Test Bank Skills in Clinical Nursing, 9th Edition Audrey J. Berman A+

$35.00
Test Bank Skills in Clinical Nursing, 9th Edition Audrey J. Berman A+

Test Bank Skills in Clinical Nursing, 9th Edition Audrey J. Berman A+

$35.00
Test Bank Skills in Clinical Nursing, 9th Edition Audrey J. Berman A+

1) The nurse is caring for a client who developed an infection after admission to the hospital. Which term should the nurse use when documenting this infection? nursing | Nursing/Integrated

1. Nosocomial infection

2. Bacterial infection

3. Health care-associated infection

4. Therapeutic infection

Answer: 1

Explanation: 1. A nosocomial infection is an infection that originates specifically in the hospital.

2. Not enough information is provided to determine whether the infection is bacterial in nature.

3. A health care-associated infection can originate in any health care setting.

4. There is no such thing as a therapeutic infection.

Page Ref: 7

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe client care | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Define the key terms used in essential skills and equipment that protect nurses and clients.

2) The nurse is caring for a group of clients. For which situation should the nurse use a Situation, Background, Assessment, and Recommendation (SBAR) process? Select all that apply.

1. Discharging a client

2. Transferring a client to another unit

3. Contacting the primary care provider

4. Changing from day to evening shift

5. Informing family members of client status

Answer: 2, 3, 4

Explanation: 1. The SBAR is not used for discharging a client.

2. The SBAR is used to enhance the safety of the client in situations where nurses are communicating with other members of the health care team, such as when transferring the client to another unit.

3. The SBAR is used to enhance the safety of the client in situations where nurses are communicating with other members of the health care team, such as when contacting the primary care provider.

4. The SBAR is used to enhance the safety of the client in situations where nurses are communicating with other members of the health care team, such as when conducting change-of-shift report.

5. The SBAR is not used for notifying family members of the client's status.

Page Ref: 14

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Management of Care

Standards: QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe client care | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Define the key terms used in essential skills and equipment that protect nurses and clients.

3) A client with HIV/AIDS is being treated for a Pneumocystis carinii infection. In order to reduce the spread of infection, in which of the following areas should the nurse instruct this client?

1. Engaging in self-care

2. Respiratory hygiene/cough etiquette

3. The use of sexual barriers

4. Standard precautions

Answer: 2

Explanation: 1. Teaching self-care might be indicated for this client, but it is not related to reducing the spread of infection.

2. The client with a respiratory infection would benefit most from learning how to use respiratory hygiene/cough etiquette in order to reduce the risk of spreading infection to others.

3. Although teaching the use of sexual barriers would reduce the risk of sexually transmitted infections, it is not the priority need at this time.

4. Standard precautions are used by the health care provider and are not generally taught to clients.

Page Ref: 5

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe client care | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching and Learning

Learning Outcome: 1. Define the key terms used in essential skills and equipment that protect nurses and clients.

4) The nurse reviews the care needs for assigned clients. Which task would be appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

1. Measuring vital signs

2. Measuring and recording intake and output

3. Postmortem care

4. Providing telephone advice

5. Weighing the client

Answer: 1, 2, 3, 5

Explanation: 1. Vital sign measurement is an appropriate task to delegate to the UAP.

2. Recording intake and output is an appropriate task to delegate to the UAP.

3. Providing postmortem care is an appropriate task to delegate to the UAP.

4. Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice.

5. Weighing the client is an appropriate task to delegate to the UAP.

Page Ref: 4

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Management of Care

Standards: QSEN Competencies: II.B.5. Assume role of team member or leader based on the situation | AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to, and supervising, other members of the health care team | NLN Competencies: Teamwork: Practice-Know-How: Function competently within one's own scope of practice as leader or member of the health care team and manage delegation effectively | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2. Recognize when it is appropriate to assign skills to unlicensed assistive personnel.

5) The nurse observes the newly hired unlicensed assistive person (UAP) performing routine client care. Which behavior should indicate the UAP understands the use of personal protective equipment?

1. The UAP removes the gown first and then gloves after providing care.

2. The UAP applies gloves before emptying the client's indwelling catheter bag, then removes gloves and washes hands before measuring urine output.

3. The UAP applies gloves to clean the client's dentures, then removes gloves and performs hand hygiene prior to bathing the client.

4. The UAP wears gown and gloves when performing postmortem care.

Answer: 3

Explanation: 1. Gloves are removed before removing the gown.

2. Gloves should not be removed until after measuring urine output and rinsing the measuring container and returning it to its storage location.

3. Gloves are required when providing denture care but are not required for bathing the client.

4. Gloves should be worn when performing postmortem care, but a gown is generally not required.

Page Ref: 10-13

Cognitive Level: Analyzing

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 4. Describe factors that affect the use of personal protective equipment such as gowns, masks, eyewear, and gloves.

6) The nurse is caring for a client with a deep draining abdominal wound. For which factor should the nurse wear a mask and goggles when caring for this client?

1. The wound is infected.

2. The client is confused and disoriented.

3. The wound is covered by wet-to-damp dressings.

4. The client is HIV-positive.

Answer: 2

Explanation: 1. The client who is confused and disoriented might not cooperate with care and could cause splashing of wound drainage, so the nurse should wear a mask and goggles when caring for this client. The other factors would cause the nurse to don gloves and a gown but would not lead to the use of mask and goggles.

2. The client who is confused and disoriented might not cooperate with care and could cause splashing of wound drainage, so the nurse should wear a mask and goggles when caring for this client. The other factors would cause the nurse to don gloves and a gown but would not lead to the use of mask and goggles.

3. The client who is confused and disoriented might not cooperate with care and could cause splashing of wound drainage, so the nurse should wear a mask and goggles when caring for this client. The other factors would cause the nurse to don gloves and a gown but would not lead to the use of mask and goggles.

4. The client who is confused and disoriented might not cooperate with care and could cause splashing of wound drainage, so the nurse should wear a mask and goggles when caring for this client. The other factors would cause the nurse to don gloves and a gown but would not lead to the use of mask and goggles.

Page Ref: 11

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Context and Environment: Practice-Know-How Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4. Describe factors that affect the use of personal protective equipment such as gowns, masks, eyewear, and gloves.

7) The nurse is reviewing tasks to delegate after receiving hand-off communication. Which procedure could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

1. Making a nursing diagnosis

2. Assisting a client to a bedside commode

3. Performing assessments on client

4. Giving the client pain medication

Answer: 2

Explanation: 1. Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Formulating a nursing diagnosis is not a task that can be delegated to the UAP.

2. Assisting a client to a bedside commode is an activity that can be delegated to the UAP.

3. Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Assessment is not a task that can be delegated to the UAP.

4. Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Administering pain medication is not an activity that can be delegated to the UAP.

Page Ref: 4

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Management of Care

Standards: QSEN Competencies: II.B.5. Assume role of team member or leader based on the situation | AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to, and supervising, other members of the health care team | NLN Competencies: Teamwork: Practice-Know-How: Function competently within one's own scope of practice as leader or member of the health care team and manage delegation effectively | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2. Recognize when it is appropriate to assign tasks to unlicensed assistive personnel.

8) The nurse assigns unlicensed assistive personnel (UAP) to complete client care tasks. Which statement indicates that the UAP understands the directions?

Select all that apply.

1. "I will bathe the client in room 402."

2. "I am done with the assigned tasks for Mr. Wells."

3. "I can give the medication for you."

4. "I will note all orders."

5. "I understand my assignment is to take and document the vital signs."

Answer: 1, 2, 5

Explanation: 1. Restating the task to the nurse indicates understanding and appropriate communication during delegation.

2. Telling the nurse that the assigned tasks are done indicates understanding and appropriate communication during delegation.

3. Medication administration cannot be delegated.

4. The UAP cannot note orders on the medical record. This activity must be done by the nurse.

5. Restating the task to the nurse indicates understanding and appropriate communication during delegation.

Page Ref: 4-5

Cognitive Level: Analyzing

Client Need/Sub: Safe and Effective Care Environment; Management of Care

Standards: QSEN Competencies: II.B.5. Assume role of team member or leader based on the situation | AACN Essential Competencies: IX.14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to, and supervising, other members of the health care team | NLN Competencies: Teamwork: Practice-Know-How: Function competently within one's own scope of practice as leader or member of the health care team and manage delegation effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2. Recognize when it is appropriate to assign tasks to unlicensed assistive personnel.

9) The nurse is preparing to care for assigned clients. Which item will the nurse use to prevent the transmission of potentially infective organisms among the nurse, client, and other individuals?

Select all that apply.

1. Hand hygiene

2. Standard precautions

3. Personal protective equipment

4. Isolation procedures

5. Antimicrobial soap

Answer: 1, 2, 3

Explanation: 1. The nurse should use hand hygiene with all clients.

2. The nurse should use standard precautions with all clients.

3. The nurse should use personal protective equipment with all clients.

4. Isolation procedures are indicated for some clients but not all.

5. Antimicrobial soap is indicated for some clients but not all.

Page Ref: 4-13

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Identify indications for standard precautions and hand hygiene.

10) The nurse observes unlicensed assistive personnel (UAP) perform hand hygiene with an alcohol-based cleanser. For which reason should the nurse provide additional teaching?

1. Rubs palm against palm when washing hands

2. Applies a palmful of product into cupped hands

3. Interlaces fingers palm to palm

4. Dries hands with clean paper towel

Answer: 4

Explanation: 1. Rubbing of hands palm to palm is continued until the product dries, which takes about 20-30 seconds.

2. A palmful of product is generally required to coat all surfaces.

3. Interlacing fingers is done until the product dries, which takes about 20-30 seconds.

4. When using an alcohol-based hand rub, the hands should not be dried.

Page Ref: 8

Cognitive Level: Analyzing

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3. Identify indications for standard precautions and hand hygiene.

11) The nurse is working in a day care center for infants with special needs where there recently has been an outbreak of viral conjunctivitis. Which instruction by the nurse to the staff is the best way to stop the spread of this infection?

1. Require all children with conjunctivitis to stay home until there is a reduction in drainage.

2. Require all children with an infection to be on otic antibiotics for at least 24 hours prior to returning to school.

3. Isolate all children with conjunctivitis in the same room away from those who are not infected.

4. Perform hand hygiene after providing personal care for all children.

Answer: 4

Explanation: 1. There would be no need to place a child with a viral illness away from the day care center.

2. Antibiotics are not used for a viral illness.

3. There would be no need to isolate children with conjunctivitis.

4. The best way to reduce the spread of infection is through thorough hand hygiene.

Page Ref: 7-10

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Identify indications for standard precautions and hand hygiene.

12) The nurse prepares to care for a client. For which situation should the nurse use clean, disposable gloves?

1. Providing denture care

2. Bathing a client

3. Applying antiembolism stockings

4. Assessing vital signs

Answer: 1

Explanation: 1. The purpose of gloves is to protect the hands when likely to handle any potentially infective material. When providing denture care, there is contact with mucous membranes and body secretions, so gloves would be required.

2. In most instances, unless the client has an open wound, gloves would not be required when bathing a client.

3. In most instances, unless the client has an open wound, gloves would not be required when applying stockings.

4. In most instances, unless the client has an open wound, gloves would not be required when assessing vital signs.

Page Ref: 10

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Describe factors that affect the use of personal protective equipment such as gowns, masks, eyewear, and gloves.

13) The nurse is preparing to care for a client with a traumatic amputation of the left hand. Which personal protective equipment should the nurse wear?

1. Gloves

2. Gown and gloves

3. Gown, gloves, and mask

4. Gloves and mask

Answer: 3

Explanation: 1. Because of the high risk of arterial blood spatter, the nurse should wear gown, gloves, and mask.

2. Because of the high risk of arterial blood spatter, the nurse should wear gown, gloves, and mask.

3. Because of the high risk of arterial blood spatter, the nurse should wear gown, gloves, and mask.

4. Because of the high risk of arterial blood spatter, the nurse should wear gown, gloves, and mask.

Page Ref: 10

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4. Describe factors that affect the use of personal protective equipment such as gowns, masks, eyewear, and gloves

14) The manager is observing a staff nurse care for a client with extensive burns. Which action by the staff nurse would indicate the need for further teaching regarding infection control procedures?

1. The nurse wears gloves and gown when dressing the client's wounds.

2. The nurse wears gloves when bathing the client.

3. The nurse wears gown, gloves, and mask when assisting the physician with debridement of the wound.

4. The nurse wears gloves when teaching a family member how to meet the client's nutritional needs after discharge.

Answer: 4

Explanation: 1. Gloves and gown would be worn when dressing the wounds due to the potential for contamination of the nurse's uniform.

2. Because of the client's extensive skin damage, gloves would be worn when bathing the client.

3. Gown, glove, and mask would be needed when debriding due to potential blood spatter.

4. There would be no need to wear protective equipment when sitting at the client's bedside conducting nutrition counseling.

Page Ref: 10-11

Cognitive Level: Analyzing

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Describe factors that affect the use of personal protective equipment such as gowns, masks, eyewear, and gloves

15) The nurse is planning care for a client. Which equipment should be used?

1. Personal protective equipment

2. Sterile gloves

3. Biohazard suit

4. Mask and eyewear

Answer: 1

Explanation: 1. All health care providers must apply PPE (clean or sterile gloves, gowns, masks, and protective eyewear) according to the risk of exposure to potentially infective materials.

2. Sterile gloves may or may not be required, depending on the risk of exposure to potentially infective materials.

3. Biohazardous waste is placed in a container with special labeling and may require the use of PPE, but not a biohazard suit.

4. Mask and eyewear may or may not be required, depending on the risk of exposure to potentially infective material.

Page Ref: 10-11

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4. Describe factors that affect the use of personal protective equipment such as gowns, masks, eyewear, and gloves.

16) The nurse is caring for a client in respiratory isolation. Which protective equipment should the nurse use?

1. Face mask

2. Gown only

3. Gloves only

4. Mask and gloves

Answer: 4

Explanation: 1. Although a face mask will be used, this answer is only partially correct as gloves are also required.

2. The nurse will require the use of more than a gown when caring for a client on respiratory isolation.

3. The nurse will require the use of more than gloves when caring for a client on respiratory isolation.

4. A face mask and gloves are essential equipment when providing care to a client on respiratory isolation.

Page Ref: 10-11

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4. Describe factors that affect the use of personal protective equipment such as gowns, masks, eyewear, and gloves.

17) The nurse is assisting the health care provider insert a chest tube into a client. Which personal protective equipment should the nurse apply to assist with this procedure? Select all that apply.

1. Sterile gown

2. Sterile gloves

3. Mask with eye shield

4. Mask

5. Clean gown

Answer: 3, 5

Explanation: 1. The nurse would not need to apply a sterile gown because the role of the nurse is to monitor the client during the procedure.

2. The nurse would not need to apply sterile gloves because the role of the nurse is to monitor the client during the procedure.

3. Due to the risk of splatter, the nurse should wear a mask with eye shield.

4. A mask alone is not sufficient.

5. A clean gown is sufficient.

Page Ref: 11-13

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4. Describe factors that affect the use of personal protective equipment such as gowns, masks, eyewear, and gloves.

18) The nurse needs to remove personal protective equipment. Which item should the nurse remove first?

1. Gown

2. Gloves

3. Mask

4. Gloves and gown at the same time

Answer: 2

Explanation: 1. Gloves are always removed first because they are the most soiled. If wearing a gown that is tied at the waist, the ties would be undone before removing the gloves, and then the gown and mask may be removed and hand hygiene should be performed.

2. Gloves are always removed first because they are the most soiled. If wearing a gown that is tied at the waist, the ties would be undone before removing the gloves, and then the gown and mask may be removed and hand hygiene should be performed.

3. Gloves are always removed first because they are the most soiled. If wearing a gown that is tied at the waist, the ties would be undone before removing the gloves, and then the gown and mask may be removed and hand hygiene should be performed.

4. Gloves are always removed first because they are the most soiled. If wearing a gown that is tied at the waist, the ties would be undone before removing the gloves, and then the gown and mask may be removed and hand hygiene should be performed.

Page Ref: 11-13

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Verbalize the steps used in:

a. Using standard precautions.

b. Performing hand hygiene.

c. Applying and removing personal protective equipment (gloves, gown, mask, eyewear).

19) The nurse is assisting the health care provider with a lumbar puncture. Which personal protective equipment should the nurse apply?

1. Sterile gloves, gown, and mask

2. Clean gloves, gown, and mask with eye shield or goggles

3. Sterile gloves, gown, and mask with eye shields or goggles

4. Clean gloves

Answer: 4

Explanation: 1. Because there is no risk of spray from a lumbar puncture, sterile gloves, gown, and mask are not needed.

2. Because there is no risk of spray from a lumbar puncture, a gown, mask with eye shield or goggles are not needed. Clean gloves are the only item required.

3. Because there is no risk of spray from a lumbar puncture, sterile gloves, a gown, mask with eye shield or goggles are not needed.

4. Because the role of the nurse is to support the client during the procedure, clean gloves should be worn.

Page Ref: 11-13

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Verbalize the steps used in:

a. Using standard precautions.

b. Performing hand hygiene.

c. Applying and removing personal protective equipment (gloves, gown, mask, eyewear).

20) The nurse is called to assist with a client in labor who has no pulse or respirations and has profuse vaginal bleeding. Which action should the nurse take first?

1. Apply gloves and assess the client for pulse and respirations.

2. Assess the client for pulse and respirations, instruct UAP to notify code team while applying personal protective equipment, and begin CPR.

3. Quickly assess pulse and respirations, next assess for bleeding, call for the code team, and then apply personal protective equipment before beginning CPR.

4. Apply gown, gloves, mask, and goggles, then assess client for pulse, respirations, and bleeding.

Answer: 2

Explanation: 1. If the client is bleeding vaginally, it would be possible to assess carotid pulse and breathing without coming in contact with bloodborne pathogens. After the nurse confirms that the client is pulseless, instruct the UAP to call a code while applying personal protective equipment and beginning CPR.

2. If the client is bleeding vaginally, it would be possible to assess carotid pulse and breathing without coming in contact with bloodborne pathogens. After the nurse confirms that the client is pulseless, instruct the UAP to call a code while applying personal protective equipment and beginning CPR.

3. If the client is bleeding vaginally, it would be possible to assess carotid pulse and breathing without coming in contact with bloodborne pathogens. After the nurse confirms that the client is pulseless, instruct the UAP to call a code while applying personal protective equipment and beginning CPR.

4. If the client is bleeding vaginally, it would be possible to assess carotid pulse and breathing without coming in contact with bloodborne pathogens. After the nurse confirms that the client is pulseless, instruct the UAP to call a code while applying personal protective equipment and beginning CPR.

Page Ref: 11-13

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies

| Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Verbalize the steps used in:

a. Using standard precautions.

b. Performing hand hygiene.

c. Applying and removing personal protective equipment (gloves, gown, mask, eyewear).

21) The nurse is assigned to care for several clients during the shift. Which action by the nurse demonstrates appropriate hand hygiene?

1. Putting on gloves

2. Washing hands with soap and water

3. Wiping hands off when entering room

4. Using the client's soap on hands

Answer: 2

Explanation: 1. Putting on gloves does not demonstrate appropriate hand hygiene.

2. Washing hands with soap and water demonstrates appropriate hand hygiene.

3. Wiping hands off when entering the room does not demonstrate appropriate hand hygiene.

4. The use of the client's soap on the hand is not appropriate when performing hand hygiene.

Page Ref: 7-8

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies

| Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Verbalize the steps used in:

a. Using standard precautions.

b. Performing hand hygiene.

c. Applying and removing personal protective equipment (gloves, gown, mask, eyewear).

22) The nurse is cleaning a client area after a procedure. Which item would be incorrectly placed in the sharps container?

1. Scalpels

2. Lancets

3. Bloody bandage

4. Needles

Answer: 3

Explanation: 1. The sharps container is used for anything sharp, so a bloody bandage would go into the red-bagged trash can, not the sharps container. The other products would go into the puncture-resistant sharps container.

2. The sharps container is used for anything sharp, so a bloody bandage would go into the red-bagged trash can, not the sharps container. The other products would go into the puncture-resistant sharps container.

3. The sharps container is used for anything sharp, so a bloody bandage would go into the red-bagged trash can, not the sharps container. The other products would go into the puncture-resistant sharps container.

4. The sharps container is used for anything sharp, so a bloody bandage would go into the red-bagged trash can, not the sharps container. The other products would go into the puncture-resistant sharps container.

Page Ref: 14

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: V.7. Examine the roles and responsibilities of the regulatory agencies and their effect on client care quality, workplace safety, and the scope of nursing and other health professionals' practice | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Demonstrate appropriate disposal of equipment and supplies.

23) The nurse has just changed a client's surgical dressing. Which action should the nurse take to follow standard precaution guidelines for proper disposal of contaminated materials?

1. The old dressing is discarded in the trash can.

2. The unsoiled disposable gown is removed and discarded in the hazardous waste container.

3. The gloves are discarded in the trash can.

4. The mask is discarded in the trash can.

Answer: 4

Explanation: 1. The old dressing should be discarded in the hazardous waste container because it is contaminated.

2. The disposable gown does not need to be placed in the hazardous waste container unless it is contaminated with blood or body fluids.

3. The gloves should be discarded in the hazardous waste container because they are contaminated.

4. The mask, unless contaminated with blood or body fluids, would be discarded in the trash can.

Page Ref: 13-14

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: V.7. Examine the roles and responsibilities of the regulatory agencies and their effect on client care quality, workplace safety, and the scope of nursing and other health professionals' practice | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Demonstrate appropriate disposal of equipment and supplies.

24) The nurse is wearing personal protective equipment (PPE) when caring for a client with projectile vomiting. In which way should the nurse properly discard the PPE?

1. All PPE would be discarded in the hazardous waste container whenever leaving the client's room, and new PPE would be applied when returning to the room.

2. The nurse could wear the same PPE if only leaving the room briefly and discard in the hazardous waste container when the client is transferred to the floor.

3. The nurse removes the PPE and places it just inside the room to put back on when reentering the client's room, then discards into the hazardous waste container when the client is transferred.

4. If the PPE is soiled, the nurse discards it when leaving the room, but if it is not visibly contaminated, the nurse can reapply the same PPE when reentering the client's room.

Answer: 1

Explanation: 1. When a client is projectile vomiting, there is a high risk of splatter that might not be seen by the nurse. The PPE should be discarded in the hazardous waste container when exiting the client's room, and clean PPE should be applied when reentering the room.

2. Under no circumstances should the nurse walk around the unit in contaminated PPE.

3. Reapplying the same soiled PPE when reentering the room, whether visibly contaminated or not, would risk the nurse's exposure to body fluids, and would be incorrect technique.

4. Reapplying the same soiled PPE when reentering the room, whether visibly contaminated or not, would risk the nurse's exposure to body fluids, and would be incorrect technique.

Page Ref: 10-11

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: V.7. Examine the roles and responsibilities of the regulatory agencies and their effect on client care quality, workplace safety, and the scope of nursing and other health professionals' practice | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Demonstrate appropriate disposal of equipment and supplies.

25) The nurse assists the health care provider with the collection of cerebrospinal fluid. Which is an important safety measure for the nurse to follow immediately after collection of the sample?

1. Maintain sterility of the procedure tray.

2. Discard all sharps in a puncture-proof container.

3. Label specimens and send to the lab.

4. Remove PPE and discard.

Answer: 2

Explanation: 1. The nurse's first action would be to discard sharps in the puncture-proof container to prevent potential injury. This should be performed before removing PPE. The next step would be to label the specimens and bag them, prior to removal of PPE, due to potential contamination of the outside of the specimen tubes. After the procedure is completed, there is no need to maintain sterility of the procedure tray.

2. The nurse's first action would be to discard sharps in the puncture-proof container to prevent potential injury. This should be performed before removing PPE. The next step would be to label the specimens and bag them, prior to removal of PPE, due to potential contamination of the outside of the specimen tubes. After the procedure is completed, there is no need to maintain sterility of the procedure tray.

3. The nurse's first action would be to discard sharps in the puncture-proof container to prevent potential injury. This should be performed before removing PPE. The next step would be to label the specimens and bag them, prior to removal of PPE, due to potential contamination of the outside of the specimen tubes. After the procedure is completed, there is no need to maintain sterility of the procedure tray.

4. The nurse's first action would be to discard sharps in the puncture-proof container to prevent potential injury. This should be performed before removing PPE. The next step would be to label the specimens and bag them, prior to removal of PPE, due to potential contamination of the outside of the specimen tubes. After the procedure is completed, there is no need to maintain sterility of the procedure tray.

Page Ref: 14

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Safety and Infection Control

Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essential Competencies: V.7. Examine the roles and responsibilities of the regulatory agencies and their effect on client care quality, workplace safety, and the scope of nursing and other health professionals' practice | NLN Competencies: Context and Environment: Practice-Know-How: Apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Demonstrate appropriate disposal of equipment and supplies.

26) The nurse is preparing to document client care. Why is it critically important for the nurse to document all client care activities in the medical record? Select all that apply.

1. Facilitate continuity of care

2. Promote effective care

3. Meet legal and accreditation requirements

4. Prove care was completed

5. Provide data for research and reimbursement

Answer: 1, 2, 3, 5

Explanation: 1. Facilitating continuity of care by careful documentation leads to improved communication and promotes more effective care.

2. Facilitating continuity of care by careful documentation leads to improved communication and promotes more effective care.

3. Documentation is done to meet legal and accreditation requirements.

4. Documenting care does not prove it was completed.

5. Data from nursing documentation are used for both research and reimbursement.

Page Ref: 14

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Management of Care

Standards: QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality | AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing's unique contribution to client outcomes | NLN Competencies: Quality and Safety: Practice-Know-How: Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation

Learning Outcome: 7. Demonstrate appropriate documentation and recording of essential skills.

27) The nurse assists a health care provider with the collection of cerebrospinal fluid via a lumbar puncture. Which information can be omitted when documenting?

1. Specimen collection and disposition

2. Health care provider's contamination of first needle, requiring the nurse to obtain a second needle

3. Client response during and after the procedure

4. Sterile technique followed throughout the collection process

Answer: 2

Explanation: 1. There would be no need to document that the first needle was contaminated, requiring a second, because no error was made, the client was not injured in any way, and it could appear to be an error. The nurse should document what specimens were collected and where they were sent, how the client responded both during and after the procedure, and that sterile technique was followed.

2. There would be no need to document that the first needle was contaminated, requiring a second, because no error was made, the client was not injured in any way, and it could appear to be an error. The nurse should document what specimens were collected and where they were sent, how the client responded both during and after the procedure, and that sterile technique was followed.

3. There would be no need to document that the first needle was contaminated, requiring a second, because no error was made, the client was not injured in any way, and it could appear to be an error. The nurse should document what specimens were collected and where they were sent, how the client responded both during and after the procedure, and that sterile technique was followed.

4. There would be no need to document that the first needle was contaminated, requiring a second, because no error was made, the client was not injured in any way, and it could appear to be an error. The nurse should document what specimens were collected and where they were sent, how the client responded both during and after the procedure, and that sterile technique was followed.

Page Ref: 15

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Management of Care

Standards: QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality | AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing's unique contribution to client outcomes | NLN Competencies: Quality and Safety: Practice-Know-How: Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation

Learning Outcome: 7. Demonstrate appropriate documentation and recording of essential skills.

28) The nurse is exposed to the client's blood and body fluids via an accidental needlestick. In which way should this event be documented?

1. Document "Nurse stuck by used needle" in the client's medical record.

2. Document "Accidental exposure of nurse to blood and body fluid" in the client's medical record.

3. There is no need to document the exposure as long as the nurse takes the proper actions and notifies the charge nurse.

4. Completion of an incident report.

Answer: 4

Explanation: 1. When an incident occurs that does not involve the client directly (no harm is done or potentially done to the client), there is no need to document it in the client's medical record. The nurse would complete an incident report and notify the nursing supervisor or charge nurse.

2. When an incident occurs that does not involve the client directly (no harm is done or potentially done to the client), there is no need to document it in the client's medical record. The nurse would complete an incident report and notify the nursing supervisor or charge nurse.

3. When an incident occurs that does not involve the client directly (no harm is done or potentially done to the client), there is no need to document it in the client's medical record. The nurse would complete an incident report and notify the nursing supervisor or charge nurse.

4. When an incident occurs that does not involve the client directly (no harm is done or potentially done to the client), there is no need to document it in the client's medical record. The nurse would complete an incident report and notify the nursing supervisor or charge nurse.

Page Ref: 6, 16

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment; Management of Care

Standards: QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality | AACN Essential Competencies: IV.5. Use standardized terminology in a care environment that reflects nursing's unique contribution to client outcomes | NLN Competencies: Quality and Safety: Practice-Know-How: Carefully maintain and use electronic and/or written health records | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation

Learning Outcome: 7. Demonstrate appropriate documentation and recording of essential skills.

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