Rationales 1 20

Chapter 1: Health and Wellness
1. 2. Rationale: The second level on the hierarchy

of needs consists of safety needs, which include
establishing stability and consistency. This patient
feels out of control and needs stability and
consistency.
in which the patient intends to take action within

the next month.
9. 3. Rationale: In the preparation stage, the
patient intends to take action within the next
month. In this stage the patient may also have
tried to make changes in the past but without
success.
2. 1. Rationale: The age of your patient helps you

to understand where the patient may be
10. 2. Rationale: At this point you are trying to
developmentally. Knowledge of developmental
increase the pros of exercising. You do not want
stages will allow you to individualize your
to try to force her into the action stage because
interventions to be age appropriate, which will help she is not ready for this yet. By helping her see
with your effectiveness.
why it is important for her, you will gradually move
her through the stages of behavior change, which
3. 3. Rationale: Routine exercise and good
may ultimately make her successful with her
nutrition are examples of health promotion
change.
activities that help patients maintain or enhance
their present levels of health and reduce their risks Chapter 2: The Health Care Delivery System
of developing certain diseases.
1. 4. Rationale: Primary care focuses on health
4. 1. Rationale: Primary prevention precedes
promotion programs and the adoption of healthy
disease or dysfunction. Eating fruits and
lifestyles. An appointment for screening
vegetables and exercising are examples of active mammography is part of a healthy lifestyle. The
strategies that decrease an individuals
emergency department visit is secondary care.
vulnerability to illness or dysfunction.
The home health nurse is restorative care. The
older couple receiving an influenza vaccine is an
5. 1. Rationale: Primary prevention precedes
example of preventive care.
disease or dysfunction. Receiving immunizations
is an example of an active strategy that decreases 2. 2. Rationale: A positive work environment is one
an individuals vulnerability to illness or
that promotes autonomy of nurses and
dysfunction.
empowerment so that nurses can provide highquality care. The regular meetings of the unit
6. 1. Rationale: Physiological risk factors involve council show a shared governance structure and
the physical functioning of the body. Heredity, or unit level participation in decision making. This
genetic predisposition to specific illness, such as a participation in decision making is a characteristic
family history of type 2 diabetes, is a major
of a positive work environment. The options that
physical risk factor.
say, The nurse manager tells the nurses that the
hospital has decided to have all nurses work 127. 4. Rationale: Eating meals high in fat, getting
hour shifts. and The nurse manager decided that
very little exercise, and smoking cigarettes are
the mentoring program was not working and
examples of lifestyle practices and behaviors that discontinued the program. are examples of
negatively impact health.
decision making by the manager rather than at the
unit level. It is also an example of a manager who
8. 2. Rationale: In the contemplation stage, the
is not supportive of the staff. The option that says,
patient is considering a change within the next 6 Each nurse is allowed to attend one education
months. This is different from the preprogram a year. shows lack of support for
contemplation stage, in which the patient is
education of the nurses. Educational opportunities
unaware of the problem and not intending to
for developing knowledge are characteristics of a
change, and different from the preparation stage, positive work environment.
Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Answer Key - Answers to Review Questions

1-2
3. 3. Rationale: The first step in the referral
measures specific nursing outcomes as a way
process is to identify the health care needs of for nursing units and health care organizations
the patient and then identify skilled nursing
to compare themselves against other health
facilities that offer the services to meet the
care organizations nationally. Examples of
patients needs and to support independence outcomes measured by NDNQI include patient
and facilitate recovery. Once the skilled
falls, pressure ulcers, RN job satisfaction, and
nursing facilities have been identified, then the hospital-acquired infection of catheterdiscussion with the patient and family to select associated urinary tract infections.
the nursing facility occurs. Before transfer of
the patient, the skilled nursing facility is
8. 4. Rationale: Managed care organizations
provided accurate information on the patient. (MCOs) provide comprehensive, preventive,
and treatment services to a specific group of
4. 2, 3. Rationale: Secondary acute care
enrolled persons. The staff model is made up
health services are focused on the diagnosis of physicians that are salaried employees of
and treatment of illnesses. Outpatient surgery the MCO. In the group model, the MCO
and treatment in the emergency department contracts with a single group practice. In the
are focused on treatment of illnesses. Setting network model, the MCO contracts with
an appointment with the nurse practitioner and multiple group practices or integrated
attending the blood pressure screening are
organizations.
examples of primary care services, which
include maternal-child health care and control 9. 4. Rationale: Medicare Part D is related to
of diseases. Wound care done weekly by the the prescription drug benefits under Medicare.
home care nurse is restorative care.
Part A is related to basic protection for
medical, surgical, and psychiatric care costs
5. 2. Rationale: Vulnerable populations are
based on diagnosis-related groups (DRGs).
those groups in a population that are at
Part B is a voluntary medical insurance that
increased risk for experiencing injury, illness, discusses coverage for physician and certain
or premature death. Older adults are a
outpatient services. Part C is related to the
vulnerable population. Changes related to
managed care provision that provides a choice
aging, presence of chronic health problems, of three insurance plans.
and often decreased income place this group
at risk for injury and illness.
10. 3. Rationale: Occupational health clinics
are primary care settings that provide
6. 2. Rationale: Respite care is a service that employees with interventions that lead to
provides short-term relief or time off for
improved health outcomes. Intensive care
persons providing home care to an ill,
units are tertiary care units. Hospice units are
disabled, or frail older adult. Because Mrs.
part of continuing care. Cardiac rehabilitation
Allen is the sole full-time caregiver for her
centers are part of restorative care.
husband with Alzheimers disease, she is
under stress and will benefit from relief from
her full-time caregiver duties.
7. 1, 2, 3, 5. Rationale: Nursing-sensitive
quality indicators or outcomes are patient
outcomes that are directly related to nursing
care. The National Database of Nursing
Quality Indicators (NDNQI) evaluates and
1-3
hearing, which often affect patient education
needs and self-care abilities.
Chapter 3: Community-Based Nursing

Practice
7. 4. Rationale: Building codes are based on

information from engineering and structural
sciences.
1. 4. Rationale: The elimination of health

disparities within a community increases
access to care and in turn improves quality of
life and life expectancy for the members of the
community.
8. 4. Rationale: The nurse designs these

courses to teach the adolescent parents to
improve the health of their children and in turn
improve the quality of life for the adolescent
parents.
2. 2, 3. Rationale: The practice of community 9. 1. Rationale: Assessment of individuals and

nursing must always recognize the impact and families, the community, and the sociopolitical
interaction of the public health practices and system enables you to collect the most
policies and the environment on the
comprehensive data about the communitys
community as a whole and the individuals and needs, resources, benefits, and barriers.
families residing in the community.
10. 3, 4. Rationale: When meeting with
3. 1, 2, 3, 4. Rationale: By assessing the
members of the community, you consult with
community and working with the leaders in the them regarding factors increasing the risk of
community, you were able to educate the
respiratory illness. At the same time you need
leaders about health care resources (the
to educate the community about these risks
clinic), allow the community to make a
and what the community can do to
decision, and plan for improved immunization. reduce/modify these risks. In this meeting you
As a result, one of the outcomes is improved do not provide care, nor will you do any case
health care for the children.
management with the members of the
community who have respiratory illnesses.
4. 2. Rationale: You are assisting this patient
with managing her disease within the
community rather than waiting until the need Chapter 4: Legal Principles in Nursing
for hospitalization.
1. 3. Rationale: The Nurse Practice Act is a
5. 4. Rationale: Although there are multiple
state law that describes the scope of practice
types of vulnerable populations, the limited
of nurses in an individual state. It sets the
access to care and lack of transportation to
standard of care to be provided by licensed
receive care contribute to their health
nurses in that state. The Nurse Practice Act
problems.
may differ from state to state. HIPAA,
Americans With Disabilities Act (ADA), and
6. 1. Rationale: Older adults frequently have Uniform Anatomical Gift Act are federal laws
one or more chronic illness for which they
applying to all states equally.
receive care and medications from more than
one provider, which contributes to
2. 3. Rationale: All pertinent information,
polypharmacy. In addition, the aging process including a full description of the incident and
usually results in changes in vision and
statements made by participants, if known,
should be included in the report. A copy of the

occurrence report is never kept in the medical
record. Subjective information is never
included in an occurrence report because it
cannot be validated at a later time. Blame is
an example of unnecessary and unhelpful
subjectivity in an occurrence report.
3. 2. Rationale: Generally the individual who
performs the procedure is obligated to obtain
informed consent. All other parties may be
witnesses to a patients signature. A patient is
not responsible for providing the necessary
information in order to achieve informed
consent for themselves.
1-4
patient that she will die without the procedure
may be seen as a threat. Both acts would
affect the voluntary nature of the patients
consent and would be illegal if the patient were
to consent under those circumstances.
8. 1, 2, 3, 4. Rationale: The standard of care
that a nurses actions are compared to arise
from several sources, among them are the
State Nurse Practice Act, community
standards, the standard of a reasonably
prudent professional under similar
circumstances, and the standard of the nurses
own competence.
4. 4. Rationale: Employer malpractice

9. 4. Rationale: The nurses best action is to
insurance provides protection for employees report the suspected abuse after documenting
who are working within the scope of their
the patients verbal statements and the nursing
employment. Incidents that occur in a persons assessment of the patients condition.
home are generally protected by home
Reporting the nurses findings to the patients
insurance, unless their home is their place of health care provider maintains patient
employment. In that case, the home owner
confidentiality and protects the patient from
generally carries a broader home owners
any potential abuser. Reporting the nurses
insurance policy. Driving to and from work is findings to the nursing supervisor meets the
generally covered by an individuals
requirements of most state laws regarding
automobile insurance.
abuse reporting. Doing nothing would violate
the nurses obligation as a patient advocate.
5. 4. Rationale: Good Samaritan laws grant
immunity from liability so long as the nurse
10. 4. Rationale: Leaving the nursing division
provides assistance that meets the standard of is not an option because, under these facts, it
care or does not fall to the level of gross
could be construed as patient abandonment.
negligence.
Contacting the patients physicians or health
care providers does not adequately inform the
6. 4. Rationale: Generally, verbal orders need hospital administration, which is legally
to be written in the physicians or health care responsible for safe staffing of the hospital.
providers orders as soon as possible and then Documenting the staffing and end-of-shift
cosigned within a specified time period.
report analyses along with the response of the
Untranscribed orders may be followed if time nursing supervisor to your notification that the
is of the essence. Illegible health care provider present staffing does not meet safe patient
orders should be clarified with the provider
care standards is your best protection in the
who wrote the order.
face of potential liability should a patient suffer
an injury as a result of the inadequate staffing.
7. 2. Rationale: A patient who has capacity to
consent to a procedure has the capacity to
withdraw that consent at any time. Efforts to
convince the patient to change her mind could
be construed as coercion. Informing the
1-5
6. 1. Rationale: The ethics of care suggest that
health care workers solve ethical dilemmas by
paying attention to relationships and
fundamental act of caring.
7. 3. Rationale: Nonmaleficence is a complex
principle, but one that will help nurses explain
why some actions can be hurtful or harmful
and yet beneficial at the same time.
8. 3. Rationale: The patients point of view is
the most important point of view in an ethical
dilemma, and nurses are in a unique position
to understand and speak for that point of view.
Chapter 5: Ethics
Answer Key - Answers to Review
Questions - With Rationales
1. 4. Rationale: Because ethical issues often
involve emotional and complicated situations,
it can be tempting to begin discussion right
away. Taking time to gather all relevant
information will help to ensure that the
discussion is effective and complete.
Chapter 6: Evidence-Based Practice

1. 2. Rationale: The PICO question would be

Does the use of chlorhexidine (I) compared
2. 4. Rationale: The ethical issues surrounding with Betadine (C) used in a surgical prep of
organ transplant will involve the use of all the patients skin (P) reduce postoperative wound
options in this question, but the primary
infections (O)?
principle at stake is the principle of just
distribution of resources.
2. 3, 1, 5, 2, 4, 6.
3. 2. Rationale: The code of ethics refers to
principles of behavior and professional
practice.
3. 4. Rationale: To measure learning, the

nurse will ask the patient to complete a
knowledge test. Observation of a patient
reading or an audit of teaching sessions only
4. 3. Rationale: Nurses bring a unique and
means instructional material reached the
valuable voice to discussions about ethical
patient, not that learning occurred. Learning is
dilemmas. Participation by nurses is not legally not a physiological measure.
mandated, but it is ethically sound.
4. 1. Rationale: The nurses interest in the
5. 1. Rationale: Utilitarianism is a term
scientific knowledge available about pin site
commonly found in ethical discussions. Its
care is a knowledge-focused trigger. If the
meaning is simple and helpful as a guideline nurses question had been driven by a trend in
for resolving differences of opinion.
recurrent pin site infections, the question

1-6
would then be a problem-focused trigger. The
nurse is asking a background question, not a Answer Key - Answers to Review
PICO question. The nurse is not posing a
hypothesis to be tested by research.
1. 4. Rationale: Using a policy and procedure
5. 4. Rationale: The Do step of a QI project involves concrete thinking based on a set of
involves selection of an intervention(s) on the rules or principles.
basis of the data reviewed and implementation
of the change. The review of initial QI reports 2. 2. Rationale: When the nurse saw the
is the Plan step. The review of the incidence patients appearance, she had a gut feeling
of pressure ulcers is the Study step,
or intuition that something was wrong, based
evaluating results of the QI intervention. The on her experience.
final step Act would involve implementing a
successful protocol on all nursing units.
3. 4. Rationale: In this case the nurse chooses
an alternative course of action because of her
6. 2. Rationale: The staff intend to develop an knowledge of the patient-daughter
instructional manual based on a lower reading relationship.
level to instruct patients about cervical cancer
risks. The outcome they hope to achieve is
4. 3. Rationale: The nurse tries to clarify what
more patients adhering to annual Pap smears. is causing the tube obstruction by analyzing
The new manual will not change the patients possible causes.
reading levels. The manual may improve
patients knowledge of cervical cancer risks, 5. 3. Rationale: The nurse applies experience
but that is not the desired outcome. The
from previously seeing phlebitis to the new
number of patients who receive the manual is patients problem.
simply a process indicator.
6. 3. Rationale: The nurses concern over
7. 3. Rationale: The question is a diagnosis
making an error leads him to critically think
question, which addresses the selection and and reflect back on the situation so as to learn
interpretation of diagnostic tests. A prognosis from the experience. It allows him to judge his
question asks about a patients likely outcome personal performance and determine how
from disease or treatment. Prevention
closely he followed standards of nursing
questions are about screening and prevention practice in his care.
methods to reduce the risk for disease. A
therapy question is about the selection of the 7. 1. Rationale: Assessing this patients
most beneficial treatments.
feelings and psychosocial needs is relevant
because the new diagnosis has been made.
8. 4. Rationale: When a nurse questions the
level of evidence, it is not about the number of 8. 4. Rationale: The nurse has not used a
articles or the scientific validity of the study
wound vacuum system before and is willing to
findings. It is also not about the relevance
admit what she does not know so that the
regarding the use of the same instrument.
procedure will be performed correctly.
Level of evidence refers to the type of study
the particular article involved in relationship to
the hierarchy of available evidence.
Chapter 8: Nursing Process
Chapter 7: Critical Thinking

1. 3. Rationale: Back-channeling is a listening
skill that includes use of prompts such as all
right, go on, or uh-huh. These indicate that
you have heard what the patient says and are
probing for a fuller story.
1-7
Chapter 9: Informatics and Documentation
1. 3. Rationale: Best practice is for health care

providers to document as soon as possible
after providing patient care to avoid lapse in
communication. Oral reports are not
2. 2. Rationale: With the goal of the pressure considered more accurate; court of law
ulcer healing in 3 weeks, an expected
recognizes written documentation as evidence
outcome would be indication of healing, such for questions in care provided. The health care
as change in diameter of wound or amount of provider is accountable for providing continuity
drainage. Thus an example of an evaluative of care, which best occurs by knowing
measure is one that measures status of the
previous patient assessments. PIE charting
outcome (e.g., measurement of the ulcer
follows the nursing model, not CBE.
diameter).
2. 2. Rationale: Focus charting saves time
3. 4. Rationale: After you collect data from a because it is easily understood by multiple
patient, review your database to decide if it is caregivers, it is adaptable to most health care
accurate and complete. Validate your data by settings, and it enables all caregivers to track
collecting measurable, objective physical
the patients condition and progress toward the
findings. For example, when a patient reports outcomes of care.
difficulty breathing, you want to also listen to
lung sounds and assess respiratory rate and 3. 1. Rationale: The patient record contains
rhythm.
much information for purposes of research,
education, auditing, communication, and legal
4. 3. Rationale: The expected outcome
(liability) reasons. However, subjective
measure was the reported pain severity level comments about the patient, family, or other
of 4 on a scale of 0 to 10. The outcome is the health care workers as a means to protect the
expected response to the intervention.
nurse should NEVER be put into the patients
record.
5. 1. Rationale: Insertion of the urinary
catheter is a physician-initiated or dependent 4. 3. Rationale: It is best to share the current
intervention that requires a physicians order. patient status and anticipated needs, such as
prn medication, laboratory work, and so forth.
6. 1. Rationale: The nursing student compares Properly performed, a change-of-shift report
assessment data with data in the medical
provides nurses an opportunity to share
record to validate if the findings are normal or essential information to provide for patient
abnormal for the patient.
safety and continuity of care. This would not
be the time to share step-by-step how-to
7. 4. Rationale: A goal is a broad statement
procedures. Community resources for the
that describes a desired change in a patients patient to contact, as well as a review of signs
condition or behavior. It is time limited; in this and symptoms of complications to report to the
example the goal is to be completed by day of health-care provider would be shared in the
surgery.
discharge summary.

1-8
5. 2. Rationale: Current 2009 NPSGs require a 10. 1. Rationale: Data include numbers,
read-back process for all telephone orders. characters, or facts that are collected
The nurse is to write the communication on the according to a perceived need for analysis and
order sheet BEFORE the information is read possible action. Information is data that are
back to the health care provider who placed interpreted, organized, or structured.
the order. The purpose is to provide patient
Information provides the answers to who,
safety from miscommunication of information. what, when, where questions. Knowledge is
the application of data and information.
6. 4. Rationale: When documenting, you
Wisdom focuses on the appropriate
should consider the patients diagnosis,
application of that knowledge.
previous patient assessments, any anticipated
or unanticipated changes, and what the next
caregiver needs to know. You should NOT
Chapter 10: Communication
document any of your personal feelings about
the patient. Information should remain
objective.
7. 4. Rationale: Nurses should avoid vague
1. 4. Rationale: The nurse has given a
documentation such as appears to be in
message and is seeking information about
severe pain. The pain should be rated and
whether it was received accurately.
documented using a standardized pain scale,
such as 0 to 10. The blood pressure and pulse 2. 3. Rationale: Eye contact varies among
need parameterselevated does not
different cultures. Persons of Asian cultures
communicate specific data pertinent to the
view eye contact as intrusive or threatening.
patient. The type of analgesic needs to be
Averting your eyes will show respect. It is
documented, as well as the name of the
important to consider the persons culture
physician notified. Adequate response is more when interpreting nonverbal behavior.
vague information that does not communicate
information specific to the patient.
3. 2. Rationale: Intrapersonal communication
is self-talk. The other options may help her
8. 1. Rationale: Complete bath represents
better understand insulin administration or
hygiene needs, not assessment needs. Level deal with her anxiety, but they do not involve
of pain is a neurological finding; turning in bed intrapersonal communication.
with assistance is a mobility assessment
parameter. The status of the dressing
4. 3. Rationale: Using the acronym SBAR, the
represents an assessment of wound care.
nurse should begin with S, which is situation.
The situation is that the patient is short of
9. 3. Rationale: Health care agencies use
breath. The history of lung cancer is
military time to minimize medical errors.
background, the respiratory rate is
Military time uses a 24-hour clock. Midnight
assessment, and the request for an order is a
starts at 0000. Each hour thereafter is
recommendation.
reflected by the addition of a numeral to the
hundredth space. For example, 2 am would be 5. 2. Rationale: Following through on what you
0200. Thus noon would be 1200, 1 pm is
tell a patient will increase trust. Trust is
1300, 2 pm is 1400, 3 pm is 1500, and so
essential to the establishment of a therapeutic
forth.
relationship.

1-9
6. 4. Rationale: Socializing is used during the 1. 1. Rationale: Learning about side effects
orientation phase of a relationship to get
requires intellectual comprehension of
acquainted and help establish trust.
information.
7. 2. Rationale: The nurse is not sure what the 2. 2, 3, 4. Rationale: Appropriate timing of
patient means by living up to expectations
teaching enhances achievement of outcomes;
and is clarifying the patients concern.
the patient will be more able to pay attention to
teaching; and including family in teaching
8. 2. Rationale: Avoid asking why questions. sessions enhances success if the patient
They tend to imply an accusation and can
wants the family to be involved.
build resentment.
3. 3. Rationale: Requiring students to be active
9. 3. Rationale: You do not want to assume
in their learning and to solve real-life problems
she is hard of hearing because she is 80, but it enhances successful teaching outcomes.
is more likely. She may have not responded
because you were across the room and there 4. 1. Rationale: Return demonstration reflects
was water running. Do not jump to
patient understanding.
conclusions, but instead try again to
communicate with her as you would with
5. 3. Rationale: This approach allows the
someone who is hard of hearing.
patient the ability to accept responsibility for
tasks and manage self-care.
10. 2. Rationale: Lateral violence can be dealt
with by using assertive communication. Simple 6. 4. Rationale: Follows teaching principles to
assertive statements include referencing who use when teaching older adults. An older adult
you are addressing, the behavior that is a
should be spoken to in a normal tone of voice
problem, and its effect. Avoiding the situation, and given time to learn. Repetition of
getting defensive, or making sarcastic remarks instruction is commonly needed.
will not help resolve the problem.
7. 3. Rationale: School-age children need to
be guided in their learningindependent
learning occurs most effectively in adulthood.
8. 2. Rationale: Before successful teaching
can occur, the nurse needs to establish trust
with the patient.
9. 1. Rationale: Psychomotor skills are needed
to use computers.
Chapter 11: Patient Education

10. 2. Rationale: This action combines nursing

care and teachingthe other actions follow
appropriate teaching techniques but do not
incorporate teaching and nursing care.
Chapter 12: Managing Patient Care

1-10
6. 1. Rationale: Total patient care is the care
delivery model in which the RN is responsible
for all aspects of the patient care during a shift.
1. 3. Rationale: Accountability is nurses being The nurse does not necessarily care for the
answerable for their own actions. In this
same patients over successive days. The
example, the nurse recognizes that an error functional nursing model assigns specific tasks
was made and appropriate follow-up was
to each of the nurses. Primary nursing is
performed.
where an RN assumes responsibility for a
caseload of patients over time. The RN
2. 2. Rationale: Treating the patients pain is provides care to the same patients for their
the priority and should be acted upon first. The length of stay in the hospital. Team nursing is
patient needs to walk, but this should not be the model in which the RN directs team
attempted until the patients pain is under
members to provide direct patient care.
control. Pain interferes with the patients ability
to concentrate and focus on instructions given 7. 3. Rationale: The right direction provides a
during a teaching session. Adequate pain
clear, concise description of the task. The
control will make it easier for the patient to
nurse provides the right direction because
undertake additional tasks. The IV solution will specific instructions on how to complete the
last for another 1 hours, which provides you walk are given. The nurse specifies the
adequate time to assess the patients pain and distance to walk the patient. The nurse also
prepare and administer an analgesic.
gives specific instructions on taking the pulse
before and after the walk and reporting the
3. 4. Rationale: It is appropriate to delegate
pulse rates.
the bed bath to the nursing assistive
personnel. Patient teaching is the
8. 1. Rationale: The right task is a task for a
responsibility of the RN. Changing the IV
specific patient that requires little supervision,
dressing is not within the scope of practice of is relatively noninvasive, has results that are
the nursing assistant. The RN should perform predictable, and has minimal potential risk.
nasotracheal suctioning the patient to assess Taking vital signs on a 2-day postoperative
patients response and outcome of the
patient meets these criteria. The other options
procedure.
are tasks that are within the scope of practice
for an RN, not a nursing assistant.
4. 3. Rationale: The directions provided are
appropriate delegation. The delegated task is 9. 2. Rationale: In Maslows hierarchy of
communicated clearly. You also make the
patient needs, interventions are focused on
nursing assistant feel part of the team because treating the patients physiological needs first.
you offer to help turn the patient and complete Therefore treatment of pain is the priority need
your assessment.
for this patient. Although the problem of
nausea is physiological, treatment of the pain
5. 3. Rationale: Patient and family teaching is may possibly relieve the nausea. After
a nonemergency or nonlife-threatening actual treatment to meet physiological needs, higherneed. High-priority needs are those that are a level needs such as education are then met.
threat to a patients survival or safety. Lowpriority needs are those problems that are not 10. 4. Rationale: Change-of-shift report helps
directly related to the patients illness.
you to prioritize activities based on what you
have learned about the patients current
condition. When you recognize that your

1-11
patients status has changed, you need to
hygiene is performed whenever the nurse
revise your work plan for the day. The revised moves from an activity requiring gloves to
plan will help you remain goal oriented,
another nursing action, leaving the patients
focused on your patients priorities, and able to room, and whenever all patient tasks are
meet the patients changing needs.
completed.
Chapter 13: Infection Prevention and
Control
1. 1. Rationale: Hands contaminated with
transient bacteria are a primary source for
transmission of infection.
2. 3. Rationale: Early intervention can reduce
the risk for sepsis due to the progression of
the infection. Fever depletes the bodys fluid
stores, resulting in an increased risk for
dehydration. Providing nutrition promotes
healing.
7. 4. Rationale: Hands become contaminated

through contact with the patient and the
environment and serve as an effective vector
of transmission.
8. 1. Rationale: Physically removing wound
drainage is most effectively accomplished by
washing with soap and water.
9. 3. Rationale: Patients on isolation
precautions may interpret the needed
restrictions as a sign of rejection by the health
care worker.
10. 3. Rationale: Hands become contaminated

through contact with the patients environment.
Clean hands interrupt the transmission of
3. 3. Rationale: The presence of a catheter in microorganism among other family members.
the urethra breaches the bodys natural
defenses. Reflux of microorganisms up the
Chapter 14: Vital Signs
catheter lumen from the drainage bag or
backflow of urine in the tubing increases the Answer Key - Answers to Review
risk for infection.
4. 2. Rationale: Gloves are contaminated from
contact with the wound. Administering
medication without removing the gloves and
performing hand hygiene results in transfer of
microorganisms from one site to another.
1. 2, 3. Rationale: Atenolol, a beta-blocker, will

affect blood pressure and heart rate; therefore
the nurse needs to assess the patients blood
pressure and heart rate at this time. The other
vital signs can be delegated to the nursing
assistive personnel in this situation.
5. 4. Rationale: The gown serves as a barrier

between the patients blood and/or body fluid 2. 2. Rationale: A blood pressure in the right
and potential contact with the caregivers skin. arm cannot be used as a baseline for a blood
pressure in the left arm. Differences between
6. 2, 3, 4. Rationale: Gloves need to be
arms may indicate cardiovascular disease,
changed and hand hygiene performed to
and the health care provider will need to be
prevent transfer of microorganisms from one notified after a current blood pressure in the
source to another. Gloves may have
left arm is obtained. It is assumed that the
microscopic holes allowing microorganisms to patient is relaxed with a blood pressure of
have contact with the caregivers skin.
102/58 mm Hg.
Therefore gloves are removed and hand

1-12
3. 4. Rationale: Tachycardia is defined as a
1. 1. Rationale: Impotence is a predictable,
pulse over 100 beats per minute; bradypnea is unavoidable, and common side effect of
defined as respiratory rate under 12 breaths antihypertensives.
per minute.
2. 4. Rationale: Combination medication
4. 2. Rationale: An accurate pulse saturation therapy is often needed to control
cannot be obtained unless the oxygen is being hypertension; the interaction between these
administered as ordered. Further assessment medications is desirable.
by measuring respiratory rate is not a priority.
Shaking may alarm the patient and is not an 3. 3. Rationale: Nurses should not prepare
appropriate action at this time.
high-risk IV medications on patient care units.
5. 3. Rationale: Hypoxia usually results in
4. 4. Rationale: This is an appropriate-size
tachycardia in an attempt to increase cardiac needle for administering a subcutaneous
output.
medication (see Skill 16-5).
6. 3. Rationale: A systolic difference of 26 mm 5. 3. Rationale: 1 Tbsp equals 15 mL.
Hg between sitting and standing is the
definition of orthostatic hypotension.
6. 2. Rationale: The nurse needs to clarify
medication orders that do not follow safe
7. 1. Rationale: The priority is to maintain
medication order guidelines.
patient safety. Dizziness and nausea can be
symptoms of hypotension, which places the
7. 4. Rationale: Each capsule is 250 mg.
patient at risk for falling. After the patient is
Therefore, to administer the correct dosage of
assisted to a supine position, the blood
500 mg, the nurse needs to give 2 capsules.
pressure should be measured.
250 mg 2 = 500 mg.
8. 2. Rationale: In the case of a postoperative 8. 2. Rationale: The rest of the patients are
patient, orthostatic hypotension is likely the
stable, so treating the pain in this situation is
result of fluid volume deficit from blood loss. the priority.
9. 1. Rationale: An excessively wide blood
9. 4. Rationale: Patients should alternate
pressure cuff can result in a false-low blood
cheeks with each buccal dose to avoid
pressure. The other options will falsely elevate mucosal irritation.
blood pressure.
10. 3. Rationale: Biological half-life is the
10. 4. Rationale: By observing how the newly amount of time it takes for the body to
hired nursing assistant measures blood
eliminate half of the medication. In the first 3
pressure, you can determine if there are any hours, the patient will excrete 500 mg, and in
errors in technique or equipment.
the second 3 hours, the patient will excrete
250 mg; therefore in 6 hours the total amount
Chapter 16: Administering Medications
of medication eliminated is 750 mg.
Chapter 17: Fluid, Electrolyte and AcidBase Balances

1. 2. Rationale: Loss of gastrointestinal fluid
along with hypotension indicates possible
hypovolemic shock and has high nursing
priority.
1-13
1. 3. Rationale: Touch is relational and can
form a meaningful connection between nurse
and patient.
2. 4. Rationale: Learning how the patient feels

2. 1. Rationale: A patient in acute renal failure about a vaginal examination is an example of
is at high risk for potassium becoming
knowing, striving to understand an event as it
extracellular, putting the patient at increased has meaning in the life of the other.
risk for hyperkalemia.
3. 3. Rationale: This is an example of
3. 3. Rationale: The patient is in respiratory
enabling, informing the patient so as to help
alkalosis in need of pulmonary toileting.
him or her prepare for the unfamiliar event of
going home with limitations.
4. 3, 6, 5, 1, 7, 4, 2, 8. Rationale: The steps
need to be done in this order to maintain
4. 1. Rationale: Instilling faith and hope
aseptic technique and prevent fluid from
involves forming a connectedness with the
spilling and a hematoma from forming.
patient that offers purpose and direction when
trying to find the meaning of an illness.
5. 3. Rationale: Highest priority if a transfusion
reaction is suspected is to stop the
5. 3. Rationale: Flexibility, autonomy, and
transfusion, resume the normal saline IV, and improved staffing give nurses the opportunity
call the health care provider.
to exercise practice in a way that is patient
focused.
6. 2. Rationale: The pH is elevated above
7.45, and the HCO3 is also elevated,
6. 4. Rationale: Families perceive caring when
indicating metabolic alkalosis.
a nurse shows sensitivity by asking permission
before performing procedures.
7. 2. Rationale: An adult urine output should
be minimally 30 mL/hr. In acute renal failure 7. 3. Rationale: Listening includes taking in
this decreased output places the patient at risk what a patient says, as well as an
for increasing serum potassium levels.
interpretation and understanding of what the
patient is saying. The other options result in
8. 3. Rationale: You cannot give KCl IV push distraction and inattention on the part of the
because when given this way, it will cause
nurse or a failure to acknowledge the patients
your patient to die; the new order is to be
story.
given at 125 mL/hour, which is most
appropriately administered in a 1000-mL IV
8. 2. Rationale: The transcultural view of care
bag, not an IV piggyback; when you receive a emphasizes that care is vital to recovery from
new order, you should implement it as soon as illness and to the maintenance of healthy life
possible; waiting for the currently hanging bag practices in all cultures.
to finish infusing is not appropriate.
9. 3. Rationale: By admitting your own ideas
Chapter 18: Caring in Nursing Practice
are not the only way of thinking, you allow your

patients from different cultures to share their
perspective.
1-14
4. 1. Rationale: Many cultures believe that
newborns and young children are vulnerable
and use a variety of ways to prevent the evil
eye. Filipinos believe rubbing oil will prevent
the evil eye.
10. 3. Rationale: Nurses use task-oriented

touch when performing a task or procedure.
The skillful performance of a nursing
procedure conveys security and competence. 5. 4. Rationale: Some Hispanic women go into
a 40-day period of la cuarantena in which they
th
Potter: Basic Nursing, 7 Edition
follow a special diet and restrict physical
activity in the postpartum period.
Chapter 19: Cultural Diversity
6. 1. Rationale: Patients who are present time
oriented believe that the event starts when
they arrive, so it is not uncommon for them to
show up to an appointment an hour late.
1. 2. Rationale: This patient is saving face by Discharge teaching, hospital admission, and
not confronting the nurse himself and avoiding compliance with a therapy regimen are not
conflict and causing the nurse embarrassment. usually affected by present time orientation.
In assertive communication and direct
communication, the patient would confront the 7. 2. Rationale: In some cultures, caring
nurse directly. In biased communication, the means active involvement of the group,
patient would not want to discuss a subject
emphasizing the need for members to care for
with the nurse manager because of a bias
each other. Although in many Hispanic
issue (the nurse manager is of a different race, cultures there are ties to both the father and
gender, etc.).
mothers side of the family as well as close ties
among extended kin, this is not manifested by
2. 1. Rationale: In cultural imposition a person the constant presence at the bedside. Present
uses his or her own values and customs as a time orientation is not an issue in this situation.
guide in dealing with patients and interpreting
their behaviors. The male nurse assumed the 8. 1. Rationale: It is important for the members
patient was comfortable with his presence and of this family to be able to provide support to
was persistent in his attempt to drape the
their loved one through their presence. The
woman. He failed to recognize the source of family most likely knows the policy. It is not
conflict. Stereotypes are a tendency to fit
appropriate for the information desk to monitor
every person into a particular pattern without the visitors. An early discharge is
further assessment. Cultural accommodation inappropriate.
is the ability to adapt or negotiate with the
patient/family to achieve beneficial or
9. 4. Rationale: Many cultures believe that if a
satisfying health outcomes. Ethnocentrism is pregnant womans food craving is not met,
the belief that ones own ways are best.
negative consequences to the baby will occur.
The other answers are inappropriate.
3. 1. Rationale: Females in Arabian culture are
very modest and do not expose their bodies to 10. 3. Rationale: Most Muslims are fatalistic
members of the opposite gender. The other
and believe that they should not question
answers are not appropriate.
Gods will. It is not appropriate to predict the
length of ones life. The other three answers
are inappropriate.
1-15
Chapter 20: Spiritual Health
mood because they capitalize on the mind,

body, spirit connection.

6. 2. Rationale: Faith allows someone to have

firm beliefs despite lack of physical evidence.
1. 1. Rationale: Spending time with and

allowing patients family members to express
their fears are nursing interventions that
establish presence.
7. 4. Rationale: People who experience

spiritual health are able to forgive others and
feel joy; this patient is not able to forgive his
brother and does not feel joy with the birth of
his grandchild.
2. 3. Rationale: Agnostics tend to discover

meaning in their actions and through their
relationships with others.
3. 4. Rationale: This diagnosis is used when
the patient has resources to cope with a
situation; the patient is experiencing a crisis
but is able to maintain inner strength and
pursue interactions with significant others.
8. 3. Rationale: This comment shows that the

patient is not maintaining connections with her
friends.
9. 2. Rationale: This intervention promotes
spiritual well-being and allows the patient to
explore feelings and fears before sharing them
with significant others.
4. 3. Rationale: You show the intellectual

10. 2. Rationale: When patients are in acute
standard of compassion when you accept the distress, you need to help them gain a sense
dignity and worth of your patient regardless of of control.
socioeconomic status, personal
characteristics, or type of health problems.
5. 1, 2, 4. Rationale: These interventions have
the potential to decrease pain and enhance

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Chapter 1: Health and Wellness

1. 2. Rationale: The second level on the hierarchy

in which the patient intends to take action within

2. 1. Rationale: The age of your patient helps you

Answer Key - Answers to Review Questions

Answer Key - Answers to Review Questions

Chapter 3: Community-Based Nursing

7. 4. Rationale: Building codes are based on

1. 4. Rationale: The elimination of health

8. 4. Rationale: The nurse designs these

2. 2, 3. Rationale: The practice of community 9. 1. Rationale: Assessment of individuals and

Answer Key - Answers to Review Questions

4. 4. Rationale: Employer malpractice

Answer Key - Answers to Review Questions

Chapter 6: Evidence-Based Practice

1. 2. Rationale: The PICO question would be

3. 4. Rationale: To measure learning, the

Answer Key - Answers to Review Questions

Answer Key - Answers to Review Questions

1. 3. Rationale: Best practice is for health care

Answer Key - Answers to Review Questions

Answer Key - Answers to Review Questions

Chapter 11: Patient Education

10. 2. Rationale: This action combines nursing

Answer Key - Answers to Review Questions

Answer Key - Answers to Review Questions

7. 4. Rationale: Hands become contaminated

10. 3. Rationale: Hands become contaminated

1. 2, 3. Rationale: Atenolol, a beta-blocker, will

5. 4. Rationale: The gown serves as a barrier

Answer Key - Answers to Review Questions

Chapter 17: Fluid, Electrolyte and AcidBase Balances

Answer Key - Answers to Review Questions

2. 4. Rationale: Learning how the patient feels

Answer Key - Answers to Review Questions

10. 3. Rationale: Nurses use task-oriented

Answer Key - Answers to Review Questions

Chapter 20: Spiritual Health

mood because they capitalize on the mind,

Answer Key - Answers to Review

6. 2. Rationale: Faith allows someone to have

1. 1. Rationale: Spending time with and

7. 4. Rationale: People who experience

2. 3. Rationale: Agnostics tend to discover

8. 3. Rationale: This comment shows that the

4. 3. Rationale: You show the intellectual

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