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Fundamentals Nursing Care 2nd Edition Ramont Niedringhaus Test Bank

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Fundamentals Nursing Care 2nd Edition Ramont Niedringhaus Test Bank

ISBN-13: 978-0132244329

ISBN-10: 0132244322

 

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Fundamentals Nursing Care 2nd Edition Ramont Niedringhaus Test Bank

ISBN-13: 978-0132244329

ISBN-10: 0132244322

 

 

 

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Free Nursing Test Questions:

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Chapter 9

Question 1

Type: MCSA

While teaching a new mother about infant safety, the nurse recognizes the need for further teaching when the mother makes which of the following statements?

  1. “I will put plugs in the electric sockets and tie up wires when my child is 7 months old.”
  2. “I need to apply locks to the doors under my kitchen sink.”
  3. “I will check the temperature of the bath water with a thermometer before putting the baby in the water.”
  4. “I will buy an approved car seat before going home, and use it whenever the baby is in the car.”

Correct Answer: 1

Rationale 1: Infants can learn to roll as early as 4-5 months of age, and could easily be tangled in wires. Some children are crawling by 6 months of age, and would be able to reach electrical outlets. These safety measures should be instituted before going home with the baby or shortly thereafter. The other statements are all correct.

Rationale 2: Infants can learn to roll as early as 4-5 months of age, and could easily be tangled in wires. Some children are crawling by 6 months of age, and would be able to reach electrical outlets. These safety measures should be instituted before going home with the baby or shortly thereafter. The other statements are all correct.

Rationale 3: Infants can learn to roll as early as 4-5 months of age, and could easily be tangled in wires. Some children are crawling by 6 months of age, and would be able to reach electrical outlets. These safety measures should be instituted before going home with the baby or shortly thereafter. The other statements are all correct.

Rationale 4: Infants can learn to roll as early as 4-5 months of age, and could easily be tangled in wires. Some children are crawling by 6 months of age, and would be able to reach electrical outlets. These safety measures should be instituted before going home with the baby or shortly thereafter. The other statements are all correct.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: List points for client teaching about safety across the life span.

 

Question 2

Type: MCSA

When moving the client up in bed, the nurse does which of the following to prevent self-injury?

  1. Keep both feet together and flat on the floor.
  2. Flex the hips and knees.
  3. Place the bed in the low position.
  4. Twist from side to side while moving the client.

Correct Answer: 2

Rationale 1: Flexing the hips and knees gives the nurse the leverage to move the client without damaging the back. The nurse could fall with both feet together because there is not a broad base of support. Working with the bed in the low position can cause muscle strain on the back because the nurse must lean over to reach the client. Twisting while moving a client can cause back injuries.

Rationale 2: Flexing the hips and knees gives the nurse the leverage to move the client without damaging the back. The nurse could fall with both feet together because there is not a broad base of support. Working with the bed in the low position can cause muscle strain on the back because the nurse must lean over to reach the client. Twisting while moving a client can cause back injuries.

Rationale 3: Flexing the hips and knees gives the nurse the leverage to move the client without damaging the back. The nurse could fall with both feet together because there is not a broad base of support. Working with the bed in the low position can cause muscle strain on the back because the nurse must lean over to reach the client. Twisting while moving a client can cause back injuries.

Rationale 4: Flexing the hips and knees gives the nurse the leverage to move the client without damaging the back. The nurse could fall with both feet together because there is not a broad base of support. Working with the bed in the low position can cause muscle strain on the back because the nurse must lean over to reach the client. Twisting while moving a client can cause back injuries.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Identify common preventable injuries in the home and in healthcare settings.

 

Question 3

Type: MCSA

The home health nurse is visiting an elderly client who has problems with balance. In assessing the home for safety, the nurse would suggest which of the following?

  1. Having the doorbell ring in the back of the house so the client can hear it
  2. Placing everything the client needs near the chair so he does not have to walk very far
  3. Installing safety rails in the bathroom
  4. Asking the physician to write an order for a wheelchair

Correct Answer: 3

Rationale 1: Clients with balance problems are at risk for falls in the bathroom. Rails in the tub and shower, and near the toilet, can help the client to maintain stability. Placing the doorbell in the back of the house will not help maintain safety for the client. Ensuring that everything the client needs is within reach decreases the client’s activity level, which could cause the balance problem to worsen because the client will become weaker due to inactivity. Asking the doctor for a wheelchair will further immobilize the client, and could contribute to low self esteem.

Rationale 2: Clients with balance problems are at risk for falls in the bathroom. Rails in the tub and shower, and near the toilet, can help the client to maintain stability. Placing the doorbell in the back of the house will not help maintain safety for the client. Ensuring that everything the client needs is within reach decreases the client’s activity level, which could cause the balance problem to worsen because the client will become weaker due to inactivity. Asking the doctor for a wheelchair will further immobilize the client, and could contribute to low self esteem.

Rationale 3: Clients with balance problems are at risk for falls in the bathroom. Rails in the tub and shower, and near the toilet, can help the client to maintain stability. Placing the doorbell in the back of the house will not help maintain safety for the client. Ensuring that everything the client needs is within reach decreases the client’s activity level, which could cause the balance problem to worsen because the client will become weaker due to inactivity. Asking the doctor for a wheelchair will further immobilize the client, and could contribute to low self esteem.

Rationale 4: Clients with balance problems are at risk for falls in the bathroom. Rails in the tub and shower, and near the toilet, can help the client to maintain stability. Placing the doorbell in the back of the house will not help maintain safety for the client. Ensuring that everything the client needs is within reach decreases the client’s activity level, which could cause the balance problem to worsen because the client will become weaker due to inactivity. Asking the doctor for a wheelchair will further immobilize the client, and could contribute to low self esteem.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Identify common preventable injuries in the home and in healthcare settings.

 

Question 4

Type: MCSA

When assisting a 300-pound immobile client in a long-term care facility to the shower, the nurse does which of the following to prevent self-injury?

  1. Request help from another staff member to transfer the client to a wheelchair.
  2. Use principles of proper body mechanics to move the client to the wheelchair alone.
  3. Notify the supervisor that the client is too heavy to move.
  4. Request assistance in using a sling device to move the client.

Correct Answer: 4

Rationale 1: The Hoyer lift and other similar devices are used for clients who cannot help with transfer. At least two people are needed to use this equipment. In the case of a client who weighs 300 pounds, attempting the transfer alone or with one other staff member without equipment is not safe. Hygiene needs cannot be ignored because of the client’s sizeRemember, declining to shower the client is not an option.

Rationale 2: The Hoyer lift and other similar devices are used for clients who cannot help with transfer. At least two people are needed to use this equipment. In the case of a client who weighs 300 pounds, attempting the transfer alone or with one other staff member without equipment is not safe. Hygiene needs cannot be ignored because of the client’s sizeRemember, declining to shower the client is not an option.

Rationale 3: The Hoyer lift and other similar devices are used for clients who cannot help with transfer. At least two people are needed to use this equipment. In the case of a client who weighs 300 pounds, attempting the transfer alone or with one other staff member without equipment is not safe. Hygiene needs cannot be ignored because of the client’s sizeRemember, declining to shower the client is not an option.

Rationale 4: The Hoyer lift and other similar devices are used for clients who cannot help with transfer. At least two people are needed to use this equipment. In the case of a client who weighs 300 pounds, attempting the transfer alone or with one other staff member without equipment is not safe. Hygiene needs cannot be ignored because of the client’s sizeRemember, declining to shower the client is not an option.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Name institutional strategies for maintaining safety.

 

Question 5

Type: MCSA

The nurse is teaching class for other staff members on safety measures implemented by the hospital to protect employees, and identifies which of the following?

  1. Use of a needle-less system
  2. Side rails on stretchers
  3. Safety rails in client bathrooms
  4. Client identification bands

Correct Answer: 1

Rationale 1: A safety practice in the hospital to protect employees is the needle-less system to prevent needle sticks. Side rails on stretchers, safety rails in bathrooms, and identification armbands are all safety measures to protect the client.

Rationale 2: A safety practice in the hospital to protect employees is the needle-less system to prevent needle sticks. Side rails on stretchers, safety rails in bathrooms, and identification armbands are all safety measures to protect the client.

Rationale 3: A safety practice in the hospital to protect employees is the needle-less system to prevent needle sticks. Side rails on stretchers, safety rails in bathrooms, and identification armbands are all safety measures to protect the client.

Rationale 4: A safety practice in the hospital to protect employees is the needle-less system to prevent needle sticks. Side rails on stretchers, safety rails in bathrooms, and identification armbands are all safety measures to protect the client.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Name institutional strategies for maintaining safety.

 

Question 6

Type: MCSA

The nurse notices smoke coming from one of the client’s rooms. Which of the following is the priority nursing action?

  1. Call a code red.
  2. Move the client to safety.
  3. Extinguish the fire.
  4. Call for help.

Correct Answer: 2

Rationale 1: The order of action for the nurse is RACE. Rescue the client first. Activate the alarm. Confine the fire by closing doors, and extinguish the fire.

Rationale 2: The order of action for the nurse is RACE. Rescue the client first. Activate the alarm. Confine the fire by closing doors, and extinguish the fire.

Rationale 3: The order of action for the nurse is RACE. Rescue the client first. Activate the alarm. Confine the fire by closing doors, and extinguish the fire.

Rationale 4: The order of action for the nurse is RACE. Rescue the client first. Activate the alarm. Confine the fire by closing doors, and extinguish the fire.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: List triage and emergency codes that are used in healthcare settings.

 

Question 7

Type: MCSA

The Emergency Department charge nurse receives a call from the emergency medical technicians that there is a train accident with numerous injured clients. Which of the following would the charge nurse do first?

  1. Call the nursing supervisor to obtain more nursing staff.
  2. Prepare triage rooms to admit the victims.
  3. Alert other departments of the possible need for added services.
  4. Activate the agency disaster plan.

Correct Answer: 4

Rationale 1: Every agency is required to have internal and external disaster plans. The charge nurse’s first responsibility is to activate the disaster plan. The other options are components of the disaster plan, and will be delegated by the command center.

Rationale 2: Every agency is required to have internal and external disaster plans. The charge nurse’s first responsibility is to activate the disaster plan. The other options are components of the disaster plan, and will be delegated by the command center.

Rationale 3: Every agency is required to have internal and external disaster plans. The charge nurse’s first responsibility is to activate the disaster plan. The other options are components of the disaster plan, and will be delegated by the command center.

Rationale 4: Every agency is required to have internal and external disaster plans. The charge nurse’s first responsibility is to activate the disaster plan. The other options are components of the disaster plan, and will be delegated by the command center.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: List triage and emergency codes that are used in healthcare settings.

 

Question 8

Type: MCSA

When caring for a client requiring the use of arm restraints to prevent the client from self-harm, the nurse would perform which of the following implementations?

  1. Assess the need for restraints every 24 hours.
  2. Remove the restraints for five minutes every four hours.
  3. Perform ROM on the restrained limbs once a shift.
  4. Offer food, fluid, and toileting every two hours.

Correct Answer: 4

Rationale 1: If the client is not NPO, basic care is offered every two hours. The need for restraints, ROM to the restrained limb, and removal of one restraint at a time are assessed or performed every two hours.

Rationale 2: If the client is not NPO, basic care is offered every two hours. The need for restraints, ROM to the restrained limb, and removal of one restraint at a time are assessed or performed every two hours.

Rationale 3: If the client is not NPO, basic care is offered every two hours. The need for restraints, ROM to the restrained limb, and removal of one restraint at a time are assessed or performed every two hours.

Rationale 4: If the client is not NPO, basic care is offered every two hours. The need for restraints, ROM to the restrained limb, and removal of one restraint at a time are assessed or performed every two hours.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe the use and legal implications of restraints.

 

Question 9

Type: MCSA

The nurse is caring for a client who has pulled out his IV twice. The nurse has replaced the IV in the left hand, and the physician has ordered restraints for the client. Which of the following restraints would meet the legal restraint requirements for this client?

  1. A leather restraint on the right hand
  2. Soft four-point restraints
  3. A jacket restraint
  4. An elbow restraint on the right arm

Correct Answer: 4

Rationale 1: The elbow restraint on the right arm would prevent the client from bending the arm to pull the IV out of the left hand. The client’s movements are minimally restricted, which is a major requirement of restraints. A jacket restraint would not prevent the client from pulling out his IV and four-point restraints would be more than is needed for this client. Leather restraints are only used for the criminal or very violent client who requires very strong restraints.

Rationale 2: The elbow restraint on the right arm would prevent the client from bending the arm to pull the IV out of the left hand. The client’s movements are minimally restricted, which is a major requirement of restraints. A jacket restraint would not prevent the client from pulling out his IV and four-point restraints would be more than is needed for this client. Leather restraints are only used for the criminal or very violent client who requires very strong restraints.

Rationale 3: The elbow restraint on the right arm would prevent the client from bending the arm to pull the IV out of the left hand. The client’s movements are minimally restricted, which is a major requirement of restraints. A jacket restraint would not prevent the client from pulling out his IV and four-point restraints would be more than is needed for this client. Leather restraints are only used for the criminal or very violent client who requires very strong restraints.

Rationale 4: The elbow restraint on the right arm would prevent the client from bending the arm to pull the IV out of the left hand. The client’s movements are minimally restricted, which is a major requirement of restraints. A jacket restraint would not prevent the client from pulling out his IV and four-point restraints would be more than is needed for this client. Leather restraints are only used for the criminal or very violent client who requires very strong restraints.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe the use and legal implications of restraints.

 

Question 10

Type: MCSA

The nurse is working on a pediatric unit with a 2-year-old client who requires venipuncture. Which of the following techniques might the nurse use in place of restraints during the venipuncture?

  1. Distract the child with toys and games, and turn on the TV.
  2. Play soft music to relax the child.
  3. Place the child in the mother’s lap facing the mother, who wraps her arms around the child.
  4. Have several staff members in the room to hold the child down during venipuncture.

Correct Answer: 3

Rationale 1: If the mother is willing, she can effectively hold the child immobile by wrapping her arms around the child with the child’s limbs exposed. If the mother is not willing, this method could be performed by another staff nurse. A child of that age will not be distracted by toys or music once the nurse begins the procedure. Having several staff members hold the child down will only make the child more anxious.

Rationale 2: If the mother is willing, she can effectively hold the child immobile by wrapping her arms around the child with the child’s limbs exposed. If the mother is not willing, this method could be performed by another staff nurse. A child of that age will not be distracted by toys or music once the nurse begins the procedure. Having several staff members hold the child down will only make the child more anxious.

Rationale 3: If the mother is willing, she can effectively hold the child immobile by wrapping her arms around the child with the child’s limbs exposed. If the mother is not willing, this method could be performed by another staff nurse. A child of that age will not be distracted by toys or music once the nurse begins the procedure. Having several staff members hold the child down will only make the child more anxious.

Rationale 4: If the mother is willing, she can effectively hold the child immobile by wrapping her arms around the child with the child’s limbs exposed. If the mother is not willing, this method could be performed by another staff nurse. A child of that age will not be distracted by toys or music once the nurse begins the procedure. Having several staff members hold the child down will only make the child more anxious.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Name several alternatives to restraints.

 

Question 11

Type: MCSA

The nurse uses appropriate body mechanics for which of the following purposes?

  1. To maintain client safety
  2. To reduce friction on the client’s skin
  3. To reduce staff fatigue
  4. To reduce client fatigue

Correct Answer: 3

Rationale 1: One purpose for using body mechanics is to reduce fatigue in the employee. An injury is more likely to occur when the staff member’s muscles are fatigued. The purpose of appropriate body mechanics is not client safety or to reduce client fatigue, it is for the protection of the staff. Even when using proper body mechanics, it is possible to cause friction to the client’s skin.

Rationale 2: One purpose for using body mechanics is to reduce fatigue in the employee. An injury is more likely to occur when the staff member’s muscles are fatigued. The purpose of appropriate body mechanics is not client safety or to reduce client fatigue, it is for the protection of the staff. Even when using proper body mechanics, it is possible to cause friction to the client’s skin.

Rationale 3: One purpose for using body mechanics is to reduce fatigue in the employee. An injury is more likely to occur when the staff member’s muscles are fatigued. The purpose of appropriate body mechanics is not client safety or to reduce client fatigue, it is for the protection of the staff. Even when using proper body mechanics, it is possible to cause friction to the client’s skin.

Rationale 4: One purpose for using body mechanics is to reduce fatigue in the employee. An injury is more likely to occur when the staff member’s muscles are fatigued. The purpose of appropriate body mechanics is not client safety or to reduce client fatigue, it is for the protection of the staff. Even when using proper body mechanics, it is possible to cause friction to the client’s skin.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Identify ways to prevent self-injury while delivering client care.

 

Question 12

Type: MCSA

The nurse is caring for an 80-year-old confused client in renal failure who is very weak. The client keeps trying to get out of bed. Which of the following would be the best safety device to use with this client?

  1. Place the client in a jacket restraint to prevent falling out of bed.
  2. Ask the family to sit with the client around the clock.
  3. Use a bed exit alarm device.
  4. Frequently check on the client to ensure that the client is in bed.

Correct Answer: 3

Rationale 1: A bed exit alarm device is activated when the client attempts to get out of bed, and alerts the nursing staff. Restraints are demeaning, are more immobilizing than necessary, and could cause further injury if the client becomes twisted in the restraint. Having the family sit with the client does not relieve the nurse’s responsibility for the client’s safety, and places an unnecessary burden on the family. No matter how many times the nurse checks on the client, the client can fall getting out of bed in between checks.

Rationale 2: A bed exit alarm device is activated when the client attempts to get out of bed, and alerts the nursing staff. Restraints are demeaning, are more immobilizing than necessary, and could cause further injury if the client becomes twisted in the restraint. Having the family sit with the client does not relieve the nurse’s responsibility for the client’s safety, and places an unnecessary burden on the family. No matter how many times the nurse checks on the client, the client can fall getting out of bed in between checks.

Rationale 3: A bed exit alarm device is activated when the client attempts to get out of bed, and alerts the nursing staff. Restraints are demeaning, are more immobilizing than necessary, and could cause further injury if the client becomes twisted in the restraint. Having the family sit with the client does not relieve the nurse’s responsibility for the client’s safety, and places an unnecessary burden on the family. No matter how many times the nurse checks on the client, the client can fall getting out of bed in between checks.

Rationale 4: A bed exit alarm device is activated when the client attempts to get out of bed, and alerts the nursing staff. Restraints are demeaning, are more immobilizing than necessary, and could cause further injury if the client becomes twisted in the restraint. Having the family sit with the client does not relieve the nurse’s responsibility for the client’s safety, and places an unnecessary burden on the family. No matter how many times the nurse checks on the client, the client can fall getting out of bed in between checks.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Name several alternatives to restraints.

 

Question 13

Type: MCSA

The nurse enters the client’s room to find that the spouse of the client is very angry. The spouse is shouting and making angry gestures. While attempting to diffuse the spouse’s anger, the nurse maintains safety by doing which of the following?

  1. Enter the room and stand close to the spouse.
  2. Stand near the doorway to talk to the spouse.
  3. Sit by the spouse.
  4. Have the spouse come into the hall to talk.

Correct Answer: 2

Rationale 1: The safest position is near the doorwayRemember, the nurse has a clear path out of the room if the spouse threatens to become violent. Under no circumstances should the student stand close to the spouse, because it might be interpreted as threatening or invading personal space, making the spouse angrier. Sitting down makes a quick exit difficult should it become necessary. Inviting the client out to the hallway exposes others to potential danger and reduces confidentiality of the things the spouse is discussing.

Rationale 2: The safest position is near the doorwayRemember, the nurse has a clear path out of the room if the spouse threatens to become violent. Under no circumstances should the student stand close to the spouse, because it might be interpreted as threatening or invading personal space, making the spouse angrier. Sitting down makes a quick exit difficult should it become necessary. Inviting the client out to the hallway exposes others to potential danger and reduces confidentiality of the things the spouse is discussing.

Rationale 3: The safest position is near the doorwayRemember, the nurse has a clear path out of the room if the spouse threatens to become violent. Under no circumstances should the student stand close to the spouse, because it might be interpreted as threatening or invading personal space, making the spouse angrier. Sitting down makes a quick exit difficult should it become necessary. Inviting the client out to the hallway exposes others to potential danger and reduces confidentiality of the things the spouse is discussing.

Rationale 4: The safest position is near the doorwayRemember, the nurse has a clear path out of the room if the spouse threatens to become violent. Under no circumstances should the student stand close to the spouse, because it might be interpreted as threatening or invading personal space, making the spouse angrier. Sitting down makes a quick exit difficult should it become necessary. Inviting the client out to the hallway exposes others to potential danger and reduces confidentiality of the things the spouse is discussing.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: List strategies for self-protection in violent or potentially violent situations.

 

Question 14

Type: MCSA

The nursing student walks into the client’s room and finds that the client is unconscious and unresponsive when his name is called. Which of the following actions would the nursing student take first?

  1. Begin CPR
  2. Shake the client and ask if he is all right.
  3. Call for help.
  4. Assess vital signs.

Correct Answer: 3

Rationale 1: For an unresponsive adult, the student first would call for help and then would shake the client gently and ask if he is all right. If the client remains unresponsive, open the airway and assess breathing. Complete vital signs are not assessed until determining whether the client has a pulse and is breathing.

Rationale 2: For an unresponsive adult, the student first would call for help and then would shake the client gently and ask if he is all right. If the client remains unresponsive, open the airway and assess breathing. Complete vital signs are not assessed until determining whether the client has a pulse and is breathing.

Rationale 3: For an unresponsive adult, the student first would call for help and then would shake the client gently and ask if he is all right. If the client remains unresponsive, open the airway and assess breathing. Complete vital signs are not assessed until determining whether the client has a pulse and is breathing.

Rationale 4: For an unresponsive adult, the student first would call for help and then would shake the client gently and ask if he is all right. If the client remains unresponsive, open the airway and assess breathing. Complete vital signs are not assessed until determining whether the client has a pulse and is breathing.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: List triage and emergency codes that are used in healthcare settings.

 

Question 15

Type: MCMA

The nurse is collecting data from the 68-year-old client about her living situation in order to assess her ability to care for herself and avoid injury. Which of the following statements indicate to the nurse that the client might be in need of interventions to ensure her safety? Select all that apply.

Standard Text: Select all that apply.

  1. The client lives in an assisted-living facility with her small dog.
  2. The client has a cataract in one eye.
  3. The client reads on an elementary level.
  4. The client takes acetaminophen for headache.
  5. The client chooses to use a cane when out walking.

Correct Answer: 1,2,3

Rationale 1: The client lives in a relatively safe setting, but is at risk for falls and tripping over the dog. Cataracts diminish eyesight, which places the client at risk for tripping or falls. Reading at an elementary level could cause problems if the client is not able to read warnings on labels. Taking acetaminophen and choosing to use a cane when walking pose no particular safety risk.

Rationale 2: The client lives in a relatively safe setting, but is at risk for falls and tripping over the dog. Cataracts diminish eyesight, which places the client at risk for tripping or falls. Reading at an elementary level could cause problems if the client is not able to read warnings on labels. Taking acetaminophen and choosing to use a cane when walking pose no particular safety risk.

Rationale 3: The client lives in a relatively safe setting, but is at risk for falls and tripping over the dog. Cataracts diminish eyesight, which places the client at risk for tripping or falls. Reading at an elementary level could cause problems if the client is not able to read warnings on labels. Taking acetaminophen and choosing to use a cane when walking pose no particular safety risk.

Rationale 4: The client lives in a relatively safe setting, but is at risk for falls and tripping over the dog. Cataracts diminish eyesight, which places the client at risk for tripping or falls. Reading at an elementary level could cause problems if the client is not able to read warnings on labels. Taking acetaminophen and choosing to use a cane when walking pose no particular safety risk.

Rationale 5: The client lives in a relatively safe setting, but is at risk for falls and tripping over the dog. Cataracts diminish eyesight, which places the client at risk for tripping or falls. Reading at an elementary level could cause problems if the client is not able to read warnings on labels. Taking acetaminophen and choosing to use a cane when walking pose no particular safety risk.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Discuss factors that affect safety and people’s ability to protect themselves from injury.

 

Question 16

Type: MCMA

The nurse is giving an inservice to a group of nurses about the physiological effects of excessive noise. Which of the following clients might be adversely affected by noise pollution? Select all that apply.

Standard Text: Select all that apply.

  1. The client with congestive heart failure
  2. The client with profound hearing loss
  3. The client with Crohn’s disease
  4. The client with impaired eyesight
  5. The client with asthma

Correct Answer: 1,3,5

Rationale 1: Excess noise can cause increased respiratory and heart rates, diarrhea and digestive problems, and nausea. In clients with diseases of these systems, (congestive heart failure, Crohn’s disease, and asthma), an increase in the symptoms could worsen their condition. The client with profound hearing loss will not be affected by noise that cannot be heard. Noise pollution has no direct bearing on eyesight.

Rationale 2: Excess noise can cause increased respiratory and heart rates, diarrhea and digestive problems, and nausea. In clients with diseases of these systems, (congestive heart failure, Crohn’s disease, and asthma), an increase in the symptoms could worsen their condition. The client with profound hearing loss will not be affected by noise that cannot be heard. Noise pollution has no direct bearing on eyesight.

Rationale 3: Excess noise can cause increased respiratory and heart rates, diarrhea and digestive problems, and nausea. In clients with diseases of these systems, (congestive heart failure, Crohn’s disease, and asthma), an increase in the symptoms could worsen their condition. The client with profound hearing loss will not be affected by noise that cannot be heard. Noise pollution has no direct bearing on eyesight.

Rationale 4: Excess noise can cause increased respiratory and heart rates, diarrhea and digestive problems, and nausea. In clients with diseases of these systems, (congestive heart failure, Crohn’s disease, and asthma), an increase in the symptoms could worsen their condition. The client with profound hearing loss will not be affected by noise that cannot be heard. Noise pollution has no direct bearing on eyesight.

Rationale 5: Excess noise can cause increased respiratory and heart rates, diarrhea and digestive problems, and nausea. In clients with diseases of these systems, (congestive heart failure, Crohn’s disease, and asthma), an increase in the symptoms could worsen their condition. The client with profound hearing loss will not be affected by noise that cannot be heard. Noise pollution has no direct bearing on eyesight.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Discuss factors that affect safety and people’s ability to protect themselves from injury.

 

Question 17

Type: SEQ

The nurse is reviewing safety concerns throughout the lifespan. List the following in order of appropriate age, from youngest to oldest.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Encourage counseling for issues with addiction coping

Choice 2. Teach about stranger danger

Choice 3. Reinforce importance of safety restraints in the vehicle

Choice 4. Make certain walkways, stairways are well lighted, uncluttered

Choice 5. Teach safety rules for recreational and sports activities

Choice 6.

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

Rationale 1: Young adults need encouragement to seek counseling for issues with addiction and coping issues.

Rationale 2: Stranger danger is appropriate to teach preschoolers.

Rationale 3: Adolescents need reinforcement of the importance of safety restraints in the vehicle while driving.

Rationale 4: Middle aged adults should make certain that stairways and walkways are well lighted and uncluttered.

Rationale 5: School age children need information regarding safety rules for recreational and sports activities.

Rationale 6:

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 18

Type: MCSA

All healthcare facilities have emergency codes that the nurse needs to know. Which of the following code is commonly used to describe a bomb threat in the facility?

  1. Code Red
  2. Code Blue
  3. Code Yellow
  4. Code Silver

Correct Answer: 3

Rationale 1: Code Red is most often used to describe a fire.

Rationale 2: Code Blue is most often used to describe an adult medical emergency.

Rationale 3: Code Yellow is most often used to describe a bomb threat.

Rationale 4: Code Silver is most often used to describe a person with a weapon or hostage situation.

Rationale 5:

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:

 

Question 19

Type: MCMA

The nurse explains to the client and family that there are several non-emergency reactions to latex exposure:

Standard Text: Select all that apply.

  1. Allergic contact dermatitis
  2. Irritant contact dermatitis
  3. Irritated area of skin
  4. Swelling of throat
  5. Anaphylaxis

Correct Answer: 1,2,3

Rationale 1: Allergic contact dermatitis includes skin rash or blisters, but is not life threatening.

Rationale 2: Irritant contact dermatitis is not life threatening.

Rationale 3: Irritated, dry itchy skin is a sign of irritant contact dermatitis and is not life threatening.

Rationale 4: Swelling of the throat is a symptom of anaphylaxis and is life threatening.

Rationale 5: Anaphylaxis is a life threatening emergency.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

 

Question 20

Type: MCMA

Which of the following is appropriate teach for the parents with a two year old?

Standard Text: Select all that apply.

  1. Place hot pots on back burners
  2. Teach to obey all traffic and safety rules
  3. Keep cleaning solutions in locked cupboards
  4. Teach to avoid the effects of drugs and alcohol on judgment and coordination
  5. Use largeRemember,ft toys with no small detachable or sharp-edged parts

Correct Answer: 1,3,5

Rationale 1: Toddlers may reach for handles.

Rationale 2: The two-year old should not be outside without supervision.

Rationale 3: Toddlers may see cleaning supplies as drinks.

Rationale 4: Toddlers will not be consuming alcohol or drugs.

Rationale 5: These are appropriate toys for a toddler to continue playing with.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 21

Type: MCMA

The nurse is likely to determine mobility and health status as a safety concern in which of the following clients?

Standard Text: Select all that apply.

  1. A post-operative client on narcotic analgesics
  2. A client who is illiterate
  3. A client with an arm cast
  4. An elderly client
  5. The client with a spinal cord injury

Correct Answer: 1,4,5

Rationale 1: Clients using mind-altering medications are at risk for injury because of lack of coordination or impaired judgment.

Rationale 2: The illiterate client is at risk for anything that requires reading.

Rationale 3: The client with an arm cast is not at special risk for injury.

Rationale 4: The elderly client may be at risk for falling due to muscle weakness and poor balance.

Rationale 5: The client with a spinal cord injury may have paralysis of both legs, and be unable to move.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 22

Type: MCSA

Which of the following lifestyle factors with the nurse assess with the young adult client entering the ambulatory care setting for a routine physical?

  1. Mobility
  2. Environment
  3. Workplace safety
  4. Diminished sensory perception

Correct Answer: 3

Rationale 1: The young adult presenting for a routine physical will not be likely to have mobility issues.

Rationale 2: The young adult presenting for a physical is unlikely to have environmental safety issues.

Rationale 3: The young adult may be at risk from exposure to hazardous chemicals, dangerous equipment or excessive noise.

Rationale 4: The healthy young adult is not likely to have altered sensory perception at his or her age.

Rationale 5:

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

 

Question 23

Type: MCSA

The nurse is aware of the risk of suicide and accidental overdose of medication are increasing among which of the following groups?

  1. Adolescents and elderly people
  2. Adolescents and young adults
  3. Elderly and school-age children
  4. Native American young adults and adolescents

Correct Answer: 1

Rationale 1: Adolescents and elderly people in all cultures are increasingly committing suicide and experiencing accidental overdose.

Rationale 2: Adolescents and elderly people in all cultures are increasingly committing suicide and experiencing accidental overdose.

Rationale 3: Adolescents and elderly people in all cultures are increasingly committing suicide and experiencing accidental overdose.

Rationale 4: Adolescents and elderly people in all cultures are increasingly committing suicide and experiencing accidental overdose.

Rationale 5:

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

 

Question 24

Type: SEQ

When providing safety during nursing procedures, the nurse always begins with the following basic interventions. Place them in the correct sequence.

Standard Text: Click and drag the options below to move them up or down.

Choice 1.

Choice 2.

Choice 3. Check the physician’s order

Choice 4. Provide privacy as needed

Choice 5. Explain the procedure

Choice 6. Gather the necessary equipment

Correct Answer: 3,6,1,4,5,2

Rationale 1:

Rationale 2:

Rationale 3:

Rationale 4:

Rationale 5:

Rationale 6:

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 25

Type: MCSA

The nurse in the long-term care facility is aware that fire is particularly hazardous when:

  1. Anesthetic gases are used
  2. Heating appliances are used
  3. People are incapacitated
  4. Children have access to matches

Correct Answer: 3

Rationale 1: Anesthetic gases are not used in the long-term care facility.

Rationale 2: Heating appliances are not used in a long-term care facility.

Rationale 3: When people are incapacitated and unable to leave a building, the risks of client and staff injury are increased.

Rationale 4: Children are not usually in the long-term care settings.

Rationale 5:

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

 

Question 26

Type: MCMA

Teaching about poison safety is particularly important for:

Standard Text: Select all that apply.

  1. Young adults
  2. Parents of young children
  3. Older adults taking medication
  4. Clients with low vision
  5. Recreational drug users

Correct Answer: 2,3,4,5

Rationale 1: Young adults are not usually at risk for poisoning.

Rationale 2: Young children are at risk for accidental poison ingestion.

Rationale 3: Older adults may not remember when to take medication, and may overdose accidentally.

Rationale 4: Clients with low vision may not be able to determine which medications are appropriate, or the appropriate dosages.

Rationale 5: Recreational drug users are at risk for accidental poisoning from substances.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

 

Question 27

Type: MCSA

The nurse explains to the children of a 82 year old client that the leading cause of injury among older adults is:

  1. Accidental poisonings
  2. Burns
  3. Falls
  4. Fires

Correct Answer: 3

Rationale 1: Poisoning is not the leading cause of injury in older adults.

Rationale 2: Burns are not the leading cause of injury in older adults.

Rationale 3: Falls are the leading cause of injury in older adults, and a major cause of hospital and nursing home admissions.

Rationale 4: Fires are not the leading cause of injury in older adults.

Rationale 5:

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

 

Question 28

Type: MCMA

The nurse teaches the older adult and his or her family the following fall prevention measures:

Standard Text: Select all that apply.

  1. Remove scatter rugs
  2. Adapt living arrangements to one floor
  3. Day and time medication boxes can be helpful
  4. Keep bed in low position
  5. Encourage frequent review of all prescribed medication

Correct Answer: 1,2,4,5

Rationale 1: Clear walking paths protect the client with poor vision from tripping.

Rationale 2: Impaired gait or balance due to arthritis may make it difficult to negotiate stairs.

Rationale 3: Day and night medication boxes would be appropriate to prevent accidental poisoning.

Rationale 4: Keeping a bed in low position minimizes risks from falling out of bed.

Rationale 5: Medications alone or interacting with other medications may decrease alertness and orientation.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

 

Question 29

Type: MCSA

In a disaster situation, which of the following is a method of prioritizing victims?

  1. Triage
  2. Assessment
  3. Diagnosis
  4. Disaster planning

Correct Answer: 1

Rationale 1:

Rationale 2:

Rationale 3:

Rationale 4:

Rationale 5:

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

 

Question 30

Type: MCMA

During a disaster, appropriate nursing actions include:

Standard Text: Select all that apply.

  1. Work as directed by supervisor
  2. Check in with family frequently during the disaster
  3. Check in with multiple units to see if they need help
  4. Observe client confidentiality
  5. Refer all questions to public information officer

Correct Answer: 1,4,5

Rationale 1: Healthcare workers must be willing to perform tasks as assigned by the command center director or supervisor .

Rationale 2: Personal communication should be put on hold to keep communication lines open.

Rationale 3: Each person should stay in his or her assigned area until directed to do otherwise.

Rationale 4: It is important to observe client confidentiality and not perpetuate rumors.

Rationale 5: All media questions should be referred to the public information officer for release of authorized information only.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 31

Type: MCMA

The nurse uses which of the following alternatives to restraints when ever possible:

Standard Text: Select all that apply.

  1. Place clients who are at risk for falls in an area that is constantly supervised
  2. Lock the wheels on the clients wheelchair
  3. Use environmental restraints
  4. Use rocking chairs to expend energy
  5. Monitor client medications

Correct Answer: 1,3,4,5

Rationale 1: Supervision is an appropriate intervention.

Rationale 2: Locking the wheels can be considered a restraint.

Rationale 3: Environmental barriers include barriers such as large plants to keep clients from wandering.

Rationale 4: Have a confused client use a rocking chair will expend some energy and will be less likely inclined to wander.

Rationale 5: Use of psychotropic or sedative medications should be minimized as possible.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:

 

Question 32

Type: MCSA

Legal implications for the use of restraints include the principle of

  1. Convenience
  2. Autonomy
  3. Least restriction
  4. Monitoring

Correct Answer: 3

Rationale 1: Clients should not be restrained for staff convenience.

Rationale 2: Client health and safety is the primary concern.

Rationale 3: The principle of least restriction applies: restrain the client only to the extent necessary.

Rationale 4: Monitoring the client with or without restraints is necessary for safety.

Rationale 5:

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:

 

Question 33

Type: MCMA

Nursing responsibilities when applying and monitoring restraints include:

Standard Text: Select all that apply.

  1. Assess the restraint every 2 to 4 hours
  2. Apply a restraint so it can be released quickly in case of an emergency
  3. Provide emotional support verbally and through touch
  4. Ensure that limb restraints are applied securely but not too tightly
  5. Record interventions at the end of the shift

Correct Answer: 2,3,4

Rationale 1: Assess the restraint every 10-30 minutes.

Rationale 2: Making sure that the restraint can be removed in case of cyanosis, pallor, or coldness of the skin area.

Rationale 3: Explaining the procedure and providing support may decrease the need for restraints.

Rationale 4: Secure but not too tight restraints protect the patient.

Rationale 5: Interventions and assessments should be recorded immediately after action.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:

 

Question 34

Type: MCSA

The most appropriate restraint for the confused client with severe itching would be:

  1. Mitt restraints
  2. Vest restraint
  3. Wrist restraint
  4. Mummy restraint

Correct Answer: 1

Rationale 1: Mitt restraints are used to prevent confused clients from scratching and injuring themselves.

Rationale 2: Mitt restraints are used to prevent confused clients from scratching and injuring themselves.

Rationale 3: Mitt restraints are used to prevent confused clients from scratching and injuring themselves.

Rationale 4: Mitt restraints are used to prevent confused clients from scratching and injuring themselves.

Rationale 5:

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:

 

Question 35

Type: MCSA

Nurses protect themselves by the efficient use of the body. This is known as

  1. Body mechanics
  2. Alignment
  3. Body balance
  4. Personal safety

Correct Answer: 1

Rationale 1: Body mechanics is the term used to describe safe, efficient use of the body to move objects and carry out activities of daily living.

Rationale 2: Alignment is involved with the efficient use of the body.

Rationale 3: Body balance helps keep the center of gravity lowered to prevent work-related back injuries.

Rationale 4: The overall concept is personal safety.

Rationale 5:

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 36

Type: MCMA

In order to prevent injury to either self or the client, the nurse is careful to use body mechanics when:

Standard Text: Select all that apply.

  1. Lifting
  2. Pulling
  3. Pivoting
  4. Twisting
  5. Sitting

Correct Answer: 1,2,3,5

Rationale 1: The use of good body mechanics while lifting will decrease the chance of injury.

Rationale 2: The use of good body mechanics while pulling will decrease the chance of injury.

Rationale 3: Pivoting and using proper body mechanics will decrease the chance of injury.

Rationale 4: Twisting must always be avoided because of the potential for back injury.

Rationale 5: Good body mechanics while sitting helps prevent back injuries.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 37

Type: MCMA

Early recognition of the escalating behavior that leads to violence is important for nurses to practice to keep self and clients and visitors safe. De-escalating behaviors include:

Standard Text: Select all that apply.

  1. Keep clear path to door
  2. Call security to report escalating behaviors
  3. Refuse to discuss issues with escalating behaviors
  4. Observe for signs of escalation
  5. Monitor visitors well

Correct Answer: 1,2,4

Rationale 1: Prevent the potential for restraint and harm by keeping a clear path to safety.

Rationale 2: Calling before behaviors escalate may diffuse the situation.

Rationale 3: Take the person to a quiet environment, such as an office. Use a calm voice and direct eye contact.

Rationale 4: Escalation of voices and tearfulness may be signs of escalation.

Rationale 5: Be alert for suspicious behaviors of client or visitors.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 38

Type: SEQ

The nurse is reviewing safety concerns throughout the lifespan. List the following in order of appropriate age, from youngest to oldest:

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Encourage counseling for issues with addiction coping.

Choice 2. Teach about stranger danger.

Choice 3. Reinforce the importance of safety restraints in the vehicle.

Choice 4. Make certain walkways and stairways are well lighted and uncluttered.

Choice 5. Teach safety rules for recreational and sports activities.

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

Rationale 1: Young adults need encouragement to seek counseling for issues with addiction and coping issues.

Rationale 2: Stranger danger is appropriate to teach preschoolers.

Rationale 3: Adolescents need reinforcement of the importance of safety restraints in the vehicle while driving.

Rationale 4: Middle-aged adults should make certain that stairways and walkways are well lighted and uncluttered.

Rationale 5: School-age children need information regarding safety rules for recreational and sports activities.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 39

Type: MCSA

All healthcare facilities have emergency codes that the nurse needs to know. Which of the following codes is commonly used to describe a bomb threat in the facility?

  1. Code Red
  2. Code Blue
  3. Code Yellow
  4. Code Silver

Correct Answer: 3

Rationale 1: Code Red is most often used to describe a fire.

Rationale 2: Code Blue is most often used to describe an adult medical emergency.

Rationale 3: Code Yellow is most often used to describe a bomb threat.

Rationale 4: Code Silver is most often used to describe a person with a weapon or a hostage situation.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:

 

Question 40

Type: MCMA

The nurse explains to the client and family that there are several non-emergency reactions to latex exposure, including:

Standard Text: Select all that apply.

  1. Allergic contact dermatitis.
  2. Irritant contact dermatitis.
  3. Irritated area of skin.
  4. Swelling of throat.
  5. Anaphylaxis.

Correct Answer: 1,2,3

Rationale 1: Allergic contact dermatitis includes skin rash or blisters, but is not life-threatening.

Rationale 2: Irritant contact dermatitis is not life-threatening.

Rationale 3: Irritated, dry, itchy skin is a sign of irritant contact dermatitis, and is not life-threatening.

Rationale 4: Swelling of the throat is a symptom of anaphylaxis, and is life-threatening.

Rationale 5: Anaphylaxis is a life-threatening emergency.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

 

Question 41

Type: MCMA

Which of the following is appropriate teaching for the parents with a 2-year-old?

Standard Text: Select all that apply.

  1. Place hot pots on back burners.
  2. Teach the child to obey all traffic and safety rules.
  3. Keep cleaning solutions in locked cupboards.
  4. Teach the parents to avoid the effects of drugs and alcohol on judgment and coordination.
  5. Use largeRemember,ft toys with no small, detachable or sharp-edged parts.

Correct Answer: 1,3,5

Rationale 1: Toddlers might reach for handles.

Rationale 2: The 2-year-old should not be outside without supervision.

Rationale 3: Toddlers might see cleaning supplies as drinks.

Rationale 4: Toddlers will not be consuming alcohol or drugs.

Rationale 5: These are appropriate toys for a toddler to continue playing with.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 42

Type: MCMA

The nurse is likely to determine mobility and health status as a safety concern in which of the following clients?

Standard Text: Select all that apply.

  1. A postoperative client on narcotic analgesics
  2. A client who is illiterate
  3. A client with an arm cast
  4. An elderly client
  5. The client with a spinal cord injury

Correct Answer: 1,4,5

Rationale 1: Clients using mind-altering medications are at risk for injury because of lack of coordination or impaired judgment.

Rationale 2: The illiterate client is at risk for anything that requires reading.

Rationale 3: The client with an arm cast is not at special risk for injury.

Rationale 4: The elderly client might be at risk for falling due to muscle weakness and poor balance.

Rationale 5: The client with a spinal cord injury might have paralysis of both legs, and be unable to move.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 43

Type: MCSA

Which of the following lifestyle factors will the nurse assess with the young adult client entering the ambulatory care setting for a routine physical?

  1. Mobility
  2. Environment
  3. Workplace safety
  4. Diminished sensory perception

Correct Answer: 3

Rationale 1: The young adult presenting for a routine physical will not be likely to have mobility issues.

Rationale 2: The young adult presenting for a physical is unlikely to have environmental safety issues.

Rationale 3: The young adult might be at risk for exposure to hazardous chemicals, dangerous equipment, or excessive noise.

Rationale 4: The healthy young adult is not likely to have altered sensory perception at his age.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

 

Question 44

Type: MCSA

The nurse is aware that the risks of suicide and accidental overdose of medication are increasing among which of the following groups?

  1. Adolescents and elderly people
  2. Adolescents and young adults
  3. Elderly and school-age children
  4. Native American young adults and adolescents

Correct Answer: 1

Rationale 1: Adolescents and elderly people in all cultures are increasingly committing suicide and experiencing accidental overdose.

Rationale 2: Adolescents and elderly people in all cultures are increasingly committing suicide and experiencing accidental overdose.

Rationale 3: Adolescents and elderly people in all cultures are increasingly committing suicide and experiencing accidental overdose.

Rationale 4: Adolescents and elderly people in all cultures are increasingly committing suicide and experiencing accidental overdose.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

 

Question 45

Type: MCSA

The nurse in the long-term care facility is aware that fire is particularly hazardous when:

  1. Anesthetic gases are used.
  2. Heating appliances are used.
  3. People are incapacitated.
  4. Children have access to matches.

Correct Answer: 3

Rationale 1: Anesthetic gases are not used in the long-term care facility.

Rationale 2: Heating appliances are not used in a long-term care facility.

Rationale 3: When people are incapacitated and unable to leave a building, the risks of client and staff injury are increased.

Rationale 4: Children are not usually in long-term care settings.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

 

Question 46

Type: MCMA

Teaching about poison safety is particularly important for:

Standard Text: Select all that apply.

  1. Young adults.
  2. Parents of young children.
  3. Older adults taking medication.
  4. Clients with poor vision.
  5. Recreational drug users.

Correct Answer: 2,3,4,5

Rationale 1: Young adults are not usually at risk for poisoning.

Rationale 2: Young children are at risk for accidental poison ingestion.

Rationale 3: Older adults might not remember when to take medication, and could overdose accidentally.

Rationale 4: Clients with poor vision might not be able to determine which medications are appropriate, or the appropriate dosages.

Rationale 5: Recreational drug users are at risk for accidental poisoning from substances.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

 

Question 47

Type: MCSA

The nurse explains to the children of an 82-year-old client that the leading cause of injury among older adults is:

  1. Accidental poisonings.
  2. Burns.
  3. Falls.
  4. Fires.

Correct Answer: 3

Rationale 1: Poisoning is not the leading cause of injury in older adults.

Rationale 2: Burns are not the leading cause of injury in older adults.

Rationale 3: Falls are the leading cause of injury in older adults, and a major cause of hospital and nursing home admissions.

Rationale 4: Fires are not the leading cause of injury in older adults.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

 

Question 48

Type: MCMA

The nurse teaches the older adult and her family the following fall prevention measures:

Standard Text: Select all that apply.

  1. Remove scatter rugs.
  2. Adapt living arrangements to one floor.
  3. Day-and-time medication boxes can be helpful.
  4. Keep bed in a low position.
  5. Encourage frequent review of all prescribed medication.

Correct Answer: 1,2,4,5

Rationale 1: Clear walking paths protect the client with poor vision from tripping.

Rationale 2: Impaired gait or balance due to arthritis can make it difficult to negotiate stairs.

Rationale 3: Day-and-night medication boxes would be appropriate to prevent accidental poisoning.

Rationale 4: Keeping a bed in low position minimizes risks from falling out of bed.

Rationale 5: Medications alone or interacting with other medications can decrease alertness and orientation.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

 

Question 49

Type: MCMA

During a disaster, appropriate nursing actions include:

Standard Text: Select all that apply.

  1. Work as directed by supervisor.
  2. Check in with family frequently during the disaster.
  3. Check in with multiple units to see if they need help.
  4. Observe client confidentiality.
  5. Refer all questions to the public information officer.

Correct Answer: 1,4,5

Rationale 1: Healthcare workers must be willing to perform tasks as assigned by the command center director or supervisor.

Rationale 2: Personal communication should be put on hold to keep communication lines open.

Rationale 3: Each person should stay in his assigned area until directed to do otherwise.

Rationale 4: It is important to observe client confidentiality and not perpetuate rumors.

Rationale 5: All media questions should be referred to the public information officer for release of authorized information only.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 50

Type: MCMA

The nurse uses which of the following alternatives to restraints whenever possible?

Standard Text: Select all that apply.

  1. Place clients who are at risk for falls in an area that is constantly supervised.
  2. Lock the wheels on the client’s wheelchair.
  3. Use environmental restraints.
  4. Use rocking chairs to expend energy.
  5. Monitor client medications.

Correct Answer: 1,3,4,5

Rationale 1: Supervision is an appropriate intervention.

Rationale 2: Locking the wheels can be considered a restraint.

Rationale 3: Environmental barriers include barriers such as large plants to keep clients from wandering.

Rationale 4: Having a confused client use a rocking chair will expend some energy, and he will be less likely to wander.

Rationale 5: Use of psychotropic or sedative medications should be minimized as possible.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:

 

Question 51

Type: MCSA

Legal implications for the use of restraints include the principle of:

  1. Convenience.
  2. Autonomy.
  3. Least restriction.
  4. Monitoring.

Correct Answer: 3

Rationale 1: Clients should not be restrained for staff convenience.

Rationale 2: Client health and safety are the primary concerns.

Rationale 3: The principle of least restriction applies: Restrain the client only to the extent necessary.

Rationale 4: Monitoring the client, with or without restraints, is necessary for safety.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:

 

Question 52

Type: MCMA

Nursing responsibilities when applying and monitoring restraints include:

Standard Text: Select all that apply.

  1. Assess the restraint every 2–4 hours.
  2. Apply a restraint such that it can be released quickly in case of an emergency.
  3. Provide emotional support verbally and through touch.
  4. Ensure that limb restraints are applied securely but not too tightly.
  5. Record interventions at the end of the shift.

Correct Answer: 2,3,4

Rationale 1: Assess the restraint every 10–30 minutes.

Rationale 2: Make sure that the restraint can be removed in case of cyanosis, pallor, or coldness of the skin area.

Rationale 3: Explaining the procedure and providing support can decrease the need for restraints.

Rationale 4: Secure but not-too-tight restraints protect the patient.

Rationale 5: Interventions and assessments should be recorded immediately after action.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:

 

Question 53

Type: MCSA

The most appropriate restraint for the confused client with severe itching would be:

  1. Mitt restraints.
  2. Vest restraint.
  3. Wrist restraint.
  4. Mummy restraint.

Correct Answer: 1

Rationale 1: Mitt restraints are used to prevent confused clients from scratching and injuring themselves.

Rationale 2: Mitt restraints are used to prevent confused clients from scratching and injuring themselves.

Rationale 3: Mitt restraints are used to prevent confused clients from scratching and injuring themselves.

Rationale 4: Mitt restraints are used to prevent confused clients from scratching and injuring themselves.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome:

 

Question 54

Type: MCSA

Nurses protect themselves through efficient use of the body. This is known as:

  1. Body mechanics.
  2. Alignment.
  3. Body balance.
  4. Personal safety.

Correct Answer: 1

Rationale 1: Body mechanics is the term used to describe safe, efficient use of the body to move objects and carry out activities of daily living.

Rationale 2: Alignment is involved with the efficient use of the body.

Rationale 3: Body balance helps keep the center of gravity low to prevent work-related back injuries.

Rationale 4: The overall concept is personal safety.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 55

Type: MCMA

In order to prevent injury to either self or the client, the nurse is careful to use body mechanics when:

Standard Text: Select all that apply.

  1. Lifting.
  2. Pulling.
  3. Pivoting.
  4. Twisting.
  5. Sitting.

Correct Answer: 1,2,3,5

Rationale 1: The use of good body mechanics while lifting will decrease the chance of injury.

Rationale 2: The use of good body mechanics while pulling will decrease the chance of injury.

Rationale 3: Pivoting and using proper body mechanics will decrease the chance of injury.

Rationale 4: Twisting must always be avoided because of the potential for back injury.

Rationale 5: Good body mechanics while sitting helps prevent back injuries.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

Question 56

Type: MCMA

Early recognition of the escalating behavior that leads to violence is important for nurses to practice to keep self, clients, and visitors safe. De-escalating behaviors include:

Standard Text: Select all that apply.

  1. Keep a clear path to the door.
  2. Call security to report escalating behaviors.
  3. Refuse to discuss issues with escalating behaviors.
  4. Observe for signs of escalation.
  5. Monitor visitors well.

Correct Answer: 1,2,4

Rationale 1: Prevent the potential for restraint and harm by keeping a clear path to safety.

Rationale 2: Calling before behaviors escalate can help diffuse the situation.

Rationale 3: Take the person to a quiet environment, such as an office. Use a calm voice and direct eye contact.

Rationale 4: Escalation of voices and tearfulness can be signs of escalation.

Rationale 5: Be alert for suspicious behaviors of client or visitors.

Global Rationale:

 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome:

 

 

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