Chapter 24, 25, 26, 27, 28, 29 and 30 Potter et al.: Fundamentals of Nursing, 9th Edition: MULTIPLE CHOICE

Document Content and Description Below

Chapter 24, 25, 26, 27, 28, 29 and 30 Potter et al.: Fundamentals of Nursing, 9th Edition: MULTIPLE CHOICE: Chapter 24: Communication .Which types of nurses make the best communicators with patie... nts? a. Those who learn effective psychomotor skills 
 b. Those who develop critical thinking skills 
 c. Those who like different kinds of people 
 d. Those who maintain perceptual biases 
 ANS: B Nurses who develop critical thinking skills make the best communicators. Just liking people does not make an effective communicator because it is important to apply critical thinking standards to ensure sound effective communication. Just learning psychomotor skills does not ensure that the nurse will use those techniques, and communication involves more than psychomotor skills. Critical thinking helps the nurse overcome perceptual biases or human tendencies that interfere with accurately perceiving and interpreting messages from others. Nurses who maintain perceptual biases do not make good communicators. DIF:Understand (comprehension)REF:317 OBJ: Identify ways to apply critical thinking to the communication process. TOP: Communication and Documentation MSC: Psychosocial Integrity 2. A nurse believes that the nurse-patient relationship is a partnership and that both are equal participants. Which term should the nurse use to describe this belief? a. Critical thinking 
 b. Authentic 
 c. Mutuality 
 d. Attend 
ANS: C Effective interpersonal communication requires a sense of mutuality, a belief that the nursepatient relationship is a partnership and that both are equal participants. Critical thinking in nursing, based on established standards of nursing care and ethical standards, promotes effective communication and uses standards such as humility, self-confidence, independent attitude, and fairness. To be authentic (one’s self) and to respond appropriately to the other person are important for interpersonal relationships but do not mean mutuality. Attending is giving all of your attention to the patient. DIF:Understand (comprehension)REF:317
OBJ: Incorporate features of a helping relationship when interacting with patients. TOP:CaringMSC:Management of Care 3. A nurse wants to present information about flu immunizations to the older adults in the community. Which type of communication should the nurse use? a. Public 
 b. Small group 
 c. Interpersonal 
 d. Intrapersonal 
 ANS: A Public communication is interaction with an audience. Nurses have opportunities to speak with groups of consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom discussions with peers or students. When nurses work on committees or participate in patient care conferences, they use a small group communication process. Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face to face. Intrapersonal communication is a powerful form of communication that you use as a professional nurse. This level of communication is also called self-talk. DIF:Apply (application)REF:318 OBJ:Utilize the five levels of communication with patients. TOP:Communication and Documentation MSC:Health Promotion and Maintenance 4. A nurse is using therapeutic communication with a patient. Which technique will the nurse use to ensure effective communication? a. Interpersonal communication to change negative self-talk to positive self-talk 
 b. Small group communication to present information to an audience 
 c. Electronic communication to assess a patient in another city d. Intrapersonal communication to build strong teams ANS: C Electronic communication is the use of technology to create ongoing relationships with patients and their health care team. Intrapersonal communication is self-talk. Interpersonal communication is one- on-one interaction between a nurse and another person that often occurs face to face. Public communication is used to present information to an audience. Small group communication is interaction that occurs when a small number of persons meet. When nurses work on committees or participate in patient care conferences, they use a small group communication process. DIF:Analyze (analysis)REF:319
OBJ:Utilize the five levels of communication with patients.
TOP: Communication and Documentation MSC: Management of Care 5. A nurse is standing beside the patient’s bed. Nurse: How are you doing?
Patient: I don’t feel good. Which element will the nurse identify as feedback? a. Nurse 
 b. Patient 
 c. How are you doing? 
d. I don’t feel good. 
 ANS: D ―I don’t feel good‖ is the feedback because the feedback is the message the receiver returns. The sender is the person who encodes and delivers the message, and the receiver is the person who receives and decodes the message. The nurse is the sender. The patient is the receiver. ―How are you doing?‖ is the message. DIF:Apply (application)REF:319-320 OBJ: Describe features of the circular transactional communication process. TOP: Communication and Documentation MSC: Psychosocial Integrity 6. A nurse is sitting at the patient’s bedside taking a nursing history. Which zone of personal space is the nurse using? a. Socio-consultative 
 b. Personal 
 c. Intimate 
 d. Public 
 ANS: B Personal space is 18 inches to 4 feet and involves things such as sitting at a patient’s bedside, taking a patient’s nursing history, or teaching an individual patient. Intimate space is 0 to 18 inches and involves things such as performing a physical assessment, bathing, grooming, dressing, feeding, and toileting a patient. The socio-consultative zone is 9 to 12 feet and involves things such as giving directions to visitors in the hallway and giving verbal report to a group of nurses. The public zone is 12 feet and greater and involves things such as speaking at a community forum, testifying at a legislative hearing, or lecturing. DIF:Understand (comprehension)REF:322 OBJ: Identify a nurse’s communication approaches within the four phases of a nurse-patient helping relationship. TOP: Assessment MSC: Psychosocial Integrity 7. A smiling patient angrily states, ―I will not cough and deep breathe.‖ How will the nurse interpret this finding? a. The patient’s denotative meaning is wrong. 
 b. The patient’s personal space was violated. 
 c. The patient’s affect is inappropriate. 
 d. The patient’s vocabulary is poor. 
 ANS: C An inappropriate affect is a facial expression that does not match the content of a verbal message (e.g., smiling when describing a sad situation). The patient is smiling but is angry, which indicates an inappropriate affect. The patient’s personal space was not violated. The patient’s vocabulary is not poor. Individuals who use a common language share denotative meaning: baseball has the same meaning for everyone who speaks English, but code denotes cardiac arrest primarily to health care providers. The patient’s denotative meaning is correct for cough and deep breathe. DIF:Apply (application)REF:321 OBJ emonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. TOP: Communication and Documentation MSC: Psychosocial Integrity 8. The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use? a. Verbal a. Nonverbal 
 b. Intonation 
 d. Vocabulary ANS: B The patient gestured (pointed), which is a type of nonverbal communication. Gestures emphasize, punctuate, and clarify the spoken word. Pointing to an area of pain is sometimes more accurate than describing its location. Verbal is the spoken word or message. Intonation or tone of voice dramatically affects the meaning of a message. Vocabulary consists of words used for verbal communication. DIF:Understand (comprehension)REF:320-321 OBJ: Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. TOP: Assessment MSC: Basic Care and Comfort 9. A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using? a. Nonjudgmental 
 b. Socializing 
 c. Narrative 
 d. SBAR 
 ANS: C In a therapeutic relationship, nurses often encourage patients to share personal stories. Sharing stories is called narrative interaction. Socializing is an important initial component of interpersonal communication. It helps people get to know one another and relax. It is easy, superficial, and not deeply personal. Nonjudgmental acceptance of the patient is an important characteristic of the relationship. Acceptance conveys a willingness to hear a message or acknowledge feelings; it is not a technique that involves personal stories. SBAR is a popular communication tool that helps standardize communication among health care providers. SBAR stands for Situation, Background, Assessment, and Recommendation. DIF:Understand (comprehension)REF:323
OBJ: Incorporate features of a helping relationship when interacting with patients. TOP: Communication and Documentation MSC: Psychosocial Integrity 10. Before meeting the patient, a nurse talks to other caregivers about the patient. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction 
 b. Orientation 
 c. Working 
 d. Termination 
 ANS: A The time before the nurse meets the patient is called the preinteraction phase. This phase can involve things such as reviewing available data, including the medical and nursing history, talking to other caregivers who have information about the patient, or anticipating health concerns or issues that can arise. The orientation phase occurs when the nurse and the patient meet and get to know one another. This phase can involve things such as setting the tone for the relationship by adopting a warm, empathetic, caring manner. The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. The termination phase occurs during the ending of the relationship. This phase can involve things such as reminding the patient that termination is near. DIF:Understand (comprehension)REF:322 OBJ:Identify a nurse’s communication approaches within the four phases of a nurse-patient helping relationship.TOP:AssessmentMSC:Management of Care 11. During the initial home visit, a home health nurse lets the patient know that the visits are expected to end in about a month. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction 
 b. Orientation 
c. Working
d. Termination ANS: B Letting the patient know when to expect the relationship to be terminated occurs in the orientation phase. Preinteraction occurs before the nurse meets the patient. Working occurs when the nurse and the patient work together to solve problems and accomplish goals. Termination occurs during the ending of the relationship. DIF:Apply (application)REF:322 OBJ:Identify a nurse’s communication approaches within the four phases of a nurse-patient helping relationship.TOP:AssessmentMSC:Management of Care 12. A nurse and a patient work on strategies to reduce weight. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction 
 b. Orientation 
 c. Working 
 d. Termination 
 ANS: C The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. Preinteraction occurs before the nurse meets the patient. Orientation occurs when the nurse and the patient meet and get to know each other. Termination occurs during the ending of the relationship. DIF:Apply (application)REF:322 OBJ:Identify a nurse’s communication approaches within the four phases of a nurse-patient helping relationship.TOP:Implementation MSC:Health Promotion and Maintenance 13. A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse’s action? a. To promote autonomy 
 b. To use common courtesy 
 c. To establish trustworthiness 
 d. To standardize communication 
 ANS: D SBAR is a popular communication tool that helps standardize communication among health care providers. Common courtesy is part of professional communication but is not the purpose of SBAR. Being trustworthy means helping others without hesitation. Autonomy is being self-directed and independent in accomplishing goals and advocating for others. DIF:Understand (comprehension)REF:323
OBJ: Identify desired outcomes of nurse–health care team member relationships. TOP lanningMSC:Management of Care 14. A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Which piece of data will the nurse use for ―B‖ when using SBAR? a. Having chest pain 
 b. Pulse rate of 108 
 c. History of angina 
d. Oxygen is needed ANS: C The B in SBAR stands for background information. The background information in this situation is the history of angina. Having chest pain is the Situation (S). Pulse rate of 108 is the Assessment (A). Oxygen is needed is the Recommendation (R). DIF:Apply (application)REF:323 OBJ: Identify desired outcomes of nurse–health care team member relationships. TOP:ImplementationMSC:Management of Care 15. A patient just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy? a. ―Tomorrow will be better.‖ 
 b. ―This must be hard news to hear.‖ 
 c. ―What’s your biggest fear about this diagnosis?‖ 
 d. ―I believe you can overcome this because I’ve seen how strong you are.‖ 
 ANS: B ―This must be hard‖ is an example of empathy. Empathy is the ability to understand and accept another person’s reality, accurately perceive feelings, and communicate this understanding to the other. An example of false reassurance is ―Tomorrow will be better.‖ ―I believe you can overcome this‖ is an example of sharing hope. ―What is your biggest fear?‖ is an open-ended question that allows patients to take the conversational lead and introduces pertinent information about a topic. DIF:Analyze (analysis)REF:328
OBJ: Identify opportunities to improve communication with patients while giving care. TOP: Communication and Documentation MSC: Psychosocial Integrity 16. A nurse is taking a history on a patient who cannot speak English. Which action will the nurse take? a. Obtain an interpreter. 
 b. Refer to a speech therapist. 
 c. Let a close family member talk. 
 d. Find a mental health nurse specialist. 
 ANS: A Interpreters are often necessary for patients who speak a foreign language. Using a family member can lead to legal issues, speech therapists help patients with aphasia, and mental health nurse specialists help angry or highly anxious patients to communicate more effectively. DIF:Understand (comprehension)REF:320 | 326 | 332 OBJ: Implement nursing care measures for patients with special communication needs. TOP:ImplementationMSC:Management of Care 17. A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for R? a. Relax 
 b. Respect 
 c. Reminisce 
 d. Reassure 
 ANS: A In SOLER, the R stands for relax. It is important to communicate a sense of being relaxed and comfortable with the patient. Active listening enhances trust because the nurse communicates acceptance and respect for the patient, but it is not the R in SOLER. Reminisce is a therapeutic communication technique, especially when used with the elderly. Reassuring can be therapeutic if the nurse reassures patients that there are many kinds of hope and that meaning and personal growth can come from illness experiences. However, false reassurance can block communication. DIF:Understand (comprehension)REF:327-328 OBJ: Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. TOP: Implementation MSC: Psychosocial Integrity 18. An older-adult patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication? a. Chew gum. 
 b. Turn off the television. 
 c. Speak clearly and loudly. 
 d. Use at least 14-point print. 
 ANS: B Turning off the television will facilitate communication. Patients who are hearing impaired benefit when the following techniques are used: check for hearing aids and glasses, reduce environmental noise, get the patient’s attention before speaking, do not chew gum, and speak at normal volume—do not shout. Using at least 14-point print is for sight/visually impaired, not hearing impaired. DIF:Apply (application)REF:326 | 332
OBJ:Engage in effective communication techniques for older patients. TOP: Implementation MSC: Psychosocial Integrity 19. When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate? a. ―You will be okay. Your surgeon will talk to you in the morning.‖ 
 b. ―Why can’t you sleep? You have the best surgeon in the hospital.‖ 
 c. ―Don’t worry. The surgeon ordered a sleeping pill to help you sleep.‖ 
 d. ―It must be difficult not to know what the surgeon will find. What can I do to help?‖ 
 ANS: D ―It must be difficult not to know what the surgeon will find. What can I do to help?‖ is using therapeutic communication techniques of empathy and asking relevant questions. False reassurances (―You will be okay‖ and ―Don’t worry‖) tend to block communication. Patients frequently interpret ―why‖ questions as accusations or think the nurse knows the reason and is simply testing them. DIF:Apply (application)REF:328-329 OBJ emonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. TOP: Communication and Documentation MSC: Psychosocial Integrity 20. Which situation will cause the nurse to intervene and follow up on the nursing assistive personnel’s (NAP) behavior? a. The nursing assistive personnel is calling the older-adult patient ―honey.‖ 
 b. The nursing assistive personnel is facing the older-adult patient when talking. 
 c. The nursing assistive personnel cleans the older-adult patient’s glasses gently. 
 d. The nursing assistive personnel allows time for the older-adult patient to respond. 
 ANS: A The nurse needs to intervene to correct the use of ―honey.‖ Avoid terms of endearment such as ―honey,‖ ―dear,‖ ―grandma,‖ or ―sweetheart.‖ Communicate with older adults on an adult level, and avoid patronizing or speaking in a condescending manner. Facing an older-adult patient, making sure the older adult has clean glasses, and allowing time to respond facilitate communication with older- adult patients and should be encouraged, not stopped. DIF:Apply (application)REF:324 OBJ:Engage in effective communication techniques for older patients. TOP:ImplementationMSC:Management of Care 21. A confused older-adult patient is wearing thick glasses and a hearing aid. Which intervention is the priority to facilitate communication? a. Focus on tasks to be completed. 
 b. Allow time for the patient to respond. 
 c. Limit conversations with the patient. 
 d. Use gestures and other nonverbal cues. 
 ANS: B Allowing time for patients to respond will facilitate communication, especially for a confused, older patient. Focusing on tasks to be completed and limiting conversations do not facilitate communication; in fact, they block communication. Using gestures and other nonverbal cues is not effective for visually impaired (thick glasses) patients or for patients who are confused. DIF:Apply (application)REF:326 | 332 OBJ:Engage in effective communication techniques for older patients. TOP: Implementation MSC: Psychosocial Integrity 22. The staff is having a hard time getting an older-adult patient to communicate. Which technique should the nurse suggest the staff use? a. Try changing topics often. a. Allow the patient to reminisce. 
 b. Ask the patient for explanations. 
 c. Involve only the patient in conversations. 
 ANS: B Encouraging older adults to share life stories and reminisce about the past has a therapeutic effect and increases their sense of well-being. Avoid sudden shifts from subject to subject. It is helpful to include the patient’s family and friends and to become familiar with the patient’s favorite topics for conversation. Asking for explanations is a nontherapeutic technique. DIF:Apply (application)REF:331 OBJ:Engage in effective communication techniques for older patients. TOP lanningMSC:Management of Care 23. A nurse is implementing nursing care measures for patients’ special communication needs. Which patient will need the most nursing care measures? a. The patient who is oriented, pain free, and blind 
 b. The patient who is alert, hungry, and has strong self-esteem 
 c. The patient who is cooperative, depressed, and hard of hearing 
 d. The patient who is dyspneic, anxious, and has a tracheostomy 
 ANS: D Facial trauma, laryngeal cancer, or endotracheal intubation often prevents movement of air past vocal cords or mobility of the tongue, resulting in inability to articulate words. An extremely breathless person needs to use oxygen to breathe rather than speak. Persons with high anxiety are sometimes unable to perceive environmental stimuli or hear explanations. People who are alert, have strong self- esteem, and are cooperative and pain free do not cause communication concerns. Although hunger, blindness, and difficulty hearing can cause communication concerns, dyspnea, tracheostomy, and anxiety all contribute to communication concerns. DIF:Analyze (analysis)REF:325 | 331 OBJ: Implement nursing care measures for patients with special communication needs. TOP: Evaluation MSC: Psychosocial Integrity 24. A patient is aphasic, and the nurse notices that the patient’s hands shake intermittently. Which nursing action ismost appropriate to facilitate communication? a. Use a picture board. 
 b. Use pen and paper. 
 c. Use an interpreter. 
 d. Use a hearing aid. 
 ANS: A Using a pen and paper can be frustrating for a nonverbal (aphasic) patient whose handwriting is shaky; the nurse can revise the care plan to include use of a picture board instead. An interpreter is used for a patient who speaks a foreign language. A hearing aid is used for the hard of hearing, not for an aphasic patient. DIF:Apply (application)REF:331-332 OBJ: Offer alternative communication devices when appropriate to promote communication with patients who have impaired communication. TOP: Implementation MSC: Psychosocial Integrity 25. Which behavior indicates the nurse is using a process recording correctly to enhance communication with patients? a. Shows sympathy appropriately a. Uses automatic responses fluently 
 b. Demonstrates passive remarks accurately 
 c. Self-examines personal communication skills 
 ANS: D Analysis of a process recording enables a nurse to evaluate the following: examine whether nursing responses blocked or facilitated the patient’s efforts to communicate. Sympathy is concern, sorrow, or pity felt for the patient and is nontherapeutic. Clichés and stereotyped remarks are automatic responses that communicate the nurse is not taking concerns seriously or responding thoughtfully. Passive responses serve to avoid conflict or to sidestep issues. DIF:Apply (application)REF:331 OBJ: Identify opportunities to improve communication with patients while giving care. TOP: Evaluation MSC: Psychosocial Integrity 26. A patient says, ―You are the worst nurse I have ever had.‖ Which response by the nurse is most assertive? a. ―I think you’ve had a hard day.‖ 
 b. ―I feel uncomfortable hearing that statement.‖ 
 c. ―I don’t think you should say things like that. It is not right.‖ 
 d. ―I have been checking on you regularly. How can you say that?‖ 
 ANS: B Assertive responses contain ―I‖ messages such as ―I want,‖ ―I need,‖ ―I think,‖ or ―I feel.‖ While all of these start with ―I,‖ the only one that is the most assertive is ―I feel uncomfortable hearing that statement.‖ An assertive nurse communicates self-assurance; communicates feelings; takes responsibility for choices; and is respectful of others’ feelings, ideas, and choices. ―I think you’ve had a hard day‖ is not addressing the problem. Arguing (―How can you say that?‖) is not assertive or therapeutic. Showing disapproval (using words like right) is not assertive or therapeutic. DIF:Analyze (analysis)REF:325 OBJ emonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. TOP: Communication and Documentation MSC: Psychosocial Integrity MULTIPLE RESPONSE 1. Which behaviors indicate the nurse is using critical thinking standards when communicating with patients? (Select all that apply.) a. Instills faith 
 b. Uses humility 
 c. Portrays self-confidence 
 d. Exhibits supportiveness 
 e. Demonstrates independent attitude 
 ANS: B, C, E A self-confident attitude is important because the nurse who conveys confidence and comfort while communicating more readily establishes an interpersonal helping-trusting relationship. In addition, an independent attitude encourages the nurse to communicate with colleagues and share ideas about nursing interventions. An attitude of humility is necessary to recognize and communicate the need for more information before making a decision. Faith and supportiveness are attributes of caring, not critical thinking standards. DIF:Understand (comprehension)REF:317
OBJ: Identify ways to apply critical thinking to the communication process. TOP:EvaluationMSC:Management of Care 2. A nurse is implementing nursing care measures for patients with challenging communication issues. Which types of patients will need these nursing care measures? (Select all that apply.) a. A child who is developmentally delayed 
 b. An older-adult patient who is demanding 
 c. A female patient who is outgoing and flirty 
 d. A male patient who is cooperative with treatments 
 e. An older-adult patient who can clearly see small print 
 f. A teenager frightened by the prospect of impending surgery 
 ANS: A, B, C, F Challenging communication situations include patients who are flirtatious, demanding, frightened, or developmentally delayed. A child who has received little environmental stimulation possibly is behind in language development, thus making communication more challenging. Patients who are cooperative and have good eyesight (see small print) do not cause challenging communication situations. DIF:Understand (comprehension)REF:318
OBJ: Implement nursing care measures for patients with special communication needs. TOP:CaringMSC:Management of Care MATCHING A nurse is using AIDET to communicate with patients and families. Match the letters of the acronym to the behavior a nurse will use. b. Nurse describes procedures and tests. 
 c. Nurse lets the patient know how long the procedure will last. 
c. Nurse recognizes the person with a positive attitude. a. Nurse thanks the patient. 
 b. Nurse tells the patient ―I am an RN and will be managing your care.‖ 
 1.A 2.I 3.D 4.E 5.T 1.ANS:CDIF:Apply (application)REF:325 OBJ: Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. TOP: Implementation MSC:Management of Care 2.ANS:EDIF:Apply (application)REF:325 OBJ: Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. TOP: Implementation MSC:Management of Care 3.ANS:BDIF:Apply (application)REF:325 OBJ: Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. TOP: Implementation MSC:Management of Care 4.ANS:ADIF:Apply (application)REF:325 OBJ: Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. TOP: Implementation MSC:Management of Care 5.ANS DIF:Apply (application)REF:325 OBJ: Demonstrate qualities, behaviors, and communication techniques of professional communication while interacting with patients. TOP: Implementation MSC:Management of Care Chapter 25: Patient Education Chapter 25: Patient Education
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. A nurse is teaching a patient’s family member about permanent tube feedings at home. Which purpose of patient education is the nurse meeting? a. Health promotion 
 b. Illness prevention 
 c. Restoration of health 
 d. Coping with impaired functions 
 ANS: D Teach family members to help the patient with health care management (e.g., giving medications through gastric tubes and doing passive range-of-motion exercises) when coping with impaired functions. Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations. Health promotion involves healthy people staying healthy, while illness prevention is prevention of diseases. Restoration of health occurs if the teaching is about a temporary tube feeding, not a permanent tube feeding. DIF:Understand (comprehension)REF:337
OBJ: Identify the purposes of patient education. TOP: Teaching/Learning MSC: Basic Care and Comfort 2. A nurse is teaching a group of healthy adults about the benefits of flu immunizations. Which type of patient education is the nurse providing? b. Health analogies 
 c. Restoration of health 
 d. Coping with impaired functions 
 e. Promotion of health and illness prevention 
 ANS: D As a nurse, you are a visible, competent resource for patients who want to improve their physical and psychological well-being. In the school, home, clinic, or workplace, you promote health and prevent illness by providing information and skills that enable patients to assume healthier behaviors. Injured and ill patients need information and skills to help them regain or maintain their level of health; this is referred to as restoration of health. Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations; this is known as coping with impaired functions. Analogies supplement verbal instruction with familiar images that make complex information more real and understandable. For example, when explaining arterial blood pressure, use an analogy of the flow of water through a hose. DIF:Apply (application)REF:337 OBJ: Identify the purposes of patient education. TOP: Teaching/Learning MSC:Health Promotion and Maintenance 3. A nurse’s goal is to provide teaching for restoration of health. Which situation indicates the nurse is meeting this goal? a. Teaching a family member to provide passive range of motion for a stroke patient 
 b. Teaching a woman who recently had a hysterectomy about possible adoption 
 c. Teaching expectant parents about changes in childbearing women 
 d. Teaching a teenager with a broken leg how to use crutches ANS: D Injured or ill patients need information and skills to help them regain or maintain their levels of health. An example includes teaching a teenager with a broken leg how to use crutches. Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations. New knowledge and skills are often necessary for patients and/or family members to continue activities of daily living. Teaching family members to help the patient with health care management (e.g., giving medications through gastric tubes, doing passive range-of-motion exercises) is an example of coping with long-term impaired functions. For a woman with a hysterectomy, teaching about adoption is not restoration of health; restoration of health in this situation would involve activity restrictions and incision care if needed. In childbearing classes, you teach expectant parents about physical and psychological changes in the woman and about fetal development; this is part of health maintenance. DIF:Apply (application)REF:337 OBJ: Identify the purposes of patient education. TOP: Teaching/Learning MSC: Basic Care and Comfort 4. A nurse attends a seminar on teaching/learning. Which statement indicates the nurse has a good understanding of teaching/learning? a. ―Teaching and learning can be separated.‖ 
 b. ―Learning is an interactive process that promotes teaching.‖ 
 c. ―Teaching is most effective when it responds to the learner’s needs.‖ 
 d. ―Learning consists of a conscious, deliberate set of actions designed to help the teacher.‖ 
 ANS: C Teaching is most effective when it responds to the learner’s needs. It is impossible to separate teaching from learning. Teaching is an interactive process that promotes learning. Teaching consists of a conscious, deliberate set of actions that help individuals gain new knowledge, change attitudes, adopt new behaviors, or perform new skills. DIF:Understand (comprehension)REF:337
OBJ: Describe the similarities and differences between teaching and learning. TOP:EvaluationMSC:Health Promotion and Maintenance
5. A nurse is determining if teaching is effective. Which finding best indicates learning has occurred? a. A nurse presents information about diabetes. 
 b. A patient demonstrates how to inject insulin. 
c. A family member listens to a lecture on diabetes. 
 d. A primary care provider hands a diabetes pamphlet to the patient. 
 ANS: B Learning is the purposeful acquisition of new knowledge, attitudes, behaviors, and skills: patient demonstrates how to inject insulin. A new mother exhibits learning when she demonstrates how to bathe her newborn. A nurse presenting information and a primary care provider handing a pamphlet to a patient are examples of teaching. A family member listening to a lecture does not indicate that learning occurred; a change in knowledge, attitudes, behaviors, and/or skills must be evident. DIF:Apply (application)REF:337 OBJ: Describe the similarities and differences between teaching and learning. TOP: Teaching/Learning MSC: Basic Care and Comfort 6. A nurse is teaching a patient about the Speak Up Initiatives. Which information should the nurse include in the teaching session? a. If you still do not understand, ask again. 
 b. Ask a nurse to be your advocate or supporter. 
 c. The nurse is the center of the health care team. d. Inappropriate medical tests are the most common mistakes. ANS: A If you still do not understand, ask again is part of the S portion of the Speak Up Initiatives. Speak up if you have questions or concerns. You (the patient) are the center of the health care team, not the nurse. Ask a trusted family member or friend to be your advocate (advisor or supporter), not a nurse. Medication errors are the most common health care mistakes, not inappropriate medical tests. DIF:Understand (comprehension)REF:337 OBJ: Identify the role of the nurse in patient education. TOP: Teaching/Learning MSC: Safety and Infection Control 7. A nurse teaches a patient with heart failure healthy food choices. The patient states that eating yogurt is better than eating cake. Which element represents feedback? a. The nurse 
 b. The patient 
 c. The nurse teaching about healthy food choices 
 d. The patient stating that eating yogurt is better than eating cake 
 ANS: D Feedback needs to demonstrate the success of the learner in achieving objectives (i.e., the learner verbalizes information or provides a return demonstration of skills learned). The nurse is the sender. The patient (learner) is the receiver. The teaching is the message. DIF:Apply (application)REF:338
OBJ: Describe appropriate communication principles when providing patient education. TOP: Teaching/Learning MSC: Basic Care and Comfort 8. While preparing a teaching plan, the nurse describes what the learner will be able to accomplish after the teaching session about healthy eating. Which action is the nurse completing? a. Developing learning objectives 
 b. Providing positive reinforcement 
 c. Presenting facts and knowledge 
 d. Implementing interpersonal communication 
ANS: A Learning objectives describe what the learner will exhibit as a result of successful instruction. Positive reinforcement follows feedback and reinforces good behavior and promotes continued compliance. Interpersonal communication is necessary for the teaching/learning process, but describing what the learner will be able to do after successful instruction constitutes learning objectives. Facts and knowledge will be presented in the teaching session. DIF:Understand (comprehension)REF:338 OBJ: Describe appropriate communication principles when providing patient education. TOP lanningMSC:Health Promotion and Maintenance 9. A patient learns that a normal adult heartbeat is 60 to 100 beats/min after a teaching session with a nurse. In which domain did learning take place? a. Kinesthetic 
 b. Cognitive 
 c. Affective 
 d. Psychomotor 
 ANS: B The patient acquired knowledge, which is cognitive. Cognitive learning includes all intellectual skills and requires thinking. In the hierarchy of cognitive behaviors, the simplest behavior is acquiring knowledge. Kinesthetic is a type of learner who learns best with a hands-on approach. Affective learning deals with expression of feelings and development of attitudes, beliefs, or values. Psychomotor learning involves acquiring skills that require integration of mental and physical activities, such as the ability to walk or use an eating utensil. DIF:Apply (application)REF:338-339 OBJ escribe the domains of learning.TOP:Teaching/Learning MSC:Health Promotion and Maintenance 10. A nurse is trying to help a patient begin to accept the chronic nature of diabetes. Which teaching technique should the nurse use to enhance learning? a. Lecture 
 b. Role play 
 c. Demonstration 
 d. Question and answer sessions 
 ANS: B Affective learning deals with expression of feelings and acceptance of attitudes, beliefs, or values. Role play and discussion (one-on-one and group) are effective teaching methods for the affective domain. Lecture and question and answer sessions are effective teaching methods for the cognitive domain. Demonstration is an effective teaching method for the psychomotor domain. DIF:Analyze (analysis)REF:339
OBJ escribe the domains of learning.TOP:Teaching/Learning MSC:Health Promotion and Maintenance 11. A nurse is describing a patient’s perceived ability to successfully complete a task. Which term should the nurse use to describe this attribute? b. Self-efficacy 
 c. Motivation 
 d. Attentional set 
 e. Active participation 
ANS: A Self-efficacy, a concept included in social learning theory, refers to a person’s perceived ability to successfully complete a task. Motivation is a force that acts on or within a person (e.g., an idea, an emotion, a physical need) to cause the person to behave in a particular way. An attentional set is the mental state that allows the learner to focus on and comprehend a learning activity. Learning occurs when the patient is actively involved in the educational session. DIF:Understand (comprehension)REF:340 OBJ:Identify basic learning principles.TOP:Teaching/Learning MSC:Health Promotion and Maintenance 12. A toddler is going to have surgery on the right ear. Which teaching method is most appropriate for this developmental stage? a. Encourage independent learning. 
 b. Develop a problem-solving scenario. 
 c. Wrap a bandage around a stuffed animal’s ear. 
 d. Use discussion throughout the teaching session. 
 ANS: C Use play to teach a procedure or activity (e.g., handling examination equipment, applying a bandage to a doll) to toddlers. Encouraging independent learning is for the young or middle adult. Use of discussion is for older children, adolescents, and adults, not for toddlers. Use problem solving to help adolescents make choices. Problem solving is too advanced for a toddler. DIF:Apply (application)REF:342 OBJ iscuss how to integrate education into patient-centered care. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 13. A nurse is preparing to teach a patient about smoking cessation. Which factors should the nurse assess to determine a patient’s ability to learn? a. Sociocultural background and motivation 
 b. Stage of grieving and overall physical health 
 c. Developmental capabilities and physical capabilities 
 d. Psychosocial adaptation to illness and active participation 
 ANS: C Developmental and physical capabilities reflect one’s ability to learn. Sociocultural background and motivation are factors determining readiness to learn. Psychosocial adaptation to illness and active participation are factors in readiness to learn. Readiness to learn is related to the stage of grieving. Overall physical health does reflect ability to learn; however, because it is paired here with stage of grieving (which is a readiness to learn factor), this is incorrect. DIF:Understand (comprehension)REF:341-342 OBJ: Differentiate factors that determine readiness to learn from those that determine ability to learn. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 14. A nurse is teaching a patient about heart failure. Which environment will the nurse use? a. A darkened, quiet room b. A well-lit, ventilated room 
 c. A private room at 85° F temperature 
 d. A group room for 10 to 12 patients with heart failure 
ANS: B The ideal environment for learning is a room that is well lit and has good ventilation, appropriate furniture, and a comfortable temperature. Although a quiet room is appropriate, a darkened room interferes with the patient’s ability to watch your actions, especially when demonstrating a skill or using visual aids such as posters or pamphlets. A room that is cold, hot, or stuffy makes the patient too uncomfortable to focus on the information being presented. Learning in a group of six or less is more effective and avoids distracting behaviors. DIF:Apply (application)REF:342 OBJ: Establish an environment that promotes learning. TOP: Teaching/Learning MSC:Health Promotion and Maintenance 15. Which assessment finding will cause the nurse to begin teaching a patient because the patient is ready to learn? a. A patient has the ability to grasp and apply the elastic bandage. 
 b. A patient has sufficient upper body strength to move from a bed to a wheelchair. 
 c. A patient with a below-the-knee amputation is motivated about how to walk with assistive devices. 
 d. A patient has normal eyesight to identify the markings on a syringe and coordination to handle a syringe. 
 ANS: C Motivation underlies a person’s desire or willingness to learn. Motivation is a force that acts on or within a person (e.g., an idea, emotion, or a physical need) to cause the person to behave in a particular way. For example, a patient with a below-the-knee amputation is motivated to learn how to walk with assistive devices, indicating a readiness to learn. Do not confuse readiness to learn with ability to learn. All the other answers are examples of ability to learn because this often depends on the patient’s level of physical development and overall physical health. To learn psychomotor skills, a patient needs to possess a certain level of strength, coordination, and sensory acuity. For example, it is useless to teach a patient to transfer from a bed to a wheelchair if he or she has insufficient upper body strength. An older patient with poor eyesight or an inability to grasp objects tightly cannot learn to apply an elastic bandage or handle a syringe. DIF:Analyze (analysis)REF:340 | 344 OBJ: Differentiate factors that determine readiness to learn from those that determine ability to learn. TOP: Evaluation MSC: Health Promotion and Maintenance 16. A nurse is teaching a patient with a risk for hypertension how to take a blood pressure. Which action by the nurse is the priority? a. Assess laboratory results for high cholesterol and other data. 
 b. Identify that teaching is the same as the nursing process. 
 c. Perform nursing care therapies to address hypertension. 
 d. Focus on a patient’s learning needs and objectives. 
 ANS: D The teaching process focuses on the patient’s learning needs, motivation, and ability to learn; writing learning objectives and goals is also included. Nursing and teaching processes are not the same. Assessing laboratory results for high cholesterol and performing nursing care therapies are all components of the nursing process, not the teaching process. DIF:Apply (application)REF:343
OBJ:Compare and contrast the nursing and teaching processes. TOP: Implementation MSC: Health Promotion and Maintenance 17. A patient has heart failure and kidney failure. The patient needs teaching about dialysis. Which nursing action ismost appropriate for assessing this patient’s learning needs? a. Assess the patient’s total health care needs. 
 b. Assess the patient’s health literacy. 
 c. Assess all sources of patient data. 
 d. Assess the goals of patient care. 
ANS: B Because health literacy influences how you deliver teaching strategies, it is critical for you to assess a patient’s health literacy before providing instruction. The nursing process requires assessment of all sources of data to determine a patient’s total health care needs. Evaluation of the teaching process involves determining outcomes of the teaching/learning process and the achievement of learning objectives; assessing the goals of patient care is the evaluation component of the nursing process. DIF:Apply (application)REF:343-345 OBJ:Compare and contrast the nursing and teaching processes. TOP:AssessmentMSC:Health Promotion and Maintenance 18. A nurse is teaching a patient about hypertension. In which order from first to last will the nurse implement the steps of the teaching process? 1. Set mutual goals for knowledge of hypertension.
2. Teach what the patient wants to know about hypertension.
3. Assess what the patient already knows about hypertension. 4. Evaluate the outcomes of patient education for hypertension. a. 1, 3, 2, 4 a. 2, 3, 1, 4 
 b. 3, 1, 2, 4 
 c. 3, 2, 1, 4 
 ANS: C Assessment is the first step of any teaching session, then diagnosing, planning (goals), implementation, and evaluation. DIF:Apply (application)REF:343
OBJ: Identify the appropriate topics that address a patient’s health education needs. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 19. A patient had a stroke and must use a cane for support. A nurse is preparing to teach the patient about the cane. Which learning objective/outcome is most appropriate for the nurse to include in the teaching plan? a. The patient will walk to the bathroom and back to bed using a cane. 
 b. The patient will understand the importance of using a cane. 
 c. The patient will know the correct use of a cane. 
 d. The patient will learn how to use a cane. 
 ANS: A Outcomes often describe a behavior that identifies the patient’s ability to do something on completion of teaching such as will empty a colostomy bag or will administer an injection. Understand, learn, and know are not behaviors that can be observed or evaluated. DIF:Apply (application)REF:346
OBJ: Write learning objectives for a teaching plan. TOP: Planning MSC:Management of Care 20. Which learning objective/outcome has the highest priority for a patient with lifethreatening, severe food allergies that require an EpiPen (epinephrine)? a. The patient will identify the main ingredients in several foods. 
 b. The patient will list the side effects of epinephrine. 
 c. The patient will learn about food labels. 
 d. The patient will administer epinephrine. 
 ANS: D Once you assist in meeting patient needs related to basic survival (how to give epinephrine), you can discuss other topics, such as nutritional needs and side effects of medications. For example, a patient recently diagnosed with coronary artery disease has deficient knowledge related to the illness and its implications. The patient benefits most by first learning about the correct way to take nitroglycerin and how long to wait before calling for help when chest pain occurs. Thus, in this situation, the patient benefits most by first learning about the correct way to take epinephrine. ―The patient will learn about food labels‖ is not objective and measurable and is not correctly written. DIF:Analyze (analysis)REF:346 OBJ: Write learning objectives for a teaching plan. TOP: Evaluation MSC: Reduction of Risk Potential 21. After a teaching session on taking blood pressures, the nurse tells the patient, ―You took that blood pressure like an experienced nurse.‖ Which type of reinforcement did the nurse use? a. Social acknowledgment 
 b. Pleasurable activity 
 c. Tangible reward 
 d. Entrusting ANS: A Reinforcers come in the form of social acknowledgments (e.g., nods, smiles, words of encouragement), pleasurable activities (e.g., walks or play time), and tangible rewards (e.g., toys or food). The entrusting approach is a teaching approach that provides a patient the opportunity to manage self-care. It is not a type of reinforcement. DIF:Apply (application)REF:348 OBJ:Identify basic learning principles.TOP:Teaching/Learning MSC:Health Promotion and Maintenance 22. A patient with heart failure is learning to reduce salt in the diet. When will be the best time for the nurse to address this topic? a. At bedtime, while the patient is relaxed 
 b. At bath time, when the nurse is cleaning the patient 
 c. At lunchtime, while the nurse is preparing the food tray 
 d. At medication time, when the nurse is administering patient medication 
 ANS: C In this situation, because the teaching is about food, coordinating it with routine nursing care that involves food can be effective. Many nurses find that they are able to teach more effectively while delivering nursing care. For example, while hanging blood, you explain to the patient why the blood is necessary and the symptoms of a transfusion reaction that need to be reported immediately. At bedtime would be a good time to discuss routines that enhance sleep. At bath time would be a good time to describe skin care and how to prevent pressure ulcers. At medication time would be a good time to explain the purposes and side effects of the medication. DIF:Apply (application)REF:348 OBJ:Include patient teaching while performing routine nursing care. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 23. A nurse is teaching a patient who has low health literacy about chronic obstructive pulmonary disease (COPD) while giving COPD medications. Which technique is most appropriate for the nurse to use? b. Use complex analogies to describe COPD. 
 c. Ask for feedback to assess understanding of COPD at the end of the session. 
 d. Offer pamphlets about COPD written at the eighth grade level with large type. 
 e. Include the most important information on COPD at the beginning of the session. 
ANS: D Include the most important information at the beginning of the session for patients with literacy or learning disabilities. Also, use visual cues and simple, not complex, analogies when appropriate. Another technique is to frequently ask patients for feedback to determine whether they comprehend the information. Additionally, provide teaching materials that reflect the reading level of the patient, with attention given to short words and sentences, large type, and simple format (generally, information written on a fifth grade reading level is recommended for adult learners). DIF:Apply (application)REF:350 OBJ:Include patient teaching while performing routine nursing care. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 24. A nurse is teaching a culturally diverse patient with a learning disability about nutritional needs. What must the nurse do first before starting the teaching session? a. Obtain pictures of food. 
 b. Get an interpreter. 
 c. Establish a rapport. d. Refer to a dietitian. ANS: C Establishing trust is important for all patients, especially culturally diverse and learning disabled patients, before starting teaching sessions. Obtaining pictures of food, getting an interpreter, and referring to a dietitian all occur after rapport/trust is established. DIF:Understand (comprehension)REF:350 OBJ iscuss how to integrate education into patient-centered care. TOP: Teaching/Learning MSC: Psychosocial Integrity 25. A nurse is teaching an older-adult patient about strokes. Which teaching technique is most appropriate for the nurse to use? a. Speak in a high tone of voice to describe strokes. 
 b. Use a pamphlet about strokes with large font in blues and greens. 
 c. Provide specific information about strokes in short, small amounts. 
 d. Begin the teaching session facing the teaching white board with stroke information. 
 ANS: C With older adults, keep the teaching session short with small amounts of information. Also, if using written material, assess the patient’s ability to read and use information that is printed in large type and in a color that contrasts highly with the background (e.g., black 14-point print on matte white paper). Avoid blues and greens because they are more difficult to see. Speak in a low tone of voice (lower tones are easier to hear than higher tones). Directly face the older-adult learner when speaking. DIF:Apply (application)REF:351-352 OBJ: Identify the appropriate topics that address a patient’s health education needs. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 26. A patient who is going to surgery has been taught how to cough and deep breathe. Which evaluation method will the nurse use? a. Return demonstration 
 b. Computer instruction 
 c. Verbalization of steps 
 d. Cloze test 
 ANS: A To demonstrate mastery of the skill, have the patient perform a return demonstration under the same conditions that will be experienced at home or in the place where the skill is to be performed. Computer instruction is use of a programmed instruction format in which computers store response patterns for learners and select further lessons on the basis of these patterns (programs can be individualized). Computer instruction is a teaching tool, rather than an evaluation tool. Verbalization of steps can be an evaluation tool, but it is not as effective as a return demonstration when evaluating a psychomotor skill. The Cloze test, a test of reading comprehension, asks patients to fill in the blanks that are in a written paragraph. DIF:Apply (application)REF:349 OBJ: Use appropriate methods to evaluate learning. TOP: Evaluation MSC:Health Promotion and Maintenance 27. A patient has been taught how to change a colostomy bag but is having trouble measuring and manipulating the equipment and has many questions. What is the nurse’s next action? a. Refer to a mental health specialist. 
 b. Refer to a wound care specialist. 
 c. Refer to an ostomy specialist. d. Refer to a dietitian. ANS: C Resources that specialize in a particular health need (e.g., wound care or ostomy specialists) are integral to successful patient education. A mental health specialist is helpful for emotional issues rather than for physical problems. A dietitian is a resource for nutritional needs. A wound care specialist provides complex wound care. DIF:Understand (comprehension)REF:346 OBJ: Use appropriate methods to evaluate learning. TOP: Implementation MSC:Management of Care 28. A nurse is teaching a patient about healthy eating habits. Which learning objective/outcome for the affective domain will the nurse add to the teaching plan? a. The patient will state three facts about healthy eating. 
 b. The patient will identify two foods for a healthy snack. 
 c. The patient will verbalize the value of eating healthy. 
 d. The patient will cook a meal with low-fat oil. 
 ANS: C Affective learning deals with expression of feelings and acceptance of attitudes, beliefs, or values. Having the patient value healthy eating habits falls within the affective domain. Stating three facts or identifying two foods for a healthy snack falls within the cognitive domain. Cooking falls within the psychomotor domain. DIF:Analyze (analysis)REF:338-339
OBJ: Write learning objectives for a teaching plan. TOP: Planning MSC:Health Promotion and Maintenance
29. A nurse is assessing the ability to learn of a patient who has recently experienced a stroke. Which question/statement will best assess the patient’s ability to learn? a. ―What do you want to know about strokes?‖ 
 b. ―Please read this handout and tell me what it means.‖ 
 c. ―Do you feel strong enough to perform the tasks I will teach you?‖ 
 d. ―On a scale from 1 to 10, tell me where you rank your desire to learn.‖ 
 ANS: B A patient’s reading level affects ability to learn. One way to assess a patient’s reading level and level of understanding is to ask the patient to read instructions from an educational handout and then explain their meaning. Reading level is often difficult to assess because patients who are functionally illiterate are often able to conceal it by using excuses such as not having the time or not being able to see. Asking patients what they want to know identifies previous learning and learning needs and preferences; it does not assess ability to learn. Motivation (desire to learn) is related to readiness to learn, not ability to learn. Just asking a patient if he or she feels strong is not as effective as actually assessing the patient’s strength. DIF:Analyze (analysis)REF:344 OBJ: Differentiate factors that determine readiness to learn from those that determine ability to learn. TOP: Assessment MSC: Health Promotion and Maintenance 30. A nurse is preparing to teach a kinesthetic learner about exercise. Which technique will the nurse use? a. Let the patient touch and use the exercise equipment. 
 b. Provide the patient with pictures of the exercise equipment. 
 c. Let the patient listen to a video about the exercise equipment. 
 d. Provide the patient with a case study about the exercise equipment. ANS: A Kinesthetic learners process knowledge by moving and participating in hands-on activities. Return demonstrations and role playing work well with these learners. Patients who are visual-spatial learners enjoy learning through pictures and visual charts to explain concepts. The verbal/linguistic learner demonstrates strength in the language arts and therefore prefers learning by listening or reading information. Patients who learn through logical-mathematical reasoning think in terms of cause and effect, and respond best when required to predict logical outcomes. Specific teaching strategies could include open-ended questioning or problem solving exercises, like a case study. DIF:Apply (application)REF:344
OBJ: Establish an environment that promotes learning. TOP: Teaching/Learning MSC:Health Promotion and Maintenance MULTIPLE RESPONSE 1. A nurse is asked by a co-worker why patient education/teaching is important. Which statements will the nurse share with the co-worker? (Select all that apply.) a. ―Patient education is an essential component of safe, patient-centered care.‖ 
 b. ―Patient education is a standard for professional nursing practice.‖ 
 c. ―Patient teaching falls within the scope of nursing practice.‖ 
 d. ―Patient teaching is documented and part of the chart.‖ 
 e. ―Patient education is not effective with children.‖ 
 f. ―Patient teaching can increase health care costs.‖ 
 ANS: A, B, C, D Patient education has long been a standard for professional nursing practice. All state Nurse Practice Acts acknowledge that patient teaching falls within the scope of nursing practice. Patient education is an essential component of providing safe, patient-centered care. It is important to document evidence of successful patient education in patients’ medical records. Patient education is effective for children. Different techniques must be used with children. Creating a well-designed, comprehensive teaching plan that fits a patient’s unique learning needs reduces health care costs, improves quality of care, and ultimately changes behaviors to improve patient outcomes. DIF:Understand (comprehension)REF:336 OBJ: Identify the role of the nurse in patient education. TOP: Evaluation MSC:Management of Care 2. A nurse is preparing to teach patients. Which patient finding will cause the nurse to postpone a teaching session? (Select all that apply.) b. The patient is hurting. 
c. The patient is fatigued. 
 d. The patient is mildly anxious. 
 e. The patient is asking questions. 
 f. The patient is febrile (high fever). 
 g. The patient is in the acceptance phase. 
 ANS: A, B, E Any condition (e.g., pain, fatigue) that depletes a person’s energy also impairs the ability to learn, so the session should be postpon Chapter 29: Infection Prevention and Control
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. The nurse and a new nurse in orientation are caring for a patient with pneumonia. Which statement by the new nurse will indicate a correct understanding of this condition? e. ―An infectious disease like pneumonia may not pose a risk to others.‖ 
 f. ―We need to isolate the patient in a private negative-pressure room.‖ 
 g. ―Clinical signs and symptoms are not present in pneumonia.‖ 
 h. ―The patient will not be able to return home.‖ 
 ANS: A Infections are infectious and/or communicable. Infectious diseases may not pose a risk for transmission to others, although they are serious for the patient. Pneumonia is not a communicable disease—a disease that is transmitted directly from one individual to the next, so there is no need for isolation. A private negative–air pressure room is used for tuberculosis, not pneumonia. Clinical signs and symptoms are present in pneumonia. Frequently, patients with pneumonia do return home unless there are extenuating circumstances. DIF:Apply (application)REF:443
OBJ: Explain the relationship between the infection chain and transmission of infection. TOP: Evaluation MSC: Safety and Infection Control 2. The patient and the nurse are discussing Rickettsia rickettsii—Rocky Mountain spotted fever. Which patient statement to the nurse indicates understanding regarding the mode of transmission for this disease? e. ―When camping, I will use sunscreen.‖ 
 f. ―When camping, I will drink bottled water.‖ 
c. ―When camping, I will wear insect repellent.‖ d. ―When camping, I will wash my hands with hand gel.‖ ANS: C Rocky Mountain spotted fever is caused by bacteria transmitted by the bite of ticks. Wearing a repellent that is designed for repelling ticks, mosquitoes, and other insects can help in preventing transmission of this disease. Drinking plenty of uncontaminated water, wearing sunscreen, and using alcohol-based hand gels for cleaning hands are all important activities to participate in while camping, but they do not contribute to or prevent transmission of this disease. DIF:Apply (application)REF:444
OBJ: Explain the relationship between the infection chain and transmission of infection. TOP: Evaluation MSC: Safety and Infection Control 3. The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group about the most important thing to do to prevent the spread of infection. Which information did the nurse share with the preschool workers? e. Encourage preschool children to eat a nutritious diet. 
 f. Suggest that parents provide a multivitamin to the children. 
 g. Clean the toys every afternoon before putting them away. 
 h. Wash their hands between each interaction with children. 
 ANS: D The single most important thing that individuals can do to prevent the spread of infection is to wash their hands before and after eating, going to the bathroom, changing a diaper, and wiping a nose and between touching each individual child. It is important for preschool children to have a nutritious diet; a healthy individual can fight infection more effectively. A health care provider, along with the parent, makes decisions about dietary supplements. Cleaning the toys can decrease the number of pathogens but is not the most important thing to do in this scenario. DIF:Understand (comprehension)REF:443 | 455 OBJ: Give an example of preventing infection for each element of the infection chain. TOP: Teaching/Learning MSC: Safety and Infection Control 4. The nurse is admitting a patient with an infectious disease process. Which question will
be most appropriate for a nurse to ask about the patient’s susceptibility to this infectious process? c. ―Do you have a spouse?‖ 
 d. ―Do you have a chronic disease?‖ 
 e. ―Do you have any children living in the home?‖ 
 f. ―Do you have any religious beliefs that will influence your care?‖ 
 ANS: B Multiple factors influence a patient’s susceptibility to infection. Patients with chronic diseases such as diabetes mellitus and multiple sclerosis are also more susceptible to infection because of general debilitation and nutritional impairment. Other factors include age, nutritional status, trauma, and smoking. The other questions are part of an admission assessment process but are not pertinent to the infectious disease process. DIF:Apply (application)REF:449
OBJ: Give an example of preventing infection for each element of the infection chain. TOP: Assessment MSC: Safety and Infection Control 5. The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse’s assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient’s temperature is 100.5° F, and the WBC is 10,500/mm3. Which action should the nurse take first? e. Plan to change the surgical dressing during the shift. 
 f. Utilize SBAR to notify the primary health care provider. 
 g. Reevaluate the temperature and white blood cell count in 4 hours. 
 h. Check to see what solution was used for skin preparation in surgery. 
 ANS: B The nursing assessment indicates signs and symptoms of infection, requiring the primary health care provider to be notified of the patient’s needs. SBAR—Situation, Background, Assessment, and Recommendation—can be utilized to organize thoughts and data and to provide a thorough explanation of the patient’s current status. The reevaluation of temperature is a good choice, but it will take longer than 4 hours to make a change in the white blood cells. Changing the dressing may be a need during the shift but is not a first priority. Checking to see about the skin preparation used 2 days ago may or may not be useful information at this time. DIF:Analyze (analysis)REF:450 | 467
OBJ: Give an example of preventing infection for each element of the infection chain. TOP: Implementation MSC: Safety and Infection Control 6. The nurse is providing an education session to an adult community group about the effects of smoking on infection. Which information is most important for the nurse to include in the educational session? e. Smoke from tobacco products clings to your clothing and hair. 
 f. Smoking affects the cilia lining the upper airways in the lungs. 
 g. Smoking can affect the color of the patient’s fingernails. 
 h. Smoking tobacco products can be very expensive. 
ANS: B A normal defense mechanism against infection in the respiratory tract is the cilia lining the upper airways of the lungs and normal mucus. When a patient inhales a microbe, the cilia and mucus trap the microbe and sweep them up and out to be expectorated or swallowed. Smoking may alter this defense mechanism and increase the patient’s potential for infection. Smoking can be expensive, the smell does cling to hair and clothing, and the tar within the smoke can alter the color of a patient’s nails. This information can be included in the education but does not constitute the most important point. DIF:Understand (comprehension)REF:447 OBJ:Identify the normal defenses of the body against infection. TOP: Teaching/Learning MSC: Safety and Infection Control 7. A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area. A nurse is taking a health history. Which question is the priority? e. ―When was the last time you visited your primary health care provider?‖ 
 f. ―Has this condition affected your eating habits in any way?‖ 
 g. ―What medications are you currently taking?‖ 
 h. ―Are you able to sleep at night?‖ 
 ANS: C Antibiotics and oral contraceptives can disrupt normal flora in the vagina, causing an overgrowth
of Candida albicansin that area. It is important to ask the patient about current medications to obtain information that may assist with diagnosis. The body contains normal flora (microorganisms) that live on the surface of skin, saliva, oral mucosa, gastrointestinal tract, and genitourinary tract. The normal flora of the vagina causes vaginal secretions to achieve a low pH, inhibiting the growth of many microorganisms. Visiting the primary health care provider is important for the patient’s health maintenance but is not the priority. Learning about the patient’s eating and sleeping habits will assist in the plan of care but is not the priority. DIF:Analyze (analysis)REF:447 | 452
OBJ:Identify the normal defenses of the body against infection. TOP: Assessment MSC: Safety and Infection Control 8. The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident. Which signs and symptoms will the nurse assess for to determine if the child is experiencing a localized inflammatory response? c. Malaise, anorexia, enlarged lymph nodes, and increased white blood cells 
 d. Chest pain, shortness of breath, and nausea and vomiting 
 e. Dizziness and disorientation to time, date, and place 
 f. Edema, redness, tenderness, and loss of function 
 ANS: D The body’s cellular response to an injury is seen as inflammation. Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. Systemic signs of inflammation include fever, malaise, and anorexia, as well as enlarged lymph nodes and increased white blood cells. Chest pain, shortness of breath, and nausea and vomiting are signs and symptoms of a cardiac alteration. Dizziness and disorientation to time, date, and place may indicate a neurologic alteration. DIF:Apply (application)REF:446 OBJ: Discuss the events in the inflammatory response. TOP: Assessment MSC: Safety and Infection Control 9. Which interventions utilized by the nurse will indicate the ability to recognize a localized inflammatory response? a. Vigorous range-of-motion exercises e. Turn, cough, and deep breathe 
 f. Orient to date, time, and place 
 g. Rest, ice, and elevation 
 ANS: D Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. One sign of the inflammatory response, particularly after an injury, is swelling or edema. Resting the affected injured area, using ice as ordered, wrapping the area to provide support—particularly if it is an extremity—and elevating the injured area will help to decrease swelling or edema. Turning, coughing, and deep breathing are utilized for postoperative patients and for immobilized patients to help prevent an infectious process such as pneumonia. Orientation to date, time, and place is an intervention utilized with many different types of patients who may be confused. Vigorous range of motion would irritate the inflammatory process. Range of motion is utilized for individuals who need to improve movement of their extremities, including immobilized patients. DIF:Analyze (analysis)REF:446 OBJ: Discuss the events in the inflammatory response. TOP: Implementation MSC: Basic Care and Comfort 10. The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing an infection? e. A patient who is in observation for chest pain 
 f. A patient who has been admitted with dehydration 
 g. A patient who is recovering from a right total hip surgery 
 h. A patient who has been admitted for stabilization of heart problems 
 ANS: C The patient who is recovering from a right total hip surgery has a large incision from the surgery. This break in the skin increases the likelihood of infection. Any break in the integrity of the skin and mucous membranes allows pathogens to enter and exit the body. The patient has had anesthesia, which depresses the respiratory system and has the potential to decrease the expansion of alveoli and to increase the chance of infection in the respiratory system. A patient who is having chest pain, experiencing dehydration, or being admitted with heart problems does not have open incisions that break the skin; therefore, his or her infection risk is lower. DIF:Analyze (analysis)REF:444-445 | 447 OBJ: Identify patients most at risk for infection. TOP: Assessment MSC: Safety and Infection Control 11. The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access (IV) device. Which nursing intervention is a priority in this procedure? c. Review the procedure with the patient. 
 d. Position the patient comfortably. 
 e. Maintain surgical aseptic technique. 
 f. Gather available supplies. 
 ANS: C You maintain surgical aseptic technique at the patient’s bedside (e.g., when inserting IV or urinary catheters, suctioning the tracheobronchial airway, and sterile dressing changes) because patients with disease processes of the immune system are at particular risk for infection. These diseases include leukemia, AIDS, lymphoma, and aplastic anemia. These disease processes weaken the defenses against an infectious organism. Reviewing the procedure with the patient, positioning the patient, and gathering the supplies are all important steps in the procedure but are not the priority in the procedure since the patient already has a compromised immune response. DIF:Apply (application)REF:449 | 467 OBJ: Identify patients most at risk for infection. TOP: Implementation MSC: Safety and Infection Control 12. The nurse is caring for an adult patient in the clinic who has been evacuated and is a victim of flooding. The nurse teaches the patient about rest, exercise, and eating properly and how to utilize deep breathing and visualization. What is the primary rationale for the nurse’s actions related to the teaching? e. Topics taught are standard information taught during health care visits. 
 f. The patient requested this information to teach the extended family members. 
 g. Stress for long periods of time can lead to exhaustion and decreased resistance to infection. 
 h. These techniques will help the patient manage the pain and loss of personal belongings. 
 ANS: C The body responds to emotional or physical stress by the general adaptation syndrome. If stress extends for long periods of time, this can lead to exhaustion, whereby energy stores are depleted and the body has no defenses against invading organisms. Techniques of deep breathing and visualization may be helpful with pain, but they are not the primary reason. The teachings listed are not all standard interventions taught at every health care visit. There is no data to indicate the patient requested this information for the family. DIF:Analyze (analysis)REF:449 OBJ: Identify patients most at risk for infection. TOP: Planning MSC: Safety and Infection Control 13. The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection? e. Teaching the patient about fall prevention 
 f. Teaching the patient to take a temperature 
 c. Teaching the patient to select nutritious foods d. Teaching the patient about the effects of alcohol ANS: C A patient’s nutritional health directly influences susceptibility to infection. A reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces body defenses against infection and impairs wound healing. This is the only teaching point that directly influences risk. Teaching the patient how to take a temperature can help the patient assess if there is a fever, but it is not related to decreasing the individual’s risk for infection. Teaching the patient about fall prevention or about the effects of alcohol does not decrease the risk of infection. DIF:Apply (application)REF:449
OBJ: Identify patients most at risk for infection. TOP: Teaching/Learning MSC: Safety and Infection Control 14. A diabetic patient presents to the clinic for a dressing change. The wound is located on the right foot and has purulent yellow drainage. Which action will the nurse take to prevent the spread of infection? d. Position the patient comfortably on the stretcher. 
 e. Explain the procedure for dressing change to the patient. 
 f. Review the medication list that the patient brought from home. 
 g. Don gloves and other appropriate personal protective equipment. 
 ANS: D Localized infections are most common in the skin or with mucous membrane breakdown. Wear gloves and other personal protective equipment as appropriate when examining or providing treatment to localized infected areas to create a protective barrier. Positioning the patient, explaining the procedure, and reviewing the medication list are all tasks that need to be completed, but they do not prevent the spread of infection. DIF:Apply (application)REF:450 | 459 | 465 OBJ: Describe the signs/symptoms of a localized infection and those of a systemic infection. TOP: Implementation MSC: Safety and Infection Control 15. A patient presents with pneumonia. Which priority intervention should be included in the plan of care for this patient? e. Observe the patient for decreased activity tolerance. 
 f. Assume the patient is in pain and treat accordingly. 
 g. Provide the patient ice chips as requested. 
 d. ANS: A Maintain the room temperature at 65° F. Systemic infection, like pneumonia, causes more generalized symptoms than local infection. This type of infection can result in fever, fatigue, nausea and vomiting, and malaise; be alert for changes in the patient’s level of activity and responsiveness. Nurses do not assume but assess and communicate with the patient about pain. While providing the patient with ice chips may be appropriate, it is not a priority and there is no reason for the patient to be limited to ice. Maintaining the room temperature at 65° F is too cold. DIF:Analyze (analysis)REF:450-451 OBJ: Describe the signs/symptoms of a localized infection and those of a systemic infection. TOP: Planning MSC: Safety and Infection Control 16. The nurse is caring for a patient in an intensive care unit who needs a bath. Which priority action will the nurse take to decrease the potential for a health care–associated infection? a. Use local anesthetic on reddened areas. e. Use nonallergenic tape on dressings. 
 f. Use a chlorhexidine wash. 
g. Use filtered water. 
 ANS: C The Centers for Disease Control and Prevention (CDC) recommends the use of chlorhexidine (CHG) bathing for patients in intensive care units, patients who are scheduled for surgery, and all patients with invasive central line catheters as part of MRSA reduction efforts. Using local anesthetics, nonallergenic tape, and filtered water does not affect the cause of a health care–associated infection by, for example, decreasing microbial counts like a CHG bath. DIF:Apply (application)REF:448
OBJ: Explain conditions that promote the transmission of health care–associated infection. TOP: Implementation MSC: Safety and Infection Control 17. The infection control nurse is reviewing data for the medical-surgical unit. The nurse notices an increase in postoperative infections from Aspergillus. Which type of health care– associated infection will the nurse report? a. Vector e. Exogenous 
 f. Endogenous 
 g. Suprainfection 
 ANS: B An exogenous infection comes from microorganisms found outside the individual such
as Salmonella, Clostridiumtetani, and Aspergillus. They do not exist as normal floras. A vector transmits microorganisms and is usually a type of insect or organism. Endogenous infection occurs when part of the patient’s flora becomes altered and an overgrowth results (e.g., staphylococci, enterococci, yeasts, and streptococci). This often happens when a patient receives broad-spectrum antibiotics that alter the normal floras. A suprainfection develops when broad-spectrum antibiotics eliminate a wide range of normal flora organisms, not just those causing infection. DIF:Understand (comprehension)REF:448 OBJ: Explain conditions that promote the transmission of health care–associated infection. TOP: Evaluation MSC: Safety and Infection Control 18. The patient has contracted a urinary tract infection (UTI) while in the hospital. Which action will most likely increase the risk of a patient contracting a UTI? e. Reusing the patient’s graduated receptacle to empty the drainage bag. 
 f. Allowing the drainage bag port to touch the graduated receptacle. 
 g. Emptying the urinary drainage bag at least once a shift. 
 h. Irrigating the catheter infrequently. 
 ANS: B Allowing the urinary drainage bag port to touch contaminated items (graduated receptacle) may introduce bacteria into the urinary system and contribute to a urinary tract infection. The urinary drainage bag should be emptied at least once a shift. Patients should have their own receptacle for measurement to prevent cross-contamination. Repeated catheter irrigations increase the chance so irrigating infrequently will be beneficial in reducing the risk. DIF:Apply (application)REF:448 | 457
OBJ: Explain conditions that promote the transmission of health care–associated infection. TOP: Implementation MSC: Safety and Infection Control 19. Which nursing action will most likely increase a patient’s risk for developing a health care– associated infection? e. Uses surgical aseptic technique to suction an airway 
 f. Uses a clean technique for inserting a urinary catheter 
 g. Uses a cleaning stroke from the urinary meatus toward the rectum 
 h. Uses a sterile bottled solution more than once within a 24-hour period 
ANS: B Using clean technique (medical asepsis) to insert a urinary catheter would place the patient at risk for a health care–associated infection. Urinary catheters need to be inserted using sterile technique, which is also referred to as surgical asepsis. Surgical aseptic technique (also called sterile technique) should be used when suctioning an airway because it is considered a sterile body cavity. Washing from clean to dirty (urinary meatus toward rectum) is correct for decreasing infection risk. Bottled solutions may be used repeatedly during a 24-hour period; however, special care is needed to ensure that the solution in the bottle remains sterile. After 24 hours, the solution should be discarded. DIF:Analyze (analysis)REF:448 | 467
OBJ: Explain conditions that promote the transmission of health care–associated infection. TOP: Evaluation MSC: Safety and Infection Control 20. The nurse is caring for a patient in labor and delivery. When near completing an assessment of the patient’s cervix, the electronic infusion device being used on the intravenous (IV) infusion alarms. Which sequence of actions is mostappropriate for the nurse to take? e. Complete the assessment, remove gloves, and silence the alarm. 
 f. Discontinue the assessment, silence the alarm, and assess the intravenous site. 
 g. Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion. 
 h. Discontinue the assessment, remove gloves, use hand gel, and assess the intravenous infusion. 
 ANS: C Completing the assessment while wearing gloves, removing gloves, washing hands after contact with body fluids, and then assessing the intravenous infusion will assist in the prevention and transfer of any potential organisms to this intravenous line. Completing the assessment, removing gloves, and silencing the alarm leaves out the crucial step of decontaminating and washing the hands. Discontinuing the assessment and assessing the IV leaves out removing the gloves and decontamination, as well as completing the assessment for the patient. Discontinuing the assessment, removing gloves, using hand gel, and assessing the IV is incorrect because upon exposure to body fluids, washing hands is appropriate. DIF:Apply (application)REF:458-459 | 465-466
OBJ:Explain the difference between medical and surgical asepsis. TOP: Implementation MSC: Safety and Infection Control 21. The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse has scrubbed hands and has donned a sterile gown and gloves. Which action will indicate a break in sterile technique? e. Touching clean protective eyewear 
 f. Standing with hands above waist area 
 g. Accepting sterile supplies from the surgeon 
 h. Staying with the sterile table once it is open 
 ANS: A Touching nonsterile (clean) protective eyewear once gowned and gloved with sterile gown and gloves would indicate a break in sterile technique. Sterile objects remain sterile only when touched by another sterile object. Standing with hands folded on the chest is common practice and prevents arms and hands from touching unsterile objects. Accepting sterile supplies from the surgeon who has opened them with the appropriate technique is acceptable. Staying with a sterile table once opened is a common practice to ascertain that no one or nothing has contaminated the table. DIF:Apply (application)REF:467 | 468 OBJ:Explain the difference between medical and surgical asepsis. TOP: Implementation MSC: Safety and Infection Control 22. The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change? d. Donning clean goggles, gown, and gloves to dress the wound 
 e. Donning sterile gown and gloves to remove the wound dressing 
f. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing 
 g. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing 
 ANS: C Utilize clean gloves (medical asepsis) to remove contaminated dressings and sterile supplies, including gloves and dressings (surgical asepsis–sterile technique) to reapply sterile dressings. Wearing sterile gowns and gloves is not necessary when removing soiled dressings. Donning clean gloves to dress a sterile wound would contaminate the sterile supplies. Utilizing clean supplies for a sterile dressing would not help in decreasing the number of microbes at the incision site. DIF:Apply (application)REF:455 | 467 OBJ:Explain the difference between medical and surgical asepsis. TOP: Implementation MSC: Safety and Infection Control 23. The nurse is caring for a patient in the endoscopy area. The nurse observes the technician performing these tasks. Which observation will require the nurse to intervene? e. Washing hands after removing gloves 
 f. Disinfecting endoscopes in the workroom 
 c. Removing gloves to transfer the endoscope d. Placing the endoscope in a container for transfer ANS: C Standard precautions are used to prevent and control the spread of infection. Transferring contaminated equipment without the protection of gloves can assist in the spread of microbes to inanimate objects and to the person doing the transfer; therefore, the nurse must intervene. Utilizing gloves, washing hands, covering contaminated supplies during transfer, and disinfecting equipment in the appropriate way in the appropriate places utilize principles of basic medical asepsis and standard precautions and can break the chain of infection. DIF:Apply (application)REF:455-456 | 459 OBJ: Explain the rationale for standard precautions. TOP: Implementation MSC:Management of Care 24. The nurse is caring for a patient who is at risk for infection. Which action by the nurse indicates correct understanding about standard precautions? e. Teaches the patient about good nutrition 
 f. Dons gloves when wearing artificial nails 
 g. Disposes an uncapped needle in the designated container 
 h. Wears eyewear when emptying the urinary drainage bag 
 ANS: D Standard precautions include the wearing of eyewear whenever there is a possibility of a splash or splatter, like when emptying the urinary drainage bag. Teaching the patient about good nutrition is positive but does not apply to standard precautions. Standard precautions apply to contact with blood, body fluid (except sweat), nonintact skin, and mucous membranes from all patients. Artificial nails are not worn when using standard precautions. Any needles should be disposed of uncapped, or a mechanical safety device is activated for recapping. DIF:Apply (application)REF:459 | 464 OBJ: Explain the rationale for standard precautions. TOP: Implementation MSC: Safety and Infection Control 25. The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the patient for excessive vaginal drainage. Which precaution will the nurse use? d. Contact 
e. Droplet 
 f. Standard 
 g. Protective environment 
 ANS: C Standard precautions apply to contact with blood, body fluid, nonintact skin, and mucous membranes of all patients. Contact precautions apply to individuals with infections that can be transmitted by direct or indirect contact. Protective environment precautions apply to individuals who have undergone transplantations and gene therapy. Droplet precautions focus on diseases that are transmitted by large droplets. DIF:Understand (comprehension)REF:458-459
OBJ: Explain the rationale for standard precautions. TOP: Implementation MSC: Safety and Infection Control 26. The nurse is caring for a patient in the hospital. The nurse observes the nursing assistive personnel (NAP) turning off the handle faucet with bare hands. Which professional practice principle supports the need for follow-up with the NAP? a. The nurse is responsible for providing a safe environment for the patient. e. Different scopes of practice allow modification of procedures. 
 f. Allowing the water to run is a waste of resources and money. 
 g. This is a key step in the procedure for washing hands. 
 ANS: A The nurse is responsible for providing a safe environment for the patient. The effectiveness of infection control practices depends on conscientiousness and consistency in using effective aseptic technique by all health care providers. After washing hands, turn off a handle faucet with a dry paper towel, and avoid touching the handles with your hands to assist in preventing the transfer of microorganisms. Wet towels and hands allow the transfer of pathogens from faucet to hands. The principles and procedures for washing hands are universal and apply to all members of health care teams. Being resourceful and aware of the cost of health care is important, but taking shortcuts that may endanger an individual’s health is not a prudent practice. DIF:Apply (application)REF:458-459 | 472 OBJ: Perform proper procedures for hand hygiene. TOP: Evaluation MSC:Management of Care 27. The nurse is caring for a patient who becomes nauseated and vomits without warning. The nurse has contaminated hands. Which action is best for the nurse to take next? f. Wash hands with an antimicrobial soap and water. 
 g. Clean hands with wipes from the bedside table. 
 h. Use an alcohol-based waterless hand gel. 
 i. Wipe hands with a dry paper towel. 
 ANS: A The Centers for Disease Control and Prevention (CDC) recommends that when hands are visibly soiled, one should wash with a non-antimicrobial soap or with antimicrobial soap. Cleaning hands with wipes or using waterless hand gel does not meet this standard. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands. Wiping hands with a dry paper towel will occur after the nurse has washed both hands. DIF:Apply (application)REF:459 OBJ: Perform proper procedures for hand hygiene. TOP: Implementation MSC: Safety and Infection Control 28. The nurse is performing hand hygiene before assisting a health care provider with insertion of a chest tube. While washing hands, the nurse touches the sink. Which action will the nurse take next? g. Inform the health care provider and recruit another nurse to assist. 
h. Rinse and dry hands, and begin assisting the health care provider. 
 i. Extend the handwashing procedure to 5 minutes. 
 j. Repeat handwashing using antiseptic soap. 
 ANS: D The inside of the sink and the edges of the sink, faucet, and handles are considered contaminated areas. If the hands touch any of these areas during handwashing, repeat the handwashing procedure utilizing antiseptic soap. There is no need to inform the health care provider or be relieved of this assignment. If the hands are contaminated when touching the sink, drying hands and proceeding with the procedure could possibly contaminate and contribute to increased microbial counts during the procedure, resulting in infection for the patient. Extending the time for washing the hands (although this is what will happen when the procedure is repeated) is not the focus. The focus is to repeat the whole hand hygiene procedure utilizing antiseptic soap. DIF:Apply (application)REF:472
OBJ: Perform proper procedures for hand hygiene. TOP: Implementation MSC: Safety and Infection Control 29. The nurse on the surgical team and the surgeon have completed a surgery. After donning gloves, gathering instruments, and placing in the transport carrier, what is the next step in handling the instruments used during the procedure? d. Sending to central sterile for cleaning and sterilization 
 e. Sending to central sterile for cleaning and disinfection 
 f. Sending to central sterile for cleaning and boiling 
 g. Sending to central sterile for cleaning 
 ANS: A Surgical instruments need to be cleaned and sterilized. Disinfecting, boiling, or cleaning is not utilized on critical items that will be reused on patients in the hospital environment. Items that are used on sterile tissue or in the vascular system present a high risk of infection if they become contaminated with bacteria. DIF:Understand (comprehension)REF:455-456
OBJ: Explain how infection control measures differ in the home versus the hospital. TOP: Implementation MSC: Safety and Infection Control 30. The nurse is observing a family member changing a dressing for a patient in the home health environment. Which observation indicates the family member has a correct understanding of how to manage contaminated dressings? c. The family member places the used dressings in a plastic bag. 
 d. The family member saves part of the dressing because it is clean. 
 e. The family member removes gloves and gathers items for disposal. 
 d. The family member wraps the used dressing in toilet tissue before placing in trash. ANS: A Contaminated dressings and other infectious, disposable items should be placed in impervious plastic or brown paper bags and then disposed of properly in garbage containers. Gloves should be worn during this process. Parts of the dressing should not be saved, even though they may seem clean, because microbes may be present. DIF:Apply (application)REF:461 | 467
OBJ: Explain how infection control measures differ in the home versus the hospital. TOP: Evaluation MSC: Safety and Infection Control
31. The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with Clostridium difficile in droplet precautions e. A patient with tuberculosis in airborne precautions 
 f. A patient with MRSA infection in contact precautions 
 g. A patient with a lung transplant in protective environment precautions 
 ANS: A A patient with Clostridium difficile should be on contact precautions, not droplet; therefore, the nurse will see this patient first to correct the precautions. All the rest are on correct precautions. Patients with tuberculosis belong in airborne precautions; patients with MRSA infection belong in contact precautions; and patients with lung transplants belong in protective environment precautions. DIF:Analyze (analysis)REF:459
OBJ: Explain procedures for each isolation category. TOP: Assessment MSC:Management of Care 32. The home health nurse is teaching a patient and family about hand hygiene in the home. Which situation will cause the nurse to emphasize washing hands before and after? f. Shaking hands 
 g. Performing treatments 
 h. Opening the refrigerator 
 i. Working on a computer 
 ANS: B Patients and family members should perform hand hygiene before and after treatments and when coming in contact with body fluids. Shaking hands does not require washing of hands before and after. Washing hands before and after opening the refrigerator and using the computer is not required. DIF:Understand (comprehension)REF:467 OBJ: Explain how infection control measures differ in the home versus the hospital. TOP: Teaching/Learning MSC: Safety and Infection Control 33. The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next? d. Apply a new mask. 
e. Reapply the mask after it air-dries. 
 f. Change the mask when relieved by next shift. 
 g. Do not change the mask if the nurse is comfortable. 
 ANS: A After the mask is worn for several hours, it can become moist. The mask should be changed as soon as possible because moisture does not provide a barrier to microorganisms and is ineffective. Waiting to change the mask, air-drying it, or wearing it because it is comfortable does not support the principles of infection control. DIF:Apply (application)REF:464 | 468 OBJ roperly apply a surgical mask, sterile gown, and sterile gloves. TOP: Implementation MSC: Safety and Infection Control 34. The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease? e. Place the patient in a room with negative airflow. 
 f. Wear a gown, gloves, face mask, and goggles for interactions with the patient. 
 g. Transport the patient safely and quickly when going to the radiology department. 
 h. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only. 
 ANS: D Contact precautions are a type of isolation precaution used for patients with illness that can be transmitted through direct or indirect contact. Patients who are on contact precautions should have dedicated equipment wherever possible. This would mean, for example, that one blood pressure cuff and one stethoscope would stay in the room with the patient and would be used for that patient only. A gown and gloves may be required for interactions with a patient who is on contact precautions. A face mask and goggles are not part of contact precautions. A room with negative airflow is needed for patients placed on airborne precautions; it is not necessary for a patient on contact precautions. When a patient on contact precautions needs to be transported, the patient should wear clean gown, and hands cleaned, and the infectious material is contained or covered. DIF:Analyze (analysis)REF:459-460
OBJ: Explain procedures for each isolation category. TOP: Implementation MSC: Safety and Infection Control 35. The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which action will the nurse take next? e. Instruct assistive personnel to use soap and water rather than sanitizer. 
 f. Wear an N95 respirator when entering the patient room. 
 g. Place the patient on droplet precautions. 
 h. Teach the patient cough etiquette. 
 ANS: A Clostridium difficile is a spore-forming organism that can be transmitted through direct and indirect patient contact. Because Clostridium difficile is a spore-forming organism, hand sanitizer is not effective in preventing its transmission. Hands must be washed with soap and water to prevent transmission. This organism is not transmitted via the droplet route; therefore, droplet precautions are not needed. An N95 respirator is used primarily for patients with airborne illness, especially tuberculosis. While all patients should be taught cough etiquette, this action is not specifically related to the patient having Clostridium difficile. DIF:Apply (application)REF:443 | 458 | 459 OBJ: Explain procedures for each isolation category. TOP: Implementation MSC: Safety and Infection Control 36. The nurse is changing linens for a postoperative patient and feels a prick in the left hand. A nonactivated safe needle is noted in the linens. For which condition is the nurse most at risk? c. Diphtheria 
 d. Hepatitis B 
 c. d. Clostridium difficile
Methicillin-resistant Staphylococcus aureus ANS: B Bloodborne pathogens such as those associated with hepatitis B and C are most commonly transmitted by contaminated needles. Clostridium difficile and MRSA are spread by contact. Diphtheria is spread by droplets when one is within 3 feet of the patient. DIF:Understand (comprehension)REF:469
OBJ: Understand the definition of occupational exposure. TOP: Assessment MSC: Safety and Infection Control 37. The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an intravenous (IV) infusion. Which step(s) will the nurse take next? e. Obtain an alcohol swab, remove the blood with an alcohol swab, and continue care. 
 f. Immediately wash the site with soap and running water, and seek guidance from the manager. 
 g. Do nothing; accidentally getting splashed with blood happens frequently and is part of the job. 
h. Delay washing of the site until the nurse is finished providing care to the patient. 
 ANS: B After getting splashed with blood from a patient who has a known bloodborne pathogen, it is important to cleanse the site immediately and thoroughly with soap and running water and notify the manager for guidance on next steps in the process. Removing the blood with an alcohol swab, delaying washing, and doing nothing because the splash was to intact skin could possibly spread the blood within the room and could spread the infection. Contain contamination immediately to prevent contact spread. DIF:Analyze (analysis)REF:466 | 470
OBJ:Explain the postexposure process.TOP:Implementation MSC: Safety and Infection Control 38. Which process will be required after exposure of a nurse to blood by a cut from a used scalpel in the operative area? e. Placing the scalpel in a needle safe container 
 f. Testing the patient and offering treatment to the nurse 
 g. Removing sterile gloves and disposing of in kick bucket 
 h. Providing a medical evaluation of the nurse to the manager 
 ANS: B Follow-up for risk of infection begins with patient testing. Patients should be tested for HIV and hepatitis B and C. Testing of the nurse is dependent on the results of patient testing; if the patient is positive for one of these infections, the nurse will be started on testing and treatment. Removing sterile gloves and placing sharps in appropriate containers are always part of the perioperative process and are not the process for postexposure. A confidential medical evaluation is provided to the nurse, not the manager. DIF:Apply (application)REF:470
OBJ:Explain the postexposure process.TOP:Implementation MSC: Safety and Infection Control 39. The nurse is caring for a patient who needs a protective environment. The nurse has provided the care needed and is now leaving the room. In which order will the nurse remove the personal protective equipment, beginning with the first step? 1. Remove eyewear/face shield and goggles.
2. Perform hand hygiene, leave room, and close door. 3. Remove gloves. 4. Untie gown, allow gown to fall from shoulders, and do not touch outside of gown; dispose of properly. 5. Remove mask by strings; do not touch outside of mask.
6. Dispose of all contaminated supplies and equipment in designated receptacles. e. 3, 1, 4, 5, 6, 2 
 f. 1, 4, 5, 3, 6, 2 
 g. 1, 4, 5, 3, 2, 6 
 h. 3, 1, 4, 5, 2, 6 
 ANS: D The correct order for removing personal protective equipment for a patient in a protective environment and for performing associated tasks is to remove gloves, remove eyewear, remove gown, remove mask, perform hand hygiene, leave room and close doors, and dispose of all contaminated supplies and equipment in a manner that prevents the spread of microorganisms. DIF:Apply (application)REF:463
OBJ: Explain procedures for each isolation category. TOP: Implementation MSC: Safety and Infection Control 40. The nurse manager is evaluating current infection control data for the intensive care unit. The nurse compares past patient data with current data to look for trends. The nurse manager examines the infection chain for possible solutions. In which order will the nurse arrange the items for the infection chain beginning with the first step? 1. A mode of transmission
2. An infectious agent or pathogen
3. A susceptible host
4. A reservoir or source for pathogen growth 5. A portal of entry to a host 6. A portal of exit from the reservoir e. 3, 2, 4, 1, 5, 6 
 f. 1, 3, 5, 4, 6, 2 
 g. 4, 2, 1, 6, 3, 5 
 h. 2, 4, 6, 1, 5, 3 
 ANS: D For spread of infection, the chain has to be uninterrupted with an infectious agent, a reservoir and portal of exit, a mode of transmission, a portal of entry, and a susceptible host. The nurse manager is evaluating the chain of infection to determine actions that could be implemented to influence the spread of infection in the intensive care unit. Understanding the spread of infection and directing actions toward those steps have the potential to decrease infection in the setting. DIF:Understand (comprehension)REF:443
OBJ: Explain the relationship between the infection chain and transmission of infection. TOP:ImplementationMSC:Management of Care MULTIPLE RESPONSE 1. The nurse is caring for a patient in protective environment. Which actions will the nurse take? (Select all that apply.) f. Wear an N95 respirator when entering the patient’s room. 
 g. Maintain airflow rate greater than 12 air exchanges/hr. 
 h. Place in special room with negative-pressure airflow. 
 i. Open drapes during the daytime. 
e. Listen to the patient’s interests. 
 f. Place dried flowers in a plastic vase. 
 ANS: B, D, E This form of isolation requires a specialized room with positive airflow. The airflow rate is set at greater than 12 air exchanges/hr, and all air is filtered through a HEPA filter. Isolation disrupts normal social relationships with visitors and caregivers. Take the opportunity to listen to a patient’s concerns or interests. Open drapes or shades and remove excess supplies and equipment. Patients are not allowed to have dried or fresh flowers or potted plants in these rooms. All health care personnel wear an N95 respirator every time they enter the room for patients, and a private room with negative airflow is required for patients on airborne precautions. DIF:Understand (comprehension)REF:459-460 OBJ: Explain procedures for each isolation category. TOP: Implementation MSC: Safety and Infection Control 2. The nurse is assessing a new patient admitted to home health. Which questions will
be most appropriate for the nurse to ask to determine the risk of infection? (Select all that apply.) e. ―Can you explain the risk for infection in your home?‖ 
 f. ―Have you traveled outside of the United States?‖ 
 g. ―Will you demonstrate how to wash your hands?‖ 
 h. ―What are the signs and symptoms of infection?‖ 
 i. ―Are you able to walk to the mailbox?‖ 
 j. ―Who runs errands for you?‖ 
 ANS: A, B, C, D In the home setting, the objective is that the patient and/or family will utilize proper infection control techniques. Asking the patient and family about handwashing, risk of infection, recent travel, and signs and symptoms of infection is important in evaluating the patient’s knowledge based on infection control strategies. Activity assessment is important for evaluation of the overall status of the patient, and knowing who runs errands gives you information on who is helping to meet the needs of the patient, but neither of these relates to decreasing the risk of infection. DIF:Apply (application)REF:450 | 467
OBJ: Explain how infection control measures differ in the home versus the hospital. TOP: Assessment MSC: Safety and Infection Control 3. The circulating nurse in the operating room is observing the surgical technologist while applying a sterile gown and gloves to care for a patient having an appendectomy. Which behaviors indicate to the nurse that the procedure by the surgical technologist is correct? (Select all that apply.) e. Ties the back of own gown 
 f. Touches only the inside of gown 
 g. Slips arms into arm holes simultaneously 
 h. Extended fingers fully into both of the gloves 
 i. Uses hands covered by sleeves to open gloves 
 j. Applies surgical cap and face mask in the operating suite 
 ANS: B, C, D, E To maintain sterility, the surgical technologist (ST) touches the inside of the gown that will be against the body. Arms are slipped simultaneously into the gown to prevent contamination. Using the sleeves covering the hands maintains the principle of sterile only touching sterile to open gloves. Extending the fingers fully into both gloves ensures that the ST has full dexterity while using the sterile gloved hand. Surgical cap, face mask, and eye wear are applied before entering the surgical area and completing the surgical scrub. Reaching behind to tie the back of the gown will contaminate the sterile area of the gown. DIF:Analyze (analysis)REF:469 | 479 OBJ roperly apply a surgical mask, sterile gown, and sterile gloves. TOP:EvaluationMSC:Management of Care 4. The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to apply the sterile gloves. Which steps will the nurse take? (Select all that apply.) e. While putting on the first glove, touch only the outside surface of the glove. 
 f. With gloved dominant hand, slip fingers underneath second glove cuff. 
 g. Remove outer glove package by tearing the package open. 
 h. Lay glove package on clean flat surface above waistline. 
 i. Glove the dominant hand of the nurse first. 
 j. After second glove is on, interlock hands. 
 ANS: B, D, E, F Sterile objects held below the waist are considered contaminated. Gloving the dominant hand helps to improve dexterity. Slipping the fingers underneath the second glove cuff helps to keep the gloved fingers sterile. Interlocking fingers ensures a smooth fit over the fingers. Sterile supplies are opened by carefully separating and peeling apart the sides of the package. This prevents the sterile contents from accidentally opening and touching contaminated objects. While putting on the first glove, touching only the outside surface of the glove will contaminate the sterile item; touch only the inside of the glove—the piece that will be against the skin. DIF:Apply (application)REF:481-482
OBJ roperly apply a surgical mask, sterile gown, and sterile gloves. TOP: Implementation MSC: Safety and Infection Control 5. The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient? (Select all that apply.) e. Private room 
 f. Negative-pressure airflow in room 
 g. Surgical mask, gown, gloves, eyewear 
 h. N95 respirator, gown, gloves, eyewear 
 i. Communication signs for droplet precautions 
 j. Communication signs for airborne precautions 
 ANS: A, B, D, F Caring for this patient requires a private room, negative-pressure airflow in room, and wearing an N95 respirator that has been fit-tested, gloves, gown, and eyewear. Tuberculosis is a disease that is transmitted by droplets that remain in the air for long periods of time, requiring airborne precautions. This patient will not be in droplet precautions and instead requires airborne precaution signs. This type of patient requires more than the average surgical mask for protection. DIF:Apply (application)REF:459-460
OBJ: Explain procedures for each isolation category. TOP: Planning MSC: Safety and Infection Control 6. The nurse and the student nurse are caring for two different patients on the medicalsurgical unit. One patient is in airborne precautions, and one is in contact precautions. The nurse explains to the student different interventions for care. Which information will the nurse include in the teaching session? (Select all that apply.) e. Dispose of supplies to prevent the spread of microorganisms. 
 f. Wash hands before entering and leaving both of the patients’ rooms. 
 g. Be consistent in nursing interventions since there is only one difference in the precautions. 
 h. Apply the knowledge the nurse has of the disease process to prevent the spread of microorganisms. 
 i. Have patients in airborne precautions wear a mask during transportation to other departments. 
Check the working order of the negative-pressure room for the airborne precaution patient on admission a 
 j. discharge. 
 ANS: A, B, D, E Washing hands, properly disposing of supplies, applying knowledge of the disease process, and having patients in airborne precautions wear a mask during transfer are all principles to follow when caring for patients in isolation. Multiple differences are evident among these types of isolation, including the type of room used for the patient and what the nurse wears while caring for the patient. It is important to check the working order of a negative-pressure room before admitting a patient to the room, each shift the patient is in the room, and if and when the device alarms. Checking the working order of the negative-pressure rooms at discharge is not necessary. DIF:Apply (application)REF:459-460
OBJ: Explain procedures for each isolation category. TOP: Teaching/Learning MSC:Management of Care [Show More]

Last updated: 1 year ago

Preview 1 out of 74 pages