Download test bank for skills in clinical nursing 8th edition by berman

Fowler’s position raises the head of the bed into a 90° angle so the client is sitting upright.. Fowler’s position raises the head of the bed into a 90° angle so the client is sitting up

Test Bank for Skills in Clinical Nursing 8th Edition by Berman

1 Unoccupied open bed

2 Occupied open bed

3 Unoccupied closed bed

4 Surgical bed

Correct Answer: 1

Rationale 1: The bed is unoccupied, and the nurse would make an open bed, with the top sheets folded back, so the bed is ready for the client to return to An occupied bed would be used if the client were unable to get out of bed A closed bed is made with the top covers over the entire bed to keep the bed clean when not in use A surgical bed would be made using extra materials in preparation for the

returning postoperative client

Rationale 2: The bed is unoccupied, and the nurse would make an open bed, with the top sheets folded back, so the bed is ready for the client to return to An

occupied bed would be used if the client were unable to get out of bed A closed bed is made with the top covers over the entire bed to keep the bed clean when not in use A surgical bed would be made using extra materials in preparation for the returning postoperative client

Rationale 3: The bed is unoccupied, and the nurse would make an open bed, with

the top sheets folded back, so the bed is ready for the client to return to An

occupied bed would be used if the client were unable to get out of bed A closed

bed is made with the top covers over the entire bed to keep the bed clean when not in use A surgical bed would be made using extra materials in preparation for the returning postoperative client

Rationale 4: The bed is unoccupied, and the nurse would make an open bed, with the top sheets folded back, so the bed is ready for the client to return to An

occupied bed would be used if the client were unable to get out of bed A closed bed is made with the top covers over the entire bed to keep the bed clean when not in use A surgical bed would be made using extra materials in preparation for the returning postoperative client

Global Rationale: The bed is unoccupied, and the nurse would make an open bed, with the top sheets folded back, so the bed is ready for the client to return to An occupied bed would be used if the client were unable to get out of bed A closed bed

is made with the top covers over the entire bed to keep the bed clean when not

in use A surgical bed would be made using extra materials in preparation for the returning postoperative client

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: II.B.3 Base individualized care plan on client values, clinical expertise, and evidence

AACN Essential Competencies: III.1 Explain the interrelationships among theory, practice, and research

NLN Competencies: Knowledge and Science: Relationships between

knowledge/science and quality and safe client care Nursing/Integrated

Concepts: Nursing Process: Implementation Learning Outcome: Define

the key terms used in the skill of bed-making Page Number: pp

1 Reverse Trendelenburg position

2 Trendelenburg position

3 Fowler’s position

4 Semi-Fowler’s position

Correct Answer: 2

Rationale 1: The Trendelenburg position is used to place the head lower than the feet to improve blood flow to the brain Reverse Trendelenburg places the bed straight but at an angle that puts the feet lower than the head Fowler’s

position raises the head of the bed into a 90° angle so the client is sitting

upright Semi-Fowler’s raises the head of the bed approximately 45° so the client’s head is upright at a reclining angle

Rationale 2: The Trendelenburg position is used to place the head lower than the feet to improve blood flow to the brain Reverse Trendelenburg places the bed straight but at an angle that puts the feet lower than the head Fowler’s

position raises the head of the bed into a 90° angle so the client is sitting

upright Semi-Fowler’s raises the head of the bed approximately 45° so the client’s head is upright at a reclining angle

Rationale 3: The Trendelenburg position is used to place the head lower than the feet to improve blood flow to the brain Reverse Trendelenburg places the bed straight but at an angle that puts the feet lower than the head Fowler’s position raises the head of the bed into a 90° angle so the client is sitting upright Semi-Fowler’s raises the head of the bed approximately 45° so the client’s head is upright at a reclining angle

Rationale 4: The Trendelenburg position is used to place the head lower than the feet to improve blood flow to the brain Reverse Trendelenburg places the bed straight but at an angle that puts the feet lower than the head Fowler’s position

raises the head of the bed into a 90° angle so the client is sitting upright Fowler’s raises the head of the bed approximately 45° so the client’s head is

Semi-upright at a reclining angle

Global Rationale: The Trendelenburg position is used to place the head lower than the feet to improve blood flow to the brain Reverse Trendelenburg places the bed straight but at an angle that puts the feet lower than the head Fowler’s position raises the head of the bed into a 90° angle so the client is sitting upright Semi- Fowler’s raises the head of the bed approximately 45° so the client’s head is

upright at a reclining angle

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: II.B.3 Base individualized care plan on client

values, clinical expertise, and evidence

AACN Essential Competencies: III.1 Explain the interrelationships among

theory, practice, and research

NLN Competencies: Knowledge and Science: Relationships between

knowledge/science and quality and safe client care Nursing/Integrated

Concepts: Nursing Process: Implementation Learning Outcome: Define

the key terms used in the skill of bed-making Page Number: p 198

Question 3

Type: MCSA

Which nursing action is inappropriate when providing the client with a hygienic and comfortable environment? 1 Speaking softly in the hall of the facility

2 Obtaining a bed extender for the client who is very tall

3 Placing a room deodorizer in the room of the client with asthma

who complains of the odor in the room

4 Maintaining room temperature between 68°

Rationale 2: Deodorizers might be contraindicated for the client with respiratory disorders All of the other activities are supportive of the client’s environmental needs

Rationale 3: Deodorizers might be contraindicated for the client with respiratory disorders All of the other activities are supportive of the client’s environmental needs

Rationale 4: Deodorizers might be contraindicated for the client with respiratory disorders All of the other activities are supportive of the client’s environmental needs

Global Rationale: Deodorizers might be contraindicated for the client with

respiratory disorders All of the other activities are supportive of the client’s

environmental needs

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.B.3 Provide client-centered care with sensitivity and

respect for the diversity of human experience

AACN Essential Competencies: IX.3 Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology,

pharmacology, medical management, and nursing management

across the health-illness continuum, across life span, and in all health care

settings NLN Competencies: Knowledge and Science: Relationships between

knowledge/science and quality and safe client care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe the elements to consider when providing

clients with a hygienic and comfortable environment Page Number: p 197

Question 4

Type: MCSA

The nurse caring for an older adult client diagnosed with dementia bathes the client

and changes the wound dressing Prior to leaving the room, which action by the nurse is the most appropriate?

1 Raise the side rails

2 Place the head of the bed in the semi-Fowler’s position

3 Place the bed in the low position

4 Remove the footboard from the bed

Correct Answer: 3

Rationale 1: The nurse should return the bed to the low position to prevent injury to the client if he attempts to get out of bed autonomously Side rails are generally contraindicated with most clients suffering from dementia because of the risk for injury if they attempt to crawl over the rail The position of the bed would be

determined by the time of day, activities the client will be performing, and client preference There would be no reason to remove the footboard from the bed

Rationale 2: The nurse should return the bed to the low position to prevent injury to the client if he attempts to get out of bed autonomously Side rails are generally contraindicated with most clients suffering from dementia because of the risk for injury if they attempt to crawl over the rail The position of the bed would be

determined by the time of day, activities the client will be performing, and client preference There would be no reason to remove the footboard from the bed

Rationale 3: The nurse should return the bed to the low position to prevent injury to the client if he attempts to get out of bed autonomously Side rails are generally contraindicated with most clients suffering from dementia because of the risk for injury if they attempt to crawl over the rail The position of the bed would be

determined by the time of day, activities the client will be performing, and client preference There would be no reason to remove the footboard from the bed Rationale 4: The nurse should return the bed to the low position to prevent injury

to the client if he attempts to get out of bed autonomously Side rails are generally contraindicated with most clients suffering from dementia because of the risk for injury if they attempt to crawl over the rail The position of the bed would be determined by the time of day, activities the client will be performing, and client preference There would be no reason to remove the footboard from the bed Global Rationale: The nurse should return the bed to the low position to prevent injury to the client if he attempts to get out of bed autonomously Side rails are generally contraindicated with most clients suffering from dementia because of the risk for injury if they attempt to crawl over the rail The position of the bed would be determined by the time of day, activities the client will be performing, and client preference There would be no reason to remove the footboard from the bed Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.B.3 Provide client-centered care with sensitivity and respect for the diversity of human experience

AACN Essential Competencies: IX.3 Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across life span, and in all health care settings

NLN Competencies: Knowledge and Science: Relationships between

knowledge/science and quality and safe client care Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe the elements to consider when providing

clients with a hygienic and comfortable environment Page Number: p 199

Question 5

Type: MCSA

The nurse is caring for a client in respiratory distress Which bed position is

the most appropriate for this client?

Rationale 1: The client with respiratory distress will breathe more easily if the bed

is placed in the Fowler’s position, because it reduces the compression of the

abdominal contents into the stomach and allows for full lung expansion Fowler’s position is the best choice if Fowler’s position is not possible due to the client’s condition, but is not as good as Fowler’s because it still allows some intrusion of abdominal contents into the diaphragm and limits full excursion

Semi-Trendelenburg position would be contraindicated because this causes abdominal organs to press into the diaphragm Flat is also contraindicated, and will increase the client’s respiratory distress

Rationale 2: The client with respiratory distress will breathe more easily if the bed

is placed in the Fowler’s position, because it reduces the compression of the

abdominal contents into the stomach and allows for full lung expansion Fowler’s position is the best choice if Fowler’s position is not possible due to the client’s condition, but is not as good as Fowler’s because it still allows some

Semi-intrusion of abdominal contents into the diaphragm and limits full excursion

Trendelenburg position would be contraindicated because this causes abdominal

organs to press into the diaphragm Flat is also contraindicated, and will

increase the client’s respiratory distress

Rationale 3: The client with respiratory distress will breathe more easily if the bed

is placed in the Fowler’s position, because it reduces the compression of the

abdominal contents into the stomach and allows for full lung expansion Fowler’s position is the best choice if Fowler’s position is not possible due to the client’s condition, but is not as good as Fowler’s because it still allows some intrusion of abdominal contents into the diaphragm and limits full excursion Trendelenburg position would be contraindicated because this causes abdominal organs to press into the diaphragm Flat is also contraindicated, and will increase the client’s respiratory distress

Semi-Rationale 4: The client with respiratory distress will breathe more easily if the bed

is placed in the Fowler’s position, because it reduces the compression of the

abdominal contents into the stomach and allows for full lung expansion Fowler’s position is the best choice if Fowler’s position is not possible due to the client’s condition, but is not as good as Fowler’s because it still allows some intrusion of abdominal contents into the diaphragm and limits full excursion Trendelenburg position would be contraindicated because this causes abdominal organs to press into the diaphragm Flat is also contraindicated, and will increase the client’s respiratory distress

Semi-Global Rationale: The client with respiratory distress will breathe more easily if the bed is placed in the Fowler’s position, because it reduces the compression of the abdominal contents into the stomach and allows for full lung expansion Semi-Fowler’s position is the best choice if Fowler’s position is not possible due to the client’s condition, but is not as good as Fowler’s because it still allows some intrusion of abdominal contents into the diaphragm and limits full excursion Trendelenburg position would be contraindicated because this causes abdominal organs to press into the diaphragm Flat is also contraindicated, and will increase the client’s respiratory distress

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.3

Base individualized care plan on client values,

clinical expertise, and evidence

AACN Essential Competencies: III.1 Explain the interrelationships among

theory, practice, and research

NLN Competencies: Knowledge and Science: Relationships

between knowledge/science and quality and safe client care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Identify indications for common bed positions

Trendelenburg position is contraindicated due to the client’s diagnosis of spinal

shock Rationale 2: A client with a fractured cervical vertebra must be

Semi-Rationale 3: A client with a fractured cervical vertebra must be maintained in a flat position to prevent any movement of the neck Placing the client into the Trendelenburg position, which would normally be indicated for a client in

shock, would put this client at risk for further damage to the spinal cord Fowler’s position is contraindicated due to the client’s spinal injury, and the reverse Trendelenburg position is contraindicated due to the client’s diagnosis of spinal shock

Semi-Rationale 4: A client with a fractured cervical vertebra must be maintained in a flat position to prevent any movement of the neck Placing the client into the Trendelenburg position, which would normally be indicated for a client in

shock, would put this client at risk for further damage to the spinal cord Fowler’s position is contraindicated due to the client’s spinal injury, and the reverse Trendelenburg position is contraindicated due to the client’s diagnosis of spinal shock

Semi-Global Rationale: A client with a fractured cervical vertebra must be maintained

in a flat position to prevent any movement of the neck Placing the client into the Trendelenburg position, which would normally be indicated for a client in

shock, would put this client at risk for further damage to the spinal cord Fowler’s position is contraindicated due to the client’s spinal injury, and the reverse Trendelenburg position is contraindicated due to the client’s diagnosis of spinal shock

Semi-Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: II.B.3 Base individualized care plan on client values, clinical expertise, and evidence AACN Essential Competencies: III.1 Explain the interrelationships among

theory, practice, and research

NLN Competencies: Knowledge and Science: Relationships

between knowledge/science and quality and safe client care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Identify indications for common bed positions

1 The postoperative client diagnosed with dementia on complete bed rest

2 The client who is diagnosed with myocardial infarction who has

bathroom privileges

3 The client with increased intracranial pressure on complete bed rest

4 The postoperative client

Correct Answer: 3

Rationale 1: The client with increased intracranial pressure will generally have an increase in pressure with any activity or movement, so the nurse should change this client’s bed, although the unlicensed assistive personnel could assist the nurse The other clients’ beds could be safely delegated to the unlicensed assistive personnel Rationale 2: The client with increased intracranial pressure will generally have an increase in pressure with any activity or movement, so the nurse should change this client’s bed, although the unlicensed assistive personnel could assist the nurse The other clients’ beds could be safely delegated to the unlicensed assistive personnel Rationale 3: The client with increased intracranial pressure will generally have an increase in pressure with any activity or movement, so the nurse should change this client’s bed, although the unlicensed assistive personnel could assist the nurse The other clients’ beds could be safely delegated to the unlicensed assistive personnel Rationale 4: The client with increased intracranial pressure will generally have an increase in pressure with any activity or movement, so the nurse should change this client’s bed, although the unlicensed assistive personnel could assist the nurse The other clients’ beds could be safely delegated to the unlicensed assistive personnel Global Rationale: The client with increased intracranial pressure will generally

have an increase in pressure with any activity or movement, so the nurse should change this client’s bed, although the unlicensed assistive personnel could assist the nurse The other clients’ beds could be safely delegated to the unlicensed assistive personnel

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: II.A.2 Describe scopes of practice and roles of health care team members

ACN Essential Competencies: IX.14 Demonstrate clinical judgment and

accountability for client outcomes when delegating to and supervising other members of the health care team

NLN Competencies: Teamwork: Manage delegation effectively

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Recognize when it is appropriate to delegate bed-making to unlicensed assistive personnel

Page Number: p 201

Question 8 Type: MCMA

When delegating bed-making to the unlicensed assistive personnel (UAP), the nurse would instruct the UAP on which items? Standard Text: Select all that apply

1 Proper disposal of linens that contain drainage

2 What tubes or dressings the client might have

3 How to make hospital corners

4 Whom to inform if they notice anything unusual

5 Placing the call bell in a specific location for a client with mobility

concerns Correct Answer: 1,2,5

Rationale 1: The nurse should instruct the UAP on how to dispose of linens that contain drainage, and should inform the UAP of any tubes or dressings the client may have in place and the importance of placing the call bell in a specific location for a client with mobility concerns The nurse should not have to teach the UAP how to make a bed, because the UAP should be familiar with the procedure There

is no need to inform the UAP whom to notify because the UAP should inform the nurse if anything unusual occurs

Rationale 2: The nurse should instruct the UAP on how to dispose of linens that contain drainage, and should inform the UAP of any tubes or dressings the client may have in place and the importance of placing the call bell in a specific location for a client with mobility concerns The nurse should not have to teach the UAP how to make a bed, because the UAP should be familiar with the procedure There

is no need to inform the UAP whom to notify because the UAP should inform the nurse if anything unusual occurs

Rationale 3: The nurse should instruct the UAP on how to dispose of linens that contain drainage, and should inform the UAP of any tubes or dressings the client may have in place and the importance of placing the call bell in a specific location