Clinical Nursing Skills and Techniques 8th Edition by Anne Griffin Perry Test Bank

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Clinical Nursing Skills and Techniques 8th Edition by Anne Griffin Perry Test Bank

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WITH ANSWERS
Clinical Nursing Skills and Techniques 8th Edition by Anne Griffin Perry Test Bank

Chapter 2: Admitting, Transfer, and Discharge

 

MULTIPLE CHOICE

 

  1. The patient is scheduled to go home after having coronary angioplasty. What would be the most effective way to provide discharge teaching to this patient?
a. Provide him with information on health care websites.
b. Provide him with written information on what he has to do.
c. Sit and carefully explain what is required before his follow-up.
d. Use a combination of verbal and written information.

 

 

ANS:  D

For discharge teaching, use a combination of verbal and written information. This most effectively provides patients with standardized care information, which has been shown to improve patient knowledge and satisfaction.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 12

OBJ:   Identify the ongoing needs of patients in the process of discharge planning.

TOP:   Admission to Discharge Process     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. While preparing for the patients discharge, the nurse uses a discharge planning checklist and notes that the patient is concerned about going home because she has to depend on her family for care. The nurse realizes that successful recovery at home is often based on:
a. the patients willingness to go home.
b. the familys perceived ability to care for the patient.
c. the patients ability to live alone.
d. allowing the patient to make her own arrangements.

 

 

ANS:  B

Discharge from an agency is stressful for a patient and family. Before a patient is discharged, the patient and family need to know how to manage care in the home and what to expect with regard to any continuing physical problems. Family caregiving is a highly stressful experience. Family members who are not properly prepared for caregiving are frequently overwhelmed by patient needs, which can lead to unnecessary hospital readmissions.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 22

OBJ:   Identify the ongoing needs of patients in the process of discharge planning.

TOP:   Medication Reconciliation              KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. The patient arrives in the emergency department complaining of severe abdominal pain and vomiting, and is severely dehydrated. The physician orders IV fluids for the dehydration and an IV antiemetic for the patient. However, the patient states that she is fearful of needles and adamantly refuses to have an IV started. The nurse explains the importance of and rationale for the ordered treatment, but the patient continues to refuse. What should the nurse do?
a. Summon the nurse technician to hold the arm down while the IV is inserted.
b. Use a numbing medication before inserting the IV.
c. Document the patients refusal and notify the physician.
d. Tell the patient that she will be discharged without care unless she complies.

 

 

ANS:  C

The Patient Self-Determination Act, effective December 1, 1991, requires all Medicare- and Medicaid-recipient hospitals to provide patients with information about their right to accept or reject medical treatment. The patient has the right to refuse treatment. Refusal should be documented and the health care provider consulted about alternate treatment.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 13

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.

TOP:   Patient Self-Determination Act       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. An unconscious patient is admitted through the emergency department. How and when is identification of the patient made?
a. Determined only when the patient is able
b. Postponed until family members arrive
c. Given an anonymous name under the blackout procedure
d. Determined before treatment is started

 

 

ANS:  B

If a patient is unconscious, identification often is not made until family members arrive. Delaying treatment can cause deterioration of the patients condition. Blackout procedures are intended mainly to protect crime victims.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 12

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.                       TOP:   The Unconscious Patient

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. During admission of a patient, the nurse notes that the patient speaks another language and may have difficulty understanding English. What should the nurse do to facilitate communication?
a. Use hand gestures to explain.
b. Request and wait for an interpreter.
c. Work with the family to gather information.
d. Complete as much of the admission assessment as possible using simple phrases.

 

 

ANS:  B

If the patient does not speak English or has a severe hearing impairment, the clerk must have access to an interpreter to assist during the admission procedure. Translation services are preferable to using family members to ensure correct translation of medical terminology.

Hand gestures and simple phrases may not be adequate for everything that will be discussed at the time of admission.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 15

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.

TOP:   The Patient Who Does Not Speak English

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. The patient has been admitted to the emergency department after being beaten and raped. She is agitated and is frightened that her attacker may find her in the hospital and try to kill her. What should the nurse tell her?
a. She is safe in the hospital, and she needs to provide her name.
b. She can be admitted to the hospital without anyone knowing it.
c. Her records will be used as evidence in the trial.
d. Since she has come to the hospital, she has to be examined by the doctor.

 

 

ANS:  B

A patient who has been a victim of crime can be admitted anonymously under an agencys blackout or do not publish procedure. HIPAA places limits on the institutions ability to use or disclose the patients PHI. The Patient Self-Determination Act prohibits the hospital from requiring her to submit to an examination.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: pp. 13-14

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.                       TOP:   Victim of Crime

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The patient is admitted to the ICU after having been in a motor vehicle accident. He was intubated in the emergency department and needs to receive two units of packed red blood cells. He is conscious but is indicating that he is in pain by guarding his abdomen. To admit this patient, the nurse first will focus on:
a. examining the patient and treating the pain.
b. orienting the family to the ICU visitation policy.
c. making sure that the consent forms are signed.
d. informing the patient of his HIPAA rights.

 

 

ANS:  A

When a critically ill patient reaches a hospitals nursing division, the patient immediately undergoes extensive examination and treatment procedures. Little time is available for the nurse to orient the patient and family to the division, or to learn of their fears or concerns.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 15

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.                       TOP:   Role of the Nurse

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is admitting the patient to the medical unit. The patient indicates that he has had several surgeries in the past and has been a diabetic for the past 15 years. He also earlier that morning, but the pain has finally gone since he received a pain shot in the emergency department. What does this information prompt the nurse to do next?
a. Provide the patient with an allergy arm band and document his allergies.
b. Postpone routine admission procedures immediately.
c. Ask the patient if he wants a smoking room.
d. Have all family or friends leave the room.

 

 

ANS:  A

Provide the patient with an allergy armband listing allergies to foods, drugs, latex, or other substances; document allergies according to hospital policy. Postpone routine admission procedures only if the patient is having acute physical problems. Smoking is prohibited throughout the hospital, and family or friends can remain if the patient wishes to have them assist with changing into a hospital gown or pajamas.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 16

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.                       TOP:   Allergies

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. At what age is separation anxiety a common problem?
a. School-aged children
b. Preschoolers
c. Middle infancy
d. Newborns

 

 

ANS:  C

Separation anxiety is most common from middle infancy throughout the toddler years, especially from ages 16 to 30 months. Preschoolers are better able to tolerate brief periods of separation, but their protest behaviors are more subtle than those of younger children (e.g., refusal to eat, difficulty sleeping, withdrawing from others). School-aged children are able to cope with separation but have an increased need for parental security and guidance.

 

DIF:    Cognitive Level: Synthesis             REF:   Text reference: p. 18

OBJ:   Explain the role of the patients family in the admission, transfer, or discharge process.

TOP:   Pediatric Considerations                 KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity

 

  1. The patient is being transferred from the emergency department to another institution for treatment. Which of the following cannot be delegated to nursing assistive personnel (NAP)?
a. Helping the patient get dressed
b. Gathering IV equipment to go with the patient
c. Escorting the patient to the transport area
d. Assessing the patients respiratory status before transport

 

 

ANS:  D

The assessment and decision making conducted during transfers cannot be delegated to nursing assistive personnel. NAP can assist the patient with dressing, can gather and secure the patients personal belongings and any necessary equipment, and can escort the patient to the nursing unit or transport area.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 19

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.                       TOP:   Delegation

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. When does the plan for patient discharge from a health care facility begin?
a. At admission
b. After a medical diagnosis has been determined
c. When the patients physical needs are identified
d. After a home environment assessment is completed

 

 

ANS:  A

Planning for discharge begins at admission and continues throughout the patients stay in the agency. Separating the processes of admission and discharge is a critical error; the two are simultaneous and continuous.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 22

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.                       TOP:   Discharge Planning

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. The phase of the discharge process where medical attention dominates discharge planning efforts is known as the _____ phase.
a. transitional
b. continuing
c. acute
d. multidisciplinary

 

 

ANS:  C

The discharge process occurs in three phases: acute, transitional, and continuing care. In the acute phase, medical attention dominates discharge planning efforts. During the transitional phase, the need for acute care is still present, but its urgency declines and patients begin to address and plan for their future health care needs. In the continuing care phase, patients participate in planning and implementing continuing care activities needed after discharge. There is no multidisciplinary stage; the discharge planning process is comprehensive and multidisciplinary.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 22

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.                       TOP:   Discharge Planning

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Once a patients discharge has been completed, which activity may be delegated to assistive personnel?
a. Provision of prescriptions to the patient
b. Completion of the discharge summary
c. Gathering of the patients personal care items
d. Provision of instructions on community health resources

 

 

ANS:  C

The assessment, care planning, and instruction included in discharging patients cannot be delegated to nursing assistive personnel. The nurse may direct the NAP to gather and secure the patients personal items and any supplies that accompany the patient.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 22

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.                       TOP:   Discharge Planning

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. The nurse is providing discharge instruction to an 80-year-old patient and her daughter. The patient lives in a two-story home. When asked if the patient has difficulty climbing stairs, the patient says No, but the nurse notices a look of surprise on the daughters face. What should the nurse do in this circumstance?
a. Speak with the daughter separately.
b. Cancel the discharge immediately.
c. Order a visiting nurse consult.
d. Notify the physician.

 

 

ANS:  A

Patients and family members often disagree on the health care needs of a patient after discharge. Identifying these discrepancies early leads to more accurate development of the discharge plan. It often is necessary to talk with the patient and family separately to learn about their true concerns or doubts.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 23

OBJ:   Explain the role of the patients family in the admission, transfer, or discharge process.

TOP:   Discharge Planning                         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. The patient has decided that he would like to create an advance directive. The nurse is asked if she would be a witness. What is the best response for the nurse to make to this request?
a. Agree to be a witness.
b. Refuse to be a witness.
c. Contact social work.
d. Contact the physician.

 

 

ANS:  C

A social worker often fulfills this requirement. Witnesses for an advance directive document should not be medical personnel, and direct refusal does not meet the nurses obligation to meet the patients needs. Referral to a department that can ensure this service is required.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 14

OBJ:   Explain the purpose and importance of advance directives.

TOP:   Advance Directives                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

MULTIPLE RESPONSE

 

  1. The patient is being admitted to the intensive care department with multiple fractures and internal bleeding. Which of the following are considered roles of the nurse in this situation? (Select all that apply.)
a. Anticipate physical and social deficits to resuming normal activities.
b. Involve the family and significant others in the plan of care.
c. Assist in making health care resources available to the patient.
d. Identify the psychological needs of the patient.

 

 

ANS:  A, B, C, D

The nurse identifies patients ongoing health care needs; anticipates physical, psychological, and social deficits that have implications for resuming normal activities; involves family and significant others in a plan of care; provides health education; and assists in making health care resources available to the patient. Separating the processes of admission and discharge is a critical error; the two are simultaneous and continuous.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 11

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.

TOP:   Admission to Discharge Process     KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. Under the Health Insurance Portability and Accountability Act (HIPAA), a patient must: (Select all that apply.)
a. provide his true name before he can be treated.
b. be informed of his privacy rights.
c. have his personal health information used for treatment or payment only.
d. have his personal health information used on a need-to-know basis only.

 

 

ANS:  B, C, D

HIPAA is a federal law designed to protect the privacy of patient health information, referred to as PHI, or protected health information. Three key concepts of HIPAA are (1) institutions are required to inform patients of the privacy rights they have and how the institution will handle their PHI; (2) the institution and health care providers are to use or disclose the patients PHI only for the purpose of treatment or payment or for health care operations; and (3) health care providers disclose only the minimum amount of PHI necessary on a need-to-know basis to accomplish the purpose of the use.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: pp. 13-14

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.                       TOP:   HIPAA

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. The patient is admitted to the unit for a cardiac catheterization. Which of the following can be delegated to nursing assistive personnel (NAP)? (Select all that apply.)
a. Obtaining admission vital signs
b. Preparing the patients room
c. Gathering and securing personal care items
d. Orienting patient and family to the nursing unit

 

 

ANS:  B, C, D

The nursing assessment conducted during admission to a health care facility cannot be delegated to NAP. You cannot delegate admission vital signs as they provide a baseline for all further comparisons. The nurse directs NAP to (1) prepare the patients room with necessary equipment before admission; (2) gather and secure the patients personal care items; (3) escort and orient the patient and family to the nursing unit; and (4) collect ordered specimens.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 15

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.                       TOP:   Delegation Considerations

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. Which of the following are considered advance directives? (Select all that apply.)
a. Living will
b. Power of attorney for health care
c. Notarized handwritten document
d. Nursing progress note

 

 

ANS:  A, B, C

Advance directives may include a living will, power of attorney for health care, or a notarized handwritten document.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 14

OBJ:   Explain the purpose and importance of advance directives.

TOP:   Advance Directives                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. The patient is being transferred from the intensive care unit to the acute care unit. The nurse must ensure that the following activities are completed: (Select all that apply.)
a. providing the receiving nurse with a report before the transfer.
b. determining any equipment needs for the patient during the transfer.
c. providing an updated report after transferring the patient to the receiving unit.
d. making sure a registered nurse accompanies the patient.

 

 

ANS:  A, B, C

When providing a handoff of a patient to another unit, it is essential that information about the patients care, treatment, services, and current condition and any recent or anticipated changes are communicated accurately to meet patient safety goals. The nurse first provides a telephone report to the receiving nurse. This allows the receiving nurse to prepare for the patient (e.g., preparing the room, securing necessary equipment). As clinically appropriate, a nurse or technician accompanies the patient during transport, providing the receiving nurse with the patients medical record; introducing the patient to the receiving nurse; and providing an updated report, including any changes in clinical status or plan of care.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 19

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.                       TOP:   Continuum of Care

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

COMPLETION

 

  1. Completing and documenting an accurate medication history from the patient is the important first step in the _____________ process.

 

ANS:

medication reconciliation

Medication reconciliation compares the patients home medication list versus the medication orders at admission, transfer, or discharge to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: p. 17

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.                       TOP:   Medication Reconciliation

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. If a patient is having acute physical problems, postpone routine admission procedures until the patients immediate needs are met. A ________________ assessment is needed at this point.

 

ANS:

focused

If a patient is having acute physical problems, postpone routine admission procedures until you meet the patients immediate needs. Complete a focused assessment at this point.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 15

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.                       TOP:   Admission Process

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. When transferring a patient, the nurse must ensure that the patient will receive ____________.

 

ANS:

continuity of nursing care

When patients transfer, you need to ensure continuity of nursing care. The aim is to continue health care so as to avoid therapeutic interruptions that may hinder progress toward recovery.

 

DIF:    Cognitive Level: Synthesis             REF:   Text reference: p. 19

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.                       TOP:   Continuity of Care

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Safe and Effective Care Environment

 

  1. The greatest challenge in effective discharge planning is _______________.

 

ANS:

communication

The greatest challenge in effective discharge planning is communication. The communication problem is minimized when an organization has a discharge coordinator or a case manager who is responsible for discharge planning.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 22

OBJ:   Describe the nurses role in maintaining continuity of care through a patients admission, transfer, and discharge from an acute care facility.                       TOP:   Discharge Planning

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. A document that provides a patients instructions in terms of future medical care or that designates another person(s) to make medical decisions if the individual loses decision-making capacity is known as an ________________.

 

ANS:

advance directive

An advance directive is a document that provides a patients instructions about future medical care or that designates another person(s) to make medical decisions if the individual loses decision-making capacity. An advance directive conveys the patients choice in continuing medical care when the patient is unable to speak or make decisions.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: p. 14

OBJ:   Explain the purpose and importance of advance directives.

TOP:   Advance Directives                        KEY:  Nursing Process Step: Diagnosis

MSC:  NCLEX: Safe and Effective Care Environment

 

Chapter 14: Disaster Preparedness

 

MULTIPLE CHOICE

 

  1. In addition to the Department of Homeland Security, which of the following agencies has a mission to ensure that the nation is well prepared to respond to an act of terrorism?
a. AMA
b. Red Cross
c. CDC
d. Salvation Army

 

 

ANS:  C

The Centers for Disease Control and Prevention (CDC) is recognized as the leading federal agency designed to protect the health and safety of people at home and abroad. The mission of the CDCs Coordinating Office for Terrorism Preparedness and Emergency Response (COTPER) is to protect the health and enhance the living of all people in terms of community preparedness and response. The CDCs mission is to ensure that the nation is well prepared to respond to an act of terrorism (CDC, 2003). The American Medical Association has developed a series of National Disaster Life Support courses designed to provide a uniform, coordinated approach to all-hazards disaster management, but these courses are not designed specifically to combat terrorism. The CDC works with the American Red Cross because both are advocates of preparedness and coordination of prompt, effective emergency efforts. This preparedness coordination goes far beyond these individual agencies and includes outreach to other agencies or groups through mutual aid agreements. However, the CDC is the preeminent agency in this field. Other agencies (e.g., department stores, the Salvation Army, Goodwill) provide clothing. Their efforts are not directed primarily toward terrorist activity.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 324

OBJ:   Discuss guidelines for patient care in the event of mass casualty care.

TOP:   Centers for Disease Control and Prevention (CDC)

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. Personal protection equipment is categorized by the level of safety provided. Standard work uniforms or work clothes offer what level of protection?
a. Level A
b. Level B
c. Level C
d. Level D

 

 

ANS:  D

Standard work uniforms or work clothes offer level D protection. There is no respiratory protection. Standard precautions are important to take when level D protection is used.

Level A protection provides maximum protection because it offers self-contained breathing apparatus, fully encloses the individual, and includes chemical-resistant boots and gloves. Level B protection provides respiratory protection but less skin protection. Used by trained responders, this PPE includes self-contained breathing apparatus, a hooded chemical-resistant suit, and face, boot, and glove protection. First responders (those emergency personnel first on the scene) and hospital personnel are trained and fitted to use level C protection. As with level A and B protection, level C protection presents danger to the user, primarily for dehydration and hyperthermia.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 327

OBJ:   Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP:   Levels of Safety                             KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The most recently labeled level of protection is BioPPE. The use of BioPPE requires which of the following items?
a. Self-contained breathing apparatus
b. Respiratory protection but less skin protection
c. Chemically resistant boots and gloves
d. Standard work clothes, contact and respiratory protective devices

 

 

ANS:  D

The most recently labeled level of protection is BioPPE. BioPPE requires the use of standard work clothes, along with contact and respiratory protection. Double gloving and an N95 mask or a better respirator is recommended. Level A protection provides maximum protection in that it offers a self-contained breathing apparatus, fully encapsulates the individual, and includes chemically resistant boots and gloves. BioPPE protection is not adequate when caring for patients exposed to toxic chemicals; however, it provides adequate protection against radiological and biological agents.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 327

OBJ:   Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP:   BioPPE           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Upon arriving at a mass causality scene, health care providers using the SALT approach will initiate triage by doing which of the following first?
a. Assess
b. Move
c. Sort
d. Send

 

 

ANS:  C

In the SALT process, the first step is to sort the affected individuals in to groups so that they may be assessed individually. Category 1 includes those who are not moving and have life-threatening injuries. Category 2 includes those who are able to wave or have purposeful movement. Category 3 consists of those able to walk on their own.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 327

OBJ:   Discuss guidelines for patient care in the event of mass casualty care.

TOP:   Triage             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Disaster nursing differs from general nursing because when caring for patients during a disaster:
a. the focus is on caring for the sickest people first.
b. using a color tag system reduces the amount of emotional stress on the nurse.
c. the focus is no longer on airway, breathing, and circulation.
d. the focus is on caring for those most likely to survive.

 

 

ANS:  D

Disaster nursing differs from general nursing in that the focus shifts from caring for the sickest people first to saving the greatest number of lives. Triage sorts the victims in to groups with color coded tags which identify statusblack for the dead or mortally injured, red for those in need of immediate attention to survive, yellow for those seriously injured but more stable than individuals coded red, and green for those with minimal injuries, This allows the rescue teams to direct resources in a most effective manner to save the greatest number of lives.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 328

OBJ:   Discuss guidelines for patient care in the event of mass casualty care.

TOP:   Disaster Nursing                             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse has arrived at the scene of a natural disaster and is assigned to care for four patients. To which patient should the nurse provide care first?
a. Patient with a closed head injury with no changes in level of consciousness
b. Patient with a 3-cm laceration to the forearm
c. Patient who is breathing eight times per minute
d. Patient with a displaced wrist fracture

 

 

ANS:  C

Nursing care should be prioritized when multiple patients are cared for at once. ABCs (airway, breathing, and circulation) should always take precedence. The patient who is breathing only eight times per minute is in need of immediate nursing care. The goal of triage is to sort, assess, and perform lifesaving measures as quickly as possible for large numbers of victims.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 328

OBJ:   Discuss guidelines for patient care in the event of mass casualty care.

TOP:   Disaster Nursing                             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The patient is brought into the emergency department as part of an MCI. The patient has white powder on his clothes, and it is suspected that the patient has been exposed to anthrax. What should the nurse do first?
a. Cut off the patients clothing and place it in a plastic bag.
b. Have the patient remove his sweater by pulling it over his head.
c. Avoid using oxygen that could decrease the patients oxygen drive.
d. Provide the patient with appropriate antibiotics.

 

 

ANS:  A

If you suspect anthrax, remove the patients clothing and place it in a labeled plastic biohazard bag. Do not have the patient pull clothing off over the head, but rather cut off clothing. Administer oxygen therapy. Various biological agents (e.g., pulmonary anthrax) commonly cause respiratory symptoms that will result in an altered gas exchange. Exposure to these agents is commonly treated with ciprofloxacin and/or doxycycline, and botulism requires supportive care and use of an antitoxin.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 334

OBJ:   Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP:   Anthrax          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following biological agent requires the use of an antitoxin if exposure occurs?
a. Anthrax
b. Plague
c. Botulism
d. Typhoid

 

 

ANS:  C

Botulism requires supportive care and use of an antitoxin. Attack with various biological agents (e.g., anthrax, plague, typhoidal tularemia) is commonly treated with ciprofloxacin and/or doxycycline.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 331

OBJ:   Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP:   Botulism        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The patient is admitted to the emergency department with possible smallpox exposure. The patient has never had a smallpox immunization. The nurse prepares to administer a smallpox vaccination, realizing that vaccination:
a. within 3 days of exposure will completely prevent the disease.
b. is effective only if received before exposure.
c. 4 to 7 days after exposure will completely prevent the disease.
d. within 3 days will offer only some protection from disease.

 

 

ANS:  A

In the event that smallpox is the biological weapon, the best treatment is prevention by immunization with vaccinia vaccine before the onset of symptoms. Vaccination within 3 days of exposure will completely prevent the disease or will significantly reduce its effect.

Vaccination 4 to 7 days post exposure offers some protection from disease or will decrease the severity of disease.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 334

OBJ:   Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP:   Smallpox        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. If a patient is receiving radiation using gamma rays, the nurse would be watching for which of the following?
a. Severe pain during administration
b. Development of an allergy to shellfish
c. Severe burns or internal injury
d. Confusion and lethargy

 

 

ANS:  C

Gamma rays pose the greatest health risk because the waves penetrate deeply, causing severe burns and internal injury. Radiation does not cause patients to develop an allergy to shellfish and is painless during administration. Confusion and lethargy are not known side effects of radiation.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 340

OBJ:   Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP:   Gamma Rays                                  KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. After a suspected radiological exposure, the initial scan of the patients extremities is positive. What will be the next step in this patients care?
a. Washing the skin with soap and water while taking care not to irritate or abrade the skin
b. Removing clothing to eliminate 70% to 90% of the contamination
c. Isolating and covering up any skin that is positive for radiation using a plastic wrap
d. Conducting a thorough survey of the patients entire body with the radiation sensing equipment

 

 

ANS:  D

If the initial assessment of the patients face, hands, and feet is positive for radiation exposure the specially trained technician will a more thorough assessment of the patients entire body. Determining the amount and level of radiation is important in determining the level of danger to the caretaker and the level of care required for the patient. This determination precedes any other care.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 341

OBJ:   Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP:   Assessment of Patient                               KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. How is a disaster best defined?
a. Any event or situation that results in multiple casualties and/or deaths
b. A catastrophic and/or destructive event that disrupts normal functioning
c. An industrial accident and unplanned release of nuclear waste
d. An event that results in human casualties that overwhelm available health care resources

 

 

ANS:  B

A disaster is defined as a catastrophic and/or destructive event that disrupts normal functioning; it may include any anticipated or unexpected event whose effects lead to significant destruction and/or adverse consequences. Any event or situation that results in multiple casualties and/or deaths is called a mass casualty incident (MCI). An industrial accident with unplanned release of nuclear waste is classified as a technological disaster. A medical disaster is a catastrophic event that results in human casualties that overwhelm available health care resources.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 323

OBJ:   Discuss the characteristics of different types of disasters.         TOP:    Disasters

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. Dispersal of biological agents is a real and psychological terrorist threat. Which of the following organisms has the potential to cause the greatest harm?
a. Anthrax
b. Ricin
c. Salmonella
d. Hantavirus

 

 

ANS:  A

Category A organisms are considered the greatest threat because they can be transmitted easily from person to person and can cause high mortality with a potential for major public health impact. Of the organisms listed here, only anthrax (Bacillus anthracis) is considered a Category A organism. Category B organisms are moderately easy to disseminate and cause moderate morbidity and low mortality. They are considered high-risk organisms. Ricin toxin and Salmonella are classified as Category B. Hantavirus is considered a Category C organism or a pathogen that could be engineered for mass dissemination.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 325

OBJ:   Discuss the characteristics of different types of disasters.

TOP:   Potential Organisms for Bioterrorism by CDC Category

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. Which of the following are goals of the Department of Homeland Security (DHS)? (Select all that apply.)
a. Prevention of terrorist attacks
b. Response to disasters
c. Recovery from disasters
d. Coordination of efforts among agencies

 

 

ANS:  A, D

The DHS focuses on efforts to prevent terrorist attacks and coordination of efforts of multiple agencies to maintain the safety of the United States.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 323

OBJ:   Discuss guidelines for patient care in the event of mass casualty care.

TOP:   Department of Homeland Security (DHS)

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following should make the nurse suspect a biological event? (Select all that apply.)
a. Large numbers of ill persons with unexplained similar symptoms
b. Unexplained deaths among young and healthy populations
c. A patient population with symptoms suggestive of a common agent
d. An unusual geographical pattern associated with the symptoms

 

 

ANS:  A, B, D

You should suspect a biological event when large numbers of ill persons present who have unexplained yet similar symptoms; when unexplained deaths occur, particularly among young and healthy populations; when an unusual pattern (e.g., geographical, season, patient population) is associated with the symptoms; when the patient fails to respond to traditional therapy; and when a single patient presents with symptoms suggestive of an uncommon agent (e.g., anthrax, smallpox). Once you suspect a biological event, notify incident command immediately.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 333

OBJ:   Identify actions to take in the event of biological, chemical, and radiation exposure.

TOP:   Bioterrorism   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. Why are children particularly vulnerable to environmental toxins? (Select all that apply.)
a. They have stronger immune systems.
b. They take in proportionally larger doses of toxins from food, water, and the air.
c. Their organ systems are less able to remove toxins than adult organs systems.
d. They have a greater number of years of life expectancy.

 

 

ANS:  B, C, D

Children are particularly vulnerable to environmental toxins because they take in larger doses, pound-for-pound, of toxins than adults, their organ systems are less able to remove the toxins than those of adults, and they have a greater number of years of life expectancy over which to develop complications from the toxic exposure.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 335

OBJ:   Discuss guidelines for patient care in the event of mass casualty care.

TOP:   Psychological Status                       KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

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