BSN 366 TEST PAPER FULL SOLUTION
QUESTIONS AND CORRECT ANSWERS
GRADED A+
●● Which biological practices are federally regulated for healthcare
workers? (Select all that apply.)
Select all that apply
1.Standard precautions.
2. N-95 tuberculosis standard.
3. Blood-borne pathogen standard.
4. Biological product exposure limit (BPEL).
5. Resource Conservation and Recovery Act (RCRA).
6. As Low as Reasonably Allowable standard (ALARA).
Answer: 3. Blood-borne pathogen standard.
5. Resource Conservation and Recovery Act (RCRA)
Basic standards for healthcare workers, as delineated by Occupational
Safety and Health Administration (OSHA), include standard precautions,
droplet precautions using N-95 respiratory particulate masks when
caring for a client who is positive for tuberculosis, and required annual
updates for healthcare workers about blood-borne pathogen
,transmission, methods of minimizing exposure, and employee rights.
Other options [BPEL and ALARA ] are not federally regulated.
●● A client with severe depression tells the nurse, "I do not know why
you bother with me or give me pills. I am never going to get well." What
is the most therapeutic response?
1. "You need to stop thinking negative thoughts. They get in the way of
your recovery."
2. "You are no bother to me or to the staff. We want you to get well and
not feel sad anymore."
3. "I have known many clients with depression who have felt better after
several weeks of treatment."
4. "You are feeling very pessimistic, but that is part of your illness. It
should go away as you recover."
Answer: 3. "I have known many clients with depression who have felt
better after several weeks of treatment."
Stating the observation that others have recovered can give a client hope.
Telling a person to stop negtive thinking is ineffective because the client
must be taught cognitive strategies to stop negative thinking. Stating the
person is "no bother" is arguing with the client's beliefs and attempting
to tell him how to feel, both of which are not therapeutic responses.
Bring up pessimistic feelings interprets the client's feelings and does not
provide the same degree of hope.
,●● The nurse is caring for a client with a nursing problem of, "Infection,
risk for, related to inadequate primary defenses as evidenced by surgical
incision and IV access." What nursing intervention should the nurse
implement?
1. Limit visitors to immediate family to decrease exposure to infection.
2. Maintain "clean" technique in the change of wound dressing and IV
site.
3. Assess and document skin condition around the incision and IV site at
each shift.
4. Require the use of a face mask by staff when providing care requiring
close contact.
Answer: 3. Assess and document skin condition around the incision and
IV site at each shift.
Early identification of infection leads to prompt treatment and decreased
nosocomial transmission to others, so the condition of any invasive lines
or breaks in the skin should be assessed and documented during each
shift.
●● A client with ulcerative colitis is scheduled for surgical creation of an
ileoanal reservoir (J pouch). As part of preoperative teaching, what
information should the nurse provide?
1. The transverse loop ostomy is permanent.
2. Easily removable appliances allow independence in self-care.
3. Daily irrigation is started after the J pouch heals.
, 4. Stool is eventually expelled through the rectum.
Answer: 4. Stool is eventually expelled through the rectum.
An ileal pouch-anal anastomosis (also known as the J pouch) is a
surgically created ileoanal reservoir in the anal canal that preserves the
rectal sphincter muscle, so that passage of stool through the rectum is the
eventual result. To promote healing of the anastomosed parts of the
colon, a temporary loop ostomy is created, not a permanent one.
Although appliances that are easy to use are advantageous, the ostomy is
reversed after healing takes place. Stool drains into the reservoir, so
daily irrigation is not usually indicated.
●● The nurse inflates the cuff on a tracheostomy tube to minimal
occlusion pressure for a client who is breathing spontaneously. Which
action should the nurse follow?
1. Check the pilot balloon to ensure that it is firm.
2. Verify the healthcare provider's prescription for the required cuff
pressure.
3. Use a manometer to maintain cuff pressure between 25 and 30
mmHg.
4. Inject air until no air is auscultated over the larynx during a deep
breath.
Answer: 4. Inject air until no air is auscultated over the larynx during a
deep breath.
QUESTIONS AND CORRECT ANSWERS
GRADED A+
●● Which biological practices are federally regulated for healthcare
workers? (Select all that apply.)
Select all that apply
1.Standard precautions.
2. N-95 tuberculosis standard.
3. Blood-borne pathogen standard.
4. Biological product exposure limit (BPEL).
5. Resource Conservation and Recovery Act (RCRA).
6. As Low as Reasonably Allowable standard (ALARA).
Answer: 3. Blood-borne pathogen standard.
5. Resource Conservation and Recovery Act (RCRA)
Basic standards for healthcare workers, as delineated by Occupational
Safety and Health Administration (OSHA), include standard precautions,
droplet precautions using N-95 respiratory particulate masks when
caring for a client who is positive for tuberculosis, and required annual
updates for healthcare workers about blood-borne pathogen
,transmission, methods of minimizing exposure, and employee rights.
Other options [BPEL and ALARA ] are not federally regulated.
●● A client with severe depression tells the nurse, "I do not know why
you bother with me or give me pills. I am never going to get well." What
is the most therapeutic response?
1. "You need to stop thinking negative thoughts. They get in the way of
your recovery."
2. "You are no bother to me or to the staff. We want you to get well and
not feel sad anymore."
3. "I have known many clients with depression who have felt better after
several weeks of treatment."
4. "You are feeling very pessimistic, but that is part of your illness. It
should go away as you recover."
Answer: 3. "I have known many clients with depression who have felt
better after several weeks of treatment."
Stating the observation that others have recovered can give a client hope.
Telling a person to stop negtive thinking is ineffective because the client
must be taught cognitive strategies to stop negative thinking. Stating the
person is "no bother" is arguing with the client's beliefs and attempting
to tell him how to feel, both of which are not therapeutic responses.
Bring up pessimistic feelings interprets the client's feelings and does not
provide the same degree of hope.
,●● The nurse is caring for a client with a nursing problem of, "Infection,
risk for, related to inadequate primary defenses as evidenced by surgical
incision and IV access." What nursing intervention should the nurse
implement?
1. Limit visitors to immediate family to decrease exposure to infection.
2. Maintain "clean" technique in the change of wound dressing and IV
site.
3. Assess and document skin condition around the incision and IV site at
each shift.
4. Require the use of a face mask by staff when providing care requiring
close contact.
Answer: 3. Assess and document skin condition around the incision and
IV site at each shift.
Early identification of infection leads to prompt treatment and decreased
nosocomial transmission to others, so the condition of any invasive lines
or breaks in the skin should be assessed and documented during each
shift.
●● A client with ulcerative colitis is scheduled for surgical creation of an
ileoanal reservoir (J pouch). As part of preoperative teaching, what
information should the nurse provide?
1. The transverse loop ostomy is permanent.
2. Easily removable appliances allow independence in self-care.
3. Daily irrigation is started after the J pouch heals.
, 4. Stool is eventually expelled through the rectum.
Answer: 4. Stool is eventually expelled through the rectum.
An ileal pouch-anal anastomosis (also known as the J pouch) is a
surgically created ileoanal reservoir in the anal canal that preserves the
rectal sphincter muscle, so that passage of stool through the rectum is the
eventual result. To promote healing of the anastomosed parts of the
colon, a temporary loop ostomy is created, not a permanent one.
Although appliances that are easy to use are advantageous, the ostomy is
reversed after healing takes place. Stool drains into the reservoir, so
daily irrigation is not usually indicated.
●● The nurse inflates the cuff on a tracheostomy tube to minimal
occlusion pressure for a client who is breathing spontaneously. Which
action should the nurse follow?
1. Check the pilot balloon to ensure that it is firm.
2. Verify the healthcare provider's prescription for the required cuff
pressure.
3. Use a manometer to maintain cuff pressure between 25 and 30
mmHg.
4. Inject air until no air is auscultated over the larynx during a deep
breath.
Answer: 4. Inject air until no air is auscultated over the larynx during a
deep breath.
