened or hard, with or without drainage, evaluate the cleaning regimen for continued use of clean technique, and increase tracheostomy care frequency. This is an unexpected outcome. Copious colored secretions present around the stoma or when the patient is suctioned are an unexpected outcome. Bloody secretions are an unexpected outcome and require evaluation of suctioning technique and frequency and size of the catheter. DIF: Cognitive Level: Application REF: Text reference: p. 1035 OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Unexpected and Expected Outcomes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. The nurse is teaching the patient and family how to perform tracheal suctioning. What does
proper technique include? a. Teaching how to instill normal saline before suctioning b. Suctioning the nasal and oral pharynx before the trachea c. Encouraging daily brushing of the teeth and oral hygiene d. Having the patient take two to three deep breaths after the procedure ANS: D
At the conclusion of the procedure, have the patient take two to three deep breaths, and determine whether symptoms that necessitated suctioning are no longer present. Deep breathing reduces oxygen loss and prevents hypoxia. Expect the patient’s respiratory status to improve after suctioning. Use of normal saline adversely affects arterial and global tissue oxygenation and dislodges bacterial colonies; therefore, this can contribute to lower airway contamination. After suctionN inU gR thS eI paN tiG enT t,B te. acChOhM im to suction the nasal and oral pharynx, and give mouth care. Encourage the patient or family member to brush the teeth with a small, soft toothbrush 2 times a day, and to use mouth moisturizer and moisturize the lips every 2 to 4 hours. DIF: Cognitive Level: Application REF: Text reference: p. 1036 OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 15. When teaching the patient about performing trach care, which of the following is an
acceptable technique? a. Remove the old ties before applying the new. b. Keep two trach tubes of the same size at the bedside. c. Place the new trach tie, then remove the old tie. d. Dispose of all old supplies and replace with new. ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank During tracheostomy care, the patient is at risk for the trach tube coming out. Never remove the old tracheostomy tube ties until the new ties have been secured properly. Keep two tracheostomy tubes, one the same size as the patient’s and one a size smaller, at the patient’s bedside, so you can insert a new tube if the tube comes out. Clean reusable supplies in warm, soapy water. Rinse thoroughly, and dry between two layers of clean paper towels. Store supplies in a loosely closed clear plastic bag. DIF: Cognitive Level: Application REF: Text reference: p. 1036 OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Trach Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 16. What is an appropriate technique to use when teaching an older patient about self-medication
in the home? a. Speak very loudly. b. Teach the family separately. c. Provide frequent pauses. d. Provide fewer but longer teaching sessions. ANS: C
Provide frequent pauses so the patient can ask questions and express understanding of content. Use short sentences and speak in a slow, low-pitched voice. Effective teaching strategies for older adults may include involvement of a family member or caregiver. Provide frequent, short teaching sessions. DIF: Cognitive Level: Application REF: Text reference: p. 1041 OBJ: Implement and evaluateN app ropr iate lear nin.gCstra UR SI NG TB OMtegies that support clients’ ability to care for themselves in the home. TOP: Teaching Older Patients KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 17. The patient’s caregiver is checking the patient’s nasogastric (NG) tube for gastric residual
before proceeding with the patient’s next feeding. The patient aspirates 250 mL of residual for the second hour in a row. The caregiver held the tube feeding within the last hour. What should the caregiver do now? a. Hold the feeding again. b. Contact the health care provider. c. Proceed with the feeding. d. Give half of the feeding and see how the patient tolerates it. ANS: B
If aspirates remain at more than 200 mL after an hour, instruct the patient or caregiver to contact the home care nurse or health care provider. DIF: Cognitive Level: Application REF: Text reference: p. 1045 OBJ: Implement and evaluate appropriate learning strategies that support positive patient outcomes. TOP: Gastric Residual KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. What does the nurse teach the patient and caregiver to do when setting up and changing
administration sets for continuous tube feedings to preserve medical asepsis? a. Add formula to formula already hung to prevent waste.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. Store unused formula at room temperature to prevent spasm. c. Hang only enough formula that will be infused in a 4- to 6-hour period. d. Change the administration set every 48 hours. ANS: C
Limit the amount of formula “hung” at one time to an amount that can be infused in a 4- to 6-hour period (less time in warmer weather to minimize risk for microorganism contamination). Do not add formula to a hanging bag. Using refrigeration and limiting “hang” time reduce microorganisms. Changing administration sets every 24 hours reduces microorganism growth. DIF: Cognitive Level: Application REF: Text reference: p. 1045 OBJ: Implement and evaluate appropriate learning strategies that support clients’ ability to care for themselves in the home. TOP: Asepsis With Tube Feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 19. Information that should be provided to the caregiver of a patient with a nasogastric (NG) tube
includes: a. keeping the head of the bed lowered for feedings. b. keeping unused formula at room temperature. c. aspirating every 4 hours when receiving continuous drip feedings. d. providing half of the feeding if the residual exceeds 250 mL. ANS: C
Patients and caregivers need to document intake and output (I&O), daily weights, amount of gastric fluid aspirated before each feeding (or every 4 hours if receiving continuous feeding), date and time of feedings, amNounRt anId tyGpe B ula, any additives, and date and time U S N Tof.foCrm OM administration sets are changed. Instruct the patient or caregiver that the patient should sit up in a chair or have the head of the bed elevated at least 30 to 45 degrees while receiving feedings or medications, or when the tube is flushed. Refrigerate unused formula. If gastric aspirates are greater than or equal to 200 mL, instruct the patient or caregiver to return gastric contents and delay tube feeding for 1 hour. If aspirates remain greater than or equal to 200 mL after an hour, instruct the patient or caregiver to contact the home health nurse or health care provider. DIF: Cognitive Level: Application REF: Text reference: p. 1046 OBJ: Implement and evaluate appropriate learning strategies that support clients’ ability to care for themselves in the home. TOP: Management of Tube Feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 20. A patient is discharged and is sent home with enteral feedings. What instructions should the
nurse give to the caregiver? a. Flush the tube out after administering medications. b. Keep the tube loose to allow for patient movement. c. Use sterile technique when preparing and administering feedings. d. Hang enough formula each time to cover 8 to 12 hours of feeding. ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Discuss flushing of the tube after administration of feedings or medications to prevent clogging. Discuss measures to stabilize the feeding tube in patients with abdominal tubes and to protect skin integrity. Perform hand hygiene to reduce the transfer of microorganisms. Sterile technique is not needed. Limiting the amount of formula “hung” at one time to an amount that can be infused in a 4- to 6-hour period will help limit bacterial growth. DIF: Cognitive Level: Application REF: Text reference: p. 1045 OBJ: Implement and evaluate appropriate learning strategies that support clients’ ability to care for themselves in the home. TOP: Management of Tube Feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 21. What instructions should the nurse provide when teaching the patient and the patient’s
caregiver how to administer parenteral nutrition (PN)? a. PN solution should be kept refrigerated until time of administration. b. Remixing separated mixture components by shaking the bag is common. c. PN is compatible with most intravenous (IV) medications. d. Blood glucose monitoring will be necessary. ANS: D
PN increases blood glucose levels, which negatively affects patient outcomes. Frequent monitoring of glucose helps the caregiver to detect problems early. Expect testing frequency to decrease as the patient’s condition and response to PN stabilize. Suggest taking PN solution out of the refrigerator for 30 to 60 minutes before scheduled infusion time. Chilled solution often causes discomfort; allowing the solution to warm enhances comfort during infusion. If a precipitate appears, if components of the mixture are separated, or if the color changes, explain that the solution needs to be discarded. Explain that PN is incompatible with most BN.tChO medications; do not add medN icU atR ioS nsItoNtG hT eP atM are not ordered to be added. DIF: Cognitive Level: Application REF: Text reference: p. 1048 OBJ: Implement and evaluate appropriate learning strategies that support clients’ ability to care for themselves in the home. TOP: Glucose Monitoring With PN KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Expected outcomes for patients who are being taught how to use a thermometer include which
of the following? (Select all that apply.) a. Ability to correctly measure temperature b. Ability to properly clean and store the thermometer c. Knowledge of normal temperature ranges d. Knowledge of signs and symptoms of fever ANS: A, B, C, D
Expected outcomes after completion of the procedure include that the patient is able to correctly measure temperature, demonstrate proper cleaning and storage of equipment, and state normal temperature range and factors that affect temperature, signs and symptoms of fever and hypothermia, and measures to take with abnormal temperatures. DIF: Cognitive Level: Analysis
REF: Text reference: p. 1018
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Implement and evaluate appropriate learning strategies that support clients’ ability to care for themselves in the home. TOP: Expected Outcomes of Teaching How to Use the Thermometer KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 2. Which of the following are signs of hyperthermia? (Select all that apply.) a. Dry, warm, flushed skin b. Chills and piloerection c. Uncontrolled shivering d. Loss of memory ANS: A, B
Symptoms of fever: warm, dry, flushed skin; feeling warm; chills; piloerection; malaise; and restlessness. The patient needs to recognize the onset of fever in self or family member for early detection and intervention. Symptoms of hypothermia: cool skin, uncontrolled shivering, loss of memory, and signs of poor judgment. DIF: Cognitive Level: Analysis REF: Text reference: p. 1018 OBJ: Implement and evaluate appropriate learning strategies that support clients’ ability to care for themselves in the home. TOP: Signs of Hyperthermia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse is teaching the patient about the signs of hypothermia. She teaches that signs of
hypothermia include which of the following? (Select all that apply.) a. Piloerection b. Restlessness c. Cool skin d. Uncontrolled shivering N R I G B.C M U S N T O ANS: C, D
Symptoms of hypothermia: cool skin, uncontrolled shivering, loss of memory, and signs of poor judgment. Symptoms of fever: warm, dry, flushed skin; feeling warm; chills; piloerection; malaise; and restlessness. The patient needs to recognize onset of fever in self or family member for early detection and intervention. DIF: Cognitive Level: Analysis REF: Text reference: p. 1018 OBJ: Implement and evaluate appropriate learning strategies that support clients’ ability to care for themselves in the home. TOP: Signs of Hypothermia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. In teaching the patient how to take his own blood pressure, the nurse instructs the patient to
avoid which of the following 30 minutes before taking blood pressure (BP)? (Select all that apply.) a. Exercise b. Caffeine c. Smoking d. Resting ANS: A, B, C
Encourage the patient to avoid exercise, caffeine, and smoking for 30 minutes before assessment to avoid an inaccurate reading. These factors cause elevations in BP and pulse.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Have the patient rest at least 5 minutes before measurement to reduce anxiety that can falsely elevate readings. DIF: Cognitive Level: Comprehension REF: Text reference: p. 1022 OBJ: Choose appropriate teaching strategies to use in the home setting. TOP: Factors That Affect Blood Pressure KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. In teaching the patient the best sites for assessing BP, which of the following should the
patient be taught to avoid? (Select all that apply.) a. Sites with intravenous catheters b. Arms with arteriovenous shunts c. Arms on the side of mastectomy d. The left arm after a heart attack ANS: A, B, C
The patient should be taught to avoid applying the cuff to an arm with an IV catheter with or without fluids infusing, an arteriovenous shunt, breast or axillary surgery, trauma, inflammation, disease, or a cast or bulky bandage. Application of pressure from an inflated bladder temporarily impairs blood flow and compromises circulation in the extremity that already has impaired circulation. There is no restriction on the BP cuff site in a heart attack patient unless he or she has one of the above conditions. DIF: Cognitive Level: Analysis REF: Text reference: p. 1022 OBJ: Choose appropriate teaching strategies to use in the home setting. TOP: Factors That Affect Blood Pressure Site Selection KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
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6. The patient needs to be taught the signs of hypoxia. Which of the following are causes of
hypoxia? (Select all that apply.) a. Incorrect flow rate b. Poor tubing connection c. Use of long oxygen tubing d. Airway plugging ANS: A, B, C, D
Hypoxia sometimes occurs at home when a patient uses oxygen. Possible causes of hypoxia include poor tubing connections, use of long oxygen tubing, and worsening of the patient’s physical problem with changes in respiratory status. Assess the patient for changes in respiratory status, such as airway plugging, respiratory tract infection, or bronchospasm. DIF: Cognitive Level: Comprehension REF: Text reference: p. 1030 OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Causes of Hypoxia. KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse will train the tracheostomy patient and caregiver that reusable supplies need to be
disinfected at least weekly. Which of the following methods is recommended for cleaning tracheostomy supplies at home? (Select all that apply.) a. Boil reusable (boilable) supplies for 5 minutes. Allow to cool and dry. b. Boil reusable (boilable) supplies for 15 minutes. Allow to cool and dry. c. Soak reusable supplies in equal parts of vinegar and water for 30 minutes.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Remove, rinse thoroughly, and dry. d. Soak reusable supplies in prepared solutions of quaternary ammonium chloride
compounds according to the manufacturer’s instructions. Rinse and dry. ANS: B, C, D
To disinfect supplies, use one of these methods as described: (1) Boil reusable (boilable) supplies for 15 minutes. Allow to cool and dry. (2) Soak reusable supplies in equal parts of vinegar and water for 30 minutes. Remove, rinse thoroughly, and dry. (3) Soak reusable supplies in prepared solutions of quaternary ammonium chloride compounds according to the manufacturer’s instructions. Rinse and dry. DIF: Cognitive Level: Application REF: Text reference: p. 1036 OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Tracheostomy Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 8. In preparing to teach a patient how to self-administer mediation, the nurse realizes that 80% of
patients who are instructed to self-medicate for preventative care fail to do so. Reasons for this include which of the following? (Select all that apply.) a. Fear of adverse events b. Inconvenient medication regimens c. Costly prescriptions d. Forgetfulness ANS: A, B, C, D
Some barriers to medication adherence include fear of adverse reactions from medications, belief that a medication doesN notRhelI U Sp,NinGcon TBve.nCienc OMe of taking medication, cost of medication, inadequate knowledge, forgetfulness, and lack of social support. DIF: Cognitive Level: Comprehension REF: Text reference: p. 1039 OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Failure to Self-Medicate KEY: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment COMPLETION 1. Temperatures in the older adult are different from those in the younger adult. The mean oral
temperature for older adults often ranges from
.
ANS:
35 C to 36.1 C (95 F to 97 F) Mean oral temperature for older adults often ranges from 35 C to 36.1 C (95 F to 97 F); therefore, temperatures considered within the normal range sometimes reflect a fever in the older adult. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1020 OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Temperature of Older Adults KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 2. Oxygen-conserving devices (OCDs) reduce the amount of oxygen the patient uses, resulting
in an overall cost reduction to the patient. The type of OCD that stores oxygen in a chamber during the expiratory phase of respirations is known as the . ANS:
reservoir nasal cannula The reservoir nasal cannula stores oxygen in a chamber during the expiratory phase of respirations. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1027 OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Reservoir Nasal Cannula KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. OCDs reduce the amount of oxygen the patient uses, resulting in an overall cost reduction to
the patient. The type of OCD that delivers oxygen only during inspiration is called a . ANS:
demand oxygen delivery system Demand oxygen delivery systems deliver a burst of oxygen only during inspiration. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1027 OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Reservoir Nasal Cannula KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
deN liU veR rsSoI xyNgG enTtB hr. ouCgO hM a catheter permanently inserted into the trachea, thus allowing the patient to speak and bypassing anatomical dead space.
4. A
ANS:
transtracheal oxygen catheter A transtracheal oxygen catheter delivers oxygen through a catheter permanently inserted into the trachea, thus allowing the patient to speak and bypassing anatomical dead space. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1027 OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Reservoir Nasal Cannula KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. While teaching how to check for gastric residual, the nurse instructs the caregiver to delay the
tube feeding if he or she obtains more than
mL of gastric aspirate.
ANS:
250 If gastric aspirates are greater than 250 mL, instruct the patient or caregiver to return gastric contents and delay tube feeding for 1 hour. If aspirates remain greater than 250 mL after an hour, instruct the patient or caregiver to contact the home care nurse or health care provider. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1045 OBJ: Implement and evaluate appropriate learning strategies that support clients’ ability to care for themselves in the home. TOP: Gastric Residual
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
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Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 43: Specimen Collection MULTIPLE CHOICE 1. How should the nurse identify a patient before obtaining a laboratory specimen from him? a. Use at least two patient identifiers. b. Look at the chart before entering the room. c. Ask the patient his name. d. Check the patient’s armband twice. ANS: A
Before obtaining a laboratory specimen, use at least two identifiers such as checking the identification number on the admission armband and asking the patient’s name. Patients who are confused or who have a language barrier may smile and not understand the question. The patient could also have the wrong armband on; checking it twice would not change that. DIF: Cognitive Level: Application REF: Text reference: p. 1055 OBJ: Identify measures to minimize anxiety and promote safety for selected techniques. TOP: Positive Patient Identification KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. When discussing the collection of a clean-voided urine specimen, it is important for the nurse
to instruct the patient to: a. use a clean specimen cup. b. collect 100 to 150 mL of urine for testing. c. void some urine first and then collect the sample. d. wash the perineal area wiN thUsR oaSpIaN ndGwTaB te. r iC mO mMediately before voiding. ANS: C
After the patient has initiated a urine stream, pass the urine specimen container into the stream and collect 90 to 120 mL of urine. A sterile specimen container is used. Pour antiseptic solution over cotton balls. A cotton ball or gauze is used to cleanse the perineum. DIF: Cognitive Level: Application REF: Text reference: p. 1056 OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens. TOP: Obtaining Urine Culture and Sensitivity (C&S) Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. The nurse needs to obtain a sterile urine specimen for culture and sensitivity (C&S) from a
patient who has an indwelling catheter. The catheter was placed the night before. What must the nurse do to obtain the specimen? a. Obtain the urine from the drainage bag. b. Clamp the drainage tubing for 10 to 15 minutes. c. Draw urine using a 20-mL syringe. d. Insert the needle into the silicone catheter. ANS: B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Clamp the drainage tubing with a clamp or rubber band for 30 minutes to permit collection of fresh, sterile urine in the catheter tubing rather than draining into the bag. Do not collect a urine specimen for culture tests from a urine drainage bag unless it is the first urine to drain into a new sterile bag. Draw urine into a 3-mL syringe (for culture), or draw urine into a 20 mL-syringe (for routine urinalysis). Proper volume is needed to perform the test. Do not puncture Silastic, silicone, or plastic catheters. These are not self-sealing. DIF: Cognitive Level: Application REF: Text reference: p. 1057 OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens. TOP: Obtaining Urine C&S Specimen From a Catheter KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. What should the nurse do first if a patient is unable to void on demand for a clean-voided
specimen? a. Perform Credé’s procedure for the suprapubic area. b. Catheterize the patient to obtain the specimen. c. Offer fluids, if allowed, and wait about 30 minutes. d. Notify the physician that the test cannot be completed. ANS: C
If the patient is unable to urinate on demand, offer fluids if permitted. Allow more time for urine to accumulate in the bladder. Try obtaining a specimen after 30 minutes. If the patient has no urine in the bladder, Credé’s would not be useful. The risk for infection precludes the use of catheterization simply to obtain a specimen. If the patient is unable to void after several hours, the physician may need to be called to obtain an order for catheterization. DIF: Cognitive Level: ApplicN atiU onRSINGRT EB F:.C TeO xtMreference: p. 1058 OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens. TOP: Obtaining Urine C&S Specimen From a Catheter KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. What must the nurse do to collect a midstream urine sample from an infant? a. Apply a sterile plastic collection bag to the perineum. b. Wring out diapers and collect the urine in a specimen container. c. Have the infant sit facing the back of the toilet. d. Catheterize the infant and collect the urine using sterile procedure. ANS: A
Use a sterile plastic urine collecting bag that adheres to the perineum of a non–toilet-trained child. Special considerations for boys: Place the penis and scrotum inside the bag. Diapers may be contaminated. Seating on a toilet generally is not realistic for an infant. Catheterization should be used as a last resort only. DIF: Cognitive Level: Application REF: Text reference: p. 1058 OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens. TOP: Obtaining Urine C&S Specimen From an Infant KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. What should the nurse do when a patient is required to provide a timed urine specimen?
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. Save all urine from the time the test began. b. Leave the collection bottle on the floor near the patient’s bed. c. Send notices along with the patient when leaving the unit to have all urine saved
and returned to the unit. d. Remove contaminants such as toilet paper from the urine before transferring it to the collection bottle. ANS: C
Place signs on the patient’s door and toileting area, indicating that a timed urine specimen collection is in progress. If the patient leaves the unit for a test or procedure, be sure that personnel in that area collect and save all urine. The nurse discards the first specimen and then collects every successive specimen until the time period has ended. Place a specimen collection container in the bathroom and, if indicated, in a pan of ice. The urine specimen is not to be contaminated with feces or toilet tissue. DIF: Cognitive Level: Application REF: Text reference: p. 1059 OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens. TOP: Obtaining a Timed Urine Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. What instructions does the nurse provide to the patient to obtain a double-voided urine
specimen? a. Save two separate specimens from the first voiding in the morning. b. Add two specimens together from the morning voiding and the evening voiding. c. Discard the first sample, then wait a half hour and void again. d. Void first and then self-catheterize to obtain the specimens. ANS: C
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A fresh specimen should be used because stagnant urine that has been in the bladder for several hours will not accurately reflect the serum glucose level at the time of testing. Ask the patient to collect a random urine specimen and discard, drink a glass of water, and collect another specimen 30 to 45 minutes later. DIF: Cognitive Level: Application REF: Text reference: p. 1060 OBJ: Identify special conditions necessary for collection of each specimen. TOP: Collecting a Double-Voided Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8. An appropriate procedure for urine testing with reagent strips for chemical properties of the
sample is to: a. obtain the first voided specimen in the morning. b. immerse the test strip in the urine and remove immediately. c. add a chemically active tablet to the urine and then test it with a reagent strip. d. wipe the strip with a sterile gauze after dipping. ANS: B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Immerse the strip briefly in the urine sample, and then remove it and tap it gently on the side of the container; prolonged exposure to excess urine can dilute reagents. Stagnant urine stored in the bladder overnight or for long periods does not reveal quantities of glucose and ketones excreted by the kidney at the time of testing. Kits that contain tablets do not also use strips; the tablet contains the reagent and changes color to indicate chemical properties of the urine. Tap the strip gently against the side of the container to shed excess urine; do not wipe it. DIF: Cognitive Level: Application REF: Text reference: p. 1060 OBJ: Discuss nursing responsibilities for processing a specimen after collection. TOP: Testing the Chemical Properties of Urine KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. A patient is concerned because her first guaiac test is positive. What information should the
nurse share with the patient? a. The patient probably has colorectal cancer. b. The test needs to be repeated after she eats some red meat. c. The test needs to be repeated at least 3 times. d. The patient needs a low-residue diet to reduce intestinal abrasions. ANS: C
A single positive test result does not confirm bleeding or indicate colorectal cancer. For confirmed positive results, the test must be repeated at least 3 times while the patient is on a meat-free, high-residue diet. More in-depth diagnosis is needed with a positive result. DIF: Cognitive Level: Application REF: Text reference: p. 1061 OBJ: Explain instructions to encourage patient cooperation for successful collection of each specimen. TOP: GN uaia c Te UR SIsting NGTB.COM KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 10. When teaching a patient about home testing for occult blood, the nurse instructs the patient
that: a. positive results are indicative of bleeding. b. poultry and fish should be eaten before testing. c. testing should be done carefully during the menstrual cycle. d. two samples should be obtained from the same part of the stool specimen. ANS: C
Specimens will be positive if contaminated by menstrual blood or hemorrhoidal blood or povidone-iodine. A single positive test result does not confirm bleeding or indicate colorectal cancer. Diets rich in meats; green, leafy vegetables; poultry; and fish may produce false-positive results. Obtain a second fecal specimen from a different portion of the stool. DIF: Cognitive Level: Application REF: Text reference: p. 1061 OBJ: Explain instructions to encourage patient cooperation for successful collection of each specimen. TOP: Guaiac Testing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. A patient asks what food may be eaten before a stool specimen is obtained for occult blood.
What food should the nurse allow the patient to eat? a. Fish
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank b. Apples c. Red meats d. Green, leafy vegetables ANS: B
Diets rich in meats; green, leafy vegetables; poultry; and fish may produce false-positive results. DIF: Cognitive Level: Comprehension REF: Text reference: p. 1061 OBJ: Explain instructions to encourage patient cooperation for successful collection of each specimen. TOP: Guaiac Testing KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 12. The nurse evaluates that an expected outcome for analysis of gastric secretions is: a. inability of the patient to discuss the rationale for the test. b. negative occult blood. c. the presence of clumps or clots. d. the presence of brown, “coffee-ground” secretions. ANS: B
An expected outcome after completion of the procedure is the test for occult blood. If frank red blood is observed or coffee-ground materials are seen, report these findings immediately. This is an unexpected finding. DIF: Cognitive Level: Comprehension REF: Text reference: p. 1064 OBJ: Explain the rationale for the collection of each specimen. TOP: Guaiac Testing of Gastric Contents KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
N R I G B.C M U S N T O
13. An appropriate technique for the nurse to implement when obtaining throat cultures is to: a. have the patient lie flat in the bed. b. do the culture before meals or an hour after meals. c. avoid touching the swab to any of the inflamed areas. d. place pressure on the tongue blade along the back of the tongue. ANS: B
Plan to do the culture before mealtime or at least 1 hour after eating. This procedure often induces gagging; timing will decrease the patient’s chances of vomiting. Ask the patient to sit erect in bed or on a chair facing the nurse. Gently but quickly swab the tonsillar area from side to side, making contact with inflamed or purulent sites. Depress the anterior third of the tongue only; placement of a tongue blade along the back of the tongue is more likely to initiate a gag reflex. DIF: Cognitive Level: Application REF: Text reference: p. 1065 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Obtaining a Throat Culture KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 14. What step should the nurse take to obtain a vaginal specimen for a culture? a. Apply sterile gloves. b. Assist the patient to a side-lying position. c. Collect discharge from the perineum on the same swab.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank d. Insert the swab to 1 inch into the orifice and rotate before removal. ANS: D
Gently insert the swab to 1 inch into the vaginal orifice and rotate before removal. Apply clean disposable gloves. The patient should be in dorsal recumbent position. If a discharge near the vagina appears different from the discharge along the perineum, collect separate specimens from each area. DIF: Cognitive Level: Application REF: Text reference: p. 1070 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Obtaining a Vaginal Culture KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. When using a commercially prepared tube to collect a culture, the nurse should: a. take the swab and mix it in the reagent to check for color changes. b. place the swab into the culture tube and then add a special reagent to the tube. c. crush the ampule at the end of the tube and put the tip of the swab into the solution. d. place the swab into the tube, close it securely, and keep it warm until it is sent to
the laboratory. ANS: C
Immediately squeeze the end of the tube to crush the ampule, and push the tip of the swab into fluid medium. DIF: Cognitive Level: Application REF: Text reference: p. 1070 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Preparing a Culture Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IN ntegR rityI G B.C M
U S N T
O
16. A nurse suspects that the patient may have tuberculosis. She sends a sputum sample to the lab
for testing. When the following tests are compared, which will best support the diagnosis of possible tuberculosis? a. Acid-fast bacilli b. General cytology c. Chemical analysis d. Culture and sensitivity ANS: A
Sputum specimens are collected to identify cancer cells, for culture and sensitivity (C&S) to identify pathogens and determine the antibiotics to which they are sensitive, and for acid-fast bacilli to diagnose pulmonary tuberculosis. Cytological or cellular examinations of sputum may identify aberrant cells or cancer. Chemical analysis would indicate chemicals within the blood, not sputum. Sputum collected for culture and sensitivity testing is used to identify specific microorganisms and to determine which antibiotics are most sensitive. A definitive diagnosis of TB also requires a sputum culture and sensitivity. DIF: Cognitive Level: Analysis REF: Text reference: p. 1071 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Acid-Fast Bacilli KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 17. The patient has come to the emergency department complaining of coughing up bloody
sputum. The patient has a 30-year history of smoking and has lost 15 pounds in the last month. What will the nurse expect the sputum specimen to be evaluated for? a. Culture and sensitivity b. AFB c. Cytology d. Chemical analysis ANS: C
The patient is showing signs of cancer. Sputum specimens are collected to identify cancer cells. Sputum collected for culture and sensitivity testing is used to identify specific microorganisms. The AFB is used to support the diagnosis of tuberculosis. Chemical analysis would indicate chemicals within the blood, not sputum. DIF: Cognitive Level: Analysis REF: Text reference: p. 1071 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Cytological Examination of Sputum KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 18. An appropriate technique that the nurse can tell the patient to implement before obtaining a
sputum specimen is to: a. use mouthwash before the collection. b. splint the surgical incision before coughing. c. try to obtain a sample immediately after eating. d. take a deep breath, cough hard, and expectorate. ANS: B
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If the patient has a surgical incision or localized area of discomfort, have the patient place hands firmly over the affected area, or place a pillow over the area. Splinting of painful areas minimizes muscular stretching and discomfort during coughing and thus makes cough more productive. The patient should not use mouthwash or toothpaste because it may decrease viability of microorganisms and culture results. Have the patient wait 1 to 2 hours after eating. After a series of deep breaths, ask the patient to cough after full inhalation. DIF: Cognitive Level: Application REF: Text reference: p. 1072 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Obtaining Sputum Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. During a sputum collection, the patient becomes hypoxic. What action should the nurse take? a. Suction the patient thoroughly. b. Continue to complete the procedure quickly. c. Stop the procedure and provide oxygen, if ordered. d. Have the patient lie down and take deep breaths before continuing with the
specimen collection. ANS: C
If the patient becomes hypoxic, discontinue the procedure until stable and provide oxygen therapy as needed, if ordered. Suctioning can decrease usable oxygen to the patient. DIF: Cognitive Level: Application
REF: Text reference: p. 1074
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Hypoxia During Suctioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. The nurse has delegated ADL care of a patient with a large wound that is draining. Which of
the follow should the nurse instruct the nurse assistant to report back to her? a. The wound has a foul odor. b. Drainage is decreased. c. The patient’s temperature is slightly below normal. d. The patient does not complain of discomfort. ANS: A
Report a foul odor, increased drainage, and increased temperature or complaints of discomfort. DIF: Cognitive Level: Application REF: Text reference: p. 1075 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Signs of Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 21. An appropriate technique for the nurse to use when culturing wound drainage that is suspected
to contain anaerobic bacteria is to: a. use older secretions for the specimen. b. add exudate from the skin to the wound specimen. c. aspirate 5 to 10 mL of exudate from a deep cavity wound. d. swab carefully and slowly in a back-and-forth motion across the wound. ANS: C
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Take a swab from a special anaerobic culture tube, swab deeply into the draining body cavity, and rotate gently. Remove the swab and return it to the culture tube, or insert the tip of a syringe into the tube, and aspirate 5 to 10 mL of exudate. Cleanse the area around the wound edges with an antiseptic swab. This removes old exudate and skin flora, preventing possible contamination of the specimen. Never collect exudate from the skin unless it is a separate culture and is labeled as such. DIF: Cognitive Level: Application REF: Text reference: p. 1076 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Obtaining Anaerobic Wound Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 22. The patient is diagnosed with suspected bacteremia. The physician has ordered blood cultures
from two different sites. The patient is complaining of chills and has an elevated temperature. What action should the nurse take in the presence of these symptoms? a. Delay drawing the blood cultures until symptoms subside. b. Draw blood from only one site to prevent further discomfort. c. Draw the blood cultures as ordered. d. Draw blood from the patient’s intravenous (IV) catheter. ANS: C
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Because bacteremia may be accompanied by fever and chills, blood cultures should be drawn when the patient is experiencing these clinical signs. It is important that at least two culture specimens be drawn from two different sites. Bacteremia exists when both cultures grow the infectious agent. Because blood culture specimens obtained from an IV catheter are frequently contaminated, tests that use them should not be performed unless catheter sepsis is suspected. DIF: Cognitive Level: Application REF: Text reference: p. 1078 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Drawing Blood Cultures KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 23. When blood specimens are drawn, which of the following is true? a. Draw cryoglobulin levels using test tubes placed on ice. b. To test ammonia and ionized calcium levels, warm the test tubes. c. To draw for lactic acid levels, do not use a tourniquet. d. To draw for vitamin levels, use light to determine density. ANS: C
Some specimens have special collection requirements before or after specimen collection, for example, for lactic acid levels, do not use a tourniquet. For cryoglobulin levels, use pre-warmed test tubes. For ammonia and ionized calcium levels, place the tube in ice for delivery to the laboratory. For vitamin levels, avoid exposure of the test tube to light. DIF: Cognitive Level: Analysis REF: Text reference: p. 1079 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Drawing Blood KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
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24. A patient is to have a venipuncture to obtain a blood sample to check ammonia levels. What
should the nurse do when given this information? a. Use pre-warmed test tubes. b. Keep the specimen out of the light. c. Avoid use of a tourniquet during the procedure. d. Place the samples on ice before sending them to the lab. ANS: D
Some specimens have special collection requirements before or after specimen collection. For ammonia levels, tubes must be placed on ice for delivery to the laboratory. For cryoglobulin levels, use pre-warmed test tubes. For vitamin levels, avoid exposure of the test tube to light. For lactic acid levels, do not use a tourniquet. DIF: Cognitive Level: Analysis REF: Text reference: p. 1079 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Drawing Blood KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. The nurse is preparing to perform a venipuncture on a patient. Which of the following is an
appropriate action for the nurse to take? a. Apply the tourniquet until the distal pulse is no longer felt. b. Remove the tourniquet after 1 minute. c. Instruct the patient to vigorously open and close the fist. d. Do not use veins that rebound.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
ANS: B
Do not keep a tourniquet on the patient longer than 1 minute. Prolonged tourniquet application causes stasis, localized acidemia, and hemoconcentration. Palpate the distal pulse (e.g., brachial) below the tourniquet. If the pulse is not palpable, reapply the tourniquet more loosely. Ask the patient to open and close the fist several times, finally leaving the fist clenched. Instruct the patient to avoid vigorous opening and closing of the fist. Palpate for a firm vein that rebounds; a patent, healthy vein is elastic and rebounds on palpation. DIF: Cognitive Level: Application REF: Text reference: p. 1079 OBJ: Use correct technique to perform venipuncture. TOP: Applying Tourniquet KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. An appropriate technique for the nurse to implement when preparing for a venipuncture is to: a. tie the tourniquet in a knot. b. tie the tourniquet so it can be easily removed. c. place the tourniquet 6 to 8 inches above the selected site. d. make the tourniquet tight enough to occlude the distal pulse. ANS: B
Apply the tourniquet by encircling the extremity and pulling one end of the tourniquet tightly over the other, looping one end under the other so it can be removed by pulling the end with a single motion. Apply the tourniquet 2 to 4 inches above the venipuncture site selected. Palpate the distal pulse below the tourniquet; if the pulse is not palpable, reapply the tourniquet more loosely. DIF: Cognitive Level: ApplicN ationR I GREB F: Text reference: p. 1079 U S venipuncture. N T .C OM OBJ: Use correct technique to perform TOP: Applying Tourniquet KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 27. The nurse is drawing blood from a patient to determine the blood alcohol level. Which step is
an appropriate action for the nurse to take? a. Swab the area with an antiseptic swab. b. Swab the area with an alcohol swab. c. Do not swab the area at all. d. Apply the tourniquet for 5 minutes. ANS: A
If drawing a sample for a blood alcohol level or blood culture, use only an antiseptic swab, not an alcohol swab. Do not keep a tourniquet on the patient longer than 1 minute. DIF: Cognitive Level: Application REF: Text reference: p. 1080 OBJ: Use correct technique to perform venipuncture. TOP: Drawing Blood for Blood Alcohol Level KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 28. When performing a venipuncture, the nurse should: a. inject with the needle at a 45-degree angle. b. select a vein that is rigid and cordlike, and that rolls when palpated.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank c. perform the needle insertion immediately after cleansing the skin with alcohol. d. place the thumb of the nondominant hand about 1 inch below the site and pull the
skin taut. ANS: D
Place the thumb or forefinger of the nondominant hand 1 inch below the site and gently pull the skin taut. Stretch the skin down until the vein is stabilized. Hold a syringe and needle at a 15- to 30-degree angle from the patient’s arm with the bevel up. Palpate for a firm vein that rebounds. Do not use veins that feel rigid or cordlike; a thrombosed vein is rigid, rolls easily, and is difficult to puncture. Allowing alcohol to dry completes its antimicrobial task and reduces the “sting” of venipuncture. Alcohol left on the skin can cause hemolysis of the sample. DIF: Cognitive Level: Application REF: Text reference: p. 1081 OBJ: Use correct technique to perform venipuncture. TOP: Venipuncture KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. When obtaining a venipuncture sample for a blood culture, the nurse should: a. recap the needles. b. shake the culture bottles well. c. use two different sites to draw samples. d. inoculate the aerobic culture bottle first. ANS: C
Collect 10 to 15 mL of venous blood by venipuncture in a 20-mL syringe from each venipuncture site. Culture specimens must be obtained from two sites. Dispose of needles, syringe, and soiled equipmenN t in perTB co.nC tain er. Do not cap the needles. Mix gently RtheSIproNG M U O after inoculation. If both aerobic and anaerobic cultures are needed, inoculate the anaerobic culture first. DIF: Cognitive Level: Analysis REF: Text reference: p. 1083 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Blood Cultures KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 30. When teaching about the procedure for capillary puncture, the nurse instructs a patient to: a. hold the finger upright. b. use the central tip of the finger. c. allow the antiseptic to dry completely. d. vigorously squeeze the end of the finger. ANS: C
Clean the site with an antiseptic swab, and allow it to dry completely. Alcohol left on the skin can cause hemolysis of the sample. Hold the finger to be punctured in a dependent position while gently massaging the finger toward the puncture site to increase blood flow to the area before puncture. Select the lateral side of the finger; be sure to avoid the central top of the finger, which has a more dense nerve supply. DIF: Cognitive Level: Application REF: Text reference: p. 1088 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Capillary Puncture KEY: Nursing Process Step: Implementation
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Physiological Integrity 31. Which of the following is the site of choice for obtaining samples for ABG? a. Radial artery b. Brachial artery c. Femoral artery d. Popliteal artery ANS: A
The radial artery is the safest, most accessible site for puncture; it is superficial, is not adjacent to large veins, and usually has adequate collateral circulation by the ulnar artery. Its use is relatively painless if the periosteum is avoided, and it is used when Allen’s test is positive. The brachial artery has reasonable collateral blood flow but is less superficial, is more difficult to palpate and stabilize, and carries increased risk for venous puncture; its use results in increased discomfort. The femoral artery should not be used by nurses without specialized training. The popliteal artery usually is not used. DIF: Cognitive Level: Application REF: Text reference: p. 1092 OBJ: Use correct technique to perform arterial puncture for blood gas measurement. TOP: Arterial Blood Gases KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 32. An appropriate technique for the nurse to implement when obtaining an ABG specimen is to: a. insert the needle at a 45-degree angle. b. use a 19-gauge, 1-inch needle. c. leave 0.5 mL of heparin in the syringe. d. aspirate blood after the puncture. ANS: A
NURSINGTB.COM
Hold the needle bevel up, and insert the needle at a 45-degree angle into the artery. Use a 23to 25-gauge needle. Aspirate 0.5 mL sodium heparin into a syringe, and then eject all heparin in the barrel out of the syringe. Allow arterial pulsations to pump 2 to 3 mL of blood into the heparinized syringe slowly to reduce the presence of air bubbles. DIF: Cognitive Level: Application REF: Text reference: p. 1093 OBJ: Use correct technique to perform arterial puncture for blood gas measurement. TOP: Arterial Blood Gases KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 33. What should the nurse do after obtaining a sample for ABG? a. Maintain pressure over the site for 3 to 5 minutes. b. Check the artery proximal to or above the puncture site. c. Place the syringe into a plastic bag, and send it to the lab. d. Apply a cool compress to hematoma formation at the puncture site. ANS: A
Maintain continuous pressure on and proximal to the site for 3 to 5 minutes. Palpate the artery below or distal to the puncture site to determine whether pulse quality has changed, indicating alteration in arterial flow. Place a syringe in a cup of crushed ice. Failure to do this may result in decreased pH, arterial oxygen pressure (PaO2), and oxygen saturation. Apply warm compresses to enhance the absorption of blood.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank DIF: Cognitive Level: Application REF: Text reference: p. 1094 OBJ: Use correct technique to perform arterial puncture for blood gas measurement. TOP: Arterial Blood Gases KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. When collecting specimens, the nurse should: (Select all that apply.) a. wear gloves and perform hand hygiene. b. handle excretions discreetly. c. explain the procedure to the patient. d. allow patients to collect their own urine specimens. ANS: A, B, C, D
When collecting specimens, wear gloves, and perform hand hygiene. Also, handle excretions discreetly. Invasive collection procedures and fear of unknown test results often cause patients anxiety. Patients who receive a clear explanation about the purpose of the specimen and how the nurse will obtain it are more cooperative. Give patients proper instruction to collect their own specimens of urine, stool, and sputum, thus avoiding embarrassment. DIF: Cognitive Level: Application REF: Text reference: p. 1053 OBJ: Identify measures to minimize anxiety and promote safety during specimen collection. TOP: Specimen Collection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. When obtaining laboratory specimens, the nurse needs to be aware that: (Select all that
apply.) N R I G B.C M a. specimen collection may caUuseSanxNietyTand em Obarrassment. b. sociocultural variations may affect a patient’s compliance. c. contact isolation precautions are required for collection of blood. d. two identifiers, including room number, must be used. ANS: A, B
The nurse should recognize that specimen collection may cause anxiety, embarrassment, and/or discomfort. Cultural considerations are important when collecting specimens and performing diagnostic procedures. Culture and beliefs may affect a patient’s response and willingness to participate in specimen collection. Use of a patient’s room number is not an acceptable identifier, and the nurse should follow standard precautions when collecting specimens of blood or other body fluids. DIF: Cognitive Level: Application REF: Text reference: p. 1053 OBJ: Recognize the impact of patient-centered issues on patients’ cooperation with collection of specimens. TOP: Obtaining Laboratory Specimens KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. A timed urine collection can be used for which of the following? (Select all that apply.) a. Glucose b. Adrenocorticosteroids c. Bacteria count d. Color
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS: A, B
Some tests of renal function and urine composition require urine to be collected over 2 to 72 hours. The 24-hour timed collection is most common. These tests measure for elements such as amino acids, creatinine, hormones, glucose, and adrenocorticosteroids, whose levels fluctuate throughout the day. A timed urine collection also can serve as a means to measure the concentration or dilution of urine. Bacteria count and color can be determined through a routine urinalysis. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1054 OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens. TOP: Obtaining a Timed Urine Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. Hemoccult testing helps to reveal blood that is visually undetectable. This test is a useful
diagnostic tool for which of the following conditions? (Select all that apply.) a. Colon cancer b. Upper gastrointestinal (GI) ulcers c. Localized gastric parasites d. Large polyps ANS: A, B, C, D
This test is a useful diagnostic tool for conditions such as colon cancer, upper gastrointestinal ulcers, and localized gastric parasitic infection or intestinal irritation. The amount of bleeding increases with the size of the polyp and the stage of cancer. People with small polyps (less than 1 cm in diameter) bleed scarcely more than those without polyps. DIF: Cognitive Level: ComprN ehen F:.C Text URsion SINGRE TB OMreference: p. 1061 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Guaiac Testing KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a patient who has had a craniotomy. The patient appears to need
endotracheal suctioning. The nurse is aware that this can be of concern because suctioning can cause which of the following? (Select all that apply.) a. Violent coughing b. Aspiration of stomach contents c. Increased intracranial pressure d. Bradycardia or tachycardia ANS: A, B, C, D
Sometimes suctioning provokes violent coughing, causes vomiting and aspiration of stomach contents, and induces constriction of pharyngeal, laryngeal, and bronchial muscles. In addition, suctioning may cause hypoxemia or vagal overload, resulting in cardiopulmonary compromise and increased intracranial pressure. DIF: Cognitive Level: Comprehension REF: Text reference: p. 1074 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Suctioning KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 6. In explaining to the patient about obtaining a sputum specimen to diagnose tuberculosis, the
nurse explains which of the following? (Select all that apply.) a. Specimens are best obtained in the early morning. b. Acid-fast bacilli (AFB) smears require three consecutive morning samples. c. Bacteria accumulate as secretions pool. d. Specimens should be obtained at bedtime. ANS: A, B, C
Specimens for AFB require three consecutive morning samples, and cultures can take up to 8 weeks. The ideal time to collect sputum is early morning because bronchial secretions tend to accumulate during the night. Bacteria also accumulate as secretions pool. DIF: Cognitive Level: Comprehension REF: Text reference: p. 1072 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Cultures for Acid-Fast Bacilli and C&S for Tuberculosis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity COMPLETION 1. Assessment of the chemical properties of urine is done by immersing a special, chemically
prepared strip of paper into a clean urine specimen, or by combining drops of urine with chemically prepared tablets. The of the strip or tablet indicates the presence of any of unique chemical properties. ANS:
change in color You assess the chemical properties by immersing a special, chemically prepared strip NU RSof INurine GTB.C M O of paper into a clean urine specimen, or by combining drops of urine with chemically prepared tablets. The change in color of the strip or tablet indicates the presence of glucose, ketones, protein, and blood as well as pH of the urine. DIF: Cognitive Level: Application REF: Text reference: p. 1060 OBJ: Discuss nursing responsibilities for processing a specimen after collection. TOP: Testing the Chemical Properties of Urine KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. A common test performed on fecal material is the
test for fecal occult blood.
ANS:
guaiac A common test performed on fecal material is the guaiac test for fecal occult blood. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1061 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Guaiac Testing KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 3.
is often indicated to collect sputum from patients unable to spontaneously produce a sample for laboratory analysis.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank ANS:
Suctioning Suctioning is often indicated to collect sputum from patients unable to spontaneously produce a sample for laboratory analysis. DIF: Cognitive Level: Comprehension REF: Text reference: p. 1072 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Suctioning KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4. Localized inflammation, tenderness, warmth at the wound site, and purulent drainage usually
signify
.
ANS:
wound infection Localized inflammation, tenderness, warmth at the wound site, and purulent drainage usually signify wound infection. DIF: Cognitive Level: Comprehension REF: Text reference: p. 1075 OBJ: Properly collect specimens for culture from the nose and throat, urethra and vagina, sputum, and wound. TOP: Wound Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
organisms grow in superficial wounds exposed to the air.
5. ANS:
Aerobic Aerobic organisms grow in sN upUeR rfiS ciI alNwGoT unBd. sC exO poMsed to the air. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1075 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Aerobic Organisms KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The least traumatic method of obtaining a blood specimen is known as
.
ANS:
skin puncture capillary puncture Skin puncture, also called capillary puncture, is the least traumatic method of obtaining a blood specimen. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1085 OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids. TOP: Skin/Capillary Puncture KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
Chapter 44: Diagnostic Procedures MULTIPLE CHOICE 1. A nurse should contact the physician to postpone intravenous moderate sedation if the patient: a. has been NPO for 1 hour. b. has a history of substance abuse. c. has no history of latex allergy. d. has demonstrated an understanding of the procedure. ANS: A
Verify that the patient has not ingested food or fluids, except for oral medications, for at least 4 hours. Verify specific agency requirements. Because a risk of moderate sedation is loss of airway protection, an empty stomach reduces the risk for aspiration. A history of substance abuse is not a contraindication to the procedure, although it usually requires dose adjustment of the sedative. With no history of latex allergy, allergic reactions are not a concern. An understanding of the procedure implies that consent was informed. DIF: Cognitive Level: Application REF: Text reference: p. 1100 OBJ: Demonstrate understanding of nursing responsibilities related to the use of intravenous sedation during diagnostic procedures. TOP: Moderate Sedation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. Which action should the nurse take after a procedure requiring intravenous moderate
sedation? a. Report to the physician a Ramsay sedation score that is less than 3. b. Monitor airway patency aNnU dR viS taI l sN igGnT s eBv. erC yO 5M minutes for 30 minutes. c. Take vital signs every 15 minutes for the next 2 hours. d. Take vital signs every 30 minutes until stable. ANS: B
After the procedure, monitor airway patency, vital signs, SpO2, pain score, and level of consciousness every 5 minutes for at least 30 minutes, then every 15 minutes for an hour, and then every 30 minutes until the patient meets the discharge criteria on the agency’s designated scoring system. Report to the physician only a Ramsay sedation score higher than 3. DIF: Cognitive Level: Application REF: Text reference: p. 1102 OBJ: Demonstrate understanding of nursing responsibilities related to the use of intravenous sedation during diagnostic procedures. TOP: Moderate Sedation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Under which circumstances should a nurse contact the physician to postpone an angiography? a. If a patient has been NPO for only 1 hour b. If a patient’s femoral site has been shaved and cleansed with an antiseptic c. If the patient received Benadryl as a pre-procedure medication d. When test results reveal a BUN level of 15 mg/100 mL and a creatinine level of
0.8 mg/mL ANS: A
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank A patient needs to be NPO for 6 to 8 hours before the procedure to prevent possible aspiration because the patient is sedated. The site of catheter insertion needs to be shaved and prepped with antiseptic just before the procedure. Benadryl is used prophylactically to block histamine and decrease allergic responses. Elevated BUN or creatinine levels would place patients at risk for renal failure induced by contrast media. DIF: Cognitive Level: Application REF: Text reference: p. 1105 OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy. TOP: Postponing Angiography KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4. What action should the nurse take after an angiography? a. Limit the patient’s fluid intake. b. Have the patient ambulate as soon as possible. c. Apply a pressure dressing to the vascular site. d. Maintain the patient in a sitting position while he or she is in bed. ANS: C
Five to 15 minutes of manual pressure is often enough to stop active site bleeding. However, a certain amount of bed rest is needed to achieve reliable hemostasis. Check agency policy for post-procedure bed rest requirements. This is often up to 6 hours when no vascular closure device is used. Encourage patient to drink 1 to 2 L of fluid after the procedure. Emphasize the need to lie flat for 6 to 12 hours. DIF: Cognitive Level: Application REF: Text reference: p. 1107 OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures. TOP: PoN st-A ogra roC cedu URngi SI NGphy TBP. OMre KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse is alert to a possible delayed reaction to the dye injected during an angiography. For
which response should she monitor the patient? a. Pallor b. Dyspnea c. Thirst d. Numbness and tingling ANS: B
Assess the patient for a possible delayed reaction to iodine dye, seen as dyspnea, hives, tachycardia, and rash. This reaction occurs up to 6 hours after injection of dye. Thirst, by itself, is not a major warning sign of reaction to the dye. Pallor, by itself, is not a major warning sign of reaction to the dye. A patient’s report of any feelings of pain, dyspnea, numbness or tingling, or other untoward symptoms may indicate cardiac complications or procedure site complications, but not a reaction to the dye. DIF: Cognitive Level: Application REF: Text reference: p. 1108 OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures. TOP: Reaction to IV Dye KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank 6. The nurse is preparing to assist with a bone marrow aspiration on a 3-month-old infant. The
nurse may expect that the physician will use which site to perform the aspiration? a. Sternum b. Anterior iliac crest c. Proximal tibia d. Posterior iliac crest ANS: C
In children, the anterior or posterior iliac crest is used, and in infants, the proximal tibia is used. DIF: Cognitive Level: Application REF: Text reference: p. 1109 OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy. TOP: Bone Marrow Aspiration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse is discussing the patient’s upcoming elective lumbar puncture, and explains that the
patient will probably need to undergo computed tomography of the brain before the procedure is done. What is the reason for this? a. Diagnose CNS infection. b. Rule out increased intracranial pressure. c. Visualize cerebrospinal fluid. d. Measure pressure in the subarachnoid space. ANS: B
In elective lumbar puncture (LP), pre-procedure computed tomography results are reviewed for evidence of brain shift to N ruleRoutIincG dC intraMcranial pressure. The purpose of the LP U S N reas TBe. O procedure itself is to measure pressure in the subarachnoid space; obtain CSF for visualization and laboratory examination; and inject anesthetic, diagnostic, or therapeutic agents. CT will not do these things. DIF: Cognitive Level: Application REF: Text reference: p. 1109 OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy. TOP: Lumbar Puncture KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. The patient is a 56-year-old man who has terminal cirrhosis and severe ascites. He is lethargic
but is demonstrating signs of discomfort and respiratory distress. The physician has spoken with the patient’s wife and has obtained consent to perform an abdominal paracentesis on the patient. After the physician leaves to prepare for the procedure, the wife asks the nurse whether the procedure is really necessary. The nurse should respond by saying this: a. is the first step in the patient’s recovery. b. may help the patient feel better. c. is needed to detect increased intracranial pressure. d. is needed to analyze pleural fluid. ANS: B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank The patient is diagnosed as terminal. Paracentesis is a palliative measure used to provide temporary relief of abdominal and respiratory discomfort caused by severe ascites. Intracranial pressure is assessed with computed tomography. Thoracentesis, not paracentesis, is performed to analyze or remove pleural fluid. DIF: Cognitive Level: Application REF: Text reference: p. 1111 OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy. TOP: Abdominal Paracentesis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. Which is the appropriate patient position for a lumbar puncture? a. Prone b. Supine c. Sims’ d. Lateral recumbent ANS: D
Position the patient in a lateral recumbent (fetal) position with the head and neck flexed. This provides spinal column full curvature. The spinal column is flexed as much as possible to allow maximal space between vertebrae. DIF: Cognitive Level: Application REF: Text reference: p. 1113 OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy. TOP: Positioning for Lumbar Puncture KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IN ntegR rityI G B.C M
U S N T
O
10. In which position is the patient usually placed for a thoracentesis? a. Dorsal recumbent position b. Supine with the arms over the head c. Sims’ position on the affected side d. Sitting and leaning over a bedside table ANS: D
Place the patient in the orthopneic position (upright position with arms and shoulders raised and supported on a padded over-bed table). If the patient is unable to tolerate this position, assist the patient to a side-lying position with the affected lung positioned upward. This expands the intercostal space for needle insertions. DIF: Cognitive Level: Application REF: Text reference: p. 1113 OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy. TOP: Positioning for Thoracentesis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. When explaining about a lumbar puncture, the nurse informs the patient that during the
procedure, he or she will be asked to: a. remain very still. b. cough during the fluid aspiration.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank c. change position. d. breathe deeply during the needle insertion. ANS: A
Emphasize the importance of remaining immobile during the procedure to prevent trauma, especially with the lumbar puncture, because sudden movement is a risk for spinal cord nerve root damage. Also, instruct the patient not to cough, sneeze, or breathe deeply during the procedure because these actions increase the risks for needle displacement and damage to other structures. DIF: Cognitive Level: Application REF: Text reference: p. 1113 OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy. TOP: Lumbar Puncture KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 12. When explaining what to expect during a bronchoscopy, the nurse informs the patient that: a. an anesthetic solution will be swallowed. b. the tube will be passed through the nose. c. nothing will be given by mouth for 2 to 3 hours before. d. no food or fluid will be provided until the gag reflex returns. ANS: D
Do not allow the patient to eat or drink until the tracheobronchial anesthesia has worn off and the gag reflex has returned—usually for 2 hours. Instruct the patient not to swallow the local anesthetic. The bronchoscope is introduced into the mouth, to the pharynx, to pass through the glottis. The patient should haN ve tR aken nothing by mouth for at least 8 hours before a U SINGTB.COM bronchoscopy. DIF: Cognitive Level: Application REF: Text reference: p. 1117 OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy. TOP: Bronchoscopy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 13. The physician needs to visually examine a patient’s esophagus, stomach, and duodenum. The
nurse anticipates that the physician will order: a. endoscopic retrograde cholangiopancreatography (ERCP). b. esophagoscopy. c. esophagogastroduodenoscopy (EGD). d. proctoscopy. ANS: C
Esophagogastroduodenoscopy (EGD) permits visualization of the esophagus, stomach, and duodenum in a single examination. Endoscopic retrograde cholangiopancreatography (ERCP) is performed for visualization of the hepatobiliary tree and pancreatic ducts. Esophagoscopy is used to examine the esophagus only. Proctoscopy offers a visual examination of the lower gastrointestinal tract. DIF: Cognitive Level: Application REF: Text reference: p. 1118 OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy. TOP: Esophagogastroduodenoscopy (EGD) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. A patient who is a candidate for an upper gastrointestinal endoscopy has: a. been NPO for 8 hours. b. evident respiratory distress. c. active gastrointestinal bleeding. d. an esophageal diverticulum. ANS: A
Verify that the patient has been NPO for at least 8 hours. Evident respiratory distress will increase risk, and the procedure may have to be delayed. This test is contraindicated in patients with severe upper gastrointestinal tract bleed, Zenker’s diverticulum, or a large aortic aneurysm. DIF: Cognitive Level: Application REF: Text reference: p. 1120 OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy. TOP: Esophagogastroduodenoscopy (EGD) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. For an upper gastrointestinal endoscopy, a nurse should: a. remove the patient’s dentures. b. suction the patient every 5 minutes. c. place the patient in high-Fowler’s position. d. provide fluids immediateN ly aR fter I the G testBis.fC inishMed.
U S N T
O
ANS: A
Remove the patient’s dentures and other dental appliances to prevent dislodgement of dental structures during the intubation phase. Position the tip of the cannula in the patient’s mouth for easy access to drain oral secretions; suction as needed. Help the patient to maintain left lateral Sims’ position. Instruct the patient not to eat or drink after the procedure until the gag reflex returns, which is usually about 2 hours after the procedure. DIF: Cognitive Level: Application REF: Text reference: p. 1120 OBJ: Effectively assist health care providers with angiogram, cardiac catheterization, intravenous (IV) pyelogram, bone marrow aspiration/biopsy, lumbar puncture, paracentesis, bronchoscopy, and endoscopy. TOP: Gastrointestinal Endoscopy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. During an electrocardiogram, the patient should anticipate that: a. chest pain may occur. b. the electrode sites will be cleaned with alcohol. c. talking and moving around will be allowed. d. the electrodes are attached with ties or rubber straps. ANS: B
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank Clean and prepare the skin; wipe the sites with alcohol to help remove oils that would prevent adherence of the electrodes. Although the procedure is painless, it is important to document and note whether the patient is experiencing any chest discomfort during the procedure. Instruct the patient to lie still without talking. Electrodes are self-sticking. DIF: Cognitive Level: Application REF: Text reference: p. 1124 OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures. TOP: Electrocardiogram (ECG) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse is caring for a patient who underwent a cardiac catheterization. The sheaths have
just been removed. You should assess the patient carefully for what potential complication? a. Vasovagal reaction b. Hypertension c. Tachycardia d. Allergic reaction ANS: A
Before removing the catheter sheath, check the health care provider’s orders for instructions on treating a vasovagal reaction. Manual pressure applied to the groin/femoral area can stimulate the baroreceptors and cause a vasovagal reaction in which the patient becomes bradycardic and hypotensive. Vasovagal reactions are usually brief and self-limited. When applying pressure to the groin after sheath removal, be alert for a vasovagal reaction and be prepared to treat it by lowering the head of the bed to the flat position and giving a bolus of IV fluids. DIF: Cognitive Level: ApplicN atiU onRSINGRT EB F:.C TeO xtMreference: p. 1107 OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures. TOP: Cardiac Catheterization KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. You are caring for a patient who has received moderate sedation for a procedure at the
bedside. Which task can you delegate to the nurse assistant during this procedure? a. Assessing sedation score b. Obtaining blood pressure c. Monitoring respiratory rate d. Recording urine output ANS: D
The task of assisting with IV moderate sedation, including the pre-procedure assessment, cannot be delegated to nursing assistive personnel (NAP). In most agencies, an RN or health care provider assesses and monitors a patient’s level of sedation, airway patency, and level of consciousness. Roles in monitoring depend on scope-of-practice guidelines as determined by state regulations (see agency policy). You could delegate to assistive personnel the task of recording urine output. DIF: Cognitive Level: Application REF: Text reference: p. 1099 OBJ: Describe the health care team collaboration and teamwork required before, during, and after procedures, including delegation to nursing assistive personnel. TOP: Conscious Sedation KEY: Nursing Process Step: Implementation
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank MSC: NCLEX: Safe and Effective Care MULTIPLE RESPONSE 1. The patient will be undergoing moderate intravenous (IV) sedation. The nurse needs to assess
which of the following during the procedure? (Select all that apply.) a. Airway compromise b. Hemodynamic instability c. Agitation d. Combativeness ANS: A, B, C, D
Patient risks during IV sedation include hypoventilation, airway compromise, hemodynamic instability, and/or altered levels of consciousness that include an overly depressed level of consciousness or agitation and combativeness. Emergency equipment appropriate for the patient’s age and size and staff with skill in airway management, oxygen delivery, and use of resuscitation equipment are essential. During and after the procedure, patients need continuous monitoring of vital signs, oxygen saturation, heart rhythm, lung sounds, and level of consciousness. DIF: Cognitive Level: Application REF: Text reference: p. 1102 OBJ: Demonstrate understanding of nursing responsibilities related to the use of intravenous sedation during diagnostic procedures. TOP: Moderate Sedation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The patient has undergone a cardiac catheterization. It has been 2 hours since the catheter and
sheath have been removed. Which theGfollowing NU RSofIN B.CO Mwould be a concern for the nurse T recovering the patient after the procedure? (Select all that apply.) a. Swelling and hardness at the catheter insertion site b. Complaints of itching and urticaria c. Urine output less than 30 mL/hour d. Low back pain radiating to both sides of the body ANS: A, B, C, D
If hematoma or hemorrhage is present at the catheter insertion site, apply pressure over the insertion site, and notify the health care provider or physician if interventions do not stop the bleeding, or if the patient demonstrates symptoms of acute blood loss (hypotension, tachycardia). If the patient has an allergic reaction to contrast medium manifested by symptoms of flushing, itching, and urticaria, continue monitoring the patient and assess for anaphylaxis. Notify the health care provider. Renal toxicity from contrast can be detected by monitoring intake and output. Urine output of less than 30 mL/hour is a sign of renal toxicity. Low back pain radiating to both sides of the body is a hallmark sign of retroperitoneal bleeding. DIF: Cognitive Level: Analysis REF: Text reference: p. 1108 OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures. TOP: Reaction to IV Dye KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. Both aspiration and biopsy diagnose and differentiate which of the following? (Select all that
apply.)
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank a. b. c. d.
Leukemia Certain malignancies Heart disease Thrombocytopenia/anemia
ANS: A, B, D
Both aspiration and biopsy diagnose and differentiate leukemia, certain malignancies, anemia, and thrombocytopenia. Heart disease is not diagnosed with these studies. DIF: Cognitive Level: Comprehension REF: Text reference: p. 1109 OBJ: Identify physiological indications for diagnostic procedures. TOP: Bone marrow Biopsy/Aspiration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is caring for a patient who has just undergone a bronchoscopy and has been in
recovery for the last 15 minutes. The nurse should be especially watchful for which of the following? (Select all that apply.) a. Return of the gag reflex b. Laryngospasm c. Respiratory status d. Facial or neck crepitus ANS: B, C, D
Laryngospasm with bronchospasm evidenced by sudden, severe shortness of breath is an unexpected and potentially lethal outcome. Call the health care provider or physician immediately, prepare emergency resuscitation equipment, and anticipate a possible cricothyrotomy. Observe respiratory status closely, particularly for facial or neck crepitus. This is an early sign of broncN hial Rper Ifora Gtion B. .ThCeOgMag reflex does not normally return until 2 U S N T hours after the procedure. DIF: Cognitive Level: Application REF: Text reference: p. 1118 OBJ: Perform appropriate physical and psychosocial assessments before, during, and after diagnostic procedures. TOP: Evaluation of Patient Undergoing Bronchoscopy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 1.
is often used for diagnostic or surgical procedures that do not require complete anesthesia in acute care, surgical care, and outpatient care settings. ANS:
Intravenous sedation Intravenous sedation is often used for diagnostic or surgical procedures that do not require complete anesthesia in acute care, surgical care, and outpatient care settings. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1099 OBJ: Demonstrate understanding of nursing responsibilities related to the use of IV sedation during the diagnostic/surgical procedure. TOP: Intravenous Sedation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank apply manual compression to prevent bleeding at the arterial site.
2. ANS:
Vascular closure devices The use of a vascular closure device is now common after procedures involving an arteriotomy. These devices apply manual compression to prevent bleeding at the arterial site. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1107 OBJ: Perform appropriate physical and psychological assessments before, during, and after related procedures. TOP: Vascular Closure Devices KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3.
is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. In addition, no interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. ANS:
Moderate sedation Moderate sedation/analgesia produces a minimally depressed level of consciousness induced by the administration of pharmacological agents in which a patient retains a continuous and independent ability to maintain protective reflexes and a patent airway and is aroused by physical or verbal stimulation. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1099 OBJ: Perform appropriate physical and psychological assessments before, during, and after related procedures. TOP: Moderate Sedation KEY: Nursing Process Step: AN ssU esR sm ntNGMTSB C. : C NC SeI OLMEX: Physiological Integrity 4. An
permits visualization of the vasculature of an organ and the organ’s
arterial system. ANS:
arteriogram (angiogram) An arteriogram (angiogram) permits visualization of the vasculature and arterial system of an organ. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1103 OBJ: Identify physiological indications for diagnostic procedures. TOP: Arteriogram (Angiogram) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. A specialized form of angiography in which a catheter is inserted into the left or right side of
the heart via a major peripheral vessel to study pressures within the heart, cardiac volumes, valvular function, and patency of coronary arteries is known as . ANS:
cardiac catheterization Cardiac catheterization is a specialized form of angiography in which a catheter is inserted into the left or right side of the heart via a major peripheral vessel. This test studies pressures within the heart, cardiac volumes, valvular function, and patency of coronary arteries.
Clinical Nursing Skills and Techniques 8th Edition Perry Test Bank
DIF: Cognitive Level: Knowledge REF: Text reference: p. 1103 OBJ: Identify physiological indications for diagnostic procedures. TOP: Cardiac Catheterization KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6.
are sterile invasive procedures involving the removal of body fluids or tissue for diagnostic procedures. ANS:
Aspirations Aspirations are sterile invasive procedures involving the removal of body fluids or tissue for diagnostic procedures. Informed consent is required for these invasive procedures. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1109 OBJ: Identify physiological indications for diagnostic procedures. TOP: Aspirations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The removal of a small amount of the liquid organic material in the medullary canals of
selected bones, in particular the sternum and the posterior superior iliac crests in adults, is known as . ANS:
bone marrow aspiration Bone marrow aspiration is the removal of a small amount of the liquid organic material in the medullary canals of selected bones, in particular the sternum and the posterior superior iliac crests in adults. NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Text reference: p. 1109 OBJ: Identify physiological indications for diagnostic procedures. TOP: Bone Marrow Aspiration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. A
involves the introduction of a needle into the subarachnoid space of the spinal column. The purpose of this test is to measure pressure in the subarachnoid space; obtain cerebrospinal fluid (CSF) for visualization and laboratory examination; and inject anesthetic, diagnostic, or therapeutic agents. ANS:
lumbar puncture (LP) A lumbar puncture (LP), called a spinal puncture or spinal tap, involves the introduction of a needle into the subarachnoid space of the spinal column. The purpose of this test is to measure pressure in the subarachnoid space; obtain CSF for visualization and laboratory examination; and inject anesthetic, diagnostic, or therapeutic agents. DIF: Cognitive Level: Knowledge REF: Text reference: p. 1109 OBJ: Identify physiological indications for diagnostic procedures. TOP: Lumbar Puncture KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity