Test Bank for Concept Based Clinical Nursing Skills 1st Edition by Stein

Test Bank for Concept Based Clinical Nursing Skills 1st Edition by Stein

1.         A nurse has applied restraints to a client. After documenting the care and ensuring the client is safe, what action does the nurse take next?

a.        Call the provider and request a prescription for the restraints.

b.        Alert the hospital’s Risk Management department.

c.        Plan to check the client at a minimum of every 2 hours.

d.        Assign  assistive personnel to sit with the client.

ANS: C

The standard required by the Centers for Medicaid and Medicare Services is to assess the restrained client at a minimum of every 2 hours. In most situations, the nurse requests the prescription before applying the restraints, however; if it is necessary to apply them first, a prescription from the provider is needed within 1 hour. Although restraints are often the source of litigation, there is no need to routinely notify the Risk Management department about the use of restraints. The client may or may not need someone to sit with him or her.

               DIF: Cognitive Level: Applying               TOP: Nursing Process: Implementation

2.         The nursing student applies restraints. What action by the student demonstrates the need for more education on this procedure?

a.        The student attempts other methods to prevent harm before applying the restraints.

b.        The student inserts two fingers between the restraint and client skin to check for tightness.

c.        The student secures the restraint by tying the restraint to the side rail but out of client reach.

d.        The student reassesses the client’s need for the restraint at least every 2 hours.

ANS: C

The student should tie the restraint to a secure part of the bed frame, not to the side rail. Attempting alternatives to restraints, checking the tightness by placing two fingers under the restraint, and reassessing the client at least every 2 hours are all appropriate actions.

               DIF: Cognitive Level: Analyzing              TOP: Nursing Process: Evaluation

3.         The new nurse grumbles “Why are there so many regulations on using restraints?” What response by the mentor is best?

a.        “Clients have the right to be free from restraint or seclusion unless medically necessary.”

b.        “Following all these regulations helps prevent law suits.”

c.        “Accrediting bodies aren’t in favor of using restraints so they make up regulations.”

d.        “Because restraints have been shown to actually increase injuries.”

ANS: A

The guiding principle for restraint use is that clients have the right to be free from unnecessary restraint or seclusion unless it is medically necessary. This is a basic human right and protects client dignity. Following regulations won’t necessarily prevent lawsuits, but will help prevent negative outcomes from the legal action. Accrediting bodies don’t “just make up regulations.” There are sound reasons for them. Restraints have been shown to increase injury, but that is secondary to the fact that clients have the right to be free from them unless absolutely needed.

              DIF:   Cognitive Level: Understanding      TOP: Integrated Process: Teaching-Learning

4.         A nurse is caring for a client in Droplet Precautions. What action does the nurse take to decrease a common complaint from clients in isolation?

a. appropriate for a client weighing under 200 pounds (90.0 kg). Since the client is not standing on the floor, the nonskid slippers are not needed.

               DIF: Cognitive Level: Applying               TOP: Nursing Process: Intervention

5.      The charge nurse is conducting an audit on compliance with Transmission-Based Precautions. Which action by the nursing staff shows good understanding and correct application of these precautions? (Select all that apply.) a.    Contact Precautions: Dons gloves and a gown before entering the room

b.        Droplet Precautions: Cares for the client only if immunity to the disease is present

c.        Standard Precautions: Combines Standard Precautions with any other precautions

d.        Droplet Precautions: Wears a mask when taking client vital signs

e.        Two levels of Precautions: Maintains compliance with both types of precautions

f.         Contact Precautions: Places two patients with MRSA in the same room

ANS: A, C, D, E, F

Transmission-based precautions are determined by the illness and mode of transmission. The minimum required for Contact Precautions is donning gloves and a gown when entering the room. Nurses always use Standard Precautions for every client, no matter what other type of precautions the client is on. Nurses put on a mask when entering the room of a client on Droplet Precautions if close contact with the client is expected, such as when taking vital signs. When a client has two (or more) levels of Transmission-based Precautions, nurses correctly maintain compliance with all types. While private rooms are preferred for clients on Transmission-Based Precautions, cohorting clients with the same infectious agent is acceptable. Immunity is an important consideration for nurses caring for clients on Airborne Precautions.

               DIF: Cognitive Level: Analyzing              TOP: Nursing Process: Evaluation

6.      What does the nurse remember about appropriate hand hygiene? (Select all that apply.)

a.        Alcohol-based hand sanitizers are the gold standard for hand hygiene.

b.        Washing with soap and water is needed after using the toilet.

c.        After contact with certain organisms, soap and water is required.

d.        Alcohol-based hand sanitizers are only good for a few client types.

e.        The presence of hand sanitizers decreases the frequency of hand hygiene.

ANS: A, B, C

The CDC and WHO have concluded that alcohol-based hand sanitizers are the gold standard for hand hygiene and should be used whenever possible and appropriate. After using the toilet, if hands are visibly soiled, or after contact with certain microbes, washing with soap and water is required. The presence of hand sanitizers has increased the frequency of hand hygiene performed.

              DIF:   Cognitive Level: Remembering       TOP: Integrated Process: Teaching-Learning

7.      Which of the following are Joint Commission accepted unique client identifiers in a hospital? (Select all that apply.) a.    Name

b.        Date of birth

c.        Room number

d.        Photograph in medical record

e.        Hospital account number

f.         Social security number

ANS: A, B, E

In the hospital setting, acceptable identifiers include the client’s name, date of birth, and account number. In a behavioral healthcare setting, a photograph may be used. In an outpatient setting, the social security is an acceptable choice.

              DIF: Cognitive Level: Remembering        TOP: Nursing Process: Assessment