Clinical Nursing Skills and Techniques 8th Edition by Anne Griffin Perry ,Potter-Ostendorf – Test Bank A+

Description

1. The patient is brought to the emergency department complaining of severe shortness of breath. She is cyanotic and her extremities are cold. In an attempt to quickly assess the patient’s respiratory status, the nurse should:

a.	remove the patient’s nail polish to get a pulse oximetry reading.
b.	use a forehead probe to get a pulse oximetry reading.
c.	use a finger probe to get a pulse oximetry reading.
d.	check the color of the patient’s nail polish before attempting a reading.

ANS: B

Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacologic vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Assess for factors that influence measurement of SpO₂ (e.g., oxygen therapy; respiratory therapy such as postural drainage and percussion; hemoglobin level; hypotension; temperature; nail polish [Cieck et al., 2010]; medications such as bronchodilators).

DIF: Cognitive Level: Analysis REF: Text reference: p. 101

OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Pulse Oximetry

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. A person’s core temperature is considered the most accurate since it is:

a.	reflective of the surrounding environment.
b.	the same for everyone.
c.	controlled by the hypothalamus.
d.	independent of external influences.

ANS: C

The core temperature, or the temperature of the deep body tissues, is under the control of the hypothalamus and remains within a narrow range. Skin or body surface temperature rises and falls as the temperature of the surrounding environment changes, and it fluctuates dramatically. Body tissues and cells function best within a relatively narrow temperature range, from 36° C to 38° C (96.8° F to 100.4° F), but no single temperature is normal for all people. For healthy young adults, the average oral temperature is 37° C (98.6° F). An acceptable temperature range for adults depends on age, gender, range of physical activity, hydration status, and state of health.

DIF: Cognitive Level: Analysis REF: Text reference: p. 67

OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Core Temperature

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. The nurse takes the patient’s temperature using a tympanic electronic thermometer. The temperature reading is 36.5° C (97.7° F). The nurse knows that this correlates with:

a.	37.0° C (98.6° F) rectally.
b.	37.0° C (98.6° F) orally.
c.	36.0° C (97.7° F) axillary.
d.	36.0° C (97.7° F) orally.

ANS: B

It generally is accepted that axillary and tympanic temperatures are usually 0.5° C (0.9° F) lower than oral temperatures. It generally is accepted that rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures.

DIF: Cognitive Level: Analysis REF: Text reference: p. 67

OBJ: Discuss factors involved in selecting temperature measurement sites.

TOP: Temperature Assessment KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette. The patient has just returned from his “cigarette break.” The nurse is about to take the patient’s temperature orally and should:

a.	wait about 15 minutes before taking his temperature.
b.	give him oral fluids to rinse the nicotine away before taking his temperature.
c.	give him a stick of chewing gum to chew and then take his temperature.
d.	take his oral temperature and record the findings.

ANS: A

The nurse should verify that the patient has not had anything to eat or drink and has not chewed gum or smoked within the 15 minutes before oral temperature is measured. Oral food and fluids and smoking and gum can alter temperature measurement.

DIF: Cognitive Level: Synthesis REF: Text reference: p. 71

OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Oral Temperature Assessment

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. When evaluating the patient’s temperature levels, the nurse expects the patient’s temperature to be lower:

a.	in the morning.
b.	after exercising.
c.	during periods of stress.
d.	during the postoperative period.

ANS: A

Temperature is lowest during early morning. Muscle activity and stress raise heat production. Drugs may impair or promote sweating, vasoconstriction, or vasodilation, or may interfere with the ability of the hypothalamus to regulate temperature.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 70

OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Temperature Assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. When inserting a rectal thermometer, the nurse encounters resistance. The nurse should:

a.	apply mild pressure to advance.
b.	ask the patient to take deep breaths.
c.	remove the thermometer immediately.
d.	remove the thermometer and reinsert it gently.

ANS: C

If resistance is felt during insertion, withdraw the thermometer immediately. Never force the thermometer. This prevents trauma to the mucosa. With the nondominant hand, separate the patient’s buttocks to expose the anus. Ask the patient to breathe slowly and relax. This fully exposes the anus for thermometer insertion and relaxes the anal sphincter for easier thermometer insertion.

DIF: Cognitive Level: Application REF: Text reference: p. 72

OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures. TOP: Rectal Temperature Assessment

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. An appropriate procedure for measurement of an adult’s temperature with a tympanic membrane sensor is:

a.	pulling the ear pinna down and back.
b.	moving into the ear in a figure-eight pattern.
c.	fitting the probe loosely into the ear canal.
d.	pointing the probe toward the mouth and chin.

ANS: B

Move the thermometer in a figure-eight pattern. Pull the ear pinna backward, up, and out for an adult; fit the speculum tip snugly in the canal and do not move; and point the speculum tip toward the nose.

DIF: Cognitive Level: Application REF: Text reference: p. 75

OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures. TOP: Rectal Temperature Assessment

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The patient is a 1-year-old male infant who is admitted with possible sepsis. The patient is irritable and agitates easily. What should the nurse do to assess the patient’s temperature?

a.	Take an oral temperature before doing anything else.
b.	Take an axillary temperature using the upper axilla.
c.	Place the child in Sims’ position for a rectal temperature.
d.	Take a rectal temperature as the last vital sign.

ANS: D

Critically ill children sometimes have cool skin but a high core temperature because of poor perfusion to the skin. Children may assume the prone position for rectal temperature measurement. With children who cry or are restless, it is best to take temperature as the last vital sign. Use axillary temperatures for screening purposes only, not to detect fevers in infants and young children. Use the lower axilla to record temperature in side-lying infants.

DIF: Cognitive Level: Application REF: Text reference: p. 76

OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures. TOP: Temperature Assessment in Pediatric Patients

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The patient is returning from a cardiac catheterization. The puncture site is in the right femoral artery. The patient is having vital signs assessed every 15 minutes. Along with vital signs, the nurse assesses the pedal pulses of the right and left feet. Which of the following would be of major concern?

a.	Both pedal pulses were bounding.
b.	The femoral artery could be palpated.
c.	The right pedal pulse was weaker than the left.
d.	The radial artery pulse was 88.

ANS: C

If a peripheral pulse distal to an injured or treated area of an extremity feels weak on palpation, the volume of blood reaching tissues below the affected area may be inadequate, and surgical intervention may be necessary. A full bounding pulse is an indication of increased volume. When the pulse wave reaches a peripheral artery, you can feel it by palpating the artery lightly against underlying bone or muscle. The pulse is the palpable bounding of the blood flow. The usual range for adults is 60 to 100 beats per minute.

DIF: Cognitive Level: Analysis REF: Text reference: p. 77

OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Pulse Assessment

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

1. The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette. The patient has just returned from his “cigarette break.” The nurse is about to take the patient’s radial pulse and should:

a.	wait about 15 minutes before taking his pulse.
b.	use her thumb to detect the pulse and get an accurate count.
c.	press hard to detect the pulse and get an accurate count.
d.	take his pulse for 15 seconds and multiply by 4.

ANS: A

If a patient has been smoking, wait 15 minutes before assessing pulse. Anxiety, activity, and smoking elevate heart rate. Assessing radial pulse rate at rest allows for objective comparison of values. Fingertips are the most sensitive parts of the hand for palpating arterial pulsation. The nurse’s thumb has pulsation that interferes with accuracy. Pulse assessment is more accurate when moderate pressure is used. Too much pressure occludes pulse and impairs blood flow. If the pulse is regular, count the rate for 30 seconds and multiply the total by 2. If the pulse is irregular, count the rate for a full 60 seconds. Assess the frequency and the pattern of irregularity.

DIF: Cognitive Level: Analysis REF: Text reference: p. 78

OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Pulse Assessment

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. When evaluating the radial pulse measurement technique of the nursing assistant, the nurse identifies appropriate technique when the assistant:

a.	has the patient’s arm elevated.
b.	positions the patient supine or sitting.
c.	applies significant pressure to the pulse site.
d.	counts the pulse for 15 seconds and multiplies by 4.

ANS: B

Assist the patient to assume a supine or sitting position. If the patient is supine, place the patient’s forearm straight alongside or across the lower chest or upper abdomen with the wrist extended straight. If the patient is sitting, bend the patient’s elbow 90 degrees and support the lower arm on the chair or on the nurse’s arm. Slightly extend or flex the wrist with the palm down until the strongest pulse is noted. Lightly compress against the radius, obliterate the pulse initially, and then relax pressure so the pulse becomes easily palpable. Pulse is assessed more accurately with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. If the pulse is regular, count the rate for 30 seconds and multiply the total by 2. If the pulse is irregular, count the rate for 60 seconds. Assess frequency and pattern of irregularity.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 79

OBJ: Appropriately delegate vital sign measurements to nursing assistive personnel (NAP).

TOP: Delegation of Pulse Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

1. The nurse is caring for an infant in the NICU. While taking vital signs, the nurse finds that the baby’s heart rate is 195. The nurse calls the physician, knowing that the normal heart rate should be:

a.	60 to 100 beats per minute.
b.	100 to 160 beats per minute.
c.	90 to 140 beats per minute.
d.	220 beats per minute or higher.

ANS: B

The infant’s heart rate at birth ranges from 100 to 160 beats per minute at rest. By adolescence, the heart rate varies between 60 and 100 beats per minute and remains so throughout adulthood. By age 2, the pulse rate slows to 90 to 140 beats per minute.

DIF: Cognitive Level: Analysis REF: Text reference: p. 82

OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Assessing Apical Pulse

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. The patient has been in the hospital for several days for urosepsis. He has been responding favorably to treatment, and his vital signs have been “normal” for 2 days. When the nurse takes his vital signs, however, the patient’s apical pulse is 152 and regular. The nurse suspects that the:

a.	patient is having a reaction to his narcotic medication.
b.	patient may be suffering from hypothermia.
c.	patient’s fever may have returned.
d.	patient may be an athlete.

ANS: C

Fever or exposure to warm environments increases heart rate. Large doses of narcotic analgesics and hypothermia can slow heart rate. A well-conditioned patient may have a slower than usual resting heart rate, which returns more quickly to resting rate after exercise.

DIF: Cognitive Level: Synthesis REF: Text reference: p. 82

OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Assessing Apical Pulse

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. What steps should the nurse take to conduct an assessment of a possible pulse deficit?

a.	A nurse measures the pulse after the patient exercises.
b.	Two nurses check the same pulse on opposite sides of the body.
c.	Two nurses assess the apical and radial pulses and determine the difference.
d.	The current pulse is compared with previous pulse measurements for differences.

ANS: C

Locate apical and radial pulse sites. One nurse auscultates the apical pulse, and one nurse palpates the radial pulse. Both nurses count the pulse rate for 60 seconds simultaneously. Subtract the radial rate from the apical rate to obtain the pulse deficit. The pulse deficit reflects the number of ineffective cardiac contractions in 1 minute. If a pulse deficit is noted, assess for other signs and symptoms of decreased cardiac output.

DIF: Cognitive Level: Application REF: Text reference: p. 85

OBJ: Explain the implications of a pulse deficit. TOP: Pulse Deficit

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. An appropriate method of assessing a patient’s respirations is for the nurse to:

a.	place the bed flat.
b.	remove all supplemental oxygen sources from documentation.
c.	explain to the patient that respirations are being assessed.
d.	gently place the patient’s hand in a relaxed position over the upper abdomen.

ANS: D

Place the patient’s arm in a relaxed position across the abdomen or lower chest, or place the nurse’s hand directly over the patient’s upper abdomen. Be sure the patient is in a comfortable position, preferably sitting or lying with the head of the bed elevated 45 to 60 degrees. Sitting erect promotes full ventilatory movement. A position of discomfort may cause the patient to breathe more rapidly. Documentation should include any supplemental oxygen that the patient is receiving. Inconspicuous assessment of respirations immediately after pulse assessment prevents the patient from consciously or unintentionally altering the rate and depth of breathing.

DIF: Cognitive Level: Application REF: Text reference: p. 88

OBJ: Accurately assess a patient’s respirations. TOP: Respiratory Assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. The nurse is about to take vital signs on a newborn patient in the nursery. She should:

a.	assess respiratory rate after taking a rectal temperature.
b.	observe the child’s chest while the child is sleeping.
c.	call the physician if the rate is over 40.
d.	expect that the child will have short periods of apnea.

ANS: D

An irregular respiratory rate and short apneic spells are normal for newborns. Assess respiratory rate before other vital signs or assessments are taken. Children up to age 7 breathe abdominally, so respirations are observed by abdominal movement. Average respiratory rate (breaths per minute) for newborns is 30 to 60; for infants (6 months to 1 year), 30 to 50; for toddlers (2 years), 25 to 32; and for children from 3 to 12 years, 20 to 30.

DIF: Cognitive Level: Analysis REF: Text reference: p. 90

OBJ: Accurately assess a patient’s respirations. TOP: Pediatric Considerations

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The nurse should report an assessment of _____ respirations per minutes for a(n) _____.

a.	14; adult patient
b.	16; 8-year-old patient
c.	25; toddler
d.	38; newborn

ANS: B

Acceptable average respiratory rate (breaths per minute) for newborns is 35 to 40; for infants (6 months), 30 to 50; for toddlers (2 years), 22 to 32; and for children, 20 to 30. Adults average 12 to 20 respirations per minute.

DIF: Cognitive Level: Application REF: Text reference: p. 90

OBJ: Identify ranges of acceptable vital sign values for infant, child, and adult.

TOP: Respiratory Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

1. During the normal cardiac cycle, blood pressure reaches a peak, followed by a trough, in the cycle. What is the peak known as?

a.	Pulse pressure
b.	Systole
c.	Diastole
d.	Korotkoff phase

ANS: B

Blood pressure is the force exerted by blood against the vessel walls. During a normal cardiac cycle, blood pressure reaches a peak, followed by a trough, or low point, in the cycle. The peak pressure occurs when the heart’s ventricular contraction, or systole, forces blood under high pressure into the aorta. The difference between systolic pressure and diastolic pressure is the pulse pressure. When the ventricles relax, the blood remaining in the arteries exerts a minimum or diastolic pressure. Diastolic pressure is the minimal pressure exerted against the arterial wall at all times. As the sphygmomanometer cuff is deflated, the five different sounds heard over an artery are called Korotkoff phases.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 90

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Systolic Blood Pressure KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

1. The patient is complaining of a severe headache. The nurse takes the patient’s blood pressure and finds it to be 240/110. What is the pulse pressure?

a.	110
b.	240
c.	130
d.	350

ANS: C

The difference between systolic pressure and diastolic pressure is the pulse pressure. For a blood pressure of 240/110, the pulse pressure is 130. The diastolic pressure is 110. The systolic pressure is 240. The sum of the systolic and diastolic pressures is 350.

DIF: Cognitive Level: Analysis REF: Text reference: p. 90

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Pulse Pressure KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. During his initial screening, the patient’s blood pressure was noted to be elevated. Two months after the first assessment, he was noted to have a blood pressure of 150/92 and 166/96 at different times during the visit. It is now a month and a half later, and the nurse is concerned because the patient’s initial blood pressure on this visit was 154/94. She is preparing to take a second blood pressure, understanding that another reading in this range could lead to a diagnosis of:

a.	hypotension
b.	prehypertension
c.	hypertension
d.	orthostatic hypotension

ANS: C

Hypertension is defined as systolic blood pressure (SBP) of 140 mm Hg or greater, diastolic blood pressure (DBP) of 90 mm Hg or greater, or taking antihypertensive medication (NHBPEP, 2003). One blood pressure recording revealing a high SBP or DBP does not qualify as a diagnosis of hypertension. However, if you assess a high reading (e.g., 150/90 mm Hg), encourage the patient to return for another checkup within 2 months. The diagnosis of hypertension in adults requires an average of two or more readings taken at each of two or more visits after an initial screening. Hypotension occurs when the systolic blood pressure falls to 90 mm Hg or below. Prehypertension is a designation for patients at high risk for developing hypertension. In these patients, early intervention through adoption of healthy lifestyles reduces the risk of or prevents hypertension. Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., lightheadedness, dizziness) and low blood pressure when rising to an upright position.

DIF: Cognitive Level: Synthesis REF: Text reference: p. 91

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Hypertension KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

1. The patient is an 86-year-old woman who is being admitted for dehydration and pneumonia. The patient is lying in bed but tells the nurse that she needs to go to the bathroom. The nurse tells the patient that she will stay with her and will help her get there. The patient states, “That’s OK. I can make it on my own.” The nurse should:

a.	help the patient to the bathroom and stay with her.
b.	allow the patient to get up on her own and go to the bathroom.
c.	allow the patient to go to the bathroom and call for help if needed.
d.	insert a Foley catheter.

ANS: A

Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., lightheadedness, dizziness) and low blood pressure when rising to an upright position. Orthostatic changes in vital signs are good indicators of blood volume depletion. In severe cases of orthostatic hypotension, loss of consciousness may occur. Foley catheters are believed to be a major source or urinary tract infection.

DIF: Cognitive Level: Synthesis REF: Text reference: p. 91 |Text reference: p. 98

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Orthostatic Hypotension KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

1. The nurse chooses a sphygmomanometer that has a circular gauge and a needle that registers the millimeter calibrations. This type of device is known as a(n) _____ manometer.

a.	mercury
b.	electronic
c.	aneroid
d.	direct (invasive)

ANS: C

The aneroid manometer has a glass-enclosed circular gauge containing a needle that registers millimeter calibrations. Metal parts in the aneroid manometer are subject to temperature expansion and contraction and must be recalibrated at least every 6 months to verify their accuracy. Before using the aneroid manometer, make sure the needle is pointing to zero. With mercury manometers, pressure created by inflation of the compression cuff moves the column of mercury up the tube against the force of gravity. Millimeter calibrations mark the height of the mercury column. Electronic or automatic blood pressure machines consist of an electronic sensor positioned inside a blood pressure cuff attached to an electronic processor. You measure arterial blood pressure either directly (invasively) or indirectly (noninvasively). The direct method requires electronic monitoring equipment and the insertion of a thin catheter into an artery. The risks associated with invasive blood pressure monitoring require use in an intensive care setting.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 91

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Manometers KEY: Nursing Process Step: Diagnosis

MSC: NCLEX: Physiological Integrity

1. The nurse is working on the general surgical unit and is caring for a patient who has a right total mastectomy. To take the patient’s vital signs and to accurately assess the patient’s blood pressure, it will be necessary to:

a.	place the blood pressure cuff on the left upper arm.
b.	place the blood pressure cuff on the right upper arm.
c.	place the blood pressure cuff on the right lower arm.
d.	use direct (invasive) blood pressure measurement.

ANS: A

Determine the best site for blood pressure assessment. Avoid applying the cuff to an extremity when intravenous fluids are infusing, an arteriovenous shunt or fistula is present, or breast or axillary surgery has been performed on that side. The risks associated with invasive blood pressure monitoring require use in an intensive care setting.

DIF: Cognitive Level: Application REF: Text reference: p. 93

OBJ: Describe factors involved in selecting an extremity to measure blood pressure.

TOP: Manometers KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. Which site is used to auscultate blood pressure?

a.	Radial
b.	Ulnar
c.	Brachial
d.	Temporal

ANS: C

Place the stethoscope over the brachial artery to measure blood pressure. Use the radial site for the radial pulse, the ulnar site for the ulnar pulse, and the temporal site for the temporal pulse.

DIF: Cognitive Level: Application REF: Text reference: p. 77

OBJ: Describe factors involved in selecting an extremity to measure blood pressure.

TOP: Brachial Pulse KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The nurse is caring for a 2-year-old child who is admitted with croup and crying. To take the child’s vital signs, the nurse should:

a.	place the pediatric blood pressure cuff on the left arm.
b.	place the blood pressure cuff on the right thigh.
c.	skip the blood pressure measurement.
d.	place the blood pressure cuff on the left thigh.

ANS: C

Blood pressure is not a routine part of assessment in children younger than 3 years. The right arm is preferred for blood pressure measurement in children older than 3. Thigh blood pressure is the least preferred and the most uncomfortable method for children.

DIF: Cognitive Level: Analysis REF: Text reference: p. 98

OBJ: Describe factors involved in selecting an extremity to measure blood pressure.

TOP: Teaching Considerations KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. When the benefits of the different types of blood pressure monitoring devices are compared, which of the following patients would be the best candidate for noninvasive electronic blood pressure measurement?

a.	A 49-year-old postsurgical patient with no history of heart disease on q15min vital signs
b.	A 22-year-old patient undergoing active grand mal seizures
c.	A 68-year-old patient with diagnosed peripheral vascular disease
d.	A 54-year-old patient with chronic atrial fibrillation

ANS: A

These devices are used when frequent assessment is required, as in critically ill or potentially unstable patients; during or after invasive procedures; or when therapies require frequent monitoring. Patients with irregular heart rate, peripheral vascular disease, seizures, tremors, and shivering are not candidates for this device.

DIF: Cognitive Level: Analysis REF: Text reference: p. 99

OBJ: Discuss the benefits and disadvantages of using an automatic blood pressure machine.

TOP: Noninvasive Electronic Blood Pressure Measurement

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

1. The patient was found in an alley on a cold winter night and is admitted with hypothermia from environmental exposure. She is elderly and is having difficulty breathing. Her breath sounds are diminished, and the tip of her nose is cyanotic. The nurse wants to assess the oxygen level in the patient’s blood. She decides to use the pulse oximeter. The best way to apply this to this patient would be with a(n):

a.	finger probe.
b.	earlobe sensor.
c.	forehead sensor.
d.	toe sensor.

ANS: C

In adults, you can apply reusable and disposable oximeter probes to the earlobe, finger, toe, bridge of the nose, or forehead. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacologic vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas.

DIF: Cognitive Level: Analysis REF: Text reference: p. 101

OBJ: Accurately assess a patient’s oxygenation status using pulse oximetry.

TOP: Oxygen Saturation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The patient is admitted in a near comatose state with a blood glucose level of 750. His respiratory rate is 42 breaths per minute, and his respiratory pattern is deep and regular. What is this type of breathing known as?

a.	Cheyne-Stokes respiration
b.	Biot’s respiration
c.	Bradypnea
d.	Kussmaul’s respiration

ANS: D

Respirations are abnormally deep, regular, and increased in rate. This is common in diabetic ketoacidosis. With Cheyne-Stokes respirations, respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. The respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses, and breathing slows and becomes shallow, climaxing in apnea before respiration resumes. With Biot’s respirations, respirations are abnormally shallow for two to three breaths followed by an irregular period of apnea. With bradypnea, the rate of breathing is regular but abnormally slow (fewer than 12 breaths per minute).

DIF: Cognitive Level: Analysis REF: Text reference: p. 89

OBJ: Accurately assess a patient’s respirations. TOP: Breathing Patterns

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. What is a disadvantage of using the disposable sensor pad for pulse oximetry?

a.	It is less restrictive.
b.	It contains latex.
c.	It is less expensive to use.
d.	It is available in different sizes.

ANS: B

A disposable sensor pad can be applied to a variety of sites, including the earlobe of an adult and the nose bridge, palm, or sole of an infant. It is less restrictive for continuous SpO₂ monitoring. It is expensive and contains latex, which some patients may not be able to tolerate. The skin under the adhesive may become moist and may harbor pathogens. It is available in a variety of sizes, and the pad can be matched to infant weight.

DIF: Cognitive Level: Application REF: Text reference: p. 101

OBJ: Accurately assess a patient’s oxygenation status using pulse oximetry.

TOP: Oxygen Saturation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. The nurse is preparing to take the patient’s temperature. Which of the following may cause the temperature to fluctuate? (Select all that apply.)

a.	Age
b.	Stress
c.	Hormones
d.	Medications

ANS: A, B, C, D

Older adults have a narrower range of temperature than younger adults. A temperature within an acceptable range in an adult may reflect a fever in an older adult. Undeveloped temperature control mechanisms in infants and children cause temperature to rise and fall rapidly. Stress elevates temperature. Women have wider temperature fluctuations than men because of menstrual cycle hormonal changes; body temperature varies during menopause. Some drugs impair or promote sweating, vasoconstriction, or vasodilation, or interfere with the ability of the hypothalamus to regulate temperature.

DIF: Cognitive Level: Analysis REF: Text reference: p. 70

OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Temperature Assessment

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. Which of the following processes are involved in respiration? (Select all that apply.)

a.	Ventilation
b.	Diffusion
c.	Oximetry
d.	Perfusion

ANS: A, B, D

Three processes are involved in respiration: ventilation, mechanical movement of gases into and out of the lungs; diffusion, movement of O₂ and CO₂ between the alveoli and the red blood cells; and perfusion, distribution of red blood cells to and from the pulmonary capillaries.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 86

OBJ: Accurately assess a patient’s respirations. TOP: Respiratory Assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. The nurse is about to teach the patient about risk factors for hypertension. Which of the following are risk factors for hypertension? (Select all that apply.)

a.	Obesity
b.	Cigarette smoking
c.	High blood cholesterol
d.	Renal disease

ANS: A, B, C, D

Persons with a family history of hypertension, premature heart disease, lipemia, or renal disease are at significant risk. Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued exposure to stress from psychosocial and environmental conditions are factors linked to hypertension.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 93

OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Teaching Considerations

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. The nurse is about to take a patient’s blood pressure. Which of the following conditions would cause the nurse to obtain a false high reading? (Select all that apply.)

a.	Bladder or cuff too narrow
b.	Bladder or cuff too wide
c.	Patient’s arm below the level of the heart
d.	Inflating the cuff too slowly

ANS: A, C, D

Bladder or cuff too narrow or too short, arm below heart level, or inflating the cuff too slowly will give a false high reading. A bladder or cuff too wide will give a false low reading.

DIF: Cognitive Level: Analysis REF: Text reference: p. 92

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Common Mistakes in Blood Pressure Assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

COMPLETION

1. ___________, a subjective symptom, is also referred to as a vital sign, along with the physiological signs.

ANS:

Pain

Pain, a subjective symptom, is also referred to as a vital sign, along with the physiological signs.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 66

OBJ: Identify when it is appropriate to assess each vital sign. TOP: Pain as a Vital Sign

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. When heat loss mechanisms are unable to keep pace with heat production, ____________ is the result.

ANS:

fever

Fever occurs when heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature.

DIF: Cognitive Level: Analysis REF: Text reference: p. 67

OBJ: Describe factors that cause variations in body temperature, pulse, blood pressure, oxygen saturation, and respirations. TOP: Core Temperature

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. The nurse is taking a rectal temperature on an adult patient. She expects to insert the thermometer __________ inches.

ANS:

1.5

Gently insert the thermometer into the anus in the direction of the umbilicus 3.5 cm (1.5 inches) for an adult. Do not force the thermometer.

DIF: Cognitive Level: Application REF: Text reference: p. 72

OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures. TOP: Rectal Temperature Assessment

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The patient has been sleeping and has been lying on his right side. The nurse is ready to take his temperature using a tympanic thermometer. She needs to insert the thermometer into his ___________ ear.

ANS:

left

If the patient has been lying on one side, use the upper ear. Heat trapped in the ear facing down will cause a false high temperature reading.

DIF: Cognitive Level: Application REF: Text reference: p. 74

OBJ: Accurately assess a patient’s oral, rectal, axillary, tympanic membrane, and temporal artery temperatures. TOP: Tympanic Membrane Temperature Assessment

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. An irregular heartbeat, often found in children, that speeds up with inspiration and slows down with expiration is known as a sinus ___________.

ANS:

dysrhythmia

Children often have a sinus dysrhythmia, which is an irregular heartbeat that speeds up with inspiration and slows down with expiration.

DIF: Cognitive Level: Analysis REF: Text reference: p. 80

OBJ: Accurately assess a patient’s radial and apical pulses.

TOP: Pulse Assessment—Pediatric Considerations

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. ___________ is the sound of the tricuspid and mitral valves closing at the end of ventricular filling.

ANS:

S1

S1 is the sound of the tricuspid and mitral valves closing at the end of ventricular filling, just before systolic contraction begins.

DIF: Cognitive Level: Application REF: Text reference: p. 81

OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Assessing Apical Pulse

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. _________ is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction.

ANS:

S2

S2 is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction.

DIF: Cognitive Level: Application REF: Text reference: p. 81

OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Assessing Apical Pulse

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a ____________.

ANS:

pulse deficit

An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. Pulse deficits frequently are associated with dysrhythmias and warn of potentially decreased cardiac function.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 85

OBJ: Accurately assess a patient’s radial and apical pulses. TOP: Pulse Deficit

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. To take a manual blood pressure, the nurse places the cuff of the _____________ around the patient’s upper arm.

ANS:

sphygmomanometer

The most common technique of measuring blood pressure is auscultation using a sphygmomanometer and stethoscope.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 90

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Sphygmomanometer KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. After applying the sphygmomanometer to the patient’s upper arm, the nurse inflates the cuff to the proper level, and then, using a stethoscope, listens for the __________________ sounds.

ANS:

Korotkoff

The most common technique used for measuring blood pressure is auscultation with a sphygmomanometer and stethoscope. As the sphygmomanometer cuff is deflated, the five different sounds heard over an artery are called Korotkoff phases. The sound in each phase has unique characteristics. Blood pressure is recorded with the systolic reading (first Korotkoff sound) before the diastolic reading (beginning of the fifth Korotkoff sound).

DIF: Cognitive Level: Application REF: Text reference: p. 90

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Korotkoff Sounds KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. _____________ occurs when the systolic blood pressure falls to 90 mm Hg or below.

ANS:

Hypotension

Hypotension occurs when the systolic blood pressure falls to 90 mm Hg or below. Although some adults normally have a low blood pressure, for most people, low blood pressure is an abnormal finding associated with illness.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 91

OBJ: Accurately assess a patient’s blood pressure using techniques of auscultation and palpation.

TOP: Hypotension KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

1. The percent to which hemoglobin is filled with oxygen is known as _________________.

ANS:

arterial blood oxygen saturation

Pulse oximetry is the noninvasive measurement of arterial blood oxygen saturation—the percent to which hemoglobin is filled with oxygen.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 101

OBJ: Accurately assess a patient’s oxygenation status using pulse oximetry.

TOP: Oxygen Saturation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

Chapter 7: Medical Asepsis

MULTIPLE CHOICE

1. The nurse understands that the priority nursing action needed when medical asepsis is used includes:

a.	handwashing.
b.	surgical procedures.
c.	autoclaving of instruments.
d.	sterilization of equipment.

ANS: A

Medical asepsis, or clean technique, includes procedures used to reduce the number, and prevent the spread, of microorganisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis. Surgical asepsis, or sterile technique, includes procedures used to eliminate all microorganisms from an area. Sterilization destroys all microorganisms and their spores. The techniques used in maintaining surgical asepsis are more rigid than those performed under medical asepsis.

DIF: Cognitive Level: Application REF: Text reference: pp. 166-167

OBJ: Explain the difference between medical and surgical asepsis.

TOP: Medical Asepsis KEY: Nursing Process Step: Intervention

MSC: NCLEX: Physiological Integrity

1. Handwashing with soap and water is:

a.	the most effective way to reduce the number of bacteria on the nurse’s hands.
b.	more effective than alcohol-based products for washing hands.
c.	necessary for hand hygiene if hands are visibly soiled.
d.	not necessary if the nurse wears artificial nails.

ANS: C

Soap and water is still necessary for hand hygiene if hands are visibly soiled. Recent research has shown that handwashing with plain soap sometimes results in paradoxical increases in bacterial counts on the skin. Alcohol-based products have been more effective for standard handwashing or hand antisepsis than soap or antiseptic soaps. Studies have shown the efficacy of alcohol-based hand sanitizers in reducing infection in a variety of settings from intensive care to long-term care. Studies have shown that health care workers with chipped nail polish or long or artificial nails have high numbers of bacteria on their fingertips. For this reason, the CDC recommends that health care workers not wear artificial nails and extenders, and that they keep natural nails less than one-quarter of an inch long when caring for high-risk patients.

DIF: Cognitive Level: Analysis REF: Text reference: p. 168

OBJ: Describe factors that can influence nursing staff compliance with hand hygiene.

TOP: Hand Hygiene KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. When caring for patients, the nurse understands that the single most important technique to prevent and control the transmission of infection is:

a.	hand hygiene.
b.	the use of disposable gloves.
c.	the use of isolation precautions.
d.	sterilization of equipment.

ANS: A

The most important and most basic technique in preventing and controlling transmission of infection is hand hygiene. Use of disposable gloves may help reduce the transmission of infection, but it is not the single most important technique to prevent and control the transmission of infection. Neither the use of isolation precautions nor the sterilization of equipment is the single most important technique to prevent and control the transmission of infection.

DIF: Cognitive Level: Application REF: Text reference: p. 168

OBJ: Describe factors that can influence nursing staff compliance with hand hygiene.

TOP: Hand Hygiene KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. Which of the following measures is appropriate when a nurse is washing his or her hands?

a.	Use very hot water.
b.	Leave rings and watches in place.
c.	Lather for at least 15 to 20 seconds.
d.	Keep the fingers and hands up and the elbows down.

ANS: C

Perform hand hygiene using plenty of lather and friction for at least 15 to 20 seconds. Interlace fingers and rub palms and back of hands with circular motion at least 5 times each. Keep fingertips down to facilitate removal of microorganisms. Hot water can be damaging to the skin. Regulate the flow of water so that the temperature is warm. Warm water removes less of the protective oils on the hands than hot water. Jewelry and watches can be a place for pathogens to hide. Push wristwatch and long uniform sleeves above wrists. Avoid wearing rings. If worn, remove during washing. This provides complete access to fingers, hands, and wrists. Wearing of rings increases the numbers of microorganisms on the hands. The position of hands and arms will aid in washing pathogens away. Wet hands and wrists thoroughly under running water. Keep hands and forearms lower than elbows during washing. Hands are the most contaminated parts to be washed. Water flows from the least to the most contaminated area, rinsing microorganisms into the sink.

DIF: Cognitive Level: Application REF: Text reference: p. 171

OBJ: Perform proper procedures for hand hygiene. TOP: Hand Hygiene

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The nurse shows an understanding of the psychological implications for a patient on isolation when planning care to control the risk for:

a.	denial.
b.	aggression.
c.	regression.
d.	isolation.
e.	depression.

ANS: D

A sense of loneliness may develop because normal social relationships become disrupted. The nurse should plan care to control the risk that the patient may feel isolated. Denial and regression are not risks related to isolation. Aggression is not a risk for the patient on isolation precautions.

DIF: Cognitive Level: Application REF: Text reference: p. 168

OBJ: Perform correct isolation techniques. TOP: Isolation

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

1. An appropriate technique for the nurse to implement for the patient on isolation precautions is to:

a.	double-bag all disposable items and linens.
b.	put another gown over the one worn if it has become wet.
c.	place specimen containers in plastic bags for transport.
d.	hand items to be reused directly to a nurse standing outside the room.

ANS: C

Transfer the specimen to a container without soiling the outside of the container. Place the container in a plastic bag and label the outside of the bag or as per agency policy. Specimens of blood and body fluids are placed in well-constructed containers with secure lids to prevent leaks during transport. Use single bags that are impervious to moisture and sturdy to contain soiled articles. Use the double-bagging technique if necessary for heavily soiled linen or heavy wet trash. Linen or refuse should be totally contained to prevent exposure of personnel to infective material. Avoid allowing the isolation gown to become wet; carry the wash basin outward, away from the gown; avoid leaning against wet tabletops. Moisture allows organisms to travel through the gown to the uniform. Remove all reusable pieces of equipment. Clean any contaminated surfaces with hospital-approved disinfectant. All items must be properly cleaned, disinfected, or sterilized for reuse.

DIF: Cognitive Level: Application REF: Text reference: p. 176

OBJ: Perform correct isolation techniques. TOP: Isolation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. Before entering the room of a patient on isolation where all protective barriers are required, the nurse first puts on the:

a.	gown.
b.	gloves.
c.	eyewear.
d.	mask/respirator.

ANS: A

Apply the gown first, making sure that it covers all outer garments. Pull sleeves down to the wrist. Tie securely at the neck and waist. Next, apply either a surgical mask or a fitted respirator around the mouth and nose. Goggles or a face shield is put on after the gown and mask are applied. Gloves are put on last.

DIF: Cognitive Level: Application REF: Text reference: p. 174

OBJ: Perform correct isolation techniques. TOP: Isolation

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

1. The patient is presenting to the hospital with a high fever and a productive cough. He says that he hasn’t felt right since he returned from visiting Somalia about a month before admission. He also states that he has lost about 20 pounds in the last month and frequently wakes up in the middle of the night sweaty and “clammy.” What should the nurse prepare to do?

a.	Place the patient on contact isolation.
b.	Place the patient in a negative-pressure room.
c.	Place the patient on droplet precautions.
d.	Use standard precautions only.

ANS: B

Suspect tuberculosis (TB) in any patient with respiratory symptoms lasting longer than 3 weeks accompanied by other suspicious symptoms, such as unexplained weight loss, night sweats, fever, and a productive cough often streaked with blood. Isolation for patients with suspected or confirmed TB includes placing the patient on airborne precautions in a single-patient negative-pressure room. In addition to standard precautions, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient’s environment. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection and colonization with multidrug-resistant bacteria judged by the infection control program as follows: (1) enteric with a low infectious dose or prolonged environmental survival, including Clostridium difficile, Escherichia coli, Shigella, hepatitis A, or rotavirus; (2) skin infections that are highly contagious or that may occur on dry skin, including diphtheria (cutaneous), herpes simplex virus (neonatal or mucocutaneous), impetigo, major (noncontained) abscesses, cellulitis, decubiti, pediculosis, scabies, staphylococcal furunculosis in infants and young children, or zoster; or (3) viral/hemorrhagic conjunctivitis or viral hemorrhagic infection (Ebola, Lassa, or Marburg). In addition to standard precautions, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, epiglottitis, and sepsis; and invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis. Other serious bacterial respiratory infections spread by droplet transmission include diphtheria (pharyngeal), Mycoplasma pneumoniae, pertussis, pneumonic plague, streptococcal pharyngitis, pneumonia, and scarlet fever in infants and young children. Serious viral infections spread by droplet transmission include adenovirus, influenza, mumps, parvovirus B19, and rubella.

DIF: Cognitive Level: Synthesis REF: Text reference: p. 172

OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Airborne Precautions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. For patients with which of the following conditions should the nurse implement airborne precautions?

a.	Rubella
b.	Influenza
c.	Tuberculosis
d.	Pediculosis

ANS: C

In addition to standard precautions, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include measles, varicella (including disseminated zoster), and TB. Airborne precautions are not appropriate for viral infections spread by droplet transmission, including adenovirus, influenza, mumps, parvovirus B19, and rubella. Contact precautions would be appropriate for a patient with pediculosis.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 173

OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Airborne Precautions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The patient is admitted to the pediatric unit with severe pertussis. The nurse explains to the parents and the child that the patient will be treated with the use of:

a.	airborne precautions.
b.	standard precautions only.
c.	droplet precautions.
d.	contact isolation.

ANS: C

In addition to standard precautions, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include invasive Haemophilus influenzae type b disease, invasive Neisseria meningitidis disease, and other serious bacterial respiratory infections spread by droplet transmission, such as diphtheria (pharyngeal), Mycoplasma pneumoniae, and pertussis. Pertussis is spread by large particle droplets. For infection spread via airborne routes, use airborne precautions, in addition to standard precautions. Examples of such illnesses include measles, varicella, and TB. Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. Persons who have infections that are spread by large particle droplets, such as pertussis, need more than just standard precautions. Pertussis is not spread through direct patient contact. For patients known or suspected to have serious illnesses easily transmitted by direct patient contact, or by contact with items in the patient’s environment, use contact precautions in addition to standard precautions. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection, Clostridium difficile, Escherichia coli, Shigella, hepatitis A, rotavirus, and skin infections that are highly contagious or that may occur on dry skin.

DIF: Cognitive Level: Analysis REF: Text reference: p. 173

OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Droplet Precautions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. Droplet precautions will be instituted for the patient admitted to the infectious disease unit with:

a.	streptococcal pharyngitis.
b.	herpes simplex.
c.	pulmonary TB.
d.	measles.

ANS: A

Droplet precautions are instituted when droplets are larger than 5 µm, as in the case of streptococcal pharyngitis. Contact precautions are instituted for herpes simplex. Airborne precautions are instituted for pulmonary TB and measles.

DIF: Cognitive Level: Analysis REF: Text reference: p. 73

OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Droplet Precautions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The patient has been hospitalized for several days and has received multiple intravenous antibiotic medications. This morning, the patient had three episodes of severe, foul-smelling diarrhea. The nurse should institute:

a.	contact precautions.
b.	standard precautions only.
c.	airborne precautions.
d.	droplet precautions.

ANS: A

In addition to standard precautions, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient’s environment. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection and colonization with multidrug-resistant bacteria judged by the infection control program as follows: (1) enteric with a low infectious dose or prolonged environmental survival, including Clostridium difficile, Escherichia coli, Shigella, hepatitis A, or rotavirus; or (2) skin infections that are highly contagious or that may occur on dry skin. Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. Patients who may be infected by pathogens that can be spread through direct patient contact may need more. The patient is not exhibiting signs of infection/colonization by pathogens that can be spread via the airborne route. In addition to standard precautions, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include measles, varicella, and TB. The patient is not exhibiting signs of infection/colonization by pathogens that can be spread via large particle droplets. In addition to standard precautions, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include invasive Haemophilus influenzae type b disease, pertussis, pneumonic plague, streptococcal pharyngitis, pneumonia, and scarlet fever in infants and young children, as well as mumps, parvovirus B19, and rubella.

DIF: Cognitive Level: Analysis REF: Text reference: pp. 172-173

OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Contact Precautions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. What should the nurse do to break the chain of infection at the reservoir level?

a.	Change a soiled dressing.
b.	Keep drainage systems intact.
c.	Cover the nose and mouth when sneezing.
d.	Avoid contact of the uniform with soiled items.

ANS: A

The reservoir is the site or source of microorganism growth. Control: sources of body fluids and drainage. Perform hand hygiene. Bathe the client with soap and water. Change soiled dressings. Dispose of soiled tissues, dressings, or linen in moisture-resistant bags. Place syringes, uncapped hypodermic needles, and intravenous needles in designated puncture-proof containers. Keep table surfaces clean and dry. Do not leave bottled solutions open for prolonged periods. Keep solutions tightly capped. Keep surgical wound drainage tubes and collection bags patent. Empty and dispose of drainage suction bottles according to agency policy. The portal of entry is the site through which a microorganism enters a host. Urinary: Keep all drainage systems closed and intact, maintaining downward flow. The portal of exit is the means by which microorganisms leave a site. Respiratory: Avoid talking, sneezing, or coughing directly over a wound or sterile dressing field. Cover nose and mouth when sneezing or coughing. Wear mask if suffering respiratory tract infection. Transmission is the means of spread. Reduce microorganism spread. Perform hand hygiene. Use personal set of care items for each client. Avoid shaking bed linen or clothes; dust with damp cloth. Avoid contact of soiled item with uniform.

DIF: Cognitive Level: Analysis REF: Text reference: p. 167

OBJ: Identify nursing care measures intended to break the chain of infection.

TOP: Breaking the Chain of Infection KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The patient is admitted with mumps. The nurse knows that she will have to:

a.	put the patient in a private room.
b.	place the patient on standard precautions.
c.	wear a mask when closer than 3 feet to the patient.
d.	place the patient on contact precautions.

ANS: C

For diseases transmitted by large droplets (larger than 5 µm), such as streptococcal pharyngitis, pneumonia, scarlet fever in infants or small children, pertussis, mumps, meningococcal pneumonia or sepsis, or pneumonic plague, place the patient in a private room, or cohort the patient and wear a mask when closer than 3 feet from the patient. For diseases transmitted by small droplet nuclei (smaller than 5 µm), such as measles, chickenpox, disseminated varicella zoster, and pulmonary or laryngeal TB, place the patient on airborne precautions in a private room with negative airflow of at least six air exchanges per hour, and wear a respirator or mask. Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. For diseases transmitted by direct patient or environmental contact, such as colonization or infection with multidrug-resistant organisms, respiratory syncytial virus, major wound infection, herpes simplex, and scabies, place the patient on contact precautions in a private room, or cohort the patient. Wear gloves and gowns.

DIF: Cognitive Level: Analysis REF: Text reference: p. 173

OBJ: Identify nursing care measures intended to break the chain of infection.

TOP: Breaking the Chain of Infection KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. For an infection to take place, which of the following must be present? (Select all that apply.)

a.	Pathogen and reservoir
b.	Portals of exit and entry
c.	Mode of transmission
d.	Susceptible host

ANS: A, B, C, D

The mere presence of a pathogen does not mean that an infection will begin. Development of an infection occurs in a cyclic process, often referred to as the chain of infection, which depends on the following six elements: an infectious agent or pathogen, a reservoir or source for pathogen growth, a portal of exit from the reservoir, a mode of transmission, a portal of entry to the host, and a susceptible host.

DIF: Cognitive Level: Analysis REF: Text reference: p. 166

OBJ: Explain how each element of the infection chain contributes to infection.

TOP: Chain of Infection KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

1. If hands are not visibly soiled, the nurse may use an alcohol-based hand rub in which of the following situations? (Select all that apply.)

a.	Before having direct contact with patients
b.	After contact with a patient’s intact skin
c.	After contact with body fluids or excretions
d.	After removing gloves

ANS: A, B, C, D

If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands before having direct contact with patients, before putting on sterile gloves, and before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices; after contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure, lifting a patient); after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled; when moving from a contaminated body site to a clean body site during care; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; and after removing gloves.

DIF: Cognitive Level: Application REF: Text reference: p. 169

OBJ: Perform proper procedures for hand hygiene. TOP: Hand Hygiene

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The nurse is planning to care for a patient diagnosed with possible tuberculosis (TB). Assessment of possible TB may be based on which of the following? (Select all that apply.)

a.	A positive AFB smear or culture
b.	Signs or symptoms of TB
c.	Cavitation on chest x-ray study
d.	History of recent exposure
e.	TB skin test

ANS: A, B, C, D

Signs of infectious pulmonary or laryngeal TB include documentation of positive AFB smear or culture, signs or symptoms of TB, cavitation on chest x-ray study, history of recent exposure, and physician progress notes indicating a plan to rule out TB.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 172

OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Assessment of Potential TB KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

COMPLETION

1. Infection control practices that reduce and eliminate sources and transmission of infection are known as _______________.

ANS:

transmission-based precautions

Transmission-based precautions are infection control practices that reduce and eliminate sources and transmission of infection and help to protect patients and health care providers from disease.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 172-173

OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Transmission-Based Precautions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The nurse has a “scratchy throat” and has been sniffling for 2 days. While at work, she wears a protective mask when coming into contact with her patients. She does this in an attempt to protect them from a __________________.

ANS:

health care–acquired infection (HAI)

Health care–acquired infections (HAIs) are those that develop as a result of contact with a health care facility/provider; the infection was not present or incubating at the time of admission.

DIF: Cognitive Level: Analysis REF: Text reference: p. 166

OBJ: Identify nursing care measures intended to break the chain of infection.

TOP: Health Care–Acquired Infection KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. ________________ is the absence of pathogenic (disease-producing) microorganisms.

ANS:

Asepsis

Asepsis is the absence of pathogenic (disease-producing) microorganisms.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 166

OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Asepsis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

1. The nurse is preparing to provide care for the patient. Before making patient contact, she washes her hands. This practice is known as __________________.

ANS:

medical asepsis

Medical asepsis, or clean technique, includes procedures used to reduce the number, and prevent the spread, of microorganisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 166-167

OBJ: Explain the difference between medical and surgical asepsis.

TOP: Medical Asepsis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

1. _______________, also known as sterile technique, includes procedures used to eliminate all microorganisms from an area.

ANS:

Surgical asepsis

Surgical asepsis, or sterile technique, includes procedures used to eliminate all microorganisms from an area. Sterilization destroys all microorganisms and their spores.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 167

OBJ: Explain the difference between medical and surgical asepsis.

TOP: Surgical Asepsis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

1. The primary strategies for prevention of infection transmission with regard to contact with blood, body fluids, nonintact skin, and mucous membranes are known as ______________.

ANS:

standard precautions

Standard precautions, the primary strategies for prevention of infection transmission, apply to contact with (1) blood, (2) body fluids, (3) nonintact skin, and (4) mucous membranes, as well as with equipment or surfaces contaminated with these potentially infectious materials.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 172

OBJ: Perform correct isolation techniques. TOP: Standard Precautions

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

1. OSHA and CDC guidelines require health care workers who care for suspected or confirmed TB patients to wear special ________________.

ANS:

respirators

OSHA and CDC guidelines require health care workers who care for suspected or confirmed TB patients to wear special respirators. These respirators are high-efficiency particulate masks that have the ability to filter particles at 95% or better efficiency. Health care workers who use these respirators must be fit-tested in a reliable way to obtain a face-seal leakage of 10% or less.

DIF: Cognitive Level: Application REF: Text reference: p. 172

OBJ: Perform correct isolation techniques.

TOP: OSHA Guidelines—Respirators KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The nurse is applying for a position at a local hospital. As part of the employment criteria, she will be required to be assessed for TB exposure. She should be prepared for the ___________ blood test to be scheduled.

ANS:

QuantiFERON-TB Gold test (QFT-G)

The CDC now recommends use of the QuantiFERON-TB Gold test (QFT-G) (CDC, 2005), a blood test, in place of the traditional TB skin test. The advantages of the QFT-G test are that it does not boost responses measured by subsequent tests, and the results are not subject to reader bias.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 172

OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: OSHA Guidelines—TB Testing KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

1. The nurse knows that the basic concept of all patient care that is implemented to prevent the spread of infection from blood, body fluids, secretions, excretions, nonintact skin, and mucus membranes is __________________.

ANS:

standard precautions

Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes.

DIF: Cognitive Level: Application REF: Text reference: p. 172

OBJ: Discuss how to apply critical thinking in the prevention of the transmission of infection.

TOP: Standard Precautions KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

Chapter 11: Orthopedic Measures

MULTIPLE CHOICE

1. According to the National Association of Orthopaedic Nurses (NAON), which of the following is possibly the most effective cleansing solution for pin-site care?

a.	Normal saline
b.	Hydrogen peroxide
c.	Chlorhexidine
d.	None of the above

ANS: C

The second group to develop clinical practice guidelines is the United States–based NAON, which indicated that chlorhexidine 2 mg/mL solution is possibly the most effective cleansing solution for pin-site care. A British consensus group of orthopedic nurse experts recommends that pin sites be cleaned only with sterile normal saline or water to remove crusts around the pins (Walker, 2007). Walker found no definitive evidence to support a pin-site dressing containing an antimicrobial agent. Several studies have found that although hydrogen peroxide is a common cleansing agent, it may cause damage to the healthy tissue surrounding the pin.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 264

OBJ: Explain nursing measures for complications from traction.

TOP: Pin-Site Care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The patient has a broken leg and needs to have a cast applied. When plaster of Paris is compared and contrasted versus the newer synthetic casts, which of the following statements is true?

a.	Plaster of Paris can tolerate earlier weight bearing than synthetic casts.
b.	Plaster of Paris is more expensive than synthetic casts.
c.	Synthetic casts can withstand contact with water better than plaster of Paris.
d.	Synthetic casts are lighter but take longer to set than plaster of Paris.

ANS: C

Although the newer synthetic casts are more expensive than plaster of Paris, they can withstand contact with water without crumbling. A plaster of Paris cast has multiple rolls of open-weave cotton saturated with calcium sulfate crystals. These casts are heavier than synthetic casts and take 24 to 72 hours with no weight bearing or application of pressure while drying. Synthetic casts are lightweight, set in 15 minutes, and can sustain weight bearing or pressure in 15 to 30 minutes.

DIF: Cognitive Level: Analysis REF: Text reference: p. 251

OBJ: Explain nursing measures for complications from traction.

TOP: Comparison of Cast Material KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

1. An expected outcome of cast application that the nurse evaluates is:

a.	skin irritation at the cast edges.
b.	decreased capillary refill and pallor.
c.	tingling and numbness distal to the cast.
d.	slight edema, soreness, and limited range of motion.

ANS: D

Expected outcomes after completion of the procedure: Patient initially experiences only slight edema, soreness, mild pain, and some limitation of active range of joint motion (ROJM) from being in the cast. Expected outcomes after completion of the procedure: Skin around proximal and distal cast edges remains intact without irritation, is free of pressure and friction from the cast edges, and is warm and of normal color with capillary refill of 3 seconds or less; and the patient verbalizes no abnormal or unusual sensations and is able to move the fingers or toes below the casted part. Neurovascular function to the body part is maintained.

DIF: Cognitive Level: Application REF: Text reference: p. 252

OBJ: Describe neurovascular assessments of a patient with an orthopedic injury.

TOP: Expected Outcomes KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

1. The patient is admitted for a fractured tibia. The nurse is preparing for cast application and expects to administer a(n) _____ to the patient minutes before the procedure.

a.	oral analgesic 10
b.	intramuscular (IM) analgesic 10
c.	intravenous (IV) analgesic 2 to 5
d.	muscle relaxant 10

ANS: C

Administer analgesic per order before cast application: IV, 2 to 5 minutes before the procedure. This is the most effective way to reduce pain during cast application.

Alternately, you could administer analgesic by mouth (PO), 30 to 40 minutes before cast application to obtain optimal analgesic effect. If administering analgesic via IM injection, give does 20 to 30 minutes before cast application for optimal analgesic effect. Administer muscle relaxant 30 minutes before cast application if spasms are present. Often, muscle spasms are treated more effectively with skeletal muscle relaxants than with opioids.

DIF: Cognitive Level: Application REF: Text reference: p. 252

OBJ: Describe how to assist in application of casts. TOP: Preprocedure Medication

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. An appropriate technique for the nurse to implement for the patient who is being casted is to:

a.	apply ice to the top of the cast.
b.	maintain the extremity below heart level.
c.	handle the wet cast with the fingertips.
d.	fold the stockinette or padding over the outer cast edges.

ANS: D

Assist with “finishing” by folding the stockinette or other padding down over the outer edge of the cast to provide a smooth edge. Smooth edges lessen possible skin irritation. When the cast is finished with a stockinette, later “petaling” with tape is not required when the cast is dry. Elevation and ice can be ordered, but ice would not be applied to the top of the wet cast because the weight could change the shape of the cast, causing indentations that can lead to pressure areas. Maintain elevation at or above heart level; elevation enhances venous return and decreases edema. Handle the casted extremity with palms only until the cast is dry. Fingers can cause indentations that can lead to pressure areas.

DIF: Cognitive Level: Application REF: Text reference: p. 254

OBJ: Describe how to assist in application of casts. TOP: Finishing the Cast

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. When teaching cast care, the nurse instructs the patient to:

a.	blow dry the wet cast on the “hot” setting.
b.	report changes in sensation or mobility to the area.
c.	use only soft objects to slide down the cast for scratching.
d.	cut away the edges of the cast if the skin becomes irritated.

ANS: B

The patient must monitor neurovascular status, paying particular attention to blueness or paleness of the nails, pain, a feeling of tightness, numbness, or a tingling sensation. Caution the patient against drying a wet cast with a hair dryer; this can cause plaster to crack or the skin underneath to be damaged. The patient should avoid sticking objects down or into the cast to scratch because these objects can cause breaks in underlying skin and subsequent infection. Inform the patient to inspect the cast and petal rough edges to reduce the risk of trauma to underlying skin and the need for cast changes. Small pieces (petals) of adhesive tape 2.5 to 5.0 cm (1 to 2 inches) are cut and taped smoothly over the edge of the cast.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 254-256

OBJ: Describe elements of education for the patient with a cast and after removal of a cast.

TOP: Cast Care KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

1. For cast removal, which of the following instructions should the nurse provide to the patient?

a.	Discomfort will be felt from the cast saw.
b.	An enzyme wash may be applied to intact skin.
c.	The skin will be scrubbed very well after the removal.
d.	Aggressive range-of-motion exercises will be performed after removal.

ANS: B

If the skin is intact, gently apply a cold water enzyme wash to the skin; let it stay on the skin 15 to 20 minutes. This helps dissolve or emulsify dead cells and fatty deposits on tissues and prevents injury to delicate tissue. A cast saw vibrates the cast loose; the patient will feel heat and vibration. Do not scrub the skin because this may traumatize delicate tissue and lead to skin breakdown. It may take several days before all residue is removed from the skin. Obtain a physician’s order to gently put joints through active and passive ROJM. Clarify the level of activity allowed. Joints and muscles will be stiff and weak. Activity is resumed slowly to avoid reinjury.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 257-258

OBJ: Describe elements of education for the patient with a cast and after removal of a cast.

TOP: Cast Removal KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The patient is brought into the emergency department after falling on the ice in her driveway. She is suspected of having a fractured hip. After comparing different available types of traction, she anticipates that which of the following will be used?

a.	Bryant’s traction
b.	Dunlop’s traction
c.	Buck’s extension
d.	Gallows traction

ANS: C

Buck’s extension provides temporary immobilization of a hip fracture until open reduction and internal fixation (ORIF) can be performed. It also reduces muscle spasms, contractures, and dislocations and occasionally is used as an interim treatment for lumbosacral muscle spasms that cause low back pain. Bryant’s traction (called Gallows in England) is no longer used because of the risk for gravitational vascular draining of the extremities and the possible tourniquet effect of bandages, triggering vasospasms and avascular necrosis. Dunlop’s traction is a simultaneous horizontal form of Buck’s extension to the humerus with an accompanying vertical Buck’s extension to the forearm.

DIF: Cognitive Level: Analysis REF: Text reference: p. 258

OBJ: Explain the purposes of placing a patient in skin or skeletal traction.

TOP: Buck’s Traction KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. Which type of traction does the nurse anticipate will be used for an adult patient with a fractured humerus?

a.	Bryant’s traction
b.	Dunlop’s traction
c.	Gallows traction
d.	Buck’s extension

ANS: B

Dunlop’s traction is a simultaneous horizontal form of Buck’s extension to the humerus with an accompanying vertical Buck’s extension to the forearm. Bryant’s traction (called Gallows in England) is no longer used because of the risk for gravitational vascular draining of the extremities and the possible tourniquet effect of bandages, triggering vasospasms and avascular necrosis. Buck’s extension provides temporary immobilization of a hip fracture until ORIF can be performed. It also reduces muscle spasms, contractures, and dislocations and occasionally is used as an interim treatment for lumbosacral muscle spasms that cause low back pain.

DIF: Cognitive Level: Analysis REF: Text reference: p. 258

OBJ: Explain the purposes of placing a patient in skin or skeletal traction.

TOP: Dunlop’s Traction KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. For a patient who is to be placed in Russell’s traction, the nurse prepares the:

a.	occipital area.
b.	arm and forearm.
c.	back and abdomen.
d.	lower extremities.

ANS: D

Russell’s traction is a modification of Buck’s extension in which Newton’s third law of motion (for each force in one direction, there is an equal force in the opposite direction) is used to double the amount of pull through the arrangement of ropes, pulleys, and weights.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 258

OBJ: Explain the purposes of placing a patient in skin or skeletal traction.

TOP: Russell’s Traction KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. The nurse places the patient in traction. Expected outcomes would include which of the following?

a.	Alignment of fracture fragments with formation of callus within 24 hours
b.	Verbalization of pain level as a “4” on a scale of 0 to 10
c.	Verbalization of immediate relief of symptoms
d.	Distal skin tissue becoming cooler, with capillary refill greater than 3 seconds

ANS: B

Expected outcomes would include verbalization of increased comfort after traction application and rating of pain as 4 or lower on a scale of 0 to 10 since injured tissues and bone are stabilized. Evidence of callus may not become apparent for 7 to 10 days or longer. Sufficient time in traction (varying from 1 to 10 or more days) elicits symptom relief. It takes time for inflammation to decrease and tissues to regain more normal function. Neurovascular status should remain stable. Distal skin tissue remains warm and of a normal color with capillary refill of 3 seconds or less.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 261-262

OBJ: Explain the purposes of placing a patient in skin or skeletal traction.

TOP: Expected Outcomes of Traction KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

1. While in Buck’s extension traction, the patient may be positioned on the back:

a.	with the head of the bed elevated 45 degrees.
b.	turning to the unaffected side for 10- to 15-minute periods.
c.	with the buttocks slightly elevated off of the bed.
d.	with the bed tilted toward the side that is opposite the traction.

ANS: B

Position varies with the part of the body to be placed in traction, plus effects of weight and gravity. Body parts are kept aligned anatomically. With Buck’s extension, the patient is primarily on his back but may be allowed to turn to the unaffected side for brief periods (10 to 15 minutes). With Buck’s extension, the patient is on his back with the head of the bed flat or elevated no more than 30 degrees. With Dunlop’s traction, the patient may be tilted on low-shock blocks toward the side opposite the traction.

DIF: Cognitive Level: Application REF: Text reference: p. 261

OBJ: Explain the purposes of placing a patient in skin or skeletal traction.

TOP: Positioning KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. An appropriate technique for the nurse to implement for a patient who is being placed in traction is to:

a.	apply a traction boot tightly.
b.	drop the weights after the traction is attached.
c.	assess neurovascular status every 1 to 2 hours for the first day.
d.	shave the hair off the area where traction is to be placed.

ANS: C

Assess neurovascular status 15 minutes after application of skin traction and every 1 to 2 hours for 24 hours, and then extend to every 4 hours if the patient is stabilizing. Ensure that boot size is correct. A traction boot should fit snugly (not too tight or too loose). Too tight leads to pressure on skin, peroneal nerve, and vascular structures. When all traction materials and spreader bars are in place, weights are placed on weight holders and are attached to a loop in the rope. The weights then are lowered slowly and gently until the rope is taut. Traction is established slowly to avoid involuntary muscle spasms or pain for the patient. Shaving may create micro nicks that could become inflamed under traction strips.

DIF: Cognitive Level: Application REF: Text reference: pp. 261-262

OBJ: Explain the purposes of placing a patient in skin or skeletal traction.

TOP: Evaluation of Traction KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

1. For a patient in traction who has skeletal pins, the nurse should:

a.	use povidone-iodine to cleanse the pin site.
b.	apply antiseptic ointment and cover with a split dressing.
c.	use hydrogen peroxide as a rinse before a dressing is applied.
d.	do both pin sites at the same time, with the same swab and solution.

ANS: B

Using a sterile applicator, apply a small amount of topical antibiotic ointment to the pin site and cover with a sterile 2 ´ 2 split gauze dressing. (Note: Some physicians leave the site uncovered.) Dip a sterile cotton-tipped applicator into a sterile container of chlorhexidine 2 mg/mL solution. Place a sterile applicator by the pin, and roll it along the skin, away from the insertion site. Clean outward in a circular fashion from the pin. Dispose of the applicator. Remove crusts from the pin site when signs of infection are present. Chlorhexidine 2 mg/mL is the most effective cleansing solution for pin-site care. Never touch one pin site with material used on another. This prevents cross-contamination.

DIF: Cognitive Level: Application REF: Text reference: p. 266

OBJ: Describe steps for applying each form of skin or skeletal traction.

TOP: Pin Care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. For a patient with a fractured femur, a nurse is alert to the possibility of a fat embolus. What should the nurse specifically watch for?

a.	Bradypnea
b.	Restlessness
c.	Bradycardia
d.	Calf pain

ANS: B

Assess for indicators of hypoxemia, such as restlessness or agitation. Recognize early signs of fat embolism syndrome. Signs of hypoxemia include tachypnea, not bradypnea. Signs of hypoxemia include tachycardia, not bradycardia. Calf pain would indicate a DVT, not a fat embolism.

DIF: Cognitive Level: Application REF: Text reference: p. 267

OBJ: Explain nursing measures for complications from traction.

TOP: Fat Embolism Syndrome KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

1. In planning nursing care, the nurse knows that she will need to provide an abduction pillow for which patient?

a.	A patient who will be immobilized for a long time
b.	A patient who has undergone repair of a fractured right arm
c.	A patient who is post hip replacement surgery
d.	A patient who has a severely sprained ankle

ANS: C

The abduction splint or pillow, used after hip replacement surgery, maintains the patient’s legs in an abducted position. This permits the patient to be turned without changing the position of the healing limb, and prevents dislocation of the hip prosthesis.

DIF: Cognitive Level: Application REF: Text reference: p. 268

OBJ: Explain nursing measures for complications from immobilization.

TOP: Abduction Pillows KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. The nurse is caring for a patient who has had a new cast applied. The nurse is performing a neurovascular assessment so as to detect signs of possible compartment syndrome. Which of the following are signs of compartment syndrome? (Select all that apply.)

a.	Inability to move body parts distal to the cast
b.	Pain on passive motion of distal body parts
c.	Hyperventilation
d.	Tachycardia

ANS: A, B, C, D

Signs of development of compartment syndrome, cast syndrome, or severe claustrophobia may result from snugness of the cast, which is common for patients in a spica or body cast. Observe the patient for signs of pain or anxiety; ask the patient to rate pain on a scale from 0 to 10; observe for inability to move body parts distal to the cast, pain on passive motion of distal body parts, hyperventilation, swallowing of air (aerophagia), nausea and/or vomiting, tachycardia, and blood pressure elevation.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 255

OBJ: Describe neurovascular assessments of a patient with an orthopedic injury.

TOP: Compartment Syndrome KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

1. The patient is in traction and is at risk for fat embolism syndrome. Signs and symptoms of fat embolism include which of the following? (Select all that apply.)

a.	Chest pain
b.	Tachypnea
c.	Tachycardia
d.	Apprehension
e.	Altered LOC

ANS: A, B, C, D

Symptoms of possible fat embolism include clinical manifestations of dyspnea, tachycardia, cyanosis, and circulatory collapse.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 267

OBJ: Explain nursing measures for complications from traction.

TOP: Fat Embolism Syndrome KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

1. The patient has been in skeletal traction for external fixation of his femur for 2 days. Suddenly, he calls the nurse complaining of chest pain and shortness of breath. The nurse notes that the patient appears anxious, and that his pulse and respirations are elevated. She should do which of the following? (Select all that apply.)

a.	Massage the lower extremity
b.	Elevate the head of the bed
c.	Administer oxygen
d.	Notify the physician

ANS: B, C, D

If symptoms of pulmonary embolus are evident, elevate the head of the bed (if conscious), administer oxygen, and notify the physician immediately. Do not massage the lower extremity.

DIF: Cognitive Level: Application REF: Text reference: p. 267

OBJ: Explain nursing measures for complications from traction.

TOP: Pulmonary Embolism KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. Skeletal traction is implemented primarily for: (Select all that apply.)

a.	simple fracture.
b.	multiple trauma.
c.	fractured ankle.
d.	acetabular fracture.
e.	cervical fracture.

ANS: B, C, D, E

Skeletal traction immobilizes fractures of the cervical spine, fractures of the femur below the trochanter, and some fractures of the bones of the arm or ankle. It is also used to immobilize the femoral head in an acetabular fracture.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 263

OBJ: Describe steps for applying each form of skin or skeletal traction.

TOP: Evaluation of Traction KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

COMPLETION

1. __________________ involves monitoring for the five Ps (pain, pallor, pulselessness, paresthesia, and paralysis).

ANS:

Neurovascular assessment

It is essential to monitor for the five Ps (pain, pallor, pulselessness, paresthesia, and paralysis) of neurovascular status because permanent damage may result if circulation is not restored or pressure is not removed.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 256

OBJ: Explain nursing measures for complications from traction.

TOP: Neurovascular Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

1. The patient has fallen and broken her leg. To keep the leg bones aligned and to reduce muscle spasms, the physician orders the patient to be placed in ____________.

ANS:

Buck’s traction

Buck’s traction is the most common type of adult skin traction. It is applied to the legs to provide temporary immobilization of the hip while reducing muscle spasms, contractures, and dislocations.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 258-259

OBJ: Explain nursing measures for complications from traction.

TOP: Traction KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

1. A _______________ is an externally applied structure that holds musculoskeletal tissues in a specific position to permit healing of injuries or fractures or to align malpositioned tissues.

ANS:

cast

A cast is an externally applied structure that holds musculoskeletal tissues in a specific position to permit healing of injuries or fractures or to align malpositioned tissues, as in clubfoot or congenital hip dislocation.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 250

OBJ: Explain nursing measures for complications from traction.

TOP: Cast KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. After application of the cast, the nurse ensures that plaster crumbs are removed and rough edges are _________ to prevent skin breakdown.

ANS:

petaled

After application of the cast, ensure that plaster crumbs are removed and rough edges are “petaled” to prevent skin breakdown.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 254

OBJ: Explain nursing measures for complications from traction.

TOP: Petaling KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. When applying a plaster of Paris cast, it is important to keep the cast exposed for at least _____________ minutes.

ANS:

15

fifteen

Explain that the patient may experience warmth during the cast application process. Plaster gives off heat from a chemical reaction when drying. Keep the cast exposed to permit maximum dissipation of the heat. Most casts cool in about 15 minutes.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 253

OBJ: Describe how to assist in application of casts. TOP: Heat Dissipation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. After applying a cast, the nurse should be able to insert _______ fingers between the cast and the limb.

ANS:

2

two

Plaster must be of sufficient thickness to give strength to the cast. More than two fingers’ space in the cast indicates that the cast is too loose and will not support the limb; less than two fingers’ space indicates that the cast may be too tight and may inhibit circulation.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 255

OBJ: Describe how to assist in application of casts.

TOP: Spacing Between Cast and Limb KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. _________________ may occur when pressure within a casted extremity increases.

ANS:

Compartment syndrome

When pressure within a casted extremity increases, this may lead to compartment syndrome, which occurs when pressure within the muscle compartment increases as a result of edema, bleeding, or decreased venous return. The fascia covering the muscle group acts as a tourniquet on structures within the compartment such as nerves, blood vessels, and muscle tissue.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 255

OBJ: Describe neurovascular assessments of a patient with an orthopedic injury.

TOP: Compartment Syndrome KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

1. _____________________ applies a pull indirectly to the bone via straps attached to the skin around the structure.

ANS:

Skin traction

Skin traction applies a pull indirectly to the bone via straps and a sling or boot applied to the skin around the structure. Skin traction typically applies between 5 and 7 lb and is commonly used for minor trauma or immediate immobilization before surgery.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 258

OBJ: Explain the purposes of placing a patient in skin or skeletal traction.

TOP: Skin Traction KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

1. ____________________ consists of a metal frame that secures pins inserted through the bone above and below the fracture site. It stabilizes a fracture with hardware visible outside the body.

ANS:

External fixation

External fixation consists of a metal frame that secures pins inserted through the bone above and below a fracture site. External fixation stabilizes a fracture with hardware visible outside the body. It fosters the healing of complex fractured bones, usually in the lower extremities.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 263

OBJ: Describe steps for applying each form of skin or skeletal traction.

TOP: Evaluation of Traction KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

1. An immobilization device used to immobilize and protect a body part is known as a ________.

ANS:

splint

Immobilization devices increase stability, support weak extremities, or reduce the load on weight-bearing structures such as hips, knees, or ankles. A splint immobilizes and protects a body part.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 268

OBJ: Explain nursing measures for complications from traction.

TOP: Splints KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity