ACCESS Test Bank for Concept-Based Clinical Nursing Skills 2nd Edition Stein
n n n n n n n n n n
Chapter 01: Foundations of Safe Client Care
n n n n n n
Stein: Concept-Based Clinical Nursing Skills, 2nd Edition
n n n n n n
MULTIPLEnCHOICE
1. Tonmeetnanrequirementnofnthen2021nAmericannAssociationnofnCollegesnofnNursing
Essentials,nwhatntopicndoesnnursingnfacultynfocusnonnthroughoutnthencurriculum?
a. Nursingnprocess
b. Safetynscience
c. Ergonomics
d. Informationntechnology
ANS:n B
Then2021nAACNnEssentialsnstatesnthatn“Provisionnofnsafe,nqualityncarennecessitatesnknowin
gnandnusingnestablishednandnemergingnprinciplesnofnsafetynscienceninncarendelivery”n(p.n43).n
Nursingnstudentsnarentaughtntonusenthennursingnprocess,nbutnthisnisnnotnconfinedntonpatientnsaf
ety.nErgonomicsnisnansubsetnofnsafetynsciencenthatnstudiesnpeoplenandntheirnworknenvironmen
ts.nInformationntechnologyncannbenusedntonimprovensafety.
DIF: CognitivenLevel:nRemembering TOP:n IntegratednProcess:nTeaching-Learning
2. Annursenmeetsnthenassignednclientsnatnthenstartnofnanshift.nAfternperformingnhandnhygienena
ndnintroducingnone’snself,nwhatndoesnthennursendonnext?
a. Beginnanhead-to-toenassessment.
b. Identifynthenclientnusingntwonidentifiers.
c. Assessnthenclientnfornpain.
d. Ensurenthencallnlightnisnwithinnreach.
ANS:n B
Ancriticalntaskninnhealthcarenfornsafety,nclientnidentificationnisnparamountnfornpreventingnerro
rs.nAfternperformingnhandnhygienenandnintroducingnhim-
nornherself,nthennursenidentifiesnthenclientnusingntwonuniquenidentifiers.nThenhead-to-
toenandnpainnassessmentsncomenshortlynafterward.nThennursenensuresnthenclientncannreachnthen
callnlightnpriorntonleavingnthenroom.
DIF: CognitivenLevel:nUnderstanding TOP:n NursingnProcess:nAssessment
3. Annursenhasnworkednwithnthensamenclientnforn2ndays.nWhennenteringnthenroomntonadministern
medications,nthennursenperformsnhandnhygiene.nWhatnactionndoesnthennursentakennext?
a. Providenanynneedednteaching.
b. Asknifnthenclientnhasnanyncarenrequests.
c. Assessnvitalnsignsnandnpain.
d. Identifynthenclientnusingntwonidentifiers.
ANS:n D
Everyntimenthenclientnisntonreceivenmedication,ndiagnosticnstudies,nornanynothernhealthcarenint
ervention,nthennursenmustnidentifynthenclientnusingntwonuniquenidentifiers,nevennifnthenclientni
snwellnknownntonthennurse.nAssessments,nteaching,nandndeterminingnclientnrequestsnwouldnco
menafterward.
DIF: CognitivenLevel:nApplying TOP:n NursingnProcess:nAssessment
mynursytest.store
,ACCESS Test Bank for Concept-Based Clinical Nursing Skills 2nd Edition Stein
n n n n n n n n n n
4. Annurse’snneighbornstatesn“Mynfatherngotnannosocomialninfectionnafternsurgery!”nWhatndoesnt
hennursenunderstandnhappenedntonthenclient?
a. Thenclientnreceivedncontaminatednbloodnproducts.
b. Thenclientnnearlyndiednfromnanpostoperativeninfection.
c. Thenclientnacquirednanninfectionnwhileninnthenhospital.
d. Thenclientnreceivednpoornpreoperativenskinnpreparation.
ANS:n C
Annosocomialninfectionnisnonenacquiredninnthenhospital.nItndoesnnotndesignatenhowntheninfect
ionnoccurred,nsonthenclientnmightnhavenbecomeninfectednthroughncontaminatednbloodnprodu
ctsnornfromnpoornpreoperativenskinnpreparation.nItndoesnnotnmeannthenclientnhadnanlife-
threateningninfection,nonlynthatnisnoccurredninnhospital.
DIF: CognitivenLevel:nUnderstanding TOP:n IntegratednProcess:nTeaching-Learning
5. Annursenisnmakingnroundsnonnclientsnatnrisknforninfection.nWhichnclientndoesnthennursensee
first?
a. Anclientnwithnannintravenousn(IV)nline
b. Anclientnwhonhasnancentralnline
c. Anclientnwithnannindwellingnbladderncatheter
d. AnclientnwithnannIVnandnbladderncatheter
ANS:n D
Onenofnthenbiggestnrisknfactorsnfornhospitalnacquiredninfectionsn(HAIs)nisnthenpresencenofninv
asivenlines.nThenmorenlines,nthenmorenrisk.nThenclientnwithnbothnannIVnandnancatheternhasnthenh
ighestnrisk.nThenclientsnwithnannIVnornancatheternhavenlessnrisk.
DIF: CognitivenLevel:nApplying TOP:n NursingnProcess:nAssessment
6. Annursingnmanagernconcernednaboutntheninfectionnratenonnthenunitnwantsntonimplementnmea
suresntonreducenthentransmissionnofninfectiousnorganisms.nWhatnactionnbynthenmanagernisnbe
st?
a. Providenanstethoscopendedicatedntoneachnclient.
b. Ensurenglovesnarenwell-stockedninneachnroom.
c. Restrictnallnplantsnandnfreshnfoodsnfromnrooms.
d. Screennallnvisitorsnforncontagiousnillnesses.
ANS:n A
Innthenchainnofninfection,nonenofnthenmostnimportantncomponentsnisnthenmodenofntransmission.
nStethoscopesncannservenasnanmodenofnindirectncontactntransmissionnunlessn theynarendisinfect
ednappropriatelynbetweennclients.nProvidingneachnclientnwithnannindividualnstethoscopenwillnr
educenthisnrisk.nGlovesnarenimportant,nbutntheyncannbecomencontaminatedntoonandnservenasnan
modenofntransmission.nPlantsnandnfreshnfoodsnarenannuncommonnsourcenofntransmissionnunle
ssnthenclientnisnimmunosuppressed.nScreeningnvisitorsnforncontagiousnillnessnisnannunrealisticn
long-termnactionnplan.
DIF: CognitivenLevel:nApplying TOP:n NursingnProcess:nImplementation
7. Annursenisnobservingnanstudentnnurse.nWhatnactionnbynthenstudentndemonstratesnthenneednfor
moreneducationnonnStandardnPrecautions?
mynursytest.store
, ACCESS Test Bank for Concept-Based Clinical Nursing Skills 2nd Edition Stein
n n n n n n n n n n
a. Thenstudentnperformsnhandnhygienenbeforenallnclientncontacts.
b. Thenstudentnconscientiouslynwearsnglovesnwhenntakingnvitalnsigns.
c. Thenstudentnconfirmsnthatnurinenpossiblyncontainsninfectiousnmicrobes.
d. Thenstudentnwearsnangownnwhenncleaningnliquidnstoolnoffnthenclient.
ANS:n B
StandardnPrecautionsnoperatesnundernthenprinciplenthatnallnbodilynfluidsnothernthannsweatncou
ldnpotentiallyncontainninfectiousnmicrobialnagentsnthatnposenanriskntonthenhealthcarenworker.n
Contactnwithnskin,nifnfreenofnthosenfluids,ndoesnnotnrequirenwearingngloves,nsonthennursenwoul
dnprovidenmoreneducationntonthenstudent.nHandnhygienenisnthenfirstnstepnofnStandardnPrecauti
ons.nThenstudentnisnbeingnprudentnbynconfirmingnanpossiblensourcenofncontamination.nNurses
ndeterminenwhichninfectionnpreventionnpracticentonusenbasednuponnthentypenofnclient–
nurseninteractionnandnthenpossibilitynofnexposurentonblood,nothernbodynfluids,nornpathogens,ns
onwearingnangownnwhilencleaningnliquidnstoolnisnappropriate.
DIF: CognitivenLevel:nAnalyzing TOP:n NursingnProcess:nEvaluation
8. Anfacultynmembernhasntaughtnthencorrectntechniquenforntakingnglovesnoffn(doffing).nWhileno
bservingnstudentsnpractice,nwhichnactionnbynanstudentnindicatesnthenneedntonreviewnthenmat
erial?
a. Pullsnglovenoffndominantnhandnfirst.
b. Takesnfirstnglovenoffnbyngraspingnitnonnthenoutside.
c. Takesnsecondnglovenoffnbyngraspingnitnundernthencuff.
d. Turnsnthenglovesninsidenoutnwhennsecondnglovenisnremoved.
ANS:n A
Thencorrectnwayntonremovenglovesnstartsnwithndoffingnthenglovenonnthennondominantnhandnfir
st,nwithoutntouchingnthenbarenskin.nThisnstudentnwouldnneednfurthernreviewnofnthenskill.nRem
ovingnthenfirstnglovenbyngraspingnitnonnthenoutside,ngraspingnthensecondnglovenundern thencuff,
nandnturningnthenglovesninsidenoutntonpreventnmicrobenspreadnarenallncorrectnactions.nThesenstu
dentsnwouldnnotnneednremediation.
DIF: CognitivenLevel:nAnalyzing TOP:n NursingnProcess:nEvaluation
9. Innorderntonmovenancooperativenclientnsafelynfromnthenbedntonchair,nwhichnofnthenfollowingna
ctionsndoesnthennursentakenfirst?
a. Gathernenoughnhelpnfornthentask.
b. Assessnthenclient’snabilityntonbearnweight.
c. Delegatenusingnthenliftnchair.
d. Administernpainnmedication.
ANS:n B
Thenfirstnthingnthennursendoesnwhennpreparingntontransfernancooperativenclientnisntonassessnthe
nclient’snabilityntonbearnweightnandnremainnbalancednwhilenstanding.nThenfindingsnwillndeter
minenhownmuchnassistancen(ifnany)nthenclientnneeds.nIfnthenclientnneedsnmaximalnassistance,nt
hennthennursengathersnenoughnhelpnandnanynliftingndevicesnneedednandnassignsnrolesntoneachnt
eamnmember.nIfnthenclientnhasnpain,nthennursenwouldnadministernpainnmedication,nbutnthatnisn
notnrelatedntonsafety.
DIF: CognitivenLevel:nApplying TOP:n NursingnProcess:nImplementation
mynursytest.store
n n n n n n n n n n
Chapter 01: Foundations of Safe Client Care
n n n n n n
Stein: Concept-Based Clinical Nursing Skills, 2nd Edition
n n n n n n
MULTIPLEnCHOICE
1. Tonmeetnanrequirementnofnthen2021nAmericannAssociationnofnCollegesnofnNursing
Essentials,nwhatntopicndoesnnursingnfacultynfocusnonnthroughoutnthencurriculum?
a. Nursingnprocess
b. Safetynscience
c. Ergonomics
d. Informationntechnology
ANS:n B
Then2021nAACNnEssentialsnstatesnthatn“Provisionnofnsafe,nqualityncarennecessitatesnknowin
gnandnusingnestablishednandnemergingnprinciplesnofnsafetynscienceninncarendelivery”n(p.n43).n
Nursingnstudentsnarentaughtntonusenthennursingnprocess,nbutnthisnisnnotnconfinedntonpatientnsaf
ety.nErgonomicsnisnansubsetnofnsafetynsciencenthatnstudiesnpeoplenandntheirnworknenvironmen
ts.nInformationntechnologyncannbenusedntonimprovensafety.
DIF: CognitivenLevel:nRemembering TOP:n IntegratednProcess:nTeaching-Learning
2. Annursenmeetsnthenassignednclientsnatnthenstartnofnanshift.nAfternperformingnhandnhygienena
ndnintroducingnone’snself,nwhatndoesnthennursendonnext?
a. Beginnanhead-to-toenassessment.
b. Identifynthenclientnusingntwonidentifiers.
c. Assessnthenclientnfornpain.
d. Ensurenthencallnlightnisnwithinnreach.
ANS:n B
Ancriticalntaskninnhealthcarenfornsafety,nclientnidentificationnisnparamountnfornpreventingnerro
rs.nAfternperformingnhandnhygienenandnintroducingnhim-
nornherself,nthennursenidentifiesnthenclientnusingntwonuniquenidentifiers.nThenhead-to-
toenandnpainnassessmentsncomenshortlynafterward.nThennursenensuresnthenclientncannreachnthen
callnlightnpriorntonleavingnthenroom.
DIF: CognitivenLevel:nUnderstanding TOP:n NursingnProcess:nAssessment
3. Annursenhasnworkednwithnthensamenclientnforn2ndays.nWhennenteringnthenroomntonadministern
medications,nthennursenperformsnhandnhygiene.nWhatnactionndoesnthennursentakennext?
a. Providenanynneedednteaching.
b. Asknifnthenclientnhasnanyncarenrequests.
c. Assessnvitalnsignsnandnpain.
d. Identifynthenclientnusingntwonidentifiers.
ANS:n D
Everyntimenthenclientnisntonreceivenmedication,ndiagnosticnstudies,nornanynothernhealthcarenint
ervention,nthennursenmustnidentifynthenclientnusingntwonuniquenidentifiers,nevennifnthenclientni
snwellnknownntonthennurse.nAssessments,nteaching,nandndeterminingnclientnrequestsnwouldnco
menafterward.
DIF: CognitivenLevel:nApplying TOP:n NursingnProcess:nAssessment
mynursytest.store
,ACCESS Test Bank for Concept-Based Clinical Nursing Skills 2nd Edition Stein
n n n n n n n n n n
4. Annurse’snneighbornstatesn“Mynfatherngotnannosocomialninfectionnafternsurgery!”nWhatndoesnt
hennursenunderstandnhappenedntonthenclient?
a. Thenclientnreceivedncontaminatednbloodnproducts.
b. Thenclientnnearlyndiednfromnanpostoperativeninfection.
c. Thenclientnacquirednanninfectionnwhileninnthenhospital.
d. Thenclientnreceivednpoornpreoperativenskinnpreparation.
ANS:n C
Annosocomialninfectionnisnonenacquiredninnthenhospital.nItndoesnnotndesignatenhowntheninfect
ionnoccurred,nsonthenclientnmightnhavenbecomeninfectednthroughncontaminatednbloodnprodu
ctsnornfromnpoornpreoperativenskinnpreparation.nItndoesnnotnmeannthenclientnhadnanlife-
threateningninfection,nonlynthatnisnoccurredninnhospital.
DIF: CognitivenLevel:nUnderstanding TOP:n IntegratednProcess:nTeaching-Learning
5. Annursenisnmakingnroundsnonnclientsnatnrisknforninfection.nWhichnclientndoesnthennursensee
first?
a. Anclientnwithnannintravenousn(IV)nline
b. Anclientnwhonhasnancentralnline
c. Anclientnwithnannindwellingnbladderncatheter
d. AnclientnwithnannIVnandnbladderncatheter
ANS:n D
Onenofnthenbiggestnrisknfactorsnfornhospitalnacquiredninfectionsn(HAIs)nisnthenpresencenofninv
asivenlines.nThenmorenlines,nthenmorenrisk.nThenclientnwithnbothnannIVnandnancatheternhasnthenh
ighestnrisk.nThenclientsnwithnannIVnornancatheternhavenlessnrisk.
DIF: CognitivenLevel:nApplying TOP:n NursingnProcess:nAssessment
6. Annursingnmanagernconcernednaboutntheninfectionnratenonnthenunitnwantsntonimplementnmea
suresntonreducenthentransmissionnofninfectiousnorganisms.nWhatnactionnbynthenmanagernisnbe
st?
a. Providenanstethoscopendedicatedntoneachnclient.
b. Ensurenglovesnarenwell-stockedninneachnroom.
c. Restrictnallnplantsnandnfreshnfoodsnfromnrooms.
d. Screennallnvisitorsnforncontagiousnillnesses.
ANS:n A
Innthenchainnofninfection,nonenofnthenmostnimportantncomponentsnisnthenmodenofntransmission.
nStethoscopesncannservenasnanmodenofnindirectncontactntransmissionnunlessn theynarendisinfect
ednappropriatelynbetweennclients.nProvidingneachnclientnwithnannindividualnstethoscopenwillnr
educenthisnrisk.nGlovesnarenimportant,nbutntheyncannbecomencontaminatedntoonandnservenasnan
modenofntransmission.nPlantsnandnfreshnfoodsnarenannuncommonnsourcenofntransmissionnunle
ssnthenclientnisnimmunosuppressed.nScreeningnvisitorsnforncontagiousnillnessnisnannunrealisticn
long-termnactionnplan.
DIF: CognitivenLevel:nApplying TOP:n NursingnProcess:nImplementation
7. Annursenisnobservingnanstudentnnurse.nWhatnactionnbynthenstudentndemonstratesnthenneednfor
moreneducationnonnStandardnPrecautions?
mynursytest.store
, ACCESS Test Bank for Concept-Based Clinical Nursing Skills 2nd Edition Stein
n n n n n n n n n n
a. Thenstudentnperformsnhandnhygienenbeforenallnclientncontacts.
b. Thenstudentnconscientiouslynwearsnglovesnwhenntakingnvitalnsigns.
c. Thenstudentnconfirmsnthatnurinenpossiblyncontainsninfectiousnmicrobes.
d. Thenstudentnwearsnangownnwhenncleaningnliquidnstoolnoffnthenclient.
ANS:n B
StandardnPrecautionsnoperatesnundernthenprinciplenthatnallnbodilynfluidsnothernthannsweatncou
ldnpotentiallyncontainninfectiousnmicrobialnagentsnthatnposenanriskntonthenhealthcarenworker.n
Contactnwithnskin,nifnfreenofnthosenfluids,ndoesnnotnrequirenwearingngloves,nsonthennursenwoul
dnprovidenmoreneducationntonthenstudent.nHandnhygienenisnthenfirstnstepnofnStandardnPrecauti
ons.nThenstudentnisnbeingnprudentnbynconfirmingnanpossiblensourcenofncontamination.nNurses
ndeterminenwhichninfectionnpreventionnpracticentonusenbasednuponnthentypenofnclient–
nurseninteractionnandnthenpossibilitynofnexposurentonblood,nothernbodynfluids,nornpathogens,ns
onwearingnangownnwhilencleaningnliquidnstoolnisnappropriate.
DIF: CognitivenLevel:nAnalyzing TOP:n NursingnProcess:nEvaluation
8. Anfacultynmembernhasntaughtnthencorrectntechniquenforntakingnglovesnoffn(doffing).nWhileno
bservingnstudentsnpractice,nwhichnactionnbynanstudentnindicatesnthenneedntonreviewnthenmat
erial?
a. Pullsnglovenoffndominantnhandnfirst.
b. Takesnfirstnglovenoffnbyngraspingnitnonnthenoutside.
c. Takesnsecondnglovenoffnbyngraspingnitnundernthencuff.
d. Turnsnthenglovesninsidenoutnwhennsecondnglovenisnremoved.
ANS:n A
Thencorrectnwayntonremovenglovesnstartsnwithndoffingnthenglovenonnthennondominantnhandnfir
st,nwithoutntouchingnthenbarenskin.nThisnstudentnwouldnneednfurthernreviewnofnthenskill.nRem
ovingnthenfirstnglovenbyngraspingnitnonnthenoutside,ngraspingnthensecondnglovenundern thencuff,
nandnturningnthenglovesninsidenoutntonpreventnmicrobenspreadnarenallncorrectnactions.nThesenstu
dentsnwouldnnotnneednremediation.
DIF: CognitivenLevel:nAnalyzing TOP:n NursingnProcess:nEvaluation
9. Innorderntonmovenancooperativenclientnsafelynfromnthenbedntonchair,nwhichnofnthenfollowingna
ctionsndoesnthennursentakenfirst?
a. Gathernenoughnhelpnfornthentask.
b. Assessnthenclient’snabilityntonbearnweight.
c. Delegatenusingnthenliftnchair.
d. Administernpainnmedication.
ANS:n B
Thenfirstnthingnthennursendoesnwhennpreparingntontransfernancooperativenclientnisntonassessnthe
nclient’snabilityntonbearnweightnandnremainnbalancednwhilenstanding.nThenfindingsnwillndeter
minenhownmuchnassistancen(ifnany)nthenclientnneeds.nIfnthenclientnneedsnmaximalnassistance,nt
hennthennursengathersnenoughnhelpnandnanynliftingndevicesnneedednandnassignsnrolesntoneachnt
eamnmember.nIfnthenclientnhasnpain,nthennursenwouldnadministernpainnmedication,nbutnthatnisn
notnrelatedntonsafety.
DIF: CognitivenLevel:nApplying TOP:n NursingnProcess:nImplementation
mynursytest.store
