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6. A nursing instructor asks the nursing student to describe the
definition of a critical path. Which of the following statements, if
made by the student, indicates a need for further understanding
regarding critical paths?
a) they are developed through the collaborative efforts of all
members of the health care team
b) they provide an effective way of monitoring care and for
reducing or controlling the length of hospital stay for the client
c) they are developed based on appropriate standards of care
d) they are nursing care plans and use the steps of the nursing
process
7. A community health nurse is working with a disaster relief
following a tornado. The nurse's goal for the community is to
prevent as much injury and death as possible from the
uncontrollable event. Finding safe housing for survivors,
providing support to families, organizing counseling, and
securing physical care when needed allexamples of which type
of prevention?
12. A nurse is caring for a client who has just had a plaster leg
cast applied. The nurse would plan to prevent the development
of compartment syndrome is instructing the licensed practical
nurseassigned to care for the client to:
a) elevate the limb and apply ice to the affected leg
b) elevate the limb and cover the limb with bath blankets
c) place the leg in a slightly dependent position and apply ice to
the affected leg
d) keep the leg horizontal and apply ice to the affected leg
c) keeps the child dry while on the cooling blanket to reduce the
risk of frostbite
b) places the cooling blanket on the bed and covers the blanket
with a sheet
d) checks the skin condition of the child before, during, and after
the use of the cooling blanket
52. A nursing instructor asks a nursing student to identify
situations that indicate a secondary level of prevention in health
care. Which situation, if identified by the student, would indicate
the need for further study of the levels of prevention?
a) teaching s stroke client how to use a walker
b) screening for hypertension in a community group
a) a foot board
d) push the lock-out button on the electric bed to keep the bed in
the lowest position
b) extra pillows
c) a bed trapeze
d) an electric bed
by
30) C
- Variances are actual deviations or detours
from the critical paths. Variances can be either
positive or negative, or avoidable or
unavoidable and can be caused by a variety of
things. Positive variance occurs when the
client achieves maximum benefit and is
discharged earlier than anticipated. Negative
variance occurs when untoward events
prevent a timely discharge. Variance analysis
occurs continually in order to anticipate and
recognize negative variance early so that
appropriate action can be taken. Option B is
the only option that identifies the need for
further action.
31) D
- The family or a legal guardian can make
treatment decisions for the client who is
unable to do so. Once the decision is made,
the physician writes the order. Generally, the
family makes decisions in collaboration with
physicians, other health care workers, and
other trusted advisors. Although a written
order by the physician is necessary, the nurse
first checks for documentation of the family's
request. Unless special circumstances exist, a
court order is not necessary. Although some
health care agencies may require reviewing
such requests via the Ethics Committee, this is
not the nurse's first action.
32) A
- The proposed project is research and
includes human subjects. Although options B,
C, and D need to be considered, they are all
secondary to the overriding principle of the
legal and ethical practice of nursing that any
client has the right to refuse to participate in
research using human subjects.
33) C
- Participative leadership demonstrates an "inbetween" style, neither authoritarian nor
democratic style. In participative leadership,
the manager presents an analysis of problems
37) A
- The autocratic style of leadership is task
oriented and directive. The leader uses his or
her power and position in an authoritarian
manner to set and implement organizational
goals. Decisions are made without input from
the staff. Democratic styles best empower
staff toward excellence because this style of
leadership allows nurses to provide input
43) C
- Proper care of an indwelling urinary catheter
is especially important to prevent prolonged
infection or reinfection in the client with
cystitis. The perineal area is cleansed
thoroughly using mild soap and water at least
twice a day and following a bowel movement.
The drainage bag is kept below the level of
the bladder to prevent urine from being
trapped in the bladder, and, for the same
reason, the drainage tubing is not placed or
looped under the client's leg. The tubing must
drain freely at all times.
40) B
44) D
41) C
- A vest restraint should never be applied
tightly because it could impair respirations. A
hitch knot may be used on the client because
it can easily be released in an emergency. The
call light must always be within the client's
reach in case the client needs assistance. The
45) D
- A potential complication of hemodialysis is
the acquisition of dialysis-associated hepatitis
B. This is a concern for clients (who may carry
the virus), client families (at risk from contact
with the client and with environmental
surfaces), and staff (who may acquire the
virus from contact with the client's blood).
This risk is minimized by the use of standard
52) A
- Secondary prevention focuses on the early
diagnosis and prompt treatment of disease.
Tertiary prevention is represented by
rehabilitation services. Options B, C, and D
identify screening procedures. Option A
identifies a rehabilitative service.
53) B
- When the nurse asks a "why" question of the
client, the nurse is requesting an explanation
for feelings and behaviors when the client
may not know the reason. Requesting an
explanation is a nontherapeutic
communication technique. In option A, the
nurse is encouraging the verbalization of
emotions or feelings, which is a therapeutic
communication technique. In option C, the
nurse is using the therapeutic communication
58) D
- The skin is cleansed with soap and water
(not Betadine), denatured with alcohol, and
allowed to air-dry before electrodes are
applied. The other three options are correct.
59) A
- A quiet, restful environment is provided as
part of seizure precautions. This includes
undisturbed times for sleep, while using a
nightlight for safety. The client should be
accompanied during activities such as bathing
and walking, so that assistance is readily
available and injury is minimized if a seizure
begins. The bed is maintained in low position
for safety.
60) B
- According to category-specific (respiratory)
isolation precautions, a client with TB requires
a private room. The room needs to be wellventilated and should have at least six
exchanges of fresh air per hour and should be
ventilated to the outside if possible. Therefore,
option 2 is the only correct option.