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[Solved] NCLEX practice questions Interventions Nursing Prep

NCLEX practice questions Interventions Nursing Prep NCLEX practice questions Interventions Nursing Prep Question 1: (see full question) When performing an abdominal assessment,the nurse uses a different order of techniques than with other systems. W hich ofthe following represents this order You selected: Correct Explanation: In an abdominal assessment, start with inspection, then auscultation, percussion, and palpation. This isthe preferred approach because palpation and percussion before auscultation may alterthe sounds heard. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 658. Chapter 25: Health Assessment - Page 658 ________________________________________ Question 2: (see full question) The nurse in post-anesthesia recovery (PAR) is caring for a 27-year-old client following an appendectomy. Twenty minutes after receiving 4 mg of intravenous (IV) morphine for abdominal pain,the client continues to report abdominal discomfort and requests more morphine. Which action bythe nurse is best? You selected: Correct Explanation: Continued abdominal pain after administration of IV morphine is an unexpected occurrence and requires further assessment bythe nurse to rule out peritonitis or internal bleeding by observingthe abdomen for distention and rigidity. Administration of more morphine could maskthe cause ofthe abdominal pain and delay diagnosis of a possible postoperative complication. Applying heat tothe abdomen would increase blood flow tothe area and potentially increase pain or internal bleeding. Positioningthe client in a knees-flexed position may relievethe discomfort, but an assessment is needed before any intervention is implemented. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 658. Chapter 25: Health Assessment - Page 658 ________________________________________ Question 3: (see full question) The nurse will obtainthe greatest amount of information aboutthe thyroid gland by using which technique of assessment? You selected: Correct Explanation: The thyroid gland is assessed by palpation, although it is not normally palpable in some patients. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 647-648. Chapter 25: Health Assessment - Page 647 ________________________________________ Question 4: (see full question) The nurse is asking admission interview questions andthe client has explainedthe reason for seeking care. Which ofthe following isthe most appropriate way to documentthe response? You selected: Client describes shortness of breath and increased sputum production. Incorrect Correct response: Explanation: The client's reason for seeking care should always be stated inthe client's own words. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 628. Chapter 25: Health Assessment - Page 628 ________________________________________ Question 5: (see full question) The nurse inthe emergency department observes a client experiencing a generalized tonic–clonic seizure. What isthe priority intervention forthe nurse to take? You selected: Correct Explanation: Risk for aspiration is a concern during a seizure becausethe client will have copious oral secretions that will need to be suctioned and allowed to drain out ofthe nurse should assessthe client's airway and maintain it by placingthe client in a side-lying position, which will allowthe oral secretions to drain from his mouth and not accumulate in his throat and compromisethe airway. It is contraindicated to place anything inthe mouth of a person who is actively convulsing. Reorientingthe client and documentingthe seizure are important actions afterthe postictal phase, but client safety isthe priority intervention during a seizure. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 625. Chapter 25: Health Assessment - Page 625 ________________________________________ Question 6: (see full question) The nurse is caring for a client who just informed her that he noticed some blood inthe toilet after a bowel nurse assessesthe client's anal area and notes a deep linear separation inthe skin that extends intothe nurse recognizes that this skin lesion is characteristic of which ofthe following? You selected: Erosion Incorrect Correct response: Explanation: A fissure is characterized as a deep linear separation inthe skin that extends intothe dermis. Erosion is a loss of superficial epidermis; it is moist and may bleed. An ulcer appears as a loss of epidermis and dermis and may bleed. Crusts are dried residue (serum, pus, or blood) onthe skin. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 641, Table 25-4. Chapter 25: Health Assessment - Page 641 ________________________________________ Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 654, Box 25-5. Chapter 25: Health Assessment - Page 654 Question 7: (see full question) The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In countingthe apical pulse,the nurse recognizes which characteristic about heart sounds? You selected: Correct Explanation: Each lub (the first heart sound) representsthe closure ofthe mitral and tricuspid valves during systole, andthe dub (the second heart sound) representsthe closure ofthe aortic and pulmonic valves during diastole. Togetherthe lub-dub sounds are counted as one two sounds occur within 1 second or less of each other, depending onthe heart rate. (less) Question 8: (see full question) Which assessment measure wouldthe nurse use to assessthe location, shape, size, and density of a tumor? You selected: Correct Explanation: Percussion isthe act of striking one object against another to produce fingertips are used to tapthe body over body tissues to produce vibrations and sound location, shape, size, and density of organs or tumors are assessed with this method. Observation is visually looking at an characteristics that can be determined about a tumor by palpation include shape, size, consistency, surface, mobility, tenderness, and pulsatile. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 635 ________________________________________ Question 9: (see full question) The nurse is palpatingthe skin of a 30-year old patient and documents that when picked up in a fold,the skin fold slowly returns to normal. What would bethe next action ofthe nurse based on this finding? You selected: Correct Explanation: Turgor isthe fullness or elasticity ofthe patient should be further assessed for signs and symptoms of dehydration because poor skin turgor is a sign of dehydration. Whenthe patient is dehydrated,the skin’s elasticity is decreased, andthe skin fold returns slowly. Poor skin turgor is neither a sign of cardiovascular disease, nor cystic fibrosis. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 639 ________________________________________ Question 10: (see full question) The nurse is using a bed scale to weigh a patient, andthe patient becomes agitated asthe sling rises inthe air. What would bethe priority nursing intervention in this situation? You selected: Enlistthe help of another nurse to holdthe patient steady duringthe procedure. Incorrect Correct response: Explanation: The nurse should stop liftingthe patient and reassure him or her. Ifthe patient continues to be agitated,the nurse lowersthe patient back tothe bed, and reevaluatesthe necessity of obtaining weight at that exact time. Continuing to liftthe patient may result in injury tothe patient. An order for sedation would only be requested if it was absolutely necessary to obtainthe patient’s weight at this time. Another nurse holdingthe patient steady does not addressthe patient’s agitation. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 674 ________________________________________ Question 11: (see full question) To obtain subjective data about a newly admitted client's sleep pattern,the nurse You selected: Correct Explanation: The assessment of sleep and rest focuses onthe client's normal sleep patterns, alterations fromthe normal pattern, and satisfaction with quality of rest and sleep. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 625. Chapter 25: Health Assessment - Page 625 ________________________________________ Question 12: (see full question) A nurse performs an assessment on a client who has been admitted to a long-term care facility for physical rehabilitation. What isthe term for this type of assessment? You selected: Correct Explanation: A comprehensive assessment with a detailed health history and complete physical examination are usually conducted when a client enters a health care setting. An ongoing and focused assessment is conducted at regular intervals during client care. An emergency assessment is a rapid, focused assessment conducted to determine potentially fatal situations. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 626. Chapter 25: Health Assessment - Page 626 ________________________________________ Question 13: (see full question) A 57-year-old male client is admitted tothe medical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique wouldthe nurse perform last? You selected: Correct Explanation: The sequence of techniques used to assessthe abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 659. Chapter 25: Health Assessment - Page 659 ________________________________________ Question 14: (see full question) You are assessing a patient's thorax and lungs. Which ofthe following findings would indicatethe need for further assessment? You selected: Correct Explanation: Crackles (short, high-pitched popping sounds) may indicate disease, such as pneumonia or heart failure. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 648. Chapter 25: Health Assessment - Page 648 ________________________________________ Question 15: (see full question) A nurse assesses a patient for blood pressure. Which ofthe following techniques would be used for this assessment? You selected: Inspection Incorrect Correct response: Explanation: Auscultation isthe act of listening with a stethoscope to sounds produced withinthe body. This technique is used to listen for blood pressure, heart sounds, lung sounds, and bowel sounds. Inspection isthe process of performing deliberate, purposeful observations in a systematic manner. It usesthe senses of smell, hearing, and hands and fingers are sensitive tools of palpation and can assess temperature, turgor, texture, moisture, pulsations, vibrations, shape and masses, and organs. Percussion is used to assessthe location, shape, and size of organs, andthe density of other underlying structures or tissues. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 632. Chapter 25: Health Assessment - Page 632 ________________________________________ Question 16: (see full question) The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which ofthe following actions, if observed, would requirethe charge nurse to intervene? You selected: Correct Explanation: Palpation of both arteries at once can obstruct blood flow tothe brain. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 655. Chapter 25: Health Assessment - Page 655 ________________________________________ Question 17: (see full question) The nurse is caring for an 88-year-old male admitted 2 days ago for nurse bringsthe client his breakfast tray and notes thatthe client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate? You selected: Correct Explanation: Ear wax (cerumen) becomes drier inthe elderly and can blockthe ear canal and cause decreased hearing. Askingthe client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating withthe hard of hearing, but this client’s hearing loss was acute and requires further assessment. When speaking tothe elderly who are hearing-impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic forthe elderly. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 646. Chapter 25: Health Assessment - Page 646 ________________________________________ Question 18: (see full question) The acute care nurse is assessing a newly admitted client's abdomen. Which ofthe following findings would indicatethe need to contactthe primary care provider? You selected: Correct Explanation: A bruit on auscultation suggests an aneurysm or arterial stenosis. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654. Chapter 25: Health Assessment - Page 654 ________________________________________ Question 19: (see full question) A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each client prior tothe client's scheduled nurse would document an unexpected finding if unable to palpate a client's ... You selected: Correct Explanation: Nonpalpable peripheral pulses are an unexpected finding, which warrants further assessment and liver, lymph nodes, and thyroid are not normally palpable in healthy individuals. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 652-655. Chapter 25: Health Assessment - Page 652 ________________________________________ Question 20: (see full question) Upon auscultation of a client's lung fields,the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? You selected: Correct Explanation: Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors;the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing againstthe chest wall. Crackles are fine to coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 652. Chapter 25: Health Assessment - Page 652 Question 18: (see full question) The acute care nurse is assessing a newly admitted client's abdomen. Which ofthe following findings would indicatethe need to contactthe primary care provider? You selected: Correct Explanation: A bruit on auscultation suggests an aneurysm or arterial stenosis. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654. Chapter 25: Health Assessment - Page 654 ________________________________________ Question 19: (see full question) A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each client prior tothe client's scheduled nurse would document an unexpected finding if unable to palpate a client's ... You selected: Correct Explanation: Nonpalpable peripheral pulses are an unexpected finding, which warrants further assessment and liver, lymph nodes, and thyroid are not normally palpable in healthy individuals. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 652-655. Chapter 25: Health Assessment - Page 652 ________________________________________ Question 20: (see full question) Upon auscultation of a client's lung fields,the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? You selected: Correct Explanation: Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors;the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing againstthe chest wall. Crackles are fine to coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 652. Chapter 25: Health Assessment - Page 652 Answer Key Question 1: (see full question) The nurse is caring for a client after a stroke that leftthe client's right side weaker thanthe nurse coordinatesthe plan of care withthe physical nurse's interventions reflect which one of nursing's four broad goals? You selected: Correct Explanation: The four broad aims of nursing practice are to promote health, prevent illness, restore health, and facilitate coping with death and/or disability. Inthe example,the nurse is coordinating care withthe other disciplines in an attempt regain some ofthe strength inthe client's right side. This is an example of restoring a client's nurse is not preventingthe stroke or promoting health prior tothe stroke or facilitating coping withthe stroke. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 10. Chapter 1: Introduction to Nursing - Page 10 ________________________________________ Question 2: (see full question) A man age 61 years is distraught because he has just learned that his most recent computed tomography (CT) scan shows that his colon cancer has metastasized to his lungs. Which ofthe following nursing aims shouldthe nurse prioritize inthe immediate care of this patient? You selected: Correct Explanation: This patient's care inthe coming weeks or months will likely encompass all ofthe four foundational roles ofthe nurse. However, becausethe patient has just recently received bad news and is emotionally distraught, helpingthe patient cope is an appropriate priority in his immediate care. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 13. Chapter 1: Introduction to Nursing - Page 13 ________________________________________ Question 3: (see full question) The nurse working with an LPN understands which ofthe following about LPNs? You selected: They may work independently. Incorrect Correct response: Explanation: Schools for practical nursing programs are located in varied settings. Most programs are 1 year in length. Upon completion ofthe program, graduates can takethe National Council Licensure Examination-Practical Nurse (NCLEX-PN) for licensure as an LPN. LPNs work underthe direction of a physician or RN to give direct care to clients, focusing on meeting healthcare needs in hospitals, nursing homes, and home health agencies. (less) Question 4: (see full question) A group of nursing students has attended a presentation aboutthe National Student Nurses' Association (NSNA). Which statement bythe group indicates that they have understoodthe information presented? You selected: The organization provides programs of current professional interest. Correct Explanation: The National Student Nurses' Association provides programs of current professional interest. It is not run by a group of registered nurses, but by nursing students themselves. It is student-funded, not funded bythe national Commission on Collegiate Nursing Education, notthe National Student Nurses' Association, contributes tothe improvement of public health. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 17. Chapter 1: Introduction to Nursing - Page 17 ________________________________________ Question 5: (see full question) Which nursing actions demonstratethe aim of nursing to facilitate coping? (Select all that apply.) You selected: Correct Explanation: Coping is another important broad aim of nursing. Nurses facilitate client and family coping with altered function, life crisis, and death. Examples of coping would be teaching a client andthe client’s family about how to live with diabetes. Another example would be assisting a client andthe client’s family to prepare for death. A third example would be providing counseling forthe family of a teenager with an eating disorder. Changing bandages, starting an IV, or teaching a class on an expected healthcare issue or need would not be examples ofthe aim of facilitating coping with disability or death. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 1: Introduction to Nursing, p. 13. Chapter 1: Introduction to Nursing - Page 13 ________________________________________ Question 6: (see full question) What was one barrier tothe development ofthe nursing profession inthe United States afterthe Civil War? You selected: Correct Explanation: A lack of educational standards was one barrier tothe development ofthe nursing profession afterthe Civil War. Other barriers included a male dominance of health care andthe pervading belief that women were dependent on location of nursing schools, a lack of influence from nursing leaders, and independent nursing orders were not barriers tothe development ofthe nursing profession afterthe Civil War. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 7. Chapter 1: Introduction to Nursing - Page 7 ________________________________________ Question 7: (see full question) In what time period did nursing care as we now know it begin? You selected: Correct Explanation: Fromthe middle ofthe 18th century tothe 19th century, social reforms changedthe roles of nurses and of women in general. It was during this time that nursing as we now know it began, based onthe beliefs of Florence Nightingale. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 7. Chapter 1: Introduction to Nursing - Page 7 ________________________________________ Question 8: (see full question) Duringthe Reformation, what factor influencedthe decline of nursing? You selected: Correct Explanation: Women were viewed as subordinate to men and were expected to remain at home caring for children; this decreasedthe number of qualified women practicing nursing. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 7. Chapter 1: Introduction to Nursing - Page 7 ________________________________________ Question 9: (see full question) Which ofthe following nursing interventions would bethe most appropriate for a new mother that callsthe nursery for help with breastfeeding? You selected: Correct Explanation: It isthe role ofthe nurse to encourage health promotion by providing information and referrals; therefore,the nurse should referthe mother for a home care visit, as this will enablethe mother to receive all ofthe breast feeing help that is needed. Emailing a link for breastfeeding provides information, but notthe support that is needed if a mother is having difficulty with breastfeeding. Suggesting bottle feeding and/or going tothe emergency room is inappropriate. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11. Chapter 1: Introduction to Nursing - Page 11 ________________________________________ Question 10: (see full question) A nurse is providing care for patients in a long-term care facility. Based onthe definitions of nursing inthe textbook, what should bethe central focus of this care? You selected: The nurse asthe caregiver Incorrect Correct response: Explanation: The client receivingthe care is alwaysthe central focus ofthe nursing care central focus is notthe nurse,the nursing actions, or nursing as a profession. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 1: Introduction to Nursing, p. 5. Chapter 1: Introduction to Nursing - Page 5 ________________________________________ Question 11: (see full question) The nurse is evaluating client health. Which ofthe following clients shouldthe nurse determine to be exhibitingthe most signs of health? You selected: Correct Explanation: As defined bythe World Health Organization, one’s health includes physical, social, and mental components and is not merelythe absence of disease or infirmity. Health is often a subjective state—a person may be medically diagnosed with an illness, but still consider himself or herself client with an amputee is performing activities of daily living, thereby demonstrating healthy behaviors. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11. Chapter 1: Introduction to Nursing - Page 11 ________________________________________ Question 12: (see full question) The nurse utilizingthe nursing process includes which ofthe following steps? Select all that apply. You selected: Correct Explanation: less Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 19. ________________________________________ Question 13: (see full question) Duringthe course of any given day of work inthe acute care setting,the nurse may need to perform which ofthe following roles? Select all that apply. You selected: Correct Explanation: The roles and functions ofthe nurse are many and include: caregiver, communicator, teacher, counselor, leader, researcher, and advocate. Acting as financier and statistician are notthe roles ofthe nurse. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11. Chapter 1: Introduction to Nursing - Page 11 ________________________________________ Question 14: (see full question) Florence Nightingale introducedthe concept of apprenticeship for nurses. Which ofthe following statements is an example of this? You selected: Correct Explanation: Florence Nightingale's concept of apprenticeship involved training student nurses in a hospital setting. Completing clinical hours is an example of other choices do not reflect this concept. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 7. Chapter 1: Introduction to Nursing - Page 7 ________________________________________ Question 15: (see full question) The nurse caring for a client with a new diagnosis of cancer allowsthe client to verbalize fears relating to how to tellthe nurse's intervention reflects which aspect of nursing? You selected: Correct Explanation: less Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 5. ________________________________________ Question 16: (see full question) The registered nurse is teaching a community health class about illness prevention. Which ofthe following statements reflects understanding of this concept? You selected: Correct Explanation: Enrolling in a smoking cessation class is an example of illness prevention. It will prevent conditions such as asthma and COPD. A hospice evaluation is for someone who is terminally ill, hypertension is already a disease entity, and an ambulance for injury does not denote illness prevention. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 12. Chapter 1: Introduction to Nursing - Page 12 ________________________________________ Question 17: (see full question) A registered nurse wishes to work as a nurse researcher. Which ofthe following is true regarding nurse researchers? You selected: Correct Explanation: Nurse researchers are responsible forthe continued development and refinement of nursing. They usually have advanced education in addition to a baccalaureate degree in nursing. Nurse administrators, not nurse researchers, serve as liaisons between staff members and directors of nursing. Nurse researchers tend to work in large teaching hospitals, research centers, and academic institutions, not community health centers and long-term care units. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 16. Chapter 1: Introduction to Nursing - Page 16 ________________________________________ Question 18: (see full question) The nurse is conducting a community education class onthe 2011 Institute of Medicine Report onthe role of nursing in transforming healthcare. Which ofthe following statements shouldthe nurse include? You selected: • Nurses should follow physicians' lead for changingthe healthcare system. •the infrastructure for data collection related to nursing is in place. Incorrect Correct response: Explanation: In 2011,the Institute of Medicine (IOM) released four key messages underlying their recommendations for transformingthe nursing profession. These include that nurses should practice tothe full extent of their education and training. Therefore,the nurse should include that nurse practitioners be allowed to practice independently and to practice atthe full extent of their IOM also recommended that nurses achieve higher levels of education and training through an improved educational system promoting seamless academic progression. Therefore,the nurse should include that barriers to diploma nurses receiving their BSN be IOM recommendations do not include that baccalaureate trained nurses do not need further academic IOM recommends that nurses be full partners versus followthe lead of physicians in changingthe healthcare IOM also recommended that there be better data collection and improved information infrastructure. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 20. Chapter 1: Introduction to Nursing - Page 20 ________________________________________ Question 19: (see full question) The diploma nurse is considering obtaining a baccalaureate degree. Which degree shouldthe nurse investigate? You selected: Correct Explanation: The diploma nurse considering obtaining a baccalaureate degree should investigate RN to BSN programs. This degree is designed for registered nurses with a diploma DNP is designed asthe terminal degree (doctorate degree) for nursing accelerated degree is designed for people with a baccalaureate degree, not in nursing to obtain their BSN in 1 to 2 MSN is designed for nurses with a baccalaureate degree to obtain a masters degree in nursing. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, pp. 14-16. Chapter 1: Introduction to Nursing - Page 14 ________________________________________ Question 20: (see full question) Which ofthe following isthe best example of a nurse inthe role of counselor? You selected: Correct Explanation: Whenthe nurse is acting as a counselor,the nurse uses therapeutic interpersonal skills to facilitatethe client's problem-solving and decision-making best example isthe nurse allowingthe client to verbalize their feelings, as verbalizing feelings letsthe client gain a better perspective of their situation for problem solving and for coming to terms withthe situation. Tellingthe client aboutthe side effects of a medication is a form of teaching. Providing test results tothe physician is communication, and ensuring a client has follow-up care at a free clinic is advocacy. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11. Chapter 1: Introduction to Nursing - Page 11 congrats! Congratulations! You've reached Mastery Level 2 for Chapter 23: Asepsis and Infection Control! Quiz Results Quiz Stats Quiz completed in: 12 min Total Questions: 20 Questions answered: 20 Number correct: 19 95% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 23: Asepsis and Infection Control 1 Quiz taken My Mastery Level: 2.00 Class Average: 2.44 congrats! Congratulations! You've reached Mastery Level 2 for Chapter 23: Asepsis and Infection Control! Quiz Results Quiz Stats Quiz completed in: 12 min Total Questions: 20 Questions answered: 20 Number correct: 19 95% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 23: Asepsis and Infection Control 1 Quiz taken My Mastery Level: 2.00 Class Average: 2.44 Answer Key Question 1: (see full question) An infection-control nurse is discussing needlestick injuries with a group of newly hired infection control nurse informsthe group that most needlestick injuries result from which ofthe following? You selected: Recapping a needle Correct Explanation: Most needlesticks occur during recapping, so nurses are instructed to never recap needles. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 552. Chapter 23: Asepsis and Infection Control - Page 552 ________________________________________ Question 2: (see full question) Which ofthe following practices is a correct application of infection control practices? You selected: A nurse performs handwashing each time she removes a pair of gloves. Correct Explanation: Handwashing should be performed afterthe removal of a pair of gloves. Gloves are not required for each and every patient contact and visibly soiled hands require a wash with soap and water. Alcohol-based handrubs are not followed by a rinse. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 542. Chapter 23: Asepsis and Infection Control - Page 542 ________________________________________ Question 3: (see full question) A client has sexual intercourse with someone infected with HIV.the vehicle of transmission is You selected: Semen Correct Explanation: Vehicle transmission involvesthe transfer of microorganisms by way of vehicles, or contaminated items that transmit pathogens. For example, food can carry Salmonella. In this case, semen can carry human immunodeficiency virus. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 535. Chapter 23: Asepsis and Infection Control - Page 535 ________________________________________ Question 4: (see full question) A nurse is taking care of a client with tuberculosis who has developed resistance tothe ordered antibiotic. Which type of client is most likely at increased risk for infection? You selected: Older adult Correct Explanation: Long-term care residents and older adult hospitalized clients are at increased risk for antibiotic-resistant infections. Pneumonia, influenza, urinary tract and skin infections, and TB are common in older people, especially residents of long-term care facilities. These infectious diseases are not commonly seen in young adults, children, or pregnant women admitted to health care facilities. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 536-537. Chapter 23: Asepsis and Infection Control - Page 536 ________________________________________ Question 5: (see full question) Which ofthe following is an accurate guideline forthe use of PPE? You selected: Replace gloves if they are visibly soiled. Correct Explanation: If gloves become torn or heavily soiled, they should be removed and replaced. PPE should be put on before enteringthe client's room and glasses should not be substituted for protective eyewear. Work should progress from “clean” areas to “dirty” areas. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 570-572. Chapter 23: Asepsis and Infection Control - Page 570 ________________________________________ Question 6: (see full question) An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistantStaphylococcus aureus (MRSA). Which ofthe following measures shouldthe nursing staff prioritize in preventingthe spread of MRSA to clients who are currently MRSA-negative? You selected: Diligent handwashing practices Correct Explanation: As with all forms of infection, thorough handwashing isthe most important infection-control measure. It is inappropriate to reduce clients' length of stay based on their MRSA status, and prophylaxis is not normally used. It is unnecessary to wear gloves at all times onthe unit. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 545-546. Chapter 23: Asepsis and Infection Control - Page 545 ________________________________________ Question 7: (see full question) When a nurse picks up a client's contaminated tissue without gloves and fails to wash his hands sufficiently,the nurse provides forthe client's organisms to be spread by which type of transmission? You selected: Contact Correct Explanation: Direct contact involves body surface–to–body surface contact, causingthe physical transfer of organisms between an infected or colonized host and a susceptible host. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 534-535. Chapter 23: Asepsis and Infection Control - Page 534 ________________________________________ Question 8: (see full question) You have completed an intervention with a patient. There is no visible soiling on your hands. Which ofthe following techniques is recommended bythe Centers for Disease Control (CDC) for hand hygiene? You selected: Decontaminate hands using an alcohol-based hand rub. Correct Explanation: Alcohol-based hand rubs can be used if hands are not visibly soiled. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 542. Chapter 23: Asepsis and Infection Control - Page 542 ________________________________________ Question 9: (see full question) When preparing to use a bottle of sterile saline for a dressing change,the nurse notes thatthe date it was opened was two days previous. What shouldthe nurse do? You selected: Obtain a new bottle of sterile saline Correct Explanation: The nurse should obtain a new bottle of sterile saline, as most solutions are considered sterile for 24 hours after they are opened. Shakingthe bottle will not impact its sterility. Switching to sterile water is not indicated. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 23: Asepsis and Infection Control, p. 553. Chapter 23: Asepsis and Infection Control - Page 553 ________________________________________ Question 10: (see full question) You are donning a pair of sterile gloves. You correctly donthe first glove, but inadvertently insertthe thumb and index finger intothe thumb hole ofthe second glove remains intact. Which ofthe following actions is most appropriate? You selected: Continue to donthe glove, then usethe other gloved hand to carefully insertthe finger intothe proper hole. Correct Explanation: It is appropriate to adjustthe gloves but touching sterile surface to sterile surface. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 571. Chapter 23: Asepsis and Infection Control - Page 571 ________________________________________ Question 11: (see full question) To eliminate needlesticks as potential hazards to nurses,the nurse should You selected: Slidethe needle intothe cap and deposit it in a puncture-proof plastic container Incorrect Correct response: Immediately deposit uncapped needles into puncture-proof plastic container Explanation: All uncapped needles should be placed in puncture-proof plastic units immediately after use. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 552. Chapter 23: Asepsis and Infection Control - Page 552 ________________________________________ Question 12: (see full question) Upon review of a client's microbiology culture results,the nurse recognizes which organism as indicative of normal flora? You selected: Escherichia coli inthe intestinal tract Correct Explanation: Escherichia coli resides inthe intestinal tract, is normal flora, and does not cause harm or infection inthe client. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 534. Chapter 23: Asepsis and Infection Control - Page 534 ________________________________________ Question 13: (see full question) When leavingthe room of a client requiring contact precautions after helping an unlicensed personnel (UP) bathethe client,the nurse observesthe unlicensed personnel taking gloves off by graspingthe inside of one gloved hand withthe opposite gloved hand and peeling it off. What isthe proper action ofthe nurse? You selected: Demonstrate proper glove removal tothe unlicensed personnel. Correct Explanation: It is important forthe unlicensed personnel to learn how to remove gloves nurse should demonstrate proper glove removal tothe unlicensed personnel. There is no need to reportthe unlicensed personnel tothe unit manager. Reassigningthe unlicensed personnel is not appropriate. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 23: Asepsis and Infection Control, p. 544. Chapter 23: Asepsis and Infection Control - Page 544 ________________________________________ Question 14: (see full question) Surgical asepsis is defined as You selected: Absence of all microorganisms Correct Explanation: Surgical asepsis refers to sterile technique and indicates procedures used to eliminate any microorganisms. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 539. Chapter 23: Asepsis and Infection Control - Page 539 ________________________________________ Question 15: (see full question) A nurse prefers to use an alcohol-based hand rub when providing care for patients. In which case is this practice contraindicated? You selected: The nurse is caring for a client with a C. difficile infection. Correct Explanation: Controversy exists regardingthe use of alcohol-based handrubs when C. difficile organisms have been identified. Alcohol does not kill C. difficile spores. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 23: Asepsis and Infection Control, p. 543. Chapter 23: Asepsis and Infection Control - Page 543 ________________________________________ Question 16: (see full question) A patient is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure? You selected: Surgical asepsis technique Correct Explanation: Surgical asepsis technique isthe technique followed to insert an indwelling urinary catheter. Surgical asepsis techniques, used regularly inthe operating room, labor and delivery areas, and certain diagnostic testing areas, are also used bythe nurse atthe patient’s bedside. Procedures that involvethe insertion of a urinary catheter, sterile dressing changes, or preparing an injectable medication are examples of surgical asepsis techniques. An object is considered sterile when all microorganisms, including pathogens and spores, have been destroyed. Medical asepsis, or clean technique, involves procedures and practices that reducethe number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Strict reverse isolation is an isolation technique wherethe client is protected fromthe nurse, other health care providers, and visitors. A client that has immune system disorders wherethe client might not be able to fight off an organism would be kept in an environment to minimize exposure tothe organism. Droplet precaution is a technique where appropriate personal protective equipment (PPE) is worn to not carrythe organism via droplet from exposed client to others. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 23: Asepsis and Infection Control, p. 553. Chapter 23: Asepsis and Infection Control - Page 553 ________________________________________ Question 17: (see full question) The use of alcohol-based hand rubs for hand hygiene in healthcare facilities is approved bythe Centers for Disease Control (CDC), butthe Joint Commission (TJC) discourages its use. You selected: False Correct Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 540. Chapter 23: Asepsis and Infection Control - Page 540 ________________________________________ Question 18: (see full question) For which ofthe following clients wouldthe use of Standard Precautions alone be appropriate? You selected: An incontinent client in a nursing home who has diarrhea Correct Explanation: Standard Precautions apply to blood and all body fluids, secretions, and excretions, except sweat. Transmission-Based Precautions are used in addition to Standard Precautions for clients hospitalized with suspected infection by pathogens that can be transmitted by airborne, droplet, or contact routes, such as isthe case in answers A, B, and D. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 550. Chapter 23: Asepsis and Infection Control - Page 550 ________________________________________ Question 19: (see full question) A nurse who is takingthe vital signs of a client with acute diarrhea is ordered to attend to another client. What isthe highest priority nursing actionthe nurse must perform before leavingthe client's room? You selected: Thorough handwashing Correct Explanation: Sincethe client has an infectious disease,the most important nursing action is to perform thorough handwashing before leavingthe client's room and before touching any other client, personnel, environmental surface, or client care item. Spraying a disinfectant before leavingthe client's room, or placing one bag of contaminated items in another is notthe most important nursing action in this case. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. Nurses removethe personal protective equipment that is most contaminated first to preservethe clean uniform underneath. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 539. Chapter 23: Asepsis and Infection Control - Page 539 ________________________________________ Question 20: (see full question) A home health nurse is completing a health history for a patient. What is one question that is important to ask to identify a latex allergy for this patient? You selected: “Have you had any unusual symptoms after blowing up balloons?” Correct Explanation: Awareness of a latex allergy is important for safe home care. Nurses need to ask whether patients have experienced any unusual signs or symptoms when blowing up balloons, using latex condoms, or wearing rubber gloves for dishwashing or cleaning. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 548. Chapter 23: Asepsis and Infection Control - Page 548 Question 1: (see full question) Which level of health care provider may makethe decision to apply physical restraints to a client? You selected: Correct Explanation: Current evidence-based research has shown that physical restraints should only be used as a last resort, and only used to prevent injury to staff, clients, or others. Federal and state guidelines, as well as accrediting bodies, such asthe Joint Commission, require that restraints be applied only when ordered by a prescriber such as a physician, nurse practitioner, or physician's assistant. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 709. Chapter 26: Safety, Security, and Emergency Preparedness - Page 709 ________________________________________ Question 2: (see full question) An boy 18 years of age is brought tothe emergency department with a head nurse knows that adolescents are vulnerable to injuries related to which ofthe following? You selected: Correct Explanation: Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling fromthe bed is common in infants. Play-related injuries are commonly seen in school-age children, and falling from staircases is a common injury among toddlers. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, pp. 702-704. Chapter 26: Safety, Security, and Emergency Preparedness - Page 702 ________________________________________ Question 3: (see full question) Which statement indicates that a family understandsthe teaching that has been provided bythe nurse related to car seat safety for their 9-month-old infant? You selected: Correct Explanation: The American Academy of Pediatrics recommends that all children from birth to 2 years of age remain in a rear-facing car seat inthe back seat ofthe car until they are 2 years, or until they reachthe maximum height and weight forthe car seat. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 700-701. Chapter 26: Safety, Security, and Emergency Preparedness - Page 700 ________________________________________ Question 4: (see full question) One ofthe leading causes of death inthe United States, particularly in southwestern states, is drowning. How canthe nurse assist in lowering this statistic? You selected: Correct Explanation: The principles of injury control have interventions centered at three primary levels:the individual level, providing education about safety hazards and prevention strategies;the design phase, using engineering and environmental controls; andthe regulatory level, creating, monitoring, and enforcing regulations to ensure safe products and environments among manufacturers, retailers, employers, workers, and product users. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 696. Chapter 26: Safety, Security, and Emergency Preparedness - Page 696 ________________________________________ Question 5: (see full question) A home care nurse provides health education to parents regardingthe care of their toddler. Which ofthe following precautions shouldthe nurse suggestthe parents take to protectthe toddler from drowning? You selected: Correct Explanation: The parents should not leavethe toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away fromthe pool may make them more curious. Monitoringthe activities ofthe toddler is not always feasible. Allowingthe child to swim with friends does not ensure safety. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, pp. 700-701. Chapter 26: Safety, Security, and Emergency Preparedness - Page 700 ________________________________________ Question 6: (see full question) The nurse is applying wrist restraints on a client and notes thatthe client is unable to move his right arm. What isthe appropriate action bythe nurse? You selected: Correct Explanation: The nurse should apply onlythe left wrist restraint. Asthe client is unable to movethe right arm, this arm does not need restraining. Vest restraints and wrist restraints are typically utilized to meet different client needs, so they are not usually interchanged for one another. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 722. Chapter 26: Safety, Security, and Emergency Preparedness - Page 722 ________________________________________ Question 7: (see full question) Which ofthe following statements about restraints used inthe acute care setting is true? You selected: Correct Explanation: A valid physician or licensed independent practitioner's order is required forthe use of restraints, regardless of setting. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 719. Chapter 26: Safety, Security, and Emergency Preparedness - Page 719 ________________________________________ Question 8: (see full question) An administrative assistant of a large factory visitsthe medical unit and tellsthe nurse she is having pain inthe right wrist, numbness inthe index finger, and decreased mobility ofthe right nurse suspectsthe client has what? You selected: Correct Explanation: Adults with jobs that require repetitive movement (typists, assembly line workers, supermarket checkers, computer operators) may develop carpal tunnel syndrome, a compression of th ... (more) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 689. Chapter 26: Safety, Security, and Emergency Preparedness - Page 689 ________________________________________ Question 9: (see full question) The nurse needs to planthe interventions necessary to reduce fall risks forthe older adult clients at her facility. Which isthe strongest indicator that a client is at risk for falls? You selected: Correct Explanation: Documentation that a client has sustained previous falls is a strong predictor of a risk for future falls. Cardiovascular medications, being forgetful, or using an assistive device do not necessarily predispose a client to falling. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 687. Chapter 26: Safety, Security, and Emergency Preparedness - Page 687 ________________________________________ Question 10: (see full question) A nurse responds tothe call bell and finds another nurse evacuatingthe client fromthe room, which has caught fire. Which ofthe following actions shouldthe nurse take? You selected: Correct Explanation: The nurse should pullthe fire alarm lever. As perthe RACE principle of fire management,the flow of activities should be rescue, alarm, confine, and client had already been evacuated by another nurse, sothe next action should be to pullthe fire alarm lever, followed by confinement ofthe fire and extinguishing. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 710. Chapter 26: Safety, Security, and Emergency Preparedness - Page 710 ________________________________________ Question 11: (see full question) What is an appropriate nursing intervention to include inthe plan of care for a client with smallpox? You selected: Correct Explanation: Clients with smallpox should receive strict contact and airborne precautions for duration of illness and supportive care. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and emergency Preparedness, p. 715. Chapter 26: Safety, Security, and Emergency Preparedness - Page 715 ________________________________________ Question 12: (see full question) If a client is exposed to Viral Hemorrhagic Fevers, which clinical manifestations wouldthe nurse assess inthe client? You selected: Flu-like symptoms and a characteristic rash Incorrect Correct response: Explanation: Anthrax exposure can result in skin lesions that progress to necrotic ulcers and fever. Exposure to viral hemorrhagic fevers can result in Petechial hemorrhages and hypotension. Botulism exposure presents with Skeletal muscle paralysis and blurred vision. Small pox exposure presents with flu-like symptoms and a characteristic rash. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 715. Chapter 26: Safety, Security, and Emergency Preparedness - Page 715 ________________________________________ Question 13: (see full question) The school nurse is preparing a presentation about safety promotion for middle school students. Which topic shouldthe nurse plan to include? You selected: Correct Explanation: Seat belt use is an important safety precaution to teach audience of all ages. Improper or lack of seat belt use increasesthe risk for injury. It is not appropriate to teach middle school children about moderation with alcohol, workplace injury, or falls. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 689. Chapter 26: Safety, Security, and Emergency Preparedness - Page 689 ________________________________________ Question 14: (see full question) Which ofthe following reasons best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk? You selected: Correct Explanation: As adolescents explore opportunities, they may know that certain behaviors are unsafe, but social pressure can persuade them to act against their better judgment. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 689. Chapter 26: Safety, Security, and Emergency Preparedness - Page 689 ________________________________________ Question 15: (see full question) The nurse is caring for an 80-year-old patient who was admitted tothe hospital in a confused and dehydrated state. Afterthe patient got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists fromthe restraints. What would bethe most appropriate nursing intervention for this patient? You selected: Correct Explanation: Physical restraints increasethe possibility ofthe occurrence of falls, skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration respiratory difficulties, and even best action in this situation is forthe nurse to removethe restraint, stay withthe patient and gently talk to her. Sedating her with sleeping pills is a chemical form of restraint. Leavingthe restraints onthe patient to talk to her is going to cause further agitation and bruising of her patient’s condition dictates whenthe patient is discharged, not confusion and agitation. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 26, Safety, Security, and Emergency Preparedness, pp. 708-710 ________________________________________ Question 16: (see full question) An 8-year-old boy fell off his bicycle. He was not wearing a helmet and has sustained a concussion. What information shouldthe nurse teachthe parents about concussions? You selected: Correct Explanation: Frequent neurologic assessments are crucial after a traumatic brain injury, to assess for subtle changes as they begin. Helmets are meant to protectthe wearer, but head injury can still occur. "Passing off" an injury as something that kids get and then they are fine is wrong and potentially harmful. Watching TV and video games stimulates brain activity and may worsenthe child’s symptoms andthe injury itself. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 701-702. Chapter 26: Safety, Security, and Emergency Preparedness - Page 701 ________________________________________ Question 17: (see full question) A school-aged child is admitted tothe Emergency Room withthe diagnosis of a concussion following a collision when playing football. Afterthe collision,the parents state that he was “knocked out” for a few minutes before recognizing his surroundings. What isthe priority assessment whenthe nurse first seesthe patient? You selected: Correct Explanation: Assessment after a head injury includes immediate evaluation of airway, breathing, and circulation. Therefore, assessment of vital signs and respiratory status is a priority for this client. Head circumference is only benefi

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