NCLEX practice questions Interventions Nursing PrepU

NCLEX practice questions Interventions Nursing PrepU Question 1: When performing an abdominal assessment, the nurse uses a (see full question) different order of techniques than with other systems. Which of the following represents this order You selected: Inspection, auscultation, percussion, palpation Correct Explanation: In an abdominal assessment, start with inspection, then auscultation, percussion, and palpation. This is the preferred approach because palpation and percussion before auscultation may alter the sounds heard. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 658. Chapter 25: Health Assessment - Page 658 When performing an abdominal assessment, the nurse uses a You selected: Observe the abdomen for distention and rigidity. Correct Explanation: Continued abdominal pain after administration of IV morphine is an unexpected occurrence and requires further assessment by the nurse to rule out peritonitis or internal bleeding by observing the abdomen for distention and rigidity. Administration of more morphine could mask the cause of the abdominal pain and delay diagnosis of a possible postoperative complication. Applying heat to the abdomen would increase blood flow to the area and potentially increase pain or internal bleeding. Positioning the client in a knees- flexed position may relieve the discomfort, but an assessment is needed before any intervention is implemented. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 658. Chapter 25: Health Assessment - Page 658 Question 3: The nurse will obtain the greatest amount of information about the (see full question) thyroid gland by using which technique of assessment? You selected: Palpation Correct Explanation: The thyroid gland is assessed by palpation, although it is not normally palpable in some patients. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 647-648. Chapter 25: Health Assessment - Page 647 Question 4: The nurse is asking admission interview questions and the client (see full question) has explained the reason for seeking care. Which of the following is the most appropriate way to document the response? You selected: Client describes shortness of breath and increased sputum production. Incorrect Correct response: Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." Explanation: The client's reason for seeking care should always be stated in the client's own words. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 628. Chapter 25: Health Assessment - Page 628 Question 5: The nurse in the emergency department observes a client (see full question) experiencing a generalized tonic–clonic seizure. What is the priority intervention for the nurse to take? You selected: Assess and maintain the client's airway. Correct Explanation: Risk for aspiration is a concern during a seizure because the client will have copious oral secretions that will need to be suctioned and allowed to drain out of the mouth. The nurse should assess the client's airway and maintain it by placing the client in a side-lying position, which will allow the oral secretions to drain from his mouth and not accumulate in his throat and compromise the airway. It is contraindicated to place anything in the mouth of a person who is actively convulsing. Reorienting the client and documenting the seizure are important actions after the postictal phase, but client safety is the priority intervention during a seizure. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 625. Chapter 25: Health Assessment - Page 625 Question 6: The nurse is caring for a client who just informed her that he (see full question) noticed some blood in the toilet after a bowel movement. The nurse n t f er er Question 8: (see full question) Which assessment measure would the nurse use to assess the location, shape, size, and density of a tumor? You selected: Percussion Correct Explanation: Percussion is the act of striking one object against another to produce sound. The fingertips are used to tap the body over body tissues to produce vibrations and sound waves. The location, shape, size, and density of organs or tumors are assessed with this method. Observation is visually looking at an object. The characteristics that can be determined about a tumor by palpation include shape, size, consistency, surface, mobility, tenderness, and pulsatile. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 635 Question 9: (see full question) The nurse is palpating the skin of a 30-year old patient and documents that when picked up in a fold, the skin fold slowly returns to normal. What would be the next action of the nurse based on this finding? You selected: Assess the patient for dehydration. Correct Explanation: Turgor is the fullness or elasticity of the skin. The patient should be further assessed for signs and symptoms of dehydration because poor skin turgor is a sign of dehydration. When the patient is dehydrated, the skin’s elasticity is decreased, and the skin fold returns slowly. Poor skin turgor is neither a sign of cardiovascular disease, nor cystic fibrosis. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 639 Question 10: The nurse is using a bed scale to weigh a patient, and the patient (see full question) becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation? You selected: Enlist the help of another nurse to hold the patient steady during the procedure. Incorrect Correct response: Stop lifting the patient and reassess him or her. Explanation: The nurse should stop lifting the patient and reassure him or her. If the patient continues to be agitated, the nurse lowers the patient back to the bed, and reevaluates the necessity of obtaining weight at that exact time. Continuing to lift the patient may result in injury to the patient. An order for sedation would only be requested if it was absolutely necessary to obtain the patient’s weight at this time. Another nurse holding the patient steady does not address the patient’s agitation. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 674 Question 11: To obtain subjective data about a newly admitted client's sleep (see full question) pattern, the nurse You selected: Asks the client what promotes sleep Correct Explanation: The assessment of sleep and rest focuses on the client's normal sleep patterns, alterations from the normal pattern, and satisfaction with quality of rest and sleep. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 625. Chapter 25: Health Assessment - Page 625 Question 12: A nurse performs an assessment on a client who has been (see full question) admitted to a long-term care facility for physical rehabilitation. What is the term for this type of assessment? You selected: Comprehensive assessment Correct Explanation: A comprehensive assessment with a detailed health history and complete physical examination are usually conducted when a client enters a health care setting. An ongoing and focused assessment is conducted at regular intervals during client care. An emergency assessment is a rapid, focused assessment conducted to determine potentially fatal situations. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 626. Chapter 25: Health Assessment - Page 626 Question 13: A 57-year-old male client is admitted to the medical unit with a 3- (see full question) day history of sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique would the nurse perform last? You selected: Palpation Correct Explanation: The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 659. Chapter 25: Health Assessment - Page 659 Question 14: You are assessing a patient's thorax and lungs. Which of the (see full question) following findings would indicate the need for further assessment? You selected: Auscultation of short, high-pitched popping sounds during inspiration Correct Explanation: Crackles (short, high-pitched popping sounds) may indicate disease, such as pneumonia or heart failure. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 648. Chapter 25: Health Assessment - Page 648 Question 15: A nurse assesses a patient for blood pressure. Which of the (see full question) following techniques would be used for this assessment? You selected: Inspection Incorrect Correct response: Auscultation Explanation: Auscultation is the act of listening with a stethoscope to sounds produced within the body. This technique is used to listen for blood pressure, heart sounds, lung sounds, and bowel sounds. Inspection is the process of performing deliberate, purposeful observations in a systematic manner. It uses the senses of smell, hearing, and sight. The hands and fingers are sensitive tools of palpation and can assess temperature, turgor, texture, moisture, pulsations, vibrations, shape and masses, and organs. Percussion is used to assess the location, shape, and size of organs, and the density of other underlying structures or tissues. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 632. Chapter 25: Health Assessment - Page 632 Question 16: The charge nurse is observing a new nurse perform an assessment (see full question) of a client's head and neck. Which of the following actions, if observed, would require the charge nurse to intervene? You selected: Palpation of both carotid arteries at the same time Correct Explanation: Palpation of both arteries at once can obstruct blood flow to the brain. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 655. Chapter 25: Health Assessment - Page 655 Question 17: The nurse is caring for an 88-year-old male admitted 2 days ago for (see full question) dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate? You selected: Check the client’s ear canals for cerumen. Correct Explanation: Ear wax (cerumen) becomes drier in the elderly and can block the ear canal and cause decreased hearing. Asking the client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating with the hard of hearing, but this client’s hearing loss was acute and requires further assessment. When speaking to the elderly who are hearing- impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic for the elderly. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 646. Chapter 25: Health Assessment - Page 646 Question 18: The acute care nurse is assessing a newly admitted client's (see full question) abdomen. Which of the following findings would indicate the need to contact the primary care provider? You selected: Auscultation of a bruit Correct Explanation: A bruit on auscultation suggests an aneurysm or arterial stenosis. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654. Chapter 25: Health Assessment - Page 654 Question 19: A nurse who works on a day-surgery unit conducts a thorough, (see full question) head to toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's ... You selected: peripheral pulses. Correct Explanation: Nonpalpable peripheral pulses are an unexpected finding, which warrants further assessment and follow-up. The liver, lymph nodes, and thyroid are not normally palpable in healthy individuals. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 652-655. Chapter 25: Health Assessment - Page 652 Question 20: Upon auscultation of a client's lung fields, the nurse hears a (see full question) continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? You selected: Wheezes Correct Explanation: Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors; the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing against the chest wall. Crackles are fine to coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 652. Chapter 25: Health Assessment - Page 652 Question 18: The acute care nurse is assessing a newly admitted client's (see full question) abdomen. Which of the following findings would indicate the need to contact the primary care provider? You selected: Auscultation of a bruit Correct Explanation: A bruit on auscultation suggests an aneurysm or arterial stenosis. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654. Chapter 25: Health Assessment - Page 654 Question 19: A nurse who works on a day-surgery unit conducts a thorough, (see full question) head to toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's ... You selected: peripheral pulses. Correct Explanation: Nonpalpable peripheral pulses are an unexpected finding, which warrants further assessment and follow-up. The liver, lymph nodes, and thyroid are not normally palpable in healthy individuals. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 652-655. Chapter 25: Health Assessment - Page 652 Question 20: Upon auscultation of a client's lung fields, the nurse hears a (see full question) continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? You selected: Wheezes Correct Explanation: Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors; the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing against the chest wall. Crackles are fine to coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 652. Chapter 25: Health Assessment - Page 652 Answer Key Question 1: The nurse is caring for a client after a stroke that left the client's right side weaker (see full than the left. The nurse coordinates the plan of care with the physical therapist. The question) nurse's interventions reflect which one of nursing's four broad goals? You • To restore health selected: Correct Explanation: The four broad aims of nursing practice are to promote health, prevent illness, restore health, and facilitate coping with death and/or disability. In the example, the nurse is coordinating care with the other disciplines in an attempt regain some of the strength in the client's right side. This is an example of restoring a client's health. The nurse is not preventing the stroke or promoting health prior to the stroke or facilitating coping with the stroke. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 10. Chapter 1: Introduction to Nursing - Page 10 Question 2: A man age 61 years is distraught because he has just learned that his most recent (see full computed tomography (CT) scan shows that his colon cancer has metastasized to question) his lungs. Which of the following nursing aims should the nurse prioritize in the immediate care of this patient? You Facilitating coping selected: Correct Explanation: This patient's care in the coming weeks or months will likely encompass all of the four foundational roles of the nurse. However, because the patient has just recently received bad news and is emotionally distraught, helping the patient cope is an appropriate priority in his immediate care. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 13. Chapter 1: Introduction to Nursing - Page 13 Question 3: The nurse working with an LPN understands which of the following about LPNs? (see full question) You They may work independently. selected: Incorrect Correct They must take a licensure exam. response: Explanation: Schools for practical nursing programs are located in varied settings. Most programs are 1 year in length. Upon completion of the program, graduates can take the National Council Licensure Examination-Practical Nurse (NCLEX-PN) for licensure as an LPN. LPNs work under the direction of a physician or RN to give direct care to clients, focusing on meeting healthcare needs in hospitals, nursing homes, and home health agencies. (less) Question 4: A group of nursing students has attended a presentation about the National Student (see full Nurses' Association (NSNA). Which statement by the group indicates that they have question) understood the information presented? You The organization provides programs of current professional interest. selected: Correct Explanation: The National Student Nurses' Association provides programs of current professional interest. It is not run by a group of registered nurses, but by nursing students themselves. It is student-funded, not funded by the national government. The Commission on Collegiate Nursing Education, not the National Student Nurses' Association, contributes to the improvement of public health. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 17. Chapter 1: Introduction to Nursing - Page 17 Question 5: Which nursing actions demonstrate the aim of nursing to facilitate coping? (Select all (see full that apply.) question) You • Assisting a patient and his/her family to prepare for death selected: • Teaching a patient and his/her family how to live with diabetes • Providing counseling for the family of a teenager with an eating disorder Correct Explanation: Coping is another important broad aim of nursing. Nurses facilitate client and family coping with altered function, life crisis, and death. Examples of coping would be teaching a client and the client’s family about how to live with diabetes. Another example would be assisting a client and the client’s family to prepare for death. A third example would be providing counseling for the family of a teenager with an eating disorder. Changing bandages, starting an IV, or teaching a class on an expected healthcare issue or need would not be examples of the aim of facilitating coping with disability or death. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 1: Introduction to Nursing, p. 13. Chapter 1: Introduction to Nursing - Page 13 Question 6: What was one barrier to the development of the nursing profession in the United (see full States after the Civil War? question) You Lack of educational standards selected: Correct Explanation: A lack of educational standards was one barrier to the development of the nursing profession after the Civil War. Other barriers included a male dominance of health care and the pervading belief that women were dependent on men. The location of nursing schools, a lack of influence from nursing leaders, and independent nursing orders were not barriers to the development of the nursing profession after the Civil War. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 7. Chapter 1: Introduction to Nursing - Page 7 Question 7: In what time period did nursing care as we now know it begin? (see full question) You 18th to 19th century selected: Correct Explanation: From the middle of the 18th century to the 19th century, social reforms changed the roles of nurses and of women in general. It was during this time that nursing as we now know it began, based on the beliefs of Florence Nightingale. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 7. Chapter 1: Introduction to Nursing - Page 7 Question 8: During the Reformation, what factor influenced the decline of nursing? (see full question) You Women's subordination to men selected: Correct Explanation: Women were viewed as subordinate to men and were expected to remain at home caring for children; this decreased the number of qualified women practicing nursing. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 7. Chapter 1: Introduction to Nursing - Page 7 Question 9: Which of the following nursing interventions would be the most appropriate for a new (see full mother that calls the nursery for help with breastfeeding? question) You Refer the mother for a home care visit. selected: Correct Explanation: It is the role of the nurse to encourage health promotion by providing information and referrals; therefore, the nurse should refer the mother for a home care visit, as this will enable the mother to receive all of the breast feeing help that is needed. Emailing a link for breastfeeding provides information, but not the support that is needed if a mother is having difficulty with breastfeeding. Suggesting bottle feeding and/or going to the emergency room is inappropriate. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11. Chapter 1: Introduction to Nursing - Page 11 Question 10: A nurse is providing care for patients in a long-term care facility. Based on the (see full definitions of nursing in the textbook, what should be the central focus of this care? question) You The nurse as the caregiver selected: Incorrect Correct The patient receiving the care response: Explanation: The client receiving the care is always the central focus of the nursing care provided. The central focus is not the nurse, the nursing actions, or nursing as a profession. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 1: Introduction to Nursing, p. 5. Chapter 1: Introduction to Nursing - Page 5 Question 11: The nurse is evaluating client health. Which of the following clients should the nurse (see full determine to be exhibiting the most signs of health? question) You A client with a leg amputation that performs activities of daily living with a prothesis selected: Correct Explanation: As defined by the World Health Organization, one’s health includes physical, social, and mental components and is not merely the absence of disease or infirmity. Health is often a subjective state—a person may be medically diagnosed with an illness, but still consider himself or herself healthy. The client with an amputee is performing activities of daily living, thereby demonstrating healthy behaviors. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11. Chapter 1: Introduction to Nursing - Page 11 Question 12: The nurse utilizing the nursing process includes which of the following steps? Select (see full all that apply. question) You • Assess selected: • Implement • Plan • Evaluate Correct Explanation: The nursing process consists of assessing the client, planning the client's care, implementing the planned interventions, and evaluating the effectiveness of those interventions. Prescribing is not a part of the nursing process. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 19. Chapter 1: Introduction to Nursing - Page 19 Question 13: During the course of any given day of work in the acute care setting, the nurse may (see full need to perform which of the following roles? Select all that apply. question) You • Communicator selected: • Teacher • Counselor Correct Explanation: The roles and functions of the nurse are many and include: caregiver, communicator, teacher, counselor, leader, researcher, and advocate. Acting as financier and statistician are not the roles of the nurse. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11. Chapter 1: Introduction to Nursing - Page 11 Question 14: Florence Nightingale introduced the concept of apprenticeship for nurses. Which of (see full the following statements is an example of this? question) You Completing clinical hours supervised by a nursing instructor selected: Correct Explanation: Florence Nightingale's concept of apprenticeship involved training student nurses in a hospital setting. Completing clinical hours is an example of this. The other choices do not reflect this concept. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 7. Chapter 1: Introduction to Nursing - Page 7 Question 15: The nurse caring for a client with a new diagnosis of cancer allows the client to (see full verbalize fears relating to how to tell the children. The nurse's intervention reflects question) which aspect of nursing? You Art of nursing selected: Correct Explanation: In this example, the nurse is utilizing a holistic approach to the provision of nursing care based on the knowledge of providing psychosocial interventions, such as allowing the client to verbalize feelings/fears. This application of knowledge is the art of nursing. The science of nursing is the knowledge base for the provision of care. Evidence-based practice and application of research is using research to make decisions on how to care for clients. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 5. Chapter 1: Introduction to Nursing - Page 5 Question 16: The registered nurse is teaching a community health class about illness prevention. (see full Which of the following statements reflects understanding of this concept? question) You "It is important to enroll in a smoking cessation class." selected: Correct Explanation: Enrolling in a smoking cessation class is an example of illness prevention. It will prevent conditions such as asthma and COPD. A hospice evaluation is for someone who is terminally ill, hypertension is already a disease entity, and an ambulance for injury does not denote illness prevention. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 12. Chapter 1: Introduction to Nursing - Page 12 Question 17: A registered nurse wishes to work as a nurse researcher. Which of the following is (see full true regarding nurse researchers? question) You They are responsible for the continued development and advancement of nursing. selected: Correct Explanation: Nurse researchers are responsible for the continued development and refinement of nursing. They usually have advanced education in addition to a baccalaureate degree in nursing. Nurse administrators, not nurse researchers, serve as liaisons between staff members and directors of nursing. Nurse researchers tend to work in large teaching hospitals, research centers, and academic institutions, not community health centers and long-term care units. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 16. Chapter 1: Introduction to Nursing - Page 16 Question 18: The nurse is conducting a community education class on the 2011 Institute of (see full Medicine Report on the role of nursing in transforming healthcare. Which of the question) following statements should the nurse include? You • Nurses should follow physicians' lead for changing the healthcare system. selected: • The infrastructure for data collection related to nursing is in place. Incorrect Correct • Barriers to diploma nurses achieving a BSN should be removed. response: • Nurse practitioners should be allowed to practice independently. Explanation: In 2011, the Institute of Medicine (IOM) released four key messages underlying their recommendations for transforming the nursing profession. These include that nurses should practice to the full extent of their education and training. Therefore, the nurse should include that nurse practitioners be allowed to practice independently and to practice at the full extent of their training. The IOM also recommended that nurses achieve higher levels of education and training through an improved educational system promoting seamless academic progression. Therefore, the nurse should include that barriers to diploma nurses receiving their BSN be removed. The IOM recommendations do not include that baccalaureate trained nurses do not need further academic training. The IOM recommends that nurses be full partners versus follow the lead of physicians in changing the healthcare system. The IOM also recommended that there be better data collection and improved information infrastructure. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 20. Chapter 1: Introduction to Nursing - Page 20 Question 19: The diploma nurse is considering obtaining a baccalaureate degree. Which degree (see full should the nurse investigate? question) You RN to BSN selected: Correct Explanation: The diploma nurse considering obtaining a baccalaureate degree should investigate RN to BSN programs. This degree is designed for registered nurses with a diploma degree. The DNP is designed as the terminal degree (doctorate degree) for nursing practice. The accelerated degree is designed for people with a baccalaureate degree, not in nursing to obtain their BSN in 1 to 2 years. The MSN is designed for nurses with a baccalaureate degree to obtain a masters degree in nursing. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, pp. 14-16. Chapter 1: Introduction to Nursing - Page 14 Question 20: Which of the following is the best example of a nurse in the role of counselor? (see full question) You A nurse allowing a crying client to verbalize their fears of death selected: Correct Explanation: When the nurse is acting as a counselor, the nurse uses therapeutic interpersonal skills to facilitate the client's problem-solving and decision-making skills. The best example is the nurse allowing the client to verbalize their feelings, as verbalizing feelings lets the client gain a better perspective of their situation for problem solving and for coming to terms with the situation. Telling the client about the side effects of a medication is a form of teaching. Providing test results to the physician is communication, and ensuring a client has follow-up care at a free clinic is advocacy. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11. Chapter 1: Introduction to Nursing - Page 11 congrats! Congratulations! You've reached Mastery Level 2 for Chapter 23: Asepsis and Infection Control! Quiz Results Quiz Stats Quiz completed in: 12 min Total Questions: 20 Questions answered: 20 Number correct: 19 95% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery Chapter 23: Asepsis and Infection Control My Mastery Level: 2.00 1 Quiz taken Class Average: 2.44 congrats! Congratulations! You've reached Mastery Level 2 for Chapter 23: Asepsis and Infection Control! Quiz Results Quiz Stats Next Take another quiz to work towards a higher mastery level. 95% See your overall performance. Performance by Chapter Chapter Mastery Chapter 23: Asepsis and Infection Control My Mastery Level: 2.00 1 Quiz taken Class Average: 2.44 Answer Key Question 1: (see full question) An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from which of the following? You selected: Recapping a needle Correct Explanation: Most needlesticks occur during recapping, so nurses are instructed to never recap needles. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 552. Chapter 23: Asepsis and Infection Control - Page 552 Question 2: (see full question) Which of the following practices is a correct application of infection control practices? You selected: A nurse performs handwashing each time she removes a pair of gloves. Correct Explanation: Handwashing should be performed after the removal of a pair of gloves. Gloves are not required for each and every patient contact and visibly soiled hands require a wash with soap and water. Alcohol-based handrubs are not followed by a rinse. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 542. Question 1: (see full question) Which level of health care provider may make the decision to apply physical restraints to a client? You selected: Nurse practitioner Correct Explanation: Current evidence-based research has shown that physical restraints should only be used as a last resort, and only used to prevent injury to staff, clients, or others. Federal and state guidelines, as well as accrediting bodies, such as The Joint Commission, require that restraints be applied only when ordered by a prescriber such as a physician, nurse practitioner, or physician's assistant. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 709. Chapter 26: Safety, Security, and Emergency Preparedness - Page 709 Question 2: (see full question) An boy 18 years of age is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to which of the following? You selected: Automobile accidents Correct Explanation: Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling from the bed is common in infants. Play-related injuries are commonly seen in school-age children, and falling from staircases is a common injury among toddlers. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, pp. 702- 704. Chapter 26: Safety, Security, and Emergency Preparedness - Page 702 Question 3: (see full question) Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for their 9-month-old infant? You selected: "We place our baby in a rear-facing car seat in the back seat of the car." Correct Explanation: The American Academy of Pediatrics recommends that all children from birth to 2 years of age remain in a rear-facing car seat in the back seat of the car until they are 2 years, or until they reach the maximum height and weight for the car seat. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 700- 701. Chapter 26: Safety, Security, and Emergency Preparedness - Page 700 Question 4: (see full question) One of the leading causes of death in the United States, particularly in southwestern states, is drowning. How can the nurse assist in lowering this statistic? You selected: Implement drowning-prevention strategies Correct Explanation: The principles of injury control have interventions centered at three primary levels: the individual level, providing education about safety hazards and prevention strategies; the design phase, using engineering and environmental controls; and the regulatory level, creating, monitoring, and enforcing regulations to ensure safe products and environments among manufacturers, retailers, employers, workers, and product users. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 696. Chapter 26: Safety, Security, and Emergency Preparedness - Page 696 Question 5: (see full question) A home care nurse provides health education to parents regarding the care of their toddler. Which of the following precautions should the nurse suggest the parents take to protect the toddler from drowning? You selected: Avoid unattended baths for the toddler. Correct Explanation: The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool may make them more curious. Monitoring the activities of the toddler is not always feasible. Allowing the child to swim with friends does not ensure safety. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, pp. 700- 701. Chapter 26: Safety, Security, and Emergency Preparedness - Page 700 Question 6: (see full question) The nurse is applying wrist restraints on a client and notes that the client is unable to move his right arm. What is the appropriate action by the nurse? You selected: Apply only the left wrist restraint. Correct Explanation: The nurse should apply only the left wrist restraint. As the client is unable to move the right arm, this arm does not need restraining. Vest restraints and wrist restraints are typically utilized to meet different client needs, so they are not usually interchanged for one another. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 722. Chapter 26: Safety, Security, and Emergency Preparedness - Page 722 Question 7: (see full question) Which of the following statements about restraints used in the acute care setting is true? You selected: A physician's order for use of a restraint is valid for 24 hours only. Correct Explanation: A valid physician or licensed independent practitioner's order is required for the use of restraints, regardless of setting. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 719. Chapter 26: Safety, Security, and Emergency Preparedness - Page 719 Question 8: (see full question) An administrative assistant of a large factory visits the medical unit and tells the nurse she is having pain in the right wrist, numbness in the index finger, and decreased mobility of the right hand. The nurse suspects the client has what? You selected: Carpal tunnel syndrome Correct Explanation: Adults with jobs that require repetitive movement (typists, assembly line workers, supermarket checkers, computer operators) may develop carpal tunnel syndrome, a compression of th ... (more) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 689. Chapter 26: Safety, Security, and Emergency Preparedness - Page 689 Question 9: (see full question) The nurse needs to plan the interventions necessary to reduce fall risks for the older adult clients at her facility. Which is the strongest indicator that a client is at risk for falls? You selected: The client has fallen before. Correct Explanation: Documentation that a client has sustained previous falls is a strong predictor of a risk for future falls. Cardiovascular medications, being forgetful, or using an assistive device do not necessarily predispose a client to falling. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 687. Chapter 26: Safety, Security, and Emergency Preparedness - Page 687 Question 10: (see full question) A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which of the following actions should the nurse take? You selected: Pull the fire alarm lever. Correct Explanation: The nurse should pull the fire alarm lever. As per the RACE principle of fire management, the flow of activities should be rescue, alarm, confine, and extinguish. The client had already been evacuated by another nurse, so the next action should be to pull the fire alarm lever, followed by confinement of the fire and extinguishing. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 710. Chapter 26: Safety, Security, and Emergency Preparedness - Page 710 Question 11: (see full question) What is an appropriate nursing intervention to include in the plan of care for a client with smallpox? You selected: Strict contact and airborne precautions for the duration of the illness Correct Explanation: Clients with smallpox should receive strict contact and airborne precautions for duration of illness and supportive care. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and emergency Preparedness, p. 715. Chapter 26: Safety, Security, and Emergency Preparedness - Page 715 Question 12: (see full question) If a client is exposed to Viral Hemorrhagic Fevers, which clinical manifestations would the nurse assess in the client? You selected: Flu-like symptoms and a characteristic rash Incorrect Correct response: Petechial hemorrhages and hypotension Explanation: Anthrax exposure can result in skin lesions that progress to necrotic ulcers and fever. Exposure to viral hemorrhagic fevers can result in Petechial hemorrhages and hypotension. Botulism exposure presents with Skeletal muscle paralysis and blurred vision. Small pox exposure presents with flu-like symptoms and a characteristic rash. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 715. Chapter 26: Safety, Security, and Emergency Preparedness - Page 715 Question 13: (see full question) The school nurse is preparing a presentation about safety promotion for middle school students. Which topic should the nurse plan to include? You selected: The importance of consistent seat belt use Correct Explanation: Seat belt use is an important safety precaution to teach audience of all ages. Improper or lack of seat belt use increases the risk for injury. It is not appropriate to teach middle school children about moderation with alcohol, workplace injury, or falls. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 689. Chapter 26: Safety, Security, and Emergency Preparedness - Page 689 Question 14: (see full question) Which of the following reasons best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk? You selected: Social pressure Correct Explanation: As adolescents explore opportunities, they may know that certain behaviors are unsafe, but social pressure can persuade them to act against their better judgment. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 689. Chapter 26: Safety, Security, and Emergency Preparedness - Page 689 Question 15: (see full question) The nurse is caring for an 80-year-old patient who was admitted to the hospital in a confused and dehydrated state. After the patient got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black- and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this patient? You selected: Take the restraints off, stay with her, and talk gently to her. Correct Explanation: Physical restraints increase the possibility of the occurrence of falls, skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration respiratory difficulties, and even death. The best action in this situation is for the nurse to remove the restraint, stay with the patient and gently talk to her. Sedating her with sleeping pills is a chemical form of restraint. Leaving the restraints on the patient to talk to her is going to cause further agitation and bruising of her wrists. The patient’s condition dictates when the patient is discharged, not confusion and agitation. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 26, Safety, Security, and Emergency Preparedness, pp. 708-710 Question 16: (see full question) An 8-year-old boy fell off his bicycle. He was not wearing a helmet and has sustained a concussion. What information should the nurse teach the parents about concussions? You selected: “It is important to monitor frequently for headache, vomiting, visual disturbances, and changes in alertness.” Correct Explanation: Frequent neurologic assessments are crucial after a traumatic brain injury, to assess for subtle changes as they begin. Helmets are meant to protect the wearer, but head injury can still occur. "Passing off" an injury as something that kids get and then they are fine is wrong and potentially harmful. Watching TV and video games stimulates brain activity and may worsen the child’s symptoms and the injury itself. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 701- 702. Chapter 26: Safety, Security, and Emergency Preparedness - Page 701 Question 17: (see full question) A school-aged child is admitted to the Emergency Room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was “knocked out” for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the patient? You selected: Assessment of vital signs and respiratory status Correct Explanation: Assessment after a head injury includes immediate evaluation of airway, breathing, and circulation. Therefore, assessment of vital signs and respiratory status is a priority for this client. Head circumference is only beneficial in children less than two years old and/or with open fontanels. Evaluation of all of his cranial nerves does not take priority over cardiopulmonary assessment, and assessment comes before intervention in the nursing process and more assessment is needed for this client before the need for an IV line is determined. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 699, 702. Chapter 26: Safety, Security, and Emergency Preparedness - Page 699 Question 18: (see full question) A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which of the following measures would be a high priority recommendation for this client? You selected: Placing the client in a bed with a bed alarm Correct Explanation: Raising all side rails on the bed would be a restraint, and may increase the client’s risk of a fall if he or she climbs out of bed. Providing a bed that is elevated would put the client at a greater risk for a fall. Using restraints are not an option at this time, but placing the client in a bed with a bed alarm would help to prevent a fall. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015,Chapter 26: Safety, Security, and Emergency Preparedness, p. 709. Chapter 26: Safety, Security, and Emergency Preparedness - Page 709 Question 19: The nurse is providing care for a client that was (see full question) involved in a nuclear terrorism attack, and, as a result, has sustained radiation burns. The nurse also knows that the client's history states that he was exposed to a high dose of radiation. What can the nurse expect this client to be at risk for based on the degree of exposure to the radiation? You selected: Cancer Correct Explanation: Bone marrow depression and cancer can occur later in clients that are exposed to high doses of radiation exposure. The skin, kidneys, and intestines are organs most sensitive to radiation, but these diseases are not specific to this exposure. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 716. Chapter 26: Safety, Security, and Emergency Preparedness - Page 716 Question 20: (see full question) A student nurse overhears another nurse talking to a group of students about work relate injuries. The student nurse understands that the nurse needs further education when she makes which statement? You selected: "Some injuries are just part of the job and cannot be prevented." Correct Explanation: Injuries should never be considered “part of the job.” OSHA standards and the involvement of safety committees help ensure a safe workplace. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and emergency Preparedness, p. 689. Chapter 26: Safety, Security, and Emergency Preparedness - Page 689 Question 1: The nurse is creating a plan of care for the older adult that has multiple medications and a difficult time reading medication labels (see full question) due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care? You selected: Risk for poisoning related to poor eyesight and the inability to read medication labels Correct Explanation: Older adults are at an increased risk for falls and can have an altered sensory perception. However, neither of those diagnoses address this client's lack of vision, causing difficulty in reading the labels of his multiple medications and thereby causing a risk for injury by overdose. There is no indication of substance abuse in this client. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 705-706. Chapter 26: Safety, Security, and Emergency Preparedness - Page 705 Question 2: The nurse caring for a client with smallpox would anticipate this (see full question) client being on which type of precautions? Select all that apply. You selected: Contact Correct Explanation: Smallpox is spread via direct contact and inhalation of droplets. Therefore, the client would be put on contact precautions, as well as respiratory precautions. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 715. Chapter 26: Safety, Security, and Emergency Preparedness - Page 715 Question 3: A school nurse is providing information to a group of older adults (see full question) during Fire Prevention Week. Which statement is correct regarding fires in the home? You selected: Most people who die in house fires die of smoke inhalation, rather than burns. Correct Explanation: Most people who die in house fires die of smoke inhalation, rather than burns. About 50% of home fire deaths occur in a home without a smoke detector. Many home fires are started because someone fell asleep smoking in bed or on a sofa, and most fatal home fires occur while people are sleeping. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 693. Chapter 26: Safety, Security, and Emergency Preparedness - Page 693 Question 4: What is the primary role of the nurse in the care of clients that (see full question) experience domestic violence? You selected: Identifying health education and counseling measures for the family Incorrect Correct response: Providing prompt recognition of the potential or actual threat to safety Explanation: The nurse is often the initial health care provider in contact with an abused child or a battered woman or man. Prompt recognition of the potential or actual threat to safety is crucial, and the nursing assessment may play a vital role in identifying a harmful environment. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 704-705. Chapter 26: Safety, Security, and Emergency Preparedness - Page 704 Question 5: A staff development nurse is providing an in-service to a group of (see full question) nurses on the use of restraints in healthcare facilities. Which of the following is an example of a chemical restraint? You selected: A dose of an analgesic Incorrect Correct response: A dose of an antipsychotic Explanation: Drugs that are used to control behavior and are not included in the person's normal medical regimen can be considered a chemical restraint. Side rails and a geriatric chair with a tray are examples of physical restraints. Analgesics address pain and are not a restraint. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 707. Chapter 26: Safety, Security, and Emergency Preparedness - Page 707 Question 6: When educating families on fire safety in the home, which (see full question) information is important for the nurse to emphasize? You selected: Keep a fire extinguisher in a closet. Incorrect Correct response: Have a meeting place outside the home in case of fire. Explanation: The whole family should regularly practice a fire escape plan, such as crawling on the floor, using escape routes, and having a meeting place outside the home in case of fire. Attempting to account for all family members before exiting the burning structure is dangerous and may result in the loss of life. Shock is possible with extension cords. Having a fire extinguisher is important, but it should be kept in a area with access and not a closet. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 694. Chapter 26: Safety, Security, and Emergency Preparedness - Page 694 Question 7: During a course on terrorism, a group of emergency room nurses (see full question) learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of what type of terrorism? You selected: Nuclear terrorism Incorrect Correct response: Mass trauma terrorism Explanation: Mass trauma terrorism is caused by bombs and other explosives that are used to inflict mass trauma and cause multiple fatalities. Bioterrorism involves the deliberate spread of pathogenic organisms into the community. Chemical terrorism involves the deliberate release of a chemical compound for the purpose of causing mass destruction. Nuclear terrorism involves the dispersal of radioactive materials into the environment for the purpose of causing injury and death. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, pp. 714-716. Chapter 26: Safety, Security, and Emergency Preparedness - Page 714 Question 8: What best describes the nurse’s role in disaster preparedness? (see full question) You selected: Multiple roles including triage and the distribution of resources Correct Explanation: Nurses will perform multiple roles when assisting with a disaster, including triage, procedures, counseling, and distribution of resources. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 717. Chapter 26: Safety, Security, and Emergency Preparedness - Page 717 Question 9: The nurse is conducting a community program on car seat safety. (see full question) The nurse determines that additional education is needed when a participant states which of the following? You selected: "I should secure the car seat tightly with the seat belt." Incorrect Correct response: "I should buy a front facing car seat when my child is 1 year old." Explanation: The nurse should determine that additional information is needed when the participant states that a front facing car seat should be bought when the child is 1 year old. The child should be kept in the rear facing car seat until 2 years of age. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 700. Chapter 26: Safety, Security, and Emergency Preparedness - Page 700 Question 10: A nurse is teaching a community group about bicycle safety. Which (see full question) statement should be included when creating a teaching plan regarding bicycle safety? You selected: "Parents are effective role models for children when they also wear helmets while riding." Correct Explanation: Parents are effective role models for children when they also wear helmets while riding. Helmets that have been damaged in a crash should not be worn. The chinstrap should fit snuggly, not loosely, and young children that are secured in a bicycle passenger seat must also wear a helmet. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 701. Chapter 26: Safety, Security,