Chapter 31 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 31

Question 1

Type: MCSA

Which of the following actions 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: Page Reference: 671

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Explain the concepts of medical and surgical asepsis.

Question 2

Type: MCSA

Which nursing action would demonstrate medical asepsis?

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: Page Reference: 671

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Explain the concepts of medical and surgical asepsis.

Question 3

Type: MCSA

The nurse recognizes that which client would be 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: Page Reference: 672

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify risks for nosocomial and health careassociated infections.

Question 4

Type: MCSA

What instructions is the most important for the nurse to give a client who is about to be discharged and 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 if with any edema, heat, or tenderness at the wound site.

4. Thoroughly irrigate the wound with hydrogen peroxide.

Correct Answer: 3

Rationale 1: Increasing 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 since 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 also would not increase healing.

Global Rationale: Page Reference: 671

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 02 Identify signs of localized and systemic infections and
inflammation.

Question 5

Type: MCSA

What will the nurse most likely assess in the client diagnosed with a systemic infection?

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 would indicate symptoms of hypocalcemia.

Global Rationale: Page Reference: 672

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 Identify signs of localized and systemic infections and
inflammation.

Question 6

Type: MCSA

An older client with gallbladder disease has had a cholecystectomy. Which factor would influence this clients susceptibility to produce an infection?

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 the body 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: Page Reference: 674

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Identify factors influencing a microorganisms capability to
produce an infectious process.

Question 7

Type: MCSA

The nurse identifies which physiological barriers as helpful to defend the 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 helps 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: Page Reference: 675

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify anatomic and physiological barriers that defend
the body against microorganisms.

Question 8

Type: MCSA

Which of the following circumstances would cause a client to develop active 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 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: Page Reference: 676

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06 Differentiate active from passive immunity.

Question 9

Type: MCSA

The nurse should prepare to provide which intervention for a client who was bitten by a rabid raccoon?

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: Page Reference: 677

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Differentiate active from passive immunity.

Question 10

Type: MCSA

When 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 be taken 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: Page Reference: 675

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 08 Identify interventions to reduce risks for infections.

Question 11

Type: MCSA

Which nursing measure is appropriate 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 just to save money.

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

Global Rationale: Page Reference: 687

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Identify measures that break each link in the chain of infection.

Question 12

Type: MCSA

Which technique should the nurse use to promote proper hand washing technique in a client with hepatitis A?

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 one teaspoon of soap should be used when performing proper hand washing technique.

Global Rationale: Page Reference: 688

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

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

Question 13

Type: MCSA

Which of 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: Page Reference: 695

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

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.

Question 14

Type: MCSA

What should the nurse do first when removing gloves?

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: Page Reference: 696

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

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.

Question 15

Type: MCSA

Which action by the nurse would cause a break in a sterile field?

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 gloved hand

Correct Answer: 4

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

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

Rationale 3: Keeping the sterile field in eyesight will maintain 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: Page Reference: 700

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

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

Question 16

Type: MCSA

The nurse should ensure that what items are included in the room of a client who is on contact isolation?

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 is needed 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: Page Reference: 693

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

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

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. Which of the following steps should be taken first for a puncture?

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: Page Reference: 711

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

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

Question 18

Type: MCSA

Which nursing action demonstrates the correct technique to remove a grossly soiled gown when leaving isolation?

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: Page Reference: 696

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

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

Question 19

Type: MCSA

The nurse is preparing a presentation on Standard Precautions. Which statement should be included 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 to be 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: Page Reference: 692

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

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

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: Page Reference: 693

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 09 Identify measures that break each link in the chain of infection.

Question 21

Type: MCMA

The nurse is concerned that a client is at risk for a nosocomial infection when what is assessed?

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: Page Reference: 672

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify risks for nosocomial and health careassociated infections.

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: Page Reference: 674

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Identify factors influencing a microorganisms capability to produce an infectious process.
05 Identify anatomic and physiological barriers that defend the body against microorganisms.

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 to filter microorganisms from inspired air.

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

Global Rationale: Page Reference: 675

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Identify anatomic and physiological barriers that defend the body against microorganisms.

Question 24

Type: MCSA

A client is diagnosed with a communicable disease, and must be placed in isolation. The nurse would 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: Page Reference: 684, 693, 700

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 07 Identify relevant nursing diagnoses and contributing factors for clients at risk for infection and who have an infection.

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 would 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, since the client is discussing the impact of the communicable disease on work and home life.

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

Rationale 3: Social Isolation is not appropriate, since 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: Page Reference: 671

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 07 Identify relevant nursing diagnoses and contributing factors for clients at risk for infection and who have an infection.

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. Handwashing 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 handwashing 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: Page Reference: 687

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Identify interventions to reduce risks for infections.

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 handwashing.

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 handwashing after going to the bathroom. The unlicensed assistive personnel should assist the client with handwashing.

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: Page Reference: 693

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Identify interventions to reduce risks for infections.

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 510 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 510 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: Page Reference: 692

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

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

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

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