TEST 4: Chapter 27 Mastering (Fundamentals of Nursing)

The nurse is teaching a vulnerable population of patients about pollution. Which instruction should the nurse provide to help patients limit exposure to air pollution?

*A. "Avoid smoking." B. "Keep your home noise free." C. "Avoid using bottled water." D. "Discard the bioactive waste properly." RATIONALE: At home, school, or in the workplace, the most common cause of air pollution is smoking. Excessive noise is also a form of pollution called as noise pollution that affects the health. Bottled or boiled water should be used for drinking and cooking when there is water contamination. Improper disposal of radioactive and bioactive waste causes land pollution rather than air pollution.

A couple approaches the nurse to seek guidance regarding taking their 10-year-old child on a long ride in a car. During the discussion, the nurse learns that the car has front-seat passenger air bags. What advice should the nurse provide to this couple?

*A. Advise that the child ride in the back seat. B. Suggest that the child ride in the front seat. C. Suggest keeping the child free from any restraints. D. Advise of the need for an appropriate car seat for this child. RATIONALE: It is safe for a 10-year-old child to ride in the back seat. In case of accidents or a car crash, the child would sustain fewer injuries if seated in the back seat. In case of a sudden stop or a car crash, the child would be susceptible to suffering severe head injuries if unrestrained. Use of seat belts for the child is advised. An appropriate car seat is usually required for children less than 8 years of age or 80 pounds in weight.

Which task related to use of patient restraints can be delegated to nursing assistive personnel (NAP)?

*A. Checking on a restraint B. Assessing a patient's behavior C. Determining a patient's need for restraints D. Orientating the patient to the environment RATIONALE: Routinely applying or checking on a restraint can be delegated to appropriately trained nursing assistive personnel (NAP). Assessing a patient's behavior, determining the need for restraints, orienting the patient to the environment, and determining the need and appropriate use of restraints must be performed by the nurse and cannot be delegated to NAP.

A patient is having left-sided weakness due to a cerebrovascular accident. The nurse observes that the patient is having difficulty focusing during the conversation. Which nursing intervention will be beneficial in this situation?

*A. Encouraging the patient to use effective coping skills he or she has previously used B. Teaching the patient about the use of a walker and cane around the home C. Consulting with a physical therapist to help the patient with strengthening exercises D. Encouraging the family to eat with the patient and remind him or her to eat food on the left side of plate RATIONALE: A patient who has anxiety related to fear of falling may have difficulty focusing during conversation. The appropriate intervention in this situation is to encourage the patient to use the effective coping skills he or she has previously used. Teaching the patient about the use of a walker and cane around the home is an intervention for impaired physical mobility. Consulting with a physical therapist to help the patient with strengthening exercises will be beneficial for a patient who is at risk for falls. Encouraging the family to eat with the patient and reminding him or her to eat food on the left side of the plate will be beneficial for a patient with unilateral neglect of the brain due to injury related to cerebrovascular accident. TEST-TAKING TIP: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

Which care intervention would reduce the risk of sudden infant death syndrome (SIDS)?

*A. Immunizing the infant B. Using snug-fitting sheets C. Using large soft toys without small hard pieces D. Avoiding leaving the baby unattended on the changing table RATIONALE: Immunizing the infant will reduce the risk of SIDS. The use of a snug-fitting sheet would prevent suffocation, strangulation, or entrapment. Small parts of toys may become dislodged and the infant may choke on them; therefore, the use of large, soft toys without small parts, such as buttons, would prevent choking and aspiration. Not leaving an infant unattended on the changing table prevents falls, not SIDS.

Which restraint is banned due to the risk of fatal injuries?

*A. Jacket restraint B. Elbow restraint C. Mitten restraint D. Extremity restraint RATIONALE: Jacket restraint is banned due to the risk of fatal injuries. Elbow restraint is used commonly with infants and children to prevent elbow flexion. Mitten restraint prevents patients from dislodging invasion equipment. Extremity restraint is designed to immobilize one or all extremities.

An 80-year-old patient demonstrates some confusion but no anxiety. The nursing assessment reveals that the patient is a fall risk because the patient continues to get out of bed without help despite frequent reminders. Which nursing intervention should be initiated to prevent falls for this patient?

*A. Place a bed alarm device on the bed. B. Place the patient in a belt restraint. C. Provide one-on-one observation of the patient. D. Apply wrist restraints RATIONALE: The nurse should consider and implement alternatives as appropriate before using a restraint. A bed alarm is an alternative that the nurse implements independently. STUDY TIP: Be clear on the requirements to be met before using restraints. For the situation in this question, alternatives had not yet been implemented.

At 3 AM the emergency department nurse hears that a tornado hit the east side of town. Which action should the nurse take first?

*A. Prepare for an influx of patients. B. Contact the American Red Cross. C. Determine how to restore essential services. D. Evacuate patients per the disaster plan. RATIONALE: The emergency department nurse first needs to prepare for the potential influx of patients. Staff should be aware of the disaster plan. Patients may need to be evacuated but not initially. The American Red Cross is not contacted initially. Determination of how to restore essential services is part of the disaster plan and is determined before an actual event.

An elderly patient who is on medications for hypertension and diabetes mellitus frequently skips doses due to diminishing memory. How can the nurse help this patient improve medication compliance?

*A. Promote the use of a medication organizer. B. Reward the patient to promote compliance. C. Explain the side effects of the medications. D. Convince the patient of the need to adhere to treatment RATIONALE: Medication organizers and pillboxes are cost-effective dispensers that help to dispense medications appropriately. Rewarding and punishing are not ideal methods of training an elderly patient with compromised memory to take medications consistently. Informing the patient about the side effects of medications would not be helpful in improving medication compliance, because the patient may already be perfectly informed of the medication but still unable to remember to take it. Convincing the patient of the importance of adhering to treatment would be appropriate for patients with normal cognitive functioning, but this approach is not suitable for patients with a memory disturbance.

A patient who has unilateral neglect related to brain injury from a cerebrovascular accident is unable to eat food on the left side of the plate. Which nursing intervention is followed in this situation?

*A. Remind the patient to eat food on the left side of the plate. B. Teach the patient to use a walker and cane around the home. C. Help the patient identify actions he or she can adapt to the left side. D. Teach the patient how to perform range-of-motion exercises on the left side RATIONALE: The nurse should remind the patient to eat food on the left side of the plate in the event of unilateral neglect related to brain injury from a cerebrovascular accident. When the patient has anxiety related to fear of falling, the nurse should help the patient identify actions he or she can adapt to the left side. When the patient is physically impaired related to left-sided weakness, the nurse should teach the patient how to use a walker and cane around the home. The nurse should teach the patient how to perform range-of-motion exercises if the patient has impaired physical mobility related to left-sided weakness. TEST-TAKING TIP: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

A patient who was admitted to the hospital receives a red-color wristband for identification purposes. What is the significance of the wristband?

*A. The patient has allergies. B. The patient is at risk for falling. C. The patient should be treated immediately. D. The patient is not indicated for resuscitation RATIONALE: The American Hospital Association issued an advisory recommendation that hospitals use standardized wristband colors. Red wristbands indicate patient allergies. Yellow wristbands are for patients who are at a risk for falling. There is no wristband for immediate treatment of patients. Purple wristbands are given to patients who have do-not-resuscitate orders. TEST-TAKING TIP: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.

Which recommendation would be appropriate to reduce the risk of falls in a patient with hemiparesis?

A. "You should perform range-of-motion exercises." B. "You should make use of coping skills that you have previously used." *C. "You should consult an ophthalmologist for a visual assessment." D. "You should touch one side of your body frequently with the other hand." RATIONALE: Hemiparesis is the condition in which there is weakness on one side of the body. Consulting an ophthalmologist for visual assessment will prevent the risk of fall in a hemiparesis patient. Performing range-of-motion exercises will be helpful for a patient with impaired physical mobility. Encouraging the patient to make use of coping skills that he or she has previously used is helpful for a patient with anxiety related to falls. A patient with unilateral neglect related to brain injury will benefit from frequently touching the left side of the body with the right hand.

Which suggestion would be appropriate to prevent unilateral neglect in a patient with hemiparesis?

A. "You should perform range-of-motion exercises." B. "You should use a walker and cane around the home." C. "You should consult with an ophthalmologist for visual assessment." *D. "You should touch one side of the body frequently with the other hand." RATIONALE: Hemiparesis is a condition in which there is weakness on one side of the body. A patient with unilateral neglect related to brain injury will benefit from touching the left side of the body frequently with the right hand. Performing range-of-motion exercises is helpful for patients with impaired physical mobility. Using a walker or cane around the home is helpful for patients with impaired physical mobility. Consulting an ophthalmologist for visual assessment will help prevent the risk of falls in a patient with hemiparesis.

Which patients are at higher risk of motor vehicle accidents according to the Centers for Disease Control and Prevention (CDC)?

A. 2-year-old patient B. 30-year-old patient C. 55-year-old patient *D. 16-year-old patient RATIONALE: According to the CDC, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age group, because teens are more likely to underestimate dangerous situations. A 2-year-old patient is not at elevated risk of motor vehicle accidents, because 2-year-olds do not use motor vehicles. A 30- or 55-year-old adult is not at elevated risk of motor vehicle accidents according to the CDC.

According to the National Quality Forum, which event is included under patient-protection events?

A. Abduction of a patient *B. Infant discharge to the wrong person C. Disability associated with a medication error D. Surgery performed on the wrong body part RATIONALE: Infant discharge to the wrong person is included under patient-protection events. Events like the abduction of a patient are considered to be criminal events. Disability associated with a medication error is included under care-management events. Surgeries performed on the wrong body part are included under surgical events.

Which should the nurse do first after discovering an electrical fire in a patient's room?

A. Activate the fire alarm. B. Confine the fire by closing all doors and windows. *C. Remove all patients in immediate danger. D. Extinguish the fire by using the nearest fire extinguisher RATIONALE: Follow the acronym RACE. The first step is to Rescue and Remove all patients in immediate danger.

Which group is at the highest risk for lead poisoning?

A. Adults *B. Infants C. Adolescents D. Older adults RATIONALE: Fetuses, infants, and children are at high risk for lead poisoning because their bodies absorb lead more easily and are more sensitive to the damaging effects of lead. Adults, older adults, and adolescents are less sensitive to lead exposure.

A child in the hospital starts to have a grand mal seizure while playing in the playroom. Which is the most important nursing intervention during this situation?

A. Begin cardiopulmonary respiration. B. Restrain the child to prevent injury. C. Place a tongue blade over the tongue to prevent aspiration. *D. Clear the area around the child to protect the child from injury. RATIONALE: Once a seizure begins, the nurse needs to monitor the patient and provide a safe environment. A seizure is not an indication for cardiopulmonary resuscitation. A person having a seizure should not be restrained, but the environment should be made safe. Objects should not be forced into the mouth.

Which restraint should the nurse use to prevent nerve injury?

A. Belt *B. Elbow C. Mitten D. Extremity RATIONALE: Elbow restraint, or the freedom splint, is commonly used with infants and children to prevent elbow flexion. This helps keep the elbow extended and prevents nerve injury in cases where the IV line is placed in the antecubital fossa. Belt restraint is used to maintain the center of gravity and prevents patients from rolling off stretchers or sitting up while on stretchers, as well as from falling out of bed. Mitten restraints prevent patients from dislodging invasive equipment, removing dressings, or scratching. Extremity restraints maintain immobilization of extremities to protect patients from falling or accidental removal of therapeutic devices. TEST-TAKING TIP: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

Which intervention would the nurse employ to reduce the risk of falling in the health care setting due to tripping?

A. Cleaning all spills promptly B. Ensuring adequate glare-free lighting *C. Keeping the floor free of clutter and obstacles D. Having assistive devices on the exit side of the bed RATIONALE: Falls in the health care setting have many etiologies. The nurse keeps the floor free of clutter and obstacles to reduce the risk of falling due to tripping, especially in an unfamiliar setting. The nurse cleans all spills promptly to reduce the risk of falling due to slipping on wet surfaces. The nurse ensures adequate, glare-free lighting to reduce the risk of falling due to visual decline or disturbances. The nurse keeps assistive devices on the exit side of the bed to reduce the risk of falling due to decreased mobility status.

The nurse is instructing the mother of an infant not to leave the mesh sides of a playpen lowered. Which accidental trauma can be prevented by this intervention?

A. Falls B. Choking *C. Asphyxiation D. Strangulation RATIONALE: If mesh sides of playpens are lowered, the child's head could become wedged in the lowered mesh side, which may result in asphyxiation. Falls in infants and toddlers can be prevented by instructing the mother not to leave standard crib sides down or leave babies unattended on changing tables or in infant seats. Choking can be prevented by avoiding the use of pacifiers attached to a ribbon clipped to the child's clothing. Strangulation can be prevented by avoiding pillows, bumper pads, large stuffed toys, or comforters in the cribs.

A couple is with their adolescent daughter for a school physical and state that they are worried about all the safety risks affecting this age. What are the greatest risks for injury for an adolescent?

A. Home accidents B. Physiological changes of aging C. Poisoning and child abduction *D. Automobile accidents, suicide, and substance abuse RATIONALE: Adolescents are at great risk for injury from automobile accidents, suicide, and substance abuse. According to the Centers for Disease Control and Prevention, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age group. In addition, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs, in an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures,. The risk of home accidents is low for this age group, because adolescents spend much of their time away from home and with their peers.

Which safety precaution performed by a parent lowers the risk of sudden infant death syndrome (SIDS) in a 1-year-old child?

A. Immunizing the infant B. Filling crib with pillows *C. Having the infant sleep on his/her side or back D. Attaching pacifier to string and placing it around the child's neck RATIONALE: Placing infants on their sides or backs confers the lowest risk of SIDS and it is the preferred position. Immunizing the child at an early age prevents the risk of several life-threatening complications. The parent should not fill the crib with pillows or bumper pads because these items increase the risk of suffocation or entrapment. String or ribbon around the neck increases the risk of choking.

The family member of an adult patient complains that the patient is a long-term smoker. Which health risk factor does the nurse anticipate?

A. Infectious disease B. Neurological disorder *C. Cardiovascular disease D. Gastrointestinal disorder RATIONALE: Long-term smoking can lead to cardiovascular or pulmonary diseases. High levels of stress may lead to infectious diseases, neurological disorders, and gastrointestinal disorders. TEST-TAKING TIP: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.

In a pediatric ward, one of the newborns died of sudden infant death syndrome (SIDS). Which nursing measure lowers the risk of death due to SIDS?

A. Massaging the baby's heels B. Attaching pacifiers with a string around the baby's neck C. Gently rubbing the baby's back *D. Having the baby sleep on his or her back RATIONALE: Sudden infant death syndrome (SIDS) is a condition in which the infant dies due to an unexplained cause. The American Academy of Pediatrics recommends having the baby sleep on his or her back to reduce the risk of sudden infant death syndrome (SIDS). Massaging the heels helps in managing an apneic episode. Pacifiers should not be attached with a string around the neck, because this increases the risk of choking. Rubbing the baby's back is helpful in stimulating respiration in newborns.

Which mnemonic should a patient follow if his or her clothing or skin is burning?

A. PASS B. RACE C. Back to sleep *D. Stop, drop, and roll RATIONALE: All patients, even young children, should follow the mnemonic "stop, drop, and roll" if his or clothing or skin is burning. PASS is the mnemonic applied for correct usage of fire extinguisher. The mnemonic RACE is used to set priorities in case of a fire. The parents should teach the mnemonic "back to sleep" to have the infants sleep on their back.

Which patient should be provided with a yellow wristband according to American Hospital Association (AHA)?

A. Patient with allergies *B. Patient with risk of falls C. Patient with hypothermia D. Patient who does not require resuscitation RATIONALE: The AHA has issued an advisory recommending that hospitals standardize wristband colors. Yellow is issued for patients with fall risks, and red is used for patients with allergies. There is no specific wristband indicated for patients with hypothermia. A purple wristband is given to patients who do not require resuscitation.

Which patient is suspected to have an electrolyte imbalance?

A. Patient with risk of falls B. Patient exposed to carbon monoxide C. Patient with lower extremity weakness *D. Patient exposed to heat for an extended period RATIONALE: A patient exposed to extreme heat experiences changes in the electrolyte balance of the body and a rise in core temperature that results in heatstroke or heat exhaustion. Risk of falls, exposure to carbon monoxide, and lower extremity weakness are not associated with electrolyte imbalance.

The nurse is performing fall prevention measures for a patient. During which step of the nursing process does the nurse perform "Timed Get up and Go" (TUG) if a patient is able to ambulate?

A. Planning B. Evaluation *C. Assessment D. Implementation RATIONALE: Performing TUG when the patient is able to ambulate is included in the assessment step of the nursing process. Planning involves gathering equipment to promote organization and performing hand hygiene to reduce the transmissions of microorganisms. Evaluation is the basic step involved when the nurse is performing visual checks in a patient. Implementation involves adjusting the bed to a proper height and inspecting the area to prevent injuries during restraint application.

The nurse works in a psychiatric unit and understands that the use of restraints may be useful for ensuring patients' safety. A patient has been advised bed rest, but the patient often becomes anxious and moves out of bed by removing the intravenous (IV) lines. Which chemical restraint would the nurse anticipate the health care provider to order for this patient?

A. Protective helmet B. A mechanical device *C. Anxiolytic medicines D. Immobilizing equipment RATIONALE: Anxiolytic medicines, which are not a part of the patient's regular prescription, can be used as chemical restraints. These medications help to manage patients' behavior by making them calm and inducing sleep. A protective helmet only allows the patient to perform activities without the risk of physical injury. It does not prevent other risks such as the risk associated with removal of the intravenous (IV) line. A mechanical device and immobilizing equipment are used as physical restraints. TEST-TAKING TIP: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. For this question, you can eliminate all three incorrect answers because they are not chemical restraints.`

While caring for an infant, the nurse places the infant on his/her back. What is the reason for this intervention?

A. Reduce the risk of suffocation B. Reduce the risk of head injury C. Reduce the risk of choking and aspiration. *D. Reduce the risk of sudden infant death syndrome (SIDS) RATIONALE: Placing infants on their backs reduces the risk of SIDS. Suffocation can be prevented by removing plastic bags from home. Risk of head injury can be reduced by preventing accidents. Choking and aspiration can be prevented by not giving the child toys with small parts, such as buttons.

Which safety precaution should the nurse follow to reduce the risk of falls in a patient with hemiparesis?

A. Standing on the patient's unaffected side when using a walker. *B. Standing on the patient's affected side when using a cane and a gait belt. C. Performing range-of-motion exercises before ambulating. D. Having the patient frequently touch one hand with the other hand. RATIONALE: When an assistive device is used, stand on the patient's affected side AND support him or her with a gait belt. Providing support by holding the patient's arm is incorrect because the nurse cannot easily support the patient's weight to lower him or her to the floor if he or she faints or falls. Performing range-of-motion exercises for patients with muscle weakness can help them move more easily, but does not necessarily prevent falls. Patients with a brain injury should be instructed to touch the other hand frequently to avoid the risk of paralysis. This intervention is unrelated to fall prevention strategies. TEST-TAKING TIP: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

A patient was diagnosed with left-sided neglect after suffering a cerebrovascular accident. Which nursing intervention would be most effective to ensure the patient's safety?

A. Teaching the patient to use a walker *B. Reminding the patient to scan the environment while walking C. Encouraging the patient to see an ophthalmologist for visual assessment D. Teaching the patient to perform strengthening exercises on the left side of the body RATIONALE: The nurse should remind the patient to scan the environment when walking in the event of left-sided neglect after suffering a cerebrovascular accident, because the patient may fail to notice people or things approaching from the left. A patient with cerebrovascular accident-caused left-sided weakness should be educated regarding the use of a walker. Visiting an ophthalmologist is effective for those patients who have problems in seeing objects at a distance. The nurse should teach the patient with left sided weakness to perform strengthening exercises on the left side of the body.

Which safety precaution should be taken by the patient with muscle weakness while walking?

A. Using side rails B. Using crutches C. Using a belt restraint *D. Wearing rubber-soled shoes

A nurse instructs a patient to color code the hot water faucets and dials. What might be the possible age group of the patient?

A. Young adult *B. Older adult C. Adolescent D. Preschooler RATIONALE: Older adults are instructed to color code the hot water faucets and dials to prevent burns and scalds. The color coding makes it easier for an older adult to know which is hot and which is cold. Young adults and adolescents usually do not confuse hot and cold water, so this suggestion may not be helpful for them. Preschoolers usually need a parent's help taking baths and would not use hot-water faucets and dials.

There is a fire in a hospital. Which is the priority action of the nurse?

Activating the fire alarms 2 Confining the fire 3 Extinguishing the fire 4 *D. Rescuing patients in immediate danger RATIONALE: The nurse should use the mnemonic RACE to set priorities in case of a fire. When there is a fire in a hospital, the nurse's first and most important intervention is to Rescue and remove all patients who are in immediate danger. After those patients are removed, the nurse should Activate the fire alarm so that other patients and staff will know of the fire danger. After this the nurse should Confine the fire by closing all doors and windows and turning off oxygen and electrical equipment. Finally, the nurse may attempt to Extinguish the fire with the use of an appropriate fire extinguisher. TEST-TAKING TIP: Did you notice the acronym RACE in the choices? When the textbook has explained (or your instructor has taught) an acronym, look for it in the choices. It may have been shuffled out of order, but recognizing that it is there will provide a huge clue for the correct response.