Chp 31
The nurse is setting up a sterile field. Which action by the nurse best exhibits surgical asepsis?
1. Disinfecting an item before adding it to a sterile field
2. Allowing sterile gloved hands to fall below the waist
3. Suctioning the oral cavity of an unconscious client
4. Touching only the inside surface of the first glove while pulling it onto the hand
Answer: 4
Explanation: 4. Touching only the inside surface of the first glove while pulling it onto the hand is the correct technique when applying sterile gloves. This prevents contamination of the outside of the glove, which must remain sterile.
Page Ref: 625
The nurse is planning care for a client. Which intervention would be appropriate to reduce the risk of infection?
1. Assess vital signs only once daily.
2. Raise the temperature in the client's room.
3. Wash hands.
4. Wear a mask for all client care.
Answer: 3
Explanation: 3. Washing hands is always the first and best way to stop the spread of microorganisms, which cause infections.
Page Ref: 612
A client who is ambulatory is able to get out of bed for morning care. What should the nurse assess before assisting the client out of the bed to change the linen? Select all that apply.
1. Pulse
2. Respirations
3. Urine output
4. Blood pressure
5. Mobility status
Answer: 1, 2, 4, 5
Explanation: 1. When changing the linen of an unoccupied bed the nurse should assess the client's pulse.
2. When changing the linen of an unoccupied bed the nurse should assess the client's respirations.
4. When changing the linen of an unoccupied bed the nurse should assess the client's blood pressure.
5. When changing the linen of an unoccupied bed the nurse should assess the client's mobility status.
Page Ref: 710
The nurse is providing care to a group of clients. For which situation would the nurse's use of critical thinking be a priority?
1. Administering IV push meds to critically ill clients
2. Educating a home health client about treatment options
3. Teaching new parents car seat safety
4. Assisting an orthopedic client with the proper use of crutches
Answer: 2
Explanation: 2. Nurses who utilize good critical thinking skills are able to think and act in areas where there are neither clear answers nor standard procedures. Treatment options, especially for the home health client, can be extensive. There are many points to consider (good and bad), and choosing between treatment options can cause conflict among family members. The nurse in this case must use creativity, analysis based on science, and problem-solving skills–all of which contribute to critical thinking skills.
Page Ref: 144
The nurse is planning care for a client who is prone to falling. Which nursing diagnoses should the nurse use for this client?
1. Deficient Knowledge
2. Risk for Injury
3. Risk for Disuse Syndrome
4. Risk for Suffocation
Answer: 2
Explanation: 2. Risk for Injury is a state in which the individual is at risk as a result of environmental conditions such as a fall.
Page Ref: 640
The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate?
1. Administering parenteral medications
2. Changing a dressing
3. Performing a urinary catheterization
4. Using personal protective equipment
Answer: 4
Explanation: 4. Using personal protective equipment demonstrates medical asepsis.
Page Ref: 636
The nurse is preparing to remove soiled gloves. What action should the nurse take first?
1. Drop the gloves into the appropriate waste receptacle.
2. Ease the fingers into the gloves.
3. Grasp the outside of the nondominant glove.
4. Hook the bare thumb inside the other glove.
Answer: 3
Explanation: 3. In order to remove gloves after use, one must grasp the outside of the nondominant glove.
Page Ref: 622
The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment as appropriate for a client. What should the nurse select as an expected outcome for this client?
1. The client will be able to name the staff that works on the day shift.
2. The client will eliminate safety hazards in her environment.
3. The client, with supervision, will brush her teeth.
4. The nurse will stress the importance of adequate fluid intake.
Answer: 3
Explanation: 3. A client with cognitive impairment would be able to brush her teeth but only with supervision. The client would not voluntarily brush her teeth without prompting from the staff.
Page Ref: 672
The nurse educator assigns students an activity to implement Socratic questioning in their daily lives. Which question provided by a student demonstrates this reasoning technique?
1. "What makes you think cramming for a test is an ineffective way to study?"
2. "What other ways of studying could you implement?"
3. "If you didn't study for your test, what is the probability you will fail?"
4. "If you study all the unit outcomes, what effect will that have?"
Answer: 1
Explanation: 1. Socratic questioning is a technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes. Questions about evidence and reason focus on just that (e.g., what evidence is there, how you know, what would change your mind).
Page Ref: 146
The nurse is identifying care goals for a client who is prone to getting hurt. Which care goal should the nurse select for this client?
1. Assess the client's mental status.
2. Keep the client dependent on the staff for all care.
3. Make all choices for the client.
4. Remain free from injury.
Answer: 4
Explanation: 4. The major goal for a client who is at risk for injury is for the client to remain injury-free.
Page Ref: 649
The nurse is reviewing the care needs for a group of assigned clients. Which client should the nurse recognize as being most at risk for a nosocomial infection?
1. A client in the emergency department with abdominal pain
2. A 19-year-old woman in her first trimester of pregnancy
3. A 72-year-old male client with COPD
4. An 86-year-old female client on steroid therapy
Answer: 4
Explanation: 4. The client most at risk for a nosocomial infection is the client who is 86 years old and on steroid therapy. The very old and very young are most susceptible to infections. The 86-year-old client is also on steroid therapy, which compromises the immune system.
Page Ref: 609
The nurse is concerned that a break occurred in a sterile field. Which action occurred that caused this break?
1. Grasping the edge of the outermost flap and opening it away from oneself
2. Keeping objects on the field 1 inch from the edge
3. Keeping the sterile field in eyesight
4. Transferring a sterile object to a sterile field with a clean gloved hand
Answer: 4
Explanation: 4. Transferring a sterile object onto a sterile field with a gloved hand would render the field unsterile only if the gloves are not sterile.
Page Ref: 627
The nurse is caring for a client with diabetes. What should the nurse include as foot care for this client?
1. Cut toenails in a rounded shape and file.
2. Dry toes thoroughly.
3. Wash feet with water at a temperature of 90°F to 98.6°F.
4. Inspect feet thoroughly once a week.
Answer: 2
Explanation: 2. Toes should be dried thoroughly after being washed to impede fungal growth and prevent maceration.
Page Ref: 686
A client is experiencing a productive cough, audible coarse crackles, elevated temperature of 102.3°F, chills, and body aches. What did the nurse use to determine that this patient is experiencing respiratory compromise?
1. Deductive reasoning
2. Inductive reasoning
3. Socratic questioning
4. Critical analysis
Answer: 1
Explanation: 1. Deductive reasoning is reasoning from the general to the specific. The nurse starts with a framework and makes descriptive interpretations of the client's condition in relation to the framework. Productive cough, crackles, fever, and chills all point to problems with respiratory status.
Page Ref: 147
The nurse is applying restraints to a client. After securing a health care provider's order, what should the nurse do?
1. Assess the restraints every 10 minutes.
2. Pad bony prominences.
3. Secure the restraint to the side rail.
4. Tie the restraint with a square knot.
Answer: 2
Explanation: 2. Padding bony prominences will prevent possible skin breakdown.
Page Ref: 660
The nurse is preparing discharge teaching for a client recovering from surgery. What instruction is the most important for the nurse to give this client who has a surgical wound?
1. Adjust the diet so it contains more fruits and vegetables.
2. Apply lubricating lotion to the edges of the wound.
3. Notify the physician of any edema, heat, or tenderness at the wound site.
4. Thoroughly irrigate the wound with hydrogen peroxide.
The nurse is preparing discharge teaching for a client recovering from surgery. What instruction is the most important for the nurse to give this client who has a surgical wound?
1. Adjust the diet so it contains more fruits and vegetables.
2. Apply lubricating lotion to the edges of the wound.
3. Notify the physician of any edema, heat, or tenderness at the wound site.
4. Thoroughly irrigate the wound with hydrogen peroxide.
The nurse is preparing to leave a client's isolation room. Which action should the nurse take first when removing a grossly soiled gown?
1. Grasp the sleeve of the dominant arm, and remove it with a gloved hand.
2. Release the neck ties of the gown and allow the gown to fall forward.
3. Untie the strings at the neck first.
4. Untie the strings at the waist first.
Answer: 4
Explanation: 4. To leave an isolation room where a gown has been worn, one must untie the gown at the waist first, not at the neck. After the neck ties are untied, the gown is allowed to fall forward.
Page Ref: 622
A client has the nursing diagnosis Risk for Impaired Skin Integrity related to immobility. Which nursing intervention should be identified for this client's problem?
1. Encourage the client to eat at least 40% of meals.
2. Keep linens dry and wrinkle-free.
3. Restrict fluid intake.
4. Turn client every 3 hours.
Answer: 2
Explanation: 2. Keeping linens dry and wrinkle-free will prevent pressure areas.
Page Ref: 686
A client with a PhD in epidemiology has been to numerous physicians and has had numerous laboratory tests, all of which were abnormal, and exploratory surgery, but no one is able to explain the etiology of his problem. The client also states that he has a rare form of a neurological disorder. Which statement should the nurse make that demonstrates critical thinking?
1. "Why don't you just tell your physician what you think you have?"
2. "Did you bring your prior tests and results with you, so we don't repeat anything?"
3. "If you know what you have, what do you want from us?"
4. "Describe what tests you've had and explain the symptoms of this disorder."
Answer: 4
Explanation: 4. In critical thinking, the nurse also differentiates statements of fact, inference, judgment, and opinion. The nurse will have to ascertain the accuracy of information and evaluate the credibility of the information sources.
Page Ref: 147
) The nurse is evaluating teaching provided to a client about home safety. Which observation indicates that teaching has been effective?
1. Smoke alarm functioning with new batteries installed
2. Scatter rugs located in the kitchen and bathroom only
3. Cord for a space heater stretched across a hallway
4. Light bulbs burned out in the bathroom and living room
Answer: 1
Explanation: 1. The installation and use of a smoke alarm in the home would indicate that home safety instruction has been effective.
Page Ref: 656
The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the client's body from microorganisms?
1. Heavy smoking
2. Moisturizing the skin
3. Breakdown of skin
4. Voiding quantity sufficient
Answer: 4
Explanation: 4. Voiding quantity sufficient is a barrier that helps the body defend itself against microorganisms. The act of voiding flushes those organisms that might try to enter the body through the urinary meatus.
Page Ref: 607
The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision? Select all that apply.
1. Client is receiving intravenous fluids.
2. Client has an indwelling urinary catheter.
3. Client is recovering from surgery.
4. Client is receiving pain medication.
5. Client is ambulating twice a day with assistance.
Answer: 1, 2, 3
Explanation: 1. Bacteremia can occur from an intravascular line.
2. The client could develop an infection from an invasive procedure or device such as an indwelling urinary catheter.
3. After surgery, the client's health status is compromised, lowering the client's defenses to fight infection.
Page Ref: 604
An older client tells the nurse that showers are not taken because of a previous fall. What can the nurse do to support the client's bathing needs?
1. Obtain a shower chair and assist the client in the shower.
2. Document that the client "refused" a morning bath in the medical record.
3. Tell the client that shower shoes can be worn to prevent falls.
4. Hold the client during the shower.
Answer: 1
Explanation: 1. To provide person-centered care with bathing, the nurse should obtain a shower chair. This should eliminate the client's fear of falling when in the shower.
Page Ref: 675
The nurse completes collecting data from a client and determines a list of problems. Which step in the nursing process should the nurse perform next?
1. Assess
2. Diagnose
3. Plan
4. Evaluate
Answer: 3
Explanation: 3. The planning portion of the nursing process involves setting criteria, weighting the criteria, and seeking/examining alternatives when compared to the decision-making process.
Page Ref: 148
A client is prescribed to have wrist restraints applied. Place in order the steps the nurse will take to apply these restraints.
1. Pad bony prominences on the wrist.
2. Apply the padded portion of the restraint around the wrist.
3. Pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight.
4. Attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot.
Answer: 1, 2, 3, 4
Explanation: 1. Prior to applying the wrist restraint, the client's bony prominences should be padded.
2. The nurse should apply the padded portion of the restraint around the wrist.
3. The nurse should then pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight.
4. The nurse should then attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot.
Page Ref: 664