2 The Health Care Delivery System

Key Points
• Levels of health care describe the scope of services and settings in which health care is delivered to patients in all stages
of health and illness.
• The primary level of health care includes medical health care services, health education, nutritional care, maternal/child
health care, family planning, and control of diseases.
• Rural Americans’ access to health care is affected by economic factors (rural Americans are more likely to live below
the poverty level), cultural and social differences, educational shortcomings, lack of recognition of the problem by
legislators, and the isolation of living in remote rural areas.
• “Pay for value” ties reimbursement to quality; if hospitals perform poorly in quality scores, they receive lower payments
for services. Levels of prevention describe the focus of health-related activities in a care setting. The holistic model of
care is used within integrated health care systems and delivers a coordinated continuum of services that supports
patients with chronic conditions and improves the health of specific populations.
• Hospitals deliver health care to patients who are acutely ill and need comprehensive specialized secondary and tertiary
health care.
• In restorative care settings, nurses know that success depends on their effective and early partnering with patients and
their families.
• Discharge planning begins at admission to a health care agency and helps in the transition of a patient’s care from one
environment to another.
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• Barriers to effective discharge planning include ineffective communication, lack of role clarity among health care team
members, and lack of resources.
• Nurses promote patient satisfaction through providing patient- and family-centered care and good interpersonal skills,
including courtesy, respect, and good communication skills.
• The nursing shortage opens vast opportunities to nurses. Furthering education and following trends in health care open
professional options for nurses.
• Social determinants affect health disparities, the differences in the health status of different groups of people in a
community. Differences in health status, particularly in a community where the majority have poor health, will affect
the productivity and vulnerability of a population.

Review Questions
1. Which activity performed by a nurse is related to maintaining competency in nursing practice?
1. Asking another nurse about how to change the settings on a medication pump
2. Regularly attending unit staff meetings
3. Participating as a member of the professional nursing council
4. Attending a review course in preparation for a certification examination
2. Which of the following are examples of a nurse participating in primary care activities? (Select all that apply.)
1. Providing prenatal teaching on nutrition to a pregnant woman during the first trimester
2. Assessing the nutritional status of older adults who come to the community center for lunch
3. Working with patients in a cardiac rehabilitation program
4. Providing home wound care to a patient
5. Teaching a class to parents at the local grade school about the importance of immunizations
3. Which of the following statements is true regarding Magnet® status recognition for a hospital?

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 1. Nursing is run by a Magnet manager who makes decisions for the nursing units.
2. Nurses in Magnet hospitals make all of the decisions on the clinical units.
3. Magnet is a term that is used to describe hospitals that are able to hire the nurses they need.
4. Magnet is a special designation for hospitals that achieve excellence in nursing practice.
4. Which of the following nursing activities is provided in a secondary health care environment?
1. Conducting blood pressure screenings for older adults at the Senior Center
2. Teaching a patient with chronic obstructive pulmonary disease purse-lipped breathing techniques at an outpatient
clinic
3. Changing the postoperative dressing for a patient on a medical-surgical unit
4. Doing endotracheal suctioning for a patient on a ventilator in the medical intensive care unit
5. A nurse is providing restorative care to a patient following an extended hospitalization for an acute illness. Which of the
following is an appropriate goal for restorative care?
1. Patient will be able to walk 200 feet without shortness of breath.
2. Wound will heal without signs of infection.
3. Patient will express concerns related to return to home.
4. Patient will identify strategies to improve sleep habits.
6. Which of the following describe characteristics of an integrated health care system? (Select all that apply.)
1. The focus is holistic.
2. Participating hospitals follow the same model of health care delivery.
3. The system coordinates a continuum of services.
4. The focus of health care providers is finding a cure for patients.
5. Members of the health care team link electronically to use the EMR to share the patient’s health care record.
7. The school nurse has been following a 9-year-old student who has shown behavioral problems in class. The student acts
out and does not follow teacher instructions. The nurse plans to meet with the student’s family to learn more about
social determinants of health that might be affecting the student. Which of the following factors would be appropriate
for this type of assessment? (Select all that apply.)
1. The student’s seating placement in the classroom
2. The level of support parents offer when the student completes homework
3. The level of violence in the family’s neighborhood
4. The age at which the child first began having behavioral problems
5. The cultural values about education held by family
8. A nurse is assigned to care for an 82-year-old patient who will be transferred from the hospital to a rehabilitation center.
The patient and her husband have selected the rehabilitation center closest to their home. The nurse learns that the
patient will be discharged in 3 days and decides to make the referral on the day of discharge. The nurse reviews the
recommendations for physical therapy and applies the information to fall prevention strategies in the hospital. What
discharge planning action by the nurse has not been addressed correctly?
1. Patient and family involvement in referral
2. Timing of referral
3. Incorporation of referral discipline recommendations into plan of care
4. Determination of discharge date
9. Which of the following are common barriers to effective discharge planning? (Select all that apply.)
1. Ineffective communication among providers
2. Lack of role clarity among health care team members
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3. Sufficient number of hospital beds to manage patient volume
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 4. Patients’ long-term disabilities
5. The patient’s cultural background
10. A nurse newly hired at a community hospital learns about intentional hourly rounding during orientation. Which of the
following are known evidence-based outcomes from intentional rounding? (Select all that apply.)
1. Reduction in nurse staffing requirements
2. Improved patient satisfaction
3. Reduction in patient falls
4. Increased costs
5. Reduction in patient call light use
Answers:1.4; 2.1, 2, 5; 3.4; 4.3; 5.1; 6.1, 3, 5; 7.2, 3, 5; 8.2; 9.1, 2; 10.2, 3, 5.

6 Health and Wellness

Key Points
• Healthy People identifies leading health indicators that are high-priority health issues in the United States.
• Definitions of health vary among individuals based on a person’s health beliefs, developmental age, and level of
functioning.
• Multiple models of health in which persons are active participants explain relationships among health beliefs, health
behaviors, health promotion, and individual well-being.
• Internal variables, such as a person’s developmental stage and spirituality, and external factors, such as family roles and
SDOH, influence a person’s health, health beliefs, and health practices.
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• Health promotion activities help maintain or enhance health, health education helps people better understand their health
and health risks, and illness prevention activities protect against health threats.
• Primary prevention reduces the incidence of disease, secondary prevention prevents the spread of disease when it occurs,
and tertiary prevention minimizes the effects of disease or disability.
• You use your understanding of different types of risk factors to select appropriate secondary prevention strategies for
your patients. Nonmodifiable risk factors, such as age and family history, cannot be changed, while modifiable risk
factors, such as smoking and activity levels, can be changed.
• Reducing risk factors and improving health usually require a change in health behaviors.
• Illness behaviors are different reactions people have when they become ill. Variables such as perceptions of the illness,
the type of illness, and the visibility of symptoms affect a person’s illness behaviors.
• Illness has many effects on a patient and family, including changes in behavior and emotions, family roles and dynamics,
body image, and self-concept.
• Using personal and professional strategies that focus on caring for self can help to decrease or prevent compassion
fatigue.
.

Review Questions
1. A patient discharged a week ago following a stroke is currently participating in rehabilitation sessions provided by
nurses, physical therapists, and registered dietitians in an outpatient setting. In what level of prevention is the patient
participating?
1. Primary prevention
2. Secondary prevention
3. Tertiary prevention
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 4. Transtheoretical prevention
2. Based on the Transtheoretical Model of Change, what is the most appropriate response to a patient who states: “Me,
stop smoking? I’ve been smoking since I was 16!”
1. “That’s fine. Some people who smoke live a long life.”
2. “OK. I want you to decrease the number of cigarettes you smoke by one each day, and I’ll see you in 1 month.”
3. “What do you think is the greatest reason why stopping smoking would be challenging for you?”
4. “I’d like you to attend a smoking-cessation class this week and use nicotine replacement patches as directed.”
3. A nurse working on a medical patient care unit states, “I am having trouble sleeping, and I eat nonstop when I get home.
All I can think of when I get to work is how I can’t wait for my shift to be over. I wish I felt happy again.” What are the
best responses from the nurse manager? (Select all that apply.)
1. “I’m sure this is just a phase you are going through. Hang in there. You’ll feel better soon.”
2. “I know several nurses who feel this way every now and then. Tell me about the patients you have cared for recently.
Did you find it difficult to care for them?”
3. “You can take diphenhydramine over the counter to help you sleep at night.”
4. “Describe for me what you do with your time when you are not working.”
5. “The hospital just started a group where nurses get together to talk about their feelings. Would you like for me to e-
mail the schedule to you?”
4. A patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his
marriage of 15 years and has been praying daily to help him through this difficult time. He does not have a primary
health care provider because he has never really been sick, and his parents never took him to a physician when he was a
child. Which external variables influence the patient’s health practices? (Select all that apply.)
1. Difficulty paying his bills
2. Praying daily
3. Age of patient (46 years)
4. Stress from the divorce and the loss of a job
5. Family practice of not routinely seeing a health care provider
5. A nurse is conducting a home visit with a new mom and her three children. While in the home the nurse weighs each
family member and reviews their 3-day food diary. She checks the mom’s blood pressure and encourages the mom to
take the children for a 15- to 30-minute walk every day. The nurse is addressing which level of need, according to
Maslow?
1. Physiological
2. Safety and security
3. Love and belonging
4. Self-actualization
6. When taking care of patients, a nurse routinely asks whether they take any vitamins or herbal medications, encourages
family members to bring in music that the patient likes to help the patient relax, and frequently prays with her patients
if that is important to them. The nurse is practicing which model?
1. Holistic
2. Health belief
3. Transtheoretical
4. Health promotion
7. Using the Transtheoretical Model of Change, order the steps that a patient goes through to make a lifestyle change
related to physical activity.
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1. The individual recognizes that he is out of shape when his daughter asks him to walk with her after school.
2. Eight months after beginning walking, the individual participates with his wife in a local 5K race.
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 3. The individual becomes angry when the physician tells him that he needs to increase his activity to lose 30 lb.
4. The individual walks 2 to 3 miles, 5 nights a week, with his wife.
5. The individual visits the local running store to purchase walking shoes and obtain advice on a walking plan.
8. Which of the following are symptoms of secondary traumatic stress and burnout that commonly affect nurses? (Select
all that apply.)
1. Regular participation in a book club
2. Lack of interest in exercise
3. Difficulty falling asleep
4. Lack of desire to go to work
5. Anxiety while working
9. As part of a faith community nursing program in her church, a nurse is developing a health promotion program on
breast self-examination for the women’s group. Which statement made by one of the participants is related to the
individual’s accurate perception of susceptibility to an illness?
1. “I have a door hanging tag in my bathroom to remind me to do my breast self-examination monthly.”
2. “Since my mother had breast cancer, I know that I am at increased risk for developing breast cancer.”
3. “Since I am only 25 years of age, the risk of breast cancer for me is very low.”
4. “I participate every year in our local walk/run to raise money for breast cancer research.”
10. The nurse assesses the risk factors for coronary artery disease (CAD) in a female patient. Which of these factors are
classified as genetic and physiological? (Select all that apply.)
1. Sedentary lifestyle
2. Mother died from CAD at age 48
3. History of hypertension
4. Eats diet high in sodium
5. Elevated cholesterol level
Answers: 1.3; 2.3; 3.2, 4, 5; 4.1, 5; 5.1; 6.1; 7.3, 1, 5, 4, 2; 8.2, 3, 4, 5; 9.2; 10.2, 3, 5.

7 Caring in Nursing Practice

Key Points
• Caring is integral to a nurse’s ability to work with people in a respectful and therapeutic manner.
• Theories of caring help explain how caring behaviors are central to a nurse’s ability to work with all patients and family
caregivers in a respectful and therapeutic way.
• Current evidence emphasizes what patients expect from their caregivers and thus provide useful guidelines for practice.
• An ethic of care is concerned with relationships between people and their values and with a nurse’s character and attitude
toward others.
• Presence is a person-to-person interaction, conveying closeness and a sense of caring that involves “being there” and
“being with” patients or family caregivers.
• Touch includes task-oriented, caring, and protective touch.
• Listening is a therapeutic skill that includes interpreting, understanding, and respecting what a patient or family caregiver
is saying and expressing that understanding and respect.
• Knowing the patient is at the core of the process the nurse uses to make clinical decisions about patient-centered care.
• Maintaining compassion in all aspects of nursing care contributes to the health and well-being of patients and can also
improve patient and nurse satisfaction.
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• Caring involves a mutual give-and-take and is specific and relational for each nurse-patient encounter.

Review Questions
1. An experienced nurse is explaining the use of touch from a caring perspective. What information does the nurse include
in the discussion with the student about touch?
1. Nurses touch patients only while performing procedures or doing assessments.
2. Touch is a type of verbal communication.
3. Nurses use touch only when a patient is in pain.
4. Touch forms a connection between nurse and patient.
2. Before implementing touch, what does a nurse need to know about touch? (Select all that apply.)
1. Some cultures may have specific restrictions about non–skill-based touch.
2. Touch is a type of verbal communication.
3. Touch can successfully influence a patient’s level of comfort.
4. There is never a problem with using touch at any time.
5. Touch only reduces physical pain.
3. A young woman comes to a clinic for the first time for a gynecological examination. Which nursing behavior applies
Swanson’s caring process of “knowing” the patient?
1. Sharing feelings about the importance of having regular gynecological examinations
2. Explaining risk factors for cervical cancer
3. Recognizing that the patient is modest and maintaining her privacy during the examination
4. Asking the patient what it means to have a vaginal examination
4. A patient is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the Bible with his
nurse, 91who recommends a favorite Bible verse. Another nurse tells the patient’s nurse that there is no place in nursing
for spiritual caring. The patient’s nurse replies:
1. “You’re correct; spiritual care should be left to a pastoral care professional.”
2. “You’re correct; religion is a personal decision.”
3. “Nurses should explain their own religious beliefs to patients.”
4. “Spiritual, mind, and body connections can affect health.”
5. Which of the following are strategies for creating work environments that support nurse caring interventions? (Select all
that apply.)
1. Increasing technological support
2. Improving flexibility for scheduling
3. Providing opportunities to discuss care
4. Promoting autonomy of practice
5. Encouraging increased input concerning nursing functions from health care providers
6. A nurse is caring for a patient newly diagnosed with testicular cancer. He asked the nurse to help him find the meaning
of cancer by supporting beliefs about life. This is an example of:
1. Instilling hope and faith.
2. Forming a human-altruistic value system.
3. Cultural caring.
4. Being with.

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7. An example of a nurse caring behavior that families of acutely ill patients perceive as important to patients’ well-being
is:
1. Making health care decisions for patients.
2. Having family members provide a patient’s total personal hygiene.
3. Injecting the nurse’s perceptions about the level of care provided.
4. Asking permission before performing a procedure on a patient.
8. A nurse demonstrates caring by helping family members to: (Select all that apply.)
1. Become active participants in care.
2. Remove themselves from personal care.
3. Make health care decisions for the patient.
4. Plan uninterrupted time for family and patient to be together.
5. Discuss their concerns.
9. A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He and his parents made the decision
that he would move home and they would help him in the final stages of his disease. The family participates in his care,
but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or
approaches the patient to give care, she touches his shoulder and tells him that she is present. This is an example of
what type of touch?
1. Caring touch
2. Protective touch
3. Task-oriented touch
4. Interpersonal touch
10. Match the following caring behaviors with their definitions.
1. Knowing a. Sustaining faith in the other’s capacity to get through an event or transition and face a future with meaning
2. Being with b. Striving to understand an event as it has meaning in the life of the other
3. Doing for c. Being emotionally present to the other
4. Maintaining belief d. Doing for the other as he or she would do for self if it were at all possible
Answers: 1.4; 2.1, 3; 3.3; 4.4; 5.2, 3, 4; 6.1; 7. 4; 8.1, 4, 5; 9.1; 10.1b, 2c, 3d, 4a.

2 3 Legal Implications in Nursing Practice

Key Points
• Constitutional law refers to rights granted to citizens in the US Constitution and state constitutions. Civil laws are passed
by Congress and state legislatures to protect the rights of individuals. Criminal laws are passed by Congress and state
legislatures to protect society and provide punishment for crimes.
• Statutory law is civil or criminal. Civil laws protect the rights of individuals as in the case of a Nurse Practice Act, which
defines the scope of nursing practice and the standards you must meet within individual states to ensure safe evidence-
based and competent nursing practice.
• The scope of nursing practice defines nursing and reflects the values of the nursing profession. Standards of nursing care
reflect the knowledge and skill ordinarily possessed and used by nurses.
• A nurse has a duty of care. When a nurse’s performance is questioned, the standard of proof in nursing is typically what
a reasonably prudent nurse would do under similar circumstances in the geographic area in which the alleged breach
occurred.
• The Health Insurance Portability and Accountability Act, Health Information Technology Act, and Americans with
Disabilities Act are examples of federal statutes that affect nursing practice.

7
• The Patient Self-Determination Act is a federal statute that requires health care institutions to provide information to
patients regarding their rights to make informed decisions about their care, including the right to create an advanced
directive. When a patient has an advanced directive that includes a “do not resuscitate” (DNR) order, you need to
ensure that the patient and provider have discussed end-of-life choices and that the discussion is documented in the
patient’s medical record.
• Physical or chemical restraints are used only as a last resort to ensure the physical safety of the patient or other patients
when less restrictive interventions are unsuccessful and require a written order from a health care provider.
• A nurse’s witness to a patient’s informed consent indicates that the patient appeared to voluntarily give consent, that he
or she appeared capable to give consent, and that the patient signed the consent in the nurse’s presence.
• Negligence occurs when a nurse had a duty of care that is breached, a patient is physically harmed, and damages are
provided to “make the person whole”; a reasonably prudent nurse under similar circumstances would have done care
differently.
• Worsening pressure injuries, failure to contact the provider as conditions change, and medication errors often trigger
complaints of negligence or malpractice against nurses.
• It is important to know your Nurse Practice Act, to implement and follow agency policies and procedures, to delegate
care appropriately, and to participate in risk-management and quality improvement activities to reduce your legal risk
when practicing nursing.

Review Questions
1. A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery
along with possible risks, complications, and benefits?
1. Family member
2. Surgeon
3. Nurse
4. Nurse manager
2. A woman has severe life-threatening injuries, is unresponsive, and is hemorrhaging following a car accident. The health
care provider ordered two units of packed red blood cells to treat the woman’s anemia. The woman’s husband refuses
to allow the nurse to give his wife the blood for religious reasons. What is the nurse’s responsibility?
1. Obtain a court order to give the blood.
2. Convince the husband to allow the nurse to give the blood.
3. Call security and have the husband removed from the hospital.
4. Gather more information about the wife’s preferences and determine whether the husband is her power of attorney
for health care.
3. A nurse sends a text message to the oncoming nurse to report that a patient refuses to take medication as ordered. What
should the oncoming nurse do? (Select all that apply).
1. Add this information to the board hanging at the patient’s bedside.
2. Tell the nurse who sent the text that the text is a HIPAA violation.
3. Inform the nursing supervisor.
4. Forward the text to the charge nurse.
5. Thank the nurse for sending the information.
4. Which of the following actions, if performed by a registered nurse, could result in both criminal and administrative law
sanctions against the nurse? (Select all that apply.)
1. Reviewing the electronic health record of a family member who is a patient in the same hospital on a different unit
2. Refusing to provide health care information to a patient’s child
3. Reporting suspected abuse and neglect of children

8
 4. Applying physical restraints without a written order
5. Completing an occurrence report on the unit
5. A nurse received bedside report at the change of shift with the night-shift nurse and the patient. The nursing student
assigned to 320the patient asks to review the patient’s medical record. The nurse lists patients’ medical diagnoses on the
message boards in the patients’ rooms. Later in the day the nurse discusses the plan of care for a patient who is dying
with the patient’s family. Which of these actions describes a violation of the Health Insurance Portability and
Accountability Act (HIPAA)?
1. Discussing patient conditions at the bedside at the change of shift
2. Allowing the nursing student to review the assigned patient’s chart before providing care during the clinical
experience
3. Posting medical information about the patient on a message board in the patient’s room
4. Releasing patient information regarding terminal illness to family when the patient has given permission for
information to be shared
6. A patient is in skeletal traction and has a plaster cast due to a fractured femur. The patient experiences decreased
sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient’s toes have become pale
and cold but forgets to document this because one of the nurse’s other patients experienced cardiac arrest at the same
time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to
amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation?
(Select all that apply.)
1. Failure to document a change in assessment data
2. Failure to provide discharge instructions
3. Failure to provide patient education about cast care.
4. Failure to use proper medical equipment ordered for patient monitoring
5. Failure to notify a health care provider about a change in the patient’s condition
7. A man who is homeless enters the emergency department seeking health care. The health care provider indicates that
the patient needs to be transferred to the city hospital for care before assessing the patient. This action is most likely a
violation of which of the following laws?
1. Health Insurance Portability and Accountability Act (HIPAA)
2. Americans with Disabilities Act (ADA)
3. Patient Self-Determination Act (PSDA)
4. Emergency Medical Treatment and Active Labor Act (EMTALA)
8. A home health nurse notices significant bruising on a 2-year-old patient’s head, arms, abdomen, and legs. The patient’s
mother describes the patient’s frequent falls. What is the best nursing action for the home health nurse to take?
1. Document her findings and treat the patient.
2. Instruct the mother on safe handling of a 2-year-old child.
3. Contact a child abuse hotline.
4. Discuss this story with a colleague.
9. Which of the following statements indicate that the new nursing graduate understands ways to remain involved
professionally? (Select all that apply.)
1. “I am thinking about joining the health committee at my church.”
2. “I need to read newspapers, watch news broadcasts, and search the Internet for information related to health.”
3. “I will join nursing committees at the hospital after I have completed orientation and better understand the issues
affecting nursing.”
4. “Nurses do not have very much voice in legislation in Washington, DC, because of the nursing shortage.”
5. “I will go back to school as soon as I finish orientation.”

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10. You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. Which is
the best nursing action to take first?
1. Call the nursing supervisor to discuss the situation.
2. Discuss the problem with a colleague.
3. Leave the nursing unit and go home.
4. Say nothing and begin your work.
Answers:1. 2; 2. 4; 3. 2,3; 4. 1,4; 5. 3; 6. 1,5; 7. 4; 8. 3; 9. 1,2,3; 10. 1.

2 8 Infection Prevention and Control

Key Points
• Transmission of infection can occur if the six elements of the infection chain are present and uninterrupted.
• Prevention of infection involves breaking an element of the chain of transmission.
• The severity of an infection determines the level and type of nursing care provided.
• Normal body flora and body system defenses help the body resist infection by reducing the number of pathogenic
organisms.
• The inflammatory response neutralizes and eliminates pathogens and promotes healing to the damaged cells and tissue.
• Health care–associated infections can lead to adverse patient events and higher health care costs.
• Advanced age, poor nutrition, stress, inherited conditions, chronic disease, and treatments that compromise the immune
response increase susceptibility to infection.
• Surgical asepsis requires more stringent techniques than medical asepsis.
• Standard Precautions are applied in all patient care activities to prevent patients and health care workers from
transmitting infection.
• Hand hygiene is the most effective basic technique in preventing and controlling infection transmission.
• Transmission-based precautions are used in addition to Standard Precautions for patients with highly transmissible
pathogens.
• Educating patients and caregivers on infection prevention in the home should include adaptations made for the home
environment.
• Proper application of protective personal equipment protects the patient and health care worker from transmission of
pathogens.
• Understanding and practicing infection prevention and control decreases the risk of the health care worker to infectious
organisms.
• Understanding the postexposure process allows health care workers to access early intervention and decrease risk of
transmission.

Review Questions
1. A patient who has been placed on Contact Precautions for Clostridium difficile (C. difficile) asks you to explain what he
should 464know about this organism. What is the most appropriate information to include in patient teaching? (Select
all that apply.)
1. The organism is usually transmitted through the fecal-oral route.
2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer.
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 3. Everyone coming into the room must be wearing a gown and gloves.
4. While the patient is in Contact Precautions, he cannot leave the room.
5. C. difficile dies quickly once outside the body.
2. A patient is diagnosed with meningitis. Which type of isolation precaution is most appropriate for this patient?
1. Reverse isolation
2. Droplet Precautions
3. Standard Precautions
4. Contact Precautions
3. A patient is placed on Airborne Precautions for pulmonary tuberculosis. The nurse notes that the patient seems to be
angry, but he knows that this is a normal response to isolation. Which is the best intervention?
1. Provide a dark, quiet room to calm the patient.
2. Reduce the level of precautions to keep the patient from becoming angry.
3. Explain the reasons for isolation procedures and provide meaningful stimulation.
4. Limit family and other caregiver visits to reduce the risk of spreading the infection.
4. Which type of personal protective equipment should the nurse wear when caring for a pediatric patient who is placed on
Airborne Precautions for confirmed chickenpox/herpes zoster? (Select all that apply.)
1. Disposable gown
2. N95 respirator mask
3. Face shield or goggles
4. Disposable mask
5. Gloves
5. The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit.
Which of the following actions on your part would contribute to reducing health care–acquired infections? (Select all
that apply.)
1. Teaching correct handwashing to assigned patients
2. Using correct procedures in starting and caring for an intravenous infusion
3. Providing perineal care to a patient with an indwelling urinary catheter
4. Isolating a patient on antibiotics who has been having loose stool for 24 hours
5. Decreasing a patient’s environmental stimuli to decrease nausea
6. Which of the following actions by the nurse demonstrate the practice of core principles of surgical asepsis? (Select all
that apply.)
1. The front and sides of the sterile gown are considered sterile from the waist up.
2. Keep the sterile field in view at all times.
3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated.
4. Only health care personnel within the sterile field must wear personal protective equipment.
5. After cleansing the hands with antiseptic rub, apply clean disposable gloves.
7. Put the following steps for removal of protective barriers after leaving an isolation room in order.
1. Remove and dispose of gloves.
2. Perform hand hygiene.
3. Remove eyewear or goggles.
4. Untie top and then bottom mask strings and remove from face.
5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side.
8. A patient is diagnosed with a multidrug-resistant organism (MDRO) in his surgical wound and asks the nurse what this
means. What is the nurse’s best response? (Select all that apply.)
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 1. There is more than one organism in the wound that is causing the infection.
2. The antibiotics the patient has received are not strong enough to kill the organism.
3. The patient will need more than one type of antibiotic to kill the organism.
4. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will
be hard to treat effectively.
5. There are no longer any antibiotic options available to treat the patient’s infection.
9. Which of these statements are true regarding disinfection and cleaning? (Select all that apply.)
1. Proper cleaning requires mechanical removal of all soil from an object or area.
2. General environmental cleaning is an example of medical asepsis.
3. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound.
4. Cleaning in a direction from the least to the most contaminated area helps reduce infections.
5. Disinfecting and sterilizing medical devices and equipment involve the same procedures.
10. Patient-to-patient transmission of infection cannot occur if gloves are routinely used.
1. True
2. False
Answers: 1.1, 2, 3; 2.2; 3.3; 4.1, 2, 5; 5.1, 2, 3; 6.2, 3; 7.1, 3, 5, 4, 2; 82, 4; 9.1, 2, 4; 10. 2.

5 0 Perioperative Nursing Care

Key Points
• Perioperative nursing includes the preoperative, intraoperative, and postoperative phases.
• The assessment of risk factors such as history of smoking, obesity, and obstructive sleep apnea allows a nurse to
anticipate patient needs and the types of preparation required preoperatively to prevent intraoperative and postoperative
complications.
• Malnutrition, diabetes, obesity, smoking, age, obstructive sleep apnea, and cardiac disorders increase patients’ risks for
perioperative complications.
• A nurse assesses a patient’s potential psychological response by identifying the patient’s previous experiences with
surgery to anticipate his or her needs, providing teaching, addressing fears, and clarifying concerns
• A standard preoperative teaching plan includes instruction that influences maintenance of ventilatory function, physical
functional capacity, and sense of well-being, as well as the reduction of patient anxiety and the patient’s length of
hospital stay.
• Postoperative exercises prevent pulmonary and vascular complications and deconditioning.
• An intraoperative assessment that focuses on a patient’s immediate clinical status, skin integrity, and joint function
allows the nurse to anticipate problems that predispose the patient to injury if he or she is not positioned on the OR
table correctly.
• The primary differences between intraoperative phases are the level of monitoring and progressive change in focus from
acute recovery to preparing patients for convalescence and recovery.
• Hand-off communication ensures that each patient receives the right surgery at the right surgical site by verifying the
patient’s situation (S) (the patient’s problem and type of surgery), background (B) (history), assessment data (A), and
recommendations (R) for the interventions that need to be implemented.

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• Standardized protocols for hand-off communication between perioperative health care providers minimize surgical risks
and promotes seamless transition between each surgical phase.
• Postoperative priorities include maintenance of a patent airway, circulatory and perfusion regulation, temperature
control, pain control, fluid and electrolyte balance, and wound care.
• Postoperative patient education should be relevant and specific, culturally appropriate, and accurate to enhance the
ability of patients to care for themselves at home.
• When caring for patients who had ambulatory surgery, prioritize education because of the limited time available,
including involvement of the family or support system.

Review Questions
1. The nurse prepares a patient with type 2 diabetes for a surgical procedure. The patient weighs 112.7 kg (248 lb) and is 5
feet, 2 inches in height. Which factors increase this patient’s risk for surgical complications? (Select all that apply.)
1. Obesity
2. Prolonged bleeding time
3. Delayed wound healing
4. Ineffective vital capacity
5. Immobility secondary to height
2. Which assessment questions should the nurse ask a preoperative patient preparing for surgery? (Select all that apply.)
1. “Are you experiencing any pain?”
2. “Do you exercise on a daily basis?”
3. “When do you regularly take your medications?”
4. “Do you have any medication allergies?”
5. “Do you use drugs and/or tobacco products?”
3. Communication between a nurse caring for a patient in the preoperative holding area and the circulating nurse in the
operating room (OR) can best be enhanced by which of the following? (Select all that apply.)
1. Documenting assessment findings in the medical record
2. Using a standardized SBAR tool
3. Being responsive in using nonverbal communication techniques
4. Giving specific information to a transport technician
5. Listening to the OR nurse’s questions
4. Which postoperative intervention best prevents atelectasis?
1. Use of intermittent compression stockings
2. Heel-toe flexion
3. Use of the incentive spirometer
4. Abdominal splinting when coughing
5. An 85-year-old patient returns to the inpatient surgical unit after leaving the PACU. Which of the following place the
patient at risk during surgery? (Select all that apply.)
1. Stiffened lung tissue
2. Reduced diaphragmatic excursion
3. Increased laryngeal reflexes
4. Reduced blood flow to kidneys
5. Increased cholinergic transmission
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6. A postoperative patient experiences tachypnea during the first hour of recovery. Which nursing intervention is a
priority?
1. Elevate the head of the patient’s bed.
2. Give ordered oxygen through a mask at 4 L/min.
3. Ask the patient to use an incentive spirometer.
4. Position the patient on one side with the face down and the neck slightly extended so that the tongue falls forward.
7. Which is the best intervention the nurse should implement to promote bowel function?
1. Early ambulation
2. Deep-breathing exercises
3. Repositioning on the left side
4. Lowering the head of the patient’s bed
8. Match the nursing interventions on the left with the complication to be prevented on the right. An intervention may
apply to more than one complication.

Nursing Intervention Complication

1. Offering glasses or hearing aid a. Deep vein thrombosis

2. Early ambulation b. Wound infection
3. Strict aseptic technique c. Delirium
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4. Deep breathing exercise d. Atelectasis

5. Hydration

9. A nurse cares for a postoperative patient in the PACU. Upon assessment, the nurse finds the surgical dressing is
saturated with serosanguineous drainage. Which interventions are a priority? (Select all that apply.)
1. Notify surgeon.
2. Maintain the intravenous fluid infusion.
3. Provide 2 L/min of oxygen via nasal cannula.
4. Monitor the patient’s vital signs every 5 to 10 minutes.
5. Reinforce the dressing.
10. A patient who returned from surgery 3 hours ago following a kidney transplant is reporting pain at a 7 on a scale of 0
to 10. The nurse has tried repositioning with no improvement in the patient’s pain report. Unmanaged surgical pain can
lead to which of the following problems? (Select all that apply.)
1. Delayed ambulation
2. Reduced ventilation
3. Catheter-associated urinary tract infection
4. Retained pulmonary secretions
5. Reduced appetite
Answers: 1. 1, 3; 2. 1, 4, 5; 3. 2, 3, 5; 4. 3; 5. 1, 2, 4; 6. 1; 7. 1; 8. 1 c, 2 a and c, 3 b, 4 d, 5 a and d; 9. 1, 5; 10. 1, 2, 4, 5.

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