Nursing Interventions & Clinical Skills, 6th Edition- by Anne Griffin Perry – Potter – Ostendorf -Test Bank
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Sample Test
Chapter 03: Documentation and Informatics
Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition
MULTIPLE CHOICE
1. The
nurse discovers a medication error on another nurse’s documentation, so the
nurse completes an incident report. Which statement should the nurse include in
the report?
|
a. |
“Nurse mistakenly gave the
wrong dose of medication for pain.” |
|
b. |
“Nurse gave incorrect dose
of pain medication, but patient is all right.” |
|
c. |
“Morphine 10 mg IM given
rather than morphine 5 mg IM as ordered.” |
|
d. |
“Physician will be notified
of error when he makes rounds tomorrow.” |
ANS: C
Stating that the patient received morphine 10 mg instead of 5 mg
is a factual statement to include on an incident report because it is objective
and provides no interpretation or conjecture from the nurse. The remaining
choices are incorrect statements that do not accurately reflect what occurred.
The physician needs to be notified as soon as the patient has been assessed,
not the following day.
DIF: Cognitive Level:
Apply
REF: Page 42
OBJ: NCLEX: Safe and Effective Care TOP:
Nursing Process: Implementation
2. The
nurse is documenting the care of a patient. Which entry would be characteristic
of charting by exception (CBE) as a documentation method?
|
a. |
The patient needed to be
turned every hour because of increasing pain. |
|
b. |
The patient’s vital signs
are stable. |
|
c. |
The patient’s gait was
steady with assistance from physical therapy. |
|
d. |
There was no odor when the
dressing was removed. |
ANS: A
CBE allows the nurse to specify exceptions to normal nursing assessments
efficiently without documenting the normal assessment data and reducing the
amount of narrative writing in patient documentation. The emphasis is on
recording abnormal findings and trends in clinical care. It is a shorthand
method for documenting based on defined standards for normal nursing
assessments and interventions. CBE simply involves completing a flow sheet that
incorporates these standards, thus minimizing the need for lengthy narrative
notes. Increasing pain would not be expected and would be outside the “normal”
or “expected.”
DIF: Cognitive Level:
Understand
REF: Page 39 | Page 41
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Assessment
3. The
nurse is documenting on a patient with a respiratory problem. Which patient
datum documented by the nurse is the least objective?
|
a. |
Cool and dusky skin |
|
b. |
Low flow rate oxygen |
|
c. |
30 breaths per minute |
|
d. |
Very restless and drowsy |
ANS: B
Low flow rate oxygen is the least objective datum and the datum most
subject to interpretation because the quantity of oxygen is not as precise as
“liters/minute” or the “percentage” of oxygen. The remaining options provide
more verifiable data.
DIF: Cognitive Level:
Understand
REF: Page 40
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Assessment
4. The
nurse runs into a co-worker whose family friend is a patient on the unit. The
co-worker asks about the friend’s health problems. Which is the correct
response by the nurse?
|
a. |
“Your friend told us to say
nothing.” |
|
b. |
“Why don’t you ask your
friend now?” |
|
c. |
“You know I can’t talk
about the patients.” |
|
d. |
“Well, it was really a very
difficult surgery.” |
ANS: C
The nurse can’t talk about the co-worker’s friend or acknowledge
the friend’s presence in the facility without breaching the friend’s right to
privacy, so the nurse reminds the co-worker about confidentiality.
DIF: Cognitive Level:
Apply
REF: Page 36
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Planning
5. The
nurse is providing home care for a patient with an infection that is not
improving. The patient refuses to see an infectious disease specialist. What
should the nurse include in the documentation of the patient teaching provided?
|
a. |
The discussion about the
consequences of refusing to see a specialist and the patient’s response |
|
b. |
The explanation that
avoiding the specialist will most likely lead to a terrible outcome |
|
c. |
A hopeful explanation that
this will most likely be the last medical specialist that the patient will
need to see |
|
d. |
The recommendation that the
patient should discuss the decision with the family |
ANS: A
The nurse documents the discussion about the consequences of
refusing to see a specialist and the patient’s response. Documenting the
factual information presented about the risks of refusing treatment and the
patient’s specific response to it (continued refusal to seek a specialist) are
key pieces of information to include. The nurse should neither try to scare the
patient into seeing the specialist nor provide false hope that only one
consultation will be required. As long as the patient is competent to make a
decision, the nurse must accept his or her choice. It is a requirement to document
the facts surrounding that choice.
DIF: Cognitive Level:
Apply
REF: Page 37
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Assessment
6. The
nurse documents patient care using the SOAP format. Which should the nurse
record under the “P” section?
|
a. |
AM fasting serum glucose
level at 122 mg/dL |
|
b. |
Patient states, “I am too
tired to walk today.” |
|
c. |
2 cm–diameter open area on
left lateral heel |
|
d. |
Check response to pain
medication in 1 hour. |
ANS: D
“P” in the SOAP format stands for “plan.” Checking the response
to pain medication is recorded at “P” because the plan is a future strategy for
nursing care and the nurse chooses nursing interventions to accomplish the
plan. Patient statements are subjective data recorded at “S.” The serum glucose
and the wound description are objective data, or facts, recorded at “O.”
DIF: Cognitive Level:
Comprehension REF: Page 40
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Planning
7. At
9:15 AM the nurse repeatedly instructs the patient to remain in bed. At 9:30
the nurse enters the patient’s room, finds the patient on the floor, and hears
the patient say, “I need pain medicine.” Which should the nurse do to document
this event?
|
a. |
Label the late entry using
the time of 9:15 AM |
|
b. |
Enclose the patient
statement within quotations |
|
c. |
Document completion of an
incident report |
|
d. |
Record medication before
its administration |
ANS: B
The nurse encloses patient statements in quotations to indicate
the patient’s precise statement. Subjective information is documented using the
patient’s words in quotes. The nurse should document instructions given at 9:15
and verify any indications of patient comprehension. A second entry noted at
9:30 documents finding patient on floor.
Completion of an incidence report is not documented in the
patient record since it is an internal evaluation report. Administration of
medication is only documented after it occurs to make sure that the documentation
is accurate in terms of time and patient response.
DIF: Cognitive Level:
Apply
REF: Page 37
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
8. A
nurse passes by a computer screen that has patient information that can be seen
by visitors. What is the appropriate action for the nurse to take at this time?
|
a. |
Leave the computer screen
alone. |
|
b. |
Try to find the nurse
caring for this patient. |
|
c. |
Document this situation on
an incident report. |
|
d. |
Close the computer screen. |
ANS: D
The nurse should minimize or close the computer screen so
patient information cannot be seen by visitors. He or she should talk with the
nurse caring for this patient about what happened. It happens frequently and
can be prevented easily. All facility staff have a responsibility to maintain
patient confidentiality and should not leave a computer displaying patient
information open. Incident reports are only filed when a patient experiences an
adverse event. This situation does not require an incident report.
DIF: Cognitive Level:
Apply
REF: Page 36
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
9. Nursing
assistive personnel (NAP) finds a patient on the floor 30 minutes after the
patient ambulated with physical therapy. What information should be charted by
the NAP on the incident report?
|
a. |
“Patient fell out of bed
and landed on the floor.” |
|
b. |
“Patient found on floor.
Upper side rails up. Bed in low position.” |
|
c. |
“Patient got dizzy and fell
although ambulated with physical therapy earlier.” |
|
d. |
“Patient unfortunately
slipped and fell.” |
ANS: B
Documentation should state facts: “Patient found on floor. Upper
side rails up. Bed in low position.” Only objective data with no interpretation
can be documented by the NAP. The NAP does not evaluate the situation. Words
such as “unfortunately” are never used in documentation. The NAP found the
patient on the floor and did not see the patient slip and fall.
DIF: Cognitive Level:
Apply
REF: Page 37
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
10. An
incident report is completed as a result of the pharmacy sending the wrong
medication to the unit, even though the medication wasn’t administered. Why
would the nurse initiate an incident report?
|
a. |
To make sure that the
pharmacy was blamed for the error and not the nurse |
|
b. |
To help the pharmacy
identify risks and prevent this situation from occurring again |
|
c. |
To prevent the hospital
from a medical malpractice suit |
|
d. |
To get the healthcare
provider’s attention about ordering medications |
ANS: B
The incident report is a risk management tool that enables
healthcare providers to identify risks within an agency, analyze them, and act
to reduce the risks and evaluate the results. This is also true when deviations
from standards occur and not only when actual adverse events happen. Alerting
the pharmacy to this type of error should help prevent it from occurring again.
There was no problem with the healthcare provider’s order, only with how it was
filled.
DIF: Cognitive Level:
Apply
REF: Page 42
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
11. The
“PIE” format is used on the nursing unit. Which entry should the nurse place in
the “E” part of the format?
|
a. |
Pain level 4/10 gnawing and
constant. |
|
b. |
Lung sounds clear
bilaterally. |
|
c. |
Patient states, “I don’t
want the blood transfusion because of the problems I had before.” |
|
d. |
Pain level 2/10 30 minutes
after receiving pain medication. |
ANS: D
In PIE, E stand for evaluation. “Pain level 2/10 30 minutes
after receiving pain medication” is an evaluation based on an action taken in
response to a problem. None of the other options are evaluation statements.
DIF: Cognitive Level:
Apply
REF: Page 40
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
12. The
nursing staff has been using the SBAR format to structure communication for the
past few months. Successful implementation of this system would be present if
the nurse manager made which statement?
|
a. |
“There are fewer omissions
in patient care than before implementing this system.” |
|
b. |
“Fewer nurses are coming in
late when they are scheduled to work.” |
|
c. |
“The medications are given
on time now.” |
|
d. |
“The patient length of stay
has decreased since last year.” |
ANS: A
Noting fewer omissions in patient care would indicate successful
implementation of the SBAR format. SBAR promotes the provision of safe,
efficient, timely, and patient-centered communication. Staff timeliness, medication
preparation, and length of patient stays are not affected by implementation of
SBAR.
DIF: Cognitive Level:
Apply
REF: Page 39
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
13. The
nursing staff is assisting nursing students in learning military time for
documenting. Instruction by the nurses has been effective if the students
identify that which entry reflects 40 minutes after midnight?
|
a. |
0040 |
|
b. |
1240 |
|
c. |
0004 |
|
d. |
0400 |
ANS: A
0040 is 12:40 AM. 1240 is 12:40 PM. 0004 is 12:04 AM. 0400 is
4:00 AM.
DIF: Cognitive Level:
Understand
REF: Page 38
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
14. The
nursing staff is using a worksheet that contains information for
change-of-shift report and facilitates access to information when referring to
the patient’s computerized record. Which document is the nursing staff using?
|
a. |
The graphic sheet |
|
b. |
The nursing Kardex |
|
c. |
The problem-oriented medical
record |
|
d. |
The Joint Commission
standards |
ANS: B
The nursing Kardex contains information for change-of-shift
report and facilitates access to information when referring to the patient’s
computerized record. It is not part of the patient’s permanent record and is
often recorded in pencil so changes can be made to provide an updated status
report of the patient. The graphic sheet contains places for frequently
monitored situations done on a repeated basis such as vital signs, bathing,
turning, and intake and output. The problem-oriented medical record is a method
of organizing data by the patient problem or diagnosis. Each member of the
healthcare team can document on the same problems and add new ones. The Joint
Commission sets the standards for documentation of health care but has not
developed a specific form for everyone to use.
DIF: Cognitive Level:
Remember
REF: Page 41
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Planning
15. The
following is an example of what part of the SBAR communication mnemonic?
“Her blood pressure has decreased from 140/90 to 100/50 and she
vomited 400 mL of bright red blood.”
|
a. |
S |
|
b. |
A |
|
c. |
R |
|
d. |
B |
ANS: A
This is an example of S-Situation—what is happening at the present
time. Background (explain the circumstances leading up to the situation).
Assessment (what you think the problem is). Recommendation (what you would do
to correct the problem)
DIF: Cognitive Level:
Apply
REF: Page 39
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
MULTIPLE RESPONSE
1. Electronic
health records (EHRs) can improve patient care. The following is an example of
an alert in an EHR. (Select
all that apply.)
|
a. |
Notification of medication
being overdue |
|
b. |
Change in patient’s blood
pressure that exceeds parameters |
|
c. |
Order entered for a
medication the patient is allergic to |
|
d. |
Routine lab orders |
|
e. |
Critical lab value |
ANS: A, B, C, E
Alerts in EHRs notify nurses of critical changes in data that
affect patient care and can be used to help nurses prioritize care. Overdue
medications, critical lab values, and medication allergies are some of the
examples of standard alerts. Alerts can also be tailored to patients to monitor
for changes in their vital signs above certain parameters. When electronic
health record alerts are used in the nurse’s practice, patient outcomes can be
improved.
DIF: Cognitive Level:
Apply
REF: Page 36
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Evaluation
2. The
Joint Commission standards require all patients admitted to a healthcare
facility to have the following documented. (Select all that apply.)
|
a. |
Self-care assessment |
|
b. |
Discharge planning needs |
|
c. |
Environment assessment |
|
d. |
Physical assessment |
|
e. |
Psychosocial assessment |
ANS: A, B, C, D, E
Current TJC (2012) standards require that all patients who are
admitted to a healthcare facility have an assessment of physical, psychosocial,
environmental, self-care, patient education, and discharge planning needs.
DIF: Cognitive Level:
Comprehension REF: Page 37
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Assessment
3. The
following is an excerpt of a discharge planning note. What elements of
discharge planning are present in this example? (Select all that apply.)
“Discussed learning about insulin injection technique. Patient
will administer his own injection next time.”
|
a. |
Measurable patient goal |
|
b. |
Progress toward goal |
|
c. |
Need for referral |
|
d. |
Discharge date |
ANS: A, B
The information within a recorded entry must be complete,
containing appropriate and essential information. There are criteria for
thorough communication for certain health situations. For example, when
recording discharge planning, measurable patient goals or expected outcomes,
progress toward goals, and need for referrals are always included.
DIF: Cognitive Level:
Apply
REF: Page 38
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Assessment
4. In a
POMR charting method of documentation, which of the following items are
used? (Select all
that apply.)
|
a. |
Progress notes |
|
b. |
Database |
|
c. |
Medical diagnosis |
|
d. |
Problem list |
|
e. |
Care plan |
ANS: A, B, D, E
The problem-oriented medical record (POMR) is a structured
method of documentation that emphasizes a patient’s problems. It is organized
using the nursing process. Organization of data is by problem or diagnosis.
Ideally each member of the healthcare team contributes to a single list of
identified patient problems. Each recording includes a database, problem list,
care plan, and progress notes.
DIF: Cognitive Level:
Understand
REF: Page 39
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Assessment
Chapter 04: Patient Safety and Quality Improvement
Perry et al.: Nursing Interventions & Clinical Skills, 6th
Edition
MULTIPLE CHOICE
1. The
nurse is caring for a 79-year-old male who has a non–weight-bearing cast on the
left lower extremity. The patient ambulates without using a walker despite
repeated instruction from the nurse to call for assistance. Which response by
the nurse is most likely to keep the patient from falling?
|
a. |
Apply a vest restraint and
offer frequent toileting. |
|
b. |
Plan fall prevention with
patient, family, and healthcare provider. |
|
c. |
Inform family that the
patient needs physical restraints. |
|
d. |
Document that the patient
has a high potential for falling. |
ANS: B
Planning an individualized fall prevention program with the help
of the patient, family, and healthcare provider is more likely to reduce the
patient’s risk of falls because he gains some control over the plan of care and
still benefits from the input of the provider, family, and nurse and the fall
prevention program. A combination of interventions is more useful in preventing
falls. Including the patient in planning also gives him ownership of the plan,
making it less likely that he will disregard a plan he helped to design. Vest
restraints are associated with serious injuries and are not recommended for
use. Documenting the patient’s risk is important because it communicates the
information and records the nurse’s acknowledgment of the risk, but it is not
as effective as engaging the patient in planning care as a prevention technique
because it is indirect. Alternative methods of engaging the patient in a care
plan that minimizes risks should be exhausted before resorting to restraints.
DIF: Cognitive Level:
Analyze
REF: Page 48-49
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
2. The
nurse plans a fall prevention program for a confused patient. Which task from
the program is suitable for the nurse to delegate to nursing assistive
personnel (NAP)?
|
a. |
Evaluating patient
understanding of fall prevention plan |
|
b. |
Keeping the patient’s bed
in the low position at all times |
|
c. |
Assessing the patient’s
circulatory and respiratory status |
|
d. |
Instructing the patient’s
family about alternatives to restraints |
ANS: B
The nurse may delegate keeping the bed lowered to the NAP
because the NAP is trained to perform the task with proper nursing supervision.
Skills used to prevent falls can often be delegated. The nurse does not
delegate the remaining options because they involve aspects of the nursing
process that require the advanced training of a nurse to perform.
DIF: Cognitive Level:
Apply
REF: Page 49
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Planning
3. The
nurse plans care for a patient who requires physical restraint. Which is a
suitable goal for this patient?
|
a. |
The patient remains free of
any injury. |
|
b. |
The nurse checks the restraint
every hour. |
|
c. |
The nurse uses the least
restrictive restraint. |
|
d. |
The patient allows the
nurse to apply restraints. |
ANS: A
When restraints become necessary, the patient must remain free
of injury; thus the nurse plans frequent neurovascular checks and removes the
restraint on a regular basis to inspect the skin for pressure points and
breakdown and perform range-of-motion exercises to maintain joint flexibility.
Checking the restraint is a nursing intervention; it is not a goal because it is
not patient centered. Using the least restrictive restraint can defeat the
purpose of a restraint. When a restraint is required, the nurse uses the proper
restraint to keep the patient safe and facilitate the therapeutic regimen. This
is not a suitable goal because it focuses on the nurse. If the patient or staff
members’ safety is at risk, the nurse applies restraints without the patient’s
permission.
DIF: Cognitive Level:
Understand
REF: Page 58-60
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Planning
4. The
nurse applies a physical restraint to the patient. Which entry should the nurse
make after applying physical restraints?
|
a. |
Performed restraint
application reluctantly |
|
b. |
Applied bilateral soft
lamb’s wool wrist restraints; skin pink, moist, and intact |
|
c. |
Will perform a
neurovascular assessment every 4 hours |
|
d. |
Checked provider’s
prescription for prn restraints |
ANS: B
The nurse documents the type of restraint applied and the
condition of the skin where the restraint was placed in the progress notes to
communicate the information to the healthcare team. The nurse does not
document subjective statements about the nurse. Neurovascular assessments of a
patient’s extremity must take place at least every 2 hours because skin
breakdown can occur very quickly. The nurse does not accept prn prescriptions
for restraints according to nursing standards and federal regulations.
DIF: Cognitive Level:
Apply
REF: Page 63
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Apply
5. The
patient sustains a minor leg abrasion and stops breathing for a few seconds
during a grand mal seizure. Which is the best nursing documentation after the
patient’s seizure?
|
a. |
Type of muscle contractions |
|
b. |
Size and description of the
abrasion |
|
c. |
Length of the patient’s
apneic episode |
|
d. |
Description of the seizure
in detail |
ANS: D
Describing the seizure in detail is the best documentation after
a seizure because it is the most comprehensive item listed and includes the
type of muscle contractions observed during the seizure, the description of
injuries, how the injuries occurred, and the description of any breathing
abnormalities.
DIF: Cognitive Level:
Analyze
REF: Page 67
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
6. A
patient at risk for falling is being ambulated. Which action by the nurse is
most important to prevent the patient from falling?
|
a. |
Raising the bed to an
appropriate working height |
|
b. |
Placing nonskid shoes on
the patient |
|
c. |
Dangling the patient on the
side of the bed for 10 minutes |
|
d. |
Turning on the brightest
lights in the room |
ANS: B
Placing nonskid surfaces on the patient’s feet helps to prevent
falls. The height of the bed should be as low as possible before attempting to
have the patient stand. Dangling prevents dizziness, but the length of time
differs, and it is not required for all patients. Adequate light is important,
but the brightest lights are not needed.
DIF: Cognitive Level:
Apply
REF: Page 50
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Planning
7. The
nurse is orienting a group of new nurses and explaining the concept of sentinel
events and their causes. What should the nurse explain as the number one root
cause of all sentinel event reports to The Joint Commission?
|
a. |
Medication errors |
|
b. |
Falls |
|
c. |
Communication failures |
|
d. |
High patient-to-nurse
ratios |
ANS: C
Communication failures are the number one root cause of all
sentinel events reported to The Joint Commission. A sentinel event is an
unexpected occurrence involving death, serious physical or psychological
injury, or risk thereof. Although the other elements may cause sentinel events,
they are not the number one root cause.
DIF: Cognitive Level:
Remember
REF: Page 46
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Planning
8. The
nurse discovers smoke in the second floor utility room. What intervention
should he or she implement first?
|
a. |
Find the fire extinguisher
and try to extinguish the fire. |
|
b. |
Evacuate the entire second
floor to the first floor lobby. |
|
c. |
Rescue any patients,
visitors, or staff in immediate danger. |
|
d. |
Pull the nearest alarm box
and call the telephone operator. |
ANS: C
The first step after identifying an actual or potential fire is
to rescue victims at risk for injury from the fire, including patients,
visitors, or staff, to reduce injuries from the fire. The second step is to
activate the alarm. The third step is to contain the fire: find the
extinguisher and empty the container onto the fire or source of the smoke.
Finally the evacuation begins if the fire is uncontrolled or the smoke is
excessive. This follows the acronym RACE.
DIF: Cognitive Level:
Apply
REF: Page 68
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
9. The
daughter of a female patient tells the home health nurse that using the
bathroom is embarrassing for the patient and she refuses to use a call light
when she needs to get up. Which is the best response by the nurse?
|
a. |
Ask the patient why she
does not use the call light. |
|
b. |
Instruct the daughter to
remain at the patient’s side. |
|
c. |
Tell the patient that home
visits require patient cooperation. |
|
d. |
Discuss call light
alternatives with patient and daughter. |
ANS: D
Discussing call light alternatives with the patient and daughter
is the best method of engaging the patient in planning nursing care. This
recognizes the patient as the source of control and full partner in providing
compassionate and coordinated care based on respect for the patient’s
preferences, values, and needs. Including the patient in planning alternatives
also gives her ownership of the plan and increases the likelihood of
cooperation. Asking a “why” question is not an ideal response because it is confrontational
and requires the patient to justify feelings. Remaining with the patient is an
impractical solution for home care.
DIF: Cognitive Level:
Analyze
REF: Page 47
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
10. Although
the interdisciplinary team is responsible for the safety of the patient, who
has the ultimate responsibility for making the patient’s bedside area safe?
|
a. |
The nurse |
|
b. |
Housekeeping |
|
c. |
Nursing assistive personnel
(NAP) |
|
d. |
The maintenance department |
ANS: A
The nurse has the ultimate responsibility for making the
patient’s bedside area safe. Other personnel assist with their specific roles,
but the nurse oversees the safety.
DIF: Cognitive Level: Analyze
REF: Page 47
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
11. The
nurse listens to a family’s request to bring a few familiar items into the room
of a patient who is confused. How does the nurse justify the decision to allow
personal items?
|
a. |
Personal items can increase
patient agitation. |
|
b. |
Personal items can restore
cognitive function. |
|
c. |
Personal items are likely
to alienate the patient. |
|
d. |
Personal items can comfort
a confused person. |
ANS: D
Personal items can comfort and calm a confused person because
familiar items are part of the patient’s customary environment, patterns, and
habits; in addition, these items personalize an otherwise strange environment
and surround the patient with recognizable things. The personal items are
likely to engage the patient but on their own do nothing to restore cognitive
function.
DIF: Cognitive Level:
Analyze
REF: Page 54-55
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Planning
12. The
nurse plans a restraint-free environment but cannot find activities to engage
an agitated middle-aged patient. Which should the nurse implement to maintain
the patient’s safety?
|
a. |
Request help from
interdisciplinary team members. |
|
b. |
Transfer the patient to a
private room to protect others. |
|
c. |
Document that the patient
is uncooperative and hostile. |
|
d. |
Ask the healthcare provider
for a sedation prescription. |
ANS: A
A nurse’s expertise does not include occupational therapy, so
the nurse collaborates with other experts to meet the patient’s safety and
psychosocial needs. After assessing the patient, the experts make
recommendations, and the nurse incorporates the activities into the patient’s
plan of care. Putting the patient in a private room decreases the risk of
injury to other patients; but it isolates the patient, increases the need for
distraction, and increases the risks to the staff and patient. Documentation
should always be descriptive and never judgmental. In this case the nurse would
document: “The patient stated, ‘Stay away.’” Sedation increases the risk of
falls from potential adverse effects, including hypotension, dizziness, and
confusion.
DIF: Cognitive Level:
Apply
REF: Page 57
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Planning
13. A
patient has been wandering and is at risk for falling. Which approach by the
nurse regarding the use of chemical and physical restraints in the long-term
care setting should be considered initially?
|
a. |
Use nonprescription
restraints first. |
|
b. |
Obtain with a telephone
prescription. |
|
c. |
Implement alternative
measures first. |
|
d. |
Notify patient’s family
within 24 hours. |
ANS: C
According to the standards governing the use of restraints, the
nurse must implement several alternative measures in a serious attempt to avoid
applying restraints. The patient must be assessed by the healthcare provider
before restraints are implemented unless the patient is a serious and imminent
risk to self and others. The patient’s family is notified in a timely manner
but is not an initial consideration.
DIF: Cognitive Level:
Remember
REF: Page 54
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Planning
14. The
nurse plans a safety program for the patients on a medical-surgical unit. Which
patient has the greatest likelihood of falling?
|
a. |
A 79-year-old after a
pacemaker battery replacement |
|
b. |
A 68-year-old anemic who is
dehydrated and has heart failure |
|
c. |
A 21-year-old fresh
postarthroscopy after a college football injury |
|
d. |
A 33-year-old post–right
salpingectomy for ectopic pregnancy |
ANS: B
The patient with anemia and dehydration with heart failure has
the highest risk of falling. The patient will be taking other medications,
including antihypertensive agents that increase the risk of falls caused by
confusion, dizziness, or orthostatic hypotension. The replacement of a
pacemaker battery in a stable patient is a low-risk, routine procedure. The
21-year-old recovering from the arthroscopy is most likely a healthy adult who
is stable while ambulating. The 33-year-old postsalpingectomy is most likely to
be healthy but may be a little hypotensive if much bleeding occurred before
surgery.
DIF: Cognitive Level:
Analyze
REF: Page 48
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Assessment
15. The
nurse finds the patient pulling on the nasogastric tube (NGT) and surgical
drain and fears that the patient will pull them out. Which nursing intervention
should the nurse implement to maintain the patient’s self-esteem and avoid
applying restraints?
|
a. |
Cover or camouflage tubes
and drains. |
|
b. |
Provide constant activity
for the patient. |
|
c. |
Instruct family members to
watch the patient. |
|
d. |
Keep the patient close to
the nurses’ station. |
ANS: B
The nurse keeps the patient busy with nursing care and
activities that provide an effective distraction to limit awareness of the NGT
and surgical drain; in this manner the nurse avoids the need for restraints and
maintains the patient’s self-esteem. Covering or camouflaging the tubes is
unlikely to be an effective method of avoiding restraints because the patient
is likely to find the tubes despite the disguise. Engaging the family in the
care of the patient is reasonable; however, the nurse does not rely on the
family to provide nursing care. Keeping the patient out by the nurses’ station
allows the nurse to observe the patient closely; however, this is likely to
lower the patient’s self-esteem because his or her problem is on public
display.
DIF: Cognitive Level:
Apply
REF: Page 56
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
16. The female
patient wearing bilateral wrist restraints complains that her hands are numb;
and the nurse assesses pale, cool fingers. Which is the nurse’s priority
intervention?
|
a. |
Notify the provider
quickly. |
|
b. |
Remove the wrist
restraints. |
|
c. |
Try another type of
restraint. |
|
d. |
Increase the restraint
padding. |
ANS: B
The patient displays clinical indicators of neurovascular
impairment, and a delay in resolving the problem can result in tissue damage,
so the nurse removes the restraint, thoroughly assesses the extremities, and
plans nursing care. Before another type of restraint is applied, the nurse
completes the assessment and notifies the provider as necessary. Increasing the
padding is a reasonable intervention after the nurse’s assessment and provider
notification.
DIF: Cognitive Level:
Analyze
REF: Page 63
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
17. The
patient is having a generalized tonic-clonic seizure. To maintain the airway,
which intervention should the nurse implement after the patient’s motor activity
ceases?
|
a. |
Apply chin-lift position. |
|
b. |
Insert a curved oral
airway. |
|
c. |
Sit the patient in upright
position. |
|
d. |
Turn the patient on his
side. |
ANS: D
Patients who have been rolled onto their side during a major
motor seizure are at greater risk for self-injury, such as a dislocated
shoulder. Since patients are not breathing during a generalized tonic-clonic
seizure, they are not at high risk for aspiration until the event ends.
Immediately following such a seizure, patients usually take a deep breath.
Therefore, a patient should be rolled over onto his or her side immediately
after the motor activity ceases. Chin-lift is an effective method of maintaining
a patient’s airway; however, it does not protect the patient against
aspiration. Oral airways are not inserted during a seizure unless the patient’s
jaw relaxes enough to properly insert the airway without causing tissue damage.
The upright position is contraindicated for airway maintenance.
DIF: Cognitive Level:
Apply
REF: Page 65
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Planning
18. The
nurse is instructing a male patient who has a difficult-to-control seizure
disorder on home care issues. Which issue affecting safety is most important
for the nurse to address with patient teaching before discharge?
|
a. |
Avoiding substances
containing alcohol |
|
b. |
Maintaining a current list
of medications |
|
c. |
Keeping a supply of
medications at work |
|
d. |
Purchasing lawn equipment
with a safety switch |
ANS: D
The most important issue to address is to have him purchase any
motorized lawn equipment with a safety switch that will stop the machine when the
handle is released. Thus the patient avoids injury if he has a seizure while
operating the equipment. Although the patient should avoid alcohol to decrease
the risk of possible alcohol-drug interactions, and he should keep a list of
current medications to avoid confusion over his therapeutic regimen, failure to
do so poses a risk only to himself. Likewise, although keeping a supply of
medication at work is a good idea, it is not a safety risk not to do so.
DIF: Cognitive Level:
Analysis
REF: Page 70
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Planning
19. A
child had surgery on his face and needs to keep his hands away from it. Which
restraint should the nurse use to accomplish this outcome?
|
a. |
A jacket restraint |
|
b. |
Mitten restraints |
|
c. |
A mummy restraint |
|
d. |
Elbow restraints |
ANS: D
The nurse applies bilateral elbow restraints so the child cannot
touch the operative area. They prevent elbow flexion. The child will still be
able to hug the parent or hold onto objects. Mitten restraints are inadequate
because the hands could still access the face. A mummy restraint is used for
short-term examination of a child. Although it does confine, the mummy
restraint is more like swaddling. The use of jacket restraints has been
discouraged because of safety risks associated with their use.
DIF: Cognitive Level:
Remember
REF: Page 62
OBJ: NCLEX: Safe and Effective Care
TOP: Nursing Process: Implementation
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