Chapter 31 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 31

Question 1

Type: MCSA

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

Correct Answer: 4

Rationale 1: Disinfecting an item is an example of medical asepsis, not surgical asepsis.

Rationale 2: If sterile gloved hands fall below the waist, they are considered to be unsterile.

Rationale 3: Suctioning the oral cavity of a client is considered contaminating.

Rationale 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.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Explain the concepts of medical and surgical asepsis.

MNL Learning Outcome: 4.2.3. Apply the principles of surgical asepsis as indicated in the clients plan of care.

Page Number: 625

Question 2

Type: MCSA

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

Correct Answer: 4

Rationale 1: Administering parenteral medications requires surgical asepsis.

Rationale 2: Changing a dressing requires surgical asepsis.

Rationale 3: Performing a urinary catheterization requires surgical asepsis.

Rationale 4: Using personal protective equipment demonstrates medical asepsis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Explain the concepts of medical and surgical asepsis.

MNL Learning Outcome: 4.2.2. Apply the principles of medical asepsis in the care of the client.

Page Number: 636

Question 3

Type: MCSA

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

Correct Answer: 4

Rationale 1: A client in the emergency department with abdominal pain has just arrived in the facility, and not enough time has elapsed for this client to be considered to have a nosocomial infection. If this client has an infection, it would be community acquired.

Rationale 2: The 19-year-old female who is pregnant is at a low risk.

Rationale 3: The 72-year-old male with COPD is at a lower risk for infection than the 82-year-old because the older client has a weakened immune system because of taking steroids.

Rationale 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.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify risks for nosocomial and health careassociated infections.

MNL Learning Outcome: 4.2.4. Integrate safe practices in the care of the client to prevent the spread of infection.

Page Number: 609

Question 4

Type: MCSA

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.

Correct Answer: 3

Rationale 1: Increasing intake of fruits and vegetables would increase vitamin C, which helps with wound healing, but more protein would be the best choice.

Rationale 2: Applying lubricating lotion to the edges of a wound would impede the healing process.

Rationale 3: A client being discharged with an open surgical wound has to be instructed on the detection of infection because the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection.

Rationale 4: Irrigating with hydrogen peroxide would break down good granulating tissue, so this would not increase healing.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Identify signs of localized and systemic infections and inflammation.

MNL Learning Outcome: 4.2.4. Integrate safe practices in the care of the client to prevent the spread of infection.

Page Number: 607

Question 5

Type: MCSA

A patient is diagnosed with a systemic infection. What will the nurse most likely assess in this client?

1. Edema, rubor, heat, and pain

2. Fever, malaise, anorexia, nausea, and vomiting

3. Palpitations, irritability, and heat intolerance

4. Tingling, numbness, and cramping of the extremities

Correct Answer: 2

Rationale 1: Edema, rubor, heat, and pain are symptoms of a local infection.

Rationale 2: Fever, malaise, anorexia, nausea, and vomiting are symptoms of a systemic infection.

Rationale 3: Palpitations, irritability, and heat intolerance are symptoms of a thyroid condition.

Rationale 4: Tingling, numbness, and cramping of the extremities are symptoms of hypocalcemia.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Identify signs of localized and systemic infections and inflammation.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 610

Question 6

Type: MCSA

An older client with gallbladder disease has had a cholecystectomy. Which factor should the nurse realize would influence the development of an infection in this client?

1. Active bowel sounds

2. Dry intact skin

3. Intact mucous membranes

4. Susceptibility of the client

Correct Answer: 4

Rationale 1: Active bowel sounds would indicate the body is able to defend itself against an infection.

Rationale 2: Dry intact skin is a factor that would help the body defend against an infection.

Rationale 3: Intact mucous membranes is a factor that would help the body defend against infection.

Rationale 4: How susceptible the client is for an infection is one of the factors that influences microorganism growth. This client is 80 years old and has a surgical incision, so the first line of defense, the skin, is not intact.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Identify factors influencing a microorganisms capability to produce an infectious process.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 620

Question 7

Type: MCSA

The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the clients body from microorganisms?

1. Heavy smoking

2. Moisturizing the skin

3. Breakdown of skin

4. Voiding quantity sufficient

Correct Answer: 4

Rationale 1: Heavy smoking does not defend the body from microorganisms; it destroys the cilia in the nose that help to filter organisms.

Rationale 2: Moisturizing the skin can allow microorganisms to enter the body.

Rationale 3: Breakdown of the skin can allow microorganisms to enter the body.

Rationale 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.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Identify anatomic and physiological barriers that defend the body against microorganisms.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 607

Question 8

Type: MCSA

The nurse determines that a client has active immunity to a microorganism. What did the nurse assess that caused the client to develop this type of immunity?

1. Becoming ill with tetanus and receiving tetanus toxoid

2. Having chickenpox

3. Receiving a rabies shot after being bitten by a rabid dog

4. Receiving an injection of gamma globulin

Correct Answer: 2

Rationale 1: Receiving an injection for tetanus is an example of acquired passive immunity.

Rationale 2: When the client has the disease, the body stimulates the process of acquired active immunity.

Rationale 3: Receiving an injection for rabies is an example of artificially acquired passive immunity.

Rationale 4: Receiving an injection of gamma globulin is an example of artificially acquired passive immunity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Differentiate active from passive immunity..

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 608

Question 9

Type: MCSA

A client was bitten by a rabid raccoon. What care should the nurse prepare to provide to this client?

1. A tetanus toxoid injection

2. An immunization for rabies

3. An injection of immunoglobulin

4. Mothers breast milk with antibodies in it

Correct Answer: 2

Rationale 1: A tetanus toxoid injection is not specific for rabies.

Rationale 2: Receiving an immunization for rabies is an example of artificially acquired passive immunity.

Rationale 3: An injection of immunoglobulin is not specific for rabies.

Rationale 4: Mothers breast milk is another example of passive immunity, but not for rabies.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Differentiate active from passive immunity.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 608

Question 10

Type: MCSA

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 clients room.

3. Wash hands.

4. Wear a mask for all client care.

Correct Answer: 3

Rationale 1: Assessing vital signs is important but should occur more frequently than once daily.

Rationale 2: Raising the temperature in a clients room would contribute to the growth of microorganisms.

Rationale 3: Washing hands is always the first and best way to stop the spread of microorganisms, which cause infections.

Rationale 4: Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is airborne and the client is in isolation.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8. Identify interventions to reduce risks for infections.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 612

Question 11

Type: MCSA

The nurse wants to protect a client from developing an infection. Which action should the nurse take to break a link in the chain of infection?

1. Cover the mouth and nose when sneezing.

2. Place contaminated linens in a paper bag.

3. Use personal protective equipment (PPE) sparingly.

4. Wear gloves at all times.

Correct Answer: 1

Rationale 1: Covering the mouth and nose when sneezing prevents airborne droplets from escaping into the air for others to contract in the chain of infection.

Rationale 2: Placing linens in a paper bag would allow germs to come out through the bag, and the linen would act as a fomite, thus allowing the chain to continue.

Rationale 3: PPE, according to OSHA standards, has to be used whenever the situation dictates, not sparingly.

Rationale 4: Gloves have to be worn but are to be changed between clients and hands washed.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Identify measures that break each link in the chain of infection.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 612

Question 12

Type: MCSA

The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper hand-washing technique with this client?

1. Allow the water to splatter forcibly when it is turned on.

2. Clean the faucet after use.

3. Hold the hands upward under the faucet.

4. Use approximately a teaspoon of soap.

Correct Answer: 4

Rationale 1: When the water is turned on, it should be adjusted so it does not splatter even if the flow is not very forceful.

Rationale 2: Cleaning the faucet after use would defeat the whole purpose of washing the hands. If the sink needs cleaning, clean it before washing the hands.

Rationale 3: Holding the hands upward under the faucet is incorrect. They should be held downward so the soap, germs, and water are washed downward from the hands and down the sink.

Rationale 4: Approximately 1 teaspoon of soap should be used when performing proper hand-washing technique.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: a. Performing hand hygiene.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 615

Question 13

Type: MCSA

The nurse is removing personal protective equipment. Which nursing action demonstrates the appropriate technique for removing a mask?

1. Bend the strip at the top of the mask.

2. Loop the ties over the ears.

3. Tie the strings in a bow.

4. Touch the mask by the strings only.

Correct Answer: 4

Rationale 1: Bending the strip at the top of the mask is done when applying a mask.

Rationale 2: Looping the ties over the ears is done when applying a mask.

Rationale 3: Tying the strings in a bow under the chin is done when applying a mask.

Rationale 4: Touching the mask by the strings is the appropriate intervention because the mask is considered contaminated.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 623

Question 14

Type: MCSA

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.

Correct Answer: 3

Rationale 1: Dropping the gloves in the appropriate waste receptacle occurs after the gloves are removed.

Rationale 2: Easing the fingers into the glove is done when applying gloves.

Rationale 3: In order to remove gloves after use, one must grasp the outside of the nondominant glove.

Rationale 4: Hooking the bare thumb inside the other glove is done after the gloves are removed.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 622

Question 15

Type: MCSA

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

Correct Answer: 4

Rationale 1: Grasping the edge of the outermost flap and opening it away from oneself will maintain the sterility of a field.

Rationale 2: Keeping objects on the field 1 inch from the edge will maintain the sterility of a field.

Rationale 3: Keeping the sterile field in eyesight will maintain the sterility of a field.

Rationale 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.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 11. Verbalize the steps used in: c. Establishing and maintaining a sterile field.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 627

Question 16

Type: MCSA

A client needs to be placed in contact isolation. What items should the nurse ensure are included in this clients room?

1. Cabinet stocked with gloves and gowns

2. Cards and records

3. Paper towels, sink, and blood pressure cuff

4. Sign on the door

Correct Answer: 3

Rationale 1: A cabinet stocked with gloves and gowns would be on the outside of the room.

Rationale 2: Cards and records should never be taken into an isolation room.

Rationale 3: Paper towels and a sink for hand washing should be in the clients room so they can be used before the staff leaves the room. A blood pressure cuff needs to stay in the clients room to prevent cross contamination.

Rationale 4: The sign explaining the kind of isolation should be on the outside of the door to alert the staff of what is needed to enter.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Compare and contrast category-specific, disease-specific, standard, and transmission-based isolation precaution systems.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 620

Question 17

Type: MCSA

The RN has just been stuck with a syringe while dropping it into a sharps container that was too full in a clients room. What action should the nurse take first for this puncture wound?

1. Complete an injury report.

2. Encourage bleeding.

3. Initiate first aid.

4. Wash the area with soap and water.

Correct Answer: 2

Rationale 1: This is not the first step. It can be done later.

Rationale 2: Encouraging bleeding is the first step.

Rationale 3: Initiating first aid is not the first step.

Rationale 4: Washing the area with soap and water is not the first step.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13. Describe the steps to take in the event of a bloodborne pathogen exposure.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 636

Question 18

Type: MCSA

The nurse is preparing to leave a clients 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.

Correct Answer: 4

Rationale 1: Gloves are not left on while taking off a soiled gown.

Rationale 2: The neck ties are untied after the ties at the waist are untied.

Rationale 3: To leave an isolation room where a gown has been worn, one must untie the gown at the waist first, not at the neck.

Rationale 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.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 622

Question 19

Type: MCSA

The nurse is preparing a presentation on standard precautions. Which statement should the nurse include in the presentation?

1. Cut the needle off a syringe after using it to give a client an injection.

2. Dispose of blood-contaminated materials in a biohazard container.

3. Gloves should not be worn for client care unless body fluids are seen.

4. Wear a mask when in direct contact with all clients.

Correct Answer: 2

Rationale 1: Needles should never be cut, bent, or altered in any way, as this would place the health care provider at risk of being stuck.

Rationale 2: Disposal of blood-contaminated materials in a biohazard container is a standard precaution.

Rationale 3: Gloves should be worn when providing client care whether body secretions are seen or not.

Rationale 4: Masks need not be worn when giving routine direct client care unless the clients condition so warrants.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Compare and contrast category-specific, disease-specific, standard, and transmission-based isolation precaution systems.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 626

Question 20

Type: MCSA

A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the transmission of the disease?

1. Have the client wear a mask when coming from admission.

2. Stock the supply cart at the beginning of each shift.

3. Wash the hands only after leaving the room.

4. Wear a mask when exiting the room.

Correct Answer: 1

Rationale 1: When a client has an airborne disease and must go elsewhere in the hospital, the client must wear a mask.

Rationale 2: Supplies to prevent transmission of disease should be stocked at the end of the shift so that adequate supplies will be available for the next health care provider.

Rationale 3: Hands should be washed before and after client care.

Rationale 4: The mask should be removed just as the staff leaves the clients room, not when coming out of the room.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 9. Identify measures that break each link in the chain of infection.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 626

Question 21

Type: MCMA

The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision?

Standard Text: 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.

Correct Answer: 1, 2, 3

Rationale 1: Bacteremia can occur from an intravascular line.

Rationale 2: The client could develop an infection from an invasive procedure or device such as an indwelling urinary catheter.

Rationale 3: After surgery, the clients health status is compromised, lowering the clients defenses to fight infection.

Rationale 4: Receiving pain medication does not increase the clients risk for developing a nosocomial infection.

Rationale 5: Ambulation does not increase the clients risk for developing a nosocomial infection.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify risks for nosocomial and health careassociated infections.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 604

Question 22

Type: MCMA

A client diagnosed with an infectious disease asks the nurse how the infection got inside her body. Which responses would be appropriate for the nurse to make?

Standard Text: Select all that apply.

1. It depends on the number of organisms present to cause a disease.

2. It depends on how aggressive the organisms are to cause a disease.

3. It depends upon how the organisms get inside the body to cause a disease.

4. It depends upon where the person is at the time the disease is present.

5. It depends upon where the person works.

Correct Answer: 1, 2, 3, 4

Rationale 1: It depends on the number of organisms present to cause a disease addresses the number of microorganisms present.

Rationale 2: It depends on how aggressive the organisms are to cause a disease addresses the virulence and potency of the microorganisms.

Rationale 3: It depends upon how the organisms get inside the body to cause a disease addresses the ability of the microorganisms to enter the body.

Rationale 4: It depends upon where the person is at the time the disease is present addresses the susceptibility of the host and the ability of the microorganisms to live in the hosts body.

Rationale 5: It depends upon where the person works does not explain a factor for the development of an infection.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Identify factors influencing a microorganisms capability to produce an infectious process.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 605

Question 23

Type: MCMA

The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client?

Standard Text: Select all that apply.

1. Intact and dry skin

2. Intact oral mucous membranes

3. Bowel sounds present in all four quadrants

4. Nasal congestion

5. Urinary retention

Correct Answer: 1, 2, 3

Rationale 1: Intact skin is the bodys first line of defense against microorganisms.

Rationale 2: Intact mucous membranes are the bodys first line of defense against microorganisms.

Rationale 3: Peristalsis tends to move microbes out of the body.

Rationale 4: Nasal congestion would mean that the nasal passages would be ineffective in filtering microorganisms from inspired air.

Rationale 5: Urinary retention would cause the urine to remain in the body, possibly leading to an infection.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Identify anatomic and physiological barriers that defend the body against microorganisms.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 607

Question 24

Type: MCSA

A client is diagnosed with a communicable disease, and must be placed in isolation. The nurse should identify which diagnosis as a priority for this client?

1. Social Isolation

2. Anxiety

3. Acute Pain

4. Imbalanced Nutrition: Less Than Body Requirements

Correct Answer: 1

Rationale 1: Social Isolation would be appropriate for the client who needs to be separated from others during a contagious episode.

Rationale 2: Anxiety would be appropriate if the client were demonstrating apprehension regarding a change in life activities because of the communicable disease.

Rationale 3: Acute Pain would be appropriate if the client were experiencing discomfort.

Rationale 4: Imbalanced Nutrition: Less Than Body Requirements would be appropriate if the client were too ill to eat adequately.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 7. Identify relevant nursing diagnoses and contributing factors for clients at risk for infection and who have an infection.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 611

Question 25

Type: MCSA

A client tells the nurse that the newly diagnosed communicable disease is negatively impacting employment and causing a stressful situation at home. What diagnosis should the nurse select as a priority for this client?

1. Anxiety

2. Acute Pain

3. Social Isolation

4. Low Self-Esteem

Correct Answer: 1

Rationale 1: Anxiety is appropriate because the client is discussing the impact of the communicable disease on work and home life.

Rationale 2: Acute Pain is not appropriate, as the client is not experiencing discomfort.

Rationale 3: Social Isolation is not appropriate, as the client has not been placed in transmission precaution at this time.

Rationale 4: Low Self-Esteem is incorrect because the client is not expressing negative comments about himself.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 7. Identify relevant nursing diagnoses and contributing factors for clients at risk for infection and who have an infection.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 611

Question 26

Type: MCMA

A client is being discharged after a surgical procedure. On what should the nurse instruct the client to reduce the risk of infection?

Standard Text: Select all that apply.

1. Hand-washing technique

2. The importance of adequate nutrition

3. Covering the mouth and nose when coughing or sneezing

4. Increasing contact with others

5. Restricting rest period

Correct Answer: 1, 2, 3

Rationale 1: The nurse should instruct the client on the correct hand-washing technique to reduce the risk of infection.

Rationale 2: The nurse should instruct the client on the importance of adequate nutrition to reduce the risk of infection.

Rationale 3: The nurse should instruct the client to cover the mouth and nose when coughing or sneezing to reduce the risk of infection.

Rationale 4: The nurse should instruct the client to minimize exposure to others when recovering from surgery to reduce the risk of infection.

Rationale 5: The nurse should instruct the client to get adequate rest and sleep when recovering from surgery to reduce the risk of infection.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Identify interventions to reduce risks for infections.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 611

Question 27

Type: MCSA

A client in isolation ambulates with assistance to the bathroom. After toileting, what should the unlicensed assistive personnel do?

1. Assist the client with hand washing.

2. Assist the client back to bed.

3. Change the clients bed.

4. Leave the clients room.

Correct Answer: 1

Rationale 1: The client should utilize good hand washing after going to the bathroom. The unlicensed assistive personnel should assist the client with hand washing.

Rationale 2: After handwashing, the unlicensed assistive personnel should assist the client back to bed.

Rationale 3: The clients bed can be changed at any time.

Rationale 4: The unlicensed assistive personnel should not leave the clients room until the client has washed her hands and has been assisted back to bed.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Identify interventions to reduce risks for infections.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 612

Question 28

Type: MCSA

While irrigating a clients abdominal wound, the irrigate splashes into the nurses nose and eyes. What should the nurse do?

1. Flush the nose and eyes for 5 to 10 minutes with water or normal saline.

2. Begin HIV high-risk exposure prophylaxis within 24 hours.

3. Wash the areas with soap and water.

4. Have blood drawn for hepatitis B antibodies.

Correct Answer: 1

Rationale 1: After an exposure to the mucous membranes, the area should be flushed for 5 to 10 minutes with saline or water.

Rationale 2: The client was not identified as being HIV-positive.

Rationale 3: Washing the area with soap and water would be appropriate for a puncture or laceration.

Rationale 4: Being tested for hepatitis B would be appropriate after a puncture or laceration but not for a splash to the mucous membranes.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13. Describe the steps to take in the event of a bloodborne pathogen exposure.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 636

Question 29

Type: MCMA

The nurse is reviewing the agents available to disinfect the hands after providing client care. Which agents should the nurse consider using?

Standard Text: Select all that apply.

1. Triclosan

2. Chlorine (bleach)

3. Isopropyl alcohol

4. Hydrogen peroxide

5. Chlorhexidine gluconate

Correct Answer: 1, 3, 5

Rationale 1: Triclosan is an agent that can be used on the hands as a disinfectant.

Rationale 2: Chlorine bleach is used to clean blood spills.

Rationale 3: Isopropyl alcohol is an agent that can be used on the hands as a disinfectant.

Rationale 4: Hydrogen peroxide is used to clean surfaces.

Rationale 5: Chlorhexidine gluconate is an agent that can be used on the hands as a disinfectant.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8. Identify interventions to reduce risks for infections.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 618

Question 30

Type: SEQ

The nurse needs to apply personal protective equipment before entering a clients room. In which order should the nurse perform the following actions?

Standard Text: Place the steps in the order in which they should be performed.

1. Apply gloves.

2. Apply eyewear.

3. Apply the gown.

4. Apply the face mask.

5. Perform hand hygiene.

Correct Answer: 5, 3, 4, 2, 1

Rationale 1: Gloves are applied last.

Rationale 2: Protective eyewear is applied after the face mask.

Rationale 3: The gown is applied after hand hygiene.

Rationale 4: The face mask is applied after the gown.

Rationale 5: Before applying personal protective equipment, hand hygiene should be performed.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. Verbalize the steps used in: b. Applying and removing a gown, face mask, eyewear, and clean gloves.

MNL Learning Outcome: 4.2.1. Explain the transmission of disease, nurses role, and types of precautions during client care.

Page Number: 621

Leave a Reply