link full download test bank for skills in clinical nursing 8th edition by berman

Skills in Clinical Nursing: 8th Edition Test Bank – Berman Berman/Snyder, Test Bank for Skills in Clinical Nursing 8th Edition Chapter Question Type: MCSA The nurse is caring for a client who is on bed rest with bathroom privileges While the client is in the bathroom, the nurse changes the client’s bed and makes the bed in what way? Unoccupied open bed Occupied open bed Unoccupied closed bed Surgical bed Correct Answer: 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 200-201 Question Type: MCSA The nurse is caring for a client in shock, and places the bed at an angle with the head lower than the feet Which term will the nurse use when documenting this position in the medical record? Reverse Trendelenburg position Trendelenburg position Fowler’s position Semi-Fowler’s position Correct Answer: 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 Semi- Fowler’s raises the head of the bed approximately 45° so the client’s head is 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 SemiFowler’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 Type: MCSA Which nursing action is inappropriate when providing the client with a hygienic and comfortable environment? Speaking softly in the hall of the facility Obtaining a bed extender for the client who is very tall Placing a room deodorizer in the room of the client with asthma who complains of the odor in the room ° ° Maintaining room temperature between 68 F and 74 F Correct Answer: Rationale 1: Deodorizers might be contraindicated for the client with respiratory disorders All of the other activities are supportive of the client’s environmental needs 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 healthillness 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 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? Raise the side rails Place the head of the bed in the semi-Fowler’s position Place the bed in the low position Remove the footboard from the bed Correct Answer: 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 healthillness 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 Type: MCSA The nurse is caring for a client in respiratory distress Which bed position is the most appropriate for this client? Semi-Fowler’s position Trendelenburg position Flat position Fowler’s position Correct Answer: 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 SemiFowler’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 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 SemiFowler’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 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 SemiFowler’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 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 SemiFowler’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 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 SemiFowler’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 Page Number: p 198 Question Type: MCSA The nurse caring for a client with a fractured third cervical vertebrae determines the client is in spinal shock Which bed position is the most appropriate for this client? Flat Semi-Fowler’s Trendelenburg Reverse Trendelenburg Correct Answer: Rationale 1: 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 SemiFowler’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 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 5: 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 Global Rationale: 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 Cognitive Level: Applying 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: Implementation Learning Outcome: Recognize when it is appropriate to delegate bed-making to unlicensed assistive personnel Page Number: pp 201-204, 205-206 Question Type: MCMA The nurse is making beds on the medical–surgical unit What would the nurse differently when making a surgical bed versus an open unoccupied bed? Standard Text: Select all that apply Strip the bed Do not tuck, miter, or toe-pleat the top covers Fold top sheets into a triangle at the side of the bed Place pillows on the chair beside the bed Raise the bed to a comfortable working height Correct Answer: 2,3,4 Rationale 1: When making a surgical bed, the top covers would not be tucked, mitered, or pleated, but rather folded to the side of the bed, forming a triangle, so the bed is prepared for the client to slide from the stretcher to the bed Pillows are removed from the bed and placed in the chair at the side of the bed because they will be in the way when the client is transferred from the stretcher The bed should always be raised to a comfortable working height to avoid back strain for the nurse when making a bed, and the old linen should be stripped prior to making the fresh bed Rationale 2: When making a surgical bed, the top covers would not be tucked, mitered, or pleated, but rather folded to the side of the bed, forming a triangle, so the bed is prepared for the client to slide from the stretcher to the bed Pillows are removed from the bed and placed in the chair at the side of the bed because they will be in the way when the client is transferred from the stretcher The bed should always be raised to a comfortable working height to avoid back strain for the nurse when making a bed, and the old linen should be stripped prior to making the fresh bed Rationale 3: When making a surgical bed, the top covers would not be tucked, mitered, or pleated, but rather folded to the side of the bed, forming a triangle so the bed is prepared for the client to slide from the stretcher to the bed Pillows are removed from the bed and placed in the chair at the side of the bed because they will be in the way when the client is transferred from the stretcher The bed should always be raised to a comfortable working height to avoid back strain for the nurse when making a bed, and the old linen should be stripped prior to making the fresh bed Rationale 4: When making a surgical bed, the top covers would not be tucked, mitered, or pleated, but rather folded to the side of the bed, forming a triangle, so the bed is prepared for the client to slide from the stretcher to the bed Pillows are removed from the bed and placed in the chair at the side of the bed because they will be in the way when the client is transferred from the stretcher The bed should always be raised to a comfortable working height to avoid back strain for the nurse when making a bed, and the old linen should be stripped prior to making the fresh bed Rationale 5: When making a surgical bed, the top covers would not be tucked, mitered, or pleated, but rather folded to the side of the bed, forming a triangle, so the bed is prepared for the client to slide from the stretcher to the bed Pillows are removed from the bed and placed in the chair at the side of the bed because they will be in the way when the client is transferred from the stretcher The bed should always be raised to a comfortable working height to avoid back strain for the nurse when making a bed, and the old linen should be stripped prior to making the fresh bed Global Rationale: When making a surgical bed, the top covers would not be tucked, mitered, or pleated, but rather folded to the side of the bed, forming a triangle, so the bed is prepared for the client to slide from the stretcher to the bed Pillows are removed from the bed and placed in the chair at the side of the bed because they will be in the way when the client is transferred from the stretcher The bed should always be raised to a comfortable working height to avoid back strain for the nurse when making a bed, and the old linen should be stripped prior to making the fresh bed Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5 Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8 Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: Verbalize the steps used in making: A closed and open unoccupied bed A surgical bed An occupied bed Page Number: p 204 Question 10 Type: SEQ The nurse is making an occupied bed for a client who is required to maintain complete bed rest Place the steps of making an occupied bed in the appropriate order to be performed Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list Response Loosen the bottom soiled linens behind the side-lying client and fanfold them close to the client Response Pull linens from the center of the bed and make that side of the bed Response Make the side of the bed behind the client and tuck sheets under the client Response Position the client supine and place the clean top linen on the bed Response Remove the soiled linen from the bed Correct Answer: 1,3,5,2,4 Rationale 1: The nurse removes the top bedding, and may cover the client with the top sheet or a bath blanket Raise the side rail on the side the client will roll toward, help the client roll, and then loosen the lower linen on the side behind the client Fan-fold soiled linen toward the client, apply fresh linen, and tuck under the mattress, fan-folding the clean linen toward the center of the bed Pull the side rail up on that side of the bed and assist the client to roll over the linen in the center of the bed Move to the other side of the bed, lowering the side rail, and remove the soiled linen Once the soiled linen is removed, the fresh linen can be pulled over the bed and tucked under the mattress The client now can be positioned supine, and fresh top sheets can be applied, removing the bath blanket or sheet covering the client by pulling it out from under the clean top linen Position the client for comfort, place the bed in the low position, and make sure the call bell is conveniently located Rationale 2: The nurse removes the top bedding, and may cover the client with the top sheet or a bath blanket Raise the side rail on the side the client will roll toward, help the client roll, and then loosen the lower linen on the side behind the client Fan-fold soiled linen toward the client, apply fresh linen, and tuck under the mattress, fan-folding the clean linen toward the center of the bed Pull the side rail up on that side of the bed and assist the client to roll over the linen in the center of the bed Move to the other side of the bed, lowering the side rail, and remove the soiled linen Once the soiled linen is removed, the fresh linen can be pulled over the bed and tucked under the mattress The client now can be positioned supine, and fresh top sheets can be applied, removing the bath blanket or sheet covering the client by pulling it out from under the clean top linen Position the client for comfort, place the bed in the low position, and make sure the call bell is conveniently located Rationale 3: The nurse removes the top bedding, and may cover the client with the top sheet or a bath blanket Raise the side rail on the side the client will roll toward, help the client roll, and then loosen the lower linen on the side behind the client Fan-fold soiled linen toward the client, apply fresh linen, and tuck under the mattress, fan-folding the clean linen toward the center of the bed Pull the side rail up on that side of the bed and assist the client to roll over the linen in the center of the bed Move to the other side of the bed, lowering the side rail, and remove the soiled linen Once the soiled linen is removed, the fresh linen can be pulled over the bed and tucked under the mattress The client now can be positioned supine, and fresh top sheets can be applied, removing the bath blanket or sheet covering the client by pulling it out from under the clean top linen Position the client for comfort, place the bed in the low position, and make sure the call bell is conveniently located Rationale 4: The nurse removes the top bedding, and may cover the client with the top sheet or a bath blanket Raise the side rail on the side the client will roll toward, help the client roll, and then loosen the lower linen on the side behind the client Fan-fold soiled linen toward the client, apply fresh linen, and tuck under the mattress, fan-folding the clean linen toward the center of the bed Pull the side rail up on that side of the bed and assist the client to roll over the linen in the center of the bed Move to the other side of the bed, lowering the side rail, and remove the soiled linen Once the soiled linen is removed, the fresh linen can be pulled over the bed and tucked under the mattress The client now can be positioned supine, and fresh top sheets can be applied, removing the bath blanket or sheet covering the client by pulling it out from under the clean top linen Position the client for comfort, place the bed in the low position, and make sure the call bell is conveniently located Rationale 5: The nurse removes the top bedding, and may cover the client with the top sheet or a bath blanket Raise the side rail on the side the client will roll toward, help the client roll, and then loosen the lower linen on the side behind the client Fan-fold soiled linen toward the client, apply fresh linen, and tuck under the mattress, fan-folding the clean linen toward the center of the bed Pull the side rail up on that side of the bed and assist the client to roll over the linen in the center of the bed Move to the other side of the bed, lowering the side rail, and remove the soiled linen Once the soiled linen is removed, the fresh linen can be pulled over the bed and tucked under the mattress The client now can be positioned supine, and fresh top sheets can be applied, removing the bath blanket or sheet covering the client by pulling it out from under the clean top linen Position the client for comfort, place the bed in the low position, and make sure the call bell is conveniently located Global Rationale: The nurse removes the top bedding, and may cover the client with the top sheet or a bath blanket Raise the side rail on the side the client will roll toward, help the client roll, and then loosen the lower linen on the side behind the client Fan-fold soiled linen toward the client, apply fresh linen, and tuck under the mattress, fan-folding the clean linen toward the center of the bed Pull the side rail up on that side of the bed and assist the client to roll over the linen in the center of the bed Move to the other side of the bed, lowering the side rail, and remove the soiled linen Once the soiled linen is removed, the fresh linen can be pulled over the bed and tucked under the mattress The client now can be positioned supine, and fresh top sheets can be applied, removing the bath blanket or sheet covering the client by pulling it out from under the clean top linen Position the client for comfort, place the bed in the low position, and make sure the call bell is conveniently located Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: III.A.5 Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8 Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: Verbalize the steps used in making: A closed and open unoccupied bed A surgical bed An occupied bed Page Number: pp 205-206 Question 11 Type: MCSA The nurse delegates the making of an occupied bed to the unlicensed assistive personnel (UAP) Which statement made by the UAP would indicate the need for further instruction prior to this assignment? “I will be sure to inform you of any wound drainage.” “I will inform you if any of the client’s tubes are loose.” “I will assess the client’s IV tubing.” “I will inform you of any problems.” Correct Answer: Rationale 1: Although the UAP cannot assess the client, it is appropriate for the UAP to inform the nurse if there is any wound drainage Rationale 2: It is appropriate for the UAP to inform the nurse if the client has any loose tubes Rationale 3: The UAP cannot assess the client’s IV tubing This is outside the scope of practice for the UAP Rationale 4: It is expected that the UAP will inform the nurse of any problems that occur during the task that is delegated Global Rationale: The UAP cannot assess the client’s IV tubing This is outside the scope of practice for the UAP Although the UAP cannot assess the client, it is appropriate for the UAP to inform the nurse if there is any wound drainage or if any tubes are loose It is expected that the UAP will inform the nurse of any problems that occur during the task that is delegated Cognitive Level: Remembering 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: Implementation Learning Outcome: Recognize when it is appropriate to delegate bed-making to unlicensed assistive personnel Page Number: pp 204-206 Question 12 Type: MCSA The nurse is instructing the unlicensed assistive personnel (UAP) about the different bed positions available Which statement by the UAP indicates the understanding of the different bed positions? “Fowler’s is used when assisting clients to bed for sleeping.” “Supine is used when assisting the client with eating.” “Trendelenburg is used to promote decreased gastric emptying.” “Semi-Fowler’s is used for clients receiving gastric feedings.” Correct Answer: Rationale 1: Fowler’s is not the desired position for sleep as this is sitting up in bed This statement indicates the need for further instruction Rationale 2: A supine position is most preferred for clients with vertebral injuries and is preferred for sleeping This position is not appropriate for eating This statement indicates the need for further instruction Rationale 3: Trendelenburg is the preferred position to promote postural drainage and assist with peripheral perfusion This position is not used to promote decreased gastric emptying This statement indicates the need for further instruction Rationale 4: Semi-Fowler’s is the desired position for gastric feedings as it helps to reduce risk for aspiration This statement indicates an appropriate understanding by the UAP Global Rationale: Semi-Fowler’s is the desired position for gastric feedings as it helps to reduce risk for aspiration This statement indicates an appropriate understanding by the UAP Fowler’s is not the desired position for sleep as this is sitting up in bed A supine position is most preferred for clients with vertebral injuries and is preferred for sleeping This position is not appropriate for eating Trendelenburg is the preferred position to promote postural drainage and assist with peripheral perfusion This position is not used to promote decreased gastric emptying Cognitive Level: Evaluating Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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 Page Number: p 198 Question 13 Type: MCSA The nurse is providing care to a client who is confused and recently suffered a fall The family is at the bedside and the nurse is discussing the use of side rails with them Which statement made by the family indicates the need for additional instruction? “We can leave one side rail up.” “We can leave all of the side rails down.” “We should not put all four side rails up.” “We can leave up the bottom two side rails.” Correct Answer: Rationale 1: It is appropriate to leave one side rail up as this provides the client with some independence This statement indicates appropriate understanding Rationale 2: Leaving all the side rails down is dangerous and the client should not be left alone as this could lead to a fall This statement indicates the need for additional instruction Rationale 3: Putting all four side rails up is a form of physical restraint and has to be ordered by the health care provider This statement indicates appropriate understanding Rationale 4: Leaving the bottom side rails up allows the client to get out of the bed from the top This statement indicates appropriate understanding Global Rationale: Leaving all the side rails down is dangerous and the client should not be left alone as this could lead to a fall This statement indicates the need for additional instruction All the other statements made by the family indicate an appropriate understanding Cognitive Level: Analyzing 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: pp 199-200 Question 14 Type: SEQ Place the steps for making an unoccupied bed in the appropriate order Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list Response Arrange the client’s room and remove and discard linens Response Reposition mattress, wipe off any moisture, and dry thoroughly Response Lower side rails on both sides of the bed and raise to comfortable working level Response Apply all bottom linens on one side of the bed before moving to the other Response Remove soiled linens and place them in a laundry bag Response Determine if the client is incontinent or if excess drainage is on the linen Correct Answer: 6,3,5,2,4,1 Rationale 1: Arranging the client’s room and removing and discarding linens is the last step in making an unoccupied bed Rationale 2: Repositioning the mattress is the fourth step of the process It is appropriate to wipe off any moisture and dry thoroughly at this point if the mattress is wet with moisture Rationale 3: Lowering the side rails on both sides of the bed and raising it to a level of comfort is necessary to prevent back injury and is the second step in making the bed Rationale 4: Applying all the bottom linens on one side of the bed before moving to the other side is the fifth step in making the bed Rationale 5: Removing soiled linen and placing it in the laundry bag is the third step in making the bed Rationale 6: Determining if the client is incontinent or if there is excess drainage on the linen is the first thing done Global Rationale: Determining if the client is incontinent or if there is excess drainage on the linen is the first thing done Lowering the side rails on both sides of the bed and raising it to a level of comfort is necessary to prevent back injury and is the second step in making the bed Removing soiled linen and placing it in the laundry bag is the third step in making the bed Repositioning the mattress is the fourth step of the process It is appropriate to wipe off any moisture and dry thoroughly at this point if the mattress is wet with moisture Applying all the bottom linens on one side of the bed before moving to the other side is the fifth step in making the bed Arranging the client’s room and removing and discarding linens is the last step in making an unoccupied bed Cognitive Level: Remembering Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: III.A.5 Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8 Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of clients and promoting health across the life span NLN Competencies: Quality and Safety: Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: Verbalize the steps used in making: A closed and open unoccupied bed A surgical bed An occupied bed Page Number: pp 201-204 Question 15 Type: MCSA The nurse is instructing the unlicensed assistive personnel (UAP) on positioning the client in the Fowler’s position Which statement by the UAP indicates appropriate understanding of Fowler’s position? “I will put the client’s head completely flat.” “I will elevate the client’s head.” “I will only raise the head of the bed 30°.” “I will place the bed in the Trendelenburg position.” Correct Answer: Rationale 1: When the client’s head is completely flat, this is the supine position and is not Fowler’s position This statement indicates the need for further instruction Rationale 2: The client’s head is elevated when using Fowler’s position This statement indicates an appropriate understanding Rationale 3: Raising the head of the bed to 30° is appropriate for semi-Fowler’s, but not Fowler’s This statement indicates the need for further instruction Rationale 4: Trendelenburg position is not the same as Fowler’s position This statement indicates the need for further instruction Global Rationale: The client’s head is elevated when using Fowler’s position This statement indicates an appropriate understanding The other statements made by the UAP indicate the need for further instruction Cognitive Level: Evaluating Client Need: Health Promotion and Maintenance Client Need Sub: 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 Page Number: p 198 ... fifth step in making the bed Rationale 5: Removing soiled linen and placing it in the laundry bag is the third step in making the bed Rationale 6: Determining if the client is incontinent or if... III.A.5 Explain the role of evidence in determining best clinical practice AACN Essential Competencies: IX.8 Implement evidence-based nursing interventions as appropriate for managing the acute... 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 Type: MCSA Which nursing action