Test Bank For Concept-Based Clinical Nursing Skills Fundamental to Advanced 1st Edition By Loren Nell Melton Stein, Connie J Hollen 9780323625579 ALL Chapters .

Chapter 01: Foundations of Safe Client Care
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Stein: Concept-Based Clinical Nursing Skills, 2nd Edition
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MULTIPLE CHOICE ss




1. To meetna requirement of the 2021 AmericannAssociation of Colleges of Nursing
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Essentials, what topic does nursingnfaculty focus on throughout thencurriculum? ss ss ss ss ss ss ss ss



a. Nursing process ss



b. Safety science ss



c. Ergonomics
d. Information technology ss




ANS: s s B
The 2021 AACN Essentials states that “Provision of safe, quality care necessitates knowin
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gnand usingnestablished and emerging principles of safety science in care delivery” (p. 43).
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Nursing students are taught tonuse the nursing process, but this is not confined tonpatient saf
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ety. Ergonomics is a subset of safety science thatnstudies people and their work environmen ts.
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Information technology can be used tonimprove safety.
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DIF: Cognitive Level: Remembering ss ss TOP: s s Integrated Process: Teaching-Learning ss ss




2. A nursenmeets the assigned clients at the start of a shift. After performing hand hygiene a nd
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ss introducing one’s self, what does the nurse do next? ss ss ss ss ss ss ss ss



a. Begin a head-to-toe assessment. ss ss ss



b. Identify the client using twonidentifiers. ss ss ss ss



c. Assess the client for pain. ss ss ss ss



d. Ensure the call light is within reach. ss ss ss ss ss ss




ANS: s s B
A critical task in healthcare for safety, client identification is paramount for preventing erro rs.
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After performing hand hygiene and introducing him-
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or herself, the nurse identifies the client using two unique identifiers. The head-to-
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toe and pain assessments comenshortly afterward. The nurse ensures the client can reach the call
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light prior to leaving the room.
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DIF: Cognitive Level: Understanding ss ss TOP: s s Nursing Process: Assessment ss ss




3. A nursenhas worked with the same client for 2 days. When entering thenroom to administer
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medications, the nurse performs hand hygiene. What action does the nurse take next?
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a. Provide any needed teaching. ss ss ss



b. Ask if the client has any carenrequests. ss ss ss ss ss ss



c. Assess vital signs and pain. ss ss ss ss



d. Identify the client using two identifiers. ss ss ss ss ss




ANS: s s D
Every time the client is to receive medication, diagnostic studies, or any other healthcare int
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ervention, the nursenmust identify the client using two uniquenidentifiers, even if the client i s
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well known to the nurse. Assessments, teaching, and determiningnclient requests would co me
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afterward.
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DIF: s s s s Cognitive Level: Applying ss ss TOP: s s Nursing Process: Assessment ss ss




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4. A nurse’s neighbor states “My father got a nosocomial infection after surgery!” What doesnt he
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ss nursenunderstand happened to the client? ss ss ss ss



a. The client received contaminated blood products.
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b. The client nearly died fromna postoperative infection.
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c. The client acquired an infection while in the hospital.
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d. The client received poor preoperative skin preparation.
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ANS: s s C
A nosocomial infection is onenacquired in thenhospital. It does not designate how the infect ion
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occurred, so the client mightnhavenbecome infected through contaminated blood produ cts or
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from poor preoperative skin preparation. Itndoes not mean thenclient hadna life-
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threateningninfection, only that isnoccurred in hospital.
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DIF: Cognitive Level: Understanding ss ss TOP: s s Integrated Process: Teaching-Learning ss ss




5. A nurse is makingnrounds on clients at risknfor infection. Which client does the nursensee
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first?
a. A client with an intravenous (IV) line
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b. A client whonhas a central line
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c. A client with an indwellingnbladder catheter
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d. A client with an IV and bladder catheter
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ANS: s s D
Onenof the biggest risk factors for hospital acquired infectionsn(HAIs) is the presence of inv
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asive lines. The more lines, the more risk. Thenclientnwith both an IV and a catheter hasnthe h
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ighest risk. The clients with annIV or a catheter have less risk.
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DIF: s s s s Cognitive Level: Applying ss ss TOP: s s Nursing Process: Assessment ss ss




6. A nursing manager concerned about theninfection rate on the unit wants to implement mea
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ss sures to reduce the transmission of infectious organisms. What action by the manager is be st?
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a. Provide a stethoscope dedicated to each client. ss ss ss ss ss ss



b. Ensure gloves are well-stocked in each room. ss ss ss ss ss ss



c. Restrict all plantsnand fresh foods from rooms. ss ss ss ss ss ss



d. Screen all visitors for contagious illnesses. ss ss ss ss ss




ANS: s s A
In the chain of infection, one of the most important components is thenmode of transmission.
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Stethoscopes can serve as a mode of indirect contact transmission unless they are
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disinfect ed appropriately between clients. Providing each client with annindividual
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stethoscope will r educenthis risk. Gloves arenimportant, but they can becomencontaminated
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toonand serve as a mode of transmission. Plants and fresh foods are an uncommon sourcenof
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transmission unle ss the client is immunosuppressed. Screening visitors for contagious
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illness is an unrealistic long-term action plan.
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DIF: s s s s Cognitive Level: Applying ss ss TOP: s s Nursing Process: Implementation ss ss




7. A nursenis observing a student nurse. What action by the student demonstrates the need for
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more education on Standard Precautions?
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a. The student performs hand hygiene before all client contacts.
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b. The student conscientiously wears gloves when takingnvital signs.
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c. The student confirms that urine possibly contains infectious microbes.
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d. The student wears a gown when cleaning liquid stool off the client.
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ANS: s s B
Standard Precautions operates under the principle that all bodily fluids other thannsweat cou ld
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potentially contain infectious microbial agents thatnpose a risk to the healthcare worker.
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Contact withnskin, if free of those fluids, does not require wearing gloves, so the nurse woul d
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provide more education to the student. Hand hygiene isnthe first step of Standard Precauti
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ons. Thenstudent is being prudent by confirming a possible source of contamination. Nurses
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determine which infection prevention practice to usenbased upon the type of client–
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nurseninteraction and thenpossibility of exposure to blood, other body fluids, or pathogens, s o
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wearing a gown while cleaning liquid stool is appropriate.
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DIF: Cognitive Level: Analyzing ss ss TOP: s s Nursing Process: Evaluation ss ss




8. A faculty member has taught the correct technique for taking gloves off (doffing). While o
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bserving students practice, which action by a student indicates the need to review the mat
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erial?
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a. Pulls glove off dominant hand first. ss ss ss ss ss



b. Takes first glove off by grasping it onnthe outside. ss ss ss ss ss ss ss ss



c. Takes second glove off by grasping it under the cuff. ss ss ss ss ss ss ss ss ss



d. Turns the gloves insidenout when secondnglove is removed. ss ss ss ss ss ss ss




ANS: s s A
The correct way to remove gloves starts with doffing the glove on the nondominant hand fir st,
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without touching thenbarenskin. This student would need further review of the skill. Rem
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oving the first glove by grasping it on the outside, grasping the second glove under the cuff,
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and turningnthengloves inside out to prevent microbenspread are all correct actions. Thesenstu
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dents wouldnnot need remediation.
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DIF: Cognitive Level: Analyzing ss ss TOP: s s Nursing Process: Evaluation ss ss




9. In order to move a cooperative client safely from the bed to chair, which of the following a
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ss ctions does the nursentake first? ss ss ss ss



a. Gather enough help for thentask. ss ss ss ss



b. Assess the client’s ability to bear weight. ss ss ss ss ss ss



c. Delegate using the lift chair. ss ss ss ss



d. Administer pain medication. ss ss




ANS: s s B
The first thing the nurse does when preparing to transfer a cooperativenclient is to assess the
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client’s ability to bear weight and remain balanced while standing. The findings will deter
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mine how much assistance (if any) the client needs. If the client needs maximal assistance, t hen
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the nurse gathers enough help and any liftingndevices needed and assigns roles toneach t
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eamnmember. If the client has pain, the nursenwould administer pain medication, but that is
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not related to safety.
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DIF: Cognitive Level: Applying ss ss TOP: s s Nursing Process: Implementation ss ss




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