1.

Question
The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a
patient with end-stage chronic obstructive pulmonary disease. How should the NAP
proceed?

A. Bathe the patient's entire body using 8 to 10 washcloths.

B. Assist the patient to a chair and provide bathing supplies.
C. Saturate a towel and blanket in a plastic bag, and then bathe the patient.
D. Assist the patient to the bathtub and provide a bath chair.
Incorrect
Correct Answer: A. Bathe the patient’s entire body using 8 to 10 washcloths.

A towel bath is a modification of the bed bath in which the NAP places a large
towel and a bath blanket into a plastic bag, saturates them with a commercially
prepared mixture of moisturizer, non rinse cleaning agent, and water; warms in them
in a microwave, and then uses them to bathe the patient. A bag bath is a
modification of the towel bath, in which the NAP uses 8 to 10 washcloths instead of
a towel or blanket. Each part of the patient’s body is bathed with a fresh cloth.

Option B: A bag bath is not given in a chair or in the tub. The bag bath is one
alternative to the traditional bed bath used in some nursing homes. The bath is
performed with a series of 10 washcloths and a no-rinse liquid cleanser. Close the
door and windows to prevent cold drafts and wash hands with warm water before
beginning.
Option C: Moisten the washcloths with water and put in a plastic bag with the
cleanser. Warm the bag in the microwave for 60 to 90 seconds. Test the temperature
of the clothes before touching a resident with them and be careful when you open
the bag, as steam can burn.
Option D: Take the bag to the resident’s bedside. When you are not cleaning a body
part, keep it covered. Only expose as much of the resident’s body as necessary to
adequately clean him or her. Be especially sensitive to exposing genitals,
buttocks, and breasts. Bathing can be an extremely stressful experience for
residents, so try to make it as easy as possible.
2. Question
For a morbidly obese patient, which intervention should the nurse choose to
counteract the pressure created by the skin folds?

A. Cover the mattress with a sheepskin.

B. Keep the linens wrinkle free.
C. Separate the skin folds with towels.
D. Apply petrolatum barrier creams.
Incorrect
Correct Answer: C. Separate the skin folds with towels.

Separating the skin folds with towels relieves the pressure of skin rubbing on
skin. Skin folds, in particular, may be difficult for the patient to clean
thoroughly; the abdominal folds and groins may be ignored, leading to an increased
risk of skin breakdown in these areas.

Option A: Sheepskins are not recommended for use at all. Skin folds present a
challenge in the management of patients who are morbidly obese. The weight from
excess adipose tissue in skinfold areas can have an increased risk of skin injury
such as friction, maceration, skin tears and pressure ulcer development.
Option B: Skin folds and areas vulnerable to skin injury should be cleaned and
dried several times a day. Alcohol-based lotions and harsh soaps, as well as talcum
powders, should be avoided in these areas. If necessary, dry cloths to absorb
moisture can be left in skin folds in between washing and drying of the skin folds.
Option D: Petrolatum barrier creams are used to minimize moisture caused by
incontinence. Patient hydration should also be considered in the nutrition plan for
the patients and the health of their skin.
3. Question
A client exhibits all of the following during a physical assessment. Which of these
is considered a primary defense against infection?

A. Fever
B. Intact skin
C. Inflammation
D. Lethargy
Incorrect
Correct Answer: B. Intact skin

Intact skin is considered a primary defense against infection. Usually, the skin
prevents invasion by microorganisms unless it is damaged (for example, by an
injury, insect bite, or burn). Mucous membranes, such as the lining of the mouth,
nose, and eyelids, are also effective barriers. Typically, mucous membranes are
coated with secretions that fight microorganisms. For example, the mucous membranes
of the eyes are bathed in tears, which contain an enzyme called lysozyme that
attacks bacteria and helps protect the eyes from infection. Fever, the inflammatory
response, and phagocytosis (a process of killing pathogens) are considered
secondary defenses against infection.

Option A: Body temperature increases as a protective response to infection and

injury. An elevated body temperature (fever) enhances the body’s defense
mechanisms, although it can cause discomfort. A part of the brain called the
hypothalamus controls body temperature. Fever results from an actual resetting of
the hypothalamus’s thermostat. The body raises its temperature to a higher level by
moving (shunting) blood from the skin surface to the interior of the body, thus
reducing heat loss.
Option C: Any injury, including an invasion by microorganisms, causes inflammation
in the affected area. Inflammation, a complex reaction, results from many different
conditions. During inflammation, the blood supply increases, helping carry immune
cells to the affected area. Because of the increased blood flow, an infected area
near the surface of the body becomes red and warm. The walls of blood vessels
become more porous, allowing fluid and white blood cells to pass into the affected
tissue. The increase in fluid causes the inflamed tissue to swell. The white blood
cells attack the invading microorganisms and release substances that continue the
process of inflammation.
Option D: Lethargy refers to a state of lacking energy. People who are experiencing
fatigue or tiredness can also be said to be lethargic because of low energy. The
same medical conditions that can lead to tiredness or fatigue can also lead to
lethargy.
4. Question
A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus
aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which
rule must be observed to follow contact precautions?

A. A clean gown and gloves must be worn when in contact with the client.
B. Everyone who enters the room must wear a N-95 respirator mask.
C. All linen and trash must be marked as contaminated and send to biohazard waste.
D. Place the client in a room with a client with an upper respiratory infection.
Incorrect
Correct Answer: A. A clean gown and gloves must be worn when in contact with the
client.

A clean gown and gloves must be worn when any contact is anticipated with the
client or with contaminated items in the room. Visitors might also be asked to wear
a gown and gloves. Patients are asked to stay in their hospital rooms as much as
possible. They should not go to common areas, such as the gift shop or cafeteria.
They may go to other areas of the hospital for treatments and tests.

Option B: A respirator mask is required only with airborne precautions, not contact
precautions. Healthcare providers will put on gloves and wear a gown over their
clothing while taking care of patients with MRSA.
Option C: All linen must be double-bagged and clearly marked as contaminated. When
leaving the room, healthcare providers and visitors remove their gown and gloves
and clean their hands.
Option D: The client should be placed in a private room or in a room with a client
with an active infection caused by the same organism and no other infections.
Whenever possible, patients with MRSA will have a single room or will share a room
only with someone else who also has MRSA.
5. Question
A client requires protective isolation. Which client can be safely paired with this
client in a client-care assignment? One:

A. Admitted with unstable diabetes mellitus.

B. Who underwent surgical repair of a perforated bowel.
C. With a stage 3 sacral pressure ulcer.
D. Admitted with a urinary tract infection.
Incorrect
Correct Answer: A. Admitted with unstable diabetes mellitus.

The client with unstable diabetes mellitus can safely be paired in a client-care
assignment because the client is free from infection. Protective Isolation aims to
protect an immunocompromised patient who is at high risk of acquiring micro-
organisms from either the environment or from other patients, staff, or visitors.

Option B: Perforation of the bowel exposes the client to infection requiring

antibiotic therapy during the postoperative period. Therefore, this client should
not be paired with a client in protective isolation. Patients should remain in
isolation whilst they remain symptomatic; a risk assessment should be undertaken to
ascertain if and when isolation precautions can be relaxed.
Option C: A client in protective isolation should not be paired with a client who
has an open wound, such as a stage 3 pressure ulcer. Patient’s requiring protective
isolation should be nursed in a single room. Where possible this room should have
an ante-room, positive pressure ventilation and Hepa filtered air. The room should
have an en-suite and hand washing facilities and the doors(s) should be kept closed
at all times.
Option D: A client in protective isolation should not be paired with a client who
has a urinary tract infection. Many infections acquired by immunocompromised
patients are endogenous infections (An infection caused by an infectious agent that
is already present in the body but has previously been inapparent or dormant),
however, the transmission of infection from other patients, staff, or the
environment can be a risk and therefore extra precautions are required.
6. Question
A newly hired at Nurseslabs Medical Center is assigned to the OR Department. Which
action demonstrates a break in sterile technique?

A. Remaining 1 foot away from non sterile areas.

B. Placing sterile items on the sterile field.
C. Avoiding the border of the sterile drape.
D. Reaching 1 foot over the sterile field.
Incorrect
Correct Answer: D. Reaching 1 foot over the sterile field.

Reaching over the sterile field while wearing sterile garb breaks the sterile
technique. While observing sterile technique, healthcare workers should remain 1
foot away from non-sterile areas while wearing sterile garb, place sterile items
needed for the procedure on the sterile drape, and avoid coming in contact with the
1-inch border of the sterile drape. The principles of the Sterile Technique are
applied in various ways. If the principle itself is understood, the applications of
it become obvious. A strict aseptic technique is needed at all times in the
Operating Room.

Option A: Sterile persons avoid leaning over an unsterile area; non-sterile persons
avoid reaching over a sterile field. Unsterile persons do not get closer than 12
inches from a sterile field.
Option B: Persons who are sterile touch only sterile articles; persons who are not
sterile touch only unsterile articles. If in doubt about the sterility of anything
consider it not sterile. If a non-sterile person brushes close consider yourself
contaminated.
Option C: Sterile persons keep contact with sterile areas to a minimum. Do not lean
on the sterile tables or on the draped patient. Do not lean on the nurse’s mayo
tray.
7. Question
Nurse Berta is facilitating a monthly mothers’ class at a small village. As a
knowledgeable nurse, she must know that a mother who breastfeeds her child passes
on which antibody through breast milk?

A. IgA
B. IgE
C. IgG
D. IgM
Incorrect
Correct Answer: A. IgA

Antibodies, which are also called immunoglobulins, take five basic forms, indicated
as IgG, IgA, IgM, IgD and IgE. All have been detected in human milk, but by far the
most abundant type is IgA, particularly the form known as secretory IgA, which is
found in great amounts throughout the gut and respiratory system of adults. The
secretory IgA molecules passed to the suckling child are helpful in ways that go
beyond their ability to bind to microorganisms and keep them away from the body’s
tissues.

Option B: IgE is a monomer. It has a molecular weight of 188 Kd and a serum

concentration of 0.00005 mg/mL. It protects against parasites and also binds to
high-affinity receptors on mast cells and basophils causing allergic reactions. IgE
is regarded as the most important host defense against different parasitic
infections which include Strongyloides stercoralis, Trichinella spiralis, Ascaris
lumbricoides, and the hookworms Necator americanus and Ancylostoma duodenal.
Option C: IgG2 forms an important host defense against bacteria that are
encapsulated. IgG is the only immunoglobulin that crosses the placentae as its Fc
portion binds to the receptors present on the surface of the placenta, protecting
the neonate from infectious diseases. IgG is thus the most abundant antibody
present in newborns.
Option D: IgM has a molecular weight of 970 Kd and an average serum concentration
of 1.5 mg/ml. It is mainly produced in the primary immune response to infectious
agents or antigens. It is a pentamer and activates the classical pathway of the
complement system. IgM is regarded as a potent agglutinin (e.g., anti-A and anti-B
isoagglutinin present in type B and type A blood respectively) and a monomer of IgM
is used as a B cell receptor (BCR).
8. Question
The clinical instructor asks her students the rationale for handwashing. The
students are correct if they answered that handwashing is expected to remove:

A. Transient flora from the skin

B. Resident flora from the skin
 C. All microorganisms from the skin
D. Media for bacterial growth
Incorrect
Correct Answer: A. Transient flora from the skin

There are two types of normal flora: transient and resident. Transient flora are
normal flora that a person picks up by coming in contact with objects or another
person (e.g., when you touch a soiled dressing). You can remove these with hand
washing. Hand washing can prevent about 30% of diarrhea-related illnesses and about
20% of respiratory infections (e.g., colds). Antibiotics often are prescribed
unnecessarily for these health issues

Option B: Resident flora live deep in skin layers where they live and multiply
harmlessly. They are permanent inhabitants of the skin and cannot usually be
removed with routine hand washing.
Option C: Removing all microorganisms from the skin (sterilization) is not possible
without damaging the skin tissues. To live and thrive in humans, microbes must be
able to use the body’s precise balance of food, moisture, nutrients, electrolytes,
pH, temperature, and light.
Option D: Food, water, and soil that provide these conditions may serve as
nonliving reservoirs. Hand washing does little to make the skin uninhabitable for
microorganisms, except perhaps briefly when an antiseptic agent is used for
cleansing. Handwashing with soap could protect about 1 out of every 3 young
children who get sick with diarrhea and almost 1 out of 5 young children with
respiratory infections like pneumonia.
9. Question
Which of the following incidents requires the nurse to complete an occurrence
report?

A. Medication given 30 minutes after scheduled dose time.

B. Patient's dentures lost after transfer.
C. Worn electrical cord discovered on an IV infusion pump.
D. Prescription without the route of administration.
Incorrect
Correct Answer: B. Patient’s dentures lost after transfer

You would need to complete an occurrence report if you suspect your patient’s
personal items to be lost or stolen. An incident report also provides vital
information the facility needs to decide whether restitution should be made—if
personal belongings were lost or damaged, for example. Without proper documentation
of the incident, there’s no way to make these important decisions effectively.

Option A: A medication can be administered within a half-hour of the administration

time without an error in administration; therefore, an occurrence report is not
necessary. An incident report invariably makes its way to risk managers and other
administrators, who review it rapidly and act quickly to change any policy or
procedure that appears to be a key contributing factor to the incident.
Option C: The worn electrical cord should be taken out of use and reported to the
biomedical department. An incident report should be filed whenever an unexpected
event occurs. The rule of thumb is that any time a patient makes a complaint, a
medication error occurs, a medical device malfunctions, or anyone—patient, staff
member, or visitor—is injured or involved in a situation with the potential for
injury, an incident report is required.
Option D: The nurse should seek clarification if the provider’s order is missing
information; an occurrence report is not necessary. The medical record is patient-
focused, and facts pertinent to an unexpected incident will likely be left out. So
if a claim were filed and the case proceeded to court, which sometimes occurs years
after the event, you or anyone else involved might be hard-pressed to recreate the
scene—especially if you consider it to be “minor” at the time. You may not be able
to rely on memory alone, but you can count on the incident report to refresh your
memory.
10. Question
The nurse is orienting a new nurse to the unit and reviews source-oriented
charting. Which statement by the nurse best describes source-oriented charting?
Source-oriented charting:

A. Separates the health record according to discipline.

B. Organizes documentation around the patient's problems.
C. Highlights the patient's concerns, problems, and strengths.
D. Is designed to streamline documentation.
Incorrect
Correct Answer: A. Separates the health record according to discipline

In source-oriented charting, each discipline documents findings in a separately

labeled section of the chart. Source-oriented (SO) charting is a narrative
recording by each member (source) of the health care team charts on separate
records. SO charting is time-consuming and can lead to fragmented care. Effective
documentation requires the use of common vocabulary; legibility and neatness; the
use of only authorized abbreviations and symbols; factual and time-sequenced
organization; and accuracy, including any errors that occurred. All documents
related to client care are confidential and clients must sign a release to have
their information released, specifying what type of information may be released and
to whom it may be released.

Option B: Problem-oriented charting organizes notes around the patient’s problems.

POMR is a structured, logical format of narrative charting, using “SOAP,” where S
means “subjective data,” O means “objective data,” A means assessment data, and P
means “plan.” Some institutions add, intervention, E, evaluation, and R, revision,
to the SOAP format. POMR is sometimes altered to become a problem-oriented record
(POR). The critical components of POMR/POR are the database; the problem list; the
initial plan; and the progress notes, based on the SOAP, SOAPIE, or SOAPIER format.
Option C: Focus charting highlights the patient’s concerns, problems, and
strengths. Focus Charting of F-DAR is intended to make the client and client
concerns and strengths the focus of care. It is a method of organizing health
information in an individual’s record. Focus Charting is a systematic approach to
documentation.
Option D: Charting by exception is a unique charting system designed to streamline
documentation. Charting by exception (CBE) is a shorthand method of documenting
normal findings, based on clearly defined normals, standards of practice, and
predetermined criteria for assessments and interventions. Significant findings or
exceptions to the predefined norms are documented in detail.
11. Question
When the nurse completes the patient’s admission nursing database, the patient
reports that he does not have any allergies. Which acceptable medical abbreviation
can the nurse use to document this finding?

A. NA
B. NDA
C. NKA
D. NPO
Incorrect
Correct Answer: C. NKA

The nurse can use the medical abbreviation NKA, which means no known allergies, to
document this finding. NKA is the abbreviation for “no known allergies,” meaning no
known allergies of any sort. By contrast, NKDA stands exclusively for “no known
drug allergies.”
Option A: NA is an abbreviation for not applicable.
Option B: NDA is an abbreviation for no known drug allergies.
Option D: NPO is an abbreviation that means nothing by mouth.
12. Question
The nurse is working on a unit that uses nursing assessment flow sheets. Which
statement best describes this form of charting? Nursing assessment flow sheets:

A. Are comprehensive charting forms that integrate assessments and nursing

actions.
B. Contain only graphic information, such as I&O, vital signs, and medication
administration.
C. Are used to record routine aspects of care; they do not contain assessment
data.
D. Contain vital data collected upon admission, which can be compared with newly
collected data.
Incorrect
Correct Answer: A. Are comprehensive charting forms that integrate assessments and
nursing actions

Nursing assessment flow sheets are organized by body systems. The nurse checks the
box corresponding to the current assessment findings. Nursing actions, such as
wound care, treatments, or IV fluid administration, are also included. A flow sheet
is simply a one- or two-page form that gathers all the important data regarding a
patient’s condition. The flow sheet is housed in the patient’s chart and serves as
a reminder of care and a record of whether care expectations have been met.

Option B: Graphic information, such as vital signs, I&O, and routine care, may be
found on the graphic record. This where records of serial measurements and
observations, nursing interventions, and nursing care plans are recorded.
Option C: Nursing documentation covers a wide variety of issues, topics, and
systems. Researchers, practitioners, and hospital administrators view recordkeeping
as an important element leading to continuity of care, safety, quality care, and
compliance.
Option D: The admission form contains baseline information. In health care
organizations, the EHR, oral reports, handoffs, conferences, and health information
technologies (HIT) are intended to facilitate information flow. In particular, the
JCAHO specifically conceptualizes the care planning process as the structuring
framework for coordinating communication that will result in safe and effective
care.
13. Question
At the end of the shift, the nurse realizes that she forgot to document a dressing
change that she performed for a patient. Which action should the nurse take?

A. Complete an occurrence report before leaving.

B. Do nothing; the next nurse will document it was done.
C. Write the note of the dressing change into an earlier note.
D. Make a late entry as an addition to the narrative notes.
Incorrect
Correct Answer: D. Make a late entry as an addition to the narrative notes.

If the nurse fails to make an important entry while charting, she should make a
late entry as an addition to the narrative notes. The nurse can only document care
directly performed or observed. Therefore, the nurse on the incoming shift would
not record the wound change as performed. A primary purpose of documentation and
recordkeeping systems is to facilitate information flow that supports the
continuity, quality, and safety of care.

Option A: An occurrence report is not necessary in this case. The issue of

completeness is important; Croke cites failure to document as one of the six top
reasons that nurses face malpractice suits. In terms of overall completeness,
Stokke and Kalfoss found many gaps in nursing documentation in Norway. Care plans,
goals, diagnoses, planned interventions, and projected outcomes were absent between
18 percent and 45 percent of the time.
Option B: If documentation is omitted, there is no legal verification that the
procedure was performed. Completeness of a record may have an impact on the quality
of care, but only if it reflects completeness of the right content. Echoed again
here is that document focus, rather than the patient-centric nature of the medical
record, does little to support shared understanding by clinicians of care and the
communication needed to ensure the continuity, quality, and safety of care.
Option C: It is illegal to add to a chart entry that was previously documented. The
typical content and format of documentation—and its lack of accessibility—have also
resulted in document-centric rather than patient-centric records.
14. Question
Patient Z asks Nurse Toni why an electronic health record (EHR) system is being
used. Which response by the nurse indicates an understanding of the rationale for
an EHR system?

A. It includes organizational reports of unusual occurrences that are not part of

the client's record.
B. This type of system consists of combined documentation and daily care plans.
C. It improves interdisciplinary collaboration that improves efficiency in
procedures.
D. This type of system tracks medication administration and usage over 24 hours.
Incorrect
Correct Answer: C. It improves interdisciplinary collaboration that improves
efficiency in procedures.

The EHR has several benefits for users, including improving interdisciplinary
collaboration and making procedures more accurate and efficient. An Electronic
Health Record (EHR) is an electronic version of a patient’s medical history, that
is maintained by the provider over time, and may include all of the key
administrative clinical data relevant to that persons care under a particular
provider, including demographics, progress notes, problems, medications, vital
signs, past medical history, immunizations, laboratory data, and radiology reports
The EHR automates access to information and has the potential to streamline the
clinician’s workflow. The EHR also has the ability to support other care-related
activities directly or indirectly through various interfaces, including evidence-
based decision support, quality management, and outcomes reporting.

Option A: An occurrence report is an organizational record of an unusual occurrence

or accident that is not a part of the client’s record. The purpose of the incident
report is to document the exact details of the occurrence while they are fresh in
the minds of those who witnessed the event. This information may be useful in the
future when dealing with liability issues stemming from the incident.
Option B: Integrated plans of care (IPOC) are a combined charting and care plan
format. It is care that is planned with people who work together to understand the
service user and their carer(s), puts them in control, and coordinates and delivers
services to achieve the best outcomes
Option D: A medication administration record (MAR) is used to document medications
administered and their usage. A Medication Administration Record (MAR, or eMAR for
electronic versions), commonly referred to as a drug chart, is the report that
serves as a legal record of the drugs administered to a patient at a facility by a
healthcare professional. The MAR is a part of a patient’s permanent record on their
medical chart.
15. Question
In the United States, the first programs for training nurses were affiliated with:

A. The military
 B. General hospitals
C. Civil service
D. Religious orders
Incorrect
Correct Answer: D. Religious orders

When the Civil War broke out, the Army used nurses who had already been trained in
religious orders. Nursing started with religious orders. The Hindu faith was the
first to write about nursing. In the United States, all training for nurses was
affiliated with religious orders until after the Civil War.

Option A: Although the Army did provide some training, it occurred later than in
the religious orders. Most people think of the nursing profession as beginning with
the work of Florence Nightingale, an upper class British woman who captured the
public imagination when she led a group of female nurses to the Crimea in October
of 1854 to deliver nursing service to British soldiers.
Option B: Although nurses were trained in hospitals, the training and the hospitals
were affiliated with religious orders. Upon her return to England, Nightingale
successfully established nurse education programs in a number of British hospitals.
These schools were organized around a specific set of ideas about how nurses should
be educated, developed by Nightingale often referred to as the “Nightingale
Principles.”
Option C: Civil service was not mentioned in Chapter 1 and was not a factor in the
early 1800s. While Nightingale’s work was groundbreaking in that she confirmed that
a corps of educated women, informed about health and the ways to promote it, could
improve the care of patients based on a set of particular principles, she was not
the first to put these principles into action.
16. Question
Which of the following is/are an example(s) of a health restoration activity?
Select all that apply.

A. Administering an antibiotic every day.

B. Teaching the importance of handwashing.
C. Assessing a client's surgical incision.
D. Advising a woman to get an annual mammogram after age 50 years.
E. Attending rehabilitation of a fractured arm.
Incorrect
Correct Answer: A, C, E

Health restoration activities help an ill client return to health. This would
include taking an antibiotic every day and assessing a client’s surgical incision.
Hand washing and mammograms both involve healthy people who are trying to prevent
illness.

Option A: Rehabilitation or restoration is defined as “a set of interventions

designed to optimize functioning and reduce disability in individuals with health
conditions in interaction with their environment”.
Option B: Disease prevention, understood as specific, population-based, and
individual-based interventions for primary and secondary (early detection)
prevention, aiming to minimize the burden of diseases and associated risk factors.
Option C: Rehabilitation helps a child, adult, or older person to be as independent
as possible in everyday activities and enables participation in education, work,
recreation, and meaningful life roles such as taking care of a family. It does so
by addressing underlying conditions (such as pain) and improving the way an
individual function in everyday life, supporting them to overcome difficulties with
thinking, seeing, hearing, communicating, eating, or moving around.
Option D: Secondary prevention deals with early detection when this improves the
chances for positive health outcomes (this comprises activities such as evidence-
based screening programs for early detection of diseases or for prevention of
congenital malformations; and preventive drug therapies of proven effectiveness
when administered at an early stage of the disease).
Option E: Rehabilitation is highly person-centered, meaning that the interventions
and approach selected for each individual depends on their goals and preferences.
Rehabilitation can be provided in many different settings, from inpatient or
outpatient hospital settings to private clinics, or community settings such as an
individual’s home.
17. Question
Which of the following aspects of nursing is essential to defining it as both a
profession and a discipline?

A. Established standards of care

B. Professional organizations
C. Practice supported by scientific research
D. Activities determined by a scope of practice
Incorrect
Correct Answer: C. Practice supported by scientific research

A profession must have knowledge that is based on technical and scientific

knowledge. The theoretical knowledge of a discipline must be based on research, so
both are scientifically based. The profession of nursing consists of persons
educated in the discipline according to nationally regulated, defined, and
monitored standards. The standards and regulations are to preserve healthcare
safety for members of society. Although the discipline and the profession of
nursing have different goals, the raison d’être of nursing is the enhancement of
quality of life for humankind. The discipline provides the science lived in the art
of practice.

Option A: The American Nurses Association (ANA) has developed standards of care,
but they are unrelated to defining nursing as a profession or discipline. Nursing
is a discipline and a profession. The goal of the discipline is to expand knowledge
about human experiences through creative conceptualization and research. This
knowledge is the scientific guide to living the art of nursing. The discipline-
specific knowledge is given birth and fostered in academic settings where research
and education move the knowledge to new realms of understanding.
Option B: Having professional organizations is not included in accepted
characteristics of either a profession or a discipline. The goal of the profession
is to provide service to humankind through living the art of science. Members of
the nursing profession are responsible for regulation of standards of practice and
education based on disciplinary knowledge that reflects safe health service to
society in all settings.
Option D: Having a scope of practice is not included in accepted characteristics of
either a profession or a discipline. The discipline of nursing encompasses the
knowledge in the extant frameworks and theories that are embedded in the totality
and simultaneity paradigms (Parse, 1987). These theories and frameworks explicate
the nature of nursing’s major phenomenon of concern, the human-universe-health
process.
18. Question
The charge nurse on the medical-surgical floor assigns vital signs to the nursing
assistive personnel (NAP) and medication administration to the licensed vocational
nurse (LVN). Which nursing model of care is this floor following?

A. Team nursing
B. Case method nursing
C. Functional nursing
D. Primary nursing
Incorrect
Correct Answer: C. Functional nursing
This medical-surgical floor is following the functional nursing model of care, in
which care is partitioned and assigned to a staff member with the appropriate
skills. For example, the NAP is assigned vital signs, and the LVN is assigned
medication administration. Functional nursing is task-oriented in scope. Instead of
one nurse performing many functions, several nurses are given one or two
assignments. For example, there is a medicine nurse whose sole responsibility is
administering medications.

Option A: With team nursing, an RN or LVN is paired with a NAP. The pair is then
assigned to render care for a group of patients. Team nursing is a system that
distributes the care of a patient amongst a team that is all working together to
provide for this person. This team consists of up to 4 to 6 members that has a team
leader who gives jobs and instructions to the group.
Option B: In case method nursing, one nurse cares for one patient during her entire
shift. Private duty nursing is an example of this care model. The case method is a
participatory, discussion-based way of learning where students gain skills in
critical thinking, communication, and group dynamics. It is a type of problem-based
learning.
Option D: When the primary nursing model is utilized, one nurse manages care for a
group of patients 24 hours a day, even though others provide care during part of
the day. A method of providing nursing services to inpatients whereby one nurse
plans the care of specific patients for a period of 24 hours. The primary nurse
provides direct care to those patients when working and is responsible for
directing and supervising their care in collaboration with other health care team
members.
19. Question
Paul Jake suffered a stroke and has difficulty swallowing. Which healthcare team
member should be consulted to assess the patient’s risk for aspiration?

A. Respiratory therapist
B. Occupational therapist
C. Dentist
D. Speech therapist
Incorrect
Correct Answer: D. Speech therapist

Speech and language therapists provide assistance to clients experiencing

swallowing and speech disturbances. They assess the risk for aspiration and
recommend a treatment plan to reduce the risk. Speech-language pathologists (SLPs)
work to prevent, assess, diagnose, and treat speech, language, social
communication, cognitive-communication, and swallowing disorders in children and
adults.

Option A: Respiratory therapists provide care for patients with respiratory

disorders. Respiratory therapists interview and examine patients with breathing or
cardiopulmonary disorders. Respiratory therapists care for patients who have
trouble breathing—for example, from a chronic respiratory disease, such as asthma
or emphysema.
Option B: Occupational therapists help patients regain function and independence.
Occupational therapists treat injured, ill, or disabled patients through the
therapeutic use of everyday activities. They help these patients develop, recover,
improve, as well as maintain the skills needed for daily living and working.
Option C: Dentists diagnose and treat dental disorders. Dentists remove tooth
decay, fill cavities, and repair fractured teeth. Dentists diagnose and treat
problems with patients’ teeth, gums, and related parts of the mouth. They provide
advice and instruction on taking care of the teeth and gums and on diet choices
that affect oral health.
20. Question
Which of the following is/are an example(s) of theoretical knowledge? Select all
that apply.

A. Antibiotics are ineffective in treating viral infections.

B. When you take a patient's blood pressure, the patient's arm should be at heart
level.
C. In Maslow's framework, physical needs are most basic.
D. When drawing medication out of a vial, inject air into the vial first.
E. Let the patient dangle his feet first before assisting him to stand or
transfer.
Incorrect
Correct Answer: A, C

Theoretical knowledge consists of research findings, facts (e.g., “Antibiotics are

ineffective . . .” is a fact), principles, and theories (e.g., “In Maslow’s
framework . . .” is a statement from a theory). Instructions for taking blood
pressure and withdrawing medications are examples of practical knowledge—what to do
and how to do it. While practical knowledge is gained by doing things, theoretical
knowledge is gained, for example, by reading a manual.

Option A: Theoretical knowledge teaches the reasoning, techniques and theory of

knowledge.
Option B: Practical knowledge is the knowledge that is acquired by day-to-day
hands-on experiences. In other words, practical knowledge is gained through doing
things; it is very much based on real-life endeavors and tasks.
Option C: While theoretical knowledge may guarantee that you understand the
fundamental concepts and have know-how about how something works and its mechanism,
it will only get you so far, as, without practice, one is not able to perform the
activity as well as he could.
Option D: Practical knowledge guarantees that you are able to actually do something
instead of simply knowing how to do it.
Option E: Theoretical and practical knowledge are interconnected and complement
each other — if one knows exactly HOW to do something, one must be able to apply
these skills and therefore succeed in practical knowledge.
21. Question
The nurse recognizes that urinary elimination changes may occur even in healthy
older adults because of which of the following?

A. The bladder distends and its capacity increases.

B. Older adults ignore the need to void.
C. Urine becomes more concentrated.
D. The amount of urine retained after voiding increases.
Incorrect
Correct Answer: D. The amount of urine retained after voiding increases

The capacity of the bladder may decrease with age but the muscle is weaker and can
cause urine to be retained. Muscle changes and changes in the reproductive system
can affect bladder control. As the volume of urine held by the bladder increases,
so too does the pressure therein. Wall pressure of 5 to 15 mm Hg creates a
sensation of bladder fullness while 30 mm Hg and beyond is painful. The sensation
of increasing bladder fullness is conveyed to the spinal cord via the pudendal and
hypogastric nerves on both A-delta and C nerve fibers.

Option A: The bladder wall changes. The elastic tissue becomes tough and the
bladder becomes less stretchy. The bladder cannot hold as much urine as before. The
urethra can become blocked. In women, this can be due to weakened muscles that
cause the bladder or vagina to fall out of position (prolapse). In men, the urethra
can become blocked by an enlarged prostate gland.
Option B: Older adults don’t ignore the urge to void and may have difficulty
getting to the toilet in time. Bladder capacity changes throughout one’s life. In
children, an approximation of bladder volume can be calculated with the formula:
(years of age + 2) x 30 mL. By adulthood, the average volume that a functional
bladder can comfortably hold is between 300 and 400 mL.
Option C: The kidney becomes less able to concentrate urine with age. Urination or
micturition primarily functions in the excretion of metabolic products and toxic
wastes. The urinary tract also serves as a storage vessel of the waste filtered
from the kidneys. Urine stored in the bladder is released from the bladder through
the urethra upon a complex network of neurological function.
22. Question
During the assessment of the client with urinary incontinence, the nurse is most
likely to assess for which of the following? Select all that apply.

A. Perineal skin irritation

B. Fluid intake of less than 1,500 mL/d
C. History of antihistamine intake
D. Hx of UTI
E. A fecal impaction
Incorrect
Correct Answer: A, B, D, and E

Urinary incontinence is the involuntary leakage of urine. This medical condition is

common in the elderly, especially in nursing homes, but it can affect younger adult
males and females as well. Urinary incontinence can impact both patient health and
quality of life. The prevalence may be underestimated as some patients do not
inform health care providers of having issues with urinary incontinence for various
reasons.

Option A: The perineum may become irritated by the frequent contact with urine.
Approximately 13 million Americans experience urinary incontinence. The prevalence
is 50% or greater among residents of nursing facilities. Caregivers report that 53%
of the homebound elderly are incontinent. A random sampling of hospitalized elderly
patients reports that 11% of patients have persistent urinary incontinence at
admission, and 23% at discharge.
Option B: Normal fluid intake is at least 1,500 mL/d and clients often decrease
their intake to try to minimize urine leakage. Functional urinary incontinence is
the involuntary leakage of urine due to environmental or physical barriers to
toileting. This type of incontinence is sometimes referred to as toileting
difficulty.
Option C: Antihistamines can cause urinary retention rather than urinary
incontinence. The urethra is the tube that takes urine from the bladder out of the
body. The problem can also be caused by using drugs such as antihistamines (like
Benadryl®), antispasmodics (like Detrol®), and tricyclic antidepressants (like
Elavil®) that can change the way the bladder muscle works.
Option D: UTIs can contribute to incontinence. Patients should be asked about
medical conditions such as chronic obstructive pulmonary disease and asthma (which
can cause cough), heart failure (with related fluid overload and diuresis),
neurologic conditions (which may suggest dysregulated bladder innervation),
musculoskeletal conditions (which may contribute to toileting barriers), etc.
Option E: A fecal impaction can compress the urethra, which results in sm. amts of
urine leakage. Overflow urinary incontinence is the involuntary leakage of urine
from an overdistended bladder due to impaired detrusor contractility and/or bladder
outlet obstruction. Neurologic diseases such as spinal cord injuries, multiple
sclerosis, and diabetes can impair detrusor function. Bladder outlet obstruction
can be caused by external compression by abdominal or pelvic masses and pelvic
organ prolapse, among other causes. A common cause in men is benign prostatic
hyperplasia.
23. Question
Which action represents the appropriate nursing management of a client wearing a
condom catheter?
 A. Ensure that the tip of the penis fits snugly against the end of the condom.
B. Check the penis for adequate circulation 30 min after applying.
C. Change the condom every 8 hours.
D. Tape the collecting tube to the lower abdomen.
Incorrect
Correct Answer: B. Check the penis for adequate circulation 30 min after applying

The penis and condom should be checked 1/2 hour after application to ensure that
it’s not too tight. and the tubing is taped to the leg or attached to a leg bag.
Condom catheters are external urinary catheters that are worn like a condom. They
collect urine as it drains out of your bladder and send it to a collection bag
strapped to your leg. They’re typically used by men who have urinary incontinence
(can’t control their bladder).

Option A: A 1 in. space should be left between the penis and the end of the condom.
Place the condom over the tip of the penis and slowly unroll it until it gets to
the base. Leave enough room at the tip (1 to 2 inches) so it won’t rub against the
condom.
Option C: The condom is changed every 24h. Condom catheters should be replaced
every 24 hours. Throw away the old one unless it’s designed to be reusable. The
collection bag should be emptied when it’s about half full or at least every three
to four hours for a small bag and every eight hours for a large one.
Option D: An indwelling catheter is taped to the lower abdomen or upper thigh. Use
a nonadhesive condom catheter to help prevent irritation from adhesive. An
inflatable ring holds it in place. Keep the bag lower than the bladder to avoid
backflow of urine from the bag. Securely attach the tube to the leg (below the
knee, such as the calf), but leave a little slack so it doesn’t pull on the
catheter.
24. Question
The catheter slips into the vagina during a straight catheterization of a female
client. The nurse does which action?

A. Leaves the catheter in place and gets a new sterile catheter.

B. Leaves the catheter in place and asks
C. Removes the catheter and redirects it
D. Removes the catheter, wipes it with a
urinary meatus.
Incorrect
Correct Answer: A. Leaves the catheter in
another nurse to attempt the procedure.
to the urinary meatus.
sterile gauze, and redirects it to the
place and gets a new sterile catheter.

The catheter in the vagina is contaminated and can’t be reused. If left in place,
it may help avoid mistaking the vaginal opening for the urinary meatus. A single
failure to catheterize the meatus doesn’t indicate that another nurse is needed
although sometimes a second nurse can assist in visualization of the meatus.
Urinary bladder catheterization is performed for both therapeutic and diagnostic
purposes. Based on the dwell time, the urinary catheter can be either intermittent
(short-term) or indwelling (long-term).

Option B: After exposing the urethral meatus, a lubricated catheter tip is advanced
in the meatus until there is a spontaneous return of urine. The catheter balloon is
then inflated as per the manufacturer’s recommendations.
Option C: In the event a catheter is inserted in the vagina, it should be left
there until a new sterile catheter is successfully inserted into the meatus.
Analgesia is of no proven clinical use in women. Lubrication jelly should be
applied to the tip of the catheter. The application of lubricant to the urethral
meatus is associated with difficulty in catheter insertion.
Option D: Urinary tract infection (UTI) is the most common complication that occurs
as a result of long-term catheterization. The normal urinary flow prevents the
ascension of microbes from the periurethral skin avoiding the infection. Alteration
of the defensive mechanism from the catheter results in an increased risk of UTIs.
Escherichia coli and Klebsiella pneumonia are the most common organisms implicated
in UTIs. Recurrent UTIs are associated with increased antibiotic resistance.
25. Question
Which statement indicates a need for further teaching of a home care client with a
long term indwelling catheter?

A. "I will keep the collecting bag below the level of the bladder at all times."
B. "Intake of cranberry juice may help decrease the risk of infection."
C. "Soaking in a warm tub bath may ease the irritation associated with the
catheter."
D. "I should use clean tech. when emptying the collecting bag."
Incorrect
Correct Answer: C. “Soaking in a warm tub bath may ease the irritation associated
with the catheter”

Soaking in a bathtub can increase the risk of exposure to bacteria. Avoid taking
baths, but shower daily. For the first few days after getting a suprapubic
catheter, use a waterproof bandage when showering. Once the wound heals, the client
can shower as usual, but avoid scented soaps.

Option A: The bag should be below the level of the bladder to promote proper
drainage. Always keep the bag below the waist. Check the tube once in a while for
bends or kinks that keep pee from flowing out. Don’t use any lotions or powders
around where the catheter goes into the body.
Option B: Intake of cranberry juice creates an environment nonconducive to
infection. “Indwelling” means inside the body. This catheter drains urine from the
bladder into a bag outside the body. Common reasons to have an indwelling catheter
are urinary incontinence (leakage), urinary retention (not being able to urinate),
a surgery that made this catheter necessary, or another health problem.
Option D: Clean technique is appropriate for touching the exterior portions of the
system. Wash hands with soap and water. Empty urine from the bag into the toilet.
Pinch the catheter closed between the fingers. Remove the bag. Wipe the end of the
catheter with a fresh alcohol pad. Wipe the tip of the new bag with the second
alcohol pad. Connect the new bag and stop pinching the catheter now. Make sure
there are no bends or kinks in the catheter tube. Wash hands again.
26. Question
During shift report, the nurse learns that an older female client is unable to
maintain continence after she senses the urge to void and becomes incontinent on
the way to the bathroom. Which nursing diagnosis is most appropriate?

A. Stress urinary incontinence

B. Reflex urinary incontinence
C. Functional urinary incontinence
D. Urge urinary incontinence
Incorrect
Correct Answer: D. Urge urinary incontinence

The key phrase is “the urge to void” option one occurs when the client coughs,
sneezes, or jars the body, resulting in accidental loss of urine. If one feels a
strong urge to urinate even when the bladder isn’t full, the incontinence might be
related to overactive bladder, sometimes called urge incontinence. This condition
occurs in both men and women and involves an overwhelming urge to urinate
immediately, frequently followed by loss of urine before the client can reach a
bathroom. Even if one never has an accident, urgency and urinary frequency can
interfere with work and a social life because of the need to keep running to the
bathroom.
Option A: Stress Urinary Incontinence (SUI) is when urine leaks out with sudden
pressure on the bladder and urethra, causing the sphincter muscles to open briefly.
With mild SUI, pressure may be from sudden forceful activities, like exercise,
sneezing, laughing, or coughing.
Option B: Reflex urinary incontinence occurs with involuntary loss of urine at
somewhat predictable intervals when a specific bladder volume is reached. Reflex
incontinence occurs when the bladder muscle contracts and urine leaks (often in
large amounts) without any warning or urge. This can happen as a result of damage
to the nerves that normally warn the brain that the bladder is filling.
Option C: Functional urinary continence is the involuntary loss of urine related to
impaired function. If the urinary tract is functioning properly but other illnesses
or disabilities are preventing one from staying dry, the client might have what is
known as functional incontinence. For example, if an illness rendered the client
unaware or unconcerned about the need to find a toilet, the client would become
incontinent. Medications, dementia, or mental illness can decrease awareness of the
need to find a toilet.
27. Question
A female client has a urinary tract infection. Which teaching points by the nurse
should be helpful to the client? Select all that apply.

A. Limit fluids to avoid the burning sensation on urination.

B. Review symptoms of UTI with the client.
C. Wipe the perineal area from back to front.
D. Wear cotton underclothes.
E. Take baths rather than showers.
Incorrect
Correct Answer: B, D

Uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder

and associated structures. These are patients with no structural abnormality and no
comorbidities, such as diabetes, immunocompromised, or pregnant. Uncomplicated UTI
is also known as cystitis or lower UTI. Forty percent of women in the United States
will develop a UTI during their lifetime, making it one of the most common
infections in women. UTI is uncommon in circumcised males, and by definition, any
male UTI is considered complicated.

Option A: Increased fluids decrease concentration and irritation. An uncomplicated

UTI usually only involves the bladder. When the bacteria invade the bladder mucosal
wall, cystitis is produced. The majority of organisms causing a UTI are enteric
coliforms that usually inhabit the periurethral vaginal introitus. These organisms
ascend into the bladder and cause a UTI.
Option B: Reviewing the symptoms of UTI with the client validates the diagnosis.
Symptoms of uncomplicated UTI are pain on urination (dysuria), frequent urination
(frequency), inability to start the urine stream (hesitation), sudden onset of the
need to urinate (urgency), and blood in the urine (hematuria). Usually, patients
with uncomplicated UTI do not have fever, chills, nausea, vomiting, or back pain,
which are signs of kidney involvement or upper tract disease/pyelonephritis.
Option C: The client should wipe the perineal area from front to back to prevent
the spread of bacteria from the rectal area to the urethra. Sexual intercourse is a
common cause of a UTI as it promotes the migration of bacteria into the bladder.
People who frequently void and empty the bladder have a much lower risk of a UTI.
Option D: Cotton underwear promotes appropriate exposure to air, resulting in
decreased bacterial growth. Urine is an ideal medium for bacterial growth; factors
that make it unfavorable for bacterial growth include a pH of less than 5, presence
of organic acids, and high levels of urea. Frequent urination is also known to
decrease the risk of UTI.
Option E: Showers reduce exposure of the area to bacteria. Bacteria that cause UTI
have adhesins on their surface which allow the organism to attach to the mucosal
surface. In addition, a short urethra also makes it easier for the uropathogen to
invade the urinary tract.
28. Question
The nurse will need to assess the client’s performance of clean intermittent self
catheterization (CISC) for a client with which urinary diversion?

A. Ileal conduit
B. Kock pouch
C. Neobladder
D. Vesicostomy
Incorrect
Correct Answer: B. Kock pouch

The ileal conduit and vesicostomy are incontinent urinary diversions, and clients
are required to use an external ostomy appliance to contain the urine. In this new
operation, a pouch or reservoir is fashioned out of the terminal ileum with a valve
mechanism at its exit to the skin surface. This allows storage of the liquid bowel
contents in an expandable container with no leakage of stool or gas and therefore
no skin problems. There is no need for appliances or bags, no embarrassment from
the involuntary noise and smell of flatus through the ileostomy. The stoma is
created flush and within the bikini line. The patient catheterizes the pouch on an
average of three times a day.

Option A: An ileal conduit aims to divert urine produced from the upper urinary
tracts to a newly formed reservoir created from the terminal ileum. The ureters are
disconnected from the bladder and implanted into the conduit.
Option C: Clients with a neobladder can control their voiding. During neobladder
surgery, the surgeon takes out the existing bladder and forms an internal pouch
from part of the intestine. The pouch, called a neobladder, stores the urine.
Option D: A vesicostomy is a stoma (opening) created between the bladder and the
abdomen. This allows urine to drain freely, with low pressure, to help protect and
prevent harm to the kidneys. It is a surgical procedure that typically involves an
overnight stay in the hospital.
29. Question
Which focus is the nurse most likely to teach for a client with a flaccid bladder?

A. Habit training: attempt voiding at specific time periods.

B. Bladder training: delay voiding according to a pre-schedule timetable.
C. Crede's maneuver: apply gentle manual pressure to the lower abdomen.
D. Kegel exercises: contract the pelvic muscles.
Incorrect
Correct Answer: C. Crede’s maneuver: apply gentle manual pressure to the lower
abdomen.

Because the bladder muscles will not contract to increase the intra-bladder
pressure to promote urination, the process is initiated manually. The Credé
maneuver is a technique used to void urine from the bladder of an individual who,
due to disease, cannot do so without aid. The Credé maneuver is executed by
exerting manual pressure on the abdomen at the location of the bladder, just below
the navel. Options one, two, and four: to promote continence bladder contractions
are required for habit training, bladder training, and increasing the tone of the
pelvic muscles.

Option A: One type of toilet training is habit training. Habit training is the
process of teaching a child to eliminate on the toilet at routine times. Habit
training involves teaching children to eliminate on the toilet by developing a
toileting routine/habit.
Option B: Bladder training is an important form of behavior therapy that can be
effective in treating urinary incontinence. The goals are to increase the amount of
time between emptying your bladder and the amount of fluids your bladder can hold.
It also can diminish leakage and the sense of urgency associated with the problem.
Option D: Kegel exercises can help make the muscles under the uterus, bladder, and
bowel (large intestine) stronger. They can help both men and women who have
problems with urine leakage or bowel control.
30. Question
Which of the following behaviors indicates that the client on a bladder training
program has met the expected outcomes? Select all that apply.

A. Voids each time there is an urge.

B. Practices slow, deep breathing until the urge decreases.
C. Uses adult diapers, for "just in case".
D. Drinks citrus juices and carbonated beverages.
E. Performs pelvic muscle exercises.
Incorrect
Correct Answer: B, E

It is important for the client to inhibit the urge to void sensation when a
premature urge is experienced. Bladder training, a program of urinating on
schedule, enables the client to gradually increase the amount of urine the client
can comfortably hold. Bladder training is a mainstay of treatment for urinary
frequency and overactive bladder in both women and men, alone or in conjunction
with medications or other techniques.

Option A: Choose an interval. Based on the typical interval between urinations,

select a starting interval for training that is 15 minutes longer. If the typical
interval is one hour, make a starting interval one hour and 15 minutes.
Option B: When the client starts training, he should empty his bladder first thing
in the morning and not again until the interval he set. If the time arrives before
he can feel the urge, he should go anyway. If the urge hits first, he should remind
himself that his bladder isn’t really full, and use whatever techniques he can to
delay going.
Option C: Some clients may need diapers; this is not the best indicator of a
successful program.
Option D: Citrus juices may irritate the bladder. Carbonated beverages increase
diuresis and the risk of incontinence.
Option E: Try the pelvic floor exercises sometimes called Kegels, or simply try to
wait another five minutes before walking slowly to the bathroom. Once comfortable
with a set interval, increase it by 15 minutes. Over several weeks or months, the
client may find that they are able to wait much longer and that they have
experienced far fewer feelings of urgency or episodes of urge incontinence.
31. Question
A nurse has identified that the patient has overflow incontinence. What is a major
factor that contributes to this clinical manifestation?

A. Coughing
B. Mobility deficits
C. Prostate enlargement
D. Urinary tract infection
Incorrect
Correct Answer: C. Prostate enlargement

An enlarged prostate compresses the urethra and interferes with the outflow of
urine, resulting in urinary retention. With urinary retention, the pressure within
the bladder builds until the external urethral sphincter temporarily opens to allow
a small volume (25-60mL) of urine to escape (overflow incontinence). Men who are
unable to completely empty their bladder and experience unexpected urine leakage
may have what is called overflow incontinence.

Option A: Coughing, which raises the intra abdominal pressure, is related to stress
incontinence, not overflow incontinence. An enlarged prostate can interfere with
the passage of urine through the urethra, the tube connected to the bladder.
Option B: Mobility deficits, such as spinal cord injuries, are related to reflex
incontinence, not overflow incontinence. Damage to nerves near the bladder causing
under-activity. This can occur with neurological injury or with diseases such as
diabetes.
Option D: Urinary tract infections are related to urge incontinence, not overflow
incontinence. Men with this type of urinary incontinence often do not feel that
their bladders are full, which then leads to leakage as the bladder has reached its
full capacity. In addition to leakage, urine left in the bladder can lead to
urinary tract infections due to the growth of bacteria as well as bladder stones.
32. Question
A nurse must measure the intake and output (I&O) for a patient who has a urinary
retention catheter. Which equipment is most appropriate to use to accurately
measure urine output from a urinary retention catheter?

A. Urinal
B. Graduate
C. Large syringe
D. Urine collection bag
Incorrect
Correct Answer: B. Graduate

A graduate is a collection container with volume markings usually at 25 mL

increments that promote accurate measurements of urine volume. To measure urine
output in critical care units, a Foley catheter is introduced through the patient’s
urethra until it reaches his/her bladder. The other end of the catheter is
connected to a graduated container that collects the urine.

Option A: Although urinals have volume markings on the side, usually they occur in
100 mL increments that do not promote accurate measurements. Urine output is the
best indicator of the state of the patient’s kidneys. If the kidneys are producing
an adequate amount of urine it means that they are well perfused and oxygenated.
Otherwise, it is a sign that the patient is suffering from some complications.
Option C: Large syringe is impractical. A large syringe is used to obtain a sterile
specimen from a retention catheter (Foley catheter). Urine output is required for
calculating the patient’s water balance, which is essential in the treatment of
burn patients. Finally, it is also used in multiple therapy protocols to check
whether the patient reacts properly to treatment
Option D: A urine collection bag is flexible and balloons outward as urine
collects. In addition, the volume markings are at 100 mL increments that do not
promote accurate measurements. In critical care units of first world countries,
measurements of every patient’s urine output are taken hourly, 24 times a day, 365
days a year. In the case of emerging countries, often only burn patients—for whom
urine output monitoring is of paramount importance—have this parameter recorded
every hour, while the remaining critical patients have it recorded every 2 or 3
hours.
33. Question
A patient’s urine is cloudy, is amber, and has an unpleasant odor. What problem may
this information indicate that requires the nurse to make a focused assessment?

A. Urinary retention
B. Urinary tract infection
C. Ketone bodies in the urine
D. High urinary calcium level
Incorrect
Correct Answer: B. Urinary tract infection

The urine appears concentrated (amber)and cloudy because of the presence of

bacteria, white blood cells, and red blood cells. The unpleasant odor is caused by
pus in the urine (pyuria). Uncomplicated urinary tract infection (UTI) is a
bacterial infection of the bladder and associated structures. These are patients
with no structural abnormality and no comorbidities, such as diabetes,
immunocompromised, or pregnancy. Uncomplicated UTI is also known as cystitis or
lower UTI.

Option A: These clinical manifestations do not reflect urinary retention. Urinary

retention is evidenced by supra pubic distention and lack of voiding or small,
frequent voiding (overflow incontinence). The mechanisms of acute urinary retention
can include outflow obstruction, which can be mechanical such as from physical
narrowing of the urethral channel. The other dynamic is from an increase in the
muscle tone within and around the urethra as in benign prostatic hypertrophy and
hyperplasia.
Option C: These clinical manifestations do not reflect ketone bodies in the urine.
A reagent strip dipped in urine will measure the presence of Ketone bodies. If the
cells don’t get enough glucose, the body burns fat for energy instead. This
produces a substance called ketones, which can show up in the blood and urine.
Option D: These clinical manifestations do not reflect excessive calcium in the
urine. Urine calcium levels are measured by assessing a 24-hour urine specimen. If
urine calcium levels are too high or too low, it may mean that the client has a
medical condition, such as kidney disease or kidney stones. Kidney stones are hard,
pebble-like substances that can form in one or both kidneys when calcium or other
minerals build up in the urine. Most kidney stones are formed from calcium.
34. Question
A nurse is caring for a debilitated female patient with nocturia. Which nursing
intervention is the priority when planning to meet this patient’s needs?

A. Encouraging the use of bladder training exercises.

B. Providing assistance with toileting every four hours.
C. Positioning a bedside commode near the bed.
D. Teaching the avoidance of fluid after 5 PM.
Incorrect
Correct Answer: C. Positioning a bedside commode near the bed.

The use of a commode requires less energy than using a bedpan and is safer than
walking to the bathroom. Sitting on the commode uses gravity to empty the bladder
fully and thus prevent urinary stasis. Nocturia is defined as the need for a
patient to get up at night on a regular basis to urinate. A period of sleep must
precede and follow the urinary episode to count as a nocturnal void. This means the
first-morning void is not considered when determining nocturia episodes. Use of a
bedside commode or urinal can minimize the bother, if not the frequency, of
nocturia and may reduce the risk of falls. Remove any obstacles, loose rugs, or
furniture between the bed and the nearest commode to reduce fall risk further.
Consider using nightlights to help illuminate the passage to the bathroom.

Option A: Although bladder training exercises should be done, it is not the

priority. Behavioral therapy, which includes pelvic floor muscle training, urge-
suppression techniques, delayed voiding, fluid management, sleep hygiene, Kegel
exercises, and peripheral edema management, has been shown to be reasonably
efficacious both when used alone or together with pharmacological therapy in
controlling nocturia.
Option B: Assisting with toileting may be too often or not often enough for the
patient. Care should be individualized for the patient. In particular, older adults
with nocturia who make multiple nocturnal trips to the bathroom are at a
substantially increased risk of potentially serious falls. A quarter of all the
falls that occur in older individuals happen overnight. Of these, 25% are directly
related to nocturia. Patients who make at least 2 or more nocturnal bathroom visits
a night, have more than double the risk of fractures and fall-related traumas.
Option D: Fluids may be decreased during the last two hours before bedtime, but
they should not be avoided completely after 5 PM (opt4). Some fluid intake is
necessary for adequate renal perfusion. Drinking large amounts of fluids shortly
before going to bed and ingesting caffeine or alcohol late in the day and before
bed is likely to contribute to nocturia as well. Be aware that some elderly
patients may already be somewhat dehydrated and might require extra fluid intake
earlier in the day before they can safely do any evening fluid restriction before
bedtime.
35. Question
A practitioner uses a urine specimen for culture and sensitivity via a straight
catheter for a patient. What should the nurse do when collecting this urine
specimen?

A. Use a sterile specimen container.

B. Collect urine from the catheter port.
C. Inflate the balloon with 10 mL of sterile water.
D. Have the patient void before collecting the specimen.
Incorrect
Correct Answer: A. Use a sterile specimen container.

A culture attempts to identify the microorganisms present in the urine, and a

sensitivity study identifies the antibiotics that are effective against the
isolated microorganisms. A sterile specimen container is used to prevent
contamination of the specimen by microorganisms outside the body (exogenous).

Option B: The urine from the straight catheter flows directly into the specimen
container. Collecting a urine specimen from a catheter port is necessary when the
patient has a urinary retention catheter. A straight catheter has a single lumen
for draining urine from the bladder.
Option C: A straight catheter does not remain in the bladder and therefore does not
have a 2nd lumen for water to be inserted into a balloon. This may result in no
urine left in the bladder for the straight catheter to collect.
Option D: A minimum of 3 mL of urine is necessary for a specimen for urine culture
and sensitivity. Do not urinate for at least 1 hour before the test. If the client
doesn’t have the urge to urinate, he may be instructed to drink a glass of water 15
to 20 minutes before the test. Otherwise, there is no preparation for the test.
36. Question
A nurse in a provider’s office is assessing a client who reports losing control of
urine whenever she coughs, laughs, or sneezes. The client relates a history of
three vaginal births, but no serious accidents or illnesses. Which of the following
interventions are appropriate for helping to control or eliminate the clients
incontinence? Select all that apply.

A. Limit total daily fluid intake

B. Decrease or avoid caffeine
C. Increase the intake of calcium supplements
D. Avoid the intake of alcohol
E. Use Crede maneuver
Incorrect
Correct Answer: B and D

Caffeine and alcohol are bladder irritants and can worsen stress incontinence.
Alcohol is a bladder irritant and can worsen stress incontinence. Quitting smoking,
losing excess weight, or treating a chronic cough will lessen the risk of stress
incontinence and improve the symptoms. Stress incontinence is different from
urgency incontinence and overactive bladder (OAB). If the client has urgency
incontinence or OAB, the bladder muscle contracts, causing a sudden urge to urinate
before he can get to the bathroom. Stress incontinence is much more common in women
than in men.
Option A: Because stress incontinence results from weak pelvic muscles and other
structures, limiting fluid will not resolve the problem. The doctor may recommend
how much and when one should consume fluids during the day and evening. However,
don’t limit what the client drinks so much that he becomes dehydrated.
Option B: Lifestyle changes should be made such as reducing caffeine intake
(including green tea), stopping smoking, and losing weight.
Option C: Calcium has no effect on stress incontinence. Bladder training involves
learning techniques to increase the length of time between feeling the need to
urinate and passing urine. The course usually lasts for at least six weeks and can
be combined with the Kegel exercises. Some individuals may find that timed
toileting is helpful, particularly for people with a learning disability or
cognitive impairment.
Option D: The doctor may also suggest that the client avoid caffeinated,
carbonated, and alcoholic beverages, which may irritate and affect bladder function
in some people. If he finds that using fluid schedules and avoiding certain
beverages significantly improves leakage, the client will have to decide whether
making these changes in the diet are worth it.
Option E: The Crede maneuver helps manage reflex incontinence, not stress
incontinence. Pelvic floor muscle training is a technique that strengthens the
pelvic floor muscles and is an effective treatment for stress incontinence,
especially if the muscle has been damaged.
37. Question
A client who has an indwelling catheter reports the need to urinate. Which of the
following interventions should the nurse perform?

A. Check to see whether the catheter is patent.

B. Reassure the client that it is not possible for her to urinate.
C. Re-catheterize the bladder with a larger gauge catheter.
D. Collect a urine specimen for analysis.
Incorrect
Correct Answer: A. Check to see whether the catheter is patent.

A clogged or kinked catheter causes the bladder to fill and stimulates the need to
urinate. An indwelling urinary catheter (IUC), generally referred to as a “Foley”
catheter, is a closed sterile system with a catheter and retention balloon that is
inserted either through the urethra or suprapubically to allow for bladder
drainage. External collecting devices (e.g. drainage tubing and bag) are connected
to the catheter for urine collection.

Option B: Reassuring the client that it is not possible to urinate is a non-

therapeutic response because it diminishes the client’s concern. Check the tube
once in a while for bends or kinks that keep pee from flowing out. Empty the leg
bag twice a day or when it’s half full. Keep the drainage bag below your bladder so
it drains well.
Option C: There are less invasive approaches the nurse can take before replacing
the catheter. Indwelling urinary catheters are recommended only for short-term use,
defined as less than 30 days (EAUN recommends no longer than 14 days.) The catheter
is inserted for continuous drainage of the bladder for two common bladder
dysfunction: urinary incontinence (UI) and urinary retention.
Option D: Although it may become necessary to collect a urine specimen, there is a
simpler approach the nurse can take to assess and possibly resolve the client’s
problem.
38. Question
A provider prescribes a 24-hour urine collection for a client. Which of the
following actions should the nurse take?

A. Discard the first voiding.

B. Keep all voidings in a container at room temperature.
 C. Ask the client to urinate and pour the urine into a specimen container.
D. Ask the client to urinate into the toilet, stop midstream, and finish urinating
into the specimen container.
Incorrect
Correct Answer: A. Discard the first voiding.

The nurse should discard the first voiding of the 24 hour urine specimen, and note
the time. 24-hour urine protein measures the amount of protein released in urine
over a 24-hour period. The normal value is less than 100 milligrams per day or less
than 10 milligrams per deciliter of urine.

Option B: The nurse should collect all voidings after that and keep them in a
refrigerated container. A 24-hour urine collection is done by collecting the urine
in a special container over a full 24-hour period. The container must be kept cool
until the urine is returned to the lab.
Option C: For a urinalysis, the nurse should ask the client to urinate and pour the
urine into a specimen container. Urine is made up of water and dissolved chemicals,
such as sodium and potassium. It also contains urea. This is made when protein
breaks down. And it contains creatinine, which is formed from muscle breakdown.
Normally, urine contains certain amounts of these waste products. It may be a sign
of a certain disease or condition if these amounts are not within a normal range.
Or if other substances are present.
Option D: For a culture, the nurse should ask the client to urinate first into the
toilet, then stop midstream, and finish urinating in the specimen container. A 24-
hour urine collection helps diagnose kidney problems. It is often done to see how
much creatinine clears through the kidneys. It’s also done to measure protein,
hormones, minerals, and other chemical compounds.
39. Question
A nurse is preparing to initiate a bladder training program for a client who has a
voiding disorder. Which of the following actions should the nurse take? Select all
that apply.

A. Establish a schedule of voiding prior to meal times.

B. Have the client record voiding times.
C. Gradually increase the voiding intervals.
D. Reminded client to hold urine until next scheduled voiding time.
E. Provide a sterile container for voiding.
Incorrect
Correct Answer: B, C, and D

Ask the client to keep track of voiding times is an appropriate nursing action.
Gradually increasing the voiding interval is an appropriate nursing action. The
client should be reminded to hold urine until the next scheduled voiding time.
Bladder training involves voiding at scheduled in frequent intervals and gradually
increasing these intervals to four hours.

Option A: Mealtimes are not regular, and the intervals may be longer than every
four hours. Bladder training requires following a fixed voiding schedule, whether
or not one feels the urge to urinate. If one feels an urge to urinate before the
assigned interval, he should use urge suppression techniques — such as relaxation
and Kegel exercises.
Option B: Keeping a diary of bladder activity is very important. This helps the
health care provider determine the correct place to start the training and to
monitor progress throughout the program.
Option C: Bladder training is an important form of behavior therapy that can be
effective in treating urinary incontinence. The goals are to increase the amount of
time between emptying the bladder and the amount of fluids the bladder can hold. It
also can diminish leakage and the sense of urgency associated with the problem.
Option D: When the client feels the urge to urinate before the next designated
time, he should use “urge suppression” techniques or try relaxation techniques like
deep breathing. Focus on relaxing all other muscles. If possible, he must sit down
until the sensation passes. If the urge is suppressed, adhere to the schedule. If
the client cannot suppress the urge, wait five minutes then slowly make way to the
bathroom. After urinating, re-establish the schedule. Repeat this process every
time an urge is felt.
Option E: A sterile container is not used in a bladder training program. When the
client has accomplished the initial goal, he should gradually increase the time
between emptying the bladder by 15-minute intervals. He should try to increase the
interval each week. However, he will be the best judge of how quickly he can
advance to the next step. Increase the time between each urination until he reaches
a three- to four-hour voiding interval.
40. Question
A nurse educator on a medical unit is reviewing factors that increase the risk of
urinary tract infections with a group of assistive personnel. Which of the
following should be included in the review? Select all that apply.

A. Having sexual intercourse on a frequent basis.

B. Lowering of testosterone levels.
C. Wiping from front to back.
D. The location of the vagina in relation to the anus.
E. Undergoing frequent catheterization.
Incorrect
Correct Answer: A, D, and E

Uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder

and associated structures. These are patients with no structural abnormality and no
comorbidities, such as diabetes, immunocompromised, or pregnancy. Uncomplicated UTI
is also known as cystitis or lower UTI. E.coli causes the majority of UTI but other
organisms of importance include proteus, klebsiella, and enterococcus. The
diagnosis of UTI is made from the clinical history and urinalysis, but the proper
collection of the urine sample is important.

Option A: Having sexual intercourse on a frequent basis is a factor that increases

the risk of UTI in both males and females. Sexual intercourse and the use of
spermicide and diaphragm are also risk factors for UTI. Sexual intercourse is a
common cause of a UTI as it promotes the migration of bacteria into the bladder.
People who frequently void and empty the bladder have a much lower risk of a UTI.
Option B: The decrease in estrogen levels during menopause increases a woman’s
susceptibility to UTIs. An uncomplicated UTI usually only involves the bladder.
When the bacteria invade the bladder mucosal wall, cystitis is produced. The
majority of organisms causing a UTI are enteric coliforms that usually inhabit the
periurethral vaginal introitus. These organisms ascend into the bladder and cause a
UTI.
Option C: Wiping from front to back decreases a woman’s risk of UTIs. After
urination, women should wipe from front to back, not from the anal area forward,
which seems to drag pathogenic organisms nearer to the urethra. Bacteria that cause
UTI have adhesins on their surface which allow the organism to attach to the
mucosal surface. In addition, a short urethra also makes it easier for the
uropathogen to invade the urinary tract. Premenopausal women have large
concentrations of lactobacilli in the vagina and prevent the colonization of
uropathogens. However, the use of antibiotics can erase this protective effect.
Option D: The close proximity of the female urethra to the anus is a factor that
increases the risk of UTIs. Pathogenic bacteria ascend from the perineum, causing
UTI. Women have shorter urethras than men and therefore are more susceptible to
UTI. Very few uncomplicated UTIs are caused by blood-borne bacteria. Escherichia
coli is the most common organism in uncomplicated UTI by a large margin.
Option E: Undergoing frequent catheterization and the use of indwelling catheters
are risk factors for UTIs. A major risk factor for UTI is the use of a catheter. In
addition, manipulation of the urethra is also a risk factor. In-and-out
catheterization of the bladder will cause UTI in uninfected women 1% of the time.
Men should start the urine stream to clean the urethra and then obtain a midstream
sample. Urine should be sent to the lab immediately or refrigerated because
bacteria grow rapidly when a sample is left at room temperature, causing an
overestimate of the infection’s severity.
41. Question
To prevent postoperative complications, Nurse Kim assists the client with coughing
and deep breathing exercises. This is best accomplished by implementing which of
the following?

A. Coughing exercises one hour before meals and deep breathing one hour after
meals.
B. Forceful coughing as many times as tolerated.
C. Huff coughing every two hours or as needed.
D. Diaphragmatic and pursed lip breathing 5 to 10 times, four times a day.
Incorrect
Correct Answer: C. Huff coughing every two hours or as needed.

Huff coughing helps keep the airways open and secretions mobilized. Huff coughing
is an alternative for clients who are unable to perform a normal forceful cough
(such as postoperatively) deep breathing and coughing should be performed at the
same time.

Option A: Only at mealtimes is not sufficient. Deep breathing and coughing

exercises can decrease the risk of lung complications following surgery. Not only
can they prevent pneumonia, deep breathing helps to get more oxygen to the body’s
cells. These exercises can also be beneficial to individuals who are susceptible to
pulmonary or respiratory problems. Coughing and deep breathing work to clear mucus
and allow moist air to enter the airways.
Option B: Extended forceful coughing fatigues the client, especially
postoperatively. If you are lying in bed and need to cough, it may be more
comfortable to bend your knees up. Lean forward when you cough, if you are sitting
in a chair. Place a pillow over your surgical incision and apply pressure to the
area while coughing. This can help to alleviate any discomfort you feel. It’s more
comfortable to sit upright if you can when doing coughing exercises.
Option D: Diaphragmatic and pursed-lip breathing are techniques used for clients
with obstructive airway disease. You can perform breathing exercises by relaxing
your shoulders and upper chest. Take a deep breath in through your nose. Hold the
breath for three seconds. Breathe out slowly through your mouth. Repeat three
times. Taking too many breaths can make you dizzy or light-headed. Perform
breathing exercises every hour.
42. Question
Nurse Trixie is preparing to perform tracheostomy care. Prior to the beginning of
the procedure, the nurse performs which action?

A. Tells the client to raise two fingers to indicate pain or distress.

B. Changes twill tape holding the tracheostomy and place.
C. Cleans the incision site.
D. Check the tightness of the ties and knot.
Incorrect
Correct Answer: A. Tells the client to raise two fingers to indicate pain or
distress.

Prior to starting the procedure, it is important to develop a means of

communication by which the client can express pain or discomfort. Tracheostomy is a
procedure where an artificial airway is established surgically or percutaneously in
the cervical trachea. The term “tracheostomy” has evolved to refer to both the
procedure as well as the clinical condition of having a tracheostomy tube. With the
increasing number of patients with tracheostomy, safe caring requires knowledge and
competencies in dealing with routine care, weaning, decannulation, as well as
tracheostomy-related emergencies.

Option B: The twill tape is not changed until after performing tracheostomy care.
Remove any sutures or ties attached to the tracheostomy tube and patient. When
doing this, the assistant must stabilize the flange at all times to prevent
premature removal.
Option C: Cleaning the incision should be done after cleaning the inner cannula.
Inspect the stoma for signs of infection, presence of granulation tissue, bleeding,
wound breakdown, and adequacy of a tract. Clean the area with moist gauze (with
normal saline or hydrogen peroxide) followed by dry gauze while ensuring no foreign
body enters the airway. Stay sutures, if present, may be used gently to pull up the
trachea to provide exposure.
Option D: Checking the tightness of the ties and knot is done after applying new
twill tape. Make sure the trach ties are not too tight and should be able to pass
an index finger in between the trach ties and neck.
43. Question
Which action by the nurse represents proper nasopharyngeal/nasotracheal suctioning
technique?

A. Lubricate the suction catheter with petroleum jelly before and between
insertion.
B. Apply suction intermittently while inserting the suction catheter.
C. Rotate the catheter while applying suction.
D. Hyper oxygenate with 100% oxygen for 30 minutes before and after suctioning.
Incorrect
Correct Answer: C. Rotate the catheter while applying suction.

Rotating the catheter prevents pulling of tissue into the opening on the catheter
tip and the side. Suction is used to clear retained or excessive lower respiratory
tract secretions in patients who are unable to do so effectively for themselves.
This could be due to the presence of an artificial airway, such as an endotracheal
or tracheostomy tube, or in patients who have a poor cough due to an array of
reasons such as excessive sedation or neurological involvement.

Option A: Suction catheters may only be lubricated with water or water-soluble

lubricant and petroleum jelly such as Vaseline has an oil base. Lubricate the
outside of the airway with a water-soluble/aqueous gel (e.g. KY Jelly). Initially,
choose the larger nostril that is clear from other tubes (e.g. nasogastric tube).
Insert the tip of the NPA into the nostril, then slightly lift the nares up and
direct the airway to follow a path along the floor of the nose, parallel to the
hard palate.
Option B: No suction should ever be applied while the catheters are being inserted
because this can traumatize tissues. Apply a gentle partial rotation to the NPA if
resistance is felt during insertion e.g. from opposition against the turbinates. If
this does not relieve the resistance/obstruction then withdraw the airway and try
the other nostril before selecting a smaller size.
Option D: The client should be hyper-oxygenated for only a few minutes before and
after suctioning and this is generally limited to clients who are intubated or have
a tracheostomy. Hyper-oxygenate the patient if able (increase mask flow rate or
FiO2) delivery of 100% oxygen for > 30 secs prior to the suction event.
44. Question
Which client statement informs the nurse that his teaching about the proper use of
an incentive spirometer was effective?

A. "I should breathe out as fast and as hard as possible into the device."
B. "I should inhale slowly and steadily to keep the balls up."
C. "I should use the device three times a day, after meals."
 D. "The entire device should be washed thoroughly in sudsy water once a week."
Incorrect
Correct Answer: B. “I should inhale slowly and steadily to keep the balls up.”

Proper use of an SMI requires the client to take slow, steady inhalations, every
hour or two, 5 to 10 reps each time. Spirometry is one of the most readily
available and useful tests for pulmonary function. It measures the volume of air
exhaled at specific time points during complete exhalation by force, which is
preceded by a maximal inhalation. The most important variables reported include
total exhaled volume, known as the forced vital capacity (FVC), the volume exhaled
in the first second, known as the forced expiratory volume in one second (FEV1),
and their ratio (FEV1/FVC).

Option A: The patient must breathe in as much air as they can with a pause lasting
for less than 1s at the total lung capacity. The mouthpiece is placed just inside
the mouth between the teeth, soon after the deep inhalation. The lips should be
sealed tightly around the mouthpiece to prevent air leakage. Exhalation should last
at least 6 seconds, or as long as advised by the instructor. If only the forced
expiratory volume is to be measured, the patient must insert the mouthpiece after
performing step 1 and must not breathe from the tube.
Option C: The procedure is repeated in intervals separated by 1 minute until two
matching, and acceptable results are acquired. Spirometry has proved to be a
crucial tool in diagnosing lung disease, monitoring patients for their pulmonary
function, and assessing their fitness for various procedures.
Option D: Only the mouthpiece can be successfully rinsed or wiped clean. The device
should not be submerged in water. Spirometry is an apparatus used to assess
pulmonary function for diagnostic or monitoring purposes. The procedure must be
explained thoroughly to the subject patient by competent personnel who underwent
training under supervision by a specialist mentor and will undergo periodic
retraining in order to ensure that the results obtained are as accurate as possible
and the complications are kept to a minimum.
45. Question
While a client with chest tubes is ambulating, the connection between the tube and
the water seal dislodges. Which action by Nurse Flora is most appropriate?

A. Assist the client to ambulate back to bed.

B. Reconnect the tube to the water seal.
C. Assess the client's lung sounds with a stethoscope.
D. Have the client cough forcibly several times.
Incorrect
Correct Answer: B. Reconnect the tube to the water seal.

The tube should be reconnected to the water seal as quickly as possible. Assisting
the client back to bed and assessing the client’s lung are possible actions after
the system is reconnected. Or place the end of the tube in a bottle of sterile
water, creating a water seal. Instruct a colleague to prepare a new sterile chest-
drainage collection device, or retrieve a new sterile connector while safely
returning the patient to bed. Observe the patient for signs and symptoms of
respiratory decline. Then reconnect the chest tube to the new drain and unclamp it.

Option A: If walking with the patient and the chest tube becomes dislodged where it
connects to the drainage tubing, immediately close off the tubing to air with a
gloved hand by crimping it or using a clamp, if readily available.
Option C: Whether chest-tube removal was planned or unplanned, monitor the patient
closely for signs and symptoms of respiratory compromise, using such techniques as
pulse oximetry (Spo2), end-tidal carbon dioxide (ETco2) monitoring, and breath
sound auscultation.
Option D: Monitor the patient’s respiratory rate and effort. A repeat chest X-ray
(if indicated) may be done to compare to previous films and evaluate for presence
or return of a pneumothorax, an effusion, or other problem.
46. Question
Nurse Peter makes the assessment that which client has the greatest risk for a
problem with the transport of oxygen from the lungs to the tissues? A client who
has:

A. Anemia
B. An infection
C. A fractured rib
D. A tumor of the medulla
Incorrect
Correct Answer: A. Anemia

Anemia is a condition of decreased red blood cells and decreased hemoglobin.

Hemoglobin is how the oxygen molecules are transported to the tissues. Anemia is
described as a reduction in the proportion of red blood cells. Anemia is not a
diagnosis, but a presentation of an underlying condition. Whether or not a patient
becomes symptomatic depends on the etiology of anemia, the acuity of onset, and the
presence of other comorbidities, especially the presence of cardiovascular disease.

Option B: An infection would depend on its location. Infections can be caused by a

variety of different organisms, including viruses, bacteria, fungi, and parasites.
The different ways that you can get an infection can be just as diverse as the
organisms that cause them.
Option C: A fractured rib would interrupt the transport of oxygen from the
atmosphere to the airways. Broken ribs are most commonly caused by direct impacts —
such as those from motor vehicle accidents, falls, child abuse, or contact sports.
Ribs also can be fractured by repetitive trauma from sports like golf and rowing or
from severe and prolonged coughing.
Option D: Damage to the medulla would interfere with neural stimulation of the
respiratory system. Tumors of the medulla cause swallowing problems and limb
weakness.
47. Question
Which term does the nurse document to best describe a client experiencing shortness
of breath while lying down who must assume an upright or sitting position to
breathe more comfortably and effectively?

A. Dyspnea
B. Hyperpnea
C. Orthopnea
D. Apnea
Incorrect
Correct Answer: C. Orthopnea

Respiratory difficulty related to a reclining position without other physical

alterations is defined as orthopnea. Orthopnea is the sensation of breathlessness
in the recumbent position, relieved by sitting or standing. Orthopnea is caused by
pulmonary congestion during recumbency. In the horizontal position there is
redistribution of blood volume from the lower extremities and splanchnic beds to
the lungs.

Option A: Dyspnea is the medical term for shortness of breath, sometimes described
as “air hunger.” It is an uncomfortable feeling. Shortness of breath can range from
mild and temporary to serious and long-lasting. It is sometimes difficult to
diagnose and treat dyspnea because there can be many different causes.
Option B: Hyperpnea is breathing more deeply and sometimes faster than usual. It’s
normal during exercise or exertion. Hyperpnea is breathing deeply, a normal
response to exertion requiring more oxygen. This is when you’re breathing in more
air but not necessarily breathing faster. It can happen during exercise or because
of a medical condition that makes it harder for your body to get oxygen, like heart
failure or sepsis (a serious overreaction by your immune system).
Option D: Apnea is breathing that stops briefly during sleep. Oxygen to the brain
is decreased. It requires treatment. Apnea is the medical term used to describe
slowed or stopped breathing. Apnea can affect people of all ages, and the cause
depends on the type of apnea one has. Apnea usually occurs while sleeping. For this
reason, it’s often called sleep apnea.
48. Question
A client with emphysema is prescribed corticosteroid therapy on a short-term basis
for acute bronchitis. The client asks the nurse how the steroids will help him. The
nurse responded by saying that the corticosteroids will do which of the following?

A. Promote bronchodilation
B. Help the client to cough
C. Prevent respiratory infection
D. Decrease inflammation in the airways
Incorrect
Correct Answer: D. Decrease inflammation in the airways

Glucocorticoids are prescribed because of their anti-inflammatory effect. Options

1, 2, and 4 are not achieved with glucocorticoids. Corticosteroids produce their
effect through multiple pathways. In general, they produce anti-inflammatory and
immunosuppressive effects, protein and carbohydrate metabolic effects, water and
electrolyte effects, central nervous system effects, and blood cell effects.

Option A: The glucocorticoid receptor is located intracellularly within the

cytoplasm and upon binding trans-locates rapidly into the nucleus where it affects
gene transcription and causes inhibition of gene expression and translation for
inflammatory leukocytes and structural cells such as epithelium. This action leads
to a reduction in proinflammatory cytokines, chemokines, and cell adhesion
molecules, as well as other enzymes involved in the inflammatory response.
Option B: The non-genomic mechanism occurs more rapidly and is mediated through
interactions between the intracellular glucocorticoid receptor or a membrane-bound
glucocorticoid receptor. Within seconds to minutes of receptor activation, a
cascade of effects is set off, including inhibition of phospholipase A2, which is
critical for the production of inflammatory cytokines, impaired release of
arachidonic acid, and regulation of apoptosis in thymocytes.
Option C: Their nonendocrine role regularly takes advantage of their potent anti-
inflammatory and immunosuppressive effects to treat patients with a wide range of
immunologic and inflammatory disorders. Corticosteroids are used at physiologic
doses as replacement therapy in cases of adrenal insufficiency and supraphysiologic
doses in treatments for anti-inflammatory and immunosuppressive effects.
49. Question
Nurse Aleli is planning to perform percussion and postural drainage. Which is an
important aspect of planning the clients’ care?

A. Percussion and postural drainage should be done before lunch.

B. The order should be coughing, percussion, positioning, and then suctioning.
C. A good time to perform percussion and postural drainage is in the morning after
breakfast when the client is well rested.
D. Percussion and postural drainage should always be preceded by three minutes of
100% oxygen.
Incorrect
Correct Answer: A. Percussion and postural drainage should be done before lunch.

Postural drainage results in expectoration of large amounts of mucus. Clients

sometimes ingest part of the secretions. The secretions may also produce an
unpleasant taste in the oral cavity, which could result in nausea/vomiting. This
procedure should be done on an empty stomach to decrease client discomfort.
Option B: PD & P involves a combination of techniques, including multiple positions
to drain the lungs, percussion, vibration, deep breathing and coughing. When the
person with CF is in one of the positions, the caregiver can clap on the person’s
chest wall. This is usually done for three to five minutes and is sometimes
followed by vibration over the same area for approximately 15 seconds (or during
five exhalations). The person is then encouraged to cough or huff forcefully to get
the mucus out of the lungs.
Option C: Generally, each treatment session can last for 20 to 40 minutes. PD & P
is best done before meals or one and a half to two hours after eating, to decrease
the chance of vomiting. Early morning and bedtimes are usually recommended. The
length of PD & P and the number of times of day it is done may need to be increased
if the person is more congested or getting sick.
Option D: When the person with CF is in one of the positions, the caregiver can
clap on the person’s chest wall. This is usually done for three to five minutes and
is sometimes followed by vibration over the same area for approximately 15 seconds
(or during five exhalations). The person is then encouraged to cough or huff
forcefully to get the mucus out of the lungs.
50. Question
Nurse Winona teaches a patient how to use an incentive spirometer. What patient
outcome will support the conclusion that the use of the incentives spirometer was
effective?

A. Supplemental oxygen use will be reduced.

B. Inspiratory volume will be increased.
C. Sputum will be expectorated.
D. Coughing will be stimulated.
Incorrect
Correct Answer: B. Inspiratory volume will be increased.

An incentive spirometry or provides a visual goal for and measurement of

inspiration. It encourages the patient to execute and maintain a sustained
inspiration. A sustained inspiration opens airways, increases the inspiratory
volume, and reduces the risk of atelectasis. Spirometry is one of the most readily
available and useful tests for pulmonary function. It measures the volume of air
exhaled at specific time points during complete exhalation by force, which is
preceded by a maximal inhalation.

Option A: Patients who use an incentive spirometer may or may not be receiving
oxygen. All patients must be informed that they must abstain from smoking, physical
exercise in the hours before the procedure. Any bronchodilator therapy must also be
stopped beforehand.
Option C: Although sputum may be expectorated after the use of an incentive
spirometer, this is not the primary reason for its use. Recent evidence also
supports the use of spirometry in non thoracic surgeries. A recent retrospective
observational study found that lower preoperative spirometry FVC may predict
postoperative pulmonary complications in high-risk patients undergoing abdominal
surgery.
Option D: Although the deep breathing associated with the use of an incentive
barometer may stimulate coughing, this is not the primary reason for its use.
Complete spirometry exams will identify FEV1, forced vital capacity (FVC), vital
capacity (VC), residual lung volume (RV), maximum voluntary minute ventilation
(MMV), and total lung capacity (TLC). One parametric that is highly indicative of
postoperative complications is predicted postoperative FEV 1(ppo FEV 1). Predicted
postoperative FEV1 <30% are at a higher risk of postoperative pulmonary
complications after thoracic surgery.
51. Question
Nurse AJ is applying a warm compress. What should the nurse explain to the patient
is the primary reason why heat is used instead of cold?
 A. Minimizes muscle spasms
B. Prevents hemorrhage
C. Increases circulation
D. Reduces discomfort
Incorrect
Correct Answer: C. Increases circulation

Heat increases the skin surface temperature, promoting vasodilation, which

increases blood flow to the area. Cold has the opposite effect: it promotes
vasoconstriction, which decreases blood flow to the area. In general, heat therapy
is also recommended prior to exercise for those who have chronic injuries. Heat
warms the muscles and helps increase flexibility. The only time one should ever
consider using cold to treat a chronic injury is after finishing exercising when
inflammation may reappear. Applying cold at this time helps reduce any residual
swelling.

Option A: Both heat and cold relax muscles and thus minimize muscle spasms. It
reduces joint stiffness and muscle spasm, which makes it useful when muscles are
tight. There is no advantage to using heat over cold. When muscles work, chemical
byproducts are made that need to be eliminated. When exercise is very intense,
there may not be enough blood flow to eliminate all the chemicals. It is the
buildup of chemicals (for example, lactic acid) that cause muscle ache. Because the
blood supply helps eliminate these chemicals, use heat to help sore muscles after
exercise.
Option B: Heat does not prevent hemorrhage; heat causes vasodilation, which
promotes hemorrhage. Apply an ice compress to the injury as soon as possible. This
will cool down the tissues, lower their metabolic rate and nerve conduction
velocity, resulting in vasoconstriction of the surrounding blood vessels and
reduced inflammation.
Option D: Both heat and cold can reduce discomfort. Cold reduces discomfort by
numbing the area, slowing the transmission of pain impulses, and increasing the
pain threshold. Heat reduces the discomfort by relaxing the muscles. When an injury
or inflammation, such as tendonitis or bursitis occurs, tissues are damaged. Cold
numbs the affected area, which can reduce pain and tenderness. Cold can also reduce
swelling and inflammation.
52. Question
A practitioner orders chest physiotherapy with percussion and vibration for a newly
admitted patient. Which information obtained by the nurse during the health history
should alert the nurse to question the practitioner’s order?

A. Emphysema
B. Osteoporosis
C. Cystic fibrosis
D. Chronic bronchitis
Incorrect
Correct Answer: B. Osteoporosis

Implementing the practitioner’s order may compromise patient safety because

percussion and vibration in the presence of osteoporosis may cause fractures.
Osteoporosis is an abnormal loss of bone mass and strength. Chest physiotherapy is
a group of physical techniques that improve lung function and help you breathe
better. Chest PT, or CPT expands the lungs, strengthens breathing muscles, and
loosens and improves drainage of thick lung secretions.

Option A: These are appropriate interventions for a patient with emphysema.

Emphysema is a chronic pulmonary disease characterized by an abnormal increase in
the size of air spaces distal to the terminal bronchioles with destructive changes
in their walls. Chest percussion and vibration to help loosen lung secretions. Some
patients wear a special CPT vest hooked up to a machine. The machine makes the vest
vibrate at a high frequency to break up the secretions.
Option C: These are appropriate interventions for a patient with cystic fibrosis
causes widespread dysfunction of the exocrine glands. It is characterized by thick,
tenacious secretions in the respiratory system that block the bronchioles, creating
breathing difficulties. Chest PT helps treat such diseases as cystic fibrosis and
COPD (chronic obstructive pulmonary disease). It also keeps the lungs clear to
prevent pneumonia after surgery and during periods of immobility.
Option D: These are appropriate interventions for a patient with chronic
bronchitis. Bronchitis is an inflammation of the mucous membranes of the bronchial
airways. The doctor may recommend chest PT to help loosen and cough up thick or
excessive lung secretions from such conditions as lung infections, which include
pneumonia, acute bronchitis, and lung abscess.
53. Question
Nurse Sue teaches a patient about pursed lip breathing. The nurse identifies that
the teaching is affected when the patient says its purpose is to:

A. Precipitate coughing
B. Help maintain open airways
C. Decrease intrathoracic pressure
D. Facilitate expectoration of mucus
Incorrect
Correct Answer: B. Help maintain open airways

Pursed-lip breathing involves deep inspiration and prolonged expiration against

slightly closed lips. The pursed lips create a resistance to the air flowing out of
the lungs, which prolongs exhalation and maintains positive airway pressure,
thereby maintaining an open airway and preventing airway collapse. Pursed lip
breathing is beneficial for people with chronic lung disease. It can help
strengthen the lungs and make them more efficient.

Option A: Deep breathing and huff coughing, not pursed-lip breathing, stimulate
effective coughing. Deep breathing prevents air from getting trapped in the lungs,
which can cause the client to feel short of breath. As a result, the client can
breathe in a more fresh air.
Option C: Pursed lip breathing increases, not decreased intrathoracic pressure.
Pursed lip breathing is a simple technique for slowing down a person’s breathing
and getting more air into their lungs. With regular practice, it can help
strengthen the lungs and make them work more efficiently. The technique involves
breathing in through the nose and breathing out slowly through the mouth.
Option D: The huff coughing stimulates the natural cough reflex and is effective
for clearing the central airways of sputum. Saying the word huff with short
forceful exhalations keeps the glottis open, mobilizes sputum, and stimulates a
cough. When one has COPD, mucus can build up more easily in the lungs. The huff
cough is a breathing exercise designed to help one cough up mucus effectively
without making one feel too tired. A huff cough should be less tiring than a
traditional cough, and it can keep one from feeling worn out when coughing up
mucus.
54. Question
What should Nurse Mavie do first if a patient is choking on food?

A. Apply sharp for thrusts over the patient's xiphoid process.

B. Determine if the patient can make any verbal sounds.
C. Hit the middle of the patients back firmly.
D. Sweep the patient's mouth with a finger.
Incorrect
Correct Answer: B. Determine if the patient can make any verbal sounds.

When a person is choking on food, the first intervention is to determine if the

person can speak because the next intervention will depend on if it is partial or
total airway obstruction. With a partial airway obstruction, the person will be
able to make sounds because some air can pass from the lungs through the vocal
cords. In this situation the person’s own efforts open parentheses gagging and
coughing) should be allowed to clear the airway. With a total airway obstruction,
the person will not be able to make a sound because the airway is blocked and the
nurse should immediately initiate the abdominal thrust maneuver (Heimlich
maneuver).

Option A: Thrusts to the xiphoid process may cause a fracture that may result in a
pneumothorax. The foreign body lodged in the larynx or trachea is most dangerous as
this causes complete airway obstruction. Alternatively, foreign bodies such as
small beads or small pieces of food may pass below the vocal cords and become
lodged at the carina or within a mainstem bronchus. In adults, due to differences
in right versus left pulmonary anatomy, foreign bodies are more commonly retrieved
from the right main bronchus. However, children will have equal likelihood in
either bronchus, due to equal growth until the age of 16.
Option C: All adults can and should receive the Heimlich maneuver while they are
conscious. If the Heimlich cannot be performed due to body habitus or pregnancy,
the American Heart Association recommends a supine patient with force again applied
just above the umbilicus in a cephalad posterior vector. If the adult loses
consciousness, it is imperative to check for a pulse and begin cardiopulmonary
resuscitation if a pulse is not detected. Advanced airway techniques are now
indicated, and you may be able to visualize the foreign body under direct
laryngoscopy.
Option D: Never sweep a choking patient’s mouth with a finger. It might further
dislodge the food. The commonly known abdominal thrust maneuver, known as the
Heimlich maneuver, is performed by a bystander on a person who appears to be
choking. The bystander stands behind the subject and wraps his/her arms around the
upper abdominal region, about two inches above the belly button. Making a fist with
one hand and wrapping the other hand tightly over the fist and delivering five
sharp midline thrusts inward and upward.
55. Question
Nurse Stephanie is assessing a client who has an acute respiratory infection that
puts her at risk for hypoxemia. Which of the following findings are early
indications that should alert the nurse that the client is developing hypoxemia?
Select all that apply.

A. Restlessness
B. Tachypnea
C. Bradycardia
D. Confusion
E. Cyanosis
Incorrect
Correct Answer: A, B, & E

Restlessness, tachypnea, and pallor are early manifestations of hypoxemia, along

with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring,
tracheal tugging, and adventitious lung sounds. Bradycardia and confusion are late
manifestations of hypoxemia, along with stupor, cyanotic skin and mucous membranes,
bradypnea, hypotension, and cardiac dysrhythmias. Hypoxemia is defined as a
decrease in the partial pressure of oxygen in the blood whereas hypoxia is defined
by reduced level of tissue oxygenation. It can be due to either defective delivery
or defective utilization of oxygen by the tissues.

Option A: When oxygen delivery is severely compromised, organ function will start
to deteriorate. Neurologic manifestations include restlessness, headache, and
confusion with moderate hypoxia. In severe cases, altered mentation and coma can
occur, and if not corrected quickly may lead to death.
Option B: The chronic presentation is usually less dramatic, with dyspnea on
exertion as the most common complaint. Symptoms of the underlying condition that
induced the hypoxia can help in narrowing the differential diagnosis. The physical
exam may show tachypnea and low oxygen saturation. Fever may point to infection as
the cause of hypoxia.
Option C: Bradycardia is a late manifestation of hypoxemia. Increase in cardiac
output with exercise results in accelerated blood flow through alveoli, reducing
the time available for gas exchange. In case of the abnormal pulmonary
interstitium, gas exchange time becomes insufficient, and hypoxemia ensues.
Option D: Both confusion and somnolence may occur in respiratory failure. Myoclonus
and seizures may occur with severe hypoxemia. Polycythemia is a complication of
long-standing hypoxemia.
Option E: Cyanosis, a bluish color of skin and mucous membranes, indicates
hypoxemia. Visible cyanosis typically is present when the concentration of
deoxygenated hemoglobin in the capillaries of tissues is at least 5 g/dL.
56. Question
Nurse CJ is caring for a client who is having difficulty breathing. The client is
lying in bed and is already receiving oxygen therapy via nasal cannula. Which of
the following interventions is the nurse’s priority?

A. Increase the oxygen flow.

B. Assist the client with Fowler's position.
C. Promote removal of pulmonary secretions.
D. Attain a specimen for arterial blood gases.
Incorrect
Correct Answer: B. Assist the client with Fowler’s position.

The priority action the nurse should take when using the airway, breathing,
circulation approach to care delivery is to relieve the clients’ dyspnea. Fowler’s
position facilitates maximal long expansion and thus optimizing breathing. With the
client in this position, the nurse can better assess and determine the cause of the
clients dyspnea.

Option A: The client may need more oxygen, as hypoxemia may be the cause of his
difficulty breathing. However, administering oxygen and adjusting the fraction of
inspired oxygen requires the provider’s prescription after a careful assessment of
the clients’ oxygenation status, there is a higher priority given the nature of the
client’s distress.
Option C: The client may need suction or expectoration, as pulmonary secretions may
be the cause of his difficulty breathing. However, there is a higher priority given
the nature of the client’s distress.
Option D: It is important to check the client’s oxygenation status, and in many
nursing situations, assessment precedes action, but there is a higher priority
given the nature of the clients’ distress.
57. Question
Nurse Aldrin is preparing to perform endotracheal suctioning for a client. Which of
the following are appropriate guidelines for the nurse to follow? Select all that
apply.

A. Apply suction while withdrawing the catheter.

B. Perform suctioning on a routine basis, every 2 to 3 hours.
C. Maintain medical asepsis during suctioning.
D. Use a new catheter for each suctioning attempt.
E. Limit suctioning to 2 to 3 attempts.
Incorrect
Correct Answer: A, D, & E

Within intensive care units (ICUs), one such common procedure is the suctioning of
respiratory secretions in patients who have been intubated or who have undergone
tracheostomy. The traditional goal of suctioning is to aid in maintaining airway
patency and prevent complications related to the retention of secretions

Option A: The nurse should apply suction pressure only while withdrawing the
catheter, not while inserting it. One interesting thing to note about ETS is that
negative pressure is created inside of the lungs only while air flows out of the
suction catheter. As soon as secretions are aspirated into the catheter, the
intrapulmonary pressure returns to that of the atmospheric level, and lung volume
loss stops.
Option B: The nurse should not suction routinely because suctioning is not without
risk. It can cause mucosal damage, bleeding, and bronchospasm. Although there has
been a very limited number of studies regarding a scheduled frequency of performing
ETS every 1, 3, 4, 6, 8, or even 12 hours, the overall recommendation is to suction
only as indicated (as needed).
Option C: Endotracheal suctioning requires surgical asepsis. The second method of
suctioning is the shallow (premeasured) technique, which is also considered
minimally invasive.1-3 With shallow ETS, the catheter is inserted only to the tip
of the ETT, thereby avoiding injury to the airway.
Option D: The nurse should not reuse the suction catheter unless an in-line
suctioning system is in place. If a suction catheter is too large for the ETT,
and/or there is too much vacuum pressure, massive atelectasis may occur. Therefore,
the general recommendation is to use a suction catheter that has an external
diameter less than 50% of the size of the ETT inner diameter.
Option E: To prevent hypoxemia, the nurse should limit each section in session to 2
to 3 attempts and allow at least one minute between passes for ventilation and
oxygenation. The reason for this is because there is considerable risk with using
“routine” suctioning. It has been suggested by Pedersen et al3 that ETS should be
performed at least every 8 hours to slow the formation of the secretion biofilm
within the lumen of the endotracheal tube (ETT). Clifton-Koeppel1 made a good
general recommendation that ETS should be performed as infrequently as possible—yet
as much as needed.
58. Question
A nurse is caring for a client who has a tracheostomy. Which of the following
actions should the nurse take each time he provides tracheostomy care? Select all
that apply.

A. Apply the oxygen source loosely if the SPO2 increases during the procedure.
B. Use surgical asepsis to remove and clean the inner cannula.
C. Clean the outer surfaces in a circular motion from the stoma site outward.
D. Replace the tracheostomy ties with new ties.
E. Cut a slit in gauze squares to place beneath the tube holder.
Incorrect
Correct Answer: A, B, & C

A tracheostomy is an opening (made by an incision) through the neck into the

trachea (windpipe). A tracheostomy opens the airway and aids breathing. A
tracheostomy may be required in an emergent setting to bypass an obstructed airway,
or (more commonly) may be placed electively to facilitate mechanical ventilation,
to wean from a ventilator, or to allow more efficient management of secretions
(referred to as pulmonary toilet), among other reasons.

Option A: The nurse must be prepared to provide supplemental oxygen in response to

any decline in oxygenation saturation while performing tracheostomy care. Nurses
need to understand all aspects of tracheostomy care, including routine and
emergency airway management, safe decannulation, weaning and safe discharge into
the community. The patient’s airway requires close monitoring 24 hours a day using
a tracheostomy care chart to record care.
Option B: The nurse should use a sterile disposable tracheostomy cleaning kit or
sterile supplies and maintain surgical asepsis throughout this part of the
procedure. The NTSP (2013) recommends that all patients with a tracheostomy have a
bed-head label with information regarding their tube and airway, including whether
it is surgical or percutaneous, the tube type, size and suction-catheter size,
patency of the upper airway and whether the tracheostomy is temporary, permanent or
involves a laryngectomy (removal of the larynx).
Option C: This action helps move mucus and contaminated material away from the
stoma for easy removal. The stoma site should be checked at least once a day, or
more frequently if required, and this requires two nurses: one to hold the tube and
one to clean the stoma site. The site should be cleaned using a tracheostomy wipe
or with 0.9% sodium chloride solution, and dried thoroughly.
Option D: To help keep the skin clean and dry, the nurse should replace the
tracheostomy ties if they are wet or soiled. There is a risk of two dislodgements
replacing the ties, so he should not replace them routinely. Leaving the old ties
in place while securing the clean ties prevents inadvertent dislodging of the
tracheostomy tube. Securing tapes in this manner avoids the use of knots, which can
come untied or cause pressure and irritation.
Option E: The nurse should use a commercially prepared tracheostomy dressing with a
slit in it. Cutting gauze squares can loosen lint or cause fibers the client could
aspirate. Use a commercially prepared tracheostomy dressing of non-raveling
material or open and refold a 4-in. X 4-in. Gauze dressing into a V shape. Avoid
using cotton-filled gauze squares or cutting the 4×4 gauze. Cotton lint or gauze
fibers can be aspirated by the client, potentially creating a tracheal abscess.
59. Question
An elderly nursing home resident has refused to eat or drink for several days and
is admitted to the hospital. The nurse should expect which assessment finding?

A. Increase blood pressure

B. Weak, rapid pulse
C. Moist mucous membranes
D. Jugular vein distention
Incorrect
Correct Answer: B. Week, rapid pulse

All other options are indicated by fluid volume excess. A client who has not eaten
or drunk anything for several days would be experiencing a fluid volume deficit.
The primary control of water homeostasis is through osmoreceptors in the brain.
Dehydration, as perceived by these osmoreceptors, stimulates the thirst center in
the hypothalamus, which leads to water consumption. These osmoreceptors can also
cause conservation of water by the kidney. When the hypothalamus detects lower
water concentration, it causes the posterior pituitary to release antidiuretic
hormone (ADH), which stimulates the kidneys to reabsorb more water.

Option A: Decreased blood pressure, which often accompanies dehydration triggers

renin secretion from the kidney. Renin converts angiotensin I to angiotensin II,
which increases aldosterone release from the adrenals. Aldosterone increases the
absorption of sodium and water from the kidney. Using these mechanisms, the body
regulates body volume and sodium and water concentration.
Option C: Some of the most common presenting symptoms of dehydration include but
are not limited to fatigue, thirst, dry skin and lips, dark urine or decreased
urine output, headaches, muscle cramps, lightheadedness, dizziness, syncope,
orthostatic hypotension, and palpitations. The physical examination could show dry
mucosa, skin tenting, delayed capillary refill, or cracked lips.
Option D: A 2015 Cochrane review evaluated predictors of dehydration in the
elderly. Historical and physical findings tested were dry axilla, mucous membranes,
tongue, increased capillary refill time, poor skin turgor, sunken eyes, orthostatic
blood pressure drop, dizziness, thirst, urine color, weakness, blue lips, altered
mentation, tiredness, and appetite. Of all these factors only fatigue and missed
drinks between meals predicted the diagnosis of dehydration.
60. Question
A man brings his elderly wife to the emergency department. He states that she has
been vomiting and has had diarrhea for the past two days. She appears lethargic and
is complaining of leg cramps. What should the nurse do first?

A. Start an IV.
B. Review the results of serum electrolytes.
C. Offer the woman foods that are high in sodium and potassium content.
D. Administer an antiemetic.
Incorrect
Correct Answer: B. Review the results of serum electrolytes.

Further assessment is needed to determine appropriate action. While the nurse may
perform some of the interventions in options one, three, and four, assessment is
needed initially. Electrolyte abnormalities may be addressed on an individual
level, although often these are caused by an overall fluid volume depletion which,
when corrected, will also cause electrolytes to normalize. Both saline and lactated
Ringer’s solutions appear to be effective for the treatment of dehydration due to
viral gastroenteritis.

Option A: The most important goal of treatment is to maintain hydration status and
effectively counter fluid and electrolyte losses. Fluid therapy is a fundamental
part of treatment. Intravenous fluids may be administered to those individuals who
appear dehydrated or to those unable to tolerate oral fluids.
Option C: No specific nutritional recommendations are universal for patients with
viral gastroenteritis. A diet of banana, rice, apples, tea, and toast is often
advised, but several studies have failed to show any significant outcome difference
when compared to regular diets.
Option D: Antiemetic medications such as ondansetron or metoclopramide may be used
to assist with controlling nausea and vomiting symptoms. Patients demonstrating
severe dehydration or intractable vomiting may require hospital admission for
continued intravenous fluids and careful monitoring of electrolyte status.
61. Question
Which of the following is the appropriate meaning of CBR?

A. Cardiac Board Room

B. Complete Bathroom
C. Complete Bed Rest
D. Complete Board Room
Incorrect
Correct Answer: C. Complete Bed Rest

CBR means complete bed rest. For more abbreviations, please see this post.
Standardization and uniform use of codes, symbols, and abbreviations can improve
communication and understanding between health care practitioners, leading to safer
and more effective care for patients.

Option A: When developing lists, hospitals need to ensure that abbreviations on the
approved list are not also on the do-not-use list, and vice versa. In addition,
abbreviations can have only one meaning within the entire organization—for example,
the abbreviation NKDA could mean “no known drug allergies,” or it could mean
“nonketotic diabetic acidosis,” but it cannot have both meanings in an
organization.
Option B: Appropriate use of abbreviations is particularly important. Numerous
studies have focused on health care practitioners’ understanding and interpretation
of abbreviations in medical documents, such as medical records, discharge
summaries, and medication orders. Findings indicate that it is not uncommon for
practitioners to have difficulty understanding the abbreviations used in their
hospitals.
Option D: To prevent misunderstandings and potential risks to patient safety,
requires hospitals to establish lists for approved and do-not-use abbreviations and
monitor for appropriate abbreviation use. There are resources for identifying
abbreviations for the do-not-use list, such as the Institute for Safe Medication
Practices (ISMP), which publishes a list of dangerous abbreviations not to be used
due to frequent misinterpretation and associated medication errors.
62. Question
One (1) tsp is equal to how many drops?

A. 15
B. 60
C. 10
D. 30
Incorrect
Correct Answer: B. 60

One teaspoon (tsp) is equal to 60 drops (gtts). When the nurse has an order for an
IV infusion, it is her responsibility to make sure the fluid will infuse at the
prescribed rate. IV fluids may be infused by gravity using a manual roller clamp or
dial-a-flow, or infused using an infusion pump. Regardless of the method, it is
important to know how to calculate the correct IV flow rate.

Option A: When calculating the flow rate, determine which IV tubing will be used,
microdrip or macrodrip, so the nurse can use the proper drop factor in her
calculations. The drop factor is the number of drops in one mL of solution, and is
printed on the IV tubing package. Macrodrip and microdrip refers to the diameter of
the needle where the drop enters the drip chamber.
Option C: Macrodrip tubing delivers 10 to 20 gtts/mL and is used to infuse large
volumes or to infuse fluids quickly. Microdrip tubing delivers 60 gtts/mL and is
used for small or very precise amounts of fluid, as with neonates or pediatric
patients.
Option D: To calculate the drops per minute, the drop factor is needed. The formula
for calculating the IV flow rate (drip rate) is… total volume (in mL) divided by
time (in min), multiplied by the drop factor (in gtts/mL), which equals the IV flow
rate in gtts/min.
63. Question
20 cc is equal to how many ml?

A. 2
B. 20
C. 2000
D. 20000
Incorrect
Correct Answer: B. 20

One cubic centimeter is equal to one milliliter. When clinicians are prepared and
know the key conversion factors, they will be less anxious about the calculation
involved. This is vital to accuracy, regardless of which formula or method
employed.

Option A: Drug calculations require the use of conversion factors, for example,
when converting from pounds to kilograms or liters to milliliters. Simplistic in
design, this method allows clinicians to work with various units of measurement,
converting factors to find the answer. These methods are useful in checking the
accuracy of the other methods of calculation, thus acting as a double or triple
check.
Option C: Units of measurement must match, for example, milliliters and
milliliters, or one needs to convert to like units of measurement. In the example
above, the ordered dose was in milligrams, and the have dose was in milligrams,
both of which cancel out leaving milliliters (answer called for milliliters), so no
further conversion is required.
Option D: All members of the interprofessional team are responsible for dose
calculations. Physicians, nurses, and pharmacists all must be conversant in the
desired overall formula. This technique is invaluable in properly treating
patients.
64. Question
1 cup is equal to how many ounces?

A. 8
B. 80
C. 800
D. 8000
Incorrect
Correct Answer: A. 8

One cup is equal to 8 ounces. Weight conversion is also utilized daily in health
care. There are two systems calculating weight used in all healthcare settings for
health management, such as medication dosing per patient body weight. First, the
metric system is in common use in health care in the US. It is also the only system
universally used in many countries on all continents of the globe. It has the
advantage of a decimal system in increments or the power of tenths. Second, the US
weight system customarily uses the ounce or pound. It derives from the British
colonial era. This non-metric system is still being used nowadays among laypersons
in the US for products sold to the public.

Option B: The metric system is essential in all health care settings. Patients are
weighed at each clinical encounter. Scales used in the US have double marking
indicators: metric and non-metric markings. Metric weight values are used in
medication calculation, radiation dosing, and weight compliance in equipment use,
such as the maximum weight of a CAT-SCAN unit or a surgical table that may hold a
person.
Option C: Nowadays, all medications are based on weight for dose calculations for
all populations but very specifically in children and infants. Adults have their
weight recorded mainly by their doctors at each physical patient-clinician
encounter. Commonly, most adults monitor their weight for weight management.
Clinicians record it in the electronic health records in both kilograms and pounds.
Option D: Commonly in healthcare and medical practices, the metric system is used
for weighing mass. In the metric system, there are increments at the power of the
tenth for calculations. This weight conversion is used daily among scientists and
health care providers.
65. Question
The nurse must verify the client’s identity before administration of medication.
Which of the following is the safest way to identify the client?

A. Ask the client his name.

B. Check the client’s identification band.
C. State the client’s name aloud and have the client repeat it.
D. Check the room number.
Incorrect
Correct Answer: B. Check the client’s identification band

The identification band is the safest way to know the identity of a patient whether
he is conscious or unconscious. Nurses have a unique role and responsibility in
medication administration, in that they are frequently the final person to check to
see that the medication is correctly prescribed and dispensed before
administration.

Option A: Ask the client his name only after you have checked his ID band. Right
patient’ – ascertaining that a patient being treated is, in fact, the correct
recipient for whom medication was prescribed. This is best practiced by nurses
directly asking a patient to provide his or her full name aloud, checking medical
wristbands if appropriate for matching name and ID number as on a chart.
Option C: It is advisable not to address patients by first name or surname alone,
in the event, there are two or more patients with identical or similar names in a
unit. Depending on the unit that a patient may be in, some patients, such as
psychiatric patients, may not wear wristbands or may have altered mentation to the
point where they are unable to identify themselves correctly. In these instances,
nurses are advised to confirm a patient’s identity through alternative means with
appropriate due diligence.
Option D: The medical literature states that the value of nurses’ critical
thinking, the role of patient advocacy, and clinical judgment are not accounted for
by the five rights framework that is commonly observed in modern practice to
deliver patient-centered care. Research has shown a clear benefit in the value of
nursing experience as it relates to decision-making capability; however, it states
that further studies are necessary to achieve an improved understanding of how
nurses apply intuition, the context of the situation, and interpretation.
66. Question
The nurse prepares to administer buccal medication. The medicine should be placed
in what area?

A. On the client’s skin.

B. Between the client’s cheeks and gums.
C. Under the client’s tongue.
D. On the client’s conjunctiva.
Incorrect
Correct Answer: B. Between the client’s cheeks and gums

Buccal administration involves placing a drug between the gums and cheek, where it
also dissolves and is absorbed into the blood. Because the medication absorbs
quickly, these types of administration can be important during emergencies when you
need the drug to work right away, such as during a heart attack.

Option A: An advantage of a transdermal drug delivery route over other types of

medication delivery such as oral, topical, intravenous, intramuscular, etc. is that
the patch provides a controlled release of the medication into the patient, usually
through either a porous membrane covering a reservoir of medication or through body
heat melting thin layers of medication embedded in the adhesive.
Option C: Sublingual administration involves placing a drug under the tongue to
dissolve and absorb into the blood through the tissue there. These drugs do not go
through the digestive system, so they aren’t metabolized through the liver. This
means you may be able to take a lower dose and still get the same results.
Option D: The three primary methods of delivery of ocular medications to the eye
are topical, local ocular (ie, subconjunctival, intravitreal, retrobulbar,
intracameral), and systemic. The most appropriate method of administration depends
on the area of the eye to be medicated. The conjunctiva, cornea, anterior chamber,
and iris usually respond well to topical therapy. The eyelids can be treated with
topical therapy but more frequently require systemic therapy. The posterior segment
always requires systemic therapy, because most topical medications do not penetrate
to the posterior segment. Retrobulbar and orbital tissues are treated systemically.
67. Question
The nurse administers a cleansing enema. The common position for this procedure is?

A. Sims left lateral

B. Dorsal Recumbent
C. Supine
D. Prone
Incorrect
Correct Answer: A. Sims left lateral
This position provides comfort to the patient and easy access to the natural
curvature of the rectum. Enemas are rectal injections of fluid intended to cleanse
or stimulate the emptying of the bowel. Enemas may also be prescribed to flush out
the colon before certain diagnostic tests or surgeries. The bowel needs to be empty
before these procedures to reduce infection risk and prevent stool from getting in
the way.

Option B: Position the patient on the left side, lying with the knees drawn to the
abdomen. This eases the passage and flow of fluid into the rectum. Gravity and the
anatomical structure of the sigmoid colon also suggest that this will aid enema
distribution and retention. Dorsal recumbent is a position in which the patient
lies on the back with the lower extremities moderately flexed and rotated outward.
It is employed in the application of obstetrical forceps, repair of lesions
following parturition, vaginal examination, and bimanual palpation.
Option C: The supine position means lying horizontally with the face and torso
facing up, as opposed to the prone position, which is face down. When used in
surgical procedures, it allows access to the peritoneal, thoracic, and pericardial
regions; as well as the head, neck, and extremities.
Option D: Prone position is a body position in which the person lies flat with the
chest down and the backup. In anatomical terms of location, the dorsal side is up,
and the ventral side is down. The supine position is the 180° contrast.
68. Question
A client complains of difficulty swallowing when the nurse tries to administer
capsule medication. Which of the following measures should the nurse do?

A. Dissolve the capsule in a glass of water.

B. Break the capsule and give the content with applesauce.
C. Check the availability of a liquid preparation.
D. Crush the capsule and place it under the tongue.
Incorrect
Correct Answer: C. Check the availability of a liquid preparation.

The nurse should check first if the medication is available in liquid form before
doing Choice A. The swallowing of capsules can be particularly difficult. This is
because capsules are lighter than water and float due to air trapped inside the
gelatine shell. In comparison, tablets are heavier than water and do not float.

Option A: The physical properties of capsules predispose them to floating in the

mouth when taken with water. As a result, the swallowing of capsules can be
problematic. In patients who experience such difficulty, it is suggested that they
try leaning forward when swallowing, as this has been found to assist. It may be
necessary to reassure patients about this technique as they may initially find it
unnatural to execute.
Option B: Some tablets, pills and capsules don’t work properly or may be harmful if
they’re crushed or opened. Most capsules are intended to be swallowed whole so
patients should be encouraged to trial the ‘lean-forward’ technique. If swallowing
difficulties remain other options, such as a liquid or tablet form of the medicine,
can be considered.
Option D: Placing it under the tongue is not the intended way of administering an
oral medication. Crushing the medication may alter the medicine’s effects. You
shouldn’t chew, crush or break tablets or pills, or open and empty powder out of
capsules unless your GP or another healthcare professional has told you to do so.
Some tablets, pills, and capsules don’t work properly or may be harmful if they’re
crushed or opened.
69. Question
Which of the following is the appropriate route of administration for insulin?

A. Intramuscular
 B. Intradermal
C. Subcutaneous
D. Intravenous
Incorrect
Correct Answer: C. Subcutaneous

The subcutaneous tissue of the abdomen is preferred because the absorption of the
insulin is more consistent from this location than subcutaneous tissues in other
locations. Insulin may be injected into the subcutaneous tissue of the upper arm
and the anterior and lateral aspects of the thigh, buttocks, and abdomen (with the
exception of a circle with a 2-inch radius around the navel).

Option A: Intramuscular injection is not recommended for routine injections.

Rotation of the injection site is important to prevent lipohypertrophy or
lipoatrophy. Rotating within one area is recommended (e.g., rotating injections
systematically within the abdomen) rather than rotating to a different area with
each injection. This practice may decrease variability in absorption from day to
day.
Option B: Site selection should take into consideration the variable absorption
between sites. The abdomen has the fastest rate of absorption, followed by the
arms, thighs, and buttocks. Exercise increases the rate of absorption from
injection sites, probably by increasing blood flow to the skin and perhaps also by
local actions.
Option D: Administration of mixtures of rapid- or short- and intermediate- or long-
acting insulins will produce a more normal glycemia in some patients than the use
of single insulin. The formulations and particle size distributions of insulin
products vary. On mixing, physicochemical changes in the mixture may occur (either
immediately or over time). As a result, the physiological response to the insulin
mixture may differ from that of the injection of the insulins separately.
70. Question
The nurse is ordered to administer ampicillin capsule TID p.o. The nurse should
give the medication by which frequency?

A. Three times a day orally

B. Three times a day after meals
C. Two times a day by mouth
D. Two times a day before meals
Incorrect
Correct Answer: A. Three times a day orally

TID is the Latin for “ter in die” which means three times a day. P.O. means per
orem or through mouth. The “time” of administration of medication is valuable
information to consider during patient counselling and is a typical query by
patients especially when filling a prescription for the first time.

Option B: The timing of doses isn’t the only question people may have when it comes
to deciphering prescriptions or oral communication from the doctor. Other
abbreviations include the number of refills allowed and whether one is receiving a
brand name or generic drug. Medical errors are a significant cause of death in the
United States. Fortunately, most of these errors are preventable when patients are
active advocates for their health and ask plenty of questions.
Option C: Two times a day by mouth is BID P.O. Seen on a prescription, b.i.d. means
twice (two times) a day. It is an abbreviation for “bis in die” which in Latin
means twice a day. The abbreviation b.i.d. is sometimes written without a period
either in lower-case letters as “bid” or in capital letters as “BID”.
Option D: However it is written, it is one of a number of hallowed abbreviations of
Latin terms that have been traditionally used in prescriptions to specify the
frequency with which medicines should be taken.
71. Question
Back Care is best described as:

A. Caring for the back by means of massage.

B. Washing of the back.
C. Application of cold compress at the back.
D. Application of hot compress at the back.
Incorrect
Correct Answer: A. Caring for the back by means of massage

Back care or massage is usually given in conjunction with the activities of bathing
the client. It can also be done on other occasions when a client seems to have a
risk of developing skin irritation due to bed rest. The goal when performing this
procedure is to enhance relaxation, reduce muscle tension and stimulate
circulation.

Option B: Help the patient to turn on his abdomen or on his side with his back
toward the nurse and his body near the edge of the bed so that he is as near the
operator as possible. If the supine position is used and the patient is a woman, a
pillow under the abdomen removes pressure from the breasts and favors relaxation.
Apply to back rubbing lotion or talcum powder to reduce friction. In rubbing the
back use firm long strokes and kneading motions. The amount of pressure to exert
depends upon the patient’s condition. Begin from the neck and shoulders then
proceed over the entire back.
Option C: Massage with both hands working with a strong stroke. In upward then in
downward motions. Give particular attention to pressure areas in rubbing (Alcohol
25%) to 50% is generally used for its refreshing effect, but rubbing lotion may be
used. Powder again the area at the completion of the rubbing process which should
consume from 3-5 minutes.
Option D: Effleurage (stroking) is a long sweeping movement with the palm of hand
conforming to the contour of the surface-treated, over a small surface (on the
neck) the thumb and fingers are used. Strokes should be slow, rhythmical, and
gentle with pressure constant and in the direction of the venous stream. Kneading
is performed with the ulnar side palm resting on the surface and the fingers, and
thumb grasping the skin and subcutaneous tissues which move with the hand of the
operator.
72. Question
It refers to the preparation of the bed with a new set of linens

A. Bed bath
B. Bed making
C. Bed shampoo
D. Bed lining
Incorrect
Correct Answer: B. Bed making

Bed making is one of the important nursing techniques to prepare various types of
bed for patients or clients to guarantee comfort and beneficial position for a
specific condition. The bed is particularly important for patients who are sick.
The nurse plays an inevitable role to ensure comfort and cleanliness for ill
patients. It should be adaptable to various positions as per patient’s needs
because they spend a varying amount of the day in bed.

Option A: Bed bathing is not as effective as showering or bathing and should only
be undertaken when there is no alternative (Dougherty and Lister, 2015). If a bed
bath is required, it is important to offer patients the opportunity to participate
in their own care, which helps to maintain their independence, self-esteem and
dignity.
Option C: The condition of their hair and how it is styled is an important part of
patients’ identity and wellbeing, so assisting them with hair care is a fundamental
aspect of nursing care
Option D: The purpose of a well-made hospital bed, as well as an appropriately
chosen mattress, is to provide a safe, comfortable place for the patient, where
repositioning is more easily achieved, and pressure ulcers are prevented.
73. Question
Which of the following is the most important purpose of handwashing?

A. To promote hand circulation.

B. To prevent the transfer of microorganisms.
C. To avoid touching the client with a dirty hand.
D. To provide comfort.
Incorrect
Correct Answer: B. To prevent the transfer of microorganism

Hand washing is the single most effective infection control measure. Handwashing
practices in the patient care setting began in the early 19th century. The practice
evolved over the years with evidential proof of its vast importance and coupled
with other hand-hygienic practices, decreased pathogens responsible for nosocomial
or hospital-acquired infections (HAI).

Option A: According to the Centers for Disease Control and Prevention (CDC), hand
hygiene is the single most important practice in the reduction of the transmission
of infection in the healthcare setting Transient microorganisms are often acquired
by healthcare workers through direct, close contact with patients or contaminated
inanimate objects or environmental surfaces. Transient flora colonizes the
superficial skin layers. It can be removed by routine hand washing more easily than
resident flora. These organisms vary in number depending upon body location.
Healthcare-associated infections are a result of these transient organisms.
Option C: Contaminated hands of healthcare providers are a primary source of
pathogenic spread. Proper hand hygiene decreases the proliferation of
microorganisms, thus reducing infection risk and overall healthcare costs, length
of stays, and ultimately, reimbursement. According to the CDC, hand hygiene
encompasses the cleansing of your hands with soap and water, antiseptic hand
washes, antiseptic hand rubs such as alcohol-based hand sanitizers, foams or gels,
or surgical hand antisepsis.
Option D: Indications for handwashing include when hands are visibly soiled,
contaminated with blood or other bodily fluids, before eating, and after restroom
use. Hands should be washed if there was potential exposure to Clostridium
difficile, Norovirus, or Bacillus anthracis. Alcohol-based hand sanitizers are the
recommended product for hand hygiene when hands are not visibly soiled. Apply
alcohol-based products per manufacturer guidelines on dispensing of the product.
Typically, 3 mL to 5 mL in the palm, rubbing vigorously, ensuring all surfaces on
both hands get covered, about 20 seconds is required for all surfaces to dry
completely.
74. Question
What should be done in order to prevent contaminating the environment in bed
making?

A. Avoid fanning soiled linens

B. Strip all linens at the same time
C. Finished both sides at the time
D. Embrace soiled linen
Incorrect
Correct Answer: A. Avoid fanning soiled linens

Fanning soiled linens would scatter the lodged microorganisms and dead skin cells
on the linens. Healthcare linens are known to harbor a number of microorganisms.
Most notably, there is an increased concern that methicillin-resistant
Staphylococcus aureus (MRSA)and vancomycin-resistant Enterococcus (VRE) can survive
for days on linens. There is further concern that these contaminated linens then
become a potential source of cross-contamination.

Option B: There is now a common understanding that linens, once in use, are usually
contaminated and could be harboring microorganisms such as MRSA and VRE. Further,
the Centers for Disease Control and Prevention (CDC) cautions that healthcare
professionals should handle contaminated textiles and fabrics with minimum
agitation to avoid contamination of air, surfaces, and persons. Even one of the
leading nursing textbooks, Fundamentals of Nursing, Soiled linen is never shaken in
the air because shaking can disseminate secretions and excretions and the
microorganisms they contain. This text also states linens that have been soiled
with excretions and secretions harbor microorganisms that can be transmitted to
others.
Option C: Healthcare laundry protocols have long relied on chlorine-based
sanitizers to kill bacteria in bed linens and other fabrics. While chlorine is
known as one of the best antimicrobial agents in the world, its power has been
limited because it evaporates from untreated fabric soon after laundering. But with
this new patented technology in HaloShield ® linens, the chlorine keeps killing
bacteria right up until the next laundering.
Option D: The environment in which linens are used in healthcare is often ideal for
the proliferation and spread of bacteria and viruses. Often the patient, in a
weakened or compromised state, is lying on a sheet. That sheet under the patient’s
body is warm, dark, and sometimes damp. Most would agree that those conditions are
considered ideal for bacteria and viruses to thrive.
75. Question
The most important purpose of cleansing bed bath is:

A. To cleanse, refresh and give comfort to the client who must remain in bed.
B. To expose the necessary parts of the body.
C. To develop skills in bed bath.
D. To check the body temperature of the client in bed.
Incorrect
Correct Answer: A. To cleanse, refresh and give comfort to the client who must
remain in bed.

The nurse provides a bed bath for patients who must remain in bed and depend on
someone else for their care. It is an important part of the patient’s daily care.
Not only does it remove sweat, oil, and micro-organisms from the patient’s skin,
but it also stimulates circulation and promotes a feeling of self-worth by
improving the patient’s appearance. For patients who are on bedrest, bathing can
also be a time for socialization.

Option B: During bed bath, the patient is always given privacy so as not to expose
their intimate parts of the body. Some patients cannot safely leave their beds to
bathe. For these people, daily bed baths can help keep their skin healthy, control
odor, and increase comfort. If moving the patient causes pain, plan to give the
patient a bed bath after the person has received pain medicine and it has taken
effect.
Option C: The nurse may develop her skills in bed bath, but it is not the main
purpose. A bed bath is a good time to inspect a patient’s skin for redness and
sores. Pay special attention to skin folds and bony areas when checking. Encourage
the patient to be involved as possible in bathing themselves.
Option D: A bed bath may give a relaxation effect on the patient. It may also
stimulate blood circulation to the skin, respiration, and elimination; maintain
joint mobility, and improve the patient’s self-image and emotional and mental well-
being. It provides the nurse with an opportunity for health teaching and
assessment; gives the patient psychological support, and the process of building
rapport may begin during the initial bath.