Fundamentals of Nursing-Exam 1-PrepU/Study Guide/Book

What is the most common client site for development of nosocomial infections? a) Respiratory tract b) Bloodstream c) Surgical wound d) Urinary tract

Urinary tract Explanation: The urinary tract is the most common site for nosocomial infections. Chapter 27: Asepsis and Infection Control, p. 665.

altruism

is a concern for the welfare and well-being of others.

integrity

is acting in accordance with an appropriate code of ethics and accepted standards of practice.

nursing practice acts

most important law from your state affecting your nursing practice.

Nursing Theory

nursing theory differentiates nursing from other disciplines and activities in that it serves the purposes of describing, explaining, predicting, and controlling desired outcomes of nursing care practices.

Developmental Theory

outlines the process of growth and development of humans as orderly and predictable, beginning with conception, and ending with death.

Choice Multiple question - Select all answer choices that apply. Which of the following are names of the transmission-based precautions defined by the Centers for Disease Control (CDC)? Select all that apply. a) Respiratory Precautions b) Droplet Precautions c) Body Fluid Precautions d) Microbial Precautions e) Contact Precautions f) Airborne Precautions

• Airborne Precautions • Droplet Precautions • Contact Precautions Chapter 27: Asepsis and Infection Control, p. 673.

The nurse has arranged for a stroke patient to participate in a daily group rehabilitation program that aims to improve the mobility, independence, and activities of daily living (ADLS) of participants. This program is likely to address which of the following needs? Select all that apply. a) Safety and security needs b) Self-esteem needs c) Love and belonging needs d) Self-actualization needs e) Physiologic needs

• Physiologic needs • Safety and security needs • Love and belonging needs • Self-esteem needs • Self-actualization needs Explanation: A rehabilitation program is likely to be multidimensional, addressing the physiology of the patient's movement while prioritizing and ensuring safety. Improving independence and ADLs is likely to benefit the patient's self-esteem and self-actualization after the effects of stroke. The group format of the program is likely to provide some measure of belonging with those who have had similar experiences, thus preventing isolation

A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had his dinner, seems restless, and is tossing on the bed. Keeping in mind that the client is a Latino, what is the most appropriate response by the nurse?

"Tell me what you are feeling." The nurse should ask the client to tell the nurse what he is feeling. Asking open-ended questions would encourage the client to verbalize his pain. Latino men may not demonstrate their feelings or readily discuss their symptoms because they may interpret doing so as being less than manly. Closed-ended questions like "Are you having pain?"; "Do you need pain medication?"; and "Are you feeling alright?" may block communication and the client may not express his feelings.

Routine nasal and rectal swabbing of a newly admitted hospital patient has come back positive for methicillin-resistant Staphylococcus aureus (MRSA), indicating that the patient is colonized with MRSA. The patient is surprised at this finding, since he enjoys generally robust health. What should the patient's nurse teach him about this diagnostic finding? a) "You may not develop any symptoms, but you will likely be given a round of antibiotics to eliminate these bacteria." b) "It's very fortunate that this was detected early, since this had the potential to make you very sick." c) "This finding becomes part of your medical record, but it is not a threat to the health of yourself or others." d) "This means that this organism in present on your skin, but it doesn't necessarily mean that you will become sick."

"This means that this organism in present on your skin, but it doesn't necessarily mean that you will become sick." Explanation: MRSA colonization does not necessarily mean that an individual will become sick, but it does pose a threat of passing on MRSA to others. Colonization does not necessitate antibiotic therapy. Chapter 27: Asepsis and Infection Control, p. 666.

Which of the following is an accurate guideline for removing soiled gloves after patient care? a) Use the nondominant hand to grasp the opposite glove near the cuffed end on the outside exposed area. b) After removing the first glove, slide the fingers of the ungloved hand between the remaining glove and the wrist and pull the glove straight off with the contaminated area on the outside. c) After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand. d) Remove the glove on the nondominant hand by pulling it straight off, keeping the contaminated area on the outside.

After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand. Explanation: When removing gloves, the dominant hand is used to grasp the opposite glove near the cuff end on the outside exposed area. It is pulled off and inverted, with the contaminated area on the inside. The removed glove is held in the remaining gloved hand. Then, the fingers of the ungloved hand are slid between the remaining glove and the wrist and the glove is pulled off and inverted. Chapter 27: Asepsis and Infection Control, p. 684.

When admitting an adolescent to the hospital, the nurse anticipates that the client will respond to questions about his health beliefs based on his a) Peer influence and education b) Gender and medical history c) Health promotion activities d) Age and developmental state

Age and developmental state Explanation: Age and developmental stage are important considerations in the health belief model.

For the nursing student to implement the most effective care for her patients, she must a) Apply clinical knowledge to theoretic knowledge b) Apply preexisting knowledge c) Have rudimentary critical-thinking skills d) Establish a clinical log for evaluation

Apply preexisting knowledge Explanation: To deal with the patient's problems appropriately, the student nurse will need to use his or her knowledge base from previous classes. Chapter 11: Blended Skills and Critical Thinking throughout the Nursing Process, p. 199.

Which of the following statements about glove use and hand hygiene is true? a) The use of sterile gloves reduces the need for hand hygiene. b) Nonsterile gloves can be decontamination with alcohol-based hand rub, but must be changed between patients. c) Artificial fingernails should not be worn by staff involved in direct patient care. d) Use of alcohol-based hand rubs is appropriate after using the restroom.

Artificial fingernails should not be worn by staff involved in direct patient care. Explanation: The CDC Guideline for Hand Hygiene in Health-Care Settings (2002) specifies that healthcare personnel involved in patient care should not wear artificial nails because they are more likely to be associated with higher bacterial counts. Chapter 27: Asepsis and Infection Control, p. 665.

The nurse assesses a patient's blood pressure, which was 160/90. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure at 140/78. This nursing action is a) Assessment b) Evaluation c) Planning d) Implementation

Assessment Explanation: The nurse is collecting data when measuring the patient's blood pressure. Collection of patient data is considered assessment regardless of when it occurs. Chapter 11: Blended Skills and Critical Thinking throughout the Nursing Process, p. 209.

An elderly patient has been recently diagnosed with vascular dementia. Because he lives alone and has poorly controlled hypertension, he has begun to receive home healthcare. This new aspect of his care is characteristic of which stage of illness? a) Achieving recovery and rehabilitation b) Experiencing the symptoms c) Assuming the sick role d) Assuming a dependent role

Assuming a dependent role Explanation: The stage of assuming a dependent role often requires assistance in carrying out activities of daily living. As well, the patient often requires care, which may be provided in the home. Experiencing symptoms and assuming a sick role may precede (or accompany) this process. Recovery and rehabilitation are not evident in the patient's present circumstances.

Which ethical principle refers to the obligation to do good? a) Veracity b) Nonmaleficence c) Fidelity d) Beneficence

Beneficence Explanation: Beneficence is the duty to do good and the active promotion of benevolent acts. Fidelity refers to the duty to be faithful to one's commitments. Veracity is the obligation to tell the truth. Nonmaleficence is the duty not to inflict, as well as to prevent and remove, harm; it is more binding than beneficence. Chapter 6: Values, Ethics, and Advocacy, p. 91.

Hepatitis is classified as a virus that a) Is localized in the liver b) Causes tissue damage c) Causes decreased urine d) Results in pallor

Causes tissue damage Explanation: Some viral infections are acute and controlled by the host's defense mechanisms; others spread throughout the body and cause severe tissue damage or result in chronic illness. Chapter 27: Asepsis and Infection Control, p. 672.

Which of the following activities is the clearest example of the evaluation step in the nursing process? a) Checking the patient's blood pressure 30 minutes after administering the captopril b) Giving the patient a PRN (as needed) dose of captopril (an antihypertensive) in light of this blood pressure reading c) Recognizing that the patient's blood pressure of 172/101 is an abnormal finding d) Taking a patient's blood pressure on both arms at the beginning of a shift

Checking the patient's blood pressure 30 minutes after administering the captopril Explanation: Rationale:Measuring the patient's blood pressure after performing an intervention such as drug administration determines the extent to which the patient has achieved the outcome desiredThe nurse is attempting to landmark an obese patient's apical pulse. Explanation: Trial-and-error problem solving can be dangerous to the patient. Testing range of motion by trial-and-error could result in dislocation; trial-and-error drug administration could result in over- or under-medicating; trial-and-error assessment of a potential swallowing deficit could result in aspiration. Each of these situations warrants more systematic problem solving. Trial-and-error landmarking of an anatomically difficult point, such as the apex of an obese patient's heart, does not pose a threat to the patient and a reasonable amount of "hunting" for the apical pulse may be necessary., which in this case is lowered blood pressure. Initially checking the patient's blood pressure is an example of assessment while recognizing it as an anomaly constitutes diagnosis. Administering the drug is a form of implementation. Chapter 11: Blended Skills and Critical Thinking Throughout the Nursing Process, p. 193.

Drag and Drop question - Click and drag the following steps to place them in the correct order. Question: The nurse has entered the room of a newly admitted patient who immediately states that she is feeling short of breath. After identifying this complaint as the patient's problem, what steps should the nurse follow in the process of scientific problem solving? 1 2 3 4 5 Formulate a hypothesis Collect assessment data Perform hypothesis testing Make a plan for action Evaluate

Collect assessment data Formulate a hypothesis Make a plan for action Perform hypothesis testing Evaluate Explanation: Scientific problem solving is a systematic, seven-step, problem-solving process that involves (1) problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6) interpretation of results, and (7) evaluation, resulting in conclusion or revision of the study. Chapter 11: Blended Skills and Critical Thinking throughout the Nursing Process, p. 191.

The police have brought a patient to emergency who is out of control and was attacking his neighbor. As you begin the admission process, the first nursing action would be to: a) ask him how he is feeling. b) search the patient for concealed weapons. c) introduce yourself to the patient. d) orient him to his surroundings.

Correct response: introduce yourself to the patient. Explanation: It is important for the nurse to first introduce her/himself and make contact, rather than search for weapons (weapons search is a police responsibility), ask how he's feeling, or orient him. Introduction is the first step in establishing a helping relationship. Chapter 11: Blended Skills and Critical Thinking throughout the Nursing Process, p. 204-205.

You are working with the experienced nurse in ICU. As you enter the room of the patient diagnosed with a cerebral hemorrhage, the nurse immediately says to you, "This patient is getting worse." This is an example of the nurse using: a) acute observation ability. b) an assumption to guide practice. c) illogical thinking. d) intuitive problem identification.

Correct response: intuitive problem identification. Explanation: Experienced nurses are able to make clinical decisions based on intuition, or an "inner prompting or hunch" that can lead to early and life-saving interventions. Intuitive problem solving is based on a background of experience, knowledge, and skill. Chapter 11: Blended Skills and Critical Thinking throughout the Nursing Process, p. 196

The inability of a person to recognize his or her own values, beliefs, and practices and those of others because of strong ethnocentric tendencies is termed what?

Cultural blindness. Cultural blindness occurs when one ignores differences and proceeds as though they do not exist, resulting in bias and stereotyping. Acculturation is the process by which members of a culture adapt or learn how to take on the behaviors of another group. Cultural imposition is the tendency to impose one's cultural beliefs, values, and patterns of behavior on a person from a different culture. Stereotyping is when one assumes that all members of a culture, ethnic group, or race act alike.

The inability of a person to recognize his or her own values, beliefs, and practices and those of others because of strong ethnocentric tendencies is termed what? a Stereotyping. b Cultural blindness. c Acculturation. d Cultural imposition.

Cultural blindness. Explanation: Cultural blindness occurs when one ignores differences and proceeds as though they do not exist, resulting in bias and stereotyping. Acculturation is the process by which members of a culture adapt or learn how to take on the behaviors of another group. Cultural imposition is the tendency to impose one's cultural beliefs, values, and patterns of behavior on a person from a different culture. Stereotyping is when one assumes that all members of a culture, ethnic group, or race act alike.

The nurse, after gathering data, analyzes the information to derive meaning. The nurse is involved in which phase of the nursing process? a) Implementation b) Planning c) Diagnosis d) Outcome identification

Diagnosis Explanation: The diagnosis phase involves the analysis of information and deriving the meaning from the analysis. The planning phase involves preparing a care plan and directing the nursing staff in providing care. The implementation phase involves initiation, evaluation of response to the plan, record of nursing actions, and client response to actions. Outcome identification involves formulating and documenting measurable, realistic, client-focused goals. Chapter 11: Blended Skills and Critical Thinking Throughout the Nursing Process, p. 193.

A patient who has limited finances and limited capacity for education requires home healthcare for a chronic illness. For the nurse to provide a high level of care to this patient, she must first a) Determine what care has been provided b) Develop a relationship with the patient c) Implement critical-thinking skills d) Engage the services of a social worker

Implement critical-thinking skills Explanation: Critical thinking requires nurses to choose solutions or identify options for patient care situations. Chapter 11: Blended Skills and Critical Thinking Throughout the Nursing Process, p. 198.

Which of the following is an important element of implementation? a) Nursing orders b) Critical thinking c) Documentation d) Client database

Documentation Explanation: An important element of implementation is documentation. The client database includes all the information that is obtained from the medical and nursing history. Physical examination and diagnostic studies are not an important element of implementation. Critical thinking is intentional, contemplative, and outcome-directed thinking. Developing good critical thinking skills will make nurses more efficient and effective at resolving situations requiring multiple interventions. Nursing orders are specific nursing directions so that all healthcare team members understand what to do for the client and, therefore, are not an important element of implementation. Chapter 11: Blended Skills and Critical Thinking Throughout the Nursing Process, p. 199.

Using the nursing process to make ethical decisions involves following several steps. Which step is the nurse implementing when he or she reflects on the decision-making process and the role it will play in making future decisions? a) Planning b) Diagnosing c) Evaluating d) Implementing

Evaluating Explanation: Evaluating an ethical decision involves reflecting on the process and evaluating those elements that will be helpful in the future. The nurse may also question how this experience can improve reasoning and decision making in the future. Diagnosing the ethical problem involves stating the problem clearly. Planning includes identifying the options and exploring the probable short-term and long-term consequences. Implementing includes the implementation of the decision and comparing the outcomes of the action with what was considered and hoped for in advance. Chapter 6: Values, Ethics, and Advocacy, p. 97.

A nurse is making an occupied bed. Which of the following is a recommended guideline for this procedure? a) Assist patient to turn toward nurse's side of the bed. b) Fold linen that is to be reused over the overbed table. c) Remove all covers and/or bath blankets from the patient. d) Fan-fold soiled linens as close to patient as possible.

Fan-fold soiled linens as close to patient as possible. Explanation: Correct steps in this procedure include: Place a bath blanket over the patient. Have patient hold onto bath blanket while you reach under it and remove top linens. Fold linen that is to be reused over the back of a chair. Assist patient to turn toward opposite side of the bed, and reposition pillow under patient's head. Fan-fold soiled linens as close to the patient as possible. Chapter 31: Hygiene, p. 910.

A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which of the following precautions should the nurse take after the testing is complete? a) Empty the specimens into a plastic biohazard bag. b) Flush the specimens and wash the sealed containers. c) Label and bury the specimen bags in landfills. d) Flush the specimens and incinerate the containers.

Flush the specimens and incinerate the containers. Explanation: When testing is complete, most specimens are flushed, incinerated, or sterilized. Specimens are not emptied into plastic biohazard bags or labeled and buried in landfills. Chapter 27: Asepsis and Infection Control, p. 672.

A nurse is caring for a client with ringworm. Which of the following microorganisms causes ringworm in a client? a) Fungi b) Helminths c) Rickettsiae d) Protozoans

Fungi Explanation: Ringworm is caused by a fungal infection. Fungi include yeasts and molds, which cause infections in the skin, mucous membranes, hair, and nails. Rickettsiae are microorganisms that resemble bacteria but cannot survive outside of another living species. They are responsible for Lyme disease. Protozoans are single-celled animals classified according to their ability to move. They do not cause ringworm. Helminths are infectious worms that may or may not be microscopic. They include roundworms, tapeworms, and flukes. Chapter 27: Asepsis and Infection Control, p. 654.

Which of the following pieces of personal protective equipment should be removed first? a) Gloves b) Respirator c) Gown d) Goggles

Gloves Explanation: The order for removal of PPE is gloves, goggles, gown, and respirator. Chapter 27: Asepsis and Infection Control, p. 684.

A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a patient. Which of the following is an accurate guideline for using this technique? a) Consider the outer 3-inch edge of a sterile field to be contaminated. b) Consider the outside of the sterile package to be sterile. c) Hold sterile objects above waist level to prevent accidental contamination. d) Open sterile packages so that the first edge of the wrapper is directed toward you.

Hold sterile objects above waist level to prevent accidental contamination. Explanation: Holding a sterile object above waist level ensures the object is kept in sight and prevents accidental contamination. The outside of the sterile package and the outer 1 inch of a sterile field are contaminated. Sterile packages should be opened so that the first edge of the wrapper is directed away from the nurse. Chapter 27: Asepsis and Infection Control, p. 686.

A nurse is spraying disinfectant on the equipment in the room of an elderly client. Which of the following pieces of equipment has the highest risk of transmitting infection to an elderly client? a) Face shield b) Gloves c) Humidifier d) Bath blanket

Humidifier Explanation: Infections are often transmitted to elderly clients through equipment reservoirs such as indwelling urinary catheters, humidifiers, and oxygen equipment, or through incisional sites such as those for intravenous tubing, parenteral nutrition, or tube feedings. Use of proper aseptic techniques is essential to prevent the introduction of microorganisms. Bath blankets, face shields, and gloves are not part of the equipment reservoir that transmits infections to elderly clients.

An Arab client has been admitted to the health care facility with varicose veins. What should the nurse avoid while conducting the interview of the client?

Maintaining eye contact While interviewing an Arab client, the nurse should avoid maintaining eye contact with the client. In Arab culture, maintaining eye contact is sexually suggestive; if the nurse does so during the interview, it may give the wrong message to the client. However, the nurse may give a light handshake or ask about the client's personal life and medical history during the interview. (less)

Drag and Drop question - Click and drag the following steps to place them in the correct order. Question: You are assigned the care of four elderly patients. Mr. A: 90 years of age. He suffered a stroke 7 days ago, and is to be transferred to the rehabilitation unit today by 10 AM. Mr. B: 67 years of age, upset as he did not sleep all night because of chest pain, and admission to the unit at 4 AM from emergency. Mr. C: recovering from abdominal surgery two days ago. He is to be discharged later today. Mr. D admitted for regulation of high blood pressure and "inappropriate behavior", his wife of 45 years died 2 weeks ago. He is quiet and sleeping when you arrive. Arrange the patients in the order you would assess them.

Mr. B Mr. A Mr. C. Mr. D Explanation: The nurse's assessment should proceed from the patient with the most acute need and interventions. Mr. B is the most acute, and needs to be assessed for chest pain; Mr. A because you need to have him ready for transfer by 10 AM; then Mr. C who will need assessment for any discomfort and discharge teaching, then finally Mr D, who is resting, but will need BP monitoring and ongoing assessment and comfort measures. Chapter 11: Blended Skills and Critical Thinking throughout the Nursing Process, p. 195

The word ________ originated from the latin word "nutrix" meaning to nourish

Nurse

While providing client care, a nurse determines that a client adheres to the health belief model. Which of the following would the nurse need to assess as a factor possibly affecting the client's response to illness? a) Nutritional awareness b) Personality characteristics c) Stress management d) Environmental sensitivity

Personality characteristics Explanation: The health belief model provides insight into the connection between the way a person sees his or her state of health and that person's response to health, illness, and treatment. According to the health belief model, personality characteristics affect the person's response to illness. Nutritional awareness, stress management, and environmental sensitivity are wellness behaviors that promote healthy functioning and help prevent illness.

What components are located at the center of a concept map? a) Nursing interventions and patient responses b) Nursing diagnoses and assessment data c) Patient's current and past medical histories d) Short-term and long-term goals

Patient's current and past medical histories Explanation: The patient's current and past medical histories are located at the center of a concept map. The nursing diagnoses are developed and prioritized around the patient's history and reasons for hospitalization. Assessment data are categorized under the nursing diagnosis. Nursing interventions, patient responses, and goals are developed based upon the prioritized nursing diagnoses on a separate page. Chapter 11: Blended Skills and Critical Thinking Throughout the Nursing Process, p. 210.

Asking questions in PICO format

Patient, Population or Problem of Interest Intervention of interest Comparison of interest Outcome of interest

A nursing instructor has assigned a student to care for a patient of Asian descent. The instructor reminds the student that personal space considerations vary among cultures. What personal space preferences are important for the student to consider when caring for this patient?

People of Asian descent prefer some distance between themselves and others. Individuals of Asian descent are more comfortable with some distance between themselves and others. Direct eye contact may be considered impolite or aggressive within the Asian culture, and they may tend to avoid direct eye contact and avert their eyes while speaking with another.

When pouring a sterile solution, what care should the nurse take to avoid contamination of the solution? a) Wash the inside surface of the cap of the container with water b) Open and place the cap of the container inside down on a flat surface c) Pour and discard a small amount of the solution before each use d) Wipe the mouth of the container with a sterile cloth before and after use

Pour and discard a small amount of the solution before each use Explanation: The nurse should pour and discard a small amount of the solution before each use to wash away airborne contaminants from the mouth of the container. This is called lipping the container. The nurse need not wash the inside surface of the cap of the container with water or wipe the mouth of the container with a sterile cloth before and after use. The nurse should open and place the cap of the container upside down, not inside down on a flat surface. Chapter 27: Asepsis and Infection Control, p. 674-675.

A nurse needs to visit the intensive care unit to administer an enema to a client. Which of the following steps should the nurse take when using the sterile solution located at the entrance to the intensive care unit? a) Hold the container from the top. b) Clean the nozzle area with a damp cloth. c) Pour and discard a small amount of the solution. d) Loosen the cap or the seal on the bottle.

Pour and discard a small amount of the solution. Explanation: Before each use of a sterile solution, the nurse should pour and discard a small amount to wash away airborne contaminants from the mouth of the container. To avoid contamination, the nurse should place the cap upside down on a flat surface or hold it during pouring. The nurse should control the height of the container to avoid splashing the sterile field, causing a wet area of contamination. The nurse should not loosen the cap or hold the container from the top. The nurse also should not clean the nozzle area with a damp cloth, as this would lead to contamination of the solution. Chapter 27: Asepsis and Infection Control, p. 689.

A nurse has cleansed the infected wound of a middle-aged client. What is the first step nurses take in the orderly sequence for removing their garments? a) Removing the garments that are most contaminated first b) Folding the soiled side of the gown to the inside before removing c) Washing hands before removing the contaminated gown d) Wiping the soiled surface of the gown with a disinfectant

Removing the garments that are most contaminated first Explanation: Nurses remove the garments that are most contaminated first, preserving the clean uniform underneath. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. Washing hands before removing the contaminated gown or wiping the soiled surface of the gown is not part of the sequence of removing garments. Folding the soiled side of the gown to the inside before removing is not the first step in the orderly sequence. Chapter 27: Asepsis and Infection Control, p. 684.

A nurse needs to check the vital signs of a client with an infectious disease who is receiving intravenous therapy through an IV pump. Before entering the client's room, the nurse follows airborne and contact precautions. Which of the following infectious diseases does the client have? a) SARS b) Polio c) HIV d) Measles

SARS Explanation: The client has severe acute respiratory syndrome (SARS). Infectious diseases like chickenpox (varicella) and SARS require both airborne and contact precautions. Measles is an acute exanthematous disease caused by measles virus, and polio is caused by poliovirus. Polio is transmitted primarily through the ingestion of material contaminated with a virus found in stool. Infection with HIV occurs through the transfer of blood, semen, vaginal fluid, pre-ejaculate, or breast milk. Chapter 27: Asepsis and Infection Control, p. 672-673.

A nurse is changing the bed linen of a client admitted to the health care facility. Which of the following isolation precautions should the nurse follow? a) Contact precautions b) Standard precautions c) Airborne precautions d) Droplet precautions

Standard precautions Explanation: Health care personnel follow standard precautions whenever there is the potential for contact with the client's blood; body fluids except sweat, regardless of whether they contain visible blood; non-intact skin; and mucous membranes. Standard precautions are measures for reducing the risk of microorganism transmission from both recognized and unrecognized sources of infection. The other three precautions are transmission-based precautions, which are measures for controlling the spread of infectious agents from clients known to be, or suspected of being, infected with highly transmissible or epidemiologically important pathogens. Chapter 27: Asepsis and Infection Control, p. 672.

The nurse is aware that many products in the hospital have the potential to contain latex. Which piece of protective equipment is most likely to contain latex? a) Goggles b) Gowns c) Surgical masks d) Nitrile gloves

Surgical masks Explanation: Surgical masks may contain latex. Nitrile gloves do not contain latex, and goggles and gowns likely to do contain latex. Chapter 27: Asepsis and Infection Control, p. 671.

In which of the following situations would the nurse be most justified in implementing trial-and-error problem solving? a) The nurse is attempting to determine the range of motion of a patient's hip joint following hip surgery. b) The nurse is attempting to determine which PRN (as needed) analgesic to offer a patient who is in pain. c) The nurse is attempting to landmark an obese patient's apical pulse. d) The nurse is attempting to determine whether a poststroke patient has a swallowing deficit.

The nurse is attempting to landmark an obese patient's apical pulse. Explanation: Trial-and-error problem solving can be dangerous to the patient. Testing range of motion by trial-and-error could result in dislocation; trial-and-error drug administration could result in over- or under-medicating; trial-and-error assessment of a potential swallowing deficit could result in aspiration. Each of these situations warrants more systematic problem solving. Trial-and-error landmarking of an anatomically difficult point, such as the apex of an obese patient's heart, does not pose a threat to the patient and a reasonable amount of "hunting" for the apical pulse may be necessary. Chapter 11: Blended Skills and Critical Thinking Throughout the Nursing Process, p. 195.

A nurse in the hospital is caring for a Native American male. What person is most important to include in the care of the client?

Tribal medicine man Observance of rituals in times of stress and uncertainty helps to restore a sense of control, competence, and familiarity; to that extent, these rituals are a desirable adjunct to nursing care.

What have the models of health promotion and illness prevention been used for?

To help healthcare providers understand health-related behaviors. Explanation: Several models of health promotion and illness prevention have been used to help healthcare providers understand health-related behaviors and adapt care to people from diverse economic and cultural backgrounds. The models include the health belief model, the health promotion model, the health-illness continuum model, and the agent-host-environment model. These models do not define a medical framework in the care of the disabled; these models do not create a forum for improving rehabilitative care; and these models do not formulate care plans for use with the disabled.

A nurse is assessing a client during a health care camp. The nurse observes that the client has poor hygiene and an itchy, infected scalp. Which of the following should the nurse ask the client to do? a) Use anti-lice shampoo b) Wash hair daily c) Use dry shampoo d) Use oil-based shampoo

Wash hair daily Explanation: The client with a scalp infection should be advised to shampoo her hair daily with a mild shampoo. For occasional use, the nurse will use dry shampoos, which are applied to the hair as a powder. Other options include aerosol spray or foam. Anti-lice shampoos or oil-based shampoos are not used for fear of aggravating the infection. Chapter 31: Hygiene, p. 886.

A nurse is caring for a client with rubella. Which nursing action is an important precaution to be taken when caring for this client? a) Washing hands with an antimicrobial agent or waterless antiseptic agent b) Using a special high-filtration particulate respirator c) Changing gloves after contact with the client's infective material d) Wearing a mask when working within 3 feet of the client

Wearing a mask when working within 3 feet of the client Explanation: Rubella spreads through droplet transmission; thus, the nurse should wear a mask when working within 3 feet of the rubella client as a precaution against droplet transmission. Changing gloves after contact with the client's infective material and washing hands with an antimicrobial agent or waterless antiseptic agent are contact precautions used in case of clients with diseases that spread through contact transmission. Also, using a special high-filtration particulate respirator is an airborne precaution followed in case of clients with active tuberculosis. Chapter 27: Asepsis and Infection Control, p. 673.

Professional Values are:

altruism-concern for well being of others. autonomy-the right to self determination. human dignity-respect for the inherent worth and uniqueness of individuals and populations. integrity-acting in accordance with an apppropriate code of ethics and accepted standards of practice. social justice-upholding moral, legal, and humanistic principles.

theories of ethics: deontologic

an action is right or wrong independently of its consequences.

Principle based approach of ethics

combines elements of both utilitarian and deontologic theories and offers specific action guides for practice. Four key principles: autonomy, nonmaleficience, beneficence, and justice.

Adaptation Theory

defines adaptation as the adjustment of livingmatter to other living things and to the environmental conditions.

General Systems Theory

describes how to break whole things into parts and then to learn how the parts work together in "systems".

The American Nurses Association (ANA) has published the standards of care for which the nurse is responsible. The Standards of Practice are: a) assessment, diagnosis, outcome identification, planning, implementation, and evaluation. b) critical thinking, clinical reasoning, problem solving, ethics, and legal nursing. c) individualized patient care, continuity of care, respect for privacy, and patient education. d) the nursing process, nurse-patient relationship, therapeutic communication, and documentation.

ssessment, diagnosis, outcome identification, planning, implementation, and evaluation. Explanation: The ANA's six Standards of Practice are assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The nursing process encompasses all significant nursing actions and forms the foundation for the nurse's decision making. Chapter 11: Blended Skills and Critical Thinking throughout the Nursing Process, p. 191.

theories of ethics: utilitarian

the rightness of wrongness of an action depends on the consequences of the action

social justice

upholding moral, legal, and humanistic principles.

Choice Multiple question - Select all answer choices that apply. A nurse is caring for a client who cannot swallow or expectorate. What interventions to keep the mouth and throat free of accumulating secretions should the nurse perform when caring for this client? Select all that apply. a) Arrange for suctioning to remove mucus. b) Assist the client to a lateral position. c) Apply mineral oil to the lips. d) Provide frequent mouth care. e) Change the client's position every 2 hours.

• Provide frequent mouth care. • Arrange for suctioning to remove mucus. • Assist the client to a lateral position. Explanation: When caring for a client who cannot swallow or expectorate, the nurse should provide frequent mouth care, arrange for suctioning to remove mucus, and assist the client to a lateral position to keep the mouth and throat free of accumulating secretions. Mineral oil is applied to the lips of the client to overcome dryness caused by oxygen therapy. The client's position should be changed every 2 hours to promote comfort and circulation. Chapter 31: Hygiene, pp. 881-882.

Choice Multiple question - Select all answer choices that apply. The nurse is responsible for establishing a caring relationship with the patient. The nurse could evaluate her priority for caring by asking self-reflection questions, such as: a) How does the patient need to change in order for me to know him better? b) When the patient's family comes, do I take the time to talk with them? c) What do I know about the patient beyond his physical condition? d) How do I decide what the patient needs and prioritize my time? e) Do I provide care that is individualized, or do I provide care as planned?

• What do I know about the patient beyond his physical condition? • Do I provide care that is individualized, or do I provide care as planned? • How do I decide what the patient needs and prioritize my time? • When the patient's family comes, do I take the time to talk with them? Explanation: Self-reflection helps the nurse to evaluate relationships with patients and others. Asking questions to reflect on the quality of care and caring will help to determine if caring is a priority. Nurses who value caring welcome the opportunity for conversation with the patient and family. Chapter 11: Blended Skills and Critical Thinking throughout the Nursing Process, p. 204-205.