Chapter 06: Infection Prevention and Control
MULTIPLE CHOICE
- The nurse points out that covering the mouth and nose with a tissue for a sneeze will reduce the probability of infection being spread by the _____ route.
| a. | droplet |
| b. | airborne |
| c. | direct contact |
| d. | indirect contact |
ANS: A
Infection from the droplet route requires the pathogens be expelled in droplets from the host and inhaled by another host.
DIF: Cognitive Level: Application REF: 110 OBJ: 1 (theory)
TOP: Disease-Producing Pathogens KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The nurse is providing infection control teaching to a patient. Additional patient teaching is warranted by which patient statement?
| a. | “It is important that I get my whooping cough vaccination as directed by my health care provider.” |
| b. | “Getting plenty of sleep each night will help my immune system.” |
| c. | “I should wash my hands before preparing my food.” |
| d. | “It is important that I take my antibiotic until I feel infection free.” |
ANS: D
The noncompletion of a protocol of prescribed antimicrobial medication can cause a pathogen to become resistant to that particular drug. Vaccinations, adequate rest, and proper hand hygiene are important infection control measures.
DIF: Cognitive Level: Application REF: 113 | Table 6-7, 121
OBJ: 1 (theory) TOP: Infection Control Measures
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- When the patient complains, “If this viral infection I have right now can’t be helped by antibiotics, why am I taking this expensive acyclovir?” The nurse’s best response is, “Acyclovir is:
| a. | an antiviral drug that kills viruses.” |
| b. | given to many patients with viral infections.” |
| c. | an antiviral drug that prevents your infection from becoming worse.” |
| d. | given to help strengthen your immune system.” |
ANS: C
The patient currently has a viral infection; acyclovir is an antiviral drug that will decrease the virulence of the infection if started in the early phase of the infection. The drug may not kill the virus and is not given frequently to patients with viruses. Acyclovir will not strengthen the immune system.
DIF: Cognitive Level: Application REF: 102 OBJ: 8 (theory)
TOP: Viruses KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The clinic nurse offers suggestions to a patient who is planning a trip to Mexico that will help prevent a protozoan infection. The most helpful suggestion is:
| a. | “We will ask the doctor for a prophylactic prescription for an antiviral drug.” |
| b. | “Broad-spectrum antibiotics will be most helpful if you contract a protozoan infection.” |
| c. | “Be sure to practice good hand hygiene while on your vacation.” |
| d. | “It would be best if you drank bottled water while on your trip.” |
ANS: D
Protozoa frequently live in the water and soil and cause infection by ingestion of the parasite. Water in many foreign countries contains protozoa, so drinking bottled water is the best suggestion.
DIF: Cognitive Level: Application REF: 102 OBJ: 1 (theory)
TOP: Protozoa KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
- While assessing an obese resident in a long-term care facility, the nurse finds a red, moist rash under the patient’s breasts, in the axilla, and in the inguinal fold. Based on this assessment, the nurse reports to the charge nurse that the resident probably has:
| a. | a fungal infection. |
| b. | a bacterial infection. |
| c. | an allergic reaction. |
| d. | contact dermatitis. |
ANS: A
Fungal infections thrive in warm, moist environments and most frequently affect the skin.
DIF: Cognitive Level: Application REF: 103 OBJ: 1 (theory)
TOP: Fungi KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The frustrated patient with a fungal infection complains, “Why is the infection taking so long to heal?” The nurse’s most informative response would be that:
| a. | fungal infections are essentially incurable. |
| b. | fungi form spores, which make them difficult to kill. |
| c. | fungi can be considered natural flora and are protected by the body. |
| d. | fungi can alter the patient’s DNA and RNA. |
ANS: B
Fungi are capable of forming spores, which makes them resistant to antifungal agents.
DIF: Cognitive Level: Comprehension REF: 103 OBJ: 1 (theory)
TOP: Fungi KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The nurse explains to the patient who is using Prilosec (a proton pump inhibitor) that the drug has reduced the amount of the natural protector _____ in the stomach lining.
| a. | lactic acid |
| b. | lysozyme |
| c. | cilia |
| d. | fatty acids |
ANS: B
Lysozyme is found in the lining of the stomach and in the stomach acids.
DIF: Cognitive Level: Application REF: 104 OBJ: 2 (theory)
TOP: Chemical Barrier KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The home health nurse advises the patient to treat a fever of 100° F with:
| a. | aspirin. |
| b. | Tylenol. |
| c. | cool baths. |
| d. | nothing at all. |
ANS: D
Allowing reasonable levels of fever allows the body’s natural defenses to make a hostile environment to the pathogen through heat.
DIF: Cognitive Level: Application REF: 104 OBJ: 3 (theory)
TOP: Fever KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The home health nurse is providing dietary recommendations to keep the immune system healthy. The patient demonstrates understanding by increasing which in the diet?
| a. | Proteins |
| b. | Fluids |
| c. | Carbohydrates |
| d. | Unsaturated fats |
ANS: A
Protein stores must be kept at an adequate level in order to produce antibodies, thus boosting the immune system. Fluids, carbohydrates, and unsaturated fats will not enhance the immune system.
DIF: Cognitive Level: Application REF: 104 | 107 OBJ: 7 (theory)
TOP: Nutrition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- The nurse is caring for several patients and determines which patient to be at the most risk for developing an infection related to a decreased anti-inflammatory response?
| a. | A patient who has been experiencing high levels of stress for the last 3 months |
| b. | A patient whose glycosylated Hgb level is 6.7% |
| c. | A patient recently diagnosed with osteoarthritis |
| d. | A patient scheduled for laparoscopic cholecystectomy in 2 weeks related to gallstones |
ANS: A
The presence of increased levels of cortisol resulting from ongoing stress inhibits the anti-inflammatory response, thus making this patient most susceptible to developing an infection. A glycosylated Hgb level of 6.7% is normal; osteoarthritis and gallstones would not significantly increase a patient’s likelihood of developing an infection.
DIF: Cognitive Level: Application REF: 102 | Box 6-1, 104
OBJ: 1 (theory) TOP: Cortisol KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- The home health nurse makes a referral to _____ to supply a home-bound older adult with a daily meal.
| a. | a community food bank |
| b. | the Salvation Army |
| c. | an agency supplying food stamps |
| d. | Meals on Wheels |
ANS: D
Meals on Wheels provides a large, nutritious meal to home-bound people. A community food bank, the Salvation Army, and food stamps would not adequately assist a home-bound individual.
DIF: Cognitive Level: Application REF: 104 | Elder Care Points
OBJ: 1 (clinical) TOP: Nutrition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- The nurse uses a visual aid to demonstrate how the antibody _____ attaches to the antigen to clear the pathogen from the body.
ANS: D
Immunoglobulin M (IgM) is the antibody that recognizes the foreign protein and attaches itself to it in order to clear the pathogen from the body.
DIF: Cognitive Level: Comprehension REF: 105 | Table 6-2
OBJ: 2 (theory) TOP: Antibodies KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse explains that exposure to a pathogen stimulates the macrophages to migrate to the area of infection to ingest and destroy the pathogen. This is the process of:
| a. | pathogen neutralization. |
| b. | immune response. |
| c. | antibody action. |
| d. | phagocytosis. |
ANS: D
Phagocytosis is the process of the ingestion of a pathogen by macrophages.
DIF: Cognitive Level: Comprehension REF: 105 OBJ: 2 (theory)
TOP: Phagocytosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- When the patient complains of the unsightly swelling of her lip at the site of an infection, the nurse explains that the swelling is part of the inflammatory response and acts as a(n):
| a. | store for blood. |
| b. | compression wall. |
| c. | antibody reservoir. |
| d. | producer of leukocytes. |
ANS: B
The swelling of the inflammatory response acts as a compression wall to delay the spread of harmful agents to the rest of the body.
DIF: Cognitive Level: Application REF: 107 OBJ: 2 (theory)
TOP: Inflammatory Response KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- The nurse is providing infection control teaching to a group of patients. The patient statement that best demonstrates understanding of the teaching provided is:
| a. | “I should take an antibiotic at the first sign of an infection.” |
| b. | “Hand hygiene is one of the most effective ways I can prevent the spread of infection.” |
| c. | “Vaccinations only prevent a disease from becoming severe.” |
| d. | “If I eat a nutritious diet, it will be difficult for me to get an infection.” |
ANS: B
Hand hygiene is the most effective single act that can reduce the spread of disease. Antibiotics should not be taken at the first sign of infection, especially if the infection is caused by a virus; vaccinations can also prevent diseases from occurring; a nutritious diet is only one component in the prevention of infection.
DIF: Cognitive Level: Analysis REF: 108-109 OBJ: 2 (theory)
TOP: Hand Hygiene KEY: Nursing Process Step: NA
MSC: NCLEX: Health Promotion and Maintenance
- The nurse discusses and demonstrates proper hand hygiene to an immunocompromised patient and his wife. The nurse determines additional teaching is necessary when the patient states:
| a. | “It is okay for my wife to wear artificial nails as long as she performs good handwashing.” |
| b. | “I should wash my hands before I eat.” |
| c. | “Hand gels work as well as handwashing under most circumstances.” |
| d. | “I should use friction and wash my hands for about 20 seconds if I am using soap and water.” |
ANS: A
Artificial nails harbor microorganisms regardless of good hand hygiene. Washing hands prior to eating is good practice, as well as using friction and washing for 15 to 30 seconds with soap and water. Hand gels are effective in most circumstances except for certain infections such as C. difficile and C. albicans.
DIF: Cognitive Level: Application REF: 108-109 OBJ: 2 (clinical)
TOP: Hand Hygiene KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The nurse explains that a vaccination provides defense against infection via:
| a. | innate immunity. |
| b. | the inflammatory response. |
| c. | antibody-mediated immunity. |
| d. | cell-mediated immunity. |
ANS: C
Vaccinations produce an antibody-mediated immunity by stimulating the host to develop specific antibodies against specific diseases.
DIF: Cognitive Level: Application REF: 104-105 | 106 | Table 6-3
OBJ: 2 (theory) TOP: Immune Response
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- The nurse will use Expanded Precautions when performing care for a patient with:
| a. | active tuberculosis (TB). |
| b. | bacterial pneumonia. |
| c. | a urinary tract infection caused by E. coli. |
| d. | a fungal infection of the groin and axilla. |
ANS: A
Active TB can be spread by airborne pathogens. Masks and gowns in addition to gloves should be worn while caring for such patients. Standard Precautions would be used for the other patients.
DIF: Cognitive Level: Application REF: 109-110 | Table 6-5
OBJ: 5 (theory) TOP: Expanded Precautions
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The nurse caring for a patient with C. difficile should:
| a. | use only alcohol-based hand cleanser. |
| b. | wear a mask. |
| c. | use eye protection. |
| d. | notify housekeeping to use appropriate cleaning agents. |
ANS: D
Notification of housekeeping to use alcohol-free cleaners is necessary in order to eradicate the pathogen. Soap and water must be used after contact with this organism. A mask and eye protection are not necessary.
DIF: Cognitive Level: Application REF: 114 OBJ: 5 (theory)
TOP: Prevention of Health Care–Associated Infections
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The nurse caring for a patient with general sepsis should notify the charge nurse immediately of the patient’s:
| a. | increased lethargy. |
| b. | coughing. |
| c. | elevated blood pressure. |
| d. | cloudy urine. |
ANS: A
Increasing lethargy is an indicator of impending septic shock. Coughing and cloudy urine are not signs of impending septic shock. Decreased rather than increased blood pressure would indicate impending septic shock.
DIF: Cognitive Level: Application REF: 115 OBJ: 1 (theory)
TOP: Septic Shock KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- The nurse who suffers an accidental needle stick following administration of an intramuscular injection to a patient anticipates that facility protocol will suggest immediate treatment with which type of immunotherapy?
ANS: D
IgG is frequently given to provide passive immunity until the body’s own immune system can defend itself; therefore, it would most likely be a component of a health care facility’s initial treatment protocol for accidental needle sticks. IgM, IgD, and IgA would not be indicated.
DIF: Cognitive Level: Application REF: 105 | Table 6-2
OBJ: 1 (theory) TOP: Immunoglobulins
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
- Following discharge teaching, the nurse determines that the patient requires additional teaching regarding antibiotic treatment when the patient states:
| a. | “It is important that I stop taking my medication when I feel completely better.” |
| b. | “I should try to take my medication as evenly spaced apart as possible.” |
| c. | “If I start feeling worse, I should call my health care provider.” |
| d. | “I should not share my medication with anyone.” |
ANS: A
The antibiotic should be taken until it is completely gone in order to ensure the infection has been adequately treated. Antibiotics are more effective if spaced evenly apart when taken. The patient should continue to improve if therapy is effective, so the health care provider should be notified if symptoms are not improving. Patients should never share any type of prescribed medication.
DIF: Cognitive Level: Application REF: 113 | Table 6-7, 121
OBJ: 8 (theory) TOP: Antimicrobial Therapy
KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance
MULTIPLE RESPONSE
- The nurse instructs the nursing assistant in a long-term care facility regarding infection control measures. Which actions by the nursing assistant demonstrate understanding? (Select all that apply.)
| a. | Assisting residents with hand hygiene prior to meals |
| b. | Cleaning incontinent residents as soon as possible |
| c. | Ensuring residents who require assistance with feeding take prescribed antibiotics during meals |
| d. | Inspecting residents’ skin for open areas during bathing |
| e. | Assisting residents with hand hygiene after participating in group activities |
ANS: A, B, D, E
It is important for the nursing assistant to assist residents with hand hygiene prior to meals and after participating in group activities in order to help prevent the spread of infection. Cleaning incontinent residents as soon as possible prevents skin breakdown, which may lead to infection. While bathing residents, the nursing assistant should monitor for signs of skin breakdown and report any areas to the nurse. Nursing assistants are not permitted to administer medications.
DIF: Cognitive Level: Application REF: 121 OBJ: 2 (clinical)
TOP: Infection Control Measures KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance
- The nurse uses a picture to show the areas of the body that are protected by normal flora. These areas include the: (Select all that apply.)
| a. | skin. |
| b. | bladder. |
| c. | lower GI tract. |
| d. | nose and throat. |
| e. | eye. |
ANS: A, C, D, E
The bladder does not have any natural flora for protection.
DIF: Cognitive Level: Comprehension REF: 101 | Table 6-1
OBJ: 2 (theory) TOP: Natural Flora
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse is obtaining a health history on a newly admitted patient. Which information will alert the nurse to an increased risk for this patient developing an infection? (Select all that apply.)
| a. | The patient reports having unprotected heterosexual sex in three previous relationships. |
| b. | The patient is employed as a biochemist in a hospital. |
| c. | The patient’s income is considered middle-class level. |
| d. | The patient reports getting 4 to 5 hours of sleep per night. |
| e. | The patient is 21% over the suggested normal weight. |
ANS: A, D, E
This patient’s lifestyle habits, insufficient sleep, and being obese increases the chance of developing an infection by the strain placed on the immune system. This patient’s occupation and income level would not increase the risk for infection.
DIF: Cognitive Level: Application REF: 102 | Box 6-1
OBJ: 1 (theory) TOP: Risk Factors KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
COMPLETION
- The nurse explains that an infection occurring in the body represents an interrelationship between the __________, __________, and __________.
ANS:
host, agent, environment
host, environment, agent
agent, host, environment
agent, environment, host
environment, host, agent
environment, agent, host
A pathologic agent, upon entering the body, must attach to a host in order to multiply in a supportive environment.
DIF: Cognitive Level: Application REF: 102 | Box 6-1
OBJ: 1 (theory) TOP: Infection Process
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- The bacteria that are rod-shaped are classified as _________.
ANS:
bacilli
Bacilli are rod-shaped bacteria.
DIF: Cognitive Level: Knowledge REF: 101 OBJ: 1 (theory)
TOP: Bacteria KEY: Nursing Process Step: NA
MSC: NCLEX: Health Promotion and Maintenance
- The nurse explains that the four lines of defense the body employs to combat infection are __________, __________, __________, and __________.
ANS:
skin, normal flora, inflammatory response, immune response
skin, normal flora, immune response, inflammatory response
skin, inflammatory response, immune response, normal flora
skin, inflammatory response, normal flora, immune response
skin, immune response, normal flora, inflammatory response
skin, immune response, inflammatory response, normal flora
The body is defended against infection by the skin, normal flora, and inflammatory and immune responses.
DIF: Cognitive Level: Comprehension REF: 103-104 OBJ: 2 (theory)
TOP: Defense Against Infection KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
Chapter 09: Chronic Illness and Rehabilitation
MULTIPLE CHOICE
- The rehabilitation nurse describes a patient who is blind, works full time as a Spanish interpreter, and lives with his wife in a downtown apartment. The nurse classifies this person as:
| a. | impaired. |
| b. | disabled. |
| c. | handicapped. |
| d. | dependent. |
ANS: A
The blindness is an impairment of vision that does not inhibit the patient from performing his job or enjoying a normal life.
DIF: Cognitive Level: Application REF: 177 OBJ: 1 (theory)
TOP: Concepts of Rehabilitation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- A resident with advanced Parkinson’s disease stays in his wheelchair all day because it is too tiring to walk and he is fearful of falling. In order to increase mobility, the best intervention would be to:
| a. | instruct the resident in crutch walking. |
| b. | assist the resident to walk in the hallway with a gait belt. |
| c. | encourage the resident to rock back and forth in his wheelchair to off load weight. |
| d. | arrange for a walking cane. |
ANS: B
Walking is the best exercise to prevent problems associated with immobility. The gait belt will make the resident more secure. Canes and crutches do not diminish the weakness or the fear of falling.
DIF: Cognitive Level: Application REF: 184 | Box 9-5
OBJ: 2 (theory) TOP: Preventing Problems of Immobility
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
- The obese resident who lies on her back because it is difficult to turn due to her weight has a pressure ulcer on her coccyx that is covered with a dressing. The most effective intervention to encourage independence is:
| a. | have staff turn the resident every 2 hours. |
| b. | turn the patient on her side and use pillows to stabilize her. |
| c. | arrange for short side rails to be used for positioning. |
| d. | arrange for a trapeze so the patient can assist with positioning. |
ANS: D
The trapeze allows for self-positioning and is less confining than are bed rails. The other options do not foster independence.
DIF: Cognitive Level: Application REF: 186-187 OBJ: 2 (theory)
TOP: Preventing Problems of Immobility
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
- When the nurse assesses reddened heels on the bed-bound stroke patient, the nurse modifies the care plan to include which intervention?
| a. | Massage heels briskly. |
| b. | Apply socks to feet. |
| c. | Swab heels with alcohol. |
| d. | Elevate feet on pillows. |
ANS: D
Elevation of the feet gets the weight off the heels and will allow them to heal. All other options are not helpful to damaged skin. Brisk massage may promote damage to the skin. Alcohol can be irritating and may further damage heel skin.
DIF: Cognitive Level: Application REF: 180 | Nursing Care Plan 9-1
OBJ: 2 (theory) TOP: Preventing Problems of Immobility
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
- The nurse cautions the 70-year-old patient who just had the cast removed from a broken arm that the immobility during the time he was in a cast can cause:
| a. | arthritis. |
| b. | phlebitis. |
| c. | frozen shoulder. |
| d. | painful swelling. |
ANS: C
Immobility can cause loss of strength and flexibility in the older adult.
DIF: Cognitive Level: Knowledge REF: 178 | 180 | Table 9-1
OBJ: 3 (theory) TOP: Effects of Immobility: Joint Stiffness
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- The nurse assessing an 85-year-old patient who has been on bed rest for a fractured hip finds the patient flushed with a temperature of 100° F, pulse of 100, and respiration rate of 24. The next intervention should be to assess:
| a. | BP. |
| b. | breath sounds. |
| c. | abdominal distention. |
| d. | amount of urinary output. |
ANS: B
The initial assessments are the cardinal signs of pneumonia. The breath sounds should be assessed next to determine the presence of any adventitious breath sounds. BP will also need to be assessed, but the breath sounds are more important with the signs and symptoms present. Abdominal distention is indicative of a gastrointestinal problem. Amount of urinary output is important to an ongoing assessment but not a priority in the present circumstances.
DIF: Cognitive Level: Analysis REF: 179 | Table 9-1
OBJ: 3 (theory) TOP: Effects of Immobility: Hypostatic Pneumonia
KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
- The 76-year-old stroke patient in a long-term care facility has sent his food tray back to the kitchen untouched for the second time today. The most effective intervention to increase nutrition would be to:
| a. | take the tray back and offer to feed the patient. |
| b. | request the dietitian to talk with the patient about food preferences. |
| c. | take a high-protein drink to the patient. |
| d. | sit with the patient during meals. |
ANS: C
Taking the high-energy drink meets the immediate challenge of inadequate nutritional intake. Referral to the dietitian and sitting with the patient may be helpful. Offering to feed from a rejected tray is not supportive.
DIF: Cognitive Level: Analysis REF: 190-191 OBJ: 2 (theory)
TOP: Effects of Immobility: Anorexia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- When the nurse is assessing a bed-bound resident, a reddened area over the coccyx that does not blanch is discovered. The best intervention to prevent further skin damage is to:
| a. | cover with a transparent film dressing. |
| b. | apply warm compress. |
| c. | turn the patient every 2 hours. |
| d. | continue to monitor the area. |
ANS: A
Since this appears to be a stage 1 pressure area, the transparent film ensures the proper amount of moisture is present for healing while allowing monitoring of the area. A warm compress is not warranted. This patient will need to be turned every hour. Monitoring of the area should continue but does not meet the immediate need.
DIF: Cognitive Level: Analysis REF: 180 | Nursing Care Plan 9-1
OBJ: 3 (theory) TOP: Effects of Immobility: Impaired Circulation
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
- The LPN/LVN making care assignments to nursing assistants would not assign a patient who has:
| a. | manipulative behavior. |
| b. | an unstable condition. |
| c. | a draining wound. |
| d. | a communicable disease. |
ANS: B
Nursing assistants are not assigned to patients who have an unstable condition. Care of an unstable patient does not fall into the scope of practice of the unlicensed personnel.
DIF: Cognitive Level: Comprehension REF: 183 | Assignment Considerations
OBJ: 5 (theory) TOP: Assigning Personnel
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- The chief goal of a long-term care facility is to:
| a. | offer restorative services. |
| b. | promote individual independence. |
| c. | facilitate achievement of complete autonomy. |
| d. | manage medication protocols. |
ANS: B
Promotion of independence is the chief goal, not complete autonomy. Other options are services directed at achieving increased independence.
DIF: Cognitive Level: Comprehension REF: 183 OBJ: 4 (theory)
TOP: Goal of Long-Term Care Facilities KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
- The nurse reminds the nursing assistant that the purpose of locking the wheels of a wheelchair is to:
| a. | supply a stable support for a patient to lift self. |
| b. | keep patient in a position at a table or bedside. |
| c. | prevent falls. |
| d. | keep the patient from moving self. |
ANS: C
Fall prevention is the purpose of locking the wheels of a wheelchair.
DIF: Cognitive Level: Comprehension REF: 184 | Box 9-5
OBJ: 2 (clinical) TOP: Fall Prevention
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- To decrease the incidence of falls, the nurse will arrange for the replacement of:
| a. | canes with 4 feet with a single-footed cane. |
| b. | hard-soled shoes with soft-soled bedroom slippers. |
| c. | area rugs with a nonslip pad. |
| d. | plain carpet with a highly patterned carpet. |
ANS: C
Loose area rugs should be replaced with nonslip carpets.
DIF: Cognitive Level: Knowledge REF: 184 | Box 9-5
OBJ: 2 (clinical) TOP: Fall Prevention
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The nurse instructing a family in the selection of a chair for an older adult with Parkinson’s disease would stress selecting a chair that:
| a. | is very wide to allow for position changes. |
| b. | has sturdy arms to aid in rising. |
| c. | is low to prevent falls. |
| d. | is soft and deep for added comfort. |
ANS: B
Sturdy arms assist in rising and sitting. Soft, low, and wide chairs cause a person to lean forward to rise and to “fall into” the chair to be seated.
DIF: Cognitive Level: Comprehension REF: 184 | Box 9-5
OBJ: 2 (clinical) TOP: Fall Prevention
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The charge nurse instructs the nursing assistants to answer the call lights promptly, especially for patients who are receiving:
| a. | diuretics for fluid reduction. |
| b. | antibiotics for infection. |
| c. | proton pump medications for gastric reflux. |
| d. | NSAIDs for arthritis. |
ANS: A
People taking diuretics need to go to the bathroom frequently, and oftentimes urgently. Prompt attention to call lights will reduce the probability of the patient getting up unassisted. Diuretics may also cause orthostatic hypotension, which increases the risk for falling.
DIF: Cognitive Level: Comprehension REF: 184 | Box 9-5
OBJ: 2 (clinical) TOP: Fall Prevention
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The nurse is caring for a resident who has a security device for safety purposes. What intervention must the nurse include in the plan of care?
| a. | Visually check the resident every hour. |
| b. | Turn and reposition the resident every hour. |
| c. | Assess condition of the skin every 4 hours. |
| d. | Reassess the need for the security device every 4 to 8 hours. |
ANS: D
The need for continuing the use of the security device must be assessed every 4 to 8 hours. The patient should be visually checked every 30 minutes, and turned and skin assessed every 2 hours.
DIF: Cognitive Level: Application REF: 184 | Box 9-5
OBJ: 2 (clinical) TOP: Use of Security Devices
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- When the confused resident pours his cereal in a cup and “drinks” it, the nurse should:
| a. | put his cereal back in the bowl and hand the resident a spoon. |
| b. | discard the cup with his cereal and bring fresh cereal in a bowl. |
| c. | calmly instruct the resident that cereal is to be eaten from a bowl. |
| d. | not interrupt the behavior. |
ANS: D
The nurse should leave the resident alone to feed himself independently. Staff should refrain from doing what the resident can do for himself.
DIF: Cognitive Level: Application REF: 186 OBJ: 4 (theory)
TOP: Long-Term Care Facility Goals: Autonomy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
- The nurse planning a group TV activity in a long-term care facility would choose a channel that offers a(n):
| a. | cartoon. |
| b. | travel documentary. |
| c. | dramatic two-part mini-series. |
| d. | opera performance. |
ANS: B
Travel documentaries are colorful and do not have a plot to follow. Cartoons are juvenile, opera does not have universal appeal, and the two-part drama would require long attention spans and good short-term memory.
DIF: Cognitive Level: Application REF: 187 OBJ: 4 (theory)
TOP: Long-Term Care Facility Goals: Autonomy
KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity
- To motivate a frustrated stroke patient who is learning to walk again, the most effective motivational intervention the rehabilitation nurse could make is to:
| a. | show short movies on ambulation techniques. |
| b. | observe the patient while in physical therapy. |
| c. | arrange a visit with another stroke victim who has learned to ambulate. |
| d. | encourage a 1-week break from therapy, which will help the resident come back refreshed. |
ANS: C
Talking with someone who can truly understand the frustration is helpful. Showing a short movie on ambulation techniques may be an effective teaching tool, but it is not a motivational tool. Observing the resident is necessary but does not provide motivation. A 1-week break will interrupt progress that has been made, thus decreasing motivation.
DIF: Cognitive Level: Application REF: 188 | Elder Care Points
OBJ: 4 (theory) TOP: Goals for Rehabilitation: Motivation
KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity
- The nurse caring for the resident who is disoriented can provide the best care with which intervention?
| a. | Ensuring activities are scheduled for the same time each day |
| b. | Changing care assignments for assistive personnel frequently to prevent burnout |
| c. | Encouraging autonomy by allowing the resident to choose clothes from the closet |
| d. | Administering sedatives to calm the patient |
ANS: A
Keeping a routine leads to less confusion. Changing assistive personnel care assignments frequently is confusing for the resident. Choosing clothing from an entire closet is overwhelming for the confused resident; rather, giving the resident a few items to choose from encourages autonomy without increasing confusion. Sedatives should not be given to treat confusion.
DIF: Cognitive Level: Application REF: 185-186 OBJ: 4 (theory)
TOP: Managing Confusion and Disorientation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
MULTIPLE RESPONSE
- Treatment resources that focus on restorative care for people with chronic illness and disabilities are: (Select all that apply.)
| a. | outpatient clinics. |
| b. | long-term health care facilities. |
| c. | home care. |
| d. | rehabilitation agencies. |
| e. | hospice agencies. |
ANS: A, B, C, D
Outpatient clinics, long-term care facilities, home care, and rehabilitation agencies are sources of rehabilitation for people with chronic illness or disability. Hospice agencies focus on care of the dying patient.
DIF: Cognitive Level: Knowledge REF: 179 OBJ: 1 (theory)
TOP: Locus of Treatment for Chronic Illness KEY: Nursing Process Step: NA
MSC: NCLEX: Health Promotion and Maintenance
- The nurse reinforces that the multifocused goal of rehabilitation is to: (Select all that apply.)
| a. | promote new coping skills. |
| b. | teach adaptive living skills. |
| c. | focus on self-care for increased independence. |
| d. | improve quality of life. |
| e. | restore former level of function. |
ANS: A, B, C, D
Restoring former level of function is not a goal of rehabilitation because this may an impossible goal. New coping and adaptive skills, and self-care skills that improve the quality of life are all goals of rehabilitation.
DIF: Cognitive Level: Application REF: 187 OBJ: 7 (theory)
TOP: Goals of Rehabilitation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The patient who has been in traction for bilateral femur fractures complains of constipation. To stimulate bowel action, the nurse will: (Select all that apply.)
| a. | provide prune juice from the snack cart. |
| b. | increase fluid intake. |
| c. | arrange for high-fiber foods such as cauliflower and broccoli. |
| d. | give prescribed stool softeners. |
| e. | encourage milk products. |
ANS: A, B, C, D
Milk products are constipating. Prune juice, extra fluid, high-fiber foods, and stool softeners will combat constipation.
DIF: Cognitive Level: Application REF: 180-181 OBJ: 2 (theory)
TOP: Preventing Problems of Immobility
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
- The rehabilitation nurse outlines the impact of disability, which includes: (Select all that apply.)
| a. | unchanged family roles. |
| b. | life patterns centered around treatment or rehabilitation. |
| c. | grief over what has been lost. |
| d. | spiritual distress. |
| e. | sense of powerlessness. |
ANS: B, C, D, E
Family roles often change as a result of a disability. Life patterns will center around treatment and rehabilitation for at least the initial phase of incurring the disability, as well as grief, spiritual distress, and powerlessness.
DIF: Cognitive Level: Application REF: 177-178 OBJ: 4 (theory)
TOP: Impact of Disability KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
- Long-term health care facilities are the center of treatment for people who are: (Select all that apply.)
| a. | recovering after the most acute phase of their illness is over. |
| b. | receiving rehabilitation after a joint replacement. |
| c. | too weak from primary illness to care for themselves presently. |
| d. | in need of a permanent home because of effects of a chronic condition. |
| e. | under treatment for substance abuse. |
ANS: A, B, C, D
Long-term health care facilities do not offer active treatment to substance abusers. Recovery from an acute illness, joint replacement rehabilitation, weakness from illness, and a permanent home for a chronic illness are common reasons individuals seek care from long-term care facilities.
DIF: Cognitive Level: Application REF: 179 | 183 OBJ: 4 (theory)
TOP: Purpose of Long-Term Health Care Facilities KEY: Nursing Process Step: NA
MSC: NCLEX: Health Promotion and Maintenance
- The LPN/LVN in a long-term health care facility may perform in the roles of: (Select all that apply.)
| a. | charge nurse. |
| b. | designer of nursing care plans. |
| c. | administrator of medications. |
| d. | administrator of wound care. |
| e. | assignment delegator. |
ANS: A, C, D, E
The LPN/LVN does not design the nursing care plan but may contribute to the care plan. This is the responsibility of the RN. The LPN/LVN may act in the role of charge nurse while under the supervision of an RN. Administration of medications and wound care and delegation of care are commonly the LPN/LVN’s responsibility.
DIF: Cognitive Level: Comprehension REF: 189 OBJ: 5 (theory)
TOP: LPN/LVN Role in Long-Term Health Care Facility KEY: Nursing Process Step: NA
MSC: NCLEX: Health Promotion and Maintenance
- When delegating care to a nursing assistant, the LPN/LVN should: (Select all that apply.)
| a. | give specific instruction as to what is to be done. |
| b. | instruct how the task is to be done. |
| c. | list information that needs to be reported. |
| d. | be aware that the nurse is responsible for outcome of delegated care. |
| e. | insist that the nursing assistant accept the responsibility. |
ANS: A, B, C, D
In delegating to unlicensed assistive personnel, the LPN/LVN should first inquire if the nursing assistant is willing to take responsibility for the care assigned.
DIF: Cognitive Level: Comprehension REF: 183 | Assignment Considerations
OBJ: 5 (theory) TOP: Delegation KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- The LPN/LVN can apply a physical restraint to a resident in a long-term care facility when: (Select all that apply.)
| a. | an order for the restraint is obtained within 12 hours of application. |
| b. | all other measures have been attempted and failed. |
| c. | documentation is made on all failed attempts. |
| d. | the family is unable to stay with the resident. |
| e. | the least restrictive device is chosen. |
ANS: B, C, D, E
The order for the restraint must be obtained within 24 to 48 hours after application of the device. The LPN/LVN who applies a physical restraint must have satisfied all of the other options.
DIF: Cognitive Level: Application REF: 184-185 OBJ: 2 (clinical)
TOP: Use of Restraints KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The student nurse is becoming familiar with Healthy People 2020 goals related to rehabilitation. The student nurse demonstrates an understanding of the goals when identifying which of the following as goals? (Select all that apply.)
| a. | Increase the proportion of adults with disabilities who participate in social activities. |
| b. | Increase the proportion of adults with disabilities who report satisfaction with life. |
| c. | Increase the proportion of people with disabilities who report not having the assistive devices and technology needed. |
| d. | Reduce the proportion of adults with disabilities who report feelings such as sadness, unhappiness, or depression that prevent them from being active. |
| e. | Reduce the proportion of people with disabilities who report environmental barriers to participation in home, school, work, or community activities. |
ANS: A, B, D, E
One of the goals of Healthy People 2020 is to reduce rather than increase the proportion of people with disabilities who report not having the assistive devices and technology needed. All other options are included as goals.
DIF: Cognitive Level: Comprehension REF: 187 OBJ: 7 (theory)
TOP: Healthy People 2020 Goals KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
COMPLETION
- The rehabilitation nurse makes the point that a dysfunction of a specific body part is termed __________.
ANS:
impairment
An impairment is a dysfunction of an organ or body part.
DIF: Cognitive Level: Comprehension REF: 177 OBJ: 1 (theory)
TOP: Concepts of Rehabilitation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse working in a long-term care facility is aware that in order to comply with Medicare guidelines, documentation of assessment findings which measure physical, psychological, and psychosocial functioning are necessary using the _____________________.
ANS:
Minimum Data Set
minimum data set
MDS
The Minimum Data Set (MDS) is a primary screening and assessment tool that is standard for all Medicare and Medicaid residents in a long-term care facility.
DIF: Cognitive Level: Application REF: 187 OBJ: 5 (theory)
TOP: Documentation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
Chapter 13: The Respiratory System
MULTIPLE CHOICE
- The nurse explains that the purpose of mucus is to:
| a. | warm the air entering the lungs. |
| b. | trap particles and bacteria. |
| c. | protect the cilia. |
| d. | clean the sinus cavity. |
ANS: B
Mucus traps particles and bacteria that may be in the inspired air.
DIF: Cognitive Level: Knowledge REF: 257 OBJ: 1 (theory)
TOP: Mucus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- A patient with emphysema enters the emergency room with severe dyspnea; O2 saturation is 74%, pulse is 120, and respirations are 26. After positioning the patient in high Fowler’s, the nurse should:
| a. | attempt to help the patient slow her respirations. |
| b. | coach in pursed-lip breathing. |
| c. | give oxygen at 5 L/min by nasal cannula. |
| d. | reposition patient in orthopneic position. |
ANS: B
Coaching in pursed-lip breathing will open the respiratory tree with negative pressure. Oxygen given at such a high concentration will cause an emphysemic patient to stop breathing. High Fowler’s position is beneficial and easy to position with minimal equipment.
DIF: Cognitive Level: Analysis REF: 272 OBJ: 2 (clinical)
TOP: Oxygen Administration to Emphysemic Patient
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- The nurse explains that the mechanism that triggers rate and depth of respiration is based on:
| a. | ease of respiration. |
| b. | alveolar pressure. |
| c. | patency of bronchi. |
| d. | blood pH. |
ANS: D
Chemoreceptors in the brainstem and carotid arteries measure hydrogen concentration, as well as CO2 and O2, to trigger respiration rate to correct the excessive CO2.
DIF: Cognitive Level: Comprehension REF: 259 OBJ: 2 (theory)
TOP: Ventilation and Blood pH KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse uses a visual aid to show the mechanics of inhaling which correctly illustrates:
| a. | the diaphragm moves down. |
| b. | the negative pressure of the lung converts to positive pressure. |
| c. | muscles contract, pulling the rib cage down. |
| d. | bronchi enlarge. |
ANS: A
On inspiration, the diaphragm moves down, increasing the area of negative pressure, muscles pull the rib cage up, and the positive-pressure room air flows into the negative-pressure lungs.
DIF: Cognitive Level: Comprehension REF: 259 OBJ: 2 (theory)
TOP: Mechanics of Inspiration KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse explains that the substance that decreases the surface tension of the alveolar walls is:
| a. | plasma. |
| b. | surfactant. |
| c. | cilia. |
| d. | mucus. |
ANS: B
Surfactant is the substance that reduces the surface tension of the walls of the alveoli, making gas exchange more effective.
DIF: Cognitive Level: Comprehension REF: 259 OBJ: 1 (theory)
TOP: Surfactant KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- Using animation, the nurse demonstrates how most of the inspired oxygen is carried to the tissues by the:
| a. | plasma. |
| b. | lymphatic system. |
| c. | red blood cells. |
| d. | white blood cells. |
ANS: C
The red blood cells carry 97% of the oxygen to the cells, attached to hemoglobin.
DIF: Cognitive Level: Comprehension REF: 260 OBJ: 1 (theory)
TOP: Oxygen Transport KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse points out to the student nurse that one of the patients she is caring for has an obstructive respiratory disorder. The student is correct in identifying the patient diagnosed with __________ as having an obstructive disorder.
| a. | atelectasis |
| b. | lung cancer |
| c. | Guillain-Barré syndrome |
| d. | chronic bronchitis |
ANS: D
Obstructive lung disease is related to the reduced ability to move air in and out of the lungs. Asthma, emphysema, and chronic bronchitis are classified as obstructive disorders. Atelectasis, lung cancer, and Guillain-Barré syndrome are restrictive disorders.
DIF: Cognitive Level: Application REF: 261 OBJ: 1 (theory)
TOP: Obstructive Lung Disease KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- When reviewing risk factors, the nurse correctly identifies which patient as having the greatest risk of throat cancer?
| a. | The patient who drinks 4 cups of coffee per day. |
| b. | The patient who smokes 1 pack of cigarettes per week. |
| c. | The patient who drinks several carbonated drinks per day. |
| d. | The patient who drinks 4 vodka tonics per day. |
ANS: D
The combination of alcohol and cigarettes increases the risk for throat cancer. However, the patient consuming 4 vodka drinks per day is at a higher risk than the patient smoking 1 pack of cigarettes per week. Coffee and carbonated drink consumption has not been found to increase the risk of throat cancer.
DIF: Cognitive Level: Analysis REF: 262 | Elder Care Points
OBJ: 2 (theory) TOP: Alcohol-Related Throat Cancer
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
- The nurse cautions each person prior to giving the influenza immunization that they should not take it if they are allergic to:
| a. | strawberries. |
| b. | ragweed. |
| c. | penicillin. |
| d. | eggs. |
ANS: D
The influenza vaccine is cultured in chicken embryos, making anyone allergic to eggs probably allergic to the immunization.
DIF: Cognitive Level: Application REF: 261 OBJ: 2 (theory)
TOP: Influenza Immunization Allergy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
- After auscultating a coarse low-pitched sonorous rattling in the left lower lobe, the nurse is concerned that the patient may be developing:
| a. | an accumulation of secretions in the larger air passages. |
| b. | narrowing in the lower lobe of the lung. |
| c. | irritation in the pleurae. |
| d. | crackles in the left lower lobe. |
ANS: A
Low-pitched sonorous wheezing sounds are caused by secretions accumulating in the larger airways. Narrowing of air passages will result in high-pitched wheezes. Irritation of pleurae will cause a pleural friction rub to be heard. Crackles are produced by air passing through moisture in the smaller airways.
DIF: Cognitive Level: Application REF: 263-264 OBJ: 4 (theory)
TOP: Breath Sounds KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- When the nurse places the diaphragm of the stethoscope over one of the main bronchi, the expected normal breath sound heard is:
| a. | bronchovesicular. |
| b. | bronchial. |
| c. | rhonchi. |
| d. | vesicular. |
ANS: A
Bronchovesicular sounds are moderate hollow sounds that are equal on inspiration and expiration.
DIF: Cognitive Level: Comprehension REF: 264 OBJ: 4 (theory)
TOP: Breath Sounds KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- The nurse performing tracheal suctioning of the patient with a respiratory disorder should suction no longer than _____ seconds.
| a. | 2 to 5 |
| b. | 5 to 10 |
| c. | 10 to 15 |
| d. | 15 to 20 |
ANS: C
The suctioning, which is done during extraction of the suction tip, should not last more than 10 to 15 seconds as it deprives the patient of oxygen.
DIF: Cognitive Level: Comprehension REF: 272 OBJ: 5 (theory)
TOP: Suctioning KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
- The nurse is aware that the patient is in respiratory failure when the blood gas findings are a PaO2 of _____ mm Hg and a PaCO2 of _____ mm Hg.
| a. | 46; 52 |
| b. | 50; 45 |
| c. | 52; 42 |
| d. | 55; 58 |
ANS: A
Respiratory failure is defined by blood gases that have a PaO2 level below 50 mm Hg and a PaCO2 level equal to or higher than 50 mm Hg.
DIF: Cognitive Level: Analysis REF: 273 OBJ: 5 (clinical)
TOP: Blood Gases KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse assesses a patient’s respirations who was recently admitted with a traumatic head injury. The nurse expects to find which type of breathing during the assessment?
| a. | Apneustic respiration |
| b. | Cheyne-Stokes |
| c. | Kussmaul’s |
| d. | Biot’s |
ANS: D
Biot’s respirations are characterized by irregular periods of apnea followed by four to five breaths of identical depth. This pattern is associated with increased intracranial pressure, which is common with a traumatic head injury. Apneustic respirations are indicative of damage to the respiratory centers in the brain. Cheyne-Stokes respirations are often seen in patients in a coma resulting from a disorder affecting the central nervous system. Kussmaul’s respiration is an abnormal breathing pattern often seen in patients with diabetic acidosis and coma.
DIF: Cognitive Level: Application REF: 273 OBJ: 4 (theory)
TOP: Biot’s Respiration KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- After having the postoperative patient deep-breathe and cough, the nurse should offer:
| a. | a warm drink. |
| b. | mouth care. |
| c. | oxygen by mask. |
| d. | an iced drink. |
ANS: B
Mouth care should be offered after deep breathing and coughing to clear the mouth of unpleasant taste.
DIF: Cognitive Level: Comprehension REF: 274 OBJ: 5 (theory)
TOP: Mouth Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- A patient is admitted to the medical unit with an acute illness accompanied by a fever for the last 3 days. What will likely be the patient’s respiratory response?
| a. | Hypercarbia |
| b. | Respiratory alkalosis |
| c. | Kussmaul’s respirations |
| d. | Respiratory acidosis |
ANS: B
Respiratory alkalosis, or hypocapnia, results from the patient’s respiratory rate being elevated for a prolonged period due to the persistent fever. The patient blows off too much CO2 as a result. Hypercarbia and respiratory acidosis are the same and result from disorders that cause hypoventilation. Kussmaul’s respirations are an abnormal breathing pattern.
DIF: Cognitive Level: Application REF: 273 OBJ: 2 (theory)
TOP: Hypocapnia KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse is caring for a patient with COPD who has been in the hospital for several days. The patient complains of shortness of breath and asks the nurse to turn up his oxygen to compensate for his labored breathing. What is the best nursing response?
| a. | Turn up the patient’s oxygen flow by 1 liter. |
| b. | Call the physician for an order to turn up the oxygen. |
| c. | Assess the patient in an attempt to identify the cause of the shortness of breath. |
| d. | Ask the patient what he usually keeps his oxygen set on at home. |
ANS: C
The nurse should assess the patient for possible causes of the shortness of breath before calling the physician. The nurse may be able to implement nursing interventions, or may need to contact the physician for orders based on the assessment findings. Since the COPD patient’s respiratory drive is lowering levels of PO2, turning up the oxygen may take away his incentive to breathe. Asking the patient about his home oxygen is not helpful at this point.
DIF: Cognitive Level: Analysis REF: 259 OBJ: 2 (clinical)
TOP: Respiration Control KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
MULTIPLE RESPONSE
- The nurse clarifies that when interstitial edema occurs in the lung tissue, ventilation is inhibited by: (Select all that apply.)
| a. | thickened alveolar membranes. |
| b. | pus formation. |
| c. | alveoli filling with fluid. |
| d. | surfactant evaporation. |
| e. | failure of gas to diffuse across membrane. |
ANS: A, C, E
Interstitial edema will cause problems that affect the alveoli: thickened walls and filling with fluid that obstructs gas exchange across the thickened walls. Pus formation is associated with infection. Surfactant decreases surface tension on the alveolar wall, allowing it to expand more easily with inspiration and preventing alveolar collapse on expiration.
DIF: Cognitive Level: Application REF: 259 OBJ: 2 (theory)
TOP: Interstitial Edema KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse reminds a group of retirees that age may alter the respiratory systems by: (Select all that apply.)
| a. | weakened cough. |
| b. | kyphosis. |
| c. | increased ciliary movement. |
| d. | decrease in body fluid. |
| e. | muscle weakness. |
ANS: A, B, D, E
Age often decreases ciliary movement. All other options are age-related changes that affect the respiratory system.
DIF: Cognitive Level: Application REF: 260 OBJ: 2 (theory)
TOP: Age-Related Changes That Affect Ventilation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The U.S. Public Health Service recommends influenza immunization for: (Select all that apply.)
| a. | physicians. |
| b. | compromised infants. |
| c. | older adults. |
| d. | chronically ill people. |
| e. | nurses. |
ANS: A, C, D, E
Compromised infants should not be immunized. Health care workers, older adults, and chronically ill individuals are at risk for contracting influenza and should be immunized.
DIF: Cognitive Level: Comprehension REF: 261 OBJ: 3 (theory)
TOP: Influenza Immunization KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
- The nurse notes physical signs of labored breathing, which include: (Select all that apply.)
| a. | grunting on expiration. |
| b. | elevating shoulders and ribs on inspiration. |
| c. | tensing neck and shoulder muscles. |
| d. | substernal retraction. |
| e. | productive cough. |
ANS: A, B, C, D
Productive cough is not a sign of labored breathing. All other options are often seen with laboring respirations.
DIF: Cognitive Level: Application REF: 262-263 OBJ: 4 (theory)
TOP: Signs of Labored Breathing KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse explains that anorexia in the patient with a respiratory disorder may be attributed to: (Select all that apply.)
| a. | increased sense of taste. |
| b. | bad taste in mouth. |
| c. | fear that eating will exacerbate coughing. |
| d. | fatigue. |
| e. | altered sense of smell. |
ANS: B, C, D, E
The sense of taste is usually altered in the patient with a respiratory disorder. All of the other factors contribute to lack of appetite in the patient with a respiratory disorder.
DIF: Cognitive Level: Comprehension REF: 274 OBJ: 2 (theory)
TOP: Anorexia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
- The nurse uses a visual aid to show the “hinged door” that helps prevent aspiration. This “hinged door” is the __________.
ANS:
epiglottis
The epiglottis is the “hinged door” that closes upon swallowing and opens when breathing.
DIF: Cognitive Level: Knowledge REF: 257 OBJ: 1 (theory)
TOP: Epiglottis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- Rapid opening and closing of the glottis combined with movement of the mouth, lips, and tongue is what makes _____________.
ANS:
speech
The rapid opening and closing of the glottis combined with the movement of the mouth, lips, and tongue is what makes speech.
DIF: Cognitive Level: Comprehension REF: 258 OBJ: 1 (theory)
TOP: Speech KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse describes the ability of the lungs to respond to change in the volume and pressure of inhaled air by expanding as lung __________.
ANS:
compliance
The lungs normal expansion in response to inhaled air is known as lung expansion. Lung compliance first increases and then decreases with age as the lungs become stiffer and the chest wall becomes more rigid.
DIF: Cognitive Level: Comprehension REF: 259 OBJ: 1 (theory)
TOP: Lung Compliance KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MATCHING
Trace the route of a molecule of oxygen inhaled from room air to the point of gas exchange.
| a. | Larynx |
| b. | Left and right bronchi |
| c. | Trachea |
| d. | Oxygen is inhaled through the nose |
| e. | Bronchioles |
| f. | Alveoli |
- Step 1
- Step 2
- Step 3
- Step 4
- Step 5
- Step 6
- ANS: D DIF: Cognitive Level: Comprehension REF: 258
OBJ: 1 (theory) TOP: Inhalation Process
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- ANS: A DIF: Cognitive Level: Comprehension REF: 258
OBJ: 1 (theory) TOP: Inhalation Process
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- ANS: C DIF: Cognitive Level: Comprehension REF: 258
OBJ: 1 (theory) TOP: Inhalation Process
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- ANS: B DIF: Cognitive Level: Comprehension REF: 258
OBJ: 1 (theory) TOP: Inhalation Process
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- ANS: E DIF: Cognitive Level: Comprehension REF: 258
OBJ: 1 (theory) TOP: Inhalation Process
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- ANS: F DIF: Cognitive Level: Comprehension REF: 258
OBJ: 1 (theory) TOP: Inhalation Process
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
Place in the appropriate sequence the steps of auscultation of the chest.
| a. | Place diaphragm of stethoscope above clavicles. |
| b. | Listen in midaxillary line to level of diaphragm. |
| c. | Move stethoscope from side to side down midline of the chest. |
| d. | Place diaphragm of stethoscope above scapulae. |
| e. | Move stethoscope side to side on either side of the spine. |
- Step 1
- Step 2
- Step 3
- Step 4
- Step 5
- ANS: A DIF: Cognitive Level: Application REF: 264
OBJ: 4 (theory) TOP: Auscultation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- ANS: C DIF: Cognitive Level: Application REF: 264
OBJ: 4 (theory) TOP: Auscultation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- ANS: D DIF: Cognitive Level: Application REF: 264
OBJ: 4 (theory) TOP: Auscultation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- ANS: E DIF: Cognitive Level: Application REF: 264
OBJ: 4 (theory) TOP: Auscultation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- ANS: B DIF: Cognitive Level: Application REF: 264
OBJ: 4 (theory) TOP: Auscultation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
