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During the change-of-shift report the night nurse states that a client mentioned having a bad experience

with surgery in the past. The nurse was called away and was unable to continue the conversation with
the client. The nurse tells the day shift nurse about the comment and notes that the client appears
anxious. When the day shift nurse visits the client to clarify the client's bad experience with surgery, the
nurse is exhibiting which aspect of critical thinking?

A. Integrity
B. Discipline
C. Confidence
D. Perseverance
D. Discipline

Discipline includes completing the task at hand, including assessments (which were not completed on
the previous shift). Integrity includes recognizing when one's opinions conflict with those of others and
finding a mutually satisfying solution. Confidence is demonstrated in one's presentation and belief in
one's knowledge and abilities. Perseverance helps the critical thinker to find effective solutions to client
care problems, especially when they have been previously unresolved.

A client tells the nurse, "I'm not happy with the way the patient care technician did my bath. He just
seemed to be in a hurry and did not wash my back like I asked." The nurse decides to go talk with the
technician to learn his side of the story as well. This is an example of:
A. Fairness
B. Curiosity
C. Risk taking
D. Responsibility
A. Fairness

Fairness involves analyzing all viewpoints to understand the situation completely before making a
decision. Curiosity gives the critical thinker the motivation to continue to ask questions and learn more.
Risk taking involves trying different ways to solve problems.

The surgical unit has initiated the use of a pain rating scale to assess the severity of clients' pain during
their postoperative recovery. The nurse assigned to a client can look at the pain flow sheet to see the
client's pain scores over the last 24 hours. Use of the pain scale is an example of adherence to which
intellectual standard?
D. Consistency

Using the same pain scale for all clients and ratings promotes consistency—each nurse has the same
measurement scale to compare assessments. Relevance refers to how applicable the assessment is. An
assessment has depth when it deals with less obvious issues. Specificity refers to the ability of the
assessment to provide information about the particular problem of interest.

During the day the nurse spends time instructing a client in how to self-administer insulin. After
discussing the technique and demonstrating an injection, the nurse asks the client to try it. After the
client makes two attempts it is clear that the client does not understand how to prepare the correct
dose. The nurse discusses the situation with the charge nurse and asks for suggestions. This is an
example of:
A. Reflection
B. Risk taking
C. Problem solving
D. Client assessment
C. Problem Solving

This is an example of problem solving because the nurse is taking a problem to a supervisor for help in
finding a different approach. Reflection is the process of purposefully thinking back and recalling a
situation to discover its purpose or meaning. Risk taking involves trying a different approach. Client
assessment is the first step in the process of instruction.

A nurse uses an institution's procedure manual to confirm how to insert a Foley catheter. The level of
critical thinking the nurse is using is:
A. Commitment
B. Scientific method
C. Basic critical thinking
D. Complex critical thinking
C. Basic critical thinking

At the basic level of critical thinking, a learner trusts the experts and follows a procedure step by step.
Complex critical thinkers separate themselves from authorities and analyze and examine choices more
independently. Commitment is the third level of critical thinking in which the person anticipates the
need to make choices without assistance from others. The scientific method is a process of problem
solving.

A nurse refers to a client's postsurgical written plan of care, noting that the client has a drainage device
collecting wound drainage. The surgeon is to be notified when drainage in the device exceeds 100 ml for
the day. The nurse carefully notes the amount of drainage currently in the device. This is an example of:
A. Planning
B. Evaluation
C. Assessment
D. Intervention
C. Assessment

Assessment is the process of observing and collecting data. Planning is the step in which the diagnosis is
analyzed for problem resolution. Intervention consists of the steps actually taken after planning.
Evaluation measures the effectiveness of the plan.

The nurse asks a client how she feels about impending surgery for breast cancer. Before initiating the
discussion the nurse reviewed information about loss and grief in addition to therapeutic
communication principles. The critical thinking component involved in the nurse's review of the
literature is:
A) Experience
B) Problem solving
C) Knowledge application
D) Clinical decision making
C. Knowledge application

The nurse sought appropriate information to be able to communicate more knowledgeably with the
client. Experience is acquired through clinical learning situations. Problem solving is a series of steps to
resolve a problem. Clinical decision making is a process in which critical thinking steps are followed for
problem resolution.

Which of the following is the most accurate information to give a nurse during change-of-shift
reporting?
A) Client refuses to take medications.
B) Client reports sharp pain in left anterior knee.
C) Client encouraged to consume more fluids.
D) Client expressed concern about pending surgery.
B. Client reports sharp pain in elft anterior knee

The information in option 2 represents objective data that the nurse can use as part of baseline
information. "Encouraged" and "more" are vague terms. "Concern" is also vague; relating the exact
concern would be more accurate. Option 1 may be true, but accurate data would also report why the
client refused medication.

On entering a client's room during change-of-shift rounds, the nurse notices that the client and spouse
have their backs turned to each other, and both have their arms folded across their chests. The best
action for the nurse to take at this time is to:
A) Introduce himself or herself and begin discharge teaching.
B) Proceed with the tasks the nurse was intending to perform.
C) Say nothing and leave quickly, closing the door behind.
D) Ask the client and spouse if they need some time alone right now.
D. Ask the client and spouse if they need smoe time alone right now.

The situation suggests that the nurse entered during a stressful time. Offering privacy would be
appropriate. Because the situation indicates tension between the couple, this is not the time to initiate
teaching.

The nurse is assessing the urinary history of a middle-aged married woman. The nurse asks her if she
gets up at night. She replies, "Yes." What other question should the nurse ask?
A) "How many times do you get up at night?"
B) "How long have you been getting up at night?"
C) "Why do you get up at night?"
D) "How easily do you go back to sleep after you get up?"
C. "Why do you get up at night?"

Perhaps it is the client's husband who is getting up in the middle of the night because of a prostate
problem, and this is why she is awakened. The nurse should not assume nocturia without further
assessment questions.

A client with diabetes mellitus who takes daily insulin injections is scheduled for surgery the next day.
The client is to take nothing by mouth (NPO status) after midnight. The nurse questions whether insulin
should be given the morning of surgery. This is an example of:
A) Problem solving
B) Previous experience
C) Clinical practice guideline
D) Scientifically based clinical judgment
D. Scientifially based clinical judgment

The nurse is demonstrating awareness of the effect of insulin, which is to lower blood glucose level.
Because the client will be NPO status for a long period of time, no calories will be consumed. Giving the
usual injection of insulin could cause the client to experience hypoglycemia.

The client is a 65-year-old overweight woman with multiple medical diagnoses, including diabetes
mellitus type 2, hypertension, and residual right-sided weakness resulting from a previous
cerebrovascular accident. What tool should be used to plan her care?
A) Care plan
B) Care map
C) Concept map
D) Critical thinking
C. Concept map

A concept map is a visual representation of client problems and interventions that shows their
relationships to each other and allows easy synthesis of data about the client.

A client newly admitted to the hospital begins to have chest pain. Before calling the physician, the nurse
should gather what additional data? (Select all that apply.)
A) Pain intensity
B) Location of pain
C) Character of pain
D) Radiation of pain
E) Meaning of pain to the client
F) Family history of myocardial infarctions
A, B, C, D, and E

The nurse should gather the data the physician will need to determine whether the chest pain
represents a myocardial infarction. Family history is important in comprehensive pain assessment;
however, taking time to obtain this information is inappropriate in this critical situation.

The purpose of assessment is to:


A) Make a diagnostic conclusion.
B) Delegate nursing responsibility.
C) Teach the client about his or her health.
D) Establish a database concerning the client.
D. Establish a database concerning the client

The purpose of assessment is to establish a database about the client's perceived needs, health
problems, and responses to these problems. The data also reveal related experiences, health practices,
goals, values, and expectations. The other options are not purposes of assessment.

Assessment data must be descriptive, concise, and complete. In performing an assessment the nurse
should not:
A) Include subjective data from the client.
B) Perform a thorough physical examination.
C) Use interpersonal and cognitive skills.
D) Include inferences or interpretative statements not supported with data.
D. Include inferences or interpretative statements not supported with data

The nurse should not generalize or form judgments not supported by the collected data. Inferences and
interpretive statements must be supported by data. Assessments do include conducting a thorough
physical examination, using interpersonal and cognitive skills, and obtaining subjective data from the
client.

A nurse assessing a client who comes to the pulmonary clinic asks, "Tell me what medications you are
taking for your breathing problem. I see from your last visit that Dr. Russell recommended routine
exercise. Can you also tell me how successful you have been in following his plan?" The nurse's
assessment covers which of Gordon's functional health patterns?
A) Value-belief pattern
B) Cognitive-perceptual pattern
C) Coping/stress tolerance pattern
D) Health perception/health management pattern
D. Health perception/health management patern

The health perception/health management pattern involves the client's self-report of health and well-
being, how the client manages his or her health, and knowledge of preventative health practices. The
cognitive-perceptual pattern involves sensory-perceptual patterns, language adequacy, memory, and
decision-making abilities. The coping/stress tolerance pattern involves the client's ability to manage
stress, sources of support, and the effectiveness of the patterns in terms of stress tolerance. The value-
belief pattern involves the values, beliefs, and goals that guide the client's choices or decisions.

The nurse asks a client, "Ms. Neil, describe for me your typical diet over a 24-hour day. What foods do
you prefer? Have you noticed a change in your weight recently?" This series of questions would likely
occur during which phase of a client interview?
A) Working
B) Orientation
C) Termination
A. Working

The nurse's questions exemplify the working phase of the interview.

During data clustering, a nurse:


A) Provides documentation of nursing care
B) Reviews data with other health care providers
C) Makes inferences about patterns of information
D) Organizes cues into patterns that lead to identification of nursing diagnoses
D. Organizes cues into paterns that lead to identification of nursing diagnoses

During data clustering, the nurse organizes cues into patterns that indicate individualized nursing
diagnoses and identify collaborative problems. The other options are incorrect.

What type of interview technique is the nurse using when the nurse asks the question, "Do you have
pain or cramping?"
A) Active listening
B) Open-ended questioning
C) Closed-ended questioning
D) Problem-oriented questioning
C. Closed-ended question

The example is a closed-ended question which the client can answer with a one-word reply. Open-ended
questions allow the client to answer with more information. The other options are not correct.

Which of the following is subjective information to be entered in the client's medical record?
A) Skin warm and dry.
B) Pain intensity 8 out of 10.
C) Breath sounds clear to auscultation.
D) Amber urine in sufficient quantities.
B. Pain intensity 8 out of 10
Pain is purely a subjective phenomenon. Although the pain intensity rating is an objective number, it
depends on the client's report. The other options are objective data.

Which of the following is objective information to be recorded in the client's medical record?
A) Anxious over upcoming test.
B) Increasing stress over past 2 months.
C) Performs breast self-examination monthly.
D) Expelled 1 tablespoon of yellow sputum.
D. Expelled 1 tablespoon of yellow sputum

Objective data are measurable data. Options 1, 2, and 3 describe data that cannot be measured by the
nurse but depend on the client's reports; thus they are subjective data.

A client who is alert and awake is being transferred to another hospital with a copy of his medical
records. Before the transfer the nurse must:
A) Ask the hospital lawyer if this requires approval from the risk management department.
B) Discuss the need to copy the medical records with the client's family.
C) Be certain that the physician writes an order for the record to be copied.
D) Obtain written permission to copy the medical records for the receiving hospital.
D. Obtain written permissin to copy the medical records for the receiving hospital

Obtaining permission to copy the records demonstrates the nurse's understanding of the provisions of
the Health Insurance Portability and Accountability Act (HIPAA). Discussing medical records with the
client's family is inappropriate because the client's family does not make the decision for a client who is
capable of making his own decision. Policies and procedures would already be in place for the nurse
with regard to copying medication records. It is not necessary to call the hospital lawyer. Copying a
client's medical record does not require a physician's order.

Which of the following is an open-ended question the nurse might use when interviewing a client?
A) "Do you have any concerns right now?"
B) "Is your family worried about your being in the hospital?"
C) "What do you mean when you say, 'I don't feel quite right'?"
D) "How many times do you get up to go to the bathroom at night?"
C. "What do you mean when you say, 'I don't feel quite right'?"

The way the nurse asks question 3 allows the client to respond completely and with more than a one-
word answer. The other options allow the client to respond with one word and make it unlikely that the
client will give additional information.

The nurse asks the client whether the client has any allergies. This is an example of:
A) Health history data
B) Biographical information
C) History of present illness
D) Environmental history data
A. Health history data

Known allergies are a part of historical data. Biographical data include age, address, occupation, work
status, marital status, course of health care, and insurance. The history of the present illness includes
when the symptoms began, whether they began suddenly or gradually, whether they come and go, and
other information about the illness. The environmental history includes data about the client's home
and working environments.

The nursing assessment is which phase of the nursing process?


A) First
B) Second
C) Third
D) Fourth
A. First

The nursing process cannot proceed unless the nurse first conducts a client assessment. The other
phases of the nursing process occur after assessment.

What techniques encourage a client to tell his or her full story? (Select all that apply.)
A) Active listening
B) Back channeling
C) Use of open-ended questions
D) Use of closed-ended questions
A, B, and C

Options 1, 2, and 3 encourage clients to tell their full stories. Closed-ended questions allow clients to
answer with one or two words, which makes it more difficult to obtain all the information required for a
full story. The other options give clients the opportunity to tell their stories and feel supported. Active
listening helps them feel that they, and their stories, are important.

The nurse gathered the following assessment data. Which of these cues form a pattern? (Select all that
apply.)
A) Client is restless.
B) Respirations are 24/min and irregular.
C) Client states feeling short of breath.
D) Fluid intake for 8 hours is 800 ml.
E) Client has drainage from surgical wound.
F) Client reports loss of appetite for over 2 weeks.
A, B, and C

The data in items 1, 2, and 3—rapid irregular breathing, complaints of shortness of breath, and
restlessness—form a pattern indicating that the client may be experiencing hypoxia, because all are
signs and symptoms characteristic of this condition. The other information, although important, is not
related to hypoxia.

The nurse asks the client's spouse, "Mrs. Smith, your husband told me that for the past week he has not
been eating the meals you prepare. Do you agree?" This is an example of __________________ of
assessment data.
Validation

16. A review of systems (ROS) is based on information obtained from the client during the interview.
This information is an example of ______________ data.
Subjective

nursing diagnosis is:


A) The diagnosis and treatment of human responses to health and illness
B) The advancement of the development, testing, and refinement of a common nursing language
C) A clinical judgment about individual, family, or community responses to actual and potential health
problems or life processes
D) The identification of a disease condition based on a specific evaluation of physical signs, symptoms,
the client's medical history, and the results of diagnostic tests
C. A clinical judgment about individual, family, or community responses toa ctual and potential health
problems or life processes

A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and
potential health problems or life processes. It is not a disease condition or medical diagnosis, or the
diagnosis and treatment of human responses to health and illness. Nursing diagnoses are not a
development or refinement in nursing language.

The nurse reviews data regarding a client's pain symptoms, comparing the defining characteristics for
Acute pain with those for Chronic pain. In the end the nurse selects Acute pain as the correct diagnosis.
This is an example of avoiding which type of error?
A) Error in data clustering
B) Error in data collection
C) Error in data interpretation
D) Error in making a diagnostic statement
D. Error in making a diagnostic statement

When a nurse compares collected assessment data with defining characteristics for two diagnoses, the
selection of the correct diagnosis is an example of avoiding an error in making a diagnostic statement.
There is no indication the data clustering or interpretation were incorrect.

One of the purposes of the use of standard formal nursing diagnostic statements is to:
A) Evaluate nursing care.
B) Gather information on client data.
C) Help nurses to focus on the role of nursing in client care.
D) Facilitate understanding of client problems by different health care providers.
D. Facilitate understanding of client problems by different health care providers.

The use of standard formal nursing diagnostic statements provides a precise definition that gives all
members of the health care team a common language for understanding the client's needs. The other
options are not part of the reason for the development of nursing diagnostic statements.

The nursing diagnosis 'Readiness' for enhanced communication is an example of which of the following?
A) Risk nursing diagnosis
B) Actual nursing diagnosis
C) Potential nursing diagnosis
D) Wellness nursing diagnosis
D. Wellness nursing diagnosis
The term readiness indicates a wellness nursing diagnosis. An actual nursing diagnosis describes a
human response to health conditions or life processes in an individual, family, or community. A potential
nursing diagnosis is a risk for diagnosis.

The nursing diagnosis Hypothermia is an example of which of the following?


A) Risk nursing diagnosis
B) Actual nursing diagnosis
C) Potential nursing diagnosis
D) Wellness nursing diagnosis
B. Actual nursing diagnosis

An actual nursing diagnosis describes a human response to health conditions or life processes in an
individual, family, or community. The term readiness is present in a wellness nursing diagnosis. A
potential nursing diagnosis is a risk for diagnosis.

In the examples given below, which nurse is acting to avoid a data collection error?
A) The nurse asks her colleague to chart her assessment data.
B) The nurse considers conflicting cues in deciding on the correct nursing diagnosis.
C) The nurse who assesses the edema in a client's lower leg is unsure of its severity and asks her co-
worker to check it with her.
D) After performing an assessment the nurse critically reviews his level of comfort and competence with
interviewing and physical assessment skills.
C. The nurse who assesses the edema in a client's lower leg is unsure of its severity and asks her co-
worker to check it with her.
A nurse who is uncertain and asks a colleague to consult is avoiding a data collection error. The nurse
reviewing his level of comfort and competence is being complete but can miss his own errors.
Considering conflicting clues does not help avoid data collection errors. Asking a colleague to chart data
is incorrect.

"Unhappy and worried about health" is not a scientifically-based nursing diagnosis, and it can lead to
error in:
A) Data collection
B) Date clustering
C) Diagnostic label
D) Medical diagnosis
C. Diagnostic label

The diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing
Diagnosis Association (NANDA) International. The question does not discuss data collection, medical
diagnosis, or data clustering.

After establishing a nursing diagnosis of Acute pain, the nurse develops which of the following
appropriate client-centered goals?
A) Determine effect of pain intensity on client function.
B) Reduce pain intensity to the level of a client rating of 3 or below during the client's hospital stay.
C) Encourage client to implement guided imagery when pain begins.
D) Administer analgesic 30 minutes before physical therapy treatment.
B. Reduce pain intensity to the level of a client rating of 3 or below during the client's hopsital stay
When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the
plan of care independent nursing interventions, including which of the following?
A) Apply a cold pack to the tibia.
B) Elevate the leg 5 inches above the heart.
C) Perform range-of-motion movement with right leg every 4 hours.
D) Administer aspirin 325 mg every 4 hours as needed.
B. Elevate the leg 5 inches above the heart

Elevation of the leg does not need a physician's order. Applying a cold pack and administering
medication do require a physician's order. Range-of-motion movement of the fractured tibia is
inappropriate.

Which of the following nursing interventions is written correctly?


A) Change dressing once a shift.
B) Perform neurovascular checks.
C) Elevate head of bed 30 degrees before meals.
D) Apply continuous passive motion machine during day.
C. Elevate head of bed 30 degrees before meals

Option 3 is specific—it indicates what to do and when

A client's wound is not healing and appears to be worsening with the current treatment. What is the
first option the nurse should consider?
A) Notifying the physician
B) Calling the wound care nurse
C) Consulting with another nurse
D) Changing the wound care treatment
B. Calling the wound care nurse

Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in the
area of wound management. Professional and competent nurses recognize limitations and seek
appropriate consultation. Notifying the physician may be appropriate after the nurse decides on a plan
of action with the wound care nurse specialist. The nurse may need to obtain orders for special wound
care products. Unless the nurse is knowledgeable in wound management, changing the wound care
treatment could delay wound healing. Also, the current wound management plan might have been
ordered by the physician. Another nurse most likely will not be knowledgeable about wounds, and the
primary nurse would know the history of the wound management plan.

When calling a nurse consultant about a difficult client-centered problem, which of the following should
the primary nurse report?
A) Client's concern about the current treatment
B) Length of time current treatment has been in place
C) Spouse's reaction to the client's current treatment
D) Physician's reluctance to change the current treatment plan
B. Length of time current treatment has been in place

Reporting the length of time the current treatment has been used gives the consulting nurse facts that
will influence formulation of a new plan. The other options are subjective and emotional issues or
conclusions about the current treatment plan and may bias the nurse consultant's decision regarding a
new treatment plan.

The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The
primary nurse is obligated to do which of the following?
A) Implement the specialist's recommendations.
B) Discuss and review advised strategies with the CNS.
C) Report the recommendations to the primary physician.
D) Clarify the suggestions with the client and family members.
B. Discuss and review advised strategies wtih the CNS

Because the primary nurse requested the consultation, it is important that the primary nurse and the
CNS communicate and discuss recommendations. The primary nurse can then accept or reject the CNS's
recommendations. A consultation requires review of the recommendations but not immediate
implementation. Reporting the recommendations to the physician would be appropriate after the nurse
first talks with the CNS about recommended changes in the plan of care and the rationale. Only then
should the primary nurse call the physician. The client and family do not have the knowledge to
determine whether new strategies are appropriate or not. It is better to wait until the new plan of care
is agreed upon by the primary nurse and physician before talking with the client and/or family.

Which of the following are defining characteristics for the nursing diagnosis of Impaired urinary
elimination? (Select all that apply.)
A) Nocturia
B) Frequency
C) Urinary retention
D) Inadequate urinary output
E) Receipt of intravenous fluids
F) Sensation of bladder fullness
A, B, and C

The defining characteristics for Impaired urinary elimination according to NANDA include nocturia,
frequency, and urinary retention. The other options are not defining characteristics from NANDA.

During the planning phase of the nursing process, the nurse along with the client decides which of the
following? (Select all that apply.)
A) Interventions
B) Nursing diagnosis
C) Expected outcomes
D) Client-centered goals
E) Nurse-centered priorities
C, and D

Expected outcomes and goals are the main components of the planning phase of the nursing process.
The nurse determines these from the assessment. The client should be the focus of the planning stage.
Interventions are initially determined by the nurse.

A nurse is assigned to a client who has returned from the recovery room following surgery for a
colorectal tumor. After an initial assessment, the nurse anticipates the need to monitor the client's
abdominal dressing, intravenous infusion, and drainage tubes. The client is in pain and will not be able
to eat or drink until intestinal function returns. The nurse will have to establish priorities of care in which
of the following situations?
A) The family comes to visit the client.
B) The client expresses concern about pain control.
C) The client's vital signs change showing a drop in blood pressure.
D) The charge nurse approaches the assigned nurse and requests a report at the end of the shift.
C. The client's vital signs change showing a drop in blood pressure

A drop in blood pressure indicates a possible emergency situation, including bleeding at the surgical site.
Concern about pain control, including a thorough assessment focusing the client's pain, would be the
second priority. The end-of-shift report and the family's visit are lesser priorities.

A postsurgical client calls for a nurse and asks to be repositioned. The nurse finds that the client's
drainage tube is disconnected and the intravenous (IV) line has 100 ml of fluid remaining. Which of the
following should be performed first?
A) Reconnect the drainage tube.
B) Inspect the condition of the IV dressing.
C) Improve the client's comfort and turn her to her side.
D) Go to the medication room and obtain the next IV fluid bag.
A. Reconnect the drainage tube

The nurse should reconnect the drainage tube first to ensure that the wound is properly draining. The
client should then be turned (with care taken to ensure that the tubing remains connected), followed by
replacing the IV fluid bag, checking the IV site, and restarting the IV fluid. With 100 ml left, the nurse has
a bit of time to replace the IV bag before it runs dry, so caring for the client's wound and comfort should
come first.

A nurse has set a time limit for expected outcomes. What is the purpose of establishing such a time
frame?
A) Indicate which outcome has priority.
B) Indicate the time it takes to complete an intervention.
C) Indicate how long the nurse is scheduled to care for the client.
D) Indicate when the client is expected to respond in the desired manner.
D. Indicate when the client is expected to respond in the dsired manner

The time limit sets measurable points to evaluate the client's response and movement toward meeting
the outcome goals. The other options are incorrect.

A client-centered goal is a specific and measurable behavior or response that reflects:


A) The physician's goal for the specific client
B) The client's desire for specified health care interventions
C) The client's response compared to that of another client with a similar problem
D) The client's highest possible level of wellness and independence in function
D. The client' highest possible level of wellness and independence in function

A client-centered goal is a specific and measurable behavior or response that reflects a client's highest
possible level of wellness and independence in function. The other options do not meet the definition of
a client-centered goal.

Which of the following is an example of an expected outcome statement in measurable terms?


A) Client will be pain free.
B) Client will have less pain.
C) Client will take pain medication every 4 hours.
D) Client will report pain intensity of less than 4 on a scale of 0 to 10.
D. Client will report pain intensity of less than 4 on a scale of 0 to 10

Reporting the level of pain on a numbered scale is a measurable, objective goal. The other options do
not specify measurable outcomes.

A client is experiencing nausea and abdominal distention postoperatively. The nurse initiates the
interventions listed below. Which of the interventions is an example of an independent intervention?
(Select all that apply.)
A) Provides frequent mouth care
B) Maintains intravenous infusion at 100 ml/hr
C) Administers prochlorperazine (Compazine) via rectal suppository
D) Consults with the dietitian on initial foods to offer the client
E) Controls aversive odors and unpleasant visual stimulation that trigger nausea
A and E

Providing frequent mouth care and controlling aversive odors and unpleasant visual stimulation that
trigger nausea are examples of independent intervention. The other options are dependent
interventions.

7. When discussing the client's care with a nurse's aide, the nurse instructs the aide to report any
coughing during meals in the client, who recently experienced a stroke and requires feeding. In this
situation the nurse is acting as which of the following?
A) Educator
B) Delegator
C) Client advocate
D) On-the-job trainer
B. Delegator

The nurse is delegating the task of feeding to the aide but is also providing directions.

The nurse prepares a client for a lumbar puncture. Before the start of the procedure the nurse is sure to:
A) Have the client void.
B) Place the client in Sims' position.
C) Premedicate the client with analgesics.
D) Insert a peripheral intravenous (IV) catheter.
A. Have the client void

The nurse takes care of physical needs (voiding) that could interrupt the procedure and possibly increase
the risk of complications. The client assumes the fetal position or sits upright with arms over a bedside
table. Because lidocaine is used in lumbar puncture, analgesics are not essential. Peripheral IV catheters
are not required for this procedure.
The nurse anticipates that a right-handed client with a fractured right arm will require assistance with
activities of daily living. What skill is the nurse demonstrating?
A) Cognitive skill
B) Behavioral skill
C) Interpersonal skill
D) Psychomotor skill
A. Cognitive skill

The nurse is using sound judgment and clinical decisions to provide individualization of care. A decision
is made without direct interaction with the client but is based on knowledge about the client. No
psychomotor skill is involved in this decision-making process. There is no such thing as a behavioral skill.

A nurse provides counseling to a family in spiritual distress caused by the recent, but expected, death of
a family member when the nurse implements which of the following interventions?
A) Praying with the family
B) Reminiscing with the family
C) Arranging for the chaplain to visit the family
D) Obtaining a consult with a psychiatric clinical nurse specialist
B. Reminiscing with the family

Reminiscing is an active intervention that allows family members to remember the deceased in a
positive way. One expects spiritual distress in the acute stage of loss. Praying with the family and
arranging for a chaplain's visit may be appropriate interventions, but they are not counseling.

The nurse requests a stimulant laxative for a client who is receiving an opioid around the clock. What is
the nurse demonstrating?
A) Concern for safety
B) Promotion of client health
C) Colleague health education
D) Control of adverse reactions
D. Control of adverse reactions

The nurse is demonstrating knowledge of opioid side effects and being proactive by asking for an
intervention that will most likely prevent the side effect of constipation associated with opioids. The
intervention does not promote health; it is aimed at preventing a side effect of an opioid. Safety is not
an issue. Requesting a laxative does not provide education.

Which of the following characteristics of a goal is missing from the statement "Client will ambulate
daily"?
A) Observable
B) Measurable
C) Client centered
D) Singular goal or outcome
B. Measurable

Goals must be measurable, such as "Client will ambulate 15 feet daily." The other characteristics are met
in this goal statement.

When determining a client's ability to perform instrumental activities of daily living, which of the
following skills does the nurse assess? (Select all that apply.)
A) Ability to cook meals
B) Ability to feed oneself
C) Ability to write checks
D) Ability to bathe oneself
E) Ability to take medications
A, C, and E

The correct options are skills that allow the client to live independently in society. They may or may not
be performed on a daily basis. The other options are activities of daily living.

Which of the following are nurse-provided indirect care activities? (Select all that apply.)
A) Delegating
B) Documenting
C) Evaluating new products
D) Administering medications
E) Providing client counseling
A, B, and C

The correct options do not involve direct interaction with the client or family. The other options do
require such direct interaction.

The unit policy and procedure manual states that, for all clients admitted to the cardiac unit, if the client
experiences chest pain, 1/150 grain nitroglycerin should be administered sublingually and an
electrocardiogram should be obtained immediately. This is an example of a(n) _____________.
protocol

A 34-year-old client had a surgical repair of an abdominal hernia in the morning. At 12 noon, the nurse
records the client's vital signs on the recovery room flow sheet. What is this an example of?
A) Psychomotor skill
B) Indirect care measure
C) Physical care technique
D) Anticipating complications
B. Indirect care measures
Recording vital signs is an example of indirect care. Taking vital signs is an example of a psychomotor
skill. Anticipating complications is a cognitive skill that is an assessment skill. Recording vital signs is a
direct care measure and not a physical care technique.

Interdisciplinary care plans represent:


A) All nursing personnel having input in the care plan.
B) Contributions of all disciplines in caring for the client.
C) The client's express wishes and advance directives.
D) Physicians and nurses working together to develop a plan of care.
B. Contributions of all disciplines in caring for the client

Interdisciplinary care plans include the contributions of all disciplines involved in the patient's care. The
client's advance directives and express wishes may be included, as well as nursing and physician input,
but other involved disciplines also contribute their plans.

Environmental factors heavily affect a client's care. Your first concern for the client includes which of the
following?
A) Safety
B) Nurse staffing
C) Confidentiality
D) Adequate pain relief
A. Safety

Client safety is an environmental factor and is always the first concern. Pain relief, staffing, and
confidentiality are important but are not environmental factors.

In order to determine whether an intervention was successful, the nurse evaluates the success of
attaining a goal. Which of the following is an example of an evaluation?
A) Dressing changed every 8 hours using sterile technique.
B) Client will ambulate 500 feet 4 times a day with minimal assistance.
C) Client performed quadriceps-setting exercises to right leg every 4 hours.
D) Wound filling in with granulation tissue is red to pink without signs of infection.
D. Wound filling in with granulation tissue is red to pink without signs of infection

Evaluation occurs after an intervention and indicates degree of achievement of goal attainment. The
qualifier "will" indicates that this is a future event and does not evaluate current attainment of goal.
Doing an intervention is not evaluating whether it was effective or not.

A client was in pain following surgery. The nurse administered the prescribed analgesics, but the client's
pain rating stayed the same (8 out of 10). What should the nurse recognize?
A) The pain plan needs changing.
B) The client is overrating the pain.
C) Complications from surgery are occurring.
D) Nonpharmacological pain-relieving strategies are now appropriate.
A. The pain plan needs changing

The current pain medications are not effectively relieving the pain. The nurse needs to call the physician
and discuss changing the medication is some way (type, dose, frequency, formulation). Pain is what the
client says it is. There is no objective way to measure pain. The clinician must accept the client's report
of pain. Nonpharmacological strategies are adjuncts to the pain plan. They are not to be used in place of
pain medications. Pain following surgery is an expectation.

7. Which steps do you follow when you are asked to perform a procedure about which you are
unfamiliar? Select all that apply.
A) Seek necessary knowledge
B) Reassess the client's condition
C) Collect all equipment necessary
D) Have an experienced nurse available to assist
E) Consider all possible consequences of the procedure
A, B, C, D, and E

Each of the five options is important in performing a new procedure. Be sure to seek all necessary
knowledge, consider the possible consequences of the procedure, reassess the patient, collect the
appropriate supplies, and ask a nurse experienced in the procedure to help out

Nursing's paradigm includes:


A) Health, person, environment, and theory
B) Concepts, theory, health, and environment
C) Nurses, physicians, models, and client needs
D) The person, health, environment/situation, and nursing
D. The person, health, environment/situation, and nursing

Nursing's paradigm includes four linkages: the person, health, environment/situation, and nursing.

Which of the following statements about prescriptive theories is accurate?


A) They describe phenomena.
B) They have the ability to explain nursing phenomena.
C) They reflect practice and address specific phenomena.
D) They provide a structural framework for broad abstract ideas.
C. They reflect paractice and address specific phenomena

Prescriptive theories address nursing interventions for a phenomenon and predict the consequence of a
specific nursing intervention. Descriptive theories describe the phenomena, speculate on the reason the
phenomena occur, and predict nursing phenomena. Grand theories are broad and complex and provide
a structural framework for broad, abstract ideas about nursing.

A theory is a set of concepts, definitions, relationships, and assumptions that:


A) Formulates legislation
B) Explains a phenomenon
C) Measures nursing functions
D) Reflects the domain of nursing practice
B. Explains a phenomenon

A theory is a set of concepts, definitions, relationships, and assumptions that explains a phenomenon.
Theories do not formulate legislation, measure nursing functions, or reflect any domain of nursing
practice.

4. There is a contemporary move toward addressing nursing as a science or as evidenced-based practice.


This suggests that:
A) One theory will guide nursing practice.
B) Scientists will make nursing decisions.
C) Theories will be tested to describe or predict client outcomes.
D) Nursing will base client care on the practice of other sciences.
C. Theories will be testing to describe or predict client outcomes

Theories will be tested to describe or predict client outcomes as nursing is addressed as a science and an
art. Scientists will not make nursing decisions, and nursing will base client care on the practice of nursing
science, which will be guided by multiple theories.
6. Which theories describe an orderly process beginning with conception and continuing through death?
A) Systems theories
B) Developmental theories
C) Interdisciplinary theories
D) Stress and adaptation theories
B. Developmental theories

Developmental theories discuss human growth from conception to death. The other options are
incorrect

Maslow's hierarchy of needs is useful to nurses, who must continually prioritize a client's nursing care
needs. The most basic or first-level needs include:
A) Self-actualization
B) Love and belonging
C) Air, water, and food
D) Esteem and self-esteem
C. Air, water, and food

The first level of Maslow's hierarchy of needs includes the need for air, food, and water—basic elements
of survival. Love and belonging are on the second level, esteem and self-esteem are on the fourth level,
and self-actualization is the final level.

Leininger's theory of cultural care diversity and universality specifically addresses:


A) Caring for clients from unique cultures
B) Understanding the humanistic aspects of life
C) Identifying variables affecting a client's response to a stressor
D) Caring for clients who cannot adapt to internal and external environmental demands
A. Caring for clietns from unique cultures

The goal of Leininger's theory is to provide the client with culturally specific nursing care, in which the
nurse integrates the client's cultural traditions, values, and beliefs into the plan of care.

As an art, nursing relies on knowledge gained from practice and reflection on past experiences. As a
science, nursing relies on:
A) Experimental research
B) Nonexperimental research
C) Physician-generated research
D) Scientifically tested knowledge
D. Scientifically tested knowledge

As a science, nursing draws on scientifically tested knowledge applied in the practice setting.

Each science has a domain, which is the perspective of the discipline. This domain:
A) Represents the recipients of the benefits of the science or discipline
B) Is a model that explains the linkage of science, philosophy, and theory that is accepted and applied by
the discipline
C) Describes the subject, central concepts, values and beliefs, phenomena of interest, and central
problems of the discipline
D) Is a dynamic state of being in which the developmental and behavioral potential of the individual is
realized to the fullest
C. Describes the subject, central concepts, values and beliefs, phenomena of interest, and central
problems of the discipline

The domain contains the subject, central concepts, values and beliefs, phenomena of interest, and the
central problems of the discipline. A paradigm is a model that explains the linkage of science, philosophy
and theory that is accepted and applied by the discipline.

A theory is a set of concepts, definitions, relationships, and assumptions or propositions to explain a


phenomenon. The purposes of the components of a theory are to:
A) Describe concepts or connect two concepts that are factual
B) Formulate a perceptual experience to describe or label a phenomenon
C) Express the global view about the individual, situations, or factors of interest to a specific discipline
D) Describe, explain, predict, and/or prescribe interrelationships among the concepts that define the
phenomenon
D. Describe, explain, predict, and/or prescribe interrelationships among the concepts that define the
phenomenon

Describing, explaining, predicting, and/or prescribing interrelationships among concepts are stated
purposes of research.

Nursing theories focus on the phenomena of nursing and nursing care. Which of the following is true of
phenomena?
A) They are aspects of reality that can be consciously sensed or experienced.
B) They convey the general meaning of concepts in a manner that fits the theory.
C) They are statements that describe concepts or connect two concepts that are factual.
D) They are mental formulations of an object or event that come from individual perceptual experience.
A. They are aspects of reality that can be consciously sensed or experienced.

Phenomena are defined as aspects of reality that can be consciously sensed or experienced.

Theories that are broad and complex are:


A) Grand theories
B) Descriptive theories
C) Middle-range theories
D) Prescriptive theories
A. Grand theories

Grand theories are described as broad and complex. Middle-range theories are limited in scope, less
abstract, address specific phenomena or concepts, and reflect practice. Descriptive theories describe
phenomena, speculate as to why the phenomena occur, and describe the consequences of phenomena.
Prescriptive theories address nursing interventions and predict the consequence of a specific
intervention.

Mishel's theory of uncertainty in illness focuses on the experience of clients with cancer who live with
continual uncertainty. The theory provides a basis for nurses to assist clients in appraising and adapting
to the uncertainty and illness response and can be described as:
A) A grand theory
B) A descriptive theory
C) A prescriptive theory
D) A middle-range theory
D. A middle-range theory

Middle-range theories are limited in scope, less abstract than grand theories, address specific
phenomena or concepts, and reflect practice. Grand theories are described as broad and complex.
Prescriptive theories address nursing interventions and predict the consequence of a specific nursing
intervention. Descriptive theories describe phenomena, speculate as to why the phenomena occur, and
describe the consequences of phenomena

The type of theory that tests the validity and predictability of nursing interventions is:
A) A grand theory
B) A descriptive theory
C) A prescriptive theory
D) A middle-range theory
Prescriptive theory addresses nursing interventions and predicts the consequence of a specific nursing
intervention. Middle-range theories are limited in scope, less abstract than grand theories, address
specific phenomena or concepts, and reflect practice. Descriptive theories describe phenomena,
speculate as to why the phenomena occur, and describe the consequences of phenomena. Grand
theories are broad and complex.

17. The nursing process is an example of an open system. An open system:


A) Is universal and dynamic
B) Represents a relationship between two concepts
C) Interacts with the environment by exchanging information
D) Is a process through which information is returned to the system
C. Interacts with the environment by exchanging information
An open system is defined as a system that interacts with the environment, exchanging information
between the system and the environment.

Evidence-based nursing practice is the end result of:


A) Prescriptive theory
B) Use of practical knowledge
C) Application of theoretical knowledge
D) Theory-generating and theory-testing research
D. Theory-generating and theory-testing research

The result of theory-generating or theory-testing research is to increase the knowledge base of nursing.
As these research activities continue, clients become the recipients of evidence-based nursing care.

The nursing theory that emphasizes the delivery of nursing care for the whole person to meet the
physical, emotional, intellectual, social, and spiritual needs of the client and family is:
A) Rogers' theory
B) Abdellah's theory
C) Henderson's theory
D) Nightingale's theory
B. Abdellah's theory

The question describes the nursing theory developed by Fay Abdellah and others. Rogers' theory
considered the individual as an energy field existing within the universe. Henderson's theory defines
nursing as "assisting the individual, sick, or well, in the performance of those activities that will
contribute to health, recovery, or a peaceful death." Nightingale viewed nursing as providing fresh air,
light, warmth, cleanliness, quiet, and adequate nutrition.

A parish nurse for a Catholic church provides a free blood pressure screening the first Sunday of every
month. This is what level of prevention?
A) Tertiary prevention
B) Primary prevention
C) Secondary prevention
D) Quaternary prevention
B. Primary prevention

Primary prevention is true prevention that precedes disease and is aimed at clients considered physically
and emotionally healthy. Secondary prevention involves individuals who are experiencing health
problems or illnesses and who are at risk for developing complications or worsening conditions. Tertiary
prevention occurs when a defect or disability is permanent and irreversible, and the aim is to reduce
negative impacts and complications. Quaternary prevention is not a recognized term.

A 72-year-old man diagnosed with chronic obstructive pulmonary disease 5 years ago has been
participating for the last 2 years in a pulmonary rehabilitation exercise class offered by the local hospital
at a fitness facility. This is what level of prevention?
A) Tertiary prevention
B) Primary prevention
C) Secondary prevention
D) Quaternary prevention
A. Tertiary prevention

Tertiary prevention occurs when a defect or disability is permanent and irreversible, and the aim is to
reduce negative impacts and complications. Primary prevention is true prevention that precedes disease
and involves clients considered physically and emotionally healthy. Secondary prevention is aimed at
individuals who are experiencing health problems or illnesses and who are at risk for developing
complications or worsening conditions. Quaternary prevention is not a recognized term.

3. Based on the transtheoretical model of change, what is the most appropriate response to the
following client statement: "Me, exercise? I haven't done that since Junior High gym class and I hated it
then!"
A) "That's fine. Exercise is bad for you anyway."
B) "OK. I want you to walk 3 miles four times a week and I'll see you in 1 month."
C) "I understand. Can you think of one reason why being more active would be helpful for you?"
D) "I'd like you to ride your bike three times this week and eat at least four fruits and vegetables every
day."
C. "I understand. Can you think of one reason why being mroe active would be helpful for you?"

The transtheoretical model of change describes a series of changes that clients move through, starting
with precontemplation and ending with maintenance. The first stage for this client would be to validate
the client's opinion and move to the first part of precontemplation. The other options are later steps in
the model.

A client says, "I've noticed how many people are out walking in my neighborhood. Is walking good for
you?" What is the best response to help the client through the stages of change toward regular
exercise?
A) "Walking is OK. I really think running is better."
B) "Yes, walking is great exercise. Do you think you could go for a 5-minute walk this next week?"
C) "Yes, I want you to begin walking. Walk for 30 minutes every day and start eating more fruits and
vegetables, too."
D) "They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes
walking if you are going to do any good."
B. "Yes, walking is great exercise. Do you think you could go for a 5-minute walk this next week?"

This option supports the preparation stage in which the client is beginning to consider making small
changes. The other options are not good ones for this client.

All of the following are examples of active strategies of health promotion except:
A) Exercise training
B) Weight reduction
C) Smoking cessation
D) Fluoridation of drinking water
D. Fluoridation of drinking water

Passive strategies of health promotion benefit individuals without any action by the individuals
themselves. The fluoridation of municipal drinking water and the fortification of homogenized milk with
vitamin D are examples of passive health promotion strategies. Weight reduction is considered an active
strategy of health promotion. With active strategies of health promotion, individuals are motivated to
adopt specific health programs. Smoking cessation requires clients to be actively involved in measures to
improve their present and future levels of wellness while decreasing the risk of disease. Exercise training
meets the criteria for active strategies of health promotion because it actively involves the client in his
or her own health.

nurse routinely asks clients if they take any vitamins or herbal medications, encourages family members
to bring in music that clients like to help them relax, and frequently prays with clients if that is important
to them. The nurse is using which model of care?
A) Holistic
B) Health belief
C) Transtheoretical
D) Health promotion
A. Holistic

The holistic model attempts to create conditions that promote optimal health. The holistic model
recognizes the natural healing abilities of the body and incorporates complementary and alternative
interventions. The health belief model addresses the relationship between a person's beliefs and
behaviors. The transtheoretical model of change discusses a series of changes through which clients
move, starting with precontemplation and ending maintenance. The health promotion model defines
health as a positive, dynamic state and not merely the absence of disease.

Different attitudes about illness cause people to react in different ways when illness does occur. Medical
sociologists call the reaction to illness:
A) Health belief
B) Illness behavior
C) Health promotion
D) Illness prevention
B. Illness behavior

Illness behavior is the client's reaction to illness. The other three options are models of health

The health belief model addresses the relationship between a person's belief and behaviors, therefore:
A) A person who smokes does not follow the model.
B) This model provides a basis for caring for clients of all ages.
C) A person who does not take necessary medications does not follow the model.
D) It provides a way of understanding and predicting how clients will behave in relation to their health
and how they will comply with health care regimens.
D. It provides a way of understanding and predicting how clients will behave in relation to their health
and how they will comply with health care regimens.

The health belief model provides a way of understanding and predicting how clients will behave in
relation to their health and how they will comply with health care regimens.

A nurse working in a special care unit for children with severe immunologic problems cares for a 3-year-
old boy from Greece. The nurse is having difficulty communicating with the father. What is the
appropriate action?
A) Care for the boy the same as for any other client.
B) Ask the manager to talk with the father and keep him out of the unit.
C) Have another nurse care for the boy, because maybe that nurse will communicate better with the
father.
D) Search for help in interpreting and understanding the culture differences by contacting someone
from the local Greek community.
D. Search for help in interpreting and understanding the culture differences by contacting someone
from the local Greek community

Acquiring cultural and language assistance will help the nurse understand the needs of both the father
and the son. The other three options are not culturally sensitive or helpful to the client and his father.

10. A nurse teaches the importance of folic acid intake to a group of pregnant women. This is considered
which level of preventive care?
A) Illness behavior
B) Primary prevention
C) Tertiary prevention
D) Secondary prevention
B. Primary prevention

Primary prevention is considered true prevention. It aims at maintaining physical and emotional health
in an already healthy individual.Primary prevention is considered true prevention. It aims at maintaining
physical and emotional health in an already healthy individual.

11. A person's ideas, convictions, and attitudes about health and illness can be described as:
A) Moral beliefs
B) Health beliefs
C) Holistic views
D) Negative health behaviors
B. Health beliefs

Health beliefs are an individual's perceptions of health or illness, which may be based on factual
information or misinformation, common sense or myths, or reality or false expectations. Moral beliefs
are learned behaviors that are in accordance with the principles of right or wrong. Holistic views
consider the emotional and spiritual well-being of the individual. Negative health behaviors include
behaviors that are typically harmful to health, such as smoking, drug or alcohol abuse, poor diet, and
refusal to take appropriate medications.

Which of the following models of health or illness defines health as a positive, dynamic state, not merely
the absence of disease?
A) Maslow's hierarchy of needs
B) Rosenstoch's health belief model
C) Pender's health promotion model
D) The holistic health model of nursing
C. Pender's health promotion model

Pender's health promotion model was developed to be a "complementary counterpart to models of


health protection." This model defines health as a positive, dynamic state, not merely the absence of
disease. Maslow's hierarchy of needs defines what is necessary for human survival and health, such as
food, water, safety, and love. Rosenstoch's health belief model addresses the relationship between a
person's belief and behaviors. It predicts how clients will behave in relation to their health and how they
will comply with their health regimen. The holistic health model creates conditions that promote
optimal health.

All of the following are considered internal variables that influence a client's health beliefs and practices
except:
A) Emotional factors
B) Developmental stage
C) Socioeconomic factors
D) Perception of functioning
C. Socioeconomic factors

Socioeconomic factors are considered external variables. A person seeks approval and support from
neighbors, peers, and co-workers; this affects health beliefs and practices. Economic variables may
affect a client's level of health. For example, a client with a fixed income who needs long-term
medications may determine that food and shelter are more important than the medication; therefore,
the client's health suffers. Perception of functioning is an internal variable. It is defined as the way an
individual perceives his or her physical functioning and how it affects health beliefs and practices.
Emotional factors are internal variables. These include a client's degree of stress, depression, or fear,
which can influence health beliefs and practices. An individual's developmental stage is considered an
internal variable. A client's thinking about health is dependent on his or her level of development.

Clients maintain health or enhance their health by routine exercise and proper nutrition. This is known
as:
A) Illness
B) Health promotion
C) Control of external variables
D) Wellness education
B. Health promotion

Health promotion activities help clients maintain and enhance their present level of health. Wellness
education instructs persons on how to care for themselves in healthy ways and includes topics such as
physical awareness, stress management, and self-responsibility. Illness is defined as poor condition or
disease. External variables are outside factors that influence a person's health beliefs and practices.
They include family practices, socioeconomic factors, and cultural background.

The nurse in a diabetic clinic conducts monthly seminars for diabetic clients. During these seminars, the
importance of taking insulin as directed to prevent diabetic complications is emphasized. This is
considered which level of preventive care?
A) Illness prevention
B) Tertiary prevention
C) Primary prevention
D) Secondary prevention
D. Secondary prevention

Secondary prevention is prevention geared toward individuals who are already experiencing health
problems or illness and who are at risk of experiencing complications or a worsening of their condition

A client comes into the clinic for a complete physical examination. The nurse obtains a health history
and determines that the client is at risk for heart disease. Which of the following would lead the nurse to
conclude this?
A) The client is 25 years old.
B) The client lives near a chemical plant.
C) The client's father died of a heart attack at age 40.
D) The client works as a carpet salesman.
C. The client's father died of a heart attack at age 40

Genetic predisposition to specific illnesses is considered a major physical risk factor. The client's father
died of a heart attack at the age of 40, which increases the client's risk of heart disease and heart attack.
Age may increase or decrease a client's susceptibility to certain illnesses. Age risk factors are often
closely associated with other risk factors, such as family history and personal habits. The client is 25
years old; therefore, based on age alone, risk is low for heart disease at this time. The client lives near a
chemical plant; this constant exposure to chemicals may lead to health problems. The physical
environment in which a person works and lives can increase the likelihood that certain illnesses will
occur, but without further information the nurse cannot assess the heart disease risk related to the
client's possible chemical exposure.

Which of the following statements is the World Health Organization's definition of health?
A) "Complete freedom from disease"
B) "Mental, social, and spiritual well-being"
C) "State of complete physical, mental, and social well-being, not merely the absence of disease"
D) "A state of being that people define in relation to their own values, personality, and lifestyle"
C. "State of complete physical, mental, and social well-being, not merely the absence of disease"

The World Health Organization defines health as a "state of complete physical, mental, and social well-
being, not merely the absence of disease or infirmity." There are several definitions of health. Health is a
state of being that people define in relation to their own values, personality, and lifestyle. Health and
illness must be defined in terms of the individual. Health can include conditions previously considered to
be illness. Pender, Murdaugh, and Parsons note that views of health include mental, social, and spiritual
well-being. Pender notes that not all people who are free of disease are equally healthy.

Which of the following terms is defined as a mental self-image of strengths and weaknesses in all
aspects of one's personality?
A) Body image
B) Family roles
C) Self-concept
D) Emotional change
C. Self-concept

Self-concept is a mental self-image of strengths and weaknesses in all aspects of one's personality. Self-
concept is important in relationships with other family members. When a client is ill, his or her self-
concept changes and this may lead to tension and conflict. Body image is defined as a subjective concept
of physical appearance. Many illnesses can cause changes in physical appearance, and clients and
families react differently to these changes. Clients react differently to illness or the threat of illness.
Individual behavioral and emotional reactions depend on the nature of the illness. Illness impacts family
roles. When an illness occurs, parents and children try to adapt to major changes resulting from a family
member's illness.

A client needs to learn to use a walker. Acquisition of this skill will require learning in which domain?
A) Affective domain
B) Cognitive domain
C) Attentional domain
D) Psychomotor domain
D. Psychomotor domain

The psychomotor domain concerns motor skills. The cognitive domain involves understanding, and the
affective domain involves attitudes. The attentional domain is not a recognized domain. Attentional set
is the mental state that allows the learner to focus on and comprehend a learning activity.

The nurse should plan to teach a client about the importance of exercise:
A) When there are visitors in the room
B) When the client's pain medications have taken effect
C) Just before lunch, when the client is most awake and alert
D) When the client is talking about current stressors in his or her life
B. When the client's pain medications have taken effect

It is difficult for a client to learn when the client is in pain. Pain medications should be administered and
the client taught while the client is alert but pain free. A quiet time should be selected when there are
no or few distractions; the nurse should avoid times when visitors are present or when the client is
discussing other stressors. The second best time to teach is when the client is most awake and alert,
providing that all pain issues have been addressed.

A client recently diagnosed with cervical cancer is going home after undergoing surgery. The client is
avoiding discussion of her illness and postoperative orders. In going over discharge instructions with the
client, the nurse:
A) Teaches the client's spouse
B) Focuses on knowledge the client will need in a few weeks
C) Provides only the information the client needs to go home
D) Convinces the client that learning about her health is necessary
C. Provides only the information teh client needs to go home

Because this client does need to have some postoperative knowledge, the teaching should focus on the
information the client will need until she has had a chance to move through the grief process. Teaching
the spouse does not focus on caring for the client, although his knowledge can be helpful. Teaching
ahead about information that the client will need in a few weeks is not appropriate. Until the client is
able to process her grief, convincing her that learning about health is not productive.

The school nurse is about to teach a freshman-level health class on nutrition. To achieve the best
learning outcomes, the nurse:
A) Provides information using a lecture format
B) Uses simple words to promote understanding
C) Develops topics for discussion that require problem solving
D) Completes an extensive literature search focusing on eating disorders
C. Develops topics for discussion that require problem solving

The use of problem solving helps adolescents to achieve learning outcomes. Providing information in a
lecture format and using simple words would probably not be successful with this age group. Literature
searches are not appropriate teaching for this age group.

A nurse is going to teach a client how to perform a breast self-examination. Which of the following
statements is the behavioral objective that best measures the client's ability to perform the
examination?
A) The nurse will discuss learning objectives.
B) The client will verbalize the steps involved in breast self-examination within 1 week.
C) The nurse will explain the importance of performing breast self-examination once a month.
D) The client will demonstrate breast self-examination on herself by the end of the teaching session.
D. The client will demonstrate breast self-examination on herself by the end of the teaching session.

Option D has a measurable outcome at a specific time. Options A and B do not show that the client has
learned to perform the examination. Option C does not show learning.

A client who is having chest pain is to undergo emergency cardiac catheterization. Which of the
following is the most appropriate teaching approach in this situation?
A) Telling approach
B) Entrusting approach
C) Reinforcing approach
D) Participating approach
A. Telling approach

The telling approach is used when teaching limited information, such as in an emergent situation. The
entrusting approach provides the client the opportunity to manage self-care. In the participating
approach, the nurse and client set objectives and become involved in the learning process together.
Reinforcement requires the delivery of a stimulus that increases the probability of a response.

The nurse is teaching a parenting class for a group of pregnant adolescents and has given the
adolescents baby dolls to bathe and talk to. This is an example of:
A) An analogy
B) Role playing
C) A demonstration
D) A return demonstration
B. Role playing

Role playing involves rehearsing a desired behavior. In demonstration the nurse shows the client what
to do, whereas in return demonstration the learner practices the skill to show that it has been learned.
An analogy is a means of translating complex language or ideas into words or concepts that the client
understands.

An older man is being given a new antihypertensive medication. In teaching the client about the
medication, the nurse should:
A) Speak loudly.
B) Present the information once.
C) Expect the client to understand the information quickly.
D) Allow the client time to express himself and ask questions.
D. Allow the client time to express himself and ask questions

The nurse should allow the client time to express himself and ask questions. Speaking loudly is typically
not effective, and information may have to be presented several times. The client will learn the
information at his own speed.

A client needs to learn how to administer a subcutaneous injection. The nurse knows the client is ready
to learn when the client:
A) Has walked 400 feet
B) Expresses the importance of learning the skill
C) Can see and understand the markings on the syringe
D) Has the dexterity needed to prepare and inject the medication
B. Expresses the importance of learning the skill

When the client can verbalize the need to learn, the client is ready to learn to read the markings on the
syringe, and the nurse can assess whether the client has the dexterity to perform the injection. The
ability to walk 400 feet is not a prerequisite for learning about subcutaneous injection.

A client who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to
give himself injections. The best teaching method would be:
A) Role playing
B) Simulation
C) Demonstration
D) Group instruction
C. Demonstration

Demonstration with return demonstration is the best method to teach a psychomotor skill. Group
instruction is not typically effective in teaching specific psychomotor skills, because it does not allow for
individualized instruction. Role playing and simulation are not appropriate in this situation.

When teaching is viewed as communication, then a specific learning objective can be said to be
developed from:
A) The message
B) The referent
C) Feedback
D) Intrapersonal variables
B. The referent

The referent is the perceived need for information. This provides the basis for the learning objective.
The message refers to the information taught. Feedback is used to determine whether or not the
learning objective was achieved. Intrapersonal variables are assessed to determine willingness and
ability to learn.

12. The client who is most ready to begin a client teaching session is the client who has:
A) Experienced nausea and vomiting for the past 24 hours
B) Just been told that he needs to have major surgery
C) Voiced a concern about how insulin injections will affect her lifestyle
D) Complained bitterly about the low-fat, low-cholesterol diet he must follow after his heart attack
C. Voiced a concern about how insulin injections will affect her lifestyle

A learning objective for a client taking digoxin (Lanoxin) is to correctly take a radial pulse for 1 minute
before medication administration. The learning objective has been achieved when the client:
A) States, "I understand."
B) States, "Just place two fingers at the thumb side of the wrist."
C) Demonstrates correct finger placement and counts the beats correctly
D) Demonstrates by placing two fingers at the inner antecubital space and counts the beats for 60
seconds
C. Demonstrates correct finger placement and counts the beats correctly

Direct observation is a means of evaluating whether a learning objective has been achieved. In option 3
the client demonstrated radial pulse taking correctly. Option 1 provides no way of measuring if the client
was able to correctly take a radial pulse. Option 2 does not indicate if the client was able to count the
number of beats for 1 minute. In option 4 the fingers were placed in the antecubital space rather than
over the radial artery. The client demonstrated incorrect placement.

Which of the following is an example of an appropriately stated learning objective?


A) The client will ambulate 100 feet.
B) The nurse will explain the importance of a diabetic diet.
C) The nurse will demonstrate a sterile dressing change by the end of the first hospital day.
D) The client will state three factors that affect cholesterol by the end of the teaching session.
D. The client will state three factors that affect cholesterol by the end of the teaching session.

This learning objective includes the required singular behavior, measurable objective, and time frame
for completion. Option 1 lacks a time frame for completion and is a behavioral objective. Options 2 and
3 are teaching objectives rather than learning objectives.

The nurse is demonstrating the proper technique for using a glucometer to a group of clients newly
diagnosed with diabetes. The nurse smiles and praises one of the clients when she correctly performs a
finger stick. This teaching approach is referred to as:
A) Timing
B) Entrusting
C) Reinforcing
D) Group instruction
C. Reinforcing

Social reinforcement includes smiles, compliments, or words of encouragement. Timing is not a teaching
approach. It refers to the planning phase of the teaching process. Entrusting allows the client to manage
his or her own care, with the nurse available for assistance if needed. A client newly diagnosed with
diabetes would not be able to manage self-care. Group instruction is an instructional method, not a
teaching approach.

When teaching older adults, the nurse should:


A) Speak in a loud tone of voice.
B) Begin and end with the most important information.
C) Avoid repeating information to reduce confusion.
D) Include as much information as possible in each teaching session.
B. Begin and end with the most important information

Short-term memory is often reduced in older adults; therefore, repeating important information, and
especially presenting it at the beginning and end, enhances retention. Speech at lower voice levels is
better understood by the older adult. Repeating information does not create confusion but rather
facilitates learning in the older adult. Older adults may have slower cognitive function and will
remember more effectively if the information is paced properly.

The assessment phase of the teaching process includes:


A) Determining learning needs
B) Setting priorities
C) Selecting teaching methods
D) Selecting teaching approach
A. Determining learning needs

Information obtained during the assessment will determine what is necessary for the client to learn.
Because the health status of the client may undergo changes, assessment for learning needs is an
ongoing process. Setting priorities and selecting teaching methods are part of the planning phase.
Selection of the teaching approach is part of the implementation phase.

Which of the following represents the most complex behavior in the psychomotor learning domain?
A) Accepting the limitations imposed by a stroke
B) Understanding the relationship of insulin, diet, and exercise in diabetes
C) Performing self-catheterization without acquiring a urinary tract infection
D) Performing activities of daily living after acquiring left-sided paralysis due to a brain injury
D. Performing activities of daily living after acquiring left-sided paralysis due to a brain injury

Origination is the most complex behavior in the psychomotor learning domain. It is highly complex and
involves developing new psychomotor skills and abilities from existing ones, as is seen in paralysis.
Accepting limitations is a behavior in the affective learning domain. Understanding relationships is a
behavior in the cognitive learning domain. Option 3 is a psychomotor learning behavior that is referred
to as complex overt response, in which the client performs a motor skill using a complex movement
pattern. It is not as complex as origination.

The nurse discovers an electrical fire in a client's room. The nurse's first action would be to:
A) Activate the fire alarm.
B) Confine the fire by closing all doors and windows.
C) Evacuate any clients or visitors in immediate danger.
D) Extinguish the fire by using the nearest fire extinguisher.
C) Evacuate any clients or visitors in immediate danger.

The nurse's first step when a fire is discovered is to evacuate any clients or visitors in immediate danger.
Then the nurse should activate the fire alarm, confine the fire, and then extinguish it.

A parent calls the pediatrician's office frantic because her 2-year-old son drank a bottle of cleaner.
Which of the following is the most important instruction the nurse can give to this parent?
A) Give the child milk.
B) Call the poison control center.
C) Give the child syrup of ipecac.
D) Take the child to the emergency department.
B) Call the poison control center.

The poison control center will direct all care given to a child who has ingested a substance. Based on the
description of the poison, poison control center staff will tell the parent whether the child needs to go to
the emergency department and what substances should be given to the child

A couple has brought in their adolescent daughter for a school physical. The parents tell the nurse that
they are worried about all the safety risks for this age group. As the nurse plans to teach the parents
about these risks, the nurse remembers that adolescents are at a greater risk for injury from:
A) Home accidents
B) Poisoning and child abduction
C) Physiological changes of aging
D) Automobile accidents, suicide, and substance abuse
D) Automobile accidents, suicide, and substance abuse

Adolescents are more likely to be involved in automobile accidents, commit suicide, and engage in
substance abuse than are those in other age groups. Children are more susceptible to poisoning and
child abduction, and older adults are more susceptible to home accidents and the physiological changes
of aging.

During the night shift a client is found wandering the hospital halls looking for a bathroom. The nurse's
initial intervention would be to:
A) Insert a urinary catheter.
B) Ask the physician to order a restraint.
C) Assign a staff member to stay with the client.
D) Provide scheduled toileting during the night shift.
D) Provide scheduled toileting during the night shift.

Providing scheduled toileting during the night makes it less likely that a client will wander while being
confused and ensures staff presence to decrease confusion at the times when the client is away from
bed. Inserting a urinary catheter is not necessary. Assigning a staff member to stay with the client might
not be necessary if the scheduled toileting is successful. Restraints are unnecessary in this case.

5. Lisa, a nurse assistant, is working with the nurse during the nurse's shift. One of the nurse's clients has
upper limb restraints. In delegating care of this client to Lisa, the nurse would tell her to:
A) Secure the restraints to the side rails.
B) Check to see if the client can have a medication for sleep.
C) Call the physician if the client becomes more agitated with the restraint.
D) Report any signs of redness, excoriation, or constriction of circulation under the restraint.
D) Report any signs of redness, excoriation, or constriction of circulation under the restraint.

The restraint sites much be checked regularly for signs of redness, excoriation, or constriction, and this
task may be delegated. Calling the physician and performing medication assessments are nursing
responsibilities. Restraints should never be secured to the side rails.
The family of the nurse's confused, ambulatory client insists that all four side rails be up when the client
is alone. The best way to handle this situation is to:
A) Ask them to stay with the client at all times.
B) Inform them of the risks associated with side rail use.
C) Thank them for being conscientious and put the four rails up.
D) Provide the client with a one-to-one sitter while the side rails are up
B) Inform them of the risks associated with side rail use.

The use of side rails when a client is disoriented will cause more confusion and further injury. A confused
client who is determined to get out of bed may attempt to climb over the side rail or climb out at the
foot of the bed, and may fall or experience other injury. After the nurse has this discussion with the
family, then the nurse should perform a thorough nursing assessment and develop a plan to ensure the
client's safety.

During the nurse's assessment of a 56-year-old man, he reports increased alcohol consumption because
of stress at work. One of the expected outcomes for this client will be to:
A) Decrease stress in his life.
B) Teach him ways to promote sleep.
C) Decrease his alcohol intake during times of stress.
D) Provide the client with information about stress management classes.
C) Decrease his alcohol intake during times of stress.

Resources for stress management and sleep promotion can help accomplish reduced alcohol intake
during times of stress in the client's life. Management of stress is the expectation, but decreasing stress
may not be possible.

A child for which the nurse is caring in the hospital starts to have a grand mal seizure while playing in the
playroom. What is the most important intervention the nurse can do during this situation?
A) Begin cardiopulmonary resuscitation.
B) Restrain the child to prevent injury.
C) Place a tongue blade over the tongue to prevent aspiration.
D) Clear the area around the child to protect the child from injury.
D) Clear the area around the child to protect the child from injury.

An area around the child should be cleared to prevent injury. Restraining the child or placing a tongue
blade in the child's mouth may actually be a cause of injury. Cardiopulmonary resuscitation is required
only if heart function stops after the seizure.

When providing health maintenance teaching to new employees in the food-handling department, the
nurse emphasizes the need to perform hand hygiene after using the bathroom to prevent:
A) Food poisoning
B) Spread of hepatitis A
C) Bacterial food infections
D) Salmonella contamination
B) Spread of hepatitis A

The hepatitis A virus is spread via fecal contamination of food, water, or milk. It is essential that food
handlers wash their hands anytime they use the bathroom. Food poisoning can be due to bacterial
contamination of food from a variety of sources, but not usually feces. Salmonella contamination usually
arises from uncooked eggs.

A student nurse is designing a health fair project aimed at reducing motor vehicle accidents. For which
group of clients would this subject be most appropriate?
A) Adolescents
B) Older adults
C) Middle-aged adults
D) School-aged children
A) Adoescents

The risk of motor vehicle accidents is higher among teen drivers than in any other age group.
As a member of the hospital's bioterrorism team, the nurse understands the importance of knowing
how an organism is transmitted. Smallpox has the potential to spread quickly because it is transmitted
via which route?
A) Airborne
B) Ingestion
C) Absorption
D) Blood-borne
A) Airborne

Organisms with an airborne route of transmission can claim many victims and spread very quickly.
Smallpox is not spread via blood. There is no such thing as an absorption or ingestion route of
transmission.

After the nurse assists a client with a history of seizures to a recliner chair, the client begins to have a
seizure. The nurse should immediately:
A) Turn the client onto his or her stomach.
B) Recline the client's chair all the way back.
C) Return the client to the bed and place the client on his or her side.
D) Slide the client to the floor and cradle the client's head in the nurse's lap.
D) Slide the client to the floor and cradle the client's head in the nurse's lap.

The nurse's lap is the safest position for the client's head, and the client is less likely to sustain an injury
if the client is already on the floor. Attempting to move the client laterally by oneself could result in
injury to the client and/or nurse. Placement in a reclining position could cause excess secretions to
accumulate in the oral pharynx and obstruct the airway. Turning the client onto his or her stomach
would decrease access to the airway.

The nurse delegates to an unlicensed assistant the task of removing the restraints from the client's
wrists every ________ hours and reporting any abnormalities.
A) 2
B) 4
C) 6
D) 8
A) 2

Removal of restraints and inspection of the contact area every 2 hours is a requirement of The Joint
Commission. The time periods in the other options are too long. The client could experience a serious
complication if restraints are not removed and the area under the restraints inspected frequently.

ealth care workers who have direct contact with individuals suspected of being contaminated with
anthrax should do which of the following? (Choose all that apply.)
A) Wear an isolation gown, gloves, and high-efficiency particle arrestor (HEPA) mask
B) Prepare the client for transfer to the radiology department for chest radiography
C) Instruct the client to wash the hands and exposed areas with soap and water
D) Have the client remove clothing and place it in a sealed biohazard bag
A and D

Anthrax is caused by a spore-forming, gram-positive bacillus. Humans become infected through skin
contact, ingestion, and inhalation. The nurse should wear an isolation gown, gloves, and a high-
efficiency particle arrestor (HEPA) mask. The client should remove potentially contaminated clothing for
testing and decontamination. The client should remain in isolation until it is certain that the bacteria
have been contained, not transferred to radiology. The client should shower thoroughly with soap and
water, not just wash hands and exposed areas.

While the nurse is administering flu immunizations in November to a group of older adults at a
community senior citizens' center, one of the seniors expresses a fear of contracting the flu from the
injection. The nurse reassures the senior that this is not possible because the vaccine contains a dead
virus and explains that this injection will produce _________ immunity, in which the senior's body will
make antibodies to the virus.
active

If an infectious disease can be transmitted directly from one person to another, it is:
A) A susceptible host
B) A communicable disease
C) A portal of entry to a host
D) A portal of exit from the reservoir
B) A communicable disease

If an infectious disease is transmitted directly from one person to another, it is a communicable disease.
Portals of entry and exit are the mechanisms of disease transmission. A susceptible host is a person who
can acquire an infection.

In infectious diseases such as hepatitis B and C, a reservoir for pathogens is:


A) The blood
B) The urinary tract
C) The respiratory tract
D) The reproductive tract
A) The blood

The blood is a reservoir for pathogens in hepatitis B and C. Neither organism can survive in the urinary,
reproductive, or respiratory tract

The most effective way to break the chain of infection is by:


A) Practicing good hand hygiene
B) Wearing gloves
C) Placing clients in isolation
D) Providing private rooms for clients
A) Practicing good hand hygiene

Good hand hygiene is the most effective way to break the chain of infection. Wearing gloves can help in
decreasing disease transmission, but clean hands are required for it to be truly effective. Placing clients
in isolation is costly and often unnecessary, and clients can be psychologically harmed by isolation. Even
providing private rooms for clients will not be effective if health care workers do not follow good hand
hygiene practices.

4. A nurse is assigned to care for a client with a deep wound infection. Which of the following actions
would result in the contamination of sterile gloves?
A) The nurse grasps a sterile cotton-tipped swab to clean wound edges.
B) The nurse takes a gauze pad in hand and places it in the wound.
C) The nurse picks up a gauze pad soaked in sterile saline to cleanse the wound.
D) The nurse pulls up the sheet over the client's perineum for better draping.
D) The nurse pulls up the sheet over the client's perineum for better draping.

If the nurse touches a sheet (nonsterile) with sterile gloves, the gloves are contaminated. The other
actions do not contaminate sterile gloves.

A client is isolated because the client has pulmonary tuberculosis. The nurse notes that the client seems
angry but knows this is a normal response to isolation. The best intervention is to:
A) Provide a dark, quiet room to calm the client.
B) Explain the isolation procedures and provide meaningful stimulation.
C) Reduce the level of precautions to keep the client from becoming angry.
D) Limit family and other caregiver visits to reduce the risk of spreading the infection.
B) Explain the isolation procedures and provide meaningful stimulation.

When a client is in isolation, the nurse should take measures to improve the client's stimulation and
make sure to explain the isolation procedures. Darkening the room can increase the sense of isolation.
The nurse should not change the isolation level but should provide plenty of emotional support and
make time for the client to prevent a sense of isolation. As long as family and caregivers follow infection
precautions, there is no reason to limit contact with these individuals.

6. A gown should be worn when:


A) The client's hygiene is poor.
B) The client has acquired immunodeficiency syndrome (AIDS) or hepatitis.
C) The nurse is assisting with medication administration.
D) Blood or body fluids may get on the nurse's clothing from a task the nurse plans to perform.
D) Blood or body fluids may get on the nurse's clothing from a task the nurse plans to perform.
Gowns should be worn when there is a possibility that blood or body fluids could get on the nurse's
clothes or when the client is on contact isolation status. The other options are not appropriate uses of
gowns.

When a nurse is performing surgical hand hygiene, the nurse must keep the hands:
A) Above the elbows
B) Below the elbows
C) At a 45-degree angle
D) In a comfortable position
A) Above the elbows

When surgical hand hygiene is performed, the hands should always be kept above the elbows so that
the water runs from the hands to the elbows.

To remove a glove that is contaminated, what should the nurse do first?


A) Rinse the glove before removing it to minimize contamination.
B) Pull the glove off the back of the hand until it slides off the entire hand and discard it.
C) Grasp the outside of the cuff or palm of the glove and pull it away from the hand without touching
the wrist or fingers.
D) Put the thumb inside the wrist to slide the glove over the hand with minimal touching of the hand by
the other gloved hand.
C) Grasp the outside of the cuff or palm of the glove and pull it away from the hand without touching
the wrist or fingers.

When the outside of the cuff is grasped with the contaminated gloved hand, then dirty to dirty remains
intact. Pulling the glove away from the hand entirely without touching the wrist or fingers further
minimizes the contamination by the gloved hand. If the nurse puts the gloved thumb inside the glove,
the nurse has contaminated the bare hand with a contaminated thumb. Pulling the glove off by holding
it at the back sounds good and could minimize contamination, but it is very difficulty to remove a glove
this way without the risk of tearing the glove and creating contamination through the tear. If excessive
secretions are present on gloves, then a towel or the drape could be used to wipe off excessive
secretions before an attempt is made to remove the gloves.

What is the single most effective method by which the nurse can break the chain of infection?
A) Give all clients antibiotics.
B) Wear gloves when caring for all clients.
C) Wash hands between procedures and clients.
D) Make sure housekeeping staff are using the right chemicals.
C) Wash hands between procedures and clients.

Adequate hand washing will remove bacteria and wastes or contaminates to minimize cross
contamination between clients. Use of alcohol-based waterless antiseptics between clients is also
effective if the guidelines for using these cleansers are followed. Giving all clients antibiotics is
impractical and is a source of new superinfections when persons who do not need antibiotics are given
them and then the bacteria mutate to become resistant to older drugs. It would be both unethical and
costly to try to control infections by treating everyone in the facility. Although wearing gloves to
perform procedures that carry the risk of direct contact with contaminated material is a correct method
of bacterial control, wearing gloves at all times is impractical, expensive, and unrealistic. Housekeeping
staff are trained to use the correct agents for decontamination and disinfection of all surfaces that place
clients at risk.

Which of the following statements reflects the current trend in the directives from the Centers for
Disease Control and Prevention (CDC) for minimizing risks of infection?
A) Discard all dressings into red bags.
B) Do not recap bottles of solutions to minimize risk of contamination.
C) Recap syringes or break needles off before discarding into sharps containers.
D) Keep all drainage tubing below the level of the waist and/or site of insertion.
D) Keep all drainage tubing below the level of the waist and/or site of insertion.

Keeping the solution in drainage tubes draining away from the drainage site on the body reduces the
risk for bacteria growth. Running any solution backward in the tubing puts the client at risk by bringing
any bacteria that may be present lower in the system back to the body, and cross contamination will
occur. As in surgical areas, anything below the waist should be considered at potential risk for infection.
Needles are not to be recapped or cut because of the increased risk of experiencing puncture wounds
while doing so. Not all dressings need to be placed in red bags; only dressings with moisture require
placement in a red bag. Bottles of solution that are sitting in the client's room should be closed to
prevent airborne contaminants from entering and creating an unsterile situation.

The nurse has just admitted a client to rule out active hepatitis B. The client is confused, spitting and
scratching everyone who enters the room. The nurse should:
A) Wait an hour until the client calms down and then use gloves when touching the client.
B) Use gloves, mask, face shield, and gown when entering the room to perform the initial assessment.
C) Administer a sedative and then perform the assessment after the client is asleep; no precautions
would be needed.
D) Realize that isolation equipment might further confuse the client and avoid using a face mask and
shield but use gown and gloves.
B) Use gloves, mask, face shield, and gown when entering the room to perform the initial assessment.

Hepatitis virus is a blood-borne virus, but the client is increasing the risk of cross contamination by
spitting (saliva can be a source of bacterial contamination) and scratching others, which can break the
skin and become a source of risk. All of the barriers listed would minimize cross contamination from the
client to the nurse. Even though gloves may be all that is needed because of limited contact with the
client, after an hour the client will remain confused and may not understand. The client may become
aggressive again and spit or scratch, and other barriers are needed to stop that source of possible risks.
A sedative may be given if needed, but trying to perform an assessment when the client is asleep is not
appropriate and will prevent the nurse from successfully establishing rapport with the client. Although
masks and shields might be frightening to some confused clients, if the client is spitting and body fluids
could be exchanged, a barrier should still be used.

12. For which airborne disease(s) would the nurse be required to use gloves, respiratory devices, and
gown when in close contact with the client?
A) Herpes simplex, scabies
B) Viral pneumonia, atelectasis
C) Chickenpox, pulmonary tuberculosis
D) Multidrug-resistant respiratory syncytial virus
C) Chickenpox, pulmonary tuberculosis

Airborne precautions are required for chickenpox and tuberculosis, because in these diseases small
particles float in the air and a barrier is required to prevent contamination of the nurse. A respiratory
protection device is form-fitted to the face to prevent the escape of air around the seal. Gloves and
gown are also worn to prevent contamination and transport of infective particles to other clients. For
viral pneumonia a regular mask is used as a barrier because the particles do not float in the air and are
more likely to be found on surfaces unless coughing or spitting is occurring. Atelectasis is the collapse of
alveoli, and airborne precautions are not needed. Herpes and scabies are spread by contact, and gloves
and gown would be necessary; masks would not be needed. For multidrug-resistant respiratory syncytial
virus the protection of the client would be as important as preventing the spread of these disorders.
Therefore, gown, gloves, and mask would be used as in reverse isolation to prevent cross contamination
of the client.

Before the nurse washes the hands when leaving an isolation room, what is the last thing that is
removed?
A) Mask
B) Gown
C) Goggles
D) Head cover
C) Goggles

Goggles are the least contaminated item and the last to be removed before hand washing. The gown
and gloves have been removed first. Head covers are usually not worn in isolation rooms as a barrier.
The mask is considered contaminated, and it should be untied and discarded after the gown is removed
to minimize contamination from the gown or gloves.

14. The nurse is setting up a sterile field for the physician. Which of the following statements concerning
a sterile field is correct?
A) The sides of the drape over the table are still sterile until they are touched.
B) Reaching over the field is not a source of contamination if the nurse has on a clean gown and gloves.
C) One inch around the border should be considered to be the barrier between the sterile field and
under the table.
D) A liquid spill onto the sterile field is a source of contamination from the table below the drape, even if
the barrier is waterproof.
C) One inch around the border should be considered to be the barrier between the sterile field and
under the table.

A 1-inch margin is considered unsterile and is the barrier spacing between the sterile field in the center
of the drape and the edge of the drape. Liquids spilled on a waterproof drape will not absorb from or be
contaminated from the surface beneath. Although such a situation could be messy, bacteria would not
cross from the unsterile to the sterile side. The edge of the table and the 1-inch border create the edge
of the sterile field. Anything below the edge, including the side of the drape, becomes unsterile.
Reaching over a sterile field is always a source of contamination and should not be done.

When transferring a sterile item to a sterile field, the nurse should:


A) Open the outer package and let the sterile assistant take the item from the nurse to put on the edge
of the drape.
B) Use a sterile lifting tool (forceps) to pick up the inner package and transfer it to the middle of the
field.
C) Open the outer package and use a sterile glove to pick up the item and drop it on the sterile field in
the middle of the drape.
D) Open the package by peeling back the cover without touching the inner package and drop the item
within the sterile field without touching the 1-inch border.
D) Open the package by peeling back the cover without touching the inner package and drop the item
within the sterile field without touching the 1-inch border.

The rule is "sterile to sterile" to prevent contamination. The outer cover is considered unsterile. As long
as the inner packet is not touched, the packet is considered sterile. The 1-inch border or barrier between
the edge of the drape and the field is the dividing line for sterile versus nonsterile. Using a sterile glove
to remove the inner packet is all right, but dropping it into the middle of the field will contaminate other
items. A sterile assistant can take the item from the nurse, but placing it on the edge of the drape will
contaminate the item because it is not inside the 1-inch border/barrier. Using sterile forceps to remove
the inner packet is acceptable, but putting the item into the middle of the field will again risk potential
contamination from reaching over the sterile field.