, TESTBANK FOR
Concept-Based Clinical Nursing Skills 2nd Edition Loren Stein
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provided.
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,Chapter 01: Foundations of Safe Client Care
Stein: Concept-Based Clinical Nursing Skills, 2nd Edition
MULTIPLE CHOICE
1. To meet a requirement of the 2021 American Association of Colleges of Nursing Essentials,
what topic does nursing faculty focus on throughout the curriculum?
a. Nursing process
b. Safety science
c. Ergonomics
d. Information technology
ANS: B
The 2021 AACN Essentials states that “Provision of safe, quality care necessitates knowing
and using established and emerging principles of safety science in care delivery” (p. 43).
Nursing students are taught to use the nursing process, but this is not confined to patient
safety. Ergonomics is a subset of safety science that studies people and their work
environments. Information technology can be used to improve safety.
DIF: Cognitive Level: Remembering TOP: Integrated Process: Teaching-Learning
2. A nurse meets the assigned clients at the start of a shift. After performing hand hygiene and
introducing one’s self, what does the nurse do next?
a. Begin a head-to-toe assessment.
b. Identify the client using two identifiers.
c. Assess the client for pain.
d. Ensure the call light is within reach.
ANS: B
A critical task in healthcare for safety, client identification is paramount for preventing errors.
After performing hand hygiene and introducing him- or herself, the nurse identifies the client
using two unique identifiers. The head-to-toe and pain assessments come shortly afterward.
The nurse ensures the client can reach the call light prior to leaving the room.
DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment
3. A nurse has worked with the same client for 2 days. When entering the room to administer
medications, the nurse performs hand hygiene. What action does the nurse take next?
a. Provide any needed teaching.
b. Ask if the client has any care requests.
c. Assess vital signs and pain.
d. Identify the client using two identifiers.
ANS: D
Every time the client is to receive medication, diagnostic studies, or any other healthcare
intervention, the nurse must identify the client using two unique identifiers, even if the client
is well known to the nurse. Assessments, teaching, and determining client requests would
come afterward.
DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment
,4. A nurse’s neighbor states “My father got a nosocomial infection after surgery!” What does the
nurse understand happened to the client?
a. The client received contaminated blood products.
b. The client nearly died from a postoperative infection.
c. The client acquired an infection while in the hospital.
d. The client received poor preoperative skin preparation.
ANS: C
A nosocomial infection is one acquired in the hospital. It does not designate how the infection
occurred, so the client might have become infected through contaminated blood products or
from poor preoperative skin preparation. It does not mean the client had a life-threatening
infection, only that is occurred in hospital.
DIF: Cognitive Level: Understanding TOP: Integrated Process: Teaching-Learning
5. A nurse is making rounds on clients at risk for infection. Which client does the nurse see first?
a. A client with an intravenous (IV) line
b. A client who has a central line
c. A client with an indwelling bladder catheter
d. A client with an IV and bladder catheter
ANS: D
One of the biggest risk factors for hospital acquired infections (HAIs) is the presence of
invasive lines. The more lines, the more risk. The client with both an IV and a catheter has the
highest risk. The clients with an IV or a catheter have less risk.
DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment
6. A nursing manager concerned about the infection rate on the unit wants to implement
measures to reduce the transmission of infectious organisms. What action by the manager is
best?
a. Provide a stethoscope dedicated to each client.
b. Ensure gloves are well-stocked in each room.
c. Restrict all plants and fresh foods from rooms.
d. Screen all visitors for contagious illnesses.
ANS: A
In the chain of infection, one of the most important components is the mode of transmission.
Stethoscopes can serve as a mode of indirect contact transmission unless they are disinfected
appropriately between clients. Providing each client with an individual stethoscope will
reduce this risk. Gloves are important, but they can become contaminated too and serve as a
mode of transmission. Plants and fresh foods are an uncommon source of transmission unless
the client is immunosuppressed. Screening visitors for contagious illness is an unrealistic
long-term action plan.
DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
7. A nurse is observing a student nurse. What action by the student demonstrates the need for
more education on Standard Precautions?
a. The student performs hand hygiene before all client contacts.
, b. The student conscientiously wears gloves when taking vital signs.
c. The student confirms that urine possibly contains infectious microbes.
d. The student wears a gown when cleaning liquid stool off the client.
ANS: B
Standard Precautions operates under the principle that all bodily fluids other than sweat could
potentially contain infectious microbial agents that pose a risk to the healthcare worker.
Contact with skin, if free of those fluids, does not require wearing gloves, so the nurse would
provide more education to the student. Hand hygiene is the first step of Standard Precautions.
The student is being prudent by confirming a possible source of contamination. Nurses
determine which infection prevention practice to use based upon the type of client–nurse
interaction and the possibility of exposure to blood, other body fluids, or pathogens, so
wearing a gown while cleaning liquid stool is appropriate.
DIF: Cognitive Level: Analyzing TOP: Nursing Process: Evaluation
8. A faculty member has taught the correct technique for taking gloves off (doffing). While
observing students practice, which action by a student indicates the need to review the
material?
a. Pulls glove off dominant hand first.
b. Takes first glove off by grasping it on the outside.
c. Takes second glove off by grasping it under the cuff.
d. Turns the gloves inside out when second glove is removed.
ANS: A
The correct way to remove gloves starts with doffing the glove on the nondominant hand first,
without touching the bare skin. This student would need further review of the skill. Removing
the first glove by grasping it on the outside, grasping the second glove under the cuff, and
turning the gloves inside out to prevent microbe spread are all correct actions. These students
would not need remediation.
DIF: Cognitive Level: Analyzing TOP: Nursing Process: Evaluation
9. In order to move a cooperative client safely from the bed to chair, which of the following
actions does the nurse take first?
a. Gather enough help for the task.
b. Assess the client’s ability to bear weight.
c. Delegate using the lift chair.
d. Administer pain medication.
ANS: B
The first thing the nurse does when preparing to transfer a cooperative client is to assess the
client’s ability to bear weight and remain balanced while standing. The findings will
determine how much assistance (if any) the client needs. If the client needs maximal
assistance, then the nurse gathers enough help and any lifting devices needed and assigns roles
to each team member. If the client has pain, the nurse would administer pain medication, but
that is not related to safety.
DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
,10. Hospital administration has rejected a request from nursing services for ceiling-mounted
lifting/transferring devices pointing to the expense. What response by the Chief Nursing
Officer would be best?
a. “We need the equipment to stay competitive in hiring nurses.”
b. “They are required by The Joint Commission so we have to get them.”
c. “The cost of employee injuries from lifting is more expensive.”
d. “We will save money with fewer client-injury lawsuits being filed.”
ANS: C
Data show that when hospitals implemented safe client handling equipment, hospitals
achieved savings by reducing lost work days and reducing worker compensation costs that
met or exceeded the cost of the equipment. This is not a main focus for nurse recruitment and
the equipment is not mandated. Fewer client injuries leading to lawsuits is a probability, but
the savings in reducing employee injury have been documented by the ANA.
DIF: Cognitive Level: Understanding
TOP: Integrated Process: Communication and Documentation
11. The nurse places a bed-bound client in the position shown. What other considerations would
the nurse have for this client?
a. Include a Trochanter roll to prevent of the neck.
b. Assess whether the client needs support to prevent foot drop.
c. Monitor for signs of increased intracranial pressure.
d. Place a rolled-up washcloth in the client’s hands.
ANS: B
The modified left lateral recumbent position is shown here. Considerations for the nurse
include providing pillow support to keep the head and neck in alignment, to support the upper
leg and prevent internal rotation, to support the upper arm and prevent internal rotation, and
provide foot support to prevent foot drop. Hyperextension of the neck and increased
intracranial pressure are concerns for clients in the Trendelenburg position. Placing something
in the client’s hands is not related to body position.
DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
,12. A nurse has applied restraints to a client. After documenting the care and ensuring the client is
safe, what action does the nurse take next?
a. Call the provider and request a prescription for the restraints.
b. Alert the hospital’s Risk Management department.
c. Plan to check the client at a minimum of every 2 hours.
d. Assign assistive personnel to sit with the client.
ANS: C
The standard required by the Centers for Medicaid and Medicare Services is to assess the
restrained client at a minimum of every 2 hours. In most situations, the nurse requests the
prescription before applying the restraints, however; if it is necessary to apply them first, a
prescription from the provider is needed within 1 hour. Although restraints are often the
source of litigation, there is no need to routinely notify the Risk Management department
about the use of restraints. The client may or may not need someone to sit with him or her.
DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
13. The nursing student applies restraints. What action by the student demonstrates the need for
more education on this procedure?
a. The student attempts other methods to prevent harm before applying the restraints.
b. The student inserts two fingers between the restraint and client skin to check for
tightness.
c. The student secures the restraint by tying the restraint to the side rail but out of
client reach.
d. The student reassesses the client’s need for the restraint at least every 2 hours.
ANS: C
The student should tie the restraint to a secure part of the bed frame, not to the side rail.
Attempting alternatives to restraints, checking the tightness by placing two fingers under the
restraint, and reassessing the client at least every 2 hours are all appropriate actions.
DIF: Cognitive Level: Analyzing TOP: Nursing Process: Evaluation
14. The new nurse grumbles “Why are there so many regulations on using restraints?” What
response by the mentor is best?
a. “Clients have the right to be free from restraint or seclusion unless medically
necessary.”
b. “Following all these regulations helps prevent law suits.”
c. “Accrediting bodies aren’t in favor of using restraints so they make up
regulations.”
d. “Because restraints have been shown to actually increase injuries.”
ANS: A
The guiding principle for restraint use is that clients have the right to be free from unnecessary
restraint or seclusion unless it is medically necessary. This is a basic human right and protects
client dignity. Following regulations won’t necessarily prevent lawsuits, but will help prevent
negative outcomes from the legal action. Accrediting bodies don’t “just make up regulations.”
There are sound reasons for them. Restraints have been shown to increase injury, but that is
secondary to the fact that clients have the right to be free from them unless absolutely needed.
DIF: Cognitive Level: Understanding TOP: Integrated Process: Teaching-Learning
, 15. After assessing a client, the nurse cleans the stethoscope. What cleaning agent chosen by the
nurse is most appropriate?
a. 70% isopropyl alcohol
b. Diluted bleach 1:10 solution
c. Cidex
d. Hydrogen peroxide
ANS: A
70% to 90% isopropyl or 60-80% ethyl alcohol is appropriate for low-level disinfecting needs
such as cleaning stethoscopes, blood pressure cuffs, and table tops. Diluted bleach is
considered an intermediate level disinfectant and used for client rooms (including isolation
rooms) and visible blood spills. Cidex is a high-level disinfectant used for equipment that
comes into contact with mucous membranes, for example, an endoscope.
DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation
16. After giving an injection, which action by the nurse is most appropriate?
a. Breaks needle off the syringe and places it in the sharps box.
b. Recaps the needle and carries the syringe to the sharps box.
c. Engages the syringe’s safety device to cover the needle.
d. Twists the needle off and throws the syringe away.
ANS: C
Needle-stick injury is an occupational hazard. Current guidelines for handling sharps include
not recapping, bending, breaking, or hand-manipulating used needles. If recapping is required,
use a one-handed scoop technique only. Use safety features when available. Place used sharps
in a puncture-resistant container. The correct action would be to engage the safety feature on
the syringe to cover the needle.
DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation
17. The nurse is working in a neonatal intensive care unit. When an infant’s oxygen saturation
drops, what action does the nurse take first?
a. Place the neonate prone.
b. Call a code blue.
c. Inform the provider.
d. Call respiratory therapy.
ANS: A
Neonates and infants improve ventilation and oxygenation in the prone position. When the
baby’s oxygen saturation drops, the nurse would place the baby in the prone position. The
nurse would call the provider afterward. There is no indication that the baby is in
cardiopulmonary arrest, so a code blue is not called. There is no indication to call respiratory
therapy.
DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
MULTIPLE RESPONSE
,1. The nurse learns that which of the following must be demonstrated to prove a claim of
malpractice? (Select all that apply.)
a. Duty
b. Breach of duty
c. Physical injury
d. Emotional distress
e. Cause: the injury was caused by the breach of duty
ANS: A, B, C, E
The four elements which must be demonstrated to prove a case of malpractice are duty, breach
of duty, injury (sometimes called harm), and causation; in other words, the injury must have
occurred due to the breach of duty. Emotional distress is not an element.
DIF: Cognitive Level: Remembering TOP: Integrated Process: Teaching-Learning
2. The nurse learns that which of the following are principles of body mechanics? (Select all that
apply.)
a. Make a wide, stable base with your feet.
b. Put the bed at the correct height.
c. Put the work directly in front of you.
d. Keep the client as far away from you as possible.
e. Keep the bed in the same position.
ANS: A, B, C
The principles of body mechanics include maintaining a wide, stable base with your feet;
having the bed at the correct height (depending on what you are doing); keeping the work
directly in front of you; and keeping the client as close as possible to you.
DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation
3. Which of the following devices are inconsistent with the nurse’s knowledge of types of
restraint devices? (Select all that apply.)
a. A seat belt on a stroller
b. A thumbless mitten
c. A single raised side rail
d. A device applied during a dental procedure
e. A positioning restraint in the operating room
ANS: A, C, D, E
A stroller seat belt, one side rail, and devices applied temporarily to immobilize the client
during medical, dental, diagnostic, or surgical procedures are not considered as restraints. The
thumbless mitten is a restraint.
DIF: Cognitive Level: Remembering TOP: Nursing Process: Evaluation
4. A new nurse is demonstrating the use of a sit-to-stand lift. What actions by the nurse
demonstrate appropriate knowledge and skills? (Select all that apply.)
a. Assesses the client’s lower extremity strength.
b. Places the bed in the lowest position.
c. Places non-skid socks on the client’s feet.
d. Widens the lift’s base of support.
, e. Ensures client’s shins touch the shin support on the lift.
f. Instructs client to lean forward over the hand grasps.
ANS: B, D, E
Using the lift correctly, the nurse would assess the client’s upper extremity strength and ability
to bear weight, places the bed in the lowest position to move the client into a sitting position,
place shoes (not non-skid socks) on the client’s feet, adjust the lift’s base of support by
widening the legs, ensures the client’s shins tough the shin support on the lift, and instruct the
client to look up and lean back slightly as the lift begins to raise the client into a standing
position.
DIF: Cognitive Level: Applying TOP: Nursing Process: Evaluation
5. The charge nurse is conducting an audit on compliance with Transmission-Based Precautions.
Which action by the nursing staff shows good understanding and correct application of these
precautions? (Select all that apply.)
a. Contact Precautions: Dons gloves and a gown before entering the room
b. Droplet Precautions: Cares for the client only if immunity to the disease is present
c. Standard Precautions: Combines Standard Precautions with any other precautions
d. Droplet Precautions: Wears a mask when taking client vital signs
e. Two levels of Precautions: Maintains compliance with both types of precautions
f. Contact Precautions: Places two patients with MRSA in the same room
ANS: A, C, D, E, F
Transmission-based precautions are determined by the illness and mode of transmission. The
minimum required for Contact Precautions is donning gloves and a gown when entering the
room. Nurses always use Standard Precautions for every client, no matter what other type of
precautions the client is on. Nurses put on a mask when entering the room of a client on
Droplet Precautions if close contact with the client is expected, such as when taking vital
signs. When a client has two (or more) levels of Transmission-based Precautions, nurses
correctly maintain compliance with all types. While private rooms are preferred for clients on
Transmission-Based Precautions, cohorting clients with the same infectious agent is
acceptable. Immunity is an important consideration for nurses caring for clients on Airborne
Precautions.
DIF: Cognitive Level: Analyzing TOP: Nursing Process: Evaluation
6. What does the nurse remember about appropriate hand hygiene? (Select all that apply.)
a. Alcohol-based hand sanitizers are the gold standard for hand hygiene.
b. Washing with soap and water is needed after using the toilet.
c. After contact with certain organisms, soap and water is required.
d. Alcohol-based hand sanitizers are only good for a few client types.
e. The presence of hand sanitizers decreases the frequency of hand hygiene.
ANS: A, B, C
The CDC and WHO have concluded that alcohol-based hand sanitizers are the gold standard
for hand hygiene and should be used whenever possible and appropriate. After using the toilet,
if hands are visibly soiled, or after contact with certain microbes, washing with soap and water
is required. The presence of hand sanitizers has increased the frequency of hand hygiene
performed.
Concept-Based Clinical Nursing Skills 2nd Edition Loren Stein
Important Notes
The file includes the complete test bank, organized chapter by chapter.
A sample of selected pages has been provided for preview.
All available appendices and Excel files (if included in the original resources) are
provided.
We continuously update our files to ensure you receive the latest and most accurate
editions.
New editions are added regularly – stay connected for updates!
Purchase Guarantee
If you believe you have purchased the wrong file, don’t worry. Contact us anytime and we
will gladly replace it with the correct version.
Contact Email:
,Chapter 01: Foundations of Safe Client Care
Stein: Concept-Based Clinical Nursing Skills, 2nd Edition
MULTIPLE CHOICE
1. To meet a requirement of the 2021 American Association of Colleges of Nursing Essentials,
what topic does nursing faculty focus on throughout the curriculum?
a. Nursing process
b. Safety science
c. Ergonomics
d. Information technology
ANS: B
The 2021 AACN Essentials states that “Provision of safe, quality care necessitates knowing
and using established and emerging principles of safety science in care delivery” (p. 43).
Nursing students are taught to use the nursing process, but this is not confined to patient
safety. Ergonomics is a subset of safety science that studies people and their work
environments. Information technology can be used to improve safety.
DIF: Cognitive Level: Remembering TOP: Integrated Process: Teaching-Learning
2. A nurse meets the assigned clients at the start of a shift. After performing hand hygiene and
introducing one’s self, what does the nurse do next?
a. Begin a head-to-toe assessment.
b. Identify the client using two identifiers.
c. Assess the client for pain.
d. Ensure the call light is within reach.
ANS: B
A critical task in healthcare for safety, client identification is paramount for preventing errors.
After performing hand hygiene and introducing him- or herself, the nurse identifies the client
using two unique identifiers. The head-to-toe and pain assessments come shortly afterward.
The nurse ensures the client can reach the call light prior to leaving the room.
DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment
3. A nurse has worked with the same client for 2 days. When entering the room to administer
medications, the nurse performs hand hygiene. What action does the nurse take next?
a. Provide any needed teaching.
b. Ask if the client has any care requests.
c. Assess vital signs and pain.
d. Identify the client using two identifiers.
ANS: D
Every time the client is to receive medication, diagnostic studies, or any other healthcare
intervention, the nurse must identify the client using two unique identifiers, even if the client
is well known to the nurse. Assessments, teaching, and determining client requests would
come afterward.
DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment
,4. A nurse’s neighbor states “My father got a nosocomial infection after surgery!” What does the
nurse understand happened to the client?
a. The client received contaminated blood products.
b. The client nearly died from a postoperative infection.
c. The client acquired an infection while in the hospital.
d. The client received poor preoperative skin preparation.
ANS: C
A nosocomial infection is one acquired in the hospital. It does not designate how the infection
occurred, so the client might have become infected through contaminated blood products or
from poor preoperative skin preparation. It does not mean the client had a life-threatening
infection, only that is occurred in hospital.
DIF: Cognitive Level: Understanding TOP: Integrated Process: Teaching-Learning
5. A nurse is making rounds on clients at risk for infection. Which client does the nurse see first?
a. A client with an intravenous (IV) line
b. A client who has a central line
c. A client with an indwelling bladder catheter
d. A client with an IV and bladder catheter
ANS: D
One of the biggest risk factors for hospital acquired infections (HAIs) is the presence of
invasive lines. The more lines, the more risk. The client with both an IV and a catheter has the
highest risk. The clients with an IV or a catheter have less risk.
DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment
6. A nursing manager concerned about the infection rate on the unit wants to implement
measures to reduce the transmission of infectious organisms. What action by the manager is
best?
a. Provide a stethoscope dedicated to each client.
b. Ensure gloves are well-stocked in each room.
c. Restrict all plants and fresh foods from rooms.
d. Screen all visitors for contagious illnesses.
ANS: A
In the chain of infection, one of the most important components is the mode of transmission.
Stethoscopes can serve as a mode of indirect contact transmission unless they are disinfected
appropriately between clients. Providing each client with an individual stethoscope will
reduce this risk. Gloves are important, but they can become contaminated too and serve as a
mode of transmission. Plants and fresh foods are an uncommon source of transmission unless
the client is immunosuppressed. Screening visitors for contagious illness is an unrealistic
long-term action plan.
DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
7. A nurse is observing a student nurse. What action by the student demonstrates the need for
more education on Standard Precautions?
a. The student performs hand hygiene before all client contacts.
, b. The student conscientiously wears gloves when taking vital signs.
c. The student confirms that urine possibly contains infectious microbes.
d. The student wears a gown when cleaning liquid stool off the client.
ANS: B
Standard Precautions operates under the principle that all bodily fluids other than sweat could
potentially contain infectious microbial agents that pose a risk to the healthcare worker.
Contact with skin, if free of those fluids, does not require wearing gloves, so the nurse would
provide more education to the student. Hand hygiene is the first step of Standard Precautions.
The student is being prudent by confirming a possible source of contamination. Nurses
determine which infection prevention practice to use based upon the type of client–nurse
interaction and the possibility of exposure to blood, other body fluids, or pathogens, so
wearing a gown while cleaning liquid stool is appropriate.
DIF: Cognitive Level: Analyzing TOP: Nursing Process: Evaluation
8. A faculty member has taught the correct technique for taking gloves off (doffing). While
observing students practice, which action by a student indicates the need to review the
material?
a. Pulls glove off dominant hand first.
b. Takes first glove off by grasping it on the outside.
c. Takes second glove off by grasping it under the cuff.
d. Turns the gloves inside out when second glove is removed.
ANS: A
The correct way to remove gloves starts with doffing the glove on the nondominant hand first,
without touching the bare skin. This student would need further review of the skill. Removing
the first glove by grasping it on the outside, grasping the second glove under the cuff, and
turning the gloves inside out to prevent microbe spread are all correct actions. These students
would not need remediation.
DIF: Cognitive Level: Analyzing TOP: Nursing Process: Evaluation
9. In order to move a cooperative client safely from the bed to chair, which of the following
actions does the nurse take first?
a. Gather enough help for the task.
b. Assess the client’s ability to bear weight.
c. Delegate using the lift chair.
d. Administer pain medication.
ANS: B
The first thing the nurse does when preparing to transfer a cooperative client is to assess the
client’s ability to bear weight and remain balanced while standing. The findings will
determine how much assistance (if any) the client needs. If the client needs maximal
assistance, then the nurse gathers enough help and any lifting devices needed and assigns roles
to each team member. If the client has pain, the nurse would administer pain medication, but
that is not related to safety.
DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
,10. Hospital administration has rejected a request from nursing services for ceiling-mounted
lifting/transferring devices pointing to the expense. What response by the Chief Nursing
Officer would be best?
a. “We need the equipment to stay competitive in hiring nurses.”
b. “They are required by The Joint Commission so we have to get them.”
c. “The cost of employee injuries from lifting is more expensive.”
d. “We will save money with fewer client-injury lawsuits being filed.”
ANS: C
Data show that when hospitals implemented safe client handling equipment, hospitals
achieved savings by reducing lost work days and reducing worker compensation costs that
met or exceeded the cost of the equipment. This is not a main focus for nurse recruitment and
the equipment is not mandated. Fewer client injuries leading to lawsuits is a probability, but
the savings in reducing employee injury have been documented by the ANA.
DIF: Cognitive Level: Understanding
TOP: Integrated Process: Communication and Documentation
11. The nurse places a bed-bound client in the position shown. What other considerations would
the nurse have for this client?
a. Include a Trochanter roll to prevent of the neck.
b. Assess whether the client needs support to prevent foot drop.
c. Monitor for signs of increased intracranial pressure.
d. Place a rolled-up washcloth in the client’s hands.
ANS: B
The modified left lateral recumbent position is shown here. Considerations for the nurse
include providing pillow support to keep the head and neck in alignment, to support the upper
leg and prevent internal rotation, to support the upper arm and prevent internal rotation, and
provide foot support to prevent foot drop. Hyperextension of the neck and increased
intracranial pressure are concerns for clients in the Trendelenburg position. Placing something
in the client’s hands is not related to body position.
DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
,12. A nurse has applied restraints to a client. After documenting the care and ensuring the client is
safe, what action does the nurse take next?
a. Call the provider and request a prescription for the restraints.
b. Alert the hospital’s Risk Management department.
c. Plan to check the client at a minimum of every 2 hours.
d. Assign assistive personnel to sit with the client.
ANS: C
The standard required by the Centers for Medicaid and Medicare Services is to assess the
restrained client at a minimum of every 2 hours. In most situations, the nurse requests the
prescription before applying the restraints, however; if it is necessary to apply them first, a
prescription from the provider is needed within 1 hour. Although restraints are often the
source of litigation, there is no need to routinely notify the Risk Management department
about the use of restraints. The client may or may not need someone to sit with him or her.
DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
13. The nursing student applies restraints. What action by the student demonstrates the need for
more education on this procedure?
a. The student attempts other methods to prevent harm before applying the restraints.
b. The student inserts two fingers between the restraint and client skin to check for
tightness.
c. The student secures the restraint by tying the restraint to the side rail but out of
client reach.
d. The student reassesses the client’s need for the restraint at least every 2 hours.
ANS: C
The student should tie the restraint to a secure part of the bed frame, not to the side rail.
Attempting alternatives to restraints, checking the tightness by placing two fingers under the
restraint, and reassessing the client at least every 2 hours are all appropriate actions.
DIF: Cognitive Level: Analyzing TOP: Nursing Process: Evaluation
14. The new nurse grumbles “Why are there so many regulations on using restraints?” What
response by the mentor is best?
a. “Clients have the right to be free from restraint or seclusion unless medically
necessary.”
b. “Following all these regulations helps prevent law suits.”
c. “Accrediting bodies aren’t in favor of using restraints so they make up
regulations.”
d. “Because restraints have been shown to actually increase injuries.”
ANS: A
The guiding principle for restraint use is that clients have the right to be free from unnecessary
restraint or seclusion unless it is medically necessary. This is a basic human right and protects
client dignity. Following regulations won’t necessarily prevent lawsuits, but will help prevent
negative outcomes from the legal action. Accrediting bodies don’t “just make up regulations.”
There are sound reasons for them. Restraints have been shown to increase injury, but that is
secondary to the fact that clients have the right to be free from them unless absolutely needed.
DIF: Cognitive Level: Understanding TOP: Integrated Process: Teaching-Learning
, 15. After assessing a client, the nurse cleans the stethoscope. What cleaning agent chosen by the
nurse is most appropriate?
a. 70% isopropyl alcohol
b. Diluted bleach 1:10 solution
c. Cidex
d. Hydrogen peroxide
ANS: A
70% to 90% isopropyl or 60-80% ethyl alcohol is appropriate for low-level disinfecting needs
such as cleaning stethoscopes, blood pressure cuffs, and table tops. Diluted bleach is
considered an intermediate level disinfectant and used for client rooms (including isolation
rooms) and visible blood spills. Cidex is a high-level disinfectant used for equipment that
comes into contact with mucous membranes, for example, an endoscope.
DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation
16. After giving an injection, which action by the nurse is most appropriate?
a. Breaks needle off the syringe and places it in the sharps box.
b. Recaps the needle and carries the syringe to the sharps box.
c. Engages the syringe’s safety device to cover the needle.
d. Twists the needle off and throws the syringe away.
ANS: C
Needle-stick injury is an occupational hazard. Current guidelines for handling sharps include
not recapping, bending, breaking, or hand-manipulating used needles. If recapping is required,
use a one-handed scoop technique only. Use safety features when available. Place used sharps
in a puncture-resistant container. The correct action would be to engage the safety feature on
the syringe to cover the needle.
DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation
17. The nurse is working in a neonatal intensive care unit. When an infant’s oxygen saturation
drops, what action does the nurse take first?
a. Place the neonate prone.
b. Call a code blue.
c. Inform the provider.
d. Call respiratory therapy.
ANS: A
Neonates and infants improve ventilation and oxygenation in the prone position. When the
baby’s oxygen saturation drops, the nurse would place the baby in the prone position. The
nurse would call the provider afterward. There is no indication that the baby is in
cardiopulmonary arrest, so a code blue is not called. There is no indication to call respiratory
therapy.
DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
MULTIPLE RESPONSE
,1. The nurse learns that which of the following must be demonstrated to prove a claim of
malpractice? (Select all that apply.)
a. Duty
b. Breach of duty
c. Physical injury
d. Emotional distress
e. Cause: the injury was caused by the breach of duty
ANS: A, B, C, E
The four elements which must be demonstrated to prove a case of malpractice are duty, breach
of duty, injury (sometimes called harm), and causation; in other words, the injury must have
occurred due to the breach of duty. Emotional distress is not an element.
DIF: Cognitive Level: Remembering TOP: Integrated Process: Teaching-Learning
2. The nurse learns that which of the following are principles of body mechanics? (Select all that
apply.)
a. Make a wide, stable base with your feet.
b. Put the bed at the correct height.
c. Put the work directly in front of you.
d. Keep the client as far away from you as possible.
e. Keep the bed in the same position.
ANS: A, B, C
The principles of body mechanics include maintaining a wide, stable base with your feet;
having the bed at the correct height (depending on what you are doing); keeping the work
directly in front of you; and keeping the client as close as possible to you.
DIF: Cognitive Level: Remembering TOP: Nursing Process: Implementation
3. Which of the following devices are inconsistent with the nurse’s knowledge of types of
restraint devices? (Select all that apply.)
a. A seat belt on a stroller
b. A thumbless mitten
c. A single raised side rail
d. A device applied during a dental procedure
e. A positioning restraint in the operating room
ANS: A, C, D, E
A stroller seat belt, one side rail, and devices applied temporarily to immobilize the client
during medical, dental, diagnostic, or surgical procedures are not considered as restraints. The
thumbless mitten is a restraint.
DIF: Cognitive Level: Remembering TOP: Nursing Process: Evaluation
4. A new nurse is demonstrating the use of a sit-to-stand lift. What actions by the nurse
demonstrate appropriate knowledge and skills? (Select all that apply.)
a. Assesses the client’s lower extremity strength.
b. Places the bed in the lowest position.
c. Places non-skid socks on the client’s feet.
d. Widens the lift’s base of support.
, e. Ensures client’s shins touch the shin support on the lift.
f. Instructs client to lean forward over the hand grasps.
ANS: B, D, E
Using the lift correctly, the nurse would assess the client’s upper extremity strength and ability
to bear weight, places the bed in the lowest position to move the client into a sitting position,
place shoes (not non-skid socks) on the client’s feet, adjust the lift’s base of support by
widening the legs, ensures the client’s shins tough the shin support on the lift, and instruct the
client to look up and lean back slightly as the lift begins to raise the client into a standing
position.
DIF: Cognitive Level: Applying TOP: Nursing Process: Evaluation
5. The charge nurse is conducting an audit on compliance with Transmission-Based Precautions.
Which action by the nursing staff shows good understanding and correct application of these
precautions? (Select all that apply.)
a. Contact Precautions: Dons gloves and a gown before entering the room
b. Droplet Precautions: Cares for the client only if immunity to the disease is present
c. Standard Precautions: Combines Standard Precautions with any other precautions
d. Droplet Precautions: Wears a mask when taking client vital signs
e. Two levels of Precautions: Maintains compliance with both types of precautions
f. Contact Precautions: Places two patients with MRSA in the same room
ANS: A, C, D, E, F
Transmission-based precautions are determined by the illness and mode of transmission. The
minimum required for Contact Precautions is donning gloves and a gown when entering the
room. Nurses always use Standard Precautions for every client, no matter what other type of
precautions the client is on. Nurses put on a mask when entering the room of a client on
Droplet Precautions if close contact with the client is expected, such as when taking vital
signs. When a client has two (or more) levels of Transmission-based Precautions, nurses
correctly maintain compliance with all types. While private rooms are preferred for clients on
Transmission-Based Precautions, cohorting clients with the same infectious agent is
acceptable. Immunity is an important consideration for nurses caring for clients on Airborne
Precautions.
DIF: Cognitive Level: Analyzing TOP: Nursing Process: Evaluation
6. What does the nurse remember about appropriate hand hygiene? (Select all that apply.)
a. Alcohol-based hand sanitizers are the gold standard for hand hygiene.
b. Washing with soap and water is needed after using the toilet.
c. After contact with certain organisms, soap and water is required.
d. Alcohol-based hand sanitizers are only good for a few client types.
e. The presence of hand sanitizers decreases the frequency of hand hygiene.
ANS: A, B, C
The CDC and WHO have concluded that alcohol-based hand sanitizers are the gold standard
for hand hygiene and should be used whenever possible and appropriate. After using the toilet,
if hands are visibly soiled, or after contact with certain microbes, washing with soap and water
is required. The presence of hand sanitizers has increased the frequency of hand hygiene
performed.
