Ati Fundamentals

Fundamentals for Nursing
REVIEW MODULE EDITION 10.0
Consultants
Christi Blair, DNP, RN
Contributors Tracey Bousquet, BSN, RN
Honey C. Holman, MSN, RN
Jenni L. Hoffman, DNP,
Debborah Williams, MSN, RN FNP-C, CLNC, FAANP
Mary Jane Janowski, RN, MA

Sheryl Sommer PhD, RN, CNE
Jessica L. Johnson DNP, MSN, BSN, RN
Janean Johnson, MSN, RN CNE
Lisa Kongable, MA, ARNP,
Brenda S. Ball, MEd, BSN, RN
PMHCNS, CNE
Cindy Morris, DNP, RN, IBCLC
Tomekia Luckett, PhD, RN
Peggy Leehy MSN, RN
Maria Sheilla Membrebe, MSN/Ed.,
Robin Hertel, EdS, MSN, RN, CMSRN RN, ONC, CMSRN, CBN
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REPRINTED APRIL 2021
FUNDAMENTALS FOR NURSING I

Director of content review: Kristen Lawler
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IMPORTANT NOTICE TO THE READER

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II CONTENT MASTERY SERIES

User’s Guide
Welcome to the Assessment Technologies Institute® ACTIVE LEARNING SCENARIOS
Fundamentals for Nursing Review Module Edition 10.0. AND APPLICATION EXERCISES
The mission of ATI’s Content Mastery Series® Review
Each chapter includes opportunities for you to test your
Modules is to provide user-friendly compendiums of
knowledge and to practice applying that knowledge. Active
nursing knowledge that will:
Learning Scenario exercises pose a nursing scenario and
● Help you locate important information quickly.
then direct you to use an ATI Active Learning Template
● Assist in your learning efforts.
(included at the back of this book) to record the important

● Provide exercises for applying your nursing knowledge.
knowledge a nurse should apply to the scenario. An
● Facilitate your entry into the nursing profession as a
example is then provided to which you can compare your
newly licensed nurse.
completed Active Learning Template. The Application
This newest edition of the Review Modules has been
Exercises include NCLEX-style questions (multiple-
redesigned to optimize your learning experience. We’ve
choice and multiple-select items), providing you with
t more content into less space and ha e done so in a
opportunities to practice answering the kinds of questions
ay that ill ma e it e en easier for you to nd and
you might expect to see on ATI assessments or the NCLEX.
understand the information you need.
After the Application Exercises, an answer key is provided,
along with rationales.
ORGANIZATION
This Review Module is organized into units covering the NCLEX® CONNECTIONS
NCLEX® major client needs categories: afe, ffecti e Care
To prepare for the NCLEX, it is important to understand
Environment, Health Promotion, Psychosocial Integrity,
how the content in this Review Module is connected to
and Physiological Integrity. Chapters within these
the NCL test plan. ou can nd information on the
units conform to one of four organizing principles for
detailed test plan at the National Council of State Boards
presenting the content.
of Nursing’s website, www.ncsbn.org. When reviewing
● Nursing concepts
content in this Review Module, regularly ask yourself,
● Growth and development
Ho does this content t into the test plan, and hat
● Procedures
types of questions related to this content should I expect?”
● System Disorders
To help you in this process, we’ve included NCLEX
Nutritional considerations for speci c Nursing concepts
Connections at the beginning of each unit and with each
chapters begin with an overview describing the central
question in the Application Exercises Answer Keys. The
concept and its relevance to nursing. Subordinate themes
NCLEX Connections at the beginning of each unit point
are covered in outline form to demonstrate relationships
out areas of the detailed test plan that relate to the content
and present the information in a clear, succinct manner.
within that unit. The NCLEX Connections attached to the
Application Exercises Answer Keys demonstrate how each
Nutritional considerations for speci c Growth and
e ercise ts ithin the detailed content outline.
development chapters cover expected growth and
These NCLEX Connections will help you understand how
development, including physical and psychosocial
the detailed content outline is organized, starting with
development, age-appropriate activities, and health
major client needs categories and subcategories and
promotion, including immunizations, health screenings,
followed by related content areas and tasks. The major
nutrition, and injury prevention.
client needs categories are:
● afe and ffecti e Care n ironment
Procedures chapters include an overview describing ◯ Management of Care
the procedure(s) covered in the chapter. These ◯ Safety and Infection Control
chapters provide nursing knowledge relevant to each ● Health Promotion and Maintenance
procedure, including indications, nursing considerations, ● Psychosocial Integrity
interpretation of ndings, and complications. ● Physiological Integrity
◯ Basic Care and Comfort
◯ Pharmacological and Parenteral Therapies
◯ Reduction of Risk Potential
◯ Physiological Adaptation
An NCLEX Connection might, for example, alert you that

content within a unit is related to:
● Basic Care and Comfort
◯ Assistive Devices
■ Assess client use of assistive devices.
FUNDAMENTALS FOR NURSING USER’S GUIDE III

QSEN COMPETENCIES ICONS
As you use the Review Modules, you will note the Icons are used throughout the Review Module to draw
integration of the Quality and Safety Education for your attention to particular areas. Keep an eye out for
Nurses (QSEN) competencies throughout the chapters. these icons.
These competencies are integral components of the
This icon is used for NCLEX Connections.
curriculum of many nursing programs in the United States
and prepare you to provide safe, high-quality care as a
This icon indicates gerontological considerations,
newly licensed nurse. Icons appear to draw your attention
or no ledge speci c to the care of older
to the six QSEN competencies.
adult clients.
Safety: The minimization of risk factors that could
This icon is used for content related to safety
cause injury or harm while promoting quality care
and is a QSEN competency. When you see this
and maintaining a secure environment for clients, self,
icon, take note of safety concerns or steps that
and others.
nurses can take to ensure client safety and a
Patient-Centered Care: The provision of caring and safe environment.
compassionate, culturally sensitive care that addresses
This icon is a QSEN competency that indicates
clients’ physiological, psychological, sociological, spiritual,
the importance of a holistic approach to
and cultural needs, preferences, and values.
providing care.
Evidence-Based Practice: The use of current knowledge
This icon, a QSEN competency, points out the
from research and other credible sources, on which to base
integration of research into clinical practice.
clinical judgment and client care.
This icon is a QSEN competency and highlights
Informatics: The use of information technology as a
the use of information technology to support
communication and information-gathering tool that
nursing practice.
supports clinical decision ma ing and scienti cally based
nursing practice. This icon is used to focus on the QSEN
competency of integrating planning processes to
Quality Improvement: Care related and organizational
meet clients’ needs.
processes that involve the development and
implementation of a plan to improve health care services This icon highlights the QSEN competency of care
and better meet clients’ needs. delivery using an interprofessional approach.
Teamwork and Collaboration: The delivery of client care This icon appears at the top-right of pages
in partnership with multidisciplinary members of the and indicates availability of an online media
health care team to achieve continuity of care and positive supplement (a graphic, animation, or video).
client outcomes. If you have an electronic copy of the Review
Module, this icon will appear alongside clickable
links to media supplements. If you have a
hard copy version of the Review Module, visit
www.atitesting.com for details on how to access
these features.
FEEDBACK
ATI welcomes feedback regarding this Review Module.
Please provide comments to comments@atitesting.com.
As needed updates to the e ie odules are identi ed,

changes to the text are made for subsequent printings
of the book and for subsequent releases of the electronic
version. For the printed books, print runs are based
on when existing stock is depleted. For the electronic
ersions, a number of factors in uence the update
schedule. As such, ATI encourages faculty and students to
refer to the Review Module addendums for information on
what updates have been made. These addendums, which
are available in the Help/FAQs on the student site and the
Resources/eBooks & Active Learning on the faculty site,
are updated regularly and always include the most current
information on updates to the Review Modules.
IV USER’S GUIDE CONTENT MASTERY SERIES

Table of Contents
NCLEX® Connections 1
UNIT 1 Safe, Effective Care Environment 3

SECTION: Management of Care 3
CHAPTER 1 Health Care Delivery Systems 3
CHAPTER 2 The Interprofessional Team 7
CHAPTER 3 Ethical Responsibilities 11
CHAPTER 4 Legal Responsibilities 15
CHAPTER 5 Information Technology 21
CHAPTER 6 Delegation and Supervision 27
CHAPTER 7 Nursing Process 31
CHAPTER 8 Critical Thinking and Clinical Judgment 37
CHAPTER 9 Admissions, Transfers, and Discharge 41
SECTION: Safety and Infection Control 49
CHAPTER 10 Medical and Surgical Asepsis 49
CHAPTER 11 Infection Control 53
CHAPTER 12 Client Safety 59
CHAPTER 13 Home Safety 65
CHAPTER 14 Ergonomic Principles 73
CHAPTER 15 Security and Disaster Plans 77
FUNDAMENTALS FOR NURSING TABLE OF CONTENTS V

UNIT 2 Health Promotion 85

SECTION: Nursing Throughout the Lifespan 85
CHAPTER 16 Health Promotion and Disease Prevention 85
CHAPTER 17 Client Education 89
CHAPTER 18 Infants (2 Days to 1 Year) 93
CHAPTER 19 Toddlers (1 to 3 Years) 99
CHAPTER 20 Preschoolers (3 to 6 Years) 103
CHAPTER 21 School-Age Children (6 to 12 Years) 107
CHAPTER 22 Adolescents (12 to 20 Years) 111
CHAPTER 23 Young Adults (20 to 35 Years) 115
CHAPTER 24 Middle Adults (35 to 65 Years) 119
CHAPTER 25 Older Adults (65 Years and Older) 123
SECTION: Health Assessment/Data Collection 129
CHAPTER 26 Data Collection and General Survey 129
CHAPTER 27 Vital Signs 135
CHAPTER 28 Head and Neck 145
CHAPTER 29 Thorax, Heart, and Abdomen 153
CHAPTER 30 Integumentary and Peripheral Vascular Systems 163
CHAPTER 31 Musculoskeletal and Neurologic Systems 169
VI TABLE OF CONTENTS CONTENT MASTERY SERIES

UNIT 3 Psychosocial Integrity 177

CHAPTER 32 Therapeutic Communication 177
CHAPTER 33 Coping 183
CHAPTER 34 Self-Concept and Sexuality 189
CHAPTER 35 Cultural and Spiritual Nursing Care 193
CHAPTER 36 Grief, Loss, and Palliative Care 203
UNIT 4 Physiological Integrity 211

SECTION: Basic Care and Comfort 211
CHAPTER 37 Hygiene 211
CHAPTER 38 Rest and Sleep 217
CHAPTER 39 Nutrition and Oral Hydration 221
CHAPTER 40 Mobility and Immobility 227
CHAPTER 41 Pain Management 235
CHAPTER 42 Complementary and Alternative Therapies 241
CHAPTER 43 Bowel Elimination 245
CHAPTER 44 Urinary Elimination 251
CHAPTER 45 Sensory Perception 259
FUNDAMENTALS FOR NURSING TABLE OF CONTENTS VII

SECTION: Pharmacological and Parenteral Therapies 269
CHAPTER 46 Pharmacokinetics and Routes of Administration 269
CHAPTER 47 Safe Medication Administration and Error Reduction 277
CHAPTER 48 Dosage Calculation 285
CHAPTER 49 Intravenous Therapy 299
CHAPTER 50 Adverse Effects, Interactions, and Contraindications 307
CHAPTER 51 Individual Considerations of Medication Administration 313
SECTION: Reduction of Risk Potential 319
CHAPTER 52 Specimen Collection for Glucose Monitoring 319
CHAPTER 53 Airway Management 323
Pulse oximetry and oxygen therapy 323
Specimen collection and airway clearance 327
Artificial airways and tracheostomy care 329
CHAPTER 54 Nasogastric Intubation and Enteral Feedings 333
SECTION: Physiological Adaptation 341
CHAPTER 55 Pressure Injury, Wounds, and Wound Management 341
CHAPTER 56 Bacterial, Viral, Fungal, and Parasitic Infections 349
CHAPTER 57 Fluid Imbalances 355
VIII TABLE OF CONTENTS CONTENT MASTERY SERIES

CHAPTER 58 Electrolyte Imbalances 359
Sodium imbalances 359
Potassium imbalances 360
Calcium imbalances 362
Magnesium imbalances 363
References 367
Active Learning Templates A1

Basic Concept A1
Diagnostic Procedure A3
Growth and Development A5
Medication A7
Nursing Skill A9
System Disorder A11
Therapeutic Procedure A13
Concept Analysis A15
FUNDAMENTALS FOR NURSING TABLE OF CONTENTS IX

X TABLE OF CONTENTS CONTENT MASTERY SERIES
NCLEX® Connections
When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:
Management of Care
CONCEPTS OF MANAGEMENT: Identify roles/
responsibilities of health care team members.
ASSIGNMENT, DELEGATION AND SUPERVISION: Identify

tasks for assignment or delegation based on client needs.
CONTINUITY OF CARE
Perform procedures necessary to safely admit,
transfer, or discharge a client.
Pro ide and recei e off of care report on assigned clients.
ESTABLISHING PRIORITIES: Prioritize the delivery of client care.
ETHICAL PRACTICE
Recognize ethical dilemmas and take appropriate action.
Practice in a manner consistent with a code of ethics for nurses.
INFORMATION TECHNOLOGY: Utilize valid resources

to enhance the care provided to a client.
LEGAL RIGHTS AND RESPONSIBILITIES:

Identify legal issues affecting the client.
REFERRALS: Assess the need for referrals and obtain necessary orders.
ADVANCE DIRECTIVES/SELF-DETERMINATION/LIFE PLANNING:

Assess client and or staff member no ledge of ad ance directi es.
INFORMED CONSENT: Participate in obtaining informed consent.
CONFIDENTIALITY/INFORMATION SECURITY: Assess staff

member and client understanding of con dentiality re uirements.
Safety and Infection Control

REPORTING OF INCIDENT/EVENT/IRREGULAR OCCURENCE/
VARIENCE: Identify need/situation where reporting of incident/
event/irregular occurence/cariance is appropriate.
FUNDAMENTALS FOR NURSING NCLEX® CONNECTIONS 1

Health Promotion and Maintenance
HEALTH PROMOTION/DISEASE PREVENTION: Assist
the client in maintaining an optimum level of health.
TECHNIQUES OF PHYSICAL ASSESSMENT: Apply

knowledge of nursing procedures and psychomotor
skills to techniques of physical assessment.
2 NCLEX® CONNECTIONS CONTENT MASTERY SERIES

CHAPTER 1
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT ● Ambulatory care clinics
SECTION: MANAGEMENT OF CARE ● Occupational health clinics
Stand-alone surgical centers
Health Care
●
● Urgent care centers

CHAPTER 1
Delivery Systems
● Complementary therapy centers
● Urgent and emergent care centers
● Public health agencies
● Crisis centers
Diagnostic centers
Health care delivery systems incorporate
●
● Specialized services (dialysis, oncology, rehabilitation,

interactions between health care providers burn) centers
and clients within the constraints of financing

mechanisms and regulatory agencies. REGULATORY AGENCIES
● U.S. Department of Health and Human Services
Health care systems include the clients who ● U.S. Food and Drug Administration (FDA)
State and local public health agencies
participate, the settings in which health care takes
●
● State licensing boards to ensure that health care

place, the agencies that regulate health care, and providers and agencies comply with state regulations
The Joint Commission to set quality standards for
the mechanisms that provide financial support.
●
accreditation of health care facilities

Professional Standards Review Organizations to monitor
Most nurses deliver care within the context of
●
health care services provided

health care systems. As these systems continue ● Utilization review committees to monitor
for appropriate diagnosis and treatment of
to become more business-driven and less hospitalized clients
service-oriented, the challenge to nursing today
is to retain its caring values while practicing HEALTH CARE FINANCING MECHANISMS
within a cost-containment structure. PUBLIC FEDERALLY FUNDED PROGRAMS
Medicare is for clients 65 years of age or older and those
who have permanent disabilities.
COMPONENTS OF HEALTH ● Part A: Insurance for hospital stays, home health, and
CARE SYSTEMS hospice (available to those 65 years of age or older and
those who have permanent disabilities)
Part B: Insurance for outpatient and provider services
PARTICIPANTS
●
(available to those 65 years or older and those who have

Consumers (clients) permanent disabilities, but is voluntary and requires a
monthly premium)
Licensed providers ● Part C: A Medicare advantage or supplement plan
● Registered nurses
(covering parts A and B, and sometimes D)
● Licensed practical nurses (also known as licensed ● Part D: Medication coverage for those eligible and
vocational nurses)
requires a monthly premium
● Advanced practice nurses (APN)
Medicaid is for clients who have low incomes.

● Medical doctors ● It is federally and state funded.
● Pharmacists ● Individual states determine eligibility requirements.
● Dentists
The Patient Protection and Affordable Care Act of 2010 is
● Dietitians
a federal statute aimed at:
● Physical, respiratory, and occupational therapists ● Increasing access to health care for all individuals and
Unlicensed providers (assistive personnel) instituting an individual mandate for health insurance.
● Decreasing health care costs.
Providing opportunities for uninsured people to become
SETTINGS
●
insured at an affordable cost.

● Hospitals State Children’s Health Insurance Program: Coverage for
● Homes uninsured children up to age 19 at low cost to parents
● Skilled-nursing, assisted-living, and
extended-care facilities
● Community/health departments
● Adult day care centers
● Schools
● Hospices
● Pro iders offices
FUNDAMENTALS FOR NURSING CHAPTER 1 HEALTH CARE DELIVERY SYSTEMS 3

PRIVATE PLANS RELATIONSHIP BETWEEN HEALTH
● Traditional insurance reimburses for services on a CARE SYSTEMS AND LEVELS OF CARE
fee-for-service basis.
People: The level of care depends on the needs of the
● Managed care organizations (MCOs): Primary care
client. Licensed and unlicensed health care personnel
providers oversee comprehensive care for enrolled
work in every level of care.
clients and focus on prevention and health promotion.
● Preferred provider organizations (PPOs): Clients choose Setting: The settings for secondary and tertiary care are
from a list of contracted providers and hospitals. usually ithin a hospital or speci c facility. ettings for
Using non-contracted providers increases the other levels of care vary.
out-of-pocket costs.
Regulatory agencies help ensure the quality and quantity
● Exclusive provider organizations (EPOs): Clients
of health care and the protection of health care consumers.
choose from a list of providers and hospitals
within a contracted organization with no Health care finance in uences the uality and type of
out-of-network coverage. care by setting parameters for cost containment and
● Long-term care insurance: A supplement for long-term reimbursement.
care expenses Medicare does not cover
SAFETY AND QUALITY

LEVELS OF HEALTH CARE In response to concerns about the safety and quality
Preventive health care focuses on educating and of client care in the United States, Quality and Safety
equipping clients to reduce and control risk factors for Education for Nurses (QSEN) assists nursing programs in
disease. Examples include programs that promote preparing nurses to provide safe, high-quality care. To
immunization, stress management, occupational health, draw attention to the six QSEN competencies, these icons
and seat belt use. appear throughout the review modules.
Primary health care emphasizes health promotion and Safety: The minimization of risk factors that could cause
includes prenatal and well-baby care, family planning, injury or harm while promoting high-quality care and
nutrition counseling, and disease control. This level maintaining a secure environment for clients, self,
of care is a sustained partnership between clients and others
and pro iders. amples include office or clinic isits,
Patient-Centered Care: The provision of caring and
community health centers, and scheduled school- or
work-centered screenings (vision, hearing, obesity).
clients’ physiological, psychological, sociological, spiritual,
Secondary health care includes the diagnosis and and cultural needs, preferences, and values. The client is
treatment of acute illness and injury. Examples include included in the decision-making process.
care in hospital settings (inpatient and emergency
Evidence Based Practice: The use of current knowledge
departments), diagnostic centers, and urgent and
from research and other credible sources on which to base
emergent care centers.
clinical judgment and client care
Tertiary health care, or acute care, involves the provision
Informatics: The use of information technology as a
of specialized and highly technical care. Examples include
communication and information-gathering tool that
intensive care, oncology centers, and burn centers.
supports clinical decision ma ing and scienti cally based
Restorative health care involves intermediate follow-up nursing practice
care for restoring health and promoting self-care.
Quality Improvement: Care-related and organizational
Examples include home health care, rehabilitation centers,
processes that involve the development and
and skilled nursing facilities.
implementation of a plan to improve health care services
Continuing health care addresses long-term or chronic and better meet clients’ needs
health care needs over a period of time. Examples include
Teamwork and Collaboration: The delivery of client care
end-of-life care, palliative care, hospice, adult day care,
in partnership with interprofessional members of the
assisted living, and in-home respite care.
health care team to achieve continuity of care and positive
client outcomes
THE FUTURE OF HEALTH CARE

The ultimate issue in designing and delivering health care
is ensuring the health and welfare of the population.
4 CHAPTER 1 HEALTH CARE DELIVERY SYSTEMS CONTENT MASTERY SERIES

Application Exercises Active Learning Scenario
1. A nurse is discussing restorative health care A nurse on a medical-surgical unit is acquainting a

with a newly licensed nurse. Which of the group of nurses with the Quality and Safety Education
following examples should the nurse include for Nurses (QSEN) initiative. Use the ATI Active Learning
in the teaching? (Select all that apply.) Template: Basic Concept to complete this item.
A. Home health care RELATED CONTENT: List the six QSEN competencies,
B. Rehabilitation facilities along with a brief description of each.
C. Diagnostic centers
D. Skilled nursing facilities
E. Oncology centers
2. A nurse is explaining the various types of health

care coverage clients might have to a group
of nurses. Which of the following health care
financing mechanisms should the nurse include
as federally funded? (Select all that apply.)
A. Preferred provider organization (PPO)
B. Medicare
C. Long-term care insurance
D. Exclusive provider organization (EPO)
E. Medicaid
3. A nurse manager is developing strategies to care

for the increasing number of clients who have
obesity. Which of the following actions should the
nurse include as a primary health care strategy?
A. Collaborating with providers to perform obesity
screenings during routine office visits
B. Ensuring the availability of specialized beds in
rehabilitation centers for clients who have obesity
C. Providing specialized intraoperative training
in surgical treatments for obesity
D. Educating acute care nurses about postoperative
complications related to obesity
4. A nurse is discussing the purpose of regulatory

agencies during a staff meeting. Which of the
following tasks should the nurse identify as the
responsibility of state licensing boards?
A. Monitoring evidence-based practice for
clients who have a specific diagnosis
B. Ensuring that health care providers
comply with regulations
C. Setting quality standards for accreditation
of health care facilities
D. Determining whether medications are
safe for administration to clients
5. A nurse is explaining the various levels of health care

services to a group of newly licensed nurses. Which of
the following examples of care or care settings should
the nurse classify as tertiary care? (Select all that apply.)
A. Intensive care unit
B. Oncology treatment center
C. Burn center
D. Cardiac rehabilitation
E. Home health care
FUNDAMENTALS FOR NURSING CHAPTER 1 HEALTH CARE DELIVERY SYSTEMS 5

Application Exercises Key Active Learning Scenario Key
1. A. CORRECT: Restorative health care involves intermediate Using the ATI Active Learning Template: Basic Concept
follow-up care for restoring health and promoting self-care. RELATED CONTENT
Home health care is a type of restorative health care. ●
Safety: Minimization of risk factors that could cause injury
B. CORRECT: Restorative health care involves intermediate or harm while promoting quality care and maintaining
follow-up care for restoring health and promoting self-care. a secure environment for clients, self, and others
Rehabilitation facilities are a type of restorative health care. ●
Patient-Centered Care: Provision of caring and
C. Secondary health care includes the diagnosis and
treatment of acute injury or illness. Diagnostic
clients’ physiological, psychological, sociological,
centers are a type of secondary health care.
spiritual, and cultural needs, preferences, and values
D. CORRECT: Restorative health care involves intermediate
follow-up care for restoring health and promoting self-care.
●
Evidence-Based Practice: Use of current knowledge
Skilled nursing facilities are a type of restorative health care. from research and other credible sources on which
E. Tertiary health care is specialized and highly technical care. to base clinical judgment and client care
An oncology center is a type of tertiary health care. ●
Informatics: Use of information technology as a communication
and information-gathering tool that supports clinical
NCLEX® Connection: Management of Care,
decision-making and scientifically based nursing practice
Health Promotion/Disease Prevention ●
Quality Improvement: Care-related and organizational processes
that involve the development and implementation of a plan to
2. A. PPOs are privately funded. improve health care services and better meet clients’ needs
B. CORRECT: Medicare is federally funded. ●
Teamwork and Collaboration: Delivery of client care in partnership
C. Long-term care insurance is privately funded. with multidisciplinary members of the health care team to
D. EPOs are privately funded. achieve continuity of care and positive client outcomes
E. CORRECT: Medicaid is federally funded. NCLEX® Connection: Management of Care, Information
NCLEX® Connection: Management of Care, Technology
Information Technology
3. A. CORRECT: Identify obesity screenings at office visits as

an example of primary health care. Primary health care
emphasizes health promotion and disease control, is often
delivered during office visits, and includes screenings.
B. Identify care that is provided in a rehabilitation center
as an example of restorative health care.
C. Identify specialized and highly technical care
as an example of tertiary health care.
D. Identify acute care of clients as an example
of secondary health care.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
4. A. Identify that utilization review committees have the

responsibility of monitoring for appropriate diagnosis
and treatment according to evidence-based practice for
diagnosis and treatment of hospitalized clients.
B. CORRECT: Identify that state licensing boards are
responsible for ensuring that health care providers
and agencies comply with state regulations.
C. Identify that the Joint Commission has the
responsibility of setting quality standards for
accreditation of health care facilities.
D. Identify that the U.S. Food and Drug Administration
has the responsibility of determining whether
medications are safe for administration to clients.
5. A. CORRECT: Tertiary health care involves the provision

of specialized and highly technical care (the care
nurses deliver in intensive care units).
B. CORRECT: Tertiary health care involves the provision
of specialized and highly technical care (the care
nurses deliver in oncology treatment centers).
C. CORRECT: Tertiary health care involves the
provision of specialized and highly technical care
(the care nurses deliver in burn centers).
D. This is an example of restorative care and also of
tertiary prevention, but not of tertiary care.
E. This is an example of restorative care.
6 CHAPTER 1 HEALTH CARE DELIVERY SYSTEMS CONTENT MASTERY SERIES

Online Video: Interdisciplinary Team
CHAPTER 2
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT Occupational therapist: Assesses and plans for clients
SECTION: MANAGEMENT OF CARE to regain activities of daily living (ADL) skills, especially
motor skills of the upper extremities.
CHAPTER 2 The Interprofessional Example of when to refer: A client has
Team difficulties using an eating utensil with

their dominant hand following a stroke.
Pharmacist: Provides, monitors, and evaluates medication.
Supervises pharmacy technicians in states that allow this
RNs and practical nurses (PNs) are integral practice.
members of the interprofessional health care Example of when to refer: A client is concerned
team. Each discipline represented on an about a new medication’s interactions
with any of their other medications.
interprofessional team uses a set of skills within
Physical therapist: Assesses and plans for clients to
the scope of practice for the specific profession. increase musculoskeletal function, especially of the lower
In some instances, the scope of practice for one extremities, to maintain mobility.
discipline overlaps with the scope of practice or Example of when to refer: Following hip
arthroplasty, a client requires assistance
set of skills for another profession. For example, learning to ambulate and regain strength.
the nurse and the respiratory care therapist both Provider: Assesses, diagnoses, and treats disease and
possess the knowledge and skill to perform injury. Providers include medical doctors (MDs), doctors
of osteopathy (DOs), advanced practice nurses (APNs),
chest physiotherapy (using postural drainage, and physician assistants (PAs). State regulations vary in
percussion, and vibration to promote drainage their requirements for supervision of APNs and PAs by a
physician (MDs and DOs).
of secretions from the lungs).
Example of when to refer: A client has a
The interprofessional health care team works temperature of 39º C (102.2º F), is achy
and shaking, and reports feeling cold.
collaboratively to provide holistic care to clients.
Radiologic technologist: Positions clients and performs
The nurse is most often the manager of care and x-rays and other imaging procedures for providers to
review for diagnosis of disorders of various body parts.
must understand the roles and responsibilities of
Example of when to refer: A client reports
other health care team members to collaborate severe pain in their hip after a fall, and the
and make appropriate referrals. provider prescribes an x-ray of the client’s hip.
Respiratory therapist: Evaluates respiratory status and
provides respiratory treatments including oxygen therapy,
INTERPROFESSIONAL PERSONNEL chest physiotherapy, inhalation therapy, and mechanical
(NON-NURSING) ventilation.
Spiritual support staff: Provides spiritual care (pastors,
Example of when to refer: A client who
rabbis, priests).
has respiratory disease is short of breath
Example of when to refer: A client requests and requests a nebulizer treatment.
communion, or the family asks for prayer prior
Social worker: Works with clients and families by
to the client undergoing a procedure.
coordinating inpatient and community resources to meet
Registered dietitian: Assesses, plans for, and educates psychosocial and environmental needs that are necessary
regarding nutrition needs. Designs special diets, and for recovery and discharge.
supervises meal preparation.
Example of when to refer: A client who has terminal
Example of when to refer: A client has a low albumin cancer wishes to go home but is no longer able to
level and recently had an unexplained weight loss. perform many ADLs. The client’s partner needs
medical equipment in the home to care for the client.
Laboratory technician: btains specimens of body uids,
and performs diagnostic tests. Speech-language pathologist: Evaluates and makes
recommendations regarding the impact of disorders or
Example of when to refer: A provider
injuries on speech, language, and swallowing. Teaches
needs to see a client’s complete blood
techniques and exercises to improve function.
count (CBC) results immediately.
Example of when to refer: A client is having difficulty
swallowing a regular diet after trauma to the head
and neck.
FUNDAMENTALS FOR NURSING CHAPTER 2 THE INTERPROFESSIONAL TEAM 7

NURSING PERSONNEL EXPANDED NURSING ROLES
The nursing team works together to advocate for and meet Advanced practice nurse (APN): Has a great deal of
the needs of clients within the health care delivery system. autonomy. APNs usually have a minimum of a master’s
degree in nursing or related eld , ad anced education in
Registered nurse (RN) pharmacology and physical assessment, and certi cation
in a specialized area of practice. Included in this role are
The RN is the lead team member, soliciting input from all
the following.
nursing team members and setting priorities for the ● Clinical nurse specialist (CNS): Typically specializes in
coordination of client care.
a practice setting or a clinical eld.
EDUCATIONAL PREPARATION ● Nurse practitioner (NP): Collaborates with one or more
● Must meet the state board of nursing’s requirements providers to deliver nonemergency primary health care
for licensure. in a variety of settings.
● Requires completion of a diploma program, an associate ● Certified registered nurse anesthetist (CRNA):
degree, or a baccalaureate degree in nursing prior to Administers anesthesia and provides care during
taking the licensure exam (licensed). procedures under the supervision of an anesthesiologist.
● Certified nurse‑midwife (CNM): Collaborates with one
ROLES AND RESPONSIBILITIES
or more providers to deliver care to maternal-newborn
● Function legally under state nurse practice acts.
clients and their families.
● Perform assessments; establish nursing diagnoses,
goals, and interventions; and conduct ongoing Nurse educator: Teaches in schools of nursing, staff
client evaluations. development departments in health care facilities, or
● Develop interprofessional plans for client care. client education departments.
● Share appropriate information among team members;
Nurse administrator: Provides leadership to nursing
initiate referrals for client assistance, including health
departments within a health care facility.
education; and identify community resources.
Nurse researcher: Conducts research primarily to improve
Practical nurse (PN) the quality of client care.
EDUCATIONAL PREPARATION
● Must meet the state board of nursing’s requirements
● Requires vocational or community college education
prior to taking the licensure exam (licensed)

● Work under the supervision of the RN.
● Collaborate within the nursing process, assist with the
plan of care, consult with other team members, and
recognize the need for referrals to assist with actual or
potential problems.
Possess technical knowledge and skills.
●
Active Learning Scenario
● Participate in the delivery of nursing care, using the
nursing process as a framework.
A nurse is teaching a group of newly licensed nurses about
the various nursing roles they can aspire to after they
Assistive personnel (AP) achieve mastery in basic nursing skills. Use the ATI Active
Learning Template: Basic Concept to complete this item.
This includes certi ed nursing assistants CNAs and
certi ed medical assistants C As , and non nursing RELATED CONTENT: Describe at least five types
personnel (dialysis technicians, monitor technicians, of advance practice nursing roles, including a brief
and phlebotomists). description of their primary responsibilities.
EDUCATIONAL PREPARATION
● Must meet the state’s formal or informal training
requirements
● Requirement by most states for training and
examination to attain CNA status

● Work under the direct supervision of an RN or PN.
● Position description in the employing facility outlines
speci c tas s.
● Tasks can include feeding clients, preparing nutritional
supplements, lifting, basic care (grooming, bathing,
transferring, toileting, positioning), measuring and
recording vital signs, and ambulating clients.
8 CHAPTER 2 THE INTERPROFESSIONAL TEAM CONTENT MASTERY SERIES

Application Exercises
1. A nurse is caring for a group of clients on a 3. A client who is postoperative following knee
medical-surgical unit. For which of the following arthroplasty is concerned about the adverse effects of
client care needs should the nurse initiate a referral the medication prescribed for pain management. Which
for a social worker? (Select all that apply.) of the following members of the interprofessional
A. A client who has terminal cancer care team can assist the client in understanding
requests hospice care in the home. the medication’s effects? (Select all that apply.)
B. A client asks about community resources A. Provider

available for older adults. B. Certified nursing assistant
C. A client states, “I would like to have my C. Pharmacist
child baptized before surgery.” D. Registered nurse
D. A client requests an electric wheelchair E. Respiratory therapist
for use after discharge.
E. A client states, “I do not understand
how to use a nebulizer.” 4. A client who had a cerebrovascular accident has
persistent problems with dysphagia. The nurse caring
for the client should initiate a referral with which of the
2. A goal for a client who has difficulty with following members of the interprofessional care team?
self-feeding due to rheumatoid arthritis is to use A. Social worker
adaptive devices. The nurse caring for the client
B. Certified nursing assistant
should initiate a referral to which of the following
members of the interprofessional care team? C. Occupational therapist
A. Social worker D. Speech-language pathologist
B. Certified nursing assistant
C. Registered dietitian 5. A nurse is acquainting a group of newly licensed
D. Occupational therapist nurses with the roles of the various members of
the health care team they will encounter on a
medical-surgical unit. When providing examples of
the types of tasks certified nursing assistants (CNAs)
can perform, which of the following client activities
should the nurse include? (Select all that apply.)
A. Bathing
B. Ambulating
C. Toileting
D. Determining pain level
E. Measuring vital signs
FUNDAMENTALS FOR NURSING CHAPTER 2 THE INTERPROFESSIONAL TEAM 9

1. A. CORRECT: Initiate a referral for a social worker Using the ATI Active Learning Template: Basic Concept
to provide information and assistance in RELATED CONTENT
coordinating hospice care for a client. ●
Clinical nurse specialist (CNS): Typically specializes
B. CORRECT: Initiate a referral for a social worker to
in a practice setting or a clinical field.
provide information and assistance in coordinating
care for community resources available for clients.
●
Nurse practitioner (NP): Collaborates with one or more providers to
C. Initiate a referral for spiritual support staff if a client deliver nonemergency primary health care in a variety of settings.
requests specific religious sacraments or prayers. ●
Certified registered nurse anesthetist (CRNA): Administers
D. CORRECT: Initiate a referral for a social anesthesia and provides care during procedures
worker to assist the client in obtaining medical under the supervision of an anesthesiologist.
equipment for use after discharge. ●
Certified nurse-midwife (CNM): Collaborates
E. Provide client teaching for concerns regarding the with one or more providers to deliver care to
use of a nebulizer. If additional information is needed, maternal-newborn clients and their families.
initiate a referral for a respiratory therapist. ●
Nurse educator: Teaches in schools of nursing,
NCLEX® Connection: Management of Care, Referrals staff development departments in health care
facilities, or client education departments.
●
Nurse administrator: Provides leadership to nursing
2. A. A social worker can coordinate community services to help departments within a health care facility.
the client, but not specifically with self-feeding devices. ●
Nurse researcher: Conducts research primarily
B. A certified nursing assistant can help the client to improve the quality of client care.
with feeding, but does not typically procure
NCLEX® Connection: Management of Care, Concepts of
adaptive devices for the client.
Management
C. A registered dietitian can help with educating the
client about meeting nutritional needs, but cannot
help with the client’s physical limitations.
D. CORRECT: An occupational therapist can assist clients
who have physical challenges to use adaptive devices
and strategies to help with self-care activities.
NCLEX® Connection: Management of Care, Referrals
3. A. CORRECT: The provider must be knowledgeable

about any medication prescribed for the client,
including its actions, effects, and interactions.
B. It is not within the scope of a certified nursing assistant’s
duties to counsel a client about medications.
C. CORRECT: A pharmacist must be knowledgeable
about any medication dispensed for the client,
including its actions, effects, and interactions.
D. CORRECT: A registered nurse must be knowledgeable
about any medication administered, including
its actions, effects, and interactions.
E. Although some analgesics can cause respiratory depression,
requiring assistance from a respiratory therapist, it is not
within this therapist’s scope of practice to counsel the
client about medications prescribed by the provider.
4. A. A social worker can coordinate community services to

help the client, but not specifically with dysphagia.
B. A certified nursing assistant can help the client with
feeding, but cannot assess and treat dysphagia.
C. An occupational therapist can assist clients who have
motor challenges to improve abilities with self-care
and work, but cannot assess and treat dysphagia.
D. CORRECT: A speech-language pathologist can
initiate specific therapy for clients who have difficulty
with feeding due to swallowing difficulties.
5. A. CORRECT: It is within the range of function for a CNA

to provide basic care to clients (bathing).
B. CORRECT: It is within the range of function for a CNA to
provide basic care to clients, (assisting with ambulation).
C. CORRECT: It is within the range of function for a CNA to
provide basic care to clients (assisting with toileting).
D. Determining pain level is a task that requires the
assessment skills of licensed personnel (nurses). It
is outside the range of function for a CNA.
E. CORRECT: It is within the range of function
for a CNA to provide basic care to clients
(measuring and recording vital signs).
NCLEX® Connection: Management of Care, Assignment,
Delegation and Supervision
10 CHAPTER 2 THE INTERPROFESSIONAL TEAM CONTENT MASTERY SERIES

CHAPTER 3
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT ETHICAL DILEMMAS
SECTION: MANAGEMENT OF CARE
● Ethical dilemmas are problems that involve more than
Ethical one choice and stem from differences in the alues and
CHAPTER 3 beliefs of the decision makers. These are common in
Responsibilities health care, and nurses must apply ethical theory and
decision-making to ethical problems.
● A problem is an ethical dilemma when:
◯ A re ie of scienti c data is not enough to sol e it.
Ethics is the study of conduct and character, and ◯ It in ol es a con ict bet een t o moral imperati es.
a code of ethics is a guide for the expectations ◯ The ans er ill ha e a profound effect on the
and standards of a profession. situation and the client.
Ethical theories examine principles, ideas,

systems, and philosophies that affect judgments ETHICAL DECISION-MAKING
about what is right and wrong, and good and Ethical decision-making is a process that requires striking
bad. Common ethical theories are utilitarianism, a balance between science and morality.
deontology, consensus in bioethics, and
ethics of care. When making an ethical decision:
● Identify whether the issue is indeed an ethical dilemma.
Ethical principles for individuals, groups of ● Gather as much relevant information as possible about
individuals, and societies are standards of what the dilemma.
is right or wrong with regard to important social ● e ect on your o n alues as they relate to
values and norms. the dilemma.
● State the ethical dilemma, including all surrounding
Values are personal beliefs about ideas that issues and the individuals it involves.
determine standards that shape behavior. ● List and analyze all possible options for resolving the
dilemma, and review the implications of each option.
Morals are personal values and beliefs about ● Select the option that is in concert with the ethical
behavior and decision-making. principle that applies to this situation, the decision
maker’s values and beliefs, and the profession’s values
for client care. Justify selecting that one option in light
ETHICAL DECISION-MAKING IN NURSING of the relevant variables.
● Apply this decision to the dilemma, and evaluate
Bioethics refers to the application of ethics to health and

the outcomes.
life. It addresses dilemmas (stem cell research, organ
transplantation, gender reassignment, and reproductive Ethics committees generally address unusual or complex
technologies [in vitro fertilization, surrogate parenting]). ethical issues.
Other ethical dilemmas include abortion and acquired
Examples of ethical guidelines for nurses are the
immunode ciency syndrome.
American Nurses Association’s Code of Ethics for Nurses With
Interpretive Statements (2015) and the International Council
BASIC PRINCIPLES OF ETHICS of Nurses’ The ICN Code of Ethics for Nurses (2012).
● Advocacy: support and defend clients’ health, wellness, Moral distress occurs when the nurse is placed in a
safety, wishes, and personal rights, including privacy. difficult situation here the actions ta en are different
● Responsibility: willingness to respect obligations and from what the nurse feels is ethically correct.
follow through on promises.
● Accountability: ability to answer for one’s own actions.
● Confidentiality: protection of privacy without 3.1 Nursing’s roles in ethical
diminishing access to high-quality care. decision-making
An agent for clients facing an ethical decision. Examples:
ETHICAL PRINCIPLES FOR CLIENT CARE ●
Caring for an adolescent client who has to
● Autonomy: the right to make one’s own personal decide whether to undergo an abortion even
though her parents believe it is wrong
decisions, even when those decisions might not be in ●
Discussing options with a parent who has to decide
that person’s own best interest. whether to consent to a blood transfusion for a
● Beneficence: action that promotes good for others, child when his religion prohibits such treatment
without any self-interest. A decision maker for health care delivery. Examples:
● Fidelity: ful llment of promises. ●
Assigning staff nurses a higher client load
than previously because administration has
● Justice: fairness in care delivery and use of resources. reduced the number of nurses per shift
● Nonmaleficence: a commitment to do no harm. ●
Witnessing a surgeon discussing only surgical options with
● Veracity: a commitment to tell the truth. a client without mentioning more conservative measures
FUNDAMENTALS FOR NURSING CHAPTER 3 ETHICAL RESPONSIBILITIES 11

1. A nurse is caring for a client who decides not to A nurse is teaching a group of newly licensed nurses about
have surgery despite significant blockages of the process of resolving ethical dilemmas. Use the ATI Active
the coronary arteries. The nurse understands Learning Template: Basic Concept to complete this item.
that this client’s choice is an example of
UNDERLYING PRINCIPLES: Define the
which of the following ethical principles?
ethical decision-making process.
A. Fidelity
NURSING INTERVENTIONS: List the steps
B. Autonomy
of making an ethical decision.
C. Justice
D. Nonmaleficence
2. A nurse offers pain medication to a client who

is postoperative prior to ambulation. The nurse
understands that this aspect of care delivery is an
example of which of the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Beneficence
3. A nurse is instructing a group of newly licensed

nurses about the responsibilities organ donation and
procurement involve. When the nurse explains that all
clients waiting for a kidney transplant have to meet the
same qualifications, the newly licensed nurses should
understand that this aspect of care delivery is an
example of which of the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence
4. A nurse questions a medication prescription

as too extreme in light of the client’s
advanced age and unstable status. The nurse
understands that this action is an example of
which of the following ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence
5. A nurse is instructing a group of newly licensed

nurses about how to know and what to expect
when ethical dilemmas arise. Which of the
following situations should the newly licensed
nurses identify as an ethical dilemma?
A. A nurse on a medical-surgical unit
demonstrates signs of chemical impairment.
B. A nurse overhears another nurse telling an
older adult client that if he doesn’t stay in
bed, she will have to apply restraints.
C. A family has conflicting feelings about
the initiation of enteral tube feedings
for their father, who is terminally ill.
D. A client who is terminally ill hesitates to name their
partner on their durable power of attorney form.
12 CHAPTER 3 ETHICAL RESPONSIBILITIES CONTENT MASTERY SERIES

Application Exercises Key
1. A. Fidelity is the fulfillment of promises. The nurse has not 3. A. Fidelity is the fulfillment of promises. Because donor
made any promises; this is the client’s decision. organs are a scarce resource compared with the numbers
B. CORRECT: In this situation, the client is exercising of potential recipients who need them, no one can promise
their right to make their own personal decision about anyone an organ. Thus, this principle does not apply.
surgery, regardless of others’ opinions of what is B. Autonomy is the right to make personal decisions,
“best” for them. This is an example of autonomy. even when they are not necessarily in the person’s
C. Justice is fairness in care delivery and in the use best interest. No personal decision is involved
of resources. Because the client has chosen not with the qualifications for organ recipients.
to use them, this principle does not apply. C. CORRECT: Justice is fairness in care delivery and in the
D. Nonmaleficence is a commitment to do no harm. use of resources. By applying the same qualifications to all
In this situation, harm can occur whether or not potential kidney transplant recipients, organ procurement
the client has surgery. However, because they organizations demonstrate this ethical principle in
choose not to, this principle does not apply. determining the allocation of these scarce resources.
NCLEX® Connection: Management of Care, Ethical Practice D. Nonmaleficence is a commitment to do no harm.
In this situation, harm can occur to organ donors
and to recipients. The requirements of the organ
2. A. Fidelity is the fulfillment of promises. Unless the nurse has procurement organizations are standard procedures
specifically promised the client a pain-free recovery, which and do not address avoidance of harm or injury.
is unlikely, this principle does not apply to this action. NCLEX® Connection: Management of Care, Ethical Practice
B. Autonomy is the right to make personal decisions,
even when they are not necessarily in the person’s
best interest. In this situation, the nurse is delivering 4. A. Fidelity is the fulfillment of promises. The nurse is not
responsible client care. This principle does not apply. addressing a specific promise when they determine
C. Justice is fairness in care delivery and in the use of the appropriateness of a prescription for the client.
resources. Pain management is available for all clients who Thus, this principle does not apply.
are postoperative, so this principle does not apply. B. Autonomy is the right to make personal decisions,
D. CORRECT: Beneficence is action that promotes good even when they are not necessarily in the person’s
for others, without any self-interest. By administering best interest. No personal decision is involved when
pain medication before the client attempts a potentially the nurse questions the client’s prescription.
painful exercise like ambulation, the nurse is taking a C. Justice is fairness in care delivery and in the use of
specific and positive action to help the client. resources. In this situation, the nurse is delivering
NCLEX® Connection: Management of Care, Ethical Practice responsible client care and is not assessing available
resources. This principle does not apply.
D. CORRECT: Nonmaleficence is a commitment to
do no harm. In this situation, administering the
medication could harm the client. By questioning it,
the nurse is demonstrating this ethical principle.
NCLEX® Connection: Management of Care, Ethical Practice
5. A Delivering client care while showing signs of a substance

use disorder is a legal issue, not an ethical dilemma.
B. A nurse who threatens to restrain a client has committed
assault. This is a legal issue, not an ethical dilemma.
C. CORRECT: Making the decision about initiating enteral
tube feedings is an example of an ethical dilemma.
A review of scientific data cannot resolve the issue,
and it is not easy to resolve. The decision will have a
profound effect on the situation and on the client.
D. The selection of a person to make health care decisions on a
client’s behalf is a legal decision, not an ethical dilemma.
Active Learning Scenario Key

Using the Active Learning Template: Basic Concept
UNDERLYING PRINCIPLES: Ethical decision-making is a process
that requires striking a balance between science and morality.
NURSING INTERVENTIONS
●
Identifying whether the issue is an ethical dilemma
●
Gathering as much relevant information
as possible about the dilemma
●
Reflecting on one’s own values as they relate to the dilemma
●
Stating the ethical dilemma, including all surrounding
issues and individuals it involves
●
Listing and analyzing all possible options for resolving
the dilemma with implications of each option
●
Selecting the option that is in concert with the ethical principle
that applies to this situation, the decision maker’s values
and beliefs, and the profession’s values for client care
●
Justifying the selection of one option in light of relevant variables
FUNDAMENTALS FOR NURSING CHAPTER 3 ETHICAL RESPONSIBILITIES 13

14 CHAPTER 3 ETHICAL RESPONSIBILITIES CONTENT MASTERY SERIES
CHAPTER 4
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT STATE LAWS
● ach state has enacted statutes that de ne the
Legal parameters of nursing practice and give the authority

CHAPTER 4 to regulate the practice of nursing to its state board
Responsibilities ●
of nursing.
In turn, the boards of nursing have the authority to
adopt rules and regulations that further regulate
nursing practice. Although the practice of nursing is
Understanding the laws governing nursing similar among states, it is critical that nurses know the
laws and rules governing nursing in the state in which
practice helps nurses protect clients’ rights and they practice.
reduce the risk of nursing liability. ● Boards of nursing have the authority to issue and revoke
a nursing license.
Nurses are accountable for practicing nursing ● Boards also set standards for nursing programs and
further delineate the scope of practice for RNs, practical
within the confines of the law to shield nurses (PNs), and advanced practice nurses.
themselves from liability; advocate for clients’ ● All states have some type of Good Samaritan law that
protects health care workers from liability when they
rights; provide care that is within the nurse’s intervene at the scene of an emergency.
scope of practice; discern the responsibilities
of nursing in relationship to the responsibilities LICENSURE
of other members of the health care team; and In general, nurses must have a current license in every
state in which they practice. The states (about half of
provide safe, proficient care consistent with them) that have adopted the nurse licensure compact are
standards of care. exceptions. This model allows licensed nurses who reside
in a compact state to practice in other compact states
under a multistate license. Within the compact, nurses
SOURCES OF LAW must practice in accordance with the statues and rules of
the state in which they provide care.
FEDERAL REGULATIONS
ederal la s affecting nursing practice
● Health Insurance Portability and 4.1 Types of torts
Accountability Act (HIPAA)
● Americans with Disabilities Act (ADA)
● Mental Health Parity Act (MHPA)

Unintentional torts
● Patient Self-Determination
NEGLIGENCE: A nurse fails to implement safety measures for a client at risk for falls.
Act (PSDA) MALPRACTICE (PROFESSIONAL NEGLIGENCE): A nurse administers a large dose
of medication due to a calculation error. The client has a cardiac arrest and dies.
CRIMINAL AND CIVIL LAWS Quasi-intentional torts

BREACH OF CONFIDENTIALITY: A nurse releases a client’s
● Criminal law is a subsection of public medical diagnosis to a member of the press.
law and relates to the relationship
DEFAMATION OF CHARACTER: A nurse tells a coworker that
between an individual and the they believe the client has been unfaithful to their partner.
go ernment. A nurse ho falsi es
a record to cover up a serious Intentional torts
mistake can be guilty of breaking a ASSAULT BATTERY FALSE IMPRISONMENT
criminal law. The conduct of one Intentional and wrongful A person is confined or
● Civil laws protect individual rights. person makes another physical contact with a restrained against their will
person fearful and person that involves an A nurse uses restraints
One type of civil law that relates apprehensive injury or offensive contact on a competent client
to the provision of nursing care is A nurse threatens to place A nurse restrains a to prevent their leaving
tort law. (4.1) an NG tube in a client client and administers the health care facility.
who is refusing to eat. an injection against
their wishes.
FUNDAMENTALS FOR NURSING CHAPTER 4 LEGAL RESPONSIBILITIES 15

PROFESSIONAL NEGLIGENCE CLIENTS’ RIGHTS
Professional negligence is the failure of a person who Nurses are accountable for protecting the rights of
has professional training to act in a reasonable and clients. Examples include informed consent, refusal
prudent manner. The terms “reasonable” and “prudent” of treatment, ad ance directi es, con dentiality, and
generally describe a person who has the average judgment, information security.
intelligence, foresight, and skill that a person with similar ● Clients’ rights are legal privileges or powers clients have
training and experience would have. when they receive health care services.
● Negligence issues that prompt most malpractice suits ● Clients using the services of a health care institution
include failure to: retain their rights as individuals and citizens.
◯ Follow professional and facility-established ● The American Hospital Association identi es
standards of care. clients’ rights in health care settings. See The
◯ Use equipment in a responsible and Patient Care Partnership on the American Hospital
knowledgeable manner. Association website.
◯ Communicate effecti ely and thoroughly ith clients. ● Nursing facilities that participate in Medicare programs
◯ Document care the nurse provided. also follow Resident Rights statutes that govern
◯ Notify the provider of a change in the their operation.
client’s condition.
Complete a prescribed procedure.
NURSING ROLE IN CLIENTS’ RIGHTS
◯
● Nursing students face liability if they harm clients as

a result of their direct actions or inaction. They should ● Nurses must ensure that clients understand their rights,
not perform tasks for which they are not prepared, and must protect their clients’ rights.
and they should have supervision as they learn new ● Regardless of the client’s age, nursing needs, or health
procedures. If a student harms a client, then the student, care setting, the basic tenets are the same. The client
instructor, educational institution, and facility share has the right to:
liability for the wrong action or inaction. (4.2) ◯ Understand the aspects of care to be active in the
● Nurses can avoid liability for negligence by: decision-making process.

◯ Following standards of care. ◯ Accept, refuse, or re uest modi cation of the
◯ Giving competent care. plan of care.
◯ Communicating with other health team members ◯ Receive care from competent individuals who treat
and clients. the client with respect.

◯ Developing a caring rapport with clients.
◯ Fully documenting assessments, interventions,
and evaluations.
◯ Being familiar with and following a facility’s policies
and procedures.
4.2 The five elements necessary to prove negligence

ELEMENT OF LIABILITY EXPLANATION EXAMPLE: CLIENT WHO IS A FALL RISK
1. Duty to provide care as Care a nurse should give or what a The nurse should complete a fall risk assessment
defined by a standard reasonably prudent nurse would do for all clients during admission.
2. Breach of duty by failure Failure to give the standard of care The nurse does not perform a fall risk
to meet standard assessment during admission.
3. Foreseeability of harm Knowledge that failing to give the proper The nurse should know that failure to take fall risk
standard of care could harm the client precautions could endanger a client at risk for falls.
4. Breach of duty has Failure to meet the standard Without a fall risk assessment, the nurse
potential to cause had potential to cause harm – does not know the client’s risk for falls and
harm (combines relationship must be provable does not take the proper precautions.
elements 2 and 3)
5. Harm occurs Actual harm to the client occurs The client falls out of bed and fractures their hip.
16 CHAPTER 4 LEGAL RESPONSIBILITIES CONTENT MASTERY SERIES

Online Video: Informed Consent
INFORMED CONSENT ● A competent adult must sign the form for informed
consent. The person who signs the form must be capable
● Informed consent is a legal process by which a client
of understanding the information from the health care
or the client’s legally appointed designee has given
professional who will perform the service (a surgical
written permission for a procedure or treatment.
procedure) and the person must be able to communicate
Consent is informed when a provider explains and the
with the health care professional. When the person
client understands:
giving the informed consent is unable to communicate
◯ The reason the client needs the treatment
due to a language barrier or a hearing impairment, a

or procedure.
trained medical interpreter must intervene. Many health
◯ Ho the treatment or procedure ill bene t the client.
care facilities contract with professional interpreters
◯ The risks involved if the client chooses to receive the
who have additional skills in medical terminology to

treatment or procedure.
assist with providing information.
◯ Other options to treat the problem, including not ● Individuals who can grant consent for another person
treating the problem.
include the following.
● The nurse’s role in the informed consent process is to ◯ Parent of a minor
witness the client’s signature on the informed consent ◯ Legal guardian
form and to ensure that the provider has obtained the ◯ Court speci ed representati e
informed consent responsibly. ◯ An individual who has durable power of attorney
INFORMED CONSENT GUIDELINES authority for health care

Clients must consent to all care they receive in a health ● Emancipated minors (minors who are independent
care facility. from their parents [a married minor]) can consent
● For most aspects of nursing care, implied consent for themselves.
is adequate. Clients provide implied consent when ● Include a mature adolescent in the informed consent
they adhere to the instructions the nurse provides. process by allowing them to sign an assent as a part of
For example, the nurse is preparing to perform a the informed consent document. (4.3)
tuberculosis skin test, and the client holds out their arm ● The nurse must verify that consent is informed and
for the nurse. witness the client signing the consent form.
● For an invasive procedure or surgery, the client must
provide written consent.
● State laws prescribe who is able to give informed
consent. Laws vary regarding age limitations and
emergencies. Nurses are responsible for knowing the
laws in the state(s) in which they practice.
4.3 Responsibilities for informed consent
Provider Client Nurse

Obtains informed consent. To do so, Gives informed consent. To give Witnesses informed consent.
the provider must give the client informed consent, the client must This means the nurse must
●
The purpose of the procedure. ●
Give it voluntarily (no coercion involved). ●
Ensure that the provider gave the
●
A complete description of the procedure. ●
Be competent and of legal age or be client the necessary information.
●
A description of the professionals an emancipated minor. When the client ●
Ensure that the client understood
who will perform and participate is unable to provide consent, another the information and is competent
in the procedure. authorized person must give consent. to give informed consent.
●
A description of the potential harm, ●
Receive enough information to ●
Have the client sign the informed
pain, or discomfort that might occur. make a decision based on an consent document.
understanding of what to expect. Notify the provider if the client has more
●
Options for other treatments. ●
questions or appears not to understand

●
The option to refuse treatment and any of the information. The provider is
the consequences of doing so. then responsible for giving clarification.
●
Document questions the client has,
notification of the provider, reinforcement
of teaching, and use of an interpreter.

REFUSAL OF TREATMENT ADVANCE DIRECTIVES
● The P DA stipulates that staff must inform clients they The purpose of advance directives is to communicate a
admit to a health care facility of their right to accept or client’s wishes regarding end-of-life care should the client
refuse care. Competent adults have the right to refuse become unable to do so.
treatment, including the right to leave a facility without ● The PSDA requires asking all clients on admission
a discharge prescription from the provider. to a health care facility whether they have
● If the client refuses a treatment or procedure, the client advance directives.
signs a document indicating that they understand the ● taff should gi e clients ho do not ha e ad ance
risk involved with refusing the treatment or procedure directives written information that outlines their rights
and that they have chosen to refuse it. related to health care decisions and how to formulate
● When a client decides to leave the facility against advance directives.
medical advice (without a discharge prescription), the ● A health care representative should be available to help
nurse noti es the pro ider and discusses ith the with this process.
client the risks to expect when leaving the facility prior
to discharge. Types of advance directives
● The nurse asks the client to sign an Against Medical
Living will
Advice form and documents the incident. ● A living will is a legal document that expresses the
client’s wishes regarding medical treatment in the

STANDARDS OF CARE (PRACTICE) event the client becomes incapacitated and is facing
end-of-life issues.
● Nurses base practice on established standards of care or ● Most state laws include provisions that protect health
legal guidelines for care, including the following.
care providers who follow a living will from liability.
◯ The nurse practice act of each state.
◯ Published standards of nursing practice from Durable power of attorney for health care
professional organizations and specialty groups, A durable power of attorney for health care is a document
including the American Nurses Association (ANA), the in which clients designate a health care proxy to make
American Association of Critical Care Nurses (AACN), health care decisions for them if they are unable to do so.
and the American Association of Occupational Health The proxy can be any competent adult the client chooses.
Nurses (AAOHN).
◯ Health care facilities’ policies and procedures, which
Provider’s orders
Unless a provider writes a “do not resuscitate” (DNR) or
establish the standard of practice for employees of
“allow natural death” (AND) prescription in the client’s
that facility. They provide detailed information about
medical record, the nurse initiates cardiopulmonary
how the nurse should respond to or provide care
resuscitation (CPR) when the client has no pulse or
in speci c situations and hile performing client
respirations. The provider consults the client and the
care procedures.
family prior to administering a DNR or AND.
● tandards of care de ne and direct the le el of care
nurses should give, and they implicate nurses who did NURSING ROLE IN ADVANCE DIRECTIVES
not follow these standards in malpractice lawsuits. Nursing responsibilities include the following.
● Nurses should refuse to practice beyond the legal scope ● Provide written information about advance directives.
of practice or outside of their areas of competence ● Document the client’s advance directives status.
regardless of reason staffing shortage, lac of ● nsure that the ad ance directi es re ect the client s
appropriate personnel). current decisions.
● Nurses should use the formal chain of command to ● Inform all members of the health care team of the
verbalize concerns related to assignment in light of client’s advance directives.
current legal scope of practice, job description, and area
of competence.
MANDATORY REPORTING
Health care providers have a legal obligation to report
IMPAIRED COWORKERS their ndings in accordance ith state la in the
Impaired health care pro iders pose a signi cant ris to following situations.
client safety.
● A nurse who suspects a coworker of any behavior that
ABUSE
Nurses must report any suspicion of abuse (child or elder
jeopardizes client care or could indicate a substance
abuse, adult violence) following facility policy.
use disorder has a duty to report the coworker to the
appropriate manager.
● Many facilities’ policies provide access to assistance
programs that facilitate entry into a treatment program.
● Each state has laws and regulations that govern the
disposition of nurses who have substance use disorders.
Criminal charges could apply.

COMMUNICABLE DISEASES
Nurses must report communicable disease diagnoses to
the local or state health department. For a complete list
of reportable diseases and a description of the reporting
system, go to the Centers for Disease Control and
Prevention’s website, www.cdc.gov. Each state mandates
which diseases to report in that state.
● eporting allo s officials to Active Learning Scenario
◯ Ensure appropriate medical treatment of diseases
(tuberculosis). A nurse is teaching a group of newly licensed nurses

◯ Monitor for common-source outbreaks (foodborne, about avoiding liability for negligence. Use the ATI Active
hepatitis A). Learning Template: Basic Concept to complete this item.
◯ Plan and evaluate control and prevention plans
UNDERLYING PRINCIPLES: List the five

(immunizations).
◯ Identify outbreaks and epidemics.
elements necessary to prove negligence.
◯ Determine public health priorities based on trends. NURSING INTERVENTIONS: List at least four
ways nurses can avoid liability for negligence.
1. A nurse observes an assistive personnel (AP) 4. A nurse is caring for a client who is about to undergo
reprimanding a client for not using the urinal an elective surgical procedure. The nurse should
properly. The AP tells the client that diapers will take which of the following actions regarding
be used next time the urinal is used improperly. informed consent? (Select all that apply.)
Which of the following torts is the AP committing? A. Make sure the surgeon obtained
A. Assault the client’s consent.
B. Battery B. Witness the client’s signature on the consent form.
C. False imprisonment C. Explain the risks and benefits of the procedure.
D. Invasion of privacy D. Describe the consequences of
choosing not to have the surgery.
E. Tell the client about alternatives
2. A nurse is caring for a competent adult client who
to having the surgery.
tells the nurse, “I am leaving the hospital this morning
whether the doctor discharges me or not.” The
nurse believes that this is not in the client’s best 5. A nurse has noticed several occasions in the past
interest, and prepares to administer a PRN sedative week when another nurse on the unit seemed
medication the client has not requested along with drowsy and unable to focus on the issue at hand.
the scheduled morning medication. Which of the Today, the nurse was found asleep in a chair in
following types of tort is the nurse about to commit? the break room not during a break time. Which
A. Assault of the following actions should the nurse take?
B. False imprisonment A. Alert the American Nurses Association.
C. Negligence B. Fill out an incident report.
D. Breach of confidentiality C. Report the observations to the
nurse manager on the unit.
D. Leave the nurse alone to sleep.
3. A nurse in a surgeon’s office is providing preoperative
teaching for a client who is scheduled for surgery
the following week. The client tells the nurse that
“I plan to prepare my advance directives before
I come to the hospital.” Which of the following
statements made by the client should indicate to
the nurse an understanding of advance directives?
A. “I’d rather have my brother make decisions
for me, but I know it has to be my wife.”
B. “I know they won’t go ahead with the
surgery unless I prepare these forms.”
C. “I plan to write that I don’t want them to
keep me on a breathing machine.”
D. “I will get my regular doctor to approve my
plan before I hand it in at the hospital.”

1. A. CORRECT: By threatening the client, the AP is Using the ATI Active Learning Template: Basic Concept
committing assault. The AP’s threats could make the
UNDERLYING PRINCIPLES
client become fearful and apprehensive.
B. Battery is actual physical contact without the
●
Duty to provide care as defined by a standard
client’s consent. Because the AP has only verbally
●
Breach of duty by failure to meet standard
threatened the client, battery has not occurred. ●
Foreseeability of harm
C. Unless the AP restrains the client, there is ●
Breach of duty has potential to cause harm
no false imprisonment involved. ●
Harm occurs
D. Invasion of privacy involves disclosing information
about a client to an unauthorized individual. NURSING INTERVENTIONS
●
Following standards of care
NCLEX Connection: Management of Care,
®
●
Giving competent care
Legal Rights and Responsibilities ●
Communicating with other health team members
●
Developing a caring rapport with clients
2. A. Assault is an action that threatens harmful ●
Fully documenting assessments, interventions, and evaluations
contact without the client’s consent. The nurse
NCLEX® Connection: Management of Care, Legal Rights and
has made no threats in this situation.
Responsibilities
B. CORRECT: Administering a medication as a chemical restraint
to keep the client from leaving the facility against medical
advice is false imprisonment, because the client neither
requested nor consented to receiving the sedative.
C. Negligence is a breach of duty that results in harm to the
client. It is unlikely that the medication the nurse administered
without his consent actually harmed the client.
D. The nurse has not disclosed any protected
health information, so there is no breach of
confidentiality involved in this situation.
Legal Rights and Responsibilities
3. A. The client can designate any competent adult to be his

health care proxy. It does not have to be his spouse.
B. The hospital staff must ask the client whether he has prepared
advance directives and provide written information about
them if he has not. The nurse should document whether the
client has signed the advance directives. The hospital staff
cannot refuse care based on the lack of advance directives.
C. CORRECT: The client has the right to decide
and specify which medical procedures he wants
when a life-threatening situation arises.
D. The client does not need his provider’s approval to submit
his advance directives. However, he should give his primary
care provider a copy of the document for his records.
Advance Directives/Self-Determination/Life Planning
4. A. CORRECT: It is the nurse’s responsibility to verify that the

surgeon obtained the client’s consent and that the client
understands the information the surgeon gave them.
B. CORRECT: It is the nurse’s responsibility to witness the
client’s signing of the consent form, and to verify that they
are consenting voluntarily and appear to be competent
to do so. The nurse also should verify that the client
understands the information the surgeon has provided.
C. It is the surgeon’s responsibility to explain the
risks and benefits of the procedure.
D. It is the surgeon’s responsibility to describe the
consequences of choosing not to have the surgery.
E. It is the surgeon’s responsibility to tell the client about
any available alternatives to having the surgery.
NCLEX® Connection: Management of Care, Informed Consent
5. A. Do not alert the American Nurses Association. The

state’s board of nursing regulates disciplinary action and
can revoke a nurse’s license for substance use.
B. Do not fill out an incident report. Incident reports are
filed to document an accident or unusual occurrence.
C. CORRECT: Any nurse who notices behavior that
could jeopardize client care or could indicate a
substance use disorder has a duty to report the
situation immediately to the nurse manager.
D. Do not leave the nurse alone to sleep. Although the nurse is
not responsible for solving the problem, she does have a duty
to take action because she has observed the problem.

Online Video: Confidentiality
CHAPTER 5
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT ELEMENTS OF DOCUMENTATION
Factual: Subjective and objective data
Information
● Nurses should document subjective data as direct
CHAPTER 5 quotes, within quotation marks, or summarize and
Technology identify the information as the client’s statement.

Subjective data should be supported by objective data so
charting is as descriptive as possible.
● Objective data should be descriptive and should include
The chart or medical record is the legal what the nurse sees, hears, feels, and smells. Document
without derogatory words, judgments, or opinions.
record of care. Document the client’s behavior accurately. Instead of
writing “client is agitated,” write “client pacing back
The medical record is a confidential, permanent, and forth in the room, yelling loudly.”
and legal document that is admissible in court.
Accurate and concise: Document facts and information
Nurses are legally and ethically responsible for precisely (what the nurse sees, hears, feels, smells)
without any interpretations of the situation. Unnecessary
ensuring confidentiality. Only health care
words and irrelevant detail are avoided. Exact
providers who are involved directly in a client’s measurements establish accuracy. Only abbreviations
and symbols approved by The Joint Commission and the
care can access that client’s medical record.
facility are acceptable.
Nurses document the care they provide as Complete and current: Document information that is
comprehensive and timely. Never pre-chart an assessment,
documentation or charting, and it should reflect
intervention, or evaluation.
the nursing process.
Organized: Communicate information in a logical sequence.
There is a rapidly growing trend for maintaining

medical records electronically, which creates LEGAL GUIDELINES
Begin each entry with the date and time.
challenges in protecting the privacy and safety
●
● Record entries legibly, in non-erasable black ink, and do

of health information. not leave blank spaces in the nurses’ notes.
● Do not use correction uid, erase, scratch out, or
Information to document includes assessments, blacken out errors in the medical record. Make
corrections promptly, following the facility’s procedure
medication administration, nursing actions, for error correction.
treatments and responses, and client education. ● Sign all documentation as the facility requires,
generally with name and title.
● Documentation should re ect assessments,
DOCUMENTATION interventions, and evaluations, not personal opinions
or criticism about client or other health care
Documentation is a standard for many accrediting
professionals’ care.
agencies, including The Joint Commission (formerly
JCAHO). The Joint Commission mandates the use of
computerized databases to expedite the accreditation
process. Health care facilities use the computerized data
DOCUMENTATION FORMATS
for budget management, quality improvement programs, Flow charts show trends in vital signs, blood glucose
research, and many other endeavors. levels, pain level, and other frequent assessments.
● Purposes for medical records include communication,
Narrative documentation records information as a
legal documentation, nancial billing, education,
sequence of events in a story-like manner.
research, and auditing.
● The purpose of reporting is to provide continuity of care Charting by exception uses standardized forms that
and enhance communication among all team members identify norms and allows selective documentation of
who provide care to the same clients, thus promoting deviations from those norms.
client safety.
Problem-oriented medical records are organized by
● Nurses should conduct reporting in a
problem or diagnosis and consist of a database, problem
con dential manner.
list, care plan, and progress notes. Examples include SOAP,
PIE, and DAR. (5.1)
FUNDAMENTALS FOR NURSING CHAPTER 5 INFORMATION TECHNOLOGY 21

Electronic health records are replacing manual formats in Transfer (hand‑off) reports
many settings.
These should include demographic information, medical
● Advantages include standardization, accuracy,
diagnosis, providers, an overview of health status

con dentiality, easy access for multiple users, pro iding
(physical, psychosocial), plan of care, recent progress, any
ease in maintaining ongoing health record of client’s
alterations that might become an urgent or emergent
condition, and rapid acquisition and transfer of clients’
situation, directives for any assessments or client care
information.
essential within the next few hours, most recent vital
● Challenges include learning the system, knowing how
signs, medications and last doses, allergies, diet, activity,
to correct errors, and maintaining security.
speci c e uipment or adapti e de ices o ygen, suction,
● Documentation rules and formats are similar to those
wheelchair), advance directives and resuscitation status,
for paper charting.
discharge plan (teaching), and family involvement in care
and health care proxy.
REPORTING FORMATS Incident reports (unusual occurrences)

Change-of-shift report Incident/variance reports are an important part of a
facility’s quality improvement plan.
Nurses give this report at the conclusion of each shift to ● An incident is the occurrence of an accident or an
the nurse assuming responsibility for the clients.

unusual event. Examples of incidents are medication
● Formats include face-to-face, audiotaping, or
errors, falls, omission of prescription, and needlesticks.
presentation during walking rounds in each client’s ● Document facts without judgment or opinion.
room (unless the client has a roommate or visitors ● Do not refer to an incident report in a client’s
are present).
medical record.
● An effecti e report should
● Incident reports contribute to changes that help improve
◯ Include signi cant ob ecti e information about the
health care quality.
client’s health problems.
◯ Proceed in a logical sequence.
◯ Include no gossip or personal opinion.
◯ Relate recent changes in medications, treatments,

INFORMATION SECURITY
procedures, and the discharge plan. Mandatory adherence with the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) began
Telephone reports in to help ensure the con dentiality of health
information.
Telephone reports are useful when contacting the provider ● A major component of HIPAA, the Privacy Rule,
or other members of the interprofessional team.

promotes the use of standard methods of maintaining
● It is important to:
the privacy of protected health information (PHI) among
◯ Have all the data ready prior to contacting any
health care agencies.

member of the interprofessional team. ● It is essential for nurses to be aware of clients’
◯ Use a professional demeanor.
rights to pri acy and con dentiality. acilities

◯ Use exact, relevant, and accurate information.
policies and procedures help ensure adherence with

◯ Document the name of the person who made the
HIPAA regulations.
call and to whom the information was given; the
time, content of the message; and the instructions or
Privacy rule
information received during the report.
The Privacy Rule requires that nurses protect all written
Telephone or verbal prescriptions and verbal communication about clients. Components of
the Privacy Rule include the following.
It is best to avoid these, but they are sometimes necessary ● Only health care team members directly responsible for
during emergencies and at unusual times.
a client’s care can access that client’s record. Nurses
● Have a second nurse listen to a telephone prescription.
cannot share information ith other clients or staff not
● Repeat it back, making sure to include the medication’s
caring for the client.
name (spell if necessary), dosage, time, and route. ● Clients have a right to read and obtain a copy of their
● Question any prescription that seems inappropriate for
medical record.
the client. ● Nurses cannot photocopy any part of a medical record
● Make sure the provider signs the prescription in
except for authorized exchange of documents between
person ithin the time frame the facility speci es,
facilities and providers.
typically 24 hr. ● taff must eep medical records in a secure area to pre ent
inappropriate access to the information. They cannot use
public display boards to list client names and diagnoses.
● Electronic records are password-protected. The public
cannot ie them. taff must use only their o n
passwords to access information.
22 CHAPTER 5 INFORMATION TECHNOLOGY CONTENT MASTERY SERIES

● Nurses must not disclose clients’
information to unauthorized 5.1 Problem-oriented medical records
individuals or family members
who request it in person or by SOAP PIE DAR
focus charting
telephone or email. S Subjective data P Problem
◯ Many hospitals use a code system to
O Objective data I Intervention D Data
identify those individuals who can A Assessment E Evaluation A Action
receive information about a client. includes a nursing
diagnosis based on
R Response
◯ Nurses should ask any individual the assessment
inquiring about a client’s status for P Plan
the code and disclose information
only when the individual can
give the code.
● Communication about a client should
only take place in a private setting where unauthorized Social media precautions
individuals cannot overhear it. ● Know the implications of HIPAA before
● To adhere to HIPAA regulations, each facility has speci c using social networking sites for school- or
policies and procedures to monitor staff adherence, work-related communication.
technical protocols, computer privacy, and data safety. ● Become familiar with your facility’s policies regarding
the use of social networking.
Information security protocols ● Do not use or view social networking media in
● Log off from the computer before lea ing the
clinical settings.
workstation to ensure that others cannot view protected ● Do not post information about your facility, clinical
health information on the monitor.
sites, clinical experiences, clients, and other health care
● Never share a user ID or password with anyone.
staff on social net or ing sites
● Never leave a medical record or other printed or written ● Do not take pictures that show clients or their
PHI where others can access it.
family members.
● Shred any printed or written client information for
reporting or client care after use.

1. A nurse is preparing information for a change-of-shift 4. A nurse is discussing occurrences that require
report. Which of the following information completion of an incident report with a newly licensed
should the nurse include in the report? nurse. Which of the following should the nurse
A. Input and output for the shift include in the teaching? (Select all that apply).
B. Blood pressure from the previous day A. Medication error
C. Bone scan scheduled for today B. Needlesticks
D. Medication routine from the medication C. Conflict with provider and nursing staff
administration record D. Omission of prescription
E. Missed specimen collection of a
prescribed laboratory test
2. A nurse manager is discussing the HIPAA Privacy
Rule with a group of newly hired nurses during
orientation. Which of the following information should 5. A nurse is receiving a provider’s prescription by
the nurse manager include? (Select all that apply.) telephone for morphine for a client who is reporting
A. A single electronic records password is moderate to severe pain. Which of the following
provided for nurses on the same unit. nursing actions are appropriate? (Select all that apply.)
B. Family members should provide a code prior A. Repeat the details of the prescription
to receiving client health information. back to the provider.
C. Communication of client information B. Have another nurse listen to the
can occur at the nurses’ station. telephone prescription.
D. A client can request a copy of their medical record. C. Obtain the provider’s signature on
E. A nurse can photocopy a client’s medical the prescription within 24 hr.
record for transfer to another facility. D. Decline the verbal prescription because
it is not an emergency situation.
E. Tell the charge nurse that the provider has
3. A charge nurse is reviewing documentation with
prescribed morphine by telephone.
a group of newly licensed nurses. Which of the
following legal guidelines should be followed when
documenting in a client’s record? (Select all that apply.)
A. Cover errors with correction fluid, and
write in the correct information.
B. Put the date and time on all entries.
C. Document objective data, leaving out opinions.
D. Use as many abbreviations as possible.
E. Wait until the end of the shift to document.

A nurse is introducing a group of newly licensed
nurses to the various approaches to problem-oriented
documentation. Use the ATI Active Learning
Template: Basic Concept to complete this item.
UNDERLYING PRINCIPLES: List three common methods of

problem-oriented charting with definitions of their acronyms.

1. A. Unless there is a significant change in intake and output, the Using the ATI Active Learning Template: Basic Concept
oncoming nurse can read that information in the chart. UNDERLYING PRINCIPLES
B. Unless there is a significant change in blood pressure ●
SOAP
measurements since the previous day, the oncoming
nurse can read that information in the chart. S: Subjective data
◯
C. CORRECT: The bone scan is important because O: Objective data

◯
the nurse might have to modify the client’s A: Assessment (includes a nursing diagnosis
◯
care to accommodate leaving the unit. based on the assessment)

D. Unless there is a significant change in the medication routine, P: Plan
◯
the oncoming nurse can read that information in the chart. ●

PIE
NCLEX® Connection: Management of Care, Continuity of Care P: Problem
◯
I: Intervention
◯
E: Evaluation
◯
2. A. The HIPAA Privacy Rule requires the protection of clients’ ●

DAR (focus charting)
electronic records. The rule states that electronic records
D: Data
◯
must be password-protected and each staff person should

use an individual password to access information. A: Action
◯
B. CORRECT: The HIPAA Privacy Rule states that information R: Response

◯
should only be disclosed to authorized individuals to whom NCLEX® Connection: Management of Care,
the client has provided consent. Many hospitals use a Information Technology
code system to identify those individuals and should only
provide information if the individual can give the code.
C. CORRECT: The HIPAA Privacy Rule states that communication
about a client should only take place in a private setting
where unauthorized individuals cannot overhear it. A unit
nurses’ station is considered a private and secure location.
D. CORRECT: The HIPAA Privacy Rule states that clients have
a right to read and obtain a copy of their medical record.
E. CORRECT: The HIPAA Privacy Rule states that nurses
can only photocopy a client’s medical record if it is to
be used for transfer to another facility or provider.
NCLEX® Connection: Safety and Infection Control,
Irregular Occurrence/Variance
3. A. Correction fluid implies that the nurse might

have tried to hide the previous documentation
or deface the medical record.
B. CORRECT: The day and time confirm the recording
of the correct sequence of events.
C. CORRECT: Documentation must be factual, descriptive,
and objective, without opinions or criticism.
D. Too many abbreviations can make the entry difficult to
understand. Nurses should minimize use of abbreviations,
and use only those the facility approves.
E. Documentation should be current. Waiting until the
end of the shift can result in data omission.
4. A. CORRECT: Complete an incident report

regarding a medication error.
B. CORRECT: Complete an incident report
regarding a needlestick.
C. Report a conflict with a provider and nursing staff
to the charge nurse or nurse manager.
D. CORRECT: Complete an incident report
following an omission of a prescription.
E. Report missed specimen collection of a
prescribed laboratory test.
Reporting of Incident/Event/Irregular Occurrence/Variance
5. A. CORRECT: The nurse should repeat the medication’s

name, dosage, time or interval, route, and any
other pertinent information back to the provider
and receive and document confirmation.
B. CORRECT: Having another nurse listen to the telephone
prescription is a safety precaution that helps prevent
medication errors due to miscommunication.
C. CORRECT: The provider must sign the prescription within the
time frame the facility specifies in its policies (generally 24 hr).
D. Unrelieved pain can become an emergency situation without
the appropriate pain management interventions.
E. There is no need to inform the charge nurse every time
a nurse receives a medication prescription, whether
by telephone, verbally, or in the medical record.
Accident/Error/Injury Prevention

CHAPTER 6
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT DELEGATION FACTORS
● Nurses can only delegate tasks appropriate for the skill
Delegation and and education level of the individual who is receiving the
CHAPTER 6 assignment (the delegatee).
Supervision ● RNs cannot delegate the nursing process, client education,

or tasks that require nursing judgment to PNs or to APs.
TASK FACTORS: Prior to delegating client care, nurses

should consider the:
Delegation is the process of transferring the ● Predictability of the outcome: Will the completion of
performance of a task to another member of the the task have a predictable outcome?
◯ Is it a routine treatment?
health care team while retaining accountability ◯ Is it a new treatment for that client?
for the outcome. ● Potential for harm

◯ Is there a chance that something negative could
Supervision is the process of directing, happen to the client (bleeding, aspiration)?

◯ Is the client unstable?
monitoring, and evaluating the performance ● Complexity of care

of tasks by another team member. Nurses are ◯ Does the client’s care require complex tasks?
◯ Does the state’s practice act or the facility’s policy
responsible for supervising the performance of allow the delegatee to perform the task, and does the
client care tasks they delegate to others. delegatee have the necessary skills?
● Need for problem solving and innovation
Licensed personnel are nurses who have ◯ Is judgment essential while performing the task?
◯ Does it require nursing assessment or
completed a course of study in nursing and data-collection skills?

successfully passed either a PN or RN examination. ● Level of interaction with the client: Does the delegatee
need psychosocial support or education during the
Unlicensed personnel are individuals who have performance of the task?
had training to function in an assistive role to

licensed nurses in providing client care. DELEGATEE FACTORS
● Education, training, and experience
These unlicensed individuals might be nursing ● Knowledge and skill to perform the task
Level of critical thinking the task requires
personnel (certified nursing assistants [CNAs],
●
● Ability to communicate with others as it pertains to the task

certified medication assistants [CMAs]) or ● Demonstration of competence
The facility’s policies and procedures
non-nursing personnel (dialysis technicians,
●
● Licensing legislation (state’s nurse practice acts) (6.1)

monitor technicians, phlebotomists).
Some facilities differentiate between licensed

6.1 Examples of tasks nurses may
and unlicensed personnel by using the acronym delegate to PNs and APs
NAP for nursing assistive personnel or AP for (provided the facility’s policy and
state’s practice guidelines permit)
assistive personnel.
TO PNS TO APS
●
Monitoring findings ●
Activities of daily
DELEGATION (as input to the RN’s
ongoing assessment)
living (ADLs)
Bathing
◯
A licensed nurse is responsible for providing clear ●

Reinforcing client teaching Grooming
◯
from a standard care plan

directions when delegating a task initially and for periodic Dressing
◯
●
Performing
reassessment and evaluation of the outcome of the task. tracheostomy care Toileting
◯
● RNs can delegate to other RNs, PNs, and AP. ●

Suctioning Ambulating
◯
◯ RNs must be knowledgeable about their state’s nurse

●
Checking NG Feeding (without
◯
swallowing precautions)
practice act and the regulations that guide the use of tube patency
Administering Positioning
◯
PNs and AP. ●
enteral feedings ●
Routine tasks
◯ RNs must delegate tasks so that they can complete
Inserting a urinary Bed making

◯
higher-level tasks that only RNs can perform. This

●
catheter Specimen collection

◯
allo s more efficient use of all team members. ●

Administering medication Intake and output
◯
● PNs can delegate to other PNs and to AP. (excluding IV medication Vital signs (for
◯
in some states) stable clients)
FUNDAMENTALS FOR NURSING CHAPTER 6 DELEGATION AND SUPERVISION 27

Online Video: Delegation
DELEGATION AND Right person

SUPERVISION GUIDELINES ● Determine and verify the competence of the delegatee.
● se the e rights of delegation to decide. (6.2) ● The task must be within the delegatee’s scope of
◯ Tasks to delegate (right task) practice or job description.
◯ Under what circumstances (right circumstances ● The delegatee must have the necessary competence and
[setting and resources]) training.
◯ To whom (right person) ● Continually review the performance of the delegatee
◯ What information to communicate (right direction and determine care competence.
and communication) ● Evaluate the delegatee’s performance according to
◯ How to oversee and appraise (right supervision standards, and when necessary, take steps to remediate
and evaluation) any failure to meet standards.
● Use professional judgment and critical thinking skills
RIGHT PERSON: Delegate a PN to administer enteral
when delegating.
feedings to a client who has a head injury.
Right task WRONG PERSON: Delegate an AP to administer
enteral feedings to a client who has a head injury.
● Identify which tasks are appropriate to delegate for each
speci c client.
Right direction and communication
A right task is repetitive, requires little supervision, and
in writing, orally, or both
●
is relatively noninvasive for the client.

● Delegate activities to appropriate levels of team ● Communicate what data to collect.
members (RN, PN, AP) according to professional ● Provide a method and timeline for reporting, including
standards of practice, legal and facility guidelines, and hen to report concerns and assessment ndings.
available resources. ● Communicate speci c tas s to perform and
client speci c instructions.
RIGHT TASK: Delegate an AP to assist a client
● Detail expected results, timelines, and expectations for
who has pneumonia to use a bedpan.
follow-up communication.
WRONG TASK: Delegate an AP to administer a
RIGHT DIRECTION AND COMMUNICATION:
nebulizer treatment to a client who has pneumonia.
Delegate an AP to assist Mr. Martin in
room 312 with a shower before 0900.
Right circumstances
WRONG DIRECTION AND COMMUNICATION:
● Determine the health status and complexity of care the
Delegate an AP to assist Mr. Martin in
client requires.
room 312 with morning hygiene.
● Match the complexity of care demands to the skill level
of the delegatee.
Right supervision and evaluation
● Consider the workload of the delegatee.
● Provide supervision, either directly or indirectly
RIGHT CIRCUMSTANCE: Delegate an AP to measure the
(assigning supervision to another licensed nurse).
vital signs of a client who is postoperative and stable. ● Monitor performance.
WRONG CIRCUMSTANCE: Delegate an AP to measure ● Intervene if necessary (for unsafe clinical practice).
the vital signs of a client who is postoperative and ● Provide feedback:
required naloxone to reverse respiratory depression. ◯ Did the delegatee complete the tasks on time?
◯ Was the delegatee’s performance satisfactory?
◯ Did the delegatee document and report
une pected ndings

◯ Did the delegatee need help completing the
tasks on time?
● Evaluate the client and determine the client’s
outcome status.
6.2 The five rights of delegation ● Evaluate task performance and identify needs
for performance-improvement activities and
Right task additional resources.
RIGHT SUPERVISION: Delegate an AP to

Right circumstance assist with ambulating a client after the RN
Right person completes the admission assessment.
Right direction and communication WRONG SUPERVISION: Delegate an AP to assist

with ambulating a client prior to the RN
Right supervision and evaluation performing an admission assessment.
28 CHAPTER 6 DELEGATION AND SUPERVISION CONTENT MASTERY SERIES

1. A nurse on a medical-surgical unit has received A nurse manager is reviewing the responsibilities of delegation
change-of-shift report and will care for four with a group of nurses on a medical unit. Use the ATI Active
clients. Which of the following tasks should the Learning Template: Basic Concept to complete this item.
nurse assign to an assistive personnel (AP)?
NURSING INTERVENTIONS: List at least five
A. Updating the plan of care for a tasks the delegating nurse must perform when
client who is postoperative supervising and evaluating a delegatee.
B. Reinforcing teaching with a client who is
learning to walk using a quad cane
C. Reapplying a condom catheter for a
client who has urinary incontinence
D. Applying a sterile dressing to a pressure injury
2. A nurse manager is assigning care of a client who is

being admitted from the PACU following thoracic
surgery. The nurse manager should assign the
client to which of the following staff members?
A. Charge nurse
B. Registered nurse (RN)
C. Practical nurse (PN)
D. Assistive personnel (AP)
3. A nurse is delegating the ambulation of a client

who had knee arthroplasty 5 days ago to an AP.
Which of the following information should the
nurse share with the AP? (Select all that apply.)
A. The roommate ambulates independently.
B. The client ambulates wearing slippers
over antiembolic stockings.
C. The client uses a front-wheeled
walker when ambulating.
D. The client had pain medication 30 min ago.
E. The client is allergic to codeine.
F. The client ate 50% of breakfast this morning.
4. A charge nurse is assigning client care for

four clients. Which of the following tasks
should the nurse assign to a PN?
A. Creating a plan of care for a client who
is recovering following a stroke
B. Assessing a pressure injury on a
client who is on bed rest
C. Providing nasopharyngeal suctioning
for a client who has pneumonia
D. Teaching a client who has asthma to
use a metered-dose inhaler
5. A nurse is preparing an in-service program about

delegation. Which of the following are components of
the five rights of delegation? (Select all that apply.)
A. Right place
B. Right supervision and evaluation
C. Right direction and communication
D. Right documentation
E. Right circumstances
FUNDAMENTALS FOR NURSING CHAPTER 6 DELEGATION AND SUPERVISION 29

1. A. Updating the plan of care for a client requires professional Using the ATI Active Learning Template: Basic Concept
nursing knowledge and judgment. Therefore, it is
outside the range of function of an AP.
B. Reinforcing teaching a client for a client requires
●
Provide supervision, either directly or indirectly
professional nursing knowledge and judgment. (assigning supervision to another licensed nurse).
C. CORRECT: The application of a condom
●
Monitor performance.
catheter is a noninvasive, routine procedure ●
Intervene if necessary (for unsafe clinical practice).
that can be delegated to an AP. ●
Provide feedback:
D. Applying a sterile dressing on a client requires professional Did the delegatee complete the tasks on time?
◯
nursing knowledge, skills, and judgment. Was the delegatee’s performance satisfactory?
◯
NCLEX® Connection: Management of Care, Assignment, Did the delegatee document and report unexpected findings?
◯
Delegation and Supervision Did the delegatee need help completing the tasks on time?
◯
●
Evaluate the client and determine the client’s outcome status.
●
Evaluate task performance and identify needs for
2. A. Although the charge nurse can provide all the care this
performance-improvement activities and additional resources.
client requires in the immediate postoperative period,
administrative responsibilities might prevent the close NCLEX® Connection: Management of Care, Assignment, Delegation
monitoring and assessment this client needs. and Supervision
B. CORRECT: A client who is postoperative following thoracic
surgery requires professional nursing knowledge, skills, and
judgment of an RN to provide safe and effective client care.
C. A client who is postoperative following thoracic surgery
requires professional nursing knowledge, skills, and
judgment that is outside the range of function of a PN.
D. A client who is postoperative following thoracic surgery
requires professional nursing knowledge, skills, and
judgment that is outside the range of function of an AP.
3. A. The AP does not need to know the status of the client’s

roommate to complete this assignment.
B. CORRECT: To complete this assignment safely, the AP
should make sure the client wears stockings and slippers.
C. CORRECT: To complete this assignment safely, the AP
should make sure the client uses a front-wheeled walker.
D. CORRECT: To complete this assignment safely,
the AP should know that the client should be
feeling the effects of the pain medication.
E. The AP does not need to know the client’s allergy
status to complete this assignment.
F. The AP does not need to know the client’s food
intake to complete this assignment.
NCLEX® Connection: Management of Care, Continuity of Care
4. A. Creating a plan of care requires professional

nursing knowledge, skills, and judgment that is
outside the scope of care of a PN.
B. Assessing a pressure injury requires professional
nursing knowledge, skills, and judgment that
is outside the scope of care of a PN.
C. CORRECT: Providing nasopharyngeal suctioning
is within the scope of practice of the PN.
D. Teaching requires professional nursing knowledge, skills,
and judgment that is outside the scope of care of a PN.
Concepts of Management
5. A. The right route is one of the rights of medication

administration, not delegation.
B. CORRECT: The right supervision and evaluation
is one of the five rights of delegation. They also
include the right task and the right person.
C. CORRECT: Right direction and communication
is one of the five rights of delegation. They also
include the right task and the right person.
D. The right documentation is one of the rights of
medication administration, not delegation.
E. CORRECT: The right circumstances is one of
the five rights of delegation. They also include
the right task and the right person.
30 CHAPTER 6 DELEGATION AND SUPERVISION CONTENT MASTERY SERIES

CHAPTER 7
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT ASSESSMENT/DATA COLLECTION
● Assessment/data collection involves the systematic
Nursing Process collection of information about clients’ present health

CHAPTER 7 statuses to identify needs and additional data to collect
based on ndings. Nurses can collect data during an
initial assessment (baseline data), focused assessment,
The nursing process is a cyclical, critical thinking and ongoing assessments.
Methods of data collection include observation,
process that consists of five steps to follow in
●
interviews with clients and families, medical history,

a purposeful, goal-directed, systematic way to comprehensive or focused physical examination,
diagnostic and laboratory reports, and collaboration
achieve optimal client outcomes. It is a variation with other members of the health care team.
of scientific reasoning that helps nurses organize ● To collect data effecti ely, nurses must as clients
appropriate questions, listen carefully to responses, and
nursing care and apply the optimal available have excellent head-to-toe physical assessment skills.
evidence to care delivery. Nurses also must employ clinical judgment and critical
thinking in accurately recognizing when to collect
The nursing process is a dynamic, continuous, assessment data. They also must recognize the need to
collect assessment data prior to interventions.
client-centered, problem-solving, and ● Nurses collect subjective data (manifestations) during
decision-making framework that is foundational a nursing history. They include clients’ feelings,
perceptions, and descriptions of health status. Clients
to nursing practice. are the only ones who can describe and verify their
own manifestations.
The nursing process provides a framework ● Nurses obser e and measure ob ecti e data ndings
throughout which nurses can apply knowledge, during a physical examination. They feel, see, hear, and
smell objective data through observation or physical
experience, judgment, and skills, as well as assessment of the client. (7.2)
established standards of nursing practice to ● During this assessment/data collection, the nurse
validates, interprets, and clusters data.
the formulation of a plan of nursing care. This ● Documentation of the assessment data must be
plan is applicable to any client system, including thorough, concise, and accurate.
individuals, families, groups, and communities.
The nursing process helps nurses integrate

critical thinking creatively to base nursing
judgments on reason.
The nursing process promotes the

professionalism of nursing while differentiating 7.2 Sources of data for collection
the practice of nursing from the practice and assessment
of medicine and that of other health Primary sources
care professionals. SUBJECTIVE: What the client tells the nurse
“My shoulder is really, really sore.”
OBJECTIVE: Data the nurse obtains through
observation and examination:
7.1 Nursing process framework Client grimaces when attempting to brush
their hair with their left arm.
The nursing process The accuracy and
includes sequential but
overlapping steps:
thoroughness of
assessment/analysis/data Secondary sources
●
Assessment/data collection and planning SUBJECTIVE
collection* have a direct effect on ●
What others tell the nurse
implementation and
●
Analysis/data collection* What the client has told them:
evaluation. Use of the ●
●
Planning nursing process results in a “They told me that their shoulder is sore every morning.”
●
Implementation comprehensive,
individualized, OBJECTIVE: Data the nurse collects from other
●
Evaluation
client-centered plan of sources (family, friends, caregivers, health care
*PNs combine the assessment professionals, literature review, medical records):
and analysis steps into a single nursing care that nurses can
data collection step. deliver in a timely and Physical therapy note in chart indicates client has
reasonable manner. decreased range of motion of left shoulder.
FUNDAMENTALS FOR NURSING CHAPTER 7 NURSING PROCESS 31

ANALYSIS/DATA COLLECTION ● Nurses do ongoing planning throughout the provision of
care. While obtaining new information and evaluating
● Nurses use critical thinking skills (a diagnostic
responses to care, they modify and individualize the
reasoning process) to identify clients’ health statuses or
initial plan of care.
problem(s), interpret or monitor the collected database, ● Discharge planning is a process of anticipating
reach an appropriate nursing judgment about health
and planning for clients’ needs after discharge.
status and coping mechanisms, and provide direction
To be effecti e, discharge planning must begin
for nursing care.
during admission.
● Analysis/data collection requires nurses to look at ● Throughout the planning process, nurses set priorities,
the data and
determine client outcomes, and select speci c
◯ Recognize patterns or trends.
nursing interventions.
◯ Compare the data with expected standards or ● Nurses participate in priority setting when they identify
reference ranges.
a preferential order of problems. This guides the
◯ Arrive at conclusions to guide nursing care.
delivery of nursing care. They can use guidelines to set

● RNs make multiple analyses based on their
priorities (Maslow’s hierarchy of basic needs). (7.3)
interpretations of collected data. They decide, using ● Nurses work with clients to identify goals and outcomes.
reasoning and judgment, which data account for clients’ ◯ Goals identify optimal status, whereas outcomes
health status or problems. At times, this requires

identify the observable criterion that will determine
further data collection and analysis. As nurses again
success or failure of the goal.
cluster the collected data, a speci c nding might ser e ◯ Often these terms are interchangeable. With any
as an alert to a speci c problem that re uires planning
format, the goal/outcome must be client-centered,
and intervention.
singular, observable, measurable, time-limited,
● As with the assessment/data collection step, complete
mutually agreeable, and reasonable.
and accurate documentation is essential. Documentation ◯ Concise, measurable goals help nurses and clients
should focus on facts and should be highly descriptive.
evaluate progress:
◯ Nurses use short- and long-term goals to guide the
client toward the planned outcome and determine the

PLANNING effecti eness of nursing care.
● When planning client care (RN) or contributing to ● Nurses identify actions and interventions that help
a client’s plan of care (PN), nurses must establish achie e optimal outcomes. cienti c principles pro ide
priorities and optimal outcomes of care they can readily the rationale for nursing interventions.
measure and evaluate. These established priorities and ◯ Nurse-initiated/independent interventions:
outcomes of client care then direct nurses in selecting Nurses use e idence and scienti c rationale to ta e
interventions to include in a plan of care to promote, autonomous actions to bene t clients. They base
maintain, or restore health. these actions on identi ed problems and health care
● Nurses do three types of planning. Initially, they needs, and make sure they are within their scope of
develop a comprehensive plan of care for clients based practice. Nurses perform or delegate the interventions
on comprehensive assessments they complete, for and are accountable for them. An example is
example, on admission to a health care facility or to a repositioning a client at least every 2 hr to prevent
home health organization. skin breakdown.
◯ Provider-initiated/dependent interventions:
Interventions nurses initiate as a result of a provider’s
7.3 Maslow’s hierarchy of basic needs prescription (written, standing, or verbal) or the
facility’s protocol (blood administration procedures).
◯ Collaborative interventions: Interventions nurses
carry out in collaboration with other health care team
professionals (ensuring that a client receives and eats
their evening snack).
● The nursing care plan (NCP) is the end product of the
planning step. Nurses organize the NCP for quick
identi cation of problems, outcomes, and inter entions
to implement.
32 CHAPTER 7 NURSING PROCESS CONTENT MASTERY SERIES

IMPLEMENTATION EVALUATION
● In this step of the nursing process, nurses base the care ● In this step of the nursing process, nurses evaluate
they provide on assessment data, analyses, and the plan clients’ responses to nursing interventions and form a
of care they developed in the previous steps of the nursing clinical judgment about the extent to which clients have
process. In this step, they must use problem-solving, met the goals and outcomes.
clinical judgment, and critical thinking to select and ● Nurses continuously evaluate clients’ progress toward
implement appropriate therapeutic interventions using outcomes, and use clients’ data to determine whether or
nursing knowledge, priorities of care, and planned not to modify the plan of care.
goals or outcomes to promote, maintain, or restore ● Nurses determine the effecti eness of the nursing care
health. Nurses also use interpersonal skills (therapeutic plan. They collect data based on the outcome criteria then
communication) and technical skills (psychomotor compare what actually happened with the planned outcomes.
performance) when implementing nursing interventions. This helps determine what further actions to take.
● Therapeutic interventions also include measures nurses ● Clients outcomes in speci c, measurable terms are
take to minimize risk (wearing personal protective easier to evaluate.
equipment). Nurses intervene to respond to unplanned
QUESTIONS TO CONSIDER
events (an observation of unsafe practice, a change in ● “Did the client meet the planned outcomes?”
status, or the emergence of a life-threatening situation). ● ere the nursing inter entions appropriate and effecti e
● Nurses use evidence-based rationale for the selection and ● “Should I modify the outcomes or interventions?”
implementation of all therapeutic interventions.

Additionally, caring and professional behavior should be at FACTORS THAT CAN LEAD TO LACK OF
the center of all therapeutic nursing interventions. GOAL ACHIEVEMENT
● During implementation, nurses perform nursing actions, ● An incomplete database
delegate tas s, super ise other health care staff, and ● Unrealistic client outcomes
document the care and clients’ responses. ● Nonspeci c nursing inter entions
● Inadequate time for the client to achieve the outcomes

1. By the second postoperative day, a client has not 4. A charge nurse is talking with a newly licensed
achieved satisfactory pain relief. Based on this nurse and is reviewing nursing interventions
evaluation, which of the following actions should the that do not require a provider’s prescription.
nurse take, according to the nursing process? Which of the following interventions should the
A. Reassess the client to determine the charge nurse include? (Select all that apply.)
reasons for inadequate pain relief. A. Writing a prescription for morphine
B. Wait to see whether the pain lessens sulfate as needed for pain
during the next 24 hr. B. Inserting a nasogastric (NG) tube
C. Change the plan of care to provide to relieve gastric distention
different pain relief interventions. C. Showing a client how to use
D. Teach the client about the plan of progressive muscle relaxation
care for managing the pain. D. Performing a daily bath after the evening meal
E. Repositioning a client every 2 hr to
2. A charge nurse is observing a newly licensed nurse care reduce pressure injury risk
for a client who reports pain. The nurse checked the
client’s MAR and noted the last dose of pain medication 5. A nurse is discussing the nursing process with
was 6 hr ago. The prescription reads every 4 hr PRN a newly licensed nurse. Which of the following
for pain. The nurse administered the medication and statements by the newly licensed nurse
checked with the client 40 min later, when the client should the nurse identify as appropriate for
reported improvement. The newly licensed nurse left the planning step of the nursing process?
out which of the following steps of the nursing process? A. “I will determine the most important client
A. Assessment problems that we should address.”
B. Planning B. “I will review the past medical history on the
C. Intervention client’s record to get more information.”
D. Evaluation C. “I will carry out the new prescriptions
from the provider.”
3. A charge nurse is reviewing the steps of the D. “I will ask the client if their nausea has resolved.”
nursing process with a group of nurses. Which
of the following data should the charge nurse
identify as objective data? (Select all that apply.)
A. Respiratory rate is 22/min with
even, unlabored respirations.
B. The client’s partner states, “They said they
hurt after walking about 10 minutes.”
C. The client’s pain rating is 3 on a scale of 0 to 10.
D. The client’s skin is pink, warm, and dry.
E. The assistive personnel reports that
the client walked with a limp.

A nurse educator is reviewing with a group of nursing
students the actions and thought processes nurses use
during the steps of the nursing process. Use the ATI Active
●
List at three actions to take during the
analysis or data collection step.
●
List four factors to consider during the evaluation
step when clients have not achieved their goals.

1. A. CORRECT: Collect further data from the client to Using the ATI Active Learning Template: Basic Concept
determine why they have not achieved satisfactory NURSING INTERVENTIONS
pain relief, because various factors might be interfering
with their comfort. The nursing process repeats in an Analysis/data collection
ongoing manner across the span of client care. ●
Recognize patterns or trends.
B. Do not wait longer to see how the client would ●
Compare the data with expected standards or reference ranges.
respond, but take action to determine why the ●
Arrive at conclusions to guide nursing care.
client is not achieving satisfactory pain relief.
C. Do not make random changes to the plan of care Factors to consider during evaluation for unmet goals
without gathering evidence to guide the nurse in
●
An incomplete database
knowing what new interventions might help. ●
Unrealistic client outcomes
D. The action does not acknowledge the client’s ●
Nonspecific nursing interventions
condition or that the current plan is ineffective. ●
Inadequate time for the client to achieve the outcomes
NCLEX® Connection: Reduction of Risk Potential, NCLEX® Connection: Health Promotion and Maintenance,
System Specific Assessments Techniques of Physical Assessment
2. A. CORRECT: The newly licensed nurse should have used

the assessment step of the nursing process by asking the
client to evaluate the severity of pain on a 0 to 10 scale.
The nurse also should have asked about the characteristics
of the pain and assessed for any changes that might
have contributed to worsening of the pain.
B. The newly licensed nurse used the planning step
of the nursing process when deciding that it was
the right time to administer the medication.
C. The newly licensed nurse used the implementation step of
the nursing process when administering the medication.
D. The newly licensed nurse used the evaluation step of
the nursing process when checking the effectiveness of
the pain medication in relieving the client’s pain.
Techniques of Physical Assessment
3. A. CORRECT: Objective data includes information

the nurse measures (vital signs).
B. Subjective data includes a client’s reported manifestations,
even if a secondary source gave the nurse the information.
C. Subjective data includes a client’s reported manifestations.
D. CORRECT: Objective data includes information
the nurse observes (skin appearance).
E. CORRECT: Objective data includes information from
the observations of others (family and staff).
4. A. Have a prescription from the provider to administer

a medication. After obtaining the prescription,
the nurse has the flexibility to determine when
to administer a PRN medication.
B. Have a prescription from the provider for the insertion of
an NG tube. This is a provider-initiated intervention.
C. CORRECT: Showing a client how to use progressive
muscle relaxation is an appropriate nurse-initiated
intervention for stress relief. Unless there is a
contraindication for a specific client, use this technique
with clients without a provider’s prescription.
D. CORRECT: Performing a bath is a routine nursing
care procedure. Unless there is a contraindication for
a specific client, determine when bathing is optimal
for a client without a provider’s prescription.
E. CORRECT: Repositioning a client every 2 hr is an
appropriate nurse-initiated intervention for clients.
Unless there is a contraindication for a specific client,
use this strategy without a provider’s prescription.
5. A. CORRECT: Prioritize the client’s problems during

the planning step of the nursing process.
B. Review the client’s history during the assessment/
data collection step of the nursing process.
C. Implement nurse- and provider-initiated actions during
the intervention step of the nursing process.
D. Gather information about whether the client’s
problems have been resolved during the
evaluation step of the nursing process.

CHAPTER 8
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT CRITICAL THINKING
● Critical thinking requires lifelong learning and the
Critical Thinking and ability to acquire relevant experiences that can be

CHAPTER 8 re ected on continuously to impro e nursing udgment.
Clinical Judgment ● The components of critical thinking include knowledge,

experience, critical thinking competencies, attitudes,
and intellectual and professional standards.
● Critical thinking is facilitated by seeking truth in an
Nursing practice requires the application of open-minded manner and being inquisitive about why
something is effecti e or ineffecti e.
knowledge from biological, social, and physical ● Critical thinking follows a systematic process or
sciences; knowledge of pathophysiology; pattern, not jumping to conclusions but using reason to
guide decisions.
and knowledge of nursing procedures and ● Nurses make inferences when making clinical decisions
skills. Nurses also must use multiple thinking by pulling pieces of information together to determine a
relationship between the data.
skills—including critical thinking skills ● Critical thin ing incorporates re ection, language, and
(interpretation, analysis, evaluation, inference, intuition, and it evolves through three distinct levels as
a nurse gains knowledge and experience while maturing
and explanation)—to make clinical judgments into a competent nursing professional.
about problems in nursing practice. These ● e ection
Purposefully thinking back or recalling a situation to
judgments lead the nurse to choosing actions discover its meaning and gain insight into the event. A
or interventions through a process called clinical nurse should re ect on the follo ing
● “Why did I say that or do this?”
reasoning. A nursing knowledge base with ● “Did the original plan of care achieve optimal client
foundational thinking skills, including recall outcomes?”

◯ If so: “Which interventions were successful?”
and comprehension, is a prerequisite to critical ◯ If not: “Which interventions were unsuccessful?”
thinking in nursing.
Language
In nursing, critical thinking is an active, orderly, Precise, clear language demonstrating focused thinking
well-thought-out reasoning process that guides and communicating unambiguous messages and
expectations to clients and other health care team
a nurse in various approaches to making a members. A nurse should ask the following:
nursing judgment by applying knowledge and ● “Did I use language appropriate for the client?”
● “Did I communicate the message clearly to the provider?”
experience, problem-solving, logic, reasoning,

and decision-making. A critical thinker prioritizes, Intuition
explores various courses of action, keeps ethics An inner sensing that facts do not currently support
something. Intuition should spark the nurse to search the
in mind, and determines appropriate outcomes. data to con rm or dispro e the feeling. The nurse should
ask the following:
To have a positive effect on a client’s health ● Did the ital signs re ect any changes that account for
status, a nurse must be able to think critically, the client’s present status?”
● “When the client’s status changed in this way last
correctly identify problems, and both devise and month, there as a speci c reason for it. Is that hat is
implement the best solutions (interventions). happening here?”
Critical thinking discourages quick judgments

that lead to single-focused solutions.
FUNDAMENTALS FOR NURSING CHAPTER 8 CRITICAL THINKING AND CLINICAL JUDGMENT 37

LEVELS OF CRITICAL THINKING Commitment
The nurse expects to make choices without help
Basic critical thinking
●
from others and fully assumes the responsibility for

● A nurse trusts the experts and thinks concretely based those choices.
on the rules. ● Commitment results from an expert level of knowledge,
● Basic critical thinking results from limited nursing e perience, de eloped intuition, and re ecti e,
knowledge and experience, as well as inadequate critical e ible attitudes.
thinking experience.
Example: A nurse increases the rate of an IV
Example: A client reports pain 1 hr after receiving a fluid infusion when a client’s blood pressure
pain medication. Instead of reassessing the client’s indicates hypovolemic shock 24 hr after surgery.
pain, the nurse tells the client he must wait two
more hours before he can receive another dose.
COMPONENTS OF CRITICAL THINKING
Complex critical thinking
Knowledge
● The nurse begins to express autonomy by analyzing and
examining data to determine the best alternative. Information that s speci c to nursing and comes from
● Complex critical thinking results from an increase in ● Basic nursing education
nursing knowledge, experience, intuition, and more ● Use of evidence-based practice
e ible attitudes. ● Continuing education courses
● Ad anced degrees and certi cations
Example: A nurse realizes that a client is not
ambulating as often as prescribed because of a
Experience
fear of missing her daughter’s phone call. The nurse
assures the client that the staff will listen for and Decision-making ability derived from opportunities to
answer her phone when she is out of her room. observe, sense, and interact with clients followed by active
re ection. A nurse
● Demonstrates an understanding of clinical situations.
● Recognizes and analyzes cues for relevance.
● Incorporates experience into intuition.
8.1 Critical thinking and the nursing process
Assessment/Data collection CRITICAL THINKING SKILLS Implementation

●
Identify clusters and cues.
Collect information about a client’s Provide care based on assessment
present health status to identify
●
Detect inferences. data, analyses, and the plan of care.
needs, and to identify additional ●
Recognize an actual or
data to collect based on findings. potential problem or risk. CRITICAL THINKING SKILLS
●
Avoid making judgments. ●
Use knowledge base.
CRITICAL THINKING SKILLS
Use appropriate skills and
Planning
●
●
Observe. teaching strategies.
●
Use correct techniques Test theories.
Establish priorities and optimal outcomes ●
for collecting data. of care to measure and evaluate. ●

Delegate and supervise nursing care.
●
Differentiate between relevant Then, select the nursing interventions ●
Communicate appropriately
and irrelevant data, and between to include in a client’s plan of care to in response to a situation.
important and unimportant data. promote, maintain, or restore health.
●
Organize, categorize, and validate data.
CRITICAL THINKING SKILLS Evaluation
●
Interpret assessment data
and draw a conclusion.
●
Identify goals and outcomes Examine a client’s response to nursing
for client care. interventions and form a clinical judgment
Analysis/Data collection ●
Set priorities. about meeting goals and outcomes.
Interpret or monitor the collected

●
Determine appropriate strategies CRITICAL THINKING SKILLS
database, reach an appropriate nursing and interventions for inclusion on a ●
Determine accuracy of theories.
judgment about a client’s health status client’s plan of care or teaching plan. ●
Evaluate outcomes based
and coping mechanisms, and provide ●
Take knowledge and apply it to on specific criteria.
direction for nursing care. While analysis more than one situation. ●
Determine understanding of teaching.
helps the nurse establish diagnoses ●
Create outcome criteria.
for the client, it occurs in an ongoing ●
Theorize.
manner throughout the nursing process. ●
Consider the consequences
of implementation.
38 CHAPTER 8 CRITICAL THINKING AND CLINICAL JUDGMENT CONTENT MASTERY SERIES

Online Video: Priority Setting
Competence Application Exercises

Cognitive processes a nurse uses to make nursing judgments.
General critical thinking

1. A nurse is caring for a client who is 24 hr postoperative
following an inguinal hernia repair. The client is
● cienti c method tolerating clear liquids well, has active bowel sounds,
● Problem-solving and is expressing a desire for “real food.” The nurse
● Decision-making tells the client, “I will call the surgeon and ask for a
● Diagnostic reasoning and inference change in diet.” The surgeon hears the nurse’s report
● Clinical decision-making; collaboration and prescribes a full liquid diet. The nurse used
which of the following levels of critical thinking?
Specific critical thinking in nursing: The nursing
A. Basic
process (8.1)
B. Commitment
Attitudes C. Complex
D. Integrity
indsets that affect ho a nurse approaches a problem.
Attitudes of critical thinkers include:
● Confidence: Feels sure of abilities. 2. A nurse receives a prescription for an antibiotic
● Independence: Analyzes ideas for logical reasoning. for a client who has cellulitis. The nurse checks
the client’s medical record, discovers that the
● Fairness: Is objective, nonjudgmental.
client is allergic to the antibiotic, and calls the
● Responsibility: Adheres to standards of practice.
provider to request a prescription for a different
● Risk-taking: Ta es calculated chances in nding antibiotic. Which of the following critical thinking
better solutions to problems. attitudes did the nurse demonstrate?
● Discipline: Develops a systematic approach to thinking. A. Fairness
● Perseverance: Continues to work at a problem until
B. Responsibility
there’s a resolution.
C. Risk-taking
● Creativity: ses imagination to nd solutions to
D. Creativity
unique client problems.
● Curiosity: Requires more information about clients
and problems. 3. A newly licensed nurse is considering strategies
● Integrity: Practices truthfully and ethically. to improve critical thinking. Which of the following
● Humility: Acknowledges weaknesses. actions should the nurse take? (Select all that apply.)
A. Find a mentor.
Standards B. Use a journal to write about the
outcomes of clinical judgments.
Model for comparing care to determine acceptability, C. Review articles about evidence-based practice.
excellence, and appropriateness.
D. Limit consultations with other professionals
● Intellectual standards ensure the thorough application involved in a client’s care.
of critical thinking.
E. Make quick decisions when unsure
● Professional standards about a client’s needs.
◯ Nursing judgment based on ethical criteria
◯ Evaluation that relies on evidence-based practice
◯ Demonstration of professional responsibility

4. A nurse is caring for a client who has a new prescription
for antihypertensive medication. Prior to administering
◯ Promotes maximal level of nursing care
the medication, the nurse uses an electronic database
● The nurse can improve their critical thinking and to gather information about the medication and
clinical reasoning ability through tactics (concept the effects it might have on this client. Which of the
mapping and re ecti e ournaling hich allo the following components of critical thinking is the nurse
nurse to recognize connections and patterns among using when he reviews the medication information?
data and outcomes. A. Knowledge
● entoring and peer relationships can positi ely in uence B. Experience
the nurse’s critical thinking ability, as nurses discuss client C. Intuition
care and learn from each other’s experiences.
D. Competence
Active Learning Scenario 5. A nurse uses a head-to-toe approach to conduct

a physical assessment of a client who will undergo
A nurse is reviewing with a group of newly licensed nurses surgery the following week. Which of the following
the critical thinking skills that nurses use during each critical thinking attitudes did the nurse demonstrate?
of the steps of the nursing process. Use the ATI Active A. Confidence
B. Perseverance
NURSING INTERVENTIONS: List at three critical thinking C. Integrity
skills for each of the five steps of the nursing process. D. Discipline
FUNDAMENTALS FOR NURSING CHAPTER 8 CRITICAL THINKING AND CLINICAL JUDGMENT 39

1. A. CORRECT: At the basic level, thinking is concrete 3. A. CORRECT: Learning from the experience of
and based on a set of rules (obtaining the peers can improve critical thinking.
prescription for diet progression). B. CORRECT: Journaling about decision-making can assist the
B. At the commitment level, the nurse expects to nurse with self-reflections and improve critical thinking.
have to make choices without help from others and C. CORRECT: Improving knowledge by learning
fully assumes the responsibility for those choices. new information about evidence-based practice
However, postoperative protocols generally involve improves the nurse’s ability to think critically.
obtaining a prescription for diet progression. D. Although nurses who have advanced critical
C. Advanced experience and knowledge at the complex thinking can do so independently, the nurse should
level will prompt the nurse to request diet progression to talk to other professionals to share information
full liquids based on active bowel sounds and the client’s and remain open-minded and inquisitive.
tolerance of clear liquid, not solely on the client’s request. E. Quick decision-making can lead to errors. A nurse’s
D. Integrity is a critical thinking attitude that comes into play intuition might cause feelings of uncertainty, which should
when the nurse’s opinion differs from that of the client. The lead the nurse to ask questions about whether the plan
nurse must then review their own position and decide how to of care makes sense and to gather more information.
proceed to help achieve outcomes satisfactory to all parties. NCLEX® Connection: Pharmacological and Parenteral Therapies,
NCLEX® Connection: Management of Care, Advocacy Pharmacological Pain Management
2. A. Fairness is using a nonjudgmental, objective 4. A. CORRECT: By using the electronic database, the nurse
approach in looking at clients and situations. takes the initiative to increase their knowledge base,
This attitude does not apply here. which is the first component of critical thinking.
B. CORRECT: The nurse is responsible for administering B. The nurse has had no prior experience with
medications in a safe manner and according to administering this medication to this client.
standards of practice. Checking the medical C. Intuition requires experience, which the nurse lacks
record for allergies helps ensure safety. in administering this medication to this client.
C. Risk-taking is a calculated approach to solving D. Competence involves making judgments, but no one
a problem that is not responding to traditional can make a judgment about how the nurse handles
methods. This attitude does not apply here. researching and administering this medication to
D. Creativity is an approach that uses imagination to find this client until they perform those tasks.
solutions to unique client problems. This problem is not NCLEX® Connection: Pharmacological and Parenteral Therapies,
unique, and it requires a straightforward solution. Medication Administration
5. A. Confidence is feeling sure of one’s own abilities.
The nurse might feel confident of their physical
assessment skills, but choosing a particular method
or sequence requires another attitude.
B. Perseverance is continuing to work at a problem until the
nurse resolves it. This attitude does not apply here.
C. Integrity is a practicing truthfully and ethically.
This specific attitude does not apply here.
D. CORRECT: Discipline includes using a systematic
approach to thinking. Using a head-to-toe approach
ensures the nurse is thorough and calculated in getting
information about the client’s physical status.

Using the ATI Active Learning Template: Basic Concept
●
Assessment/Data collection ●
Implementation
Observe.
◯ ◯
Use knowledge base.
Use correct techniques for collecting data.
◯ ◯
Use appropriate skills and teaching strategies.
Differentiate between relevant and irrelevant data and
◯ ◯
Test theories.
between important and unimportant data. ◯
Delegate and supervise nursing care.
Organize, categorize, and validate data.
◯ ◯
Communicate appropriately in response to a situation.
Interpret assessment data and draw a conclusion.
◯ ●
Evaluation
●
Analysis/Data Collection ◯
Determine accuracy of theories.
Identify clusters and cues.
◯ ◯
Evaluate outcomes based on specific criteria.
Detect inferences.
◯ ◯
Determine understanding of teaching.
Recognize an actual or potential problem or risk.
◯
NCLEX® Connection: Management of Care, Legal Rights and

Avoid making judgments.
◯
Responsibilities
●
Planning
Identify goals and outcomes for client care.
◯
Set priorities.
◯
Determine appropriate strategies and interventions

◯
for inclusion on a plan of care or teaching plan.

Take knowledge and apply it to more than one situation.
◯
Create outcome criteria.

◯
Theorize.
◯
Consider the consequences of implementation.

◯
40 CHAPTER 8 CRITICAL THINKING AND CLINICAL JUDGMENT CONTENT MASTERY SERIES

CHAPTER 9
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
Admission process
CHAPTER 9 Admissions, EQUIPMENT
Transfers, and Prior to arrival of the client, bring necessary equipment
Discharge into the room. This should include appropriate

documentation forms, equipment to measure vital signs, a
pulse oximeter, and hospital attire for the client.
Responsibilities of nurses include ensuring

continuity of care and information sharing PROCEDURE
Introduce yourself and identify your role.
throughout the processes of admission,
●
● plain the roles of other care deli ery staff.

transfers, and discharge. The admission ● If in a semiprivate room, introduce the client to
their roommate.
assessment provides baseline data to use in ● Provide hospital attire and assist as necessary.
the development of the nursing care plan. ● Position the client comfortably.
Apply the identi cation bracelet and allergy band,
Comparisons with future assessments help
●
if needed.
monitor client status and response to treatment. ● Pro ide facility speci c brochures and
informational material.
Many clients experience anxiety, fear of the ● Provide information about advance directives.
Document the client’s advance directives status in the
unknown, and loss of independence and
●
medical record. Place a copy in the medical record if it

self-identity at the time of admission to the is available.
hospital or health care facility. Children can

experience separation anxiety if guardians are ASSESS/COLLECT DATA
Baseline data: Vital signs, height, weight, allergy status
not present during the hospitalization. When
Biographical information
nurses recognize clients’ concerns and provide
Client’s reason for seeking health care
respectful, culturally-sensitive care, the clients’
Present illness and findings
experiences will be more positive.
Health history
● Current illness
NURSING CONSIDERATIONS ● Current medications (prescription, over-the-counter
[including dietary or herbal supplements])
● Discharge planning is an interprofessional process that ● Prior illnesses, chronic diseases
starts at admission. Nurses conduct discharge planning ● Surgeries
with clients and families for optimal results. ● Previous hospitalizations
● Nurses establish the ability of clients to participate in ● Other relevant data
the admission assessment. Clients in distress or who
have mental status changes might need to have a family Family history (hypertension, cancer, heart disease,
member provide necessary information. diabetes mellitus)
● Nurses begin establishing the therapeutic relationship
Psychosocial assessment
with clients and families during the admission process. ● Alcohol, tobacco, recreational drugs, caffeine use
● Nurses promote professional communication ● History of mental illness
between providers. ● History of abuse or homelessness
● Nurses use the nursing process as a guide to plan ● Home situation signi cant others
teaching and interventions for clients during discharge.
● Nurses use standard hand off communication tools Nutrition
(Introduction, Situation, Background, Assessment, ● Current diet, any chewing or swallowing problems
Recommendation [ISBAR]) to facilitate transfers ● Recent weight gain/loss
and discharges. ● Use of nutritional or herbal supplements
● Dentures
Spiritual health/quality-of-life concerns

● Religion
● Advance directives, living will
FUNDAMENTALS FOR NURSING CHAPTER 9 ADMISSIONS, TRANSFERS, AND DISCHARGE 41

Online Video: Discharge Teaching
Review of systems
Transfer and
discharge process
● Collect subjective data about each body system (changes,
altered function).
● Collect objective data with a head-to-toe
physical examination.
Safety assessments
INDICATIONS FOR TRANSFER
● History of falls
AND DISCHARGE
● ensory de cits ision, hearing ● The level of care changed (health status improved so a
● Use of assistive devices (walker, cane, crutches, client no longer needs intensive care).
wheelchair) ● Another setting is required to provide necessary care
(transfer from medical unit to surgical suite).
Discharge information ● The facility does not offer the type of care a client no
● Family members in the home
requires (after the acute phase of a stroke, the client
● Transportation for discharge
requires care in a skilled facility).
● Relevant phone numbers ● The client no longer needs inpatient care and is ready to
● Medical equipment needs at home
return home.
● Home health care needs at home
● Stairs in the home
DISCHARGE PLANNING
INVENTORY PERSONAL ITEMS This should begin on admission for every client.
● Assess whether the client will be able to return to their
Examples are clothing, jewelry, money, credit cards,

previous residence.
assistive devices (eyeglasses, contacts, hearing aids, cane, ● Determine whether the client needs or has someone to
dentures), medications, cell phones and other technology
assist them at home.
devices, and religious articles. ● Assess the residence to see if the client needs
● Discourage keeping valuables at the bedside.
adaptations or speci c e uipment.
● Document communication with client related to items ● Make a referral to the social worker to arrange for
left within the room, and valuables locked in the
community services.
facility’s safe. ● Communicate health status and needs to community
service providers.
ORIENTATION ● The provider documents that the client can be discharged.
However, a client who is legally competent has the right
Orient the client and family to the room and the facility.
to lea e the facility at any time. The nurse noti es the
Share information, including the following.
client’s provider, has the client sign the proper forms if
● Call light operation
possible, and provides discharge teaching.
● Electric bed operation ● Involve the client and family as much as possible in the
● Telephone services/television controls
discharge planning.
● Overhead lighting operation
● Smoking policy
Restroom locations
DISCHARGE EDUCATION
●
● Waiting areas
● Meal times The nurse discusses the discharge instructions with the
● Usual time for providers’ visits client and provides a printed copy.
● Dining/vending services ● Instructions should use clear, concise language that the
● Visiting policies client will understand.
● The nurse should verify understanding of the
instructions by the client.
Standards for discharge education

● Identify safety concerns at home.
● Review manifestations of potential complications and
when to contact emergency care or the provider.
● Provide the phone number of the provider.
● Provide names and phone numbers of community
resources that give care at the client’s residence.
● Provide step-by-step instructions for performing
continuing treatments (dressing changes).
● Enforce dietary restrictions and guidelines, including
those that pertain to medication administration.
● Enforce the amount and frequency of therapies to
perform to support continued independence at home.
● Provide directions regarding how to take medications,
potential interactions, and why adherence is important.
42 CHAPTER 9 ADMISSIONS, TRANSFERS, AND DISCHARGE CONTENT MASTERY SERIES

EQUIPMENT TRANSFER DOCUMENTATION
Items to transfer/discharge with the client ● Medical diagnosis and care providers
● Personal belongings at the bedside and from dresser ● Demographic information
dra ers and closet o ers, boo s, clothing, personal ● Overview of health status, plan of care, recent progress
care items) ● Alterations that can precipitate an immediate concern
● Valuables from the safe (if leaving the facility) ● Noti cation of assessments or care essential ithin the
● Medications (especially that belong to the client or that next few hours
cannot be returned to the pharmacy for credit) ● Most recent vital signs and medications, including PRN
● Assistive devices ● Allergies
● Medical records or a transfer form ● Diet and activity orders
● peci c e uipment or adapti e de ices o ygen,
suction, wheelchair)
PROCEDURE ● Advance directives and emergency code status
● Family involvement in care and health care proxy,
if applicable
RESPONSIBILITIES OF THE NURSE
Transferring/discharging a client
● n the day and time of transfer, con rm that the
DISCHARGE DOCUMENTATION
receiving facility or unit is expecting the client, and ● Type of discharge (provider prescription or against
that the room or bed is available. medical advice [AMA])
● Communicate the time the client will transfer to the ● Date and time of discharge, who went with the
receiving facility or unit. client, and transportation (wheelchair to car, gurney
● Complete documentation (medical records, to ambulance)
transfer form). ● Where the client went (home, long-term care facility)
● Give a verbal transfer report in person or via telephone. ● Summary of the client’s condition at discharge (steady
● Con rm the mode of transportation the client gait, ambulating independently, in no apparent distress)
will use to complete the transfer or discharge (car, ● Description of any unresol ed difficulties and
wheelchair, ambulance). procedures for follow-up
● Make sure the client is dressed appropriately if going ● Disposition of valuables, medications brought from
outside the facility. home, and prescriptions
● Account for all the client’s valuables.
Receiving a transferred client DISCHARGE INSTRUCTIONS

● Have any specialized equipment ready.
Documentation of understanding of instructions by
● If appropriate, inform the client’s roommate of the
the client
impending admission or transfer. ● Written instructions in the client’s language
● Inform other health care team members of the client’s ● Diet at home
arrival and needs. ● Step-by-step instructions for procedures at home
● Meet with the client and family on arrival to complete ● Precautions to take when performing procedures or
the admission process and orient the client and family
administering medications
to the new facility or unit. ● Manifestations of complications to report
● Assess how the client tolerates the transfer.
● Names and numbers of providers and community
● Review transfer documentation.
services to contact
● Implement appropriate nursing interventions in a ● Plans for follow-up care and therapies
timely manner.

1. A nurse is performing an admission assessment for A nurse is reviewing with a group of newly licensed
nurses the essential components of an admission
an older adult client. After gathering the assessment
assessment. Use the ATI Active Learning Template:
data and performing the review of systems, which
Basic Concept to complete this item.
of the following actions is a priority for the nurse?
A. Orient the client to their room. NURSING INTERVENTIONS: List at least three aspects of
B. Conduct a client care conference. the health history the nurse must gather and document,
as well as at least three aspects of the psychosocial
C. Review medical prescriptions.
evaluation the nurse must gather and document.
D. Develop a plan of care.
2. A nurse is admitting a client who has acute

cholecystitis to a medical-surgical unit. Which of
the following actions are essential steps of the
admission procedure? (Select all that apply.)
A. Explain the roles of other care delivery staff.
B. Begin discharge planning.
C. Inform the client that advance directives
are required for hospital admission.
D. Document the client’s wishes
about organ donation.
E. Introduce the client to their roommate.
3. A nurse is caring for a client who had a stroke and is

scheduled for transfer to a rehabilitation center. Which
of the following tasks are the responsibility of the nurse
at the transferring facility? (Select all that apply.)
A. Ensure that the client has possession
of their valuables.
B. Confirm that the rehabilitation center has a
room available at the time of transfer.
C. Assess how the client tolerates the transfer.
D. Give a verbal transfer report via telephone.
E. Complete a transfer form for the receiving facility.
4. A nurse is preparing the discharge summary for

a client who has had knee arthroplasty and is
going home. Which of the following information
about the client should the nurse include in the
discharge summary? (Select all that apply.)
A. Advance directives status
B. Follow-up care
C. Instructions for diet and medications
D. Most recent vital sign data
E. Contact information for the
home health care agency
5. As part of the admission process, a nurse at a

long-term care facility is gathering a nutrition history
for a client who has dementia. Which of the following
components of the nutrition evaluation is the priority
for the nurse to determine from the client’s family?
A. Body mass index
B. Usual times for meals and snacks
C. Favorite foods
D. Any difficulty swallowing

1. A. CORRECT: The greatest risk to this client is injury from 4. A. Advance directives status is important in transfer
unfamiliar surroundings. Therefore, the priority action documentation, when other care providers will
is to orient the client to the room. Before the nurse take over a client’s care. They are not an essential
leaves the room, the client should know how to use the component of a discharge summary for a client
call light and other equipment at the bedside. who is returning to their home.
B. Conduct a client care conference. However, B. CORRECT: It is essential to include the names and
another action is the priority. contact information of providers and community
C. Review prescriptions in the medical record. resources the client will need after they return home.
However, another action is the priority. C. CORRECT: The client will need written information detailing
D. Develop a plan of care. However, home medication and dietary therapy. A client who
another action is the priority. has had knee arthroscopy typically requires analgesics,
NCLEX® Connection: Management of Care, Continuity of Care possibly anticoagulants, and dietary instructions for
avoiding postoperative complications (constipation).
D. Vital sign measurements are important in transfer
2. A. CORRECT: The client’s hospitalization is likely to documentation, when other care providers will take over
be more positive if the client understands who a client’s care. They are not an essential component of a
can perform which care activities. discharge summary for a client who is returning home.
B. CORRECT: Unless the client is entering a long-term care E. CORRECT: It is essential to include the names and
facility, discharge planning should begin on admission. contact information of providers and community
C. The Patient Self-Determination Act does not resources the client will need after returning home. For
require that clients have advance directives prior example, a client who had a knee arthroplasty might
to hospital admission. The act requires asking require physical therapy at home until able to travel
clients if they have advance directives. to a physical therapy department or facility.
D. CORRECT: Upon hospital admission, required NCLEX® Connection: Management of Care, Continuity of Care
request laws direct providers to ask clients older than
18 years if they are organ or tissue donors.
E. CORRECT: Any action that can reduce the stress 5. A. It is important to calculate body mass index to
of hospitalization is therapeutic. Introductions determine the client’s weight status and related
to other clients and staff can encourage risks. However, there is a higher priority.
communication and psychological comfort. B. It is important to know and try to follow the meal schedule the
NCLEX® Connection: Management of Care, Continuity of Care client follows at home. However, there is a higher priority.
C. It is important to know which foods are the client’s favorites
in case it becomes difficult to get the client to consume
3. A. CORRECT: Account for all of the client’s adequate nutrients. However, there is a higher priority.
valuables at the time of transfer. D. CORRECT: The greatest risk to this client related
B. CORRECT: On the day of the transfer, confirm to a nutrition-related evaluation is from difficulty
that the receiving facility is expecting the swallowing, or dysphagia. It puts the client at risk
client and that the room is available. for aspiration, which can be life-threatening.
C. It is the responsibility of the nurse at the receiving NCLEX® Connection: Basic Care and Comfort,
facility to assess the client upon arrival to Nutrition and Oral Hydration
determine how they tolerated the transfer.
D. CORRECT: Provide the nurse at the receiving facility with
a verbal transfer report in person or via telephone.
E. CORRECT: Complete any documentation for the transfer,
including a transfer form and the client’s medical records.

Health history
●
Current illness
●
Current medications (prescription, herbal supplements, and over the counter)
●
Prior illnesses, chronic diseases
●
Surgeries
●
Previous hospitalizations
Psychosocial assessment
●
Alcohol, tobacco, recreational drug, and caffeine use
●
History of mental illness
●
History of abuse or homelessness
●
Home situation/significant others

NCLEX® Connections
Management of Care
LEGAL RIGHTS AND RESPONSIBILITIES: Report
client conditions as required by law.
Physiological Adaptation
PATHOPHYSIOLOGY: Understand general principles of pathophysiology.
Reduction of Risk Potential

POTENTIAL FOR COMPLICATIONS OF DIAGNOSTIC TESTS/
TREATMENTS/PROCEDURES: Intervene to prevent aspiration.

ACCIDENT/ERROR/INJURY PREVENTION
Identify de cits that may impede client safety.
Protect client from injury.
ERGONOMIC PRINCIPLES: Assess client ability to balance,

transfer, and use assistive devices prior to planning care.
HOME SAFETY: Educate client on home safety issues.
SAFE USE OF EQUIPMENT: Teach client about the

safe use of equipment needed for health care.
STANDARD PRECAUTIONS/
TRANSMISSION-BASED PRECAUTIONS/SURGICAL ASEPSIS
Apply principles of infection control.
se appropriate techni ue to set up a sterile eld maintain asepsis.
ESTABLISHING PRIORITIES: Evaluate plan of care for

multiple clients and revise plan of care as needed.
HANDLING HAZARDOUS AND INFECTIOUS MATERIALS: Follow

procedures for handling biohazardous and hazardous materials.

CHAPTER 10
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT ● All health care personnel must perform hand hygiene,
SECTION: SAFETY AND INFECTION CONTROL either with an alcohol-based product or with soap and
water, before and after every client contact, and after
CHAPTER 10 Medical and removing gloves. When hands are visibly soiled, after
Surgical Asepsis
contact ith body uids, before eating, and after using
the restroom, wash them with a nonantimicrobial or
antimicrobial soap and water. It is also important for
clients and visitors to practice hand hygiene.
Perform hand hygiene using recommended
Asepsis is the absence of illness-producing
●
antiseptic solutions when caring for clients who

micro-organisms. Hand hygiene is the are immunocompromised or have infections
with multidrug-resistant or extremely virulent
primary behavior. micro-organisms.
Perform hand hygiene after contact with anything in
Medical asepsis refers to the use of precise
●
clients’ rooms and after touching any contaminated

practices to reduce the number, growth, and items, whether or not gloves were worn, and
before putting glo es on and after ta ing them off.
spread of micro-organisms (“clean technique”). It Performing hand hygiene might be necessary between
applies to administering oral medication, managing tasks and procedures on the same client to prevent
cross contamination of different body sites.
nasogastric tubes, providing personal hygiene, and ● Wash hands with soap and warm water. Rub hands
performing many other common nursing tasks. together vigorously, and rinse under running water.
ash for at least seconds to remo e transient ora
Surgical asepsis refers to the use of precise and up to 2 min when hands are more soiled. After
washing, dry hands with a clean paper towel before
practices to eliminate all micro-organisms from an turning off the faucet. If the sin does not ha e foot or
object or area and prevent contamination (“sterile nee pedals for turning off the ater, use a clean, dry
paper to el to turn off the faucet s .
technique”). It applies to parenteral medication ● For hand hygiene with an alcohol-based product,
administration, insertion of urinary catheters, dispense the manufacturer’s recommended amount
(usually 3 to 5 mL) in the palm of the hand. Rub hands
surgical procedures, sterile dressing changes, together vigorously, remembering to cover all surfaces
and many other common nursing procedures. of both hands and ngers. Continue to rub until both
hands are completely dry.
Before beginning any task or procedure that
requires aseptic technique, health care team ADDITIONAL PERSONAL
HYGIENE MEASURES
members must check for latex allergies. If the ● Emphasize the importance of covering the mouth and
client or any member of the team has a latex nose when coughing or sneezing, using and disposing of
facial tissues, and performing hand hygiene to prevent
allergy, the team must use latex-free gloves, spraying and spreading droplet infections. Encourage
equipment, and supplies. Most facilities use clients and visitors to practice respiratory hygiene/
cough etiquette. Ensure spatial separation of 3 ft from
non-latex (nitrile) gloves. However, it is the those with a cough, or have them wear a mask.
health care team’s responsibility to identify latex ● Wash hair frequently and keep it short or pulled back to
prevent contamination of the care area or the clients.
allergies and use items that are latex-free. ● Keep natural nails short and clean and free of nail gels
and acrylic nails. The area around and under the nails
can harbor micro-organisms.
PRACTICES THAT PROMOTE Remove jewelry from hands and wrists to facilitate
MEDICAL ASEPSIS
●
hand disinfection.
HAND HYGIENE PROTECTIVE CLOTHING

Always use hand hygiene. Wash hands with an antimicrobial Use masks, gloves, gowns, and protective eyewear to help
or plain soap and water, using alcohol-based products (gels, control the contact and spread of micro organisms to staff
foams, and rinses; or performing a surgical scrub). and clients.
● The three essential components of handwashing are
the following.
◯ Soap
◯ Running water
◯ Friction
FUNDAMENTALS FOR NURSING CHAPTER 10 MEDICAL AND SURGICAL ASEPSIS 49

PHYSICAL ENVIRONMENT Any sterile, non-waterproof wrapper that comes in
contact with moisture becomes non-sterile by a wicking
Additional examples of practices that reduce the growth
action that allows microbes to travel rapidly from a non-
and spread of micro-organisms are changing linens daily,
sterile surface to the sterile surface.
cleaning oors and bedside stands, and separating clean ● Keep all surfaces dry.
from contaminated materials. ● Discard any sterile packages that are torn,
● Do not place items on the oor e en soiled laundry .
punctured, or wet.
The oor is grossly contaminated.
● Do not shake linens because doing so can spread
micro-organisms in the air. Keep soiled items from
touching clothing.
● Clean the least soiled areas rst to pre ent mo ing more
contaminants into the cleaner areas. EQUIPMENT
● Use plastic bags for moist, soiled items, following ● Select a clean area above waist level in the client’s
facility protocol for bag selection, to prevent further
en ironment a bedside stand to set up the sterile eld.
contamination of items or of individuals handling ● Check that all sterile packages (additional dressings,
the soiled items. Put all soiled items directly into the
sterile bowl, sterile gloves, and solution) are dry and
appropriate receptacle to avoid handling soiled items
intact and have a future expiration date. Any chemical
more than once.
tape must show the appropriate color change.
● Place all laboratory specimens in biohazard containers ● Make sure an appropriate waste receptacle is nearby.
or bags for transport or disposal.
● Pour any liquids used for client care directly into the drain
and avoid splattering to prevent spreading droplets. Empty PROCEDURE
body uids at ater le el of toilet to a oid splashing.
Perform hand hygiene.
STERILE FIELD SETUP

PRACTICES THAT MAINTAIN ● Open the covering of the package per the
A STERILE FIELD manufacturer’s directions, slipping the package onto
the center of the or space ith the top ap of the
Prolonged exposure to airborne micro-organisms can
wrapper opening away from the body.
make sterile items non-sterile. ● rasp the tip of the top ap of the pac age, and ith
● Avoid coughing, sneezing, and talking directly over a
the arm positioned a ay from the sterile eld, unfold

sterile eld.
the top ap a ay from the body.
● Advise clients to avoid sudden movements; refrain from
● Ne t, open the side aps, using the right hand for the
touching supplies, drapes, or the nurse’s gloves and gown;
right ap and the left hand for the left ap.
and a oid coughing, snee ing, or tal ing o er a sterile eld. ● rasp the last ap and turn it do n to ard the body.
Only sterile items can be in a sterile field.
ADDITIONAL STERILE PACKAGES
● The outer wrappings and 1-inch edges of packaging that ● pen ne t to the sterile eld by holding the bottom
contains sterile items are not sterile. The inner surface
edge ith one hand and pulling bac on the top ap
of the sterile drape or kit, except for that 1-inch border
with the other hand. Place the packages that will be
around the edges, is the sterile eld to hich other
used last furthest from the sterile eld open these rst.
sterile items can be added. To position the eld on the ● Add them directly to the sterile eld. Lift the pac age
table surface, grasp the 1-inch border before donning
from the dry surface, holding it 15 cm (6 in) above
sterile gloves. Discard any object that comes into
the sterile eld, pulling the t o surfaces apart, and
contact with the 1-inch border.
dropping it onto the sterile eld.
● Touch sterile materials only with sterile gloves.
● Consider any object held below the waist or above the POUR STERILE SOLUTIONS
chest contaminated. ● Remove the bottle cap.
● Sterile materials can touch other sterile surfaces or ● Place the bottle cap face up on a clean (non-
materials; however, contact with non-sterile materials sterile) surface.
at any time contaminates a sterile area, no matter how ● Hold the bottle with the label in the palm of the hand so
short the contact. that the solution does not run down the label.
● First pour a small amount (1 to 2 mL) of the solution
Microbes can move by gravity from a non-sterile item to
into an available receptacle.
a sterile item. ● Pour the solution (without splashing) onto the dressing
● Do not reach across or abo e a sterile eld.
or site without touching the bottle to the site.
● Do not turn your bac on a sterile eld. ● Sterile solutions expire 24 hr after opening and
● Hold items to add to a sterile eld at a minimum of
recapping in some facilities. Other facilities’ policies
inches abo e the eld.
state that once a sterile solution container is opened, it
can be used only once and then thrown away.
50 CHAPTER 10 MEDICAL AND SURGICAL ASEPSIS CONTENT MASTERY SERIES

STERILE GLOVES
● nce the sterile eld is set up, don sterile glo es.
● Sterile gloving includes opening the wrapper and
handling only the outside of the wrapper. Don gloves by
using the following steps.
● ith the cuff side pointing to ard the body, use the
nondominant hand and pick up the dominant-hand
glo e by grasping the folded bottom edge of the cuff and
lifting it up and away from the wrapper.
● hile pic ing up the edge of the cuff, pull the dominant
glove onto the hand.
● With the sterile dominant-gloved hand, place the
ngers of the dominant hand inside the cuff of the
nondominant glo e, lifting it off the rapper and
putting the nondominant hand into it.
● hen both hands are glo ed, ad ust the ngers.
● During that time, only a sterile gloved hand can touch
the other sterile gloved hand.
● At the close of the sterile procedure or if the gloves tear,
remo e the glo es. Ta e them off by grasping the outer Active Learning Scenario
part of one glo e at the cuff area, a oiding touching
the rist and pulling the glo e do n o er the ngers A nurse is reviewing with a newly licensed nurse the
and into the hand that is still gloved. Then, place the procedure for putting on sterile gloves. Use the ATI Active
ungloved hand inside the soiled glove and pull the glove Learning Template: Nursing Skill to complete this item.
off so that it is inside out and only the clean inside part
DESCRIPTION OF SKILL: List the steps involved
is exposed. Discard into an appropriate receptacle.
in putting on a pair of sterile gloves.
1. When entering a client’s room to change a surgical 4. A nurse is reviewing hand hygiene techniques with
dressing, a nurse notes that the client is coughing a group of assistive personnel (AP). Which of the
and sneezing. Which of the following actions should following instructions should the nurse include when
the nurse take when preparing the sterile field? discussing handwashing? (Select all that apply.)
A. Keep the sterile field at least 6 ft A. Apply 3 to 5 mL of liquid soap to dry hands.
away from the client’s bedside. B. Wash the hands with soap and
B. Instruct the client to refrain from coughing water for at least 15 seconds.
and sneezing during the dressing change. C. Rinse the hands with hot water.
C. Place a mask on the client to limit the spread D. Use a clean paper towel to turn off hand faucets.
of micro-organisms into the surgical wound. E. Allow the hands to air dry after washing.
D. Keep a box of facial tissues nearby for the
client to use during the dressing change.
5. A nurse has prepared a sterile field for assisting a
provider with a chest tube insertion. Which of the
2. A nurse has removed a sterile pack from its outside following events should the nurse recognize as
cover and placed it on a clean work surface in contaminating the sterile field? (Select all that apply.)
preparation for an invasive procedure. Which of A. The provider drops a sterile instrument
the following flaps should the nurse unfold first? onto the near side of the sterile field.
A. The flap closest to the body B. The nurse moistens a cotton ball with sterile
B. The right side flap normal saline and places it on the sterile field.
C. The left side flap C. The procedure is delayed 1 hr because the
D. The flap farthest from the body provider receives an emergency call.
D. The nurse turns to speak to someone who
enters through the door behind the nurse.
3. A nurse is wearing sterile gloves in preparation E. The client’s hand brushes against the
for performing a sterile procedure. Which of the outer edge of the sterile field.
following objects can the nurse touch without
breaching sterile technique? (Select all that apply.)
A. A bottle containing a sterile solution
B. The edge of the sterile drape at the base of the field
C. The inner wrapping of an item on the sterile field
D. An irrigation syringe on the sterile field
E. One gloved hand with the other gloved hand
FUNDAMENTALS FOR NURSING CHAPTER 10 MEDICAL AND SURGICAL ASEPSIS 51

1. A. It would be difficult for to maintain a sterile field away from Using the ATI Active Learning Template: Nursing Skill
the bedside. But more important, this might not have any DESCRIPTION OF SKILL
effect on the transmission of some micro-organisms. ●
With the cuff side pointing toward the body, use the nondominant
B. The client might be unable to refrain from coughing
hand to pick up the dominant-hand glove by grasping the folded
and sneezing during the dressing change.
bottom edge of the cuff and lifting it up and away from the wrapper.
C. CORRECT: Placing a mask on the client
prevents contamination of the surgical
●
While picking up the edge of the cuff, pull
wound during the dressing change. the dominant glove onto the hand.
D. Keeping tissues close by for the client to use still
●
With the sterile dominant-gloved hand, place the fingers of the
allows contamination of the surgical wound. dominant hand inside the cuff of the nondominant glove, lifting
it off the wrapper and putting the nondominant hand into it.
NCLEX® Connection: Safety and Infection Control, Standard ●
Adjust the fingers.
Precautions/Transmission-Based Precautions/Surgical Asepsis
NCLEX® Connection: Safety and Infection Control, Standard
2. A. The flap closest to the body is the innermost
flap and the last one to unfold.
B. Unfold the side flap that is closest to the top
of the package before the one underneath it;
however, there is another flap to unfold first.
C. Unfold the side flap that is closest to the top
of the package before the one underneath it;
however, there is another flap to unfold first.
D. CORRECT: The priority goal in setting up a sterile field is to
maintain sterility and thus reduce the risk to the client’s safety.
Unless the nurse pulls the top flap (the one farthest from her
body) away from the body first, there is a risk of touching part
of the inner surface of the wrap and thus contaminating it.
3. A. A bottle of sterile solution is sterile on the inside and

non-sterile on the outside. Prepare the sterile container of
solution on the field before putting on sterile gloves.
B. The 1-inch border at the outer edge of the sterile field
is not sterile. Do not touch it with sterile gloves.
C. CORRECT: The inner wrappings of any objects dropped onto
the sterile field are sterile. Touch them with sterile gloves.
D. CORRECT: Any objects dropped onto the sterile field during
the setup are sterile. Touch the syringe with sterile gloves.
E. CORRECT: One sterile gloved hand may touch the
other sterile gloved hand because both are sterile.
4. A. The APs should apply alcohol rubs to dry hands and wet the
hands first before applying soap for handwashing.
B. CORRECT: This is the amount of time it takes to
remove transient flora from the hands. For soiled
hands, the recommendation is 2 minutes.
C. The APs should use warm water to minimize
the removal of protective skin oils.
D. CORRECT: If the sink does not have foot or knee
pedals, the APs should turn off the water with a
clean paper towel and not with their hands.
E. The APs should dry their hands with a clean paper
towel. This helps prevent chapped skin.
5. A. As long as the provider has not reached over the

sterile field (by placing the instrument on a near
portion of the field), the field remains sterile.
B. CORRECT: Fluid permeation of the sterile
drape or barrier contaminates the field.
C. CORRECT: Prolonged exposure to air
contaminates a sterile field.
D. CORRECT: Turning away from a sterile field contaminates
the field because the nurse cannot see if a piece of
clothing or hair made contact with the field.
E. The 1-inch border at the outer edge of the sterile
field is not sterile. Unless the client reached farther
into the field, the field remains sterile.
52 CHAPTER 10 MEDICAL AND SURGICAL ASEPSIS CONTENT MASTERY SERIES

CHAPTER 11
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT Active: Antibodies are produced in response to an antigen.
SECTION: SAFETY AND INFECTION CONTROL ● Requires time to react to antigens
Provides permanent immunity
Infection Control
●
● Involves B- and T-lymphocytes

CHAPTER 11
● Produces speci c antibodies against speci c antigens
(immunoglobulins [IgA, IgD, IgE, IgG, IgM])
An infection occurs when the presence of

a pathogen leads to a chain of events. All INFECTION PROCESS
components of the chain must be present and Chain of infection (11.1)
intact for the infection to occur. A nurse uses Causative agent (bacteria, virus, fungus, prion, parasite)
infection control practices (medical asepsis, Reservoir (human, animal, food, organic matter on
inanimate surfaces, water, soil, insects)
surgical asepsis, standard precautions) to break
Portal of exit from (means for leaving) the host
the chain and thus stop the spread of infection. ● Respiratory tract (droplet, airborne): Mycobacterium
tuberculosis and Streptococcus pneumoniae
TYPES OF PATHOGENS ● Gastrointestinal tract: Shigella, Salmonella enteritidis,
Salmonella typhi, hepatitis A
Pathogens are the micro-organisms or microbes that ● Genitourinary tract: Escherichia coli, hepatitis A, HSV, HIV
cause infections. ● Skin/mucous membranes: HSV and varicella
● Bacteria (Staphylococcus aureus, Escherichia coli, ● lood body uids HI and hepatitis and C
Mycobacterium tuberculosis) ● Transplacental
● Viruses: Organisms that use the host’s genetic
machinery to reproduce (HIV, hepatitis, herpes zoster, Mode of transmission
herpes simplex virus [HSV]) ● Contact
● Fungi: Molds and yeasts (Candida albicans, Aspergillus) ◯ Direct physical contact: Person to person
● Prions: Protein particles (new variant ◯ Indirect contact with an inanimate object:
Creutzfeldt-Jakob disease) Object to person

● Parasites: Protozoa (malaria, toxoplasmosis) and ◯ Fecal-oral transmission: Handling food after using a
helminths orms at orms, round orms , u es restroom and failing to wash hands
[Schistosoma]) ● Droplet: Sneezing, coughing, and talking
● Airborne: Sneezing and coughing
Virulence is the ability of a pathogen to invade and ● Vector borne: Animals or insects as intermediaries (ticks
injure a host.
transmit Lyme disease; mosquitoes transmit West Nile
Herpes zoster is a common viral infection that erupts and malaria)
years after e posure to chic enpo and in ades a speci c
Portal of entry to the host: Might be the same as the
nerve tract.
portal of exit
Susceptible host: Compromised defense mechanisms

IMMUNE DEFENSES (immunocompromised, breaks in skin), leaving the host
more susceptible to infections
Nonspecific innate
Native immunity restricts entry or immediately responds
to a foreign organism (antigen) through the activation of
phagocytic cells, complement, and in ammation. This occurs 11.1 Chain of infection
with all micro-organisms, regardless of previous exposure.
Passive: Antibodies are produced by an external source.

● Temporary immunity that does not have memory of
past exposures
● Intact s in, the body s rst line of defense
● Mucous membranes, secretions, enzymes, phagocytic
cells, and protective proteins
● In ammatory response ith phagocytic cells, the
complement system, and interferons to localize the
invasion and prevent its spread
Specific adaptive immunity

Specific adaptive immunity allows the body to make
antibodies in response to a foreign organism (antigen). This
reaction directs against an identi able micro organism.
FUNDAMENTALS FOR NURSING CHAPTER 11 INFECTION CONTROL 53

Stages of an infection ● OLDER ADULT CLIENTS: Older adults can have a slowed
response to antibiotic therapy, slowed immune response,
Incubation: interval between the pathogen entering the
loss of subcutaneous tissue and thinning of the skin,
body and the presentation of the rst nding
decreased vascularity and slowed wound healing,
Prodromal stage: inter al from onset of general ndings decreased cough and gag re e es, chronic illnesses,
to more distinct ndings during this time, the pathogen decreased gastric acid production, decreased mobility,
multiplies bowel and bladder incontinence, dementia, and greater
incidence of invasive devices (a urinary catheter or
Illness stage: inter al hen ndings speci c to the
feeding tube).
infection occur ● Individuals who make poor lifestyle choices that put
Convalescence: inter al hen acute ndings disappear, them at risk, which include:
total recovery taking days to months ◯ Clients who use IV drugs and share needles
◯ Clients who engage in unprotected sex
● Clients who have recently been exposed to:
ASSESSMENT/DATA COLLECTION ◯ Poor sanitation
◯ Mosquito-borne or parasitic diseases
◯ Diseases endemic to the area visited, but not in the
RISK FACTORS client’s home country

A nurse should assess each client for the risks of infection
speci c to the client, the disease or in ury, and the
environment. The most common risks include:
EXPECTED FINDINGS
● Inadequate hand hygiene (client and caregivers) ● indings identi able in the nursing assessment of
● Individuals who have compromised health or defenses generalized or systemic infection include the following.
against infection, which include: ◯ Fever
◯ Those who are immunocompromised ◯ Presence of chills, which occur when temperature
◯ Those who have had surgery is rising, and diaphoresis, which occurs when
◯ Those with indwelling devices temperature is decreasing
◯ A break in the skin (the body’s best protection ◯ Increased pulse and respiratory rate (in response to
against infection). the high fever)

◯ Those with poor oxygenation ◯ Malaise
◯ Those with impaired circulation ◯ Fatigue
◯ Those who have chronic or acute disease (diabetes ◯ Anorexia, nausea, and vomiting
mellitus, adrenal insufficiency, renal failure, hepatic ◯ Abdominal cramping and diarrhea
failure, or chronic lung disease) ◯ Enlarged lymph nodes (repositories for “waste”)
● Caregivers using medical or surgical asepsis that does ● OLDER ADULT CLIENTS
not follow the established standards (11.2) ◯ lder adults ha e a reduced in ammatory and
● Clients who have poor personal hygiene or poor immune response and thus might have an advanced
nutrition, smoke, or consume excessive amounts of infection before it is identi ed. Atypical ndings
alcohol, and those experiencing stress (agitation, confusion, or incontinence) can be the only
● Clients who live in a very crowded environment manifestations.
◯ ther ndings can ary depending on the site of the
infection (dyspnea, cough, purulent sputum, and
crac les in lung elds, dysuria, urinary fre uency,
11.2 Health-care associated infections
hematuria and pyuria, rash, skin lesions, purulent
Health-care associated infections (HAIs) are infections wound drainage, erythema and odynophagia, dysphagia,
that a client acquires while receiving care in a health hyperemia, enlarged tonsils, change in level of
care setting. Formerly called nosocomial infections,
these can come from an exogenous source (from consciousness, nuchal rigidity, photophobia, headache).
outside the client) or an endogenous source (inside ● In ammation is the body s local response to in ury or
the client when part of the client’s flora is altered). infection. The in ammatory response has three stages.
●
Often occur in the intensive care unit. ◯ indings during the rst stage of the in ammatory
●
The best way to prevent HAIs is through response (local infection) include the following.
frequent and effective hand hygiene.
■ Redness (from dilation of arterioles bringing blood
●
A common site of HAIs is the urinary tract and these
are often caused by Escherichia coli, Staphylococcus to the area)
aureus, and enterococci. Other sites of HAIs are surgical ■ Warmth of the area on palpation
wounds, the respiratory tract, and the bloodstream. ■ Edema

●
An iatrogenic infection is a type of HAI resulting ■ Pain or tenderness
from a diagnostic or therapeutic procedure.
■ Loss of use of the affected part
●
HAIs are not always preventable and
are not always iatrogenic.
●
Use current evidence-based practice guidelines to
prevent HAIs due to multidrug-resistant organisms.
54 CHAPTER 11 INFECTION CONTROL CONTENT MASTERY SERIES

Online Video: Precautions
◯ In the second stage, the micro-organisms are ● For immobile clients, ensure that pulmonary hygiene
killed. Fluid containing dead tissue cells and WBCs (turning, coughing, deep breathing, incentive spirometry)
accumulates and exudate appears at the site of the is done every 2 hr, or as prescribed. Good pulmonary
infection. The exudate leaves the body by draining hygiene decreases the growth of micro-organisms and
into the lymph system. The types of exudate are: the development of pneumonia by preventing stasis of
■ Serous (clear). pulmonary excretions, stimulating ciliary movement and
■ Sanguineous (contains red blood cells). clearance, and expanding the lungs.
■ Purulent (contains leukocytes and bacteria). ● Use of aseptic technique and proper personal protective
◯ In the third stage, damaged tissue is replaced by scar equipment (gloves, masks, gowns, and goggles) in the
tissue. Gradually, the new cells take on characteristics provision of care to all clients prevents unnecessary
that are similar in structure and function to the old cells. exposure to micro-organisms.
● Teach and use respiratory hygiene/cough etiquette.
It applies to anyone entering a health care setting
LABORATORY TESTS clients, isitors, staff ith manifestations of illness,
● Leukocytosis (WBCs greater than 10,000/µL) whether diagnosed or undiagnosed. This includes cough,
● Increases in the speci c types of Cs on differential congestion, rhinorrhea, or an increase in the production
(left shift = an increase in neutrophils) of respiratory secretions. The components of respiratory
● Elevated erythrocyte sedimentation rate (ESR) over hygiene and cough etiquette include:
mm hr an increase indicates an acti e in ammatory ◯ Covering the mouth and nose when coughing
process or infection and sneezing.
● Presence of micro-organisms on culture of the ◯ Using facial tissues to contain respiratory secretions and
speci c uid area disposing of them promptly into a hands-free receptacle.

◯ Wearing a surgical mask when coughing to minimize
contamination of the surrounding environment.

DIAGNOSTIC PROCEDURES ◯ Turning the head when coughing and staying a
● Gallium scan: Nuclear scan that uses a radioactive minimum of 3 ft away from others, especially in
substance to identify hot spots of WBCs common waiting areas.
● Radioactive gallium citrate: Injected by IV and ◯ Performing hand hygiene after contact with respiratory
accumulates in area of in ammation secretions and contaminated objects/materials.

● X-rays, CT scan, magnetic resonance imaging (MRI),
and biopsies to determine the presence of infection,
abscesses, and lesions
ISOLATION GUIDELINES
● Isolation guidelines are a group of actions that include
hand hygiene and the use of barrier precautions, which
PATIENT-CENTERED CARE intend to reduce the transmission of infectious organisms.
● The precautions apply to every client, regardless of the
diagnosis, and implementation of them must occur
NURSING CARE whenever there’s anticipation of coming into contact
● se fre uent and effecti e hand hygiene before and with a potentially infectious material.
after care. ● Change personal protective equipment after contact with
● Educate the client about the required and recommended each client and between procedures with the same client
immunizations and where to obtain them. The target if in contact ith large amounts of blood and body uids.
groups include children, older adults, those with chronic ● Clients in isolation are at a higher risk for depression and
disease, and those who are immunocompromised and loneliness. Assist the client and their family to understand
their families and contacts. the reason for isolation and provide sensory stimulation.
● Educate the client and ask for a return demonstration of
good oral hygiene. Good oral hygiene decreases the protein Standard precautions (tier one)
(which attracts micro-organisms) in the oral cavity, which
This tier of standard precautions applies to all body uids
thereby decreases the growth of micro-organisms that
(except sweat), non-intact skin, and mucous membranes. A
can migrate through breaks in the oral mucosa.
nurse should implement standard precautions for all clients.
● Encourage the client to consume an adequate amount of ● Hand hygiene using an alcohol-based waterless product
uids. Ade uate uid inta e pre ents the stasis of urine
is recommended after contact with the client when the
by ushing the urinary tract and decreasing the gro th
hands are not visibly soiled or contaminated with blood
of micro-organisms. Adequate hydration also keeps
or body uids and after the remo al of glo es.
the skin from breaking down. Intact skin prevents ● Alcohol-based waterless antiseptic is preferred unless
micro-organisms from entering the body.

the hands are visibly dirty, because the alcohol-based
product is more effecti e in remo ing micro organisms.
● Wash hands with soap and water if contamination with
spores is suspected.
● Hand hygiene using nonantimicrobial soap or an
antimicrobial soap and water is recommended when
isibly soiled or contaminated ith blood or body uids.

● se soap and ater not alcohol for C. difficile. Contact precautions
● Remove gloves and complete hand hygiene between Contact precautions protect visitors and caregivers
each client. when they are within 3 ft of the client against direct
● Masks, eye protection, and face shields are required when client and environmental contact infections (respiratory
care might cause splashing or spraying of body uids. syncytial virus, shigella, enteric diseases caused by
● Clean gloves are worn when touching anything that has micro-organisms, wound infections, herpes simplex,
the potential to contaminate the hands of the nurse. impetigo, scabies, multidrug-resistant organisms).
This includes body secretions, excretions, blood and
Contact precautions require:
body uids, non intact s in, mucous membranes, and ● A private room or a room with other clients who have
contaminated items.
the same infection.
● Hand hygiene is required after removal of the gown. Use ● Gloves and gowns worn by the caregivers and visitors.
a sturdy, moisture-resistant bag for soiled items and tie ● Disposal of infectious dressing material into a single,
the bag securely in a knot at the top.
nonporous bag without touching the outside of the bag.
● Properly clean all equipment for client care; dispose of
one-time use items according to facility policy. Protective environment
● Bag and handle contaminated laundry to prevent Protective environment is an intervention (not
leaking or contamination of clothing or skin. type of precautions) to protect clients who are
● Enable safety devices on all equipment and supplies after immunocompromised. This includes clients who have had
use; dispose of all sharps in a puncture-resistant container. an allogeneic hematopoietic stem cell transplant.
● A client does not need a private room unless they are
A protective environment requires:
unable to maintain appropriate hygienic practices. ● Private room.
Positi e air o or more air e changes hr.
Transmission precautions (tier two)
●
● H PA ltration for incoming air.

Airborne precautions ● Mask for the client when out of room.
Use airborne precautions to protect against droplet
infections smaller than 5 mcg (measles, varicella,
pulmonary or laryngeal tuberculosis).
MEDICATIONS
Airborne precautions require: Antipyretics
● A private room.
Antipyretics (acetaminophen and aspirin) are used for

● Masks and respiratory protection devices for caregivers
fever and discomfort as prescribed.
and visitors.
NURSING ACTIONS
Use an N95 or high-efficiency particulate ● onitor fe er to determine effecti eness of medication.
air (HEPA) respirator if the client is known ● Document the client s temperature uctuations on the
or suspected to have tuberculosis.
medical record for trending.
● Negati e pressure air o e change in the room of at
least six to 12 exchanges per hour, depending on the age Antimicrobial therapy
of the structure.
Antimicrobial therapy kills or inhibits the growth of
● If splashing or spraying is a possibility, wear full face
micro-organisms (bacteria, fungi, viruses, protozoans).
(eyes, nose, mouth) protection.
Antimicrobial medications either kill pathogens or prevent
● Clients who have an airborne infection should wear a
their growth. Give anthelmintics for worm infestations. (11.3)
mask while outside of the room/home.
NURSING ACTIONS
Droplet precautions ● Administer antimicrobial therapy as prescribed.
Droplet precautions protect against droplets larger than ● onitor for medication effecti eness reduced fe er,
5 mcg and travel 3 to 6 ft from the client (streptococcal
increase in the level of comfort, decreasing WBC count).
pharyngitis or pneumonia, Haemophilus in uen ae type ● Maintain a medication schedule to ensure consistent
B, scarlet fever, rubella, pertussis, mumps, mycoplasma
therapeutic blood levels of the antibiotic.
pneumonia, meningococcal pneumonia and sepsis,
pneumonic plague).
Droplet precautions require:

INTERPROFESSIONAL CARE
● A private room or a room with other clients who have
Transporting a client
the same infectious disease. Ensure that clients have
their own equipment. If movement of the client to another area of the facility is
● Masks for providers and visitors. unavoidable, the nurse takes precautions to ensure that
● Clients who have a droplet infection should wear a mask the environment is not contaminated. For example, a
while outside of the room/home. surgical mask is placed on the client who has an airborne
or droplet infection, and a draining wound is well covered.

Reporting communicable diseases Application Exercises
A complete list of reportable diseases and the reporting
system are available through the Centers for Disease 1. A nurse is caring for a client who has severe acute
Control and Prevention’s website (www.cdc.gov). There respiratory syndrome (SARS). The nurse knows
are more than 60 communicable diseases that must be that health care professionals are required to
reported to the public health departments to allow for report communicable and infectious diseases.
officials to Which of the following illustrate the rationale
● Ensure appropriate medical treatment of diseases for reporting? (Select all that apply.)
(tuberculosis). A. Planning and evaluating control
● Monitor for common-source outbreaks (foodborne— and prevention strategies
hepatitis A). B. Determining public health priorities
● Plan and evaluate control and prevention plans C. Ensuring proper medical treatment
(immunizations for preventable diseases). D. Identifying endemic disease
● Identify outbreaks and epidemics. E. Monitoring for common-source outbreaks
● Determine public health priorities based on trends.
2. A nurse is caring for a client who has had a cough for 3
CLIENT EDUCATION weeks and is beginning to cough up blood. The client
has manifestations of which of the following conditions?
Teach the client about: A. Allergic reaction
● Any infection control measures at home.
B. Ringworm
● Self-administration of medication therapy. C. Systemic lupus erythematosus
● Complications to report immediately. D. Tuberculosis
3. A nurse is caring for a client who reports a

11.3 Multidrug-resistant infection severe sore throat, pain when swallowing, and
swollen lymph nodes. The client is experiencing
Antimicrobials are becoming less effective for some which of the following stages of infection?
strains of pathogens due to the pathogen’s ability to
adapt and become resistant to previously sensitive A. Prodromal
antibiotics. This significantly limits the number of B. Incubation
antibiotics that are effective against the pathogen. C. Convalescence
Use of antibiotics, especially broad-spectrum antibiotics, D. Illness
has significantly decreased to prevent new strains from
evolving. Taking the measures below can ensure that
an antimicrobial is necessary and therapy is effective.
Methicillin-resistant Staphylococcus aureus
4. A charge nurse is reviewing with a newly
(MRSA) is a strain of Staphylococcus aureus that hired nurse the difference in manifestations
is resistant to many antibiotics. Vancomycin of a localized versus a systemic infection.
and linezolid are used to treat MRSA. Which of the following are manifestations of a
Vancomycin-resistant Staphylococcus aureus systemic infection? (Select all that apply.)
(VRSA) is a strain of Staphylococcus aureus that is A. Fever
resistant to vancomycin, but so far is sensitive to
other antibiotics specific to a client’s strain. B. Malaise
NURSING ACTIONS C. Edema
●
Obtain specimens for culture and sensitivity D. Pain or tenderness
prior to initiation of antimicrobial therapy. E. Increase in pulse and respiratory rate
●
Monitor antimicrobial levels and ensure that
therapeutic levels are maintained.
CLIENT EDUCATION
5. A nurse is contributing to the plan of care for
a client who is being admitted to the facility
●
Complete the full course of antimicrobial therapy.
with a suspected diagnosis of pertussis.
●
Avoid overuse of antimicrobials.
Which of the following interventions should
the nurse include? (Select all that apply.)
A. Place the client in a room that has negative air
pressure of at least six exchanges per hour.
Active Learning Scenario B. Wear a mask when providing care
within 3 ft of the client.
A nurse manager is teaching a module on the chain C. Place a surgical mask on the client if transportation
of infection during nursing orientation to a group of to another department is unavoidable.
newly licensed nurses. Use the ATI Active Learning D. Use sterile gloves when handling soiled linens.
E. Wear a gown when performing care that might
RELATED CONTENT: List the six links in the chain of result in contamination from secretions.
infection that must be present for an infection to occur.

1. A. CORRECT: Reporting of communicable and infectious Using the ATI Active Learning Template: Basic Concept
diseases assists with planning and evaluating RELATED CONTENT: The infection process (chain of infection)
control and prevention strategies. ●
Causative agent
B. CORRECT: Reporting of communicable and infectious
diseases assists with determining public health policies.
●
Reservoir
C. CORRECT: Reporting of communicable and
●
Portal of exit (means of leaving) from the host
infectious diseases assists with ensuring ●
Mode of transmission
proper medical treatment is available. ●
Portal of entry to the host
D. Endemic disease is already prevalent within a ●
Susceptible host
population, so reporting is not necessary.
E. CORRECT: Reporting of communicable and NCLEX® Connection: Safety and Infection Control,
infectious diseases assists with monitoring Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
for common-source outbreaks.
NCLEX® Connection: Physiological Adaptation,
Illness Management
2. A. A pink body rash is a manifestation of

an allergic reaction.
B. Red circles with white centers is a manifestation of ringworm.
C. A red edematous rash bilaterally on the cheeks is a
manifestation of systemic lupus erythematosus.
D. CORRECT: A cough for 3 weeks and beginning to
cough up blood are manifestations of tuberculosis.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
3. A. The prodromal stage consists of nonspecific

manifestations of the infection.
B. The incubation period consists of the time when
the pathogen first enters the body prior to the
appearance of any manifestations of infection.
C. During convalescence, manifestations of the infection fade.
D. CORRECT: The illness stage is when the client
experiences manifestations specific to the infection.
4. A. CORRECT: A fever indicates that the infection is affecting

the whole body, and therefore systemic.
B. CORRECT: Malaise indicates that the infection
is affecting the whole body.
C. Edema is a localized manifestation
indicating a localized infection.
D. Pain and tenderness is a localized manifestation
indicating a localized infection.
E. CORRECT: An increase in pulse and respiratory rate
indicates that the infection is affecting the whole body.
5. A. Place a client in a private room and initiate droplet

precautions if they have pertussis. Negative-pressure airflow
is required for a client who is on airborne precautions.
B. CORRECT: Wear a mask when within 3 ft of the client.
C. CORRECT: Place a surgical mask on the client during
transport to another area of the facility.
D. Wear a gown and non-sterile gloves when performing care
that might result in contamination from body fluids.
E. CORRECT: Wear a gown if the nurse’s clothing or skin might
be contaminated with body secretions or excretions.

CHAPTER 12
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT FALLS
SECTION: SAFETY AND INFECTION CONTROL
● Older adult clients can be at an increased risk for falls
Client Safety due to decreased strength, impaired mobility and

CHAPTER 12 balance, improper use of mobility aids, unsafe clothing,
environmental hazards, endurance limitations, and
decreased sensory perception.
Safety is freedom from injury. Providing for ● Other clients at increased risk include those with
decreased visual acuity, generalized weakness, urinary
safety and preventing injury are major nursing frequency, gait and balance problems (cerebral palsy,
responsibilities. injury, multiple sclerosis), and cognitive dysfunction.
Ad erse effects of medications orthostatic hypotension,
Many factors affect clients’ ability to protect drowsiness) can also increase the risk for falls.
Clients are at greater risk for falls when they have more
themselves. Those factors include the client’s
●
than one risk factor.

age, with the young and old at greater risk; ● Prevention of client falls is a major nursing priority.
Nurses must evaluate all clients in health care facilities
mobility; cognitive and sensory awareness; for risk factors for falls and implement preventative
emotional state; ability to communicate; and measures accordingly.
Programs to prevent falls are essential for settings that
lifestyle and safety awareness.
●
provide services to older adult clients.

Health care facilities must actively prevent falls,
It is the provider’s responsibility to assess,
●
especially because Medicare and Medicaid no longer

report, and document clients’ allergies and to reimburse for treating injuries resulting from falls.
provide care that avoids exposure to allergens.

PREVENTING FALLS
Complete a fall-risk assessment for each client at
NURSING ACTIONS
●
admission and at regular intervals. Individualize the

● Use risk assessment tools to evaluate clients and their plan for each client according to the results of the
environment for safety. fall-risk assessment. For example, instruct a client who
● Encourage clients to speak up and take an active role in has orthostatic hypotension to avoid getting up too
their health care and in preventing errors. quickly, to sit on the side of the bed for a few seconds
● Create a culture of checks and balances to avoid errors prior to standing, and to stand at the side of the bed for
when working in stressful circumstances. a few seconds prior to walking.
● Communicate risk factors and plans of care to clients, ● Be sure the client knows how to use the call light (by
family, and other staff. giving a return demonstration), that it is in reach, and
● Use protocols for responding to dangerous situations. to encourage its use.
● Adopt quality care priorities from the National Quality ● Respond to call lights in a timely manner.
Forum, including “Never Events.” ● Use fall-risk alerts (color-coded wristbands).
● Use current evidence to promote a culture of safety, ● Provide regular toileting and orientation of clients who
while using the National Patient Safety Goals as a guide. have cognitive impairment.
● Know the facility’s disaster plan, understand the chain ● Provide adequate lighting.
of command and roles, and use common terminology ● Orient clients to the setting to make sure they know
when communicating with the team. how to use all assistive devices (grab bars) and can
● Identify and document incidents and responses according locate necessary items.
to the facility’s policy. These reports help identify trends, ● Place clients at risk for falls near the nurses’ station.
patterns, and the root cause of adverse events. ● Provide hourly rounding.
● Know the location of safety data sheets and hazardous ● Make sure’ bedside tables, overbed tables, and
chemicals in the environment. frequent-use items (telephone, water, facial tissues) are
● Use equipment only after adequate instruction and within reach.
safety inspection. ● Keep the bed in the low position and lock the brakes.
● For clients who are sedated, unconscious, or otherwise
compromised, keep the side rails up.
● Avoid the use of full side rails for clients who get out of
bed or attempt to get out of bed without assistance.
● Provide nonskid footwear and nonskid bath mats for use
in tubs and showers.
● Use gait belts and additional safety equipment when
moving clients.
● eep the oor clean, dry, and free from clutter ith a clear
path to the bathroom (no scatter rugs, cords, or furniture).
FUNDAMENTALS FOR NURSING CHAPTER 12 CLIENT SAFETY 59

● Keep assistive devices nearby after validation of safe use SECLUSION AND RESTRAINT
(eyeglasses, walkers, transfer devices). ● Nurses must know and follow federal, state, and facility
● Educate the client and family about safety risks and the
policies for the use of restraints.
plan of care. Clients and family who are aware of risks are ● Some clients require seclusion rooms and/or restraints.
more likely to call for assistance. ● In general, use seclusion or restraints for the shortest
● Lock the wheels on beds, wheelchairs, and carts to prevent
duration necessary and only if less restrictive measures
them from rolling during transfers or stops.
are not sufficient. They are for the physical protection of
● Use electronic safety monitoring devices (chair or bed
the client or the protection of other clients or staff.
sensors) for clients at risk for getting up without assistance ● Clients can voluntarily request temporary seclusion if
to alert staff of independent ambulation.
the environment is disturbing or seems too stimulating.
● Report and document all incidents. This provides valuable ● Restraints can be either physical (devices that restrict
information that can help prevent similar incidents.
movement: vest, belt, mitt, limb) or chemical (sedatives,
neuroleptic or psychotropic medications) to calm
the client.
SEIZURES ● Restraints can cause complications, including
A seizure is a sudden surge of electrical activity in the brain. pneumonia, incontinence, and pressure injuries.
It can occur at any time due to epilepsy, fever, or a variety ● It is inappropriate to use seclusion or restraints for:
of medical problems. Partial seizures (also called focal ◯ Con enience of the staff
seizures) are due to electrical surges in one hemisphere ◯ Punishment for the client
of the brain, and generalized seizures involve both ◯ Clients who are extremely physically or
hemispheres of the brain. Status epilepticus (a prolonged mentally unstable
seizure) is a medical emergency. ◯ Clients who cannot tolerate the decreased stimulation
of a seclusion room
Restraints should:
SEIZURE PRECAUTIONS
●
◯ Never interfere with treatment
Seizure precautions (measures to protect clients from ◯ Restrict movement as little as is necessary
injury during a seizure) are imperative for clients who ◯ Fit properly and be as discreet as possible
have a history of seizures that involve the entire body ◯ Be easy to remove or change
and/or result in unconsciousness. ● When all other less restrictive means have failed to
● Make sure rescue equipment is at the bedside, including prevent a client from harming themselves or others
oxygen, an oral airway, suction equipment, and padding for (orientation to the environment, supervision of a family
the side rails. Clients at high risk for generalized seizures member or sitter, diversional activities, electronic
should have a saline lock in place for immediate IV access. devices), the following must occur before using
● Ensure rapid intervention to maintain airway patency. seclusion or restraints.
● Inspect the client’s environment for items that could ◯ The provider must prescribe seclusion or restraints in
cause injury during a seizure, and remove items that are writing, after a face-to-face assessment of the client.
not necessary for current treatment.
● Assist clients at risk for seizures with ambulation and
In an emergency situation when there is immediate
risk to the client or others, nurses can place
transferring to reduce the risk of injury.
● Advise all caregivers and family not to put anything
restraints on a client. The nurse must obtain a
prescription from the provider as soon as possible
in the client’s mouth (except an airway for status
according to the facility’s policy (usually within 1 hr).
epilepticus) during a seizure.
● Advise all caregivers and family not to restrain the client ◯ The prescription must include the reason for the
during a sei ure but to lo er the client to the oor or restraints, the type of restraints, the location of the
bed, protect their head, remove nearby furniture, provide restraints, how long to use the restraints, and the
pri acy, put them on one side ith the head e ed type of behavior that warrants using the restraints.
slightly forward if possible, and loosen their clothing. ◯ The prescription allows only 4 hr of restraints
for an adult, 2 hr for clients ages 9 to 17, and 1 hr
for clients younger than 9 years of age. Providers
DURING A SEIZURE can renew these prescriptions with a maximum of
● Stay with the client, and call for help. 24 consecutive hours.
● Maintain airway patency and suction PRN. ◯ Providers cannot write PRN prescriptions
● Administer medications. for restraints.
● Note the duration of the seizure and the sequence and type
of movements.
● After a seizure, determine mental status and measure
oxygenation saturation and vital signs. Explain what
happened, and provide comfort, understanding, and a quiet
environment for recovery.
● Document the seizure with any precipitating behavior and
a description of the event (movements, injuries, duration of
seizures, aura, postictal state), and report it to the provider.
60 CHAPTER 12 CLIENT SAFETY CONTENT MASTERY SERIES

NURSING RESPONSIBILITIES FOR FIRE SAFETY
CLIENTS IN RESTRAINTS Fires in health care facilities are usually due to problems
● Explain the need for the restraints to the client and with electrical or anesthetic equipment, or from smoking.
family, emphasizing that the restraints keep the client
All staff must:
safe and are temporary. ● no the location of e its, alarms, re e tinguishers,
● Ask the client or guardian to sign a consent form.
and o ygen shut off al es.
● Review the manufacturer’s instructions for ● a e sure e uipment does not bloc re doors.
correct application. ● Know the evacuation plan for the unit and the facility.
◯ Assess skin integrity, and provide skin care according
to the facility’s protocol, usually every 2 hr.

Fire response follows the RACE sequence
◯ ffer food and uid.
◯ Provide a means for hygiene and elimination. R: Rescue and protect clients in close proximity to the
◯ Monitor vital signs. re by mo ing them to a safer location. Clients ho are
◯ ffer range of motion e ercises of e tremities. ambulatory can walk independently to a safe location.
● Pad bony prominences to prevent skin breakdown.
A: Alarm: Activate the facility’s alarm system and then
● Secure restraints to a movable part of the bed frame. If
report the re s details and location.
restraints with a buckle strap are not available, use a
quick-release knot to tie the strap. C: Contain Con ne the re by closing doors and indo s
● Make sure the restraints are loose enough for range of and turning off any sources of o ygen and any electrical
motion and that there is enough room to t t o ngers devices. Ventilate clients who are on life support with a
between the restraints and the client. bag-valve mask.
● Remove or replace restraints frequently to ensure good
E: tinguish the re if possible using the appropriate re
circulation to the area and allow for full range of motion
extinguisher.
to the limbs.
● Conduct an ongoing evaluation of the client.
● Regularly determine the need to continue using FIRE EXTINGUISHERS
the restraints.
To use a re e tinguisher, use the PA se uence.
● Never leave the client alone without the restraints.
● Check facility policy regarding types of restraints. Many P: Pull the pin.
facilities no longer use vest restraints due to the risk
A: Aim at the base of the re.
for strangulation.
S: Squeeze the handle.
DOCUMENT S: Sweep the extinguisher from side to side, covering the

area of the re.
● Precipitating events and behavior of the client prior to
seclusion or restraints
Classes of fire extinguishers
● Alternative actions to avoid seclusion or restraints
● Time of application and removal of the restraints Class A is for combustibles (paper, wood, upholstery, rags,
● Type of restraints and location other types of trash res .
● The client’s behavior while in restraints
Class B is for ammable li uids and gas res.
● Type and frequency of care (range of motion, neurologic
checks, removal, integumentary checks) Class C is for electrical res.
● Condition of the body part in restraints
● The client’s response at removal of the restraints
● Medication administration

1. A nurse is caring for a client who fell at a nursing A nurse educator is addressing the safe use of seclusion
home. The client is oriented to person, place, and restraints with a group of newly licensed nurses. What
and time and can follow directions. Which of the information should the nurse include? Use the ATI Active
following actions should the nurse take to decrease Learning Template: Basic Concept to complete this item.
the risk of another fall? (Select all that apply.)
NURSING INTERVENTIONS: Describe at least
A. Place a belt restraint on the client when they six nursing responsibilities when caring for a
are sitting on the bedside commode. client in either seclusion or restraints.
B. Keep the bed in its lowest position
with all side rails up.
C. Make sure that the client’s call light is within reach.
D. Provide the client with nonskid footwear.
E. Complete a fall-risk assessment.
2. A nurse manager is reviewing with nurses on

the unit in the care of a client who has had a
seizure. Which of the following statements
by a nurse requires further instruction?
A. “I will place the client on their side.”
B. “I will go to the nurses’ station for assistance.”
C. “I will note the time that the seizure begins.”
D. “I will prepare to insert an airway.”
3. A nurse observes smoke coming from under

the door of the staff’s lounge. Which of the
following actions is the nurse’s priority?
A. Extinguish the fire.
B. Activate the fire alarm.
C. Move clients who are nearby.
D. Close all open doors on the unit.
4. A nurse is caring for a client who has a history of falls.

Which of the following actions is the nurse’s priority?
A. Complete a fall-risk assessment.
B. Educate the client and family about fall risks.
C. Eliminate safety hazards from
the client’s environment.
D. Make sure the client uses assistive
aids in their possession.
5. A nurse discovers a small paper fire in a trash can

in a client’s bathroom. The client has been taken
to safety and the alarm has been activated. Which
of the following actions should the nurse take?
A. Open the windows in the client’s
room to allow smoke to escape.
B. Obtain a class C fire extinguisher
to extinguish the fire.
C. Remove all electrical equipment
from the client’s room.
D. Place wet towels along the base of
the door to the client’s room.

1. A. By restraining the client, there is a liability Using the ATI Active Learning Template: Basic Concept
risk for false imprisonment. NURSING INTERVENTIONS
B. Full side rails for this client puts the client at ●
Explain the need for the restraints to the client
risk for a fall because they might attempt to
and family, emphasizing that the restraints keep
climb over the rails to get out of bed.
the client safe and are temporary.
C. CORRECT: Making sure that the call light is within
reach enables the client to contact the nursing staff to
●
Ask the client or guardian to sign a consent form.
ask for assistance and prevents the client from falling
●
Review the manufacturer’s instructions for correct application.
out of bed while reaching for the call light. ●
Assess skin integrity, and provide skin care according
D. CORRECT: Nonskid footwear keeps the client from slipping. to the facility’s protocol, usually every 2 hr.
E. CORRECT: A fall-risk assessment serves as the basis for a ●
Offer food and fluid.
plan of care that can then individualize for the client. ●
Provide a means for hygiene and elimination.
NCLEX® Connection: Safety and Infection Control, ●
Monitor vital signs.
Accident/Error/Injury Prevention ●
Offer range-of-motion exercises of extremities.
●
Pad bony prominences to prevent skin breakdown.
●
Secure restraints to a movable part of the bed frame.
2. A. During a seizure, place the client in a side-lying position If restraints with a buckle strap are not available,
to allow for drainage of secretions and to prevent use a quick-release knot to tie the strap.
the tongue from occluding the airway. ●
Make sure the restraints are loose enough for range
B. CORRECT: During a seizure, stay with the client
of motion and that there is enough room to fit two
and use the call light to summon assistance.
fingers between the restraints and the client.
C. Note the time the seizure begins, and
track how long the seizure lasts.
●
Remove or replace restraints frequently to ensure good circulation
D. Place nothing in the client’s mouth except an to the area and allow for full range of motion to the limbs.
oral airway, if necessary. A tongue blade can
●
Conduct an ongoing evaluation of the client.
cause injury and airway obstruction. NCLEX® Connection: Safety and Infection Control, Use of
NCLEX® Connection: Physiological Adaptation, Restraints/Safety Devices
Alterations in Body Systems
3. A. Although extinguishing the fire is part of the protocol for

responding to a fire, it is not the priority action.
B. Although activating the fire alarm is part of the protocol
for responding to a fire, it is not the priority action.
C. CORRECT: The greatest risk to this client is injury from the fire.
Therefore, the priority intervention is to rescue the clients.
Protect and move clients in close proximity to the fire.
D. Although containing the fire by closing doors and
windows is part of the protocol for responding
to a fire, it is not the priority action.
4. A. CORRECT: The first action to take using the nursing process is

to assess or collect data from the client. Therefore, the priority
action is to determine the client’s fall risk. This will work as a
guide in implementing appropriate safety measures.
B. Educate the client and family about fall risk factors so they can
help promote client safety, but this is not the priority action.
C. Eliminate safety hazards from the client’s environment to help
reduce the risk for falls, but this is not the priority action.
D. Aids (eyeglasses, hearing aids, canes, and walkers)
should be accessible to reduce the client’s risk
for falls, but this is not the priority action.
5. A. Close all doors and windows to contain the fire.

B. Attempt to extinguish the fire with a class A fire extinguisher,
which is used for ordinary combustibles (cloth and paper).
C. Removing all the electrical equipment is not needed, but do
turn off all the electrical equipment in the client’s room.
D. CORRECT: Place wet towels along the base of the door to the
client’s room to contain the fire and smoke in the room.
NCLEX® Connection: Reduction of Risk Potential,
System Specific Assessments

CHAPTER 13
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT INFANTS AND TODDLERS
SECTION: SAFETY AND INFECTION CONTROL
Aspiration
Home Safety
● eep all small ob ects out of reach.
CHAPTER 13 ● Check toys and objects for loose or small parts and
sharp edges.
● Do not feed the infant hard candy, peanuts, popcorn, or
In addition to taking measures to prevent injury hole or sliced pieces of hot dog.
Do not place the infant in the supine position while
of clients in a health care setting, nurses play a
●
feeding or prop the infant s bottle.

pivotal role in promoting safety in the client’s ● A paci er if used should be constructed of one piece
and ne er placed on string or ribbon around the nec .
home and community. Nurses often collaborate
Suffocation
with the client, family, and members of the ● Teach “back to sleep” mnemonic and always place
interprofessional team (social workers, infants on their bac s to rest.
eep plastic bags out of reach.
occupational therapists, and physical therapists)
●
● a e sure the crib mattress ts snugly and that crib

to promote the safety of the client. slats are no more than 2 3/8 inches apart.
● Ne er lea e an infant or toddler alone in the bathtub.
To initiate a plan of care, the nurse must identify ● Do not place anything in crib ith infant.
emo e crib toys mobiles from o er the bed as soon as
risk factors using a risk assessment tool and
●
the infant begins to push up.

complete a nursing history, physical examination, ● Infants should sleep in a crib or bassinet. Co sleeping in
bed ith adults increases the ris for in ury.
and home hazard appraisal. ● eep late balloons a ay from infants and toddlers.
ence s imming pools and use a loc ed gate.
In the plan of care for safety preparedness,
●
● Begin swimming lessons when the child’s

the nurse should include emergency nursing developmental status allows for protective responses
eeping the mouth closed under ater .
principles (basic first aid and CPR). ● Teach caregi ers CP and Heimlich maneu er.
● eep toilet lids do n and bathroom doors closed.
RISK FACTORS FOR CLIENT INJURY Poisoning
● Age and developmental status ● eep houseplants and cleaning agents out of reach.
● Mobility and balance ● Inspect and remo e sources of lead paint chips , and
● Knowledge about safety hazards provide parents with information about prevention of
● Sensory and cognitive awareness lead poisoning.
● Communication skills ● Ha e the poison control hotline number a ailable.
● Home and work environment ● Place poisons, paint, and gasoline in loc ed cabinet.
● Community in which the client lives ● Keep medications, including vitamins, in child-proof
● Lifestyle choices containers and loc ed up.
● Dispose of medication that is expired or no longer
ta en. A medication ta e bac program is a ailable,
SAFETY RISKS BASED ON AGE or medication can be mixed in a sealable bag with an
AND DEVELOPMENTAL STATUS undesirable substance like cat litter and disposed of in
household trash.
● The age and developmental status of the client create
speci c safety ris s. Falls
● Infants and toddlers are at risk for injury due to a ● eep crib and playpen rails up.
tendency to put objects in their mouth and from ● Never leave the infant unattended on a changing table
ha ards encountered hile e ploring their en ironment. or other high surface.
● Preschool- and school-age children often face injury ● Use gates on stairs, and ensure windows have
from limited or underde eloped motor coordination. indo guards.
● Adolescents’ risks for injury can stem from increased ● Restrain according to manufacturer’s recommendations
desire to make independent decisions and relying on and super ise hen in high chair, s ing, stroller, etc.
peers for guidance rather than family. Discontinue use when the infant or toddler outgrows
● ome of the accident pre ention measures for speci c si e or acti ity limits.
age groups include the follo ing. ● Place in a lo bed hen toddler starts to climb.
FUNDAMENTALS FOR NURSING CHAPTER 13 HOME SAFETY 65

Motor vehicle injury Play injury
● Place infants and toddlers in a rear-facing car seat ● Teach to not run with candy or objects in mouth.
until 2 years of age or until they exceed the height ● Remove doors from refrigerators or other
and weight limit of the car seat. They can then sit in a potentially con ning structures.
forward-facing car seat. ● Ensure that bikes are the appropriate size for child.
● se a car seat ith a e point harness for infants ● Teach playground safety.
and children. ● Teach to play in safe areas, and avoid heavy
● All car seats should be federally approved and be placed machinery, railroad tracks, excavation areas,
in the back seat, which is the safest place in the vehicle. quarries, trunks, and vacant buildings.
● Infants and toddlers remain in a rear-facing car seat ● Teach to never swim alone and to
until the age of 2 years or the height recommended by wear a life jacket in boats.
the manufacturer. ● Wear protective helmets and knee
● Toddlers over the age of 2 years, or who exceed the and elbow pads, when needed.
height recommendations for rear-facing car seats, ● Teach to avoid strangers and keep
should use a forward-facing car seat until they reach parents informed of strangers.
the height and weight requirements for a booster seat.
Burns
Burns ● Reduce setting on water heater to no higher than 120° F.
● Test the temperature of formula and bath water. ● Teach dangers of playing with matches,
● Place pots on back burner and turn handle away from re or s, and rearms.
front of stove. ● Teach school-age child how to properly use
● Supervise the use of faucets. microwave and other cooking instruments.
● Keep matches and lighters out of reach. ● Apply sunscreen of SPF 30 or higher to the
● Cover electrical outlets. child’s skin to prevent sunburn. Dress the

● Apply sunblock of SPF 30 or higher for an infant or child with clothing to protect the skin.
toddler to prevent sunburn. Dress the infant or toddler
Poison
with clothing to protect the skin. ● Teach child about the hazards of alcohol, cigarettes, and
prescription, non-prescription, and illicit drugs.
PRESCHOOLERS AND ● Keep potentially dangerous substances out of reach.
SCHOOL-AGE CHILDREN ● Have the poison control hotline number available.
Drowning
● Be sure child has learned to swim and knows rules of ADOLESCENTS
water safety.
Educate on the hazards of smoking, alcohol, legal and
● Have the child wear a life jacket when near water.
illegal drugs, and unprotected sex.
Implement a buddy system for the school-aged child.
● Place locked fences around home and neighborhood pools. Motor vehicle and injury
● Provide supervision near pools or water. ● Ensure the teen has completed a driver’s education course.
● Set rules on the number of people allowed
Motor vehicle injury
to ride in cars, seat belt use, and to call for
● Use booster seats for children who are less than 4 feet
a ride home if a driver is impaired.
9 inches tall and weigh less than 40 lb (usually 4 to ● Educate on the hazards of driving while distracted
8 years old). The child should be able to sit with their
(eating or drinking, making phone calls or texting).
back against the car seat, and both legs should dangle ● Reinforce teaching on proper use of protective
over the seat.
equipment when participating in sports.
● If the car has a passenger air bag, place children under ● Be alert to manifestations of depression,
12 years in the back seat.
anxiety, or other behavioral changes
● Use seat belts properly after booster seats are no ● Teach about the ha ards of rearms and
longer necessary.
safety precautions ith rearms.
● Use protective equipment when participating in sports, ● Teach water safety and to check water depth before diving.
riding a bike, or riding as a passenger on a bike.
● Supervise and teach safe use of equipment. Burns
● Teach the child to play in safe areas and never to run ● Teach to use sunscreen of SPF 30 or higher and
after a ball or toy that goes into a road. protective clothing.
● Teach child safety rules of the road. ● Teach the dangers of sunbathing and tanning beds.
Begin sex education for school-age child. Social media: Discuss, monitor, and limit exposure to
social networking and the Internet. Parents should role
Firearms
model appropriate social interactions.
● eep rearms unloaded, loc ed up, and out of reach.
● Teach to never touch a gun or stay at a friend’s house
where a gun is accessible.
● tore bullets in a different location from guns.
66 CHAPTER 13 HOME SAFETY CONTENT MASTERY SERIES

YOUNG AND MIDDLE-AGE ADULTS ● Use a nonskid mat in the tub or shower.
● Place a shower chair in the shower and
Motor vehicle crashes are the most common cause of death
provide a bedside commode if needed.
and injury to adults. Occupational injuries contribute to ● Ensure that lighting is adequate inside and
the injury and death rate of adults. High consumption of
outside the home and remove clutter.
alcohol and suicide are also major concerns for adults.
CLIENT EDUCATION
● Drive defensively and do not drive after drinking alcohol. FIRE SAFETY IN THE HOME
● There are long term effects related to high alcohol
Home res continue to be a ma or cause of death and
consumption, smoking, second-hand smoke from tobacco
injury for people of all ages. Educate clients about the
use, illicit drug use, and e cessi e caffeine consumption.
importance of a home safety plan.
● Ensure home safety with smoke and carbon monoxide
detectors, re alarms, ell lit and uncluttered staircases.
● Be attuned to behaviors that suggest the ELEMENTS OF A HOME SAFETY PLAN
presence of depression or thoughts of suicide. ● Keep emergency numbers near the phone for prompt use
Consider counseling as appropriate.
in the event of an emergency of any type.
● Adhere to diving and water safety. ● nsure that the number and placement of re
● Become proactive about safety in the
extinguishers and smoke alarms are adequate, that they
workplace and in the home.
are functional, and that family members understand
● Remember the dangers of social
how to operate them. Set a time to routinely change
networking and the Internet.
batteries in smoke alarms (in the fall when the clocks
● Understand the hazards of excessive sun exposure and
are set to standard time and spring when set to Daylight
the need to protect the skin with the use of sun-blocking
Saving Time).
agents of SPF 30 or higher and protective clothing. ● Ha e a family e it plan for res that is re ie ed and
practiced regularly. Be sure to include closing windows
OLDER ADULTS and doors if able and to e it a smo e lled area by
covering the mouth and nose with a damp cloth and
● The rate at which age-related changes occur varies
getting do n as close to the oor as possible.
greatly among older adults. ● Review with clients of all ages that in the event that the
● Many older adults are able to maintain a lifestyle
client s clothing or s in is on re, the mnemonic stop,
that promotes independence and the ability to protect
drop, and roll should be used to e tinguish the re.
themselves from safety hazards. ● Review oxygen safety measures. Because oxygen can
● Prevention is important because elderly clients can
cause materials to combust more easily and burn more
have longer recovery times from injuries and the risk
rapidly, the client and family must be provided with
of complications.
information on use of the oxygen delivery equipment
● A decrease in tactile sensitivity can place the client at
and the dangers of combustion. Include the following
risk for burns and other types of tissue injury.
information in the teaching plan:
● When the client demonstrates factors that increases ◯ Use and store oxygen equipment according to the
the risk for injury (regardless of age), a home hazard

manufacturer’s recommendations.
evaluation should be conducted by a nurse, physical ◯ Place a “No Smoking” sign in a conspicuous place
therapist, and/or occupational therapist. The client is

near the front door of the home. A sign can also be
made aware of the environmental factors that can pose
placed on the door to the client’s bedroom.
a ris to safety and suggestion modi cations to be made. ◯ Inform the client and family of the danger of smoking
RISK FACTORS FOR FALLS IN OLDER ADULTS in the presence of oxygen. Family members and
● Physical, cognitive, and sensory changes visitors who smoke should do so outside the home.
● Changes in the musculoskeletal and neurologic systems ◯ Ensure that electrical equipment is in good repair and
● Impaired vision or hearing well grounded.

● Frequent trips to the bathroom at night because of ◯ Replace bedding that can generate static electricity
nocturia and incontinence (wool, nylon, synthetics) with items made from cotton.
◯ eep ammable materials heating oil and nail polish
MODIFICATIONS TO IMPROVE HOME SAFETY
remover) away from the client when oxygen is in use.
● Remove items that could cause the client to ◯ ollo general measures for re safety in the home
trip (throw rugs and loose carpets).
ha ing a re e tinguisher readily a ailable and an
● Place electrical cords and extension cords
established e it route if a re occurs .
against a wall behind furniture.
● Monitor gait and balance, and provide aids as needed.
● Make sure that steps and sidewalks are in good repair.
● Place grab bars near the toilet and in the
tub or shower, and install a stool riser.

ADDITIONAL RISKS IN THE Food poisoning
HOME AND COMMUNITY Food poisoning is a major cause of illness in the United
Additional risks in the home and community include States. Most food poisoning is caused by bacteria
passive smoking, carbon monoxide poisoning, and food (Escherichia coli, Listeria monocytogenes, and Salmonella).
poisoning. Clients should have their homes checked for ● Healthy individuals usually recover from the illness in
radon, the second-leading cause of lung cancer. a few days.
Bioterrorism also has become a concern, making disaster ● Very young, very old, immunocompromised, and
plans a mandatory part of community safety. Nurses pregnant individuals are at risk for complications.
should teach clients about the dangers of these ● Clients who are especially at risk are instructed to
additional risks. follow a low-microbial diet.
● Most food poisoning occurs because of unsanitary food
Passive smoking (secondhand smoke) practice. Perform hand hygiene before, during, and
after food preparation, avoiding cross-contamination
● Passive smoking is the unintentional inhalation of
of equipment and foods, and cleaning food preparation
tobacco smoke.
surfaces well.
● Exposure to nicotine and other toxins places people ● nsure meat and sh are coo ed to the correct
at risk for numerous diseases including cancer, heart
temperature, handling raw and fresh food separately to
disease, and lung infections.
avoid cross contamination, and refrigerating perishable
● Low-birth-weight infants, prematurity, stillbirths,
items are measures that can prevent food poisoning.
and sudden infant death syndrome (SIDS) have been ● Check expiration dates, and refrigerate perishable items.
associated with maternal smoking. ● Avoid any products made from unpasteurized dairy or
● Smoking in the presence of children is associated with
meat spreads, or uncooked eggs.
the development of bronchitis, pneumonia, and middle ● Do not eat raw sprouts, damaged or moldy raw foods, or
ear infections.
unwashed produce.
● For children who have asthma, exposure to passive ● Heat hot dogs and deli or luncheon meats.
smoke can result in an increase in the frequency and the
severity of asthma attacks.
CLIENT EDUCATION PRIMARY SURVEY

Be aware and remind family of:
A primary survey is a rapid assessment of life-threatening
● The hazards of smoking.
conditions. It should take no longer than 60 seconds
● Available resources to stop smoking (smoking cessation
to perform.
programs, medication support, self-help groups). ● The primary survey should be completed systematically
● The effect that isiting indi iduals ho smo e or riding
so conditions are not missed.
in the automobile of a smoker has on a nonsmoker. ● Standard precautions (gloves, gowns, eye protection,
face masks, and shoe covers) must be worn to prevent
Carbon monoxide
contamination ith bodily uids.
Carbon monoxide is a very dangerous gas because it binds
with hemoglobin and ultimately reduces the oxygen
supplied to the tissues in the body.
ABCDE PRINCIPLE
● Carbon monoxide cannot be seen, smelled, or tasted. The ABCDE principle guides the primary survey and
● Manifestations of carbon monoxide poisoning emergency care.
include nausea, vomiting, headache, weakness,
Airway/Cervical Spine: This is the most important step in
and unconsciousness.
performing the primary survey. If a patent airway is not
● Death can occur with prolonged exposure.
established, subsequent steps of the primary survey are
● Measures to prevent carbon monoxide poisoning include
futile. Protect the cervical spine if head or neck trauma
ensuring proper ventilation when using fuel-burning
is suspected.
de ices la n mo ers, ood burning and gas replaces,
charcoal grills). Breathing: After achieving a patent airway, assess for the
● Gas-burning furnaces, water heaters, and appliances presence and effecti eness of breathing.
should be inspected annually.
Circulation: After ensuring adequate ventilation, assess
● Flues and chimneys should be unobstructed.
circulation.
● Carbon monoxide detectors should be installed and
inspected regularly. Disability: Perform a quick assessment to determine the
● Check carbon monoxide batteries at the same time as client’s level of consciousness.
smoke detector batteries. Change the batteries annually
Exposure: Perform a quick physical assessment to
on a speci c date, li e on a birthday.
determine the client’s exposure to adverse elements (heat
or cold).
SEE THE CHAPTER ON EMERGENCY NURSING PRINCIPLES AND

MANAGEMENT IN THE ADULT MEDICAL SURGICAL NURSING
REVIEW MODULE FOR FURTHER DETAIL ON THE PRIMARY SURVEY.

BASIC FIRST AID Frostnip and frostbite
Complete the primary sur ey before performing rst aid. ● Occurs when the body is exposed to freezing
temperatures.
Bleeding ● Common sites include the earlobes, tip of the nose,
ngers, and toes.
● Identify any sources of external bleeding and apply ● Frostnip does not lead to tissue injury and can be
direct pressure to the wound site.
treated by warming.
● DO NOT remove impaling objects. Instead, stabilize ● Frostbite presents as white, waxy areas on exposed skin.
the object.
Tissue injury occurs.
● Internal bleeding can require intravascular volume ● Frostbite can be full- or partial-thickness.
replacement ith uids and or blood products, or ● arm the affected area in a to C . to
surgical intervention.
water bath.
Provide pain medication.
Fractures and splinting
●
● Administer a tetanus vaccination.

● Assess the site for swelling, deformity, and
skin integrity. Burns
● Assess temperature, distal pulses, and mobility. ● Burns can result from electrical current, chemicals,
● Apply a splint to immobilize the fracture. Cover open
radiation, or ames.
areas with a sterile cloth if available. ● Home hazards include pot handles that protrude over
● Reassess neurovascular status below the injury site
the stove, hot bath water, and electrical appliances.
after splinting. ● Remove the agent (electrical current, radiation source,
chemical).
Sprains ● mother any ames that are present. Perform a
● Use the acronym RICE to manage sprains: primary survey.
◯ Refrain from weight-bearing. ● Cover the client and maintain NPO status.
◯ Apply ice to decrease in ammation. ● Elevate the client’s extremities if not contraindicated
◯ Apply a compression dressing to minimize swelling. (presence of a fracture).
◯ le ate the affected limb. ● Perform a head-to-toe assessment and estimate the
surface area and thickness of burns.
Heat stroke ● Administer uids and a tetanus to oid.
The nurse should identify heat stroke (body temperature

Altitude-related illnesses
●
greater than 40° C [104° F]) quickly and treat

it aggressively. Clients can become hypoxic in high altitudes. Altitude
● Manifestations of heat stroke include hot, dry skin; sickness can progress to cerebral and pulmonary edema
hypotension; tachypnea; tachycardia; anxiety; and requires immediate treatment.
confusion; unusual behavior; seizures; and coma. The
EXPECTED FINDINGS
client does not sweat. ● Throbbing headache
● Intervene to provide rapid cooling. ● Nausea
◯ Remove the client’s clothing.
● Vomiting
◯ Place ice packs over the major arteries (axillae, chest,
● Dyspnea
groin, neck). ● Anorexia
◯ Apply a hypothermia blanket to promote cooling.
◯ Irrigate the stomach and large intestine with NURSING INTERVENTIONS

cooling solution. ● Administer oxygen.
◯ Wet the client’s body, then fan with rapid ● Descend to a lower altitude.
movement of air. ● Provide pharmacological therapy (steroids and diuretics)
◯ Do not allow client to shiver. If client shivers, cover if indicated.
with a sheet. ● Promote rest.

CPR Application Exercises
CPR is a combination of basic interventions designed to
sustain oxygen and circulation to vital organs until more 1. A nurse is providing discharge instructions to a
advanced interventions can be initiated to correct the root client who has a prescription for oxygen use at
cause of the cardiac arrest. home. Which of the following information should
● fficient CP impro es the client s chance of sur i al. the nurse include? (Select all that apply.)
● Trained individuals can deliver basic interventions, but A. Family members who smoke must be at least
special training and certi cation is re uired for the use 10 ft from the client when oxygen is in use.
of advanced interventions with emergency equipment B. Nail polish should not be used near a
(advanced cardiac life support [ACLS]). client who is receiving oxygen.
● CP is directed at arti cially pro iding a client ith C. A “No Smoking” sign should be
circulation (chest compressions) and oxygenation placed on the front door.
(ventilations) in the absence of cardiac output. D. Cotton bedding and clothing should be
● CPR is a component of basic life support (BLS). replaced with items made from wool.
● The goal of BLS is to provide oxygen to the vital organs E. A fire extinguisher should be readily
until appropriate advanced resuscitation measures can available in the home.
be initiated or until resuscitati e efforts are ordered to
be stopped.
● BLS involves the CABs (Chest Compression, Airway, and 2. A nurse educator is presenting a module on basic first
Breathing) of CPR. aid for newly licensed home health nurses. The client
◯ Assess client for a response and look for breathing.
who has heat stroke will have which of the following?
Do not take time to perform a “look, listen, and feel” A. Hypotension
assessment of breathing. If there is no breathing or no B. Bradycardia
normal breathing (only gasping), call for help. C. Clammy skin
◯ If alone, activate emergency response system and D. Bradypnea
get an automated e ternal de brillator A D , if
available, and return to the client. If a second person 3. A nurse educator is conducting a parenting
is available, ask the second person to activate the class for new guardians of infants. Which
emergency response system and get an AED. of the following statements made by a
◯ Check pulse. Begin CPR compressions alternated with participant indicates understanding?
breaths if a pulse is not detected. A. “I will set my water heater at 130° F.”
● For further detail on CPR, visit the American Heart B. “Once my baby can sit up, they
Association website. should be safe in the bathtub.”
CLIENT EDUCATION C. “I will place my baby on their stomach to sleep.”
● Ta e basic rst aid and CP courses, along ith family D. “Once my infant starts to push up, I will
members. Consider joining a community agency where remove the mobile from over the crib.”
basic rst aid and CP are taught.
● eep emergency numbers poison control, re rescue, 4. A home health nurse is discussing the dangers of
providers, nearest hospitals and urgent care facilities) carbon monoxide poisoning with a client. Which of
in the home. the following information should the nurse include?
A. Carbon monoxide has a distinct odor.
B. Water heaters should be inspected every 5 years.
C. The lungs are damaged from
carbon monoxide inhalation.
Active Learning Scenario D. Carbon monoxide binds with
hemoglobin in the body.
A nurse educator is teaching a module on the basic
principles of creating a home safety plan during
nursing orientation to a group of newly appointed 5. A home health nurse is discussing the
home health nurses. Use the ATI Active Learning dangers of food poisoning with a client.
Template: Basic Concept to complete this item. Which of the following information should
NURSING INTERVENTIONS: List four key elements A. Most food poisoning is caused by a virus.
that a home safety plan should include.
B. Immunocompromised individuals are at increased
risk for complications from food poisoning.
C. Clients who are at high risk should eat or
drink only pasteurized dairy products.
D. Healthy individuals usually recover
from the illness in a few weeks.
E. Handling raw and fresh food separately
can prevent food poisoning.

1. A. Remind family members who smoke to do so outside. Using the ATI Active Learning Template: Basic Concept
B. CORRECT: Remind the client to not use nail polish NURSING INTERVENTIONS
or other flammable materials in the home.
C. CORRECT: Have the client place a “No Smoking” sign near A home safety plan should include the following.
the front door, and possibly on the client’s bedroom door. ●
Keep emergency numbers near the phone for prompt
D. Tell the client to choose cotton materials for clothing use in the event of an emergency of any type.
and bedding. Woolen and synthetic materials create ●
Ensure that the number and placement of fire extinguishers
static electricity and could cause a fire. and smoke alarms are adequate, that they are operable,
E. CORRECT: Remind all individuals to have a fire and that family members know how to operate them. Set a
extinguisher at home. This is especially important time to routinely change the batteries in the smoke alarms
for a client who is receiving oxygen. (for example, in the fall when the clocks are set to standard
NCLEX® Connection: Safety and Infection Control, time and spring when set to Daylight Saving Time).
Safe Use of Equipment ●
Have a family exit plan for fires that the family reviews and practices
regularly. Be sure to include closing windows and doors if able and
to exit a smoke filled area by covering the mouth and nose with a
2. A. CORRECT: Hypotension is a manifestation of heat stroke. damp cloth and getting down as close to the floor as possible.
B. Tachycardia is a manifestation of heat stroke. ●
Review with clients of all ages that in the event that the
C. Hot, dry skin is a manifestation of heat stroke. client’s clothing or skin is on fire, the client should use the
D. Dyspnea is a manifestation of heat stroke. mnemonic “stop, drop, and roll” to extinguish the fire.
NCLEX® Connection: Physiological Adaptation, Pathophysiology ●
Review oxygen safety measures. Because oxygen can cause
materials to combust more easily and burn more rapidly, the
client and family must be provided with information on use of the
3. A. Instruct the guardian to set the home water oxygen delivery equipment and the dangers of combustion.
heater temperature to 120° F or less.
NCLEX® Connection: Safety and Infection Control, Home Safety
B. Although the baby can hold their head above the
water by sitting up, this does not make the child safe
in the bathtub. Warn the guardian to never leave
an infant or toddler alone in the bathtub.
C. Remind the guardian to place the infant on their back to
sleep, and to remove suffocation hazards from the crib.
D. CORRECT: The guardian should plan to remove crib toys
(mobiles) from over the bed as soon as the infant begins
to push up so the infant is unable to touch them.
4. A. Include that carbon monoxide cannot be

seen, smelled, or tasted.
B. Tell the client to inspect gas-burning furnaces,
water heaters, and appliances annually.
C. Inform the client that carbon monoxide impairs the body’s
ability to use oxygen, but the lungs are not damaged.
D. CORRECT: Warn the client that carbon monoxide is very
dangerous because it binds with hemoglobin and ultimately
reduces the oxygen supplied to the tissues in the body.
5. A. Include that most food poisoning is caused

by bacteria (Escherichia coli, Listeria
monocytogenes, and Salmonella).
B. CORRECT: Warn the client that very young, very old,
immunocompromised, and pregnant individuals are at
increased risk for complications from food poisoning.
C. CORRECT: Include that clients who are at high
risk should follow a low-microbial diet, which
includes eating or drinking only pasteurized milk,
yogurt, cheese, and other dairy products.
D. Inform the client that healthy individuals usually
recover from the illness in a few days.
E. CORRECT: Include interventions to prevent food
poisoning (performing proper hand hygiene, cooking
meat and fish to the correct temperature, handling raw
and fresh food separately to avoid cross-contamination,
and refrigerating perishable items).

CHAPTER 14 Online Video: Ergonomic Principles
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT ● When the human body is in the upright position, the
SECTION: SAFETY AND INFECTION CONTROL center of gravity is the pelvis.
When an individual moves, the center of gravity shifts.
Ergonomic
●
● The closer the line of gravity is to the center of the base

CHAPTER 14
Principles
of support, the more stable the individual is.
● The vertical line from the center of gravity must fall
through a stable base of support in order to maintain
balance. To lower the center of gravity, bend the hips
and knees.
Ergonomics is a science that focuses on the ● Spread your feet apart to lower your center of gravity
factors or qualities in an object’s design or use and broaden your base of support. This results in greater
stability and balance.
that contribute to comfort, safety, efficiency, and
ease of use. LIFTING
Using good body mechanics when positioning ● Situational factors that increase the risk of injury
◯ Having to twist while lifting
and moving clients promotes safety for the client ◯ Lifting in a small space
and the staff. ◯ Lifting while kneeling or sitting
◯ Lifting while arms are extended away from the body
Before attempting to position or move a ◯ Having worked longer than 8 hr
Client factors that can increase the risk for injury

client, perform a mobility assessment. Begin
●
include lifting a client who has a physical condition

with the easiest movements (range of motion) that affects their ability to be mo ed pain, presence of
drains) or is combative or uncooperative.
and progress as long as the client tolerates it ● Use the major muscle groups to prevent back strain, and
(balance, gait, exercise). tighten the abdominal muscles to increase support to
the back muscles.
Client and bed positions are often part of the ● Distribute your weight between the large muscles of the
arms and legs to decrease the strain on any one muscle
provider’s prescription, or a nursing intervention group and to avoid strain on smaller muscles.
that corresponds with the client’s condition and ● hen lifting an ob ect from the oor, e your hips,
knees, and back. Bring the object to thigh level, bending
physiological needs. your knees and keeping your back straight. Stand up
while holding the object as close as possible to your
body, bringing the load to the center of gravity to
ERGONOMIC PRINCIPLES increase stability and decrease back strain.
AND BODY MECHANICS ● Use assistive devices whenever possible and seek
● Body mechanics is the use of muscles to maintain assistance whenever needed.
balance, posture, and body alignment when performing ● Use an assistive device if lifting more than
a physical task. Nurses use body mechanics when 15.9 kg (35 lb).
providing care to clients by lifting, bending, and
assisting clients with the activities of daily living.
● Body alignment keeps the center of gravity stable,
PUSHING OR PULLING
which promotes comfort and reduces strain on When pushing or pulling a load:
the muscles. ● Widen your base of support.
● Good body mechanics reduces the risk of injury. ● When opportunity allows, pull objects toward the center
Whenever possible, use mechanical lift devices to lift of gravity rather than pushing them away.
and transfer clients. Many facilities have “no manual ● If pushing, move your front foot forward and, if pulling,
lift” and “no solo lift” policies. move your rear leg back to promote stability.
● Face the direction of movement when moving a client.
Use your own body as a counterweight when pushing or
CENTER OF GRAVITY
●
pulling to make the movement easier.

● The center of gravity is the center of a mass. ● Sliding, rolling, and pushing require less energy than
● Weight is a quantity of matter on which the force of lifting and offer less ris for in ury.
gravity acts. ● Face the direction of movement. Avoid twisting your
● To lift an object, it is essential to overcome the weight of thoracic spine and bending your back while your hips
the object and to know the center of gravity of the object. and knees are straight.
FUNDAMENTALS FOR NURSING CHAPTER 14 ERGONOMIC PRINCIPLES 73

TRANSFERS AND USE OF POSITIONING CLIENTS
ASSISTIVE DEVICES ● Position clients, especially those who are unable to
● Evaluate each situation and use an algorithm to move themselves, so that they maintain good body
determine the safest method to transfer or move the alignment. Frequent position changes prevent
client. Answer these questions: Can the client bear discomfort, contractures, pressure on tissues, and nerve
weight? Can they assist? Are they cooperative? and circulatory damage, and they stimulate postural
● Determine the client’s ability to help with transfers re e es and muscle tone.
(balance, muscle strength, endurance, use of a trapeze bar). ● Use pillows, bath blankets, hand rolls, boots, splints,
● aluate the need for additional staff or assisti e de ices trochanter rolls, ankle support devices, and other aids
(transfer belt, hydraulic lift, sliding board). to maintain proper body alignment.
● Assess and monitor the use of mobility aids (canes,
walkers, crutches).
● Include assistance or mobility aids in the plan of care BED AND CLIENT POSITIONS
for safe transfers and ambulation.
Semi-Fowler’s
GUIDELINES FOR PREVENTING INJURY ● The client lies supine with the head of the bed elevated
15° to 45° (typically 30°).
● Know your facility’s policies for lifting and safe client ● This position prevents regurgitation of enteral feedings
handling.
and aspiration by clients ho ha e difficulty s allo ing.
● Ha e one or more staff members assist ith positioning ● It also promotes lung expansion for clients who have
clients. o ing them up in bed is a signi cant cause of
dyspnea or are receiving mechanical ventilation.
back pain and injury.
Plan ahead for activities that require lifting, transfer,
Fowler’s
●
and ambulation of a client, and ask others to be

available to assist. ● The client lies supine with the head of the bed elevated
● Prepare the environment by removing obstacles prior to 45° to 60°.
the procedure. ● This position is useful during procedures (nasogastric
● Explain the process to the client and assistants to tube insertion and suctioning). It allows for better
clarify their roles. chest expansion and ventilation and better dependent
● Be aware that the safest way to lift a client is with drainage after abdominal surgeries.
assistive equipment.
● Rest between heavy activities to decrease muscle fatigue. High-Fowler’s
● Maintain good posture and exercise regularly to increase ● The client lies supine with the head of the bed elevated
the strength of your arms, legs, back, and abdominal
60° to 90°.
muscles, so these activities will require less energy. ● This position promotes lung expansion by lowering the
● Keep your head and neck in a straight line with your
diaphragm and thus helps relieve severe dyspnea.
pel is to a oid nec e ion and hunched shoulders, ● It also helps prevent aspiration during meals.
which can cause impingement of nerves in your neck.
Use smooth movements when lifting and moving
Supine or dorsal recumbent
●
clients to prevent injury from sudden or jerky

muscle movements. ● The client lies on their back with the head and
● hen standing for long periods of time, e your hips and shoulders elevated on a pillow and forearms on pillows
knees by using a footrest. When sitting for long periods of or at their sides. A foot support prevents foot drop and
time, keep your knees slightly higher than your hips. maintains proper alignment. Ensure that the vertebrae
● Avoid repetitive movements of the hands, wrists, and are in straight alignment ithout e cessi e e ion or
shoulders. Ta e a brea e ery to min to e and extension of the head and neck.
stretch joints and muscles whenever possible.
● Avoid twisting your spine or bending at the waist Prone
e ion to minimi e the ris for in ury. ● The client lies at on their abdomen and chest ith the
head to one side and back in correct alignment.
● A pillow may be placed under the leg. This promotes
rela ation by permitting some nee e ion and
dorsi e ion of the an les.
● This position promotes drainage from the mouth after
throat or oral surgery, but inhibits chest expansion. It is
for short-term use only.
● This position helps pre ent hip e ion contractures
following a lower extremity amputation.
74 CHAPTER 14 ERGONOMIC PRINCIPLES CONTENT MASTERY SERIES

Lateral or side-lying Application Exercises
● The client lies on their side with most of the weight on
the dependent hip and shoulder and the arms in e ion 1. A nurse is caring for a client who is receiving
in front of the body. They should have a pillow under enteral tube feedings due to dysphagia.
the head and neck, upper arms, and legs and thighs to Which of the following bed positions should
the nurse use for safe care of this client?
maintain body alignment.
● This is a good sleeping position, but the client needs A. Supine
turning regularly to prevent the development of B. Semi-Fowler’s
pressure ulcers on the dependent areas. A 30° lateral C. Semi-prone
position is essential for clients at risk for D. Trendelenburg
pressure ulcers.
2. A nurse is caring for a client who is sitting in a chair
Sims’ or semi-prone and asks to return to bed. Which of the following
actions is the nurse’s priority at this time?
● The client is on their side halfway between lateral and
A. Obtain a walker for the client to
prone positions, with the weight on their anterior ileum,
use to transfer back to bed.
humerus, and clavicle. The lower arm is behind them
B. Call for additional staff to assist with the transfer.
hile the upper arm is in front. oth legs are in e ion
C. Use a transfer belt and assist
but the upper leg is e ed at a greater angle than the the client back into bed.
lo er leg at the hip as ell as at the nee. It differs D. Determine the client’s ability to
from the side-lying position in the distribution of the help with the transfer.
client’s weight.
This is a comfortable sleeping position for many clients,
3.
●
A nurse is instructing a client who has COPD

and it promotes oral drainage.
about using the orthopneic position to relieve
shortness of breath. Which of the following
Orthopneic statements should the nurse make?
● The client sits in the bed or at the bedside with a pillow on A. “Lie on your back with our head and
the overbed table, which is across the client’s lap. They rest shoulders supported by a pillow.”
their arms on the overbed table. B. “Have your head turned to the side
● This position allows for chest expansion and is especially while you lie on your stomach.”
bene cial for clients ho ha e C PD. C. “Have a table beside your bed so you can sit on
the bedside and rest your arms on the table.”
Trendelenburg D. “Lie on your side with your top arm resting
on the bed and your weight on your hip.”
● The entire bed is tilted with the head of the bed lower
than the foot of the bed. 4. A nurse manager is reviewing guidelines for
● This position facilitates postural drainage and preventing injury with staff nurses. Which of
venous return. the following instructions should the nurse
manager include? (Select all that apply.)
Reverse Trendelenburg A. Request assistance when repositioning a client.
● The entire bed is tilted with the foot of the bed lower B. Avoid twisting your spine or bending at the waist.
than the head of the bed. C. Keep your knees slightly lower than your hips
● This position promotes gastric emptying and prevents when sitting for long periods of time.
esophageal re u . D. Use smooth movements when
lifting and moving clients.
E. Take a break from repetitive movements every 2
Modified Trendelenburg
to 3 hr to flex and stretch your joints and muscles.
● The client remains at ith the legs abo e the le el of
their heart. 5. A nurse educator is reviewing proper body
● This position helps prevent and treat hypovolemia and mechanics during employee orientation. Which
facilitates venous return. of the following statements should the nurse
identify as an indication that an attendee
understands the teaching? (Select all that apply.)
A. “My line of gravity should fall
outside my base of support.”
Active Learning Scenario B. “The lower my center of gravity,
the more stability I have.”
A nurse is presenting the basic principles of proper lifting C. “To broaden my base of support, I
to a group of assistive personnel. Use the ATI Active should spread my feet apart.”
Learning Template: Basic Concept to complete this item. D. “When I lift an object, I should hold it
as close to my body as possible.”
UNDERLYING PRINCIPLES: List four key E. “When pulling an object, I should
elements of proper lifting techniques. move my front foot forward.”
FUNDAMENTALS FOR NURSING CHAPTER 14 ERGONOMIC PRINCIPLES 75

1. A. In the supine position, the client lies on their back Using the ATI Active Learning Template: Basic Concept
with the head and shoulders elevated on a pillow. UNDERLYING PRINCIPLES
This angle will not prevent regurgitation. ●
Use the major muscle groups to prevent back strain, and tighten
B. CORRECT: In the semi-Fowler’s position, the client lies supine
the abdominal muscles to increase support to the back muscles.
with the head of the bed elevated 15° to 45° (typically 30°).
This position helps prevent regurgitation and aspiration
●
Distribute your weight between the large muscles of the
by clients who have difficulty swallowing. This is the safest arms and legs to decrease the strain on any one muscle
position for clients receiving enteral tube feedings. group and to avoid strain on smaller muscles.
C. In the semi-prone or Sims’ position, the client is on their
●
When lifting an object from the floor, flex your hips, knees, and
side halfway between lateral and prone positions. This back. Bring the object to thigh level, bending your knees and
position is not safe because it promotes regurgitation. keeping your back straight. Stand up while holding the object as
D. In the Trendelenburg position, the entire bed is tilted with close as possible to your body, bringing the load to the center
the head of the bed lower than the foot of the bed. This of gravity to increase stability and decrease back strain.
position is not safe because it promotes regurgitation. ●
Use assistive devices whenever possible, and
seek assistance whenever you need it.
NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures NCLEX® Connection: Safety and Infection Control, Ergonomic
Principles
2. A. Although this might be a necessary assistive

device for this client, obtaining a walker is not the
priority action the nurse should take.
B. Although this might be necessary for a safe
transfer, calling for assistance is the not the
priority action the nurse should take.
C. Although this might be a necessary assistive device
for the transfer of this client, using a transfer belt is
not the priority action the nurse should take.
D. CORRECT: The first action that should be taken using
the nursing process is to assess or collect data from
the client. Determine the client’s ability to help with
transfers and then proceed with a safe transfer.
Ergonomic Principles
3. A. The nurse is describing the supine position,

not the orthopneic position.
B. The nurse is describing the prone position,
not the orthopneic position.
C. CORRECT: This is an accurate description for the orthopneic
position. This position allows for chest expansion and
is especially beneficial for clients who have COPD.
D. The nurse is describing the lateral or side-lying
position, not the orthopneic position.
4. A. CORRECT: To reduce the risk of injury, at least two

staff members should reposition clients.
B. CORRECT: Twisting the spine or bending at the
waist (flexion) increases the risk for injury.
C. When sitting for long periods of time, it is essential
to keep the knees slightly higher, not lower, than
the hips to decrease strain on the lower back.
D. CORRECT: Using smooth movements instead of sudden
or jerky muscle movements helps prevent injury.
E. It is important to take a break every 15 to 20 min,
not every 2 to 3 hr, from repetitive movements
to flex and stretch joints and muscles.
5. A. To reduce the risk of falling, the line of gravity should

fall within the base of support, not outside it.
B. CORRECT: Being closer to the ground lowers the center
of gravity, which leads to greater stability and balance.
C. CORRECT: Spreading the feet apart increases
and widens the base of support.
D. CORRECT: Holding an object as close to the body as
possible helps avoid displacement of the center of
gravity and thus prevent injury and instability.
E. To promote stability, move the rear leg
back when pulling on an object.
76 CHAPTER 14 ERGONOMIC PRINCIPLES CONTENT MASTERY SERIES

CHAPTER 15
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT THE JOINT COMMISSION AND
SECTION: SAFETY AND INFECTION CONTROL EMERGENCY PREPAREDNESS
Security and The Joint Commission established emergency

CHAPTER 15 preparedness management standards for various types of
Disaster Plans health care facilities. These standards mandate that an

institutional emergency preparedness plan is developed by
all health care institutions and that these plans include
institution speci c procedures for the follo ing.
A disaster is a mass casualty or intra-facility ● Notifying and assigning personnel.
Notifying external authorities of emergencies.
event that at least temporarily overwhelms
●
● Managing space and supplies and providing security.

or interrupts the normal flow of services of a ● Isolating and decontaminating radioactive or
chemical agents (measures to contain contamination,
hospital. Disasters that health care facilities face decontamination at the scene of exposure).
include internal and external emergencies. ● Evacuating and setting up an alternative care site when
the environment cannot support adequate client care
Internal emergencies include loss of electric and treatment. Critical processes when an alternative
care site is necessary include the following.
power or potable water, loss of communication ◯ Client information/care packaging (medications,
ability, disruption of computer information supplies, admissions, medical records, and tracking)
◯ Interfacility communication
systems, and severe damage or casualties within ◯ Transportation of clients, staff, and e uipment
the facility related to fire, weather (tornado, ◯ Cross pri ileging of medical staff
Performing triage of incoming clients.
hurricane), explosion, or a terrorist act. Internal
●
● Managing clients during emergencies, including

emergency readiness includes evacuation and scheduling, modi cation or discontinuation of ser ices,
control of client information, and client discharge
relocation plans, procedures to notify extra and transportation.
personnel, safety and hazardous materials ● Interacting with family members and the media and
responding to public reaction.
protocols, and infection control policies ● Identifying bac up resources electricity, ater, re
and practices. protection, fuel sources, medical gas, and vacuum) for
utilities and communication.
External emergencies include hurricanes, ● Orienting and educating personnel participating in
implementation of the emergency preparedness plan.
floods, volcano eruptions, earthquakes, disease ● Providing crisis support for health care workers (access
epidemics, industrial accidents, chemical plant to vaccines, infection control recommendations, mental
health counseling).
explosions, major transportation accidents, ● Providing performance monitoring and evaluation
building collapse, and terrorist acts (including related to emergency preparedness.
Conducting two emergency preparedness drills
biological and chemical warfare). External
●
each year.
emergency readiness includes a plan for ◯ Drills should include an in u of clients beyond those
being treated by the facility.
participation in community-wide emergencies ◯ Drills should include either an internal or an external
and disasters. disaster (a situation beyond the normal capacity of

the facility).
● Participating in one community-wide practice
drill per year.
FUNDAMENTALS FOR NURSING CHAPTER 15 SECURITY AND DISASTER PLANS 77

NURSING ROLE IN DISASTER PLANNING DISCHARGE/RELOCATION OF CLIENTS
AND EMERGENCY RESPONSE PLANS During an emergency a re or a mass casualty e ent ,
decisions are made regarding discharging clients or
Emergency response plans
relocating them so their beds can be given to clients who
Each health care institution must have an emergency have higher-priority needs.
preparedness plan developed by a planning committee.
Criteria for identifying when clients can be
This committee reviews information regarding the
safely discharged
potential for various types of natural and man-made ● Ambulatory clients requiring minimal care are
emergencies depending on the characteristics of the

discharged or relocated rst.
community. Resources necessary to meet the potential ● Clients requiring assistance are next and arrangements
emergency are determined and a plan is developed that
are made for continuation of their care.
takes into consideration all of the above factors. ● Clients who are unstable and/or require nursing care
● Nurses, as well as a cross-section of other members of
are not discharged or relocated unless they are in
the health care team, are involved in the development
imminent danger.
of a disaster plan for such emergencies. Criteria under
which the disaster plan is activated must be clear. Roles FIRE
for each employee are outlined and administrative ● If evacuation of the unit is necessary, horizontal (lateral)
control determined. A designated area for the area
e acuation is done rst. ertical e acuation to other
command center is identi ed as ell as a person to
oors is done if client safety cannot be maintained.
serve as the incident control manager. ● If a nurse disco ers a re that threatens the safety of
● Communication, using common terminology, is
a client, use the RACE (Rescue, Alarm, Contain, and
important within any emergency management plan.
Extinguish) mnemonic to guide the order of actions. (15.1)
● Nurses are expected to set up an emergency action plan ● Turn supplemental o ygen off for clients ho can safely
for personal family needs.
tolerate room air.
● Ask ambulatory clients to assist removing clients who
TRIAGE are in wheel chairs.
Principles of triage are followed in health care facilities

in ol ed in a mass casualty e ent. These differ from the
SEVERE THUNDERSTORM/TORNADO
principles of triage that are typically followed during ● Draw shades and close drapes to protect against
provision of day-to-day services in an emergency shattering glass.
or urgent care setting. During mass casualty events, ● Lower beds to the lowest position and move away from
casualties are separated in relation to their potential for the windows.
survival, and treatment is allocated accordingly. ● Place blan ets o er all clients ho are con ned to beds.
● Close all doors.
Categories of triage during mass casualty events ● Relocate as many ambulatory clients as possible into the
hallways (away from windows) or other secure location
Emergent or Immediate Category (Class I): Highest
designated by the facility.
priority is given to clients who have life-threatening ● Do not use elevators.
injuries but also have a high possibility of survival once ● Monitor for severe weather warnings using television,
they are stabilized.
radio, or Internet.
Urgent or Delayed Category
(Class II): Second-highest priority
is given to clients who have 15.1 Race mnemonic
major injuries that are not yet
life-threatening and can usually
wait 30 min to 2 hr for treatment.
R
Rescue the client and other individuals from the area.
RESCUE
Nonurgent or Minimal Category
(Class III): The next highest A Sound the fire alarm, which activates the EMS response system.
Systems that could increase fire spread are automatically
priority is given to clients who ALARM shut down with activation of the alarm.
have minor injuries that are not After clearing the room or area, close the door
life-threatening and do not need
C leading to the area in which the fire is located as
well as the fire doors and any open windows.
immediate attention.
CONTAIN Fire doors are kept closed as much as possible when moving from
Expectant Category (Class IV): The area to area within the facility to avoid the spread of smoke and fire.
lowest priority is given to clients Make an attempt to extinguish small fires using a single fire
who are not expected to live and are extinguisher, smothering them with a blanket, or dousing
allowed to die naturally. Comfort with water (except with an electrical or grease fire).
E Complete evacuation of the area occurs if the nurse
measures can be provided, but
restorative care is not. EXTINGUISH cannot put the fire out with these methods.
Attempts at extinguishing the fire are only made when
the employee is properly trained in the safe use of a fire
extinguisher and when only one extinguisher is needed.
78 CHAPTER 15 SECURITY AND DISASTER PLANS CONTENT MASTERY SERIES

BIOLOGICAL PATHOGENS ● Use recommended isolation measures as indicated.
● Transport or move clients only if needed for
Bioterrorism is the intentional release of pathogens
treatment and care.
that can harm people, livestock, or crops. Be alert ● Take measures to protect self and others.
to indications of a possible bioterrorism attack, as ● Recognize indications of infection/poisoning and
early detection and management is key. Often the
recommended treatment. (15.2)
manifestations are similar to other illnesses.
● Be alert for the appearance of a disease that does not
usually occur at a speci c time or place, has atypical CHEMICAL INCIDENTS
manifestations, or occurs in a speci c community or
Chemical incidents can occur as result of an accident or
people group.
due to a purposeful action (terrorism).
● In most instances, infection from biological agents is ● Take measures to protect self and to avoid contact.
not spread from one client to another. Management ● Assess and intervene to maintain the client’s airway,
of the incident includes recognition of the occurrence,

breathing, and circulation. Administer rst aid as needed.
directing personnel in the proper use of personal
protective equipment, and, in some situations,
decontamination and isolation.
15.2 Biological pathogen manifestations, prevention, and treatment
Inhalational anthrax Viral hemorrhagic fevers Smallpox

MANIFESTATIONS
(Ebola, yellow fever) MANIFESTATIONS
●
Fever ●
Mild chest pain MANIFESTATIONS ●
High fever ●
Chills
●
Cough ●
Meningitis ●
Fatigue ●
Internal and ●
Fatigue ●
Vomiting
●
Shortness ●
Shock ●
Kidney failure external bleeding ●
Severe headache ●
Delirium
of breath ●
Sweats (often ●
Elevated ●
Shock ●
Rash
●
Muscle aches drenching) temperature ●
Jaundice
(yellow fever) PREVENTION
PREVENTION
●
Nausea, vomiting,
diarrhea
●
Vaccine; can vaccinate within
●
Anthrax vaccine for high-risk 4 days of exposure
●
Ciprofloxacin & Doxycycline IV/PO PREVENTION ●
Contact and airborne precautions
●
Vaccination available for yellow fever,
TREATMENT: includes one or two Argentine hemorrhagic fever TREATMENT
additional antibiotics (vancomycin, Supportive care (prevent
Barrier protection from infected person,
●
penicillin, and anthrax antitoxin)

●
isolation precautions specific to disease dehydration, provide skin care,

medications for pain and fever)
Insect repellent use
Cutaneous anthrax
●
●
Antibiotics for secondary infections
TREATMENT
MANIFESTATIONS
Starts as a lesion that can be itchy
●
No cure, supportive care only Tularemia
Minimize invasive procedures
●
●
●
Develops into a vesicular lesion MANIFESTATIONS
that later becomes necrotic with Sudden fever Dry cough
Plague
● ●
the formation of black eschar ●

Chills ●
Progressive
●
Fever, chills MANIFESTATIONS weakness
●
Headache
PREVENTION: Anthrax ●
Yersinia pestis bacterium is ●
Diarrhea ●
If airborne,
vaccine for high-risk the causative agent life-threatening
●
Muscle aches
●
These forms can occur separately pneumonia and
TREATMENT: Ciprofloxacin, Doxycycline ●
Joint pain systemic infection
or in combination
Pneumonic plague: fever, headache, PREVENTION
Botulism
◯
weakness, pneumonia with shortness ●

Vaccine under review by the Food
of breath, chest pain, cough, and and Drug Administration
MANIFESTATIONS bloody or watery sputum.
Difficulty swallowing ●
Insect repellent use
Bubonic plague: swollen, tender
●
◯
●
Double vision lymph glands, fever, headache, TREATMENT: streptomycin or gentamicin
●
Slurred speech chills, and weakness. are the medications of choice; in mass
●
Descending progressive weakness Septicemic plague: fever, chills,
◯ causality, use doxycycline or ciprofloxacin
●
Nausea, vomiting, abdominal cramps prostration, abdominal pain, shock,
disseminated intravascular coagulation
●
Difficulty breathing (DIC), gangrene of nose and digits.
●
Sensation of a thickened tongue
(difficulty controlling tongue) PREVENTION: Contact precautions until
decontaminated or buboes no longer drain
PREVENTION/TREATMENT (bubonic, septicemic); droplet precautions
●
Airway management until 72 hr after antibiotics (pneumonic)
●
Antitoxin TREATMENT: Streptomycin/gentamicin
●
Elimination of toxin or tetracycline/doxycycline.

● emo e the offending chemical by undressing the client, NUCLEAR INCIDENTS
remo ing all identi able particulate matter. Pro ide ● Can result in long-term contamination, burn injuries,
immediate and prolonged irrigations of contaminated
and puncture wounds.
areas. Irrigate skin with running water, with the ● Decontamination is necessary.
exception of dry chemicals (lye or white phosphorus). In
the case of exposure to a dry chemical, brush the agent
off of the client s clothing and s in. EXPLOSIVE INCIDENTS
● ather a speci c history of the in ury, if possible name
Can result in burn injuries, wounds from airborne
and concentration of the chemical, duration of exposure).
fragments, force due to altered air pressure, and
● In the event of a chemical attack, have knowledge of
temperature changes.
which facilities are open to exposed clients and which
are only open to unexposed clients.
● Follow the facility’s emergency response plans (personal BOMB THREAT
protection measures, the handling and disposal of wastes,
When a phone call is received:
use of space and equipment, reporting procedures). ● Extend the conversation as long as possible.
● Listen for distinguishing background noises (music,
HAZARDOUS MATERIAL INCIDENTS oices, traffic, airplanes .
● Note distinguishing voice characteristics of the caller.
● Take measures to protect self and to avoid contact. ● Ask where and when the bomb is set to explode.
● Approach the scene with caution. ● Note whether the caller is familiar with the physical
● Identify the hazardous material with available resources
arrangement of the facility.
(emergency response guidebook, poison control centers). ● If a bomb-like device is located, do not touch it. Clear
Know the location of the safety data sheets manual.
the area and isolate the device as much as possible by
● Try to contain the material in one place prior to the
closing doors, for example.
arrival of the hazardous materials team. ● Notify the appropriate authorities and personnel (police,
● If individuals are contaminated, decontaminate them as
administrator, director of nursing).
much as possible at the scene or as close as possible to ● Cooperate with police and others. Assist to conduct a
the scene.
search as needed, pro ide copies of oor plans, ha e
◯ Don gloves, gown, mask, and shoe covers to protect
master keys available, and watch for and isolate

self from contamination.
suspicious objects (packages and boxes).
◯ With few exceptions, water is the universal antidote.
● Keep elevators available for authorities.
For biological hazardous materials, wash skin with ● Remain calm and alert and try not to alarm clients.
copious amounts of water and antibacterial soap.
◯ Carefully and slowly remove contaminated clothing
so that deposited material does not become airborne. ACTIVE SHOOTER SITUATION
◯ Place all contaminated material into large plastic bags
One or more persons attempting to kill people in a

and seal them.
con ned area.
Run
RADIOLOGIC INCIDENTS ● Evacuate if there is a clear path of exit.
● The amount of exposure is related to the duration ● Leave belongings behind.
of the exposure, distance from source, and amount ● Instruct others to follow, but do not wait for them.
of shielding. ● Prevent others from entering the area.
● The facility where victims are treated activates Hide
interventions to prevent contamination of treatment ● If unable to evacuate
areas oors and furniture are co ered, air ents and ◯ Stay out of shooter's sight.
ducts are covered, radiation-contaminated waste is ◯ Find a protected area.
disposed of according to procedural guidelines). ◯ Block or lock doors.
● Wear water-resistant gowns, double glove, and fully cover ◯ Silence phone and remain quiet.
their bodies with caps, shoe covers, masks, and goggles. Fight
● Wear radiation or dosimetry badges to monitor the ● If unable to run or hide and if danger is imminent
amount of their radiation exposure. ◯ Throw items and yell at shooter to stop, or wound
● Survey clients initially with a radiation meter to the shooter.

determine the amount of contamination.
Call 911 if possible, remain calm, do not attempt to
● Decontamination with soap, water, and disposable
move wounded people, and keep hands visible if police
to els occurs prior to entering the facility. ater runoff
enter the area.
is contaminated and contained.
● After decontamination, resurvey clients for residual
contamination. Continue irrigation of the skin until the
client is clean of all contamination.

SECURITY PLAN Application Exercises
All health care facilities have security plans in place that
include preventive, protective, and response measures 1. A nurse is caring for multiple clients
designed for identi ed security needs. during a mass casualty event. Which of the
● Security issues faced by health care facilities include following clients is the nurse's priority?
admission of potentially dangerous individuals, A. A client who received crush injuries to the
vandalism, infant abduction, and information theft. chest and abdomen and is expected to die
● The International Association for Healthcare Security & B. A client who has a 4-inch laceration to the head
Safety provides recommendations for the development C. A client who has partial-thickness and
of security plans. full-thickness burns to his face, neck, and chest
D. A client who has a fractured fibula and tibia
NURSING ROLE IN SECURITY PLAN

2. A nurse educator is teaching staff members
Nurses should be aware that security measures include: about facility protocol in the event of a
● An identi cation system that identi es employees, tornado. Which of the following should the
volunteers, physicians, students, and regularly nurse include? (Select all that apply.)
scheduled contract ser ices staff as authori ed A. Open doors to client rooms.
personnel of the health care facility. B. Place blankets over clients who
● Electronic security systems in high-risk areas (maternal are confined to beds.
newborn to prevent infant abductions, the emergency C. Move beds away from the windows.
department to prevent unauthorized entrance). D. Draw shades and close drapes.
◯ Key code access into and out of high-risk areas
E. Instruct ambulatory clients in the
◯ Wristbands that electronically link parents and
hallways to return to their rooms.
their infants
◯ Alarms integrated with closed-circuit
television cameras 3. An occupational health nurse is caring for an employee

who was exposed to an unknown dry chemical, resulting
Nurses should prepare to take immediate action when in a chemical burn. Which of the following interventions
breaches in security occur. Time is of the essence in should the nurse include in the plan of care?
preventing or stopping a breach in security. A. Irrigate the affected area with running water.
B. Wash the affected area with antibacterial soap.
C. Brush the chemical off the skin and clothing.
Active Learning Scenario D. Leave the clothing in place until
emergency personnel arrive.
A nurse educator is teaching a module on biological
pathogens during orientation to a group of newly
hired nurses. What information should the nurse 4. A security officer is reviewing actions to take in
educator include? Use the ATI Active Learning the event of a bomb threat by phone to a group
Template: Basic Concept to complete this item. of nurses. Which of the following statements
by a nurse indicates understanding?
RELATED CONTENT: List four manifestations A. “I will get the caller off the phone as soon
and the recommended treatment for anthrax, as possible so I can alert the staff.”
botulism, pneumonic plague, and tularemia.
B. “I will begin evacuating clients using the elevators.”
C. “I will not ask any questions and
just let the caller talk.”
D. “I will listen for background noises.”
5. A nurse on a medical-surgical unit is informed that

a mass casualty event occurred in the community
and that it is necessary to discharge stable
clients to make beds available for injury victims.
Which of the following clients should the nurse
recommend for discharge? (Select all that apply.)
A. A client who is dehydrated and
receiving IV fluid and electrolytes
B. A client who has a nasogastric tube to
treat a small bowel obstruction
C. A client who is scheduled for elective surgery
D. A client who has chronic hypertension
and blood pressure 135/85 mm Hg
E. A client who has acute appendicitis and
is scheduled for an appendectomy

1. A. A client who has crush injuries to the chest and abdomen Using the ATI Active Learning Template: Basic Concept
has a minimal chance of survival even with intervention. RELATED CONTENT
The nurse should provide comfort measures for this
client (Expectant Category: Class IV). Anthrax
B. A client who has a laceration to the head does not have ●
Manifestations
an immediate threat to life and can wait for treatment Fever
◯
(Nonurgent (Minimal) Category: Class III). Cough

◯
C. CORRECT: A client who has burns to the face, neck, Shortness of breath
◯
and chest is at risk for airway obstruction and requires

Muscle aches
◯
immediate intervention for survival. Using the survival

approach to client care, the nurse should give priority to Meningitis
◯
this client (Emergent (Immediate) Category: Class I). Shock

◯
D. A client who has major fractures does not have an ●

Nursing interventions
immediate threat to life and can wait for treatment Ciprofloxacin
◯
(Urgent (Delayed) Category: Class II). One or two additional antibiotics (vancomycin or penicillin)
◯
NCLEX® Connection: Management of Care, Establishing Botulism

Priorities ●
Manifestations
Difficulty swallowing
◯
2. A. Close all client doors to minimize the threat Double vision

◯
of flying glass and debris. Slurred speech

◯
B. CORRECT: Place blankets over clients to protect Descending progressive weakness

◯
them from shattering glass or flying debris. Nausea, vomiting, abdominal cramps
◯
C. CORRECT: Move all beds away from windows to protect Difficulty breathing
◯
clients from shattering glass or flying debris. ●

D. CORRECT: Draw shades and close drapes to
Airway management
◯
protect clients against shattering glass.

E. Instruct ambulatory clients to go to the Antitoxin
◯
hallways, away from windows, or other secure Elimination of toxin

◯
locations designated by the facility. Pneumonic plague

NCLEX® Connection: Safety and Infection Control, ●
Manifestations
Accident/Error/Injury Prevention Fever
◯
Headache
◯
Weakness
◯
3. A. Do not apply water to a dry chemical exposure because it

could activate the chemical and cause further harm. Rapidly developing pneumonia
◯
B. Wash the skin with antibacterial soap in the Shortness of breath

◯
event of a biological exposure. Chest pain

◯
C. CORRECT: Use a brush to remove the Cough

◯
chemical off the skin and clothing. Bloody or watery sputum

◯
D. Plan to remove the client’s clothing ●

following decontamination. Early treatment is essential
◯
NCLEX® Connection: Safety and Infection Control, Streptomycin, gentamicin, the tetracyclines
◯
Handing Hazardous and Infectious Materials

Tularemia
●
Manifestations
4. A. In the event of a bomb threat, keep the caller on Sudden fever
◯
the line in order to trace the call and to collect Chills

◯
as much information as possible. Headache

◯
B. Avoid using the elevators so that they are free for Diarrhea
◯
the authorities to use, and should not evacuate

Muscle aches
◯
clients unless directed to by facility protocol.

C. Ask the caller about the location of the bomb Joint pain
◯
and the time it is set to explode in order to Dry cough

◯
gather as much information as possible. Progressive weakness

◯
D. CORRECT: In order to identify the location of the If airborne, life-threatening pneumonia and systemic infection
◯
caller, listen for background noises (church bells, ●

train whistles, or other distinguishing noises). Streptomycin IV or gentamicin IV or IM are the drugs of choice.
◯
NCLEX® Connection: Safety and Infection Control, In mass casualty, use doxycycline or ciprofloxacin.
◯
Handing Hazardous and Infectious Materials

NCLEX® Connection: Safety and Infection Control, Handing
Hazardous and Infectious Materials
5. A. Recognize that a client who is receiving IV fluid
and electrolytes requires ongoing nursing care
and is therefore unstable for discharge.
B. Recognize that a client who has a nasogastric
tube requires ongoing nursing care and is
therefore unstable for discharge.
C. CORRECT: Identify a client who is scheduled elective
surgery is stable and should recommend for discharge.
D. CORRECT: A blood pressure 135/85 mm Hg is within the
reference range for prehypertension. Identify this client
as stable and should recommend for discharge.
E. Recognize that a client who has an acute illness and
is scheduled for surgery requires ongoing nursing
care and is therefore unstable for discharge.
NCLEX® Connection: Management of Care, Establishing
Priorities

NCLEX® Connections

ACCIDENT/ERROR/INJURY PREVENTION
Identify factors that in uence accident in ury pre ention.
Identify and facilitate correct use of infant and child car seats.
HOME SAFETY: Educate the client on home safety issues.

DEVELOPMENTAL STAGES AND TRANSITIONS: Identify expected
physical, cognitive, and psychosocial stages of development.
HEALTH PROMOTION/DISEASE PREVENTION

Assess client’s readiness to learn, learning
preferences and barriers to learning.
Educate the client on actions to promote/
maintain health and prevent disease.
HEALTH SCREENING
Perform targeted screening assessments.
Utilize appropriate procedure and interviewing
techniques when taking the client health history.
Basic Care and Comfort

NUTRITION AND ORAL HYDRATION: Evaluate client
intake and output and intervene as needed.
REST AND SLEEP: Assess client sleep/rest

pattern and intervene as needed.

84 CONTENT MASTERY SERIES
CHAPTER 16
UNIT 2 HEALTH PROMOTION TESTS
SECTION: NURSING THROUGHOUT THE LIFESPAN
Frequency of some major examinations and screenings are
Health Promotion baseline for clients who are asymptomatic and do not have
CHAPTER 16 risk factors.
and Disease Routine physical examination: Generally every 1 to
Prevention 3 years for females and every 5 years for males from
age 20 to 40, more often after age 40.
Dental assessment: Every 6 months.

Health promotion includes activities to
Tuberculosis screen: Tuberculosis (TB) skin test every
improve general health (exercise and good
2 years. TB tests are generally not needed for people who
nutrition). Disease prevention activities aimed
have a low risk of infection with TB bacteria. Higher risks
at preventing specific disorders (obtaining an
include weak immune system and drug use. Health care
influenza vaccine).
workers should be screened annually.
Nurses use traditional nursing measures and Blood pressure: At least every 2 years; annually if
complementary therapies (guided imagery, previously elevated.
massage, relaxation, and music) to help promote
Body mass index: At each routine health care visit.
health and prevent disease.
Blood cholesterol: Starting at age 20, a minimum of
Levels of prevention address health-related every 5 years.
activities that are primary, secondary, and
Blood glucose: Starting at age 45, a minimum of every
tertiary. Levels of prevention are not the same as
3 years.
levels of care.
Visual acuity: Age 40 and under: every 3 to 5 years. Every
2 years ages 40 to 64. Every year 65 and older.
RISK ASSESSMENT Hearing acuity: Periodic hearing checks as needed; more
frequently if hearing loss is noted.
RISK FACTORS Skin assessment: Every 3 years by a skin specialist for age
is factors are ariables speci c to an indi idual hich 20 to 40; annually over age 40 years.
increases the individual’s chance of acquiring a disease or
Digital rectal exam: During routine physical examination
condition. ome ris factors are modi able, hile others
or annually if have at least a 10-year life expectancy.
are not. Nurses identify client speci c ris factors for
Consult with the provider if screen should continue after
disease and help the client take action to counteract the
age 76.
risk factors, which can reduce the risk of disease.
Colorectal screening: Every year between the age of 50
Genetics: Heredity creates a predisposition for various
and 75 for high-sensitivity fecal occult blood testing, or
disorders (heart disease, cancers, mental illnesses).
e ible sigmoidoscopy e ery years, or colonoscopy
Sex: Some diseases are more common in one sex. For every 10 years. Consult with the provider if screen should
example, females have a higher incidence of autoimmune continue after age 76.
disorders, while males have a higher suicide rate.
Tests specific for women
Physiologic factors: Various physiologic states place
clients at an increased risk for health problems (body Cervical cancer screening: Ages 21 to 65 years:
mass index [BMI] above 25, pregnancy). Papanicolaou test (Pap smear) every 3 years; at age 30,
can decrease Pap screening to every 5 years if human
Environmental factors: Toxic substances and chemicals
papilloma virus screening performed as well. After age 65,
can affect health here clients li e and or ater
no testing is needed if previous testing was normal and
quality, pesticide exposure, air pollution).
not high risk for cervical cancer.
Lifestyle-risk behaviors: Clients have control over
Breast cancer screening: Ages 20 to 39: clinical breast
how they choose to live, and making positive choices
examination every 3 years, then annually. Clients ages
can reduce risk factors. Risk behaviors to screen for
40 to 44 years should have the choice to start annual
include stress, substance use disorders, tobacco use, diet
mammography; ages 40 to 54: annual mammogram;
de ciencies, lac of e ercise, and sun e posure.
ages 55 and older should have the choice to have a
Age: Screening guidelines from the American Diabetes mammogram every 1 to 2 years.
Association, American Heart Association, and American
Cancer Society promote early detection and intervention.
Ages vary with individual practices (for example, a woman
who is sexually active before the age of 20 should start
screenings when sexual activity begins).
FUNDAMENTALS FOR NURSING CHAPTER 16 HEALTH PROMOTION AND DISEASE PREVENTION 85

Online Video: Health Screening
Tests specific for men NURSING INTERVENTIONS

Clinical testicular examination: At each routine health Examine risk factors to identify modi cations, adopt
care visit starting at puberty. mutually agreeable goals, and identify support systems.
● Refer clients to educational/community/support
Prostate‑specific antigen test, digital rectal examination:
resources. Help clients recogni e bene ts not smo ing
Discuss starting this screening with the provider starting
reduces the risk of lung cancer) and overcome barriers
at age 50 years, and again whether to continue after age 76.
(not smoking covers expenses for healthful pursuits).
● Advocate for changes in the community.
PREVENTION
Use behavior-change strategies.
Primary, secondary, and tertiary prevention describe the ● Identify clients’ readiness to receive and apply
focus of activities and the level of prevention.
health information.
Identify acceptable interventions.
PRIMARY
●
● Help motivate change by setting realistic timelines.

Primary prevention addresses the needs of healthy clients ● Reinforce steps toward change
to promote health and pre ent disease ith speci c ● Assist the client to recognize their personal perceived
protections. It decreases the risk of exposure individual/ barriers that can hinder commitment to adopting and
community to disease. maintaining the plan for a healthy lifestyle change.
● Immunization programs ● Encourage clients to maintain the change.
● Child car seat education ● Model healthy behaviors.
● Nutrition, tness acti ities
Promote healthy lifestyle behaviors by instructing clients
● Health education in schools
to do the following.
Use stress management strategies.
SECONDARY
●
● Get adequate sleep and rest.

Secondary prevention focuses on identifying illness, ● Eat a nutritious diet to achieve and maintain a
providing treatment, and conducting activities that help healthy weight.
prevent a worsening health status. ● Avoid saturated fats.
● Communicable disease screening, case nding ● Participate in regular physical activity most days.
● Early detection, treatment of diabetes mellitus ● While outdoors, wear protective clothing, use sunscreen,
● Exercise programs for older adults who are frail and avoid sun exposure between 10 a.m. and 4 p.m.
● Wear safety gear (bike helmets, knee and elbow pads)
TERTIARY when participating in physical activity.
● Avoid tobacco products, alcohol, and illegal drugs.
Tertiary prevention aims to prevent the long-term ● Practice safe sex.

consequences of a chronic illness or disability and to ● Seek medical care when necessary, get routine
support optimal functioning.
screenings, and perform recommended
● Begins after an injury or illness
self-examinations (breast, testicular).
● Prevention of pressure ulcers after spinal cord injury
● Promoting independence after traumatic brain injury
● Referrals to support groups
● Rehabilitation center
HEALTHY PEOPLE 2020

The Healthy People 2020 provides a list of national
objectives to promote health and prevent disease among
the national population. The objectives are updated
e ery years and in ol e a collaborati e effort for
implementation by the local governments, voluntary and
professional organizations, businesses, and individuals.
● Improve health priorities
● Improve awareness and understanding of the progress
involving health, disease, and disability.
● Apply measurable health goals at the local, state, and
national level
● Apply best practice to strengthen polices and improve
health practice
● Identify the need for research, evaluation, and data
collection of health disparities
86 CHAPTER 16 HEALTH PROMOTION AND DISEASE PREVENTION CONTENT MASTERY SERIES

1. A nurse is caring for a young adult at a A nurse is caring for a client in a rehabilitation center
college health clinic. Which of the following following a bicycle crash. The client had surgery
actions should the nurse take first? following the crash to stabilize their cervical spine. Now,
the client and their partner are learning mobility and
A. Give the client information about wound care techniques. Use the ATI Active Learning
immunization against meningitis. Template: Basic Concept to complete this item.
B. Tell the client to have a TB skin test every 2 years.
C. Determine the client’s health risks. RELATED CONTENT: List each of the three levels of
prevention with an example of each level from this
D. Teach the client about exercise recommendations. client’s history or from what this client might have done
to prevent this injury and its life-altering consequences.
2. A nurse in a clinic is planning health promotion
and disease prevention strategies for a client
who has multiple risk factors for cardiovascular
disease. Which of the following interventions
A. Help the client see the benefits of their actions.
B. Identify the client’s support systems.
C. Suggest and recommend community resources.
D. Devise and set goals for the client.
E. Teach stress management strategies.
3. A nurse in a health clinic is caring for a 21-year-old

client who tells the nurse that their last physical
exam was in high school. Which of the following
health screenings should the nurse expect
the provider to perform for this client?
A. Testicular examination
B. Blood glucose
C. Fecal occult blood
D. Prostate-specific antigen
4. A nurse at a health department is planning

strategies related to heart disease. Which
of the following activities should the nurse
include as part of primary prevention?
A. Providing cholesterol screening
B. Teaching about a healthy diet
C. Providing information about
antihypertensive medications
D. Developing a list of cardiac rehabilitation programs
5. A nurse at a provider’s office is talking about routine

screenings with a 45-year-old female client who has no
specific family history of cancer or diabetes mellitus.
Which of the following client statements indicates
that the client understands how to proceed?
A. “So I don’t need the colon cancer
procedure for another 2 or 3 years.”
B. “For now, I should continue to have
a mammogram each year.”
C. “Because the doctor just did a Pap smear,
I’ll come back next year for another one.”
D. “I had my blood glucose test last year,
so I won’t need it again for 4 years.”
FUNDAMENTALS FOR NURSING CHAPTER 16 HEALTH PROMOTION AND DISEASE PREVENTION 87

1. A. The nurse should give the client information on Using the ATI Active Learning Template: Basic Concept
the meningococcal vaccine as part of the primary RELATED CONTENT
disease prevention. However, there is another ●
Primary: take various courses, read about bicycle safety (wear
action the nurse should take first.
a helmet, use reflective accessories and lights for visibility
B. The nurse should recommend TB screening every 2 years
to drivers, follow the rules of the road for cyclists)
as part of secondary disease prevention. However,
there is another action the nurse should take first.
●
Secondary: emergency care, surgery
C. CORRECT: The first action that should be taken
●
Tertiary: rehabilitative care, learning
using the nursing process is assessment. Talk self-management procedures, strategies
with the client first to determine what risk factors NCLEX® Connection: Health Promotion and Maintenance,
the client might have before initiating the health Health Promotion/Disease Prevention
promotion and disease prevention measures.
D. The nurse should instruct the client about exercise and
activity recommendations as part of health promotion.
However, there is another action the nurse should take first.
Health Screening
2. A. CORRECT: Assist the client to recognize the

benefits of their health-promoting actions while also
overcoming barriers to implementing actions.
B. CORRECT: Collect information about who can help the client
change unhealthful behaviors, and then suggest steps to have
friends and family to become involved and supportive.
C. CORRECT: Promote the client’s use of any available
community or online resources that can help the
client progress toward meeting set goals.
D. The nurse and the client should work together
to devise and set mutually agreeable goals
that are also realistic and achievable.
E. CORRECT: Teach that stress is a contributing
factor to cardiovascular disease, as well as many
other specific and systemic disorders.
3. A. CORRECT: Starting at puberty, the client should

have examinations for testicular cancer, along
with blood pressure and body mass index and
cholesterol measurements. Testicular cancer is most
common in males 15 to 34 years of age.
B. Blood glucose testing begins at age 45.
C. Testing for fecal occult blood usually begins at age 50.
D. Testing for prostate-specific antigen
usually begins at age 50.
Health Screening
4. A. Cholesterol screening is an example of

secondary prevention.
B. CORRECT: Primary prevention encompasses strategies
that help prevent illness or injury. This level of prevention
includes health information about nutrition, exercise, stress
management, and protection from injuries and illness.
C. Taking medication to lower blood pressure
is part of secondary prevention.
D. Cardiac rehabilitation is an example of tertiary prevention.
5. A. The female client who has no specific family or

personal history of colorectal cancer should begin
screening procedures at age 50.
B. CORRECT: The female client who is between the ages
of 45 and 54 should have a mammogram annually.
C. The female client who is between the ages of 30 and
65, with no family or personal history of cervical cancer,
should have either a Pap smear and human papilloma
virus test every 5 years, or a Pap test every 3 years.
D. The client who is age 45 should have a blood glucose
test at least every 3 years. Unless there is a specific
family or personal history of diabetes mellitus, annual
blood glucose determinations are not necessary.
88 CHAPTER 16 HEALTH PROMOTION AND DISEASE PREVENTION CONTENT MASTERY SERIES

Online Video: Client Education
CHAPTER 17
UNIT 2 HEALTH PROMOTION Affective learning involves feelings, beliefs, and values.
SECTION: NURSING THROUGHOUT THE LIFESPAN Hearing the instructor’s words, responding verbally and
nonverbally, valuing the content or believing that it is worth
CHAPTER 17 Client Education learning, creating a method for identifying values and
resol ing differences, and employing alues consistently in
decision ma ing are all characteristics of affecti e learning.
Teaching is goal-driven and interactive. It For example, affective learning takes place when
clients learn about the life changes necessary
involves purposeful actions to help individuals for managing diabetes mellitus and then
acquire knowledge, modify attitudes and discuss their feelings about having diabetes.
behavior, and learn new skills. Psychomotor learning is gaining skills that require mental
and physical activity. Psychomotor learning relies on
Learning is the intentional gain of new perception (or sensory awareness), set (readiness to learn),
guided response (task performance with an instructor),
information, attitudes, or skills, and it promotes mechanism increased con dence allo ing for more comple
behavioral change. learning), adaptation (the ability to alter performance when
problems arise), and origination (use of skills to perform
Motivation influences how much and how quickly a complex tasks that require creating new skills).
person learns. The desire to learn and the ability to For example, psychomotor learning takes place
when clients practice preparing insulin injections.
learn and understand the content affect motivation.
Information technology increases access to and ADULT LEARNERS

delivery of knowledge. Plan to teach adult clients in a different manner from
children because learning usually occurs in different ays.
● Adults are often able to identify what they need to learn.
NURSING AND CLIENT EDUCATION ● Adults learn well by building on prior
information and life experiences.

● Nurses provide health education to individuals, families, ● Adults learning abilities can be in uenced
and communities.
by other life factors. The nurse might need
● ome of the most common factors in uencing
to help resolve issues (employment concerns,
clients’ educational needs are health, education level,
nances so the client is ready to learn.
socioeconomic status, and cultural and family in uences. ● Learning for adults is enhanced when the nurse
● Emotional status, spiritual factors, health perception,
works with the client to set mutual goals.
willingness to participate, and developmental level are also
important to consider when providing client education.
● Client education provides clients with information and TEACHING GROUPS
skills to:
Teaching in small groups (six people or fewer) often
◯ Maintain and promote health and prevent illness
increases learning and learner satisfaction.

(immunizations, lifestyle changes, prenatal care). ● The nurse is able to teach more than
◯ Restore health (self-administration of insulin).
one client or family at a time.

◯ Adapt to permanent illness or injury (ostomy care,
● The nurse can use several types of
swallowing techniques, speech therapy).
learning strategies at once.
● Learners can interact and learn from each other.
DOMAINS OF LEARNING ● Group settings do not work for all clients, especially
if physical or emotional barriers are present.
Cognitive learning requires intellectual behaviors and
focuses on thinking. It involves knowledge (learning the
new information), comprehension (understanding the new
information), application (using the new information in a
ASSESSMENT/DATA COLLECTION
concrete way), analysis (organizing the new information), ● Assess/monitor learning needs.
synthesis (using the knowledge for a new outcome), and ● Evaluate the learning environment.
e aluation determining the effecti eness of learning the ● Identify learning style (auditory, visual, kinesthetic).
new information). ● Identify areas of concern (low literacy levels,
pain, distractions).
For example, cognitive learning takes place when ● Identify a ailable resources nancial,
clients learn the manifestations of hypoglycemia
social, community).
and then can verbalize when to notify the provider. ● Identify developmental level.
● Determine physical and cognitive ability.
● Identify speci c needs isual impairment, decreased
manual dexterity, learning challenges).
FUNDAMENTALS FOR NURSING CHAPTER 17 CLIENT EDUCATION 89

● Determine motivation and readiness to learn. EVALUATION
● Consider the client’s culture or personal values, and how ● Ask clients to explain the information in their
that ill affect the client s illingness to learn.
own words.
● Assess the client’s ability to make health decisions by basic ● Observe return demonstrations (psychomotor learning).
understanding of health (health literacy), and what the ● Use written tools to measure the accuracy
client belie es affects health and illness health beliefs .
of information.
● Evaluate the client’s progress without appearing
judgmental. Continue to provide support
PLANNING and encouragement.
● Identify mutually agreeable outcomes. ● Ask clients to evaluate their own progress.
● Prioritize the learning objectives with clients’ ● Observe nonverbal communication.
needs in mind. ● Reevaluate learning during follow-up telephone calls or
● Use methods that emphasize the learning style. contacts (home health visits or appointments with the
Strategies include demonstration, lecture, role-playing, provider).
simulation, visual aids (charts, graphs, images, objects ● Revise the care plan accordingly. Teaching sessions
equipment), and media resources (audio, video). might need to be repeated, or the client might need to
● Select age-appropriate teaching methods and materials. practice to demonstrate adequate learning.
● Speak and provide print materials at the sixth- to
eighth-grade reading level.
● Avoid nursing terminology (administer, monitor, FACTORS AFFECTING LEARNING
implement, assess).
FACTORS THAT ENHANCE LEARNING
● Speak and write in the second person, not the third ● Percei ed bene t
(“your leg,” not “the leg”). ● Cognitive and physical ability
● Avoid using all capital letters, minimal white space, and ● Active participation
small type in print materials. ● Age- and education level-appropriate methods
● Speak and write in active voice (“take the medication,”
not “the medication should be taken”). BARRIERS TO LEARNING
● Provide electronic educational resources (CDs, DVDs, ● Fear, anxiety, depression
software programs, mobile applications). ● Physical discomfort, pain, fatigue
● Use reliable Internet sources to access information and ● Environmental distractions
support services. ● ensory and perceptual de cits
● Organize learning activities to move from simple to ● Psychomotor de cits
more complex tasks and known to unknown concepts.
● Incorporate active participation in the learning process.
● Schedule teaching sessions at optimal times for learning
(teaching ostomy care while replacing the pouch).
IMPLEMENTATION
● Create an environment that promotes learning (minimal
distractions and interruptions, privacy).
● Use therapeutic communication (active listening,
empathy) to develop trust and promote sharing
of concerns.
● Consider the client’s values, and help the client
understand why the information is relevant
or important.
● Review previous knowledge and experiences.
● Explain the therapeutic regimen or procedure.
● Present steps that build toward more complex tasks.
● Demonstrate psychomotor skills.
● Allow time for return demonstrations.
● Provide positive reinforcement.
90 CHAPTER 17 CLIENT EDUCATION CONTENT MASTERY SERIES

1. A nurse is observing a client drawing up and A nurse is preparing a presentation at a community

mixing insulin. Which of the following findings center for a group of guardians who want to learn how to
should the nurse identify as an indication that prevent childhood obesity. Use the ATI Active Learning
psychomotor learning has taken place? Template: Basic Concept to complete this item.
A. The client is able to discuss the RELATED CONTENT

appropriate technique.
●
List at least three factors the nurse should consider
B. The client is able to demonstrate when incorporating ways to enhance learning.
the appropriate technique.
●
List at least three barriers the nurse might
C. The client states an understanding of the process. encounter among the attendees.
D. The client is able to write the
steps on a piece of paper.
2. A nurse in a provider’s office is collecting data from

the caregiver of a 12-month-old infant who asks if the
child is old enough for toilet training. Following an
educational session with the nurse, the client agrees to
postpone toilet training until the child is older. Learning
has occurred in which of the following domains?
A. Cognitive
B. Affective
C. Psychomotor
D. Kinesthetic
3. A nurse is providing preoperative education for a client

who will undergo a mastectomy the next day. Which
of the following statements should the nurse identify
as an indication that the client is ready to learn?
A. “I don’t want my spouse to see my incision.”
B. “Will you give me pain medicine after the surgery?”
C. “Can you tell me about how long
the surgery will take?”
D. “My roommate listens to everything I say.”
4. A nurse is preparing an instructional session for

a client about managing stress incontinence.
Which of the following actions should the nurse
take first when meeting with the client?
A. Encourage the client to participate
actively in learning.
B. Select instructional materials.
C. Identify goals the nurse and the
client agree are reasonable.
D. Determine what the client knows
about stress incontinence.
5. A nurse is evaluating how well a client learned

the information presented in an instructional
session about following a heart-healthy diet.
Which of the following actions should the nurse
take to evaluate the client’s learning?
A. Encourage the client to ask questions.
B. Ask the client to explain how to
select or prepare meals.
C. Encourage the client to fill out an evaluation form
about how the nurse presented the information.
D. Ask whether the client has resources for
further instruction on this topic.
FUNDAMENTALS FOR NURSING CHAPTER 17 CLIENT EDUCATION 91

1. A. Discussing the appropriate technique demonstrates learning, Using the ATI Active Learning Template: Basic Concept
but it does not involve the use of motor skills.
RELATED CONTENT
B. CORRECT: Demonstrating the appropriate technique
indicates that psychomotor learning has taken place. Factors that enhance learning
C. Verbalizing understanding demonstrates learning, ●
Perceived benefit
but it does not involve the use of motor skills. ●
Cognitive and physical ability
D. Writing steps on paper demonstrates learning, ●
Active participation
but it does not involve the motor skills essential ●
Age
for performing the procedure. ●
Educational level-appropriate methods
NCLEX Connection: Health Promotion and Maintenance,
®
Health Promotion/Disease Prevention Barriers to learning

●
Fear
●
Anxiety
2. A. An example of cognitive learning is stating the behavior ●
Depression
the child will demonstrate when ready to toilet train. ●
Physical discomfort
B. CORRECT: Affective learning has taken place because ●
Pain
the client’s ideas about toilet training changed.
C. An example of psychomotor learning is performing the proper
●
Fatigue
techniques for introducing the child to toilet training.
●
Environmental distractions
D. Kinesthetic learning is a learning style, ●
Sensory and perceptual deficits
not a domain of learning. ●
Psychomotor deficits
NCLEX® Connection: Health Promotion and Maintenance, NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention Health Promotion/Disease Prevention
3. A. The client’s concern about their spouse seeing the

incision could indicate anxiety or depression.
B. The client’s request for pain medicine
could indicate fear and anxiety.
C. CORRECT: Asking a concrete question about the
surgery indicates that the client is ready to discuss
the surgery. The client’s new diagnosis of cancer
can cause anxiety, fear, or depression, all of which
can interfere with the learning process.
D. The lack of privacy due to the presence of a
roommate can be a barrier to learning.
Therapeutic Procedures
4. A. Active participation in the learning process is

essential for the success of the session. However,
this is not the priority action.
B. It is essential to prepare and select instructional materials
appropriate for the client’s age, developmental level, and
other parameters. However, this is not the priority action.
C. Establishing mutually agreeable goals is
essential for the success of the session.
However, this is not the priority action.
D. CORRECT: The first action to take using the nursing process
is to assess or collect data from the client. Determine how
much the client knows about stress incontinence, the accuracy
of this knowledge, and what the client needs to learn to
manage this problem before instructing the client.
5. A. The client’s cultural values about the nurse as an

authority figure or other factors could prevent the
client from asking questions. This method is not an
accurate way to evaluate client understanding.
B. CORRECT: Having the client explain the information
in their own words will allow the nurse to evaluate
exactly what the client remembers and whether
the client comprehends the information.
C. Evaluating the nurse’s performance might not offer
clues about what the client has learned.
D. Identify the client’s resources early in the instructional
process. At this point, the exploration of resources does
not help the nurse evaluate the client’s learning.
92 CHAPTER 17 CLIENT EDUCATION CONTENT MASTERY SERIES

CHAPTER 18
UNIT 2 HEALTH PROMOTION EXPECTED GROWTH AND
SECTION: NURSING THROUGHOUT THE LIFESPAN DEVELOPMENT FOR INFANTS
CHAPTER 18 Infants PHYSICAL DEVELOPMENT

(2 Days to 1 Year) ●
●
Posterior fontanel closes by 2 to 3 months of age.
Anterior fontanel closes by 12 to 18 months of age.
Tracking parameters
EXPECTED GROWTH AND WEIGHT: Birth weight should double by 4 to 6 months and
DEVELOPMENT FOR NEWBORNS triple by the end of the rst year.
PHYSICAL DEVELOPMENT HEIGHT: Infants grow about 2.5 cm (1 in) per month in the
rst months, and then about . cm . in per month
● Lose to body birth eight in rst fe days, but
until the end of the rst year.
should regain it by the second week.
● Weight gain is about 150 to 210 g (5 to 7 oz) per week in HEAD CIRCUMFERENCE: The circumference of infants’
the rst months. heads increases approximately 2 cm (0.8 in) per month
● Measurements of crown-to-rump length, head-to-heel during the rst months, cm . in per month from
length, head circumference, and chest circumference are to 6 months, and then approximately 0.5 cm (0.2 in) per
key indicators of appropriate growth. month during the second 6 months.
● Head molding (overlapping of skull bones) present;
DENTITION: Six to eight teeth erupt in the infant’s mouth
fontanels are palpable.
by the end of the rst year.
REFLEXES ● Use cold teething rings, over-the-counter teething gels,
● Include startling, sucking, rooting, grasping, yawning, and acetaminophen or ibuprofen.
coughing, plantar and palmar grasp, and Babinski. ● Use a cool, wet washcloth to clean the teeth.
● Con rm presence or absence of e pected re e es to ● Do not give infants a bottle when they are falling asleep.
monitor for appropriate neurological development. Prolonged exposure to milk or juice can cause dental
caries (bottle-mouth caries).
BODY POSITION
● enerally e ed at rest.
● Movement should involve all four extremities equally,
but can be sporadic.
SLEEP
● Sleep patterns can be reversed for 18.1 Motor skill development by age
several months (daytime sleeping
and nighttime wakefulness). GROSS MOTOR SKILLS FINE MOTOR SKILLS
● Average 15 hr of sleep 1 MONTH Demonstrates head lag Has a strong grasp reflex
time each day. Lifts head off mattress Holds hands in an open position
2 MONTHS
when prone Grasp reflex fading
COGNITIVE DEVELOPMENT Raises head and shoulders
No longer has a grasp reflex
3 MONTHS off mattress when prone
● Learn to respond to visual stimuli. Keeps hands loosely open
Only slight head lag
● Use cry as a form
Grasps objects with both hands
of communication. 4 MONTHS Rolls from back to side
Places objects in mouth
● Cry patterns can change to re ect
different needs. 5 MONTHS Rolls from front to back Uses palmar grasp dominantly
6 MONTHS Rolls from back to front Holds bottle
Bears full weight on feet
PSYCHOSOCIAL 7 MONTHS Sits, leaning forward Moves objects from hand to hand
DEVELOPMENT on both hands
● Interactions ith caregi ers affect 8 MONTHS Sits unsupported Begins using pincer grasp
psychosocial development. Positive Has a crude pincer grasp
interactions promote nurturing 9 MONTHS Pulls to a standing position Dominant hand
preference evident
and attachment. Negative
experience or lack of interaction Changes from a prone
10 MONTHS Grasps rattle by its handle
to a sitting position
hinders appropriate attachment.
Cruises or walks while Places objects into a container
● Most newborns can mimic 11 MONTHS
holding onto something Neat pincer grasp
the smile of the caregiver by
2 weeks of life. Sits down from a standing Tries to build a two-block
12 MONTHS position without assistance tower without success
Walks with one hand held Can turn pages in a book
FUNDAMENTALS FOR NURSING CHAPTER 18 INFANTS (2 DAYS TO 1 YEAR) 93

COGNITIVE DEVELOPMENT AGE-APPROPRIATE ACTIVITIES
Piaget: Sensorimotor stage (birth to 24 months) ● Infants have a short attention span and do not
● Separation is the sense of being distinct from other interact with other children during play (solitary play).
objects in the environment. Age-appropriate activities can promote cognitive, social,
● Object permanence develops at about 9 months. This is and motor development.
the process of knowing that an object still exists when ● Appropriate toys and activities that stimulate the senses
it is hidden from view. and encourage development include rattles, mobiles,
● Mental representation is the recognition of symbols. teething toys, nesting toys, playing pat-a-cake, playing
with balls, and reading books.
Language development
Responds to noises
HEALTH PROMOTION FOR
●
Vocalizes with “oohs” and “aahs”

NEWBORNS AND INFANTS
●
● Laughs and squeals

● Turns head to the sound of a rattle
● Begins to comprehend simple commands SCREENINGS
● Pronounces single-syllable words ● Newborn screenings for metabolism disorders can
● Begins speaking two- and then three-word phrases
be repeated in early weeks of life (phenylketonuria,
galactosemia).
PSYCHOSOCIAL DEVELOPMENT ● Developmental milestone screenings occur ongoing
as part of routine well checkups with the provider at
Erikson: Trust vs. mistrust (birth to 1 year)
2 weeks, and 2, 4, 6, 9, and 12 months.
● Infants trust that others will meet their feeding,
comfort, stimulation, and caring needs.
● Infants re e i e beha ior attachment, separation IMMUNIZATIONS
recognition an iety, and stranger fear in uences their
Follow the latest Centers for Disease Control and
social development.
Prevention (CDC) immunization recommendations (see
● Attachment, when infants begin to bond with their
.cdc.go for healthy infants. During the rst year,

parents, de elops ithin the rst month, but actually
these generally include immunizations against hepatitis B,
begins before birth. The process is optimal when the
diphtheria, tetanus, pertussis, rota irus, polio, in uen a,
infant and parents are in good health, have positive
and pneumococcal pneumonia. The recommendations
feeding experiences, and receive adequate rest.
change periodically, so check them often.
● eparation recognition occurs during the rst year as
infants recognize the boundaries between themselves
and others. Learning how to respond to people in their NUTRITION
environment is the next phase of development. Positive ● reastfeeding pro ides optimal nutrition during the rst
interactions with parents, siblings, and other caregivers
12 months.
help establish trust. ● Feeding alternatives:
● Separation anxiety develops between 4 and 8 months of ◯ Iron forti ed formula is an acceptable alternati e to
age. Infants protest loudly when separated from parents,
breast milk.
which can cause considerable anxiety for the parents. ◯ Cow’s milk is inadequate and should not be given
● Stranger fear becomes evident between ages
before 1 year of age.
6 to 8 months, when infants are less likely to ● Weaning from the breast or bottle can begin when
accept strangers.
infants can drink from a cup (after 6 months).
◯ Replace a single bottle- or breast-feeding with breast
Self-concept development
milk or formula in a cup.
y the end of the rst year, infants distinguish themsel es ◯ Every few days, replace another feeding with a cup.
as separate from their parents. ◯ Replace the bedtime feeding last.
● Solid food is appropriate around 6 months.

Body-image changes ◯ Indicators for readiness include voluntary control
of the head and trunk and disappearance of the

● Infants discover that the mouth is a pleasure producer.
e trusion re e pushing food out of the mouth .
● Hands and feet are objects of play. ◯ Introduce iron forti ed rice cereal rst.
● Smiling makes others react.
94 CHAPTER 18 INFANTS (2 DAYS TO 1 YEAR) CONTENT MASTERY SERIES

◯ Start new foods one at a time over a 5- to 7-day Drowning: Do not leave infants unattended in the bathtub.
period to observe for signs of allergy or intolerance
Falls
(fussiness, rash, vomiting, diarrhea, constipation). ● Keep the crib mattress in the lowest position with the
Vegetables, fruits, and meats follow, generally in
rails all the way up.
that order. ● Use restraints in infant seats.
◯ Do not give honey to infants until after 12 months of ● Place infants seat on the ground or oor, and do not
age because it can cause infant botulism.
leave them unattended or on elevated surfaces.
◯ Appropriate nger foods to introduce around ● Use safety gates across stairs.
9 months include ripe bananas, toast strips, graham
crackers, cheese cubes, noodles, and peeled chunks of Poisoning
apples, pears, and peaches. ● Avoid lead paint exposure.
◯ Remind parents that solid food is not a substitute for ● Keep toxins and plants out of reach.
breast milk or formula until after 12 months. ● Keep safety locks on cabinets that contain cleaners and
◯ luoridated ater or supplemental uoride is other household chemicals.
recommended after 6 months to protect against ● Keep a poison control number handy or program it into
dental caries. the phone.
● Keep medications in childproof containers and
out of reach.
INJURY PREVENTION ● Have a carbon monoxide detector in the home.
Aspiration
● Avoid small objects (grapes, coins, and candy), which
Motor-vehicle injuries: Use an approved rear-facing car
seat in the back seat, preferably in the middle (away from
can become lodged in the throat.
air bags and side impact). Infants should sit in a rear-
● Provide age-appropriate toys.
facing position at least until age 2 or until they reach the
● Check clothing for safety hazards (loose buttons).
maximum height and weight for their car seat (as long
Bodily harm as the top of the head is below the top of the seat back).
● Keep sharp objects out of reach. Con ertible restraints should ha e a e point harness or
● Keep infants away from heavy objects they can a T-shield.
pull down.
Suffocation
● Do not leave infants alone with animals. ● Keep balloons and plastic bags away from infants.
● Monitor for shaken baby syndrome. ● e sure the crib mattress is rm and ts tightly.
Burns ● Ensure crib slats are no farther apart than 6 cm (2.4 in).
● Check the temperature of bath water. ● Remove crib mobiles or crib gyms by
● Turn down the thermostat on the hot water heater to 4 to 5 months of age.
49° C (120° F) or below. ● Do not use pillows in the crib.
● Have smoke detectors in the home and change their ● Place infants on the back for sleep.
batteries regularly. ● Keep toys that have small parts out of reach.
● Turn handles of pots and pans toward the back of ● Remove drawstrings from jackets and other clothing.
the stove.
● Apply sunscreen when outdoors during daylight hours.
● Cover electrical outlets.

1. A nurse is talking with the parents of a 6-month-old A nurse is explaining to the parents of a 4-month-old
infant what infant milestones to expect during the first
infant about gross motor development. Which of the
year of life, and how to foster infant development.
following gross motor skills are expected findings
Use the ATI Active Learning Template: Growth
in the next 3 months? (Select all that apply.)
and Development to complete this item.
A. Rolls from back to front
B. Bears weight on legs COGNITIVE DEVELOPMENT
C. Walks holding onto furniture ●
Name the developmental stage Piaget has
D. Sits unsupported identified for the first two years of life.
E. Sits down from a standing position ●
Identify three essential components that comprise this stage.
AGE-APPROPRIATE ACTIVITIES: Identify at least

2. A nurse is reviewing safety measures with the two toys and two activities the nurse should suggest
parent of an 8-month-old infant. Which of the that the parents provide for their infant.
following statements by the parent indicates
an understanding of safety for the infant?
A. “My baby loved to play with the crib
gym, but I took it out of the crib.”
B. “I just bought a soft mattress so
my baby will sleep better.”
C. “My baby really likes sleeping on
the fluffy pillow we just got.”
D. “I put the baby’s car seat out of the way
on the table after I put him in it.”
3. A nurse is reviewing car seat safety with the parents of a

1-month-old infant. When reviewing car seat use, which
of the following instructions should the nurse include?
A. Use a car seat that has a three-point
harness system.
B. Position the car seat so that the infant is rear-facing.
C. Secure the car seat in the front
passenger seat of the vehicle.
D. Convert to a booster seat after 12 months.
4. A nurse is assessing a 2-week-old newborn during

a routine checkup. Which of the following findings
should the nurse expect? (Select all that apply.)
A. Sleeps 14 to 16 hr each day
B. Posterior fontanel closed
C. Pincer grasp present
D. Hands remain in a closed position
E. Current weight same as birth weight
5. The mother of a 7-month-old infant tells the nurse at

the pediatric clinic that her baby has been fussy with
occasional loose stools since she started feeding him
fruits and vegetables. Which of the following responses
should the nurse make? (Select all that apply.)
A. “It might be good to add bananas, as
they can help with loose stools.”
B. “Let’s make a list of the foods your baby is
eating so we can spot any problems.”
C. “Did the changes begin after you
started one particular food?”
D. “Has your baby been vomiting since
starting these new foods?”
E. “Most babies react with a little indigestion
when you start new foods.”

1. A. CORRECT: The infant should be able to roll Using the ATI Active Learning Template:
from back to front by 6 months. Growth and Development
B. CORRECT: The infant should be able to
bear weight on legs by 7 months. COGNITIVE DEVELOPMENT
C. The infant should not be able to walk while Piaget’s sensorimotor stage (first 2 years)
holding furniture until around 11 months. ●
Separation
D. CORRECT: The infant should be able to ●
Object permanence
sit unsupported by 8 months. ●
Mental representation
E. The infant should not be able to sit down from a
standing position until around 12 months. AGE-APPROPRIATE ACTIVITIES
NCLEX® Connection: Health Promotion and Maintenance, ●
Toys and activities
Developmental Stages and Transitions ●
Rattles
●
Mobiles
●
Teething toys
2. A. CORRECT: Parents should remove gyms and mobiles ●
Nesting toys
at 4 to 5 months of age to prevent injury that can ●
Playing pat-a-cake
occur from choking or strangulation.
B. Remind parents the infant’s crib mattress should
●
Playing with balls
be firm and fit tightly to prevent suffocation.
●
Reading books
C. Remind parents to remove pillows or stuffed animals NCLEX® Connection: Health Promotion and Maintenance,
from the crib to prevent possible suffocation. Developmental Stages and Transitions
D. Remind parents to place the infant seat on the ground
level when not in a vehicle to prevent falls.
Developmental Stages and Transitions
3. A. Instruct parents to provide a car seat with

a five-point harness system.
B. CORRECT: Instruct parents to position the infant car seat
in a rear-facing position until the infant reaches age 2, or
outgrows the seat limitations. The parent should place
the seat in the center of the vehicle, when possible.
C. Instruct parents to place the infant car seat in the back
seat to reduce the risk for injury in the event of a crash.
D. Instruct parents to continue using an infant
seat until the child reaches age 2, or meets the
height and weight limits for the seat.
4. A. CORRECT: Expect the newborn to sleep

about 15 hr each day.
B. Expect the posterior fontanel to close
around 2 to 3 months of age.
C. Expect the pincer grasp to develop around 8 months of age.
D. CORRECT: Expect the newborn to keep hands in a
closed position until about 2 months of life.
E. CORRECT: Expect the newborn to have lost 5% to
10% of birth weight in the first few days of life, and to
regain the weight by the second week of life.
5. A. This response by the nurse suggests an intervention without

first determining the cause of the infant’s problem.
B. CORRECT: This response by the nurse is an
attempt to assess about the infant’s diet to help
determine whether a food allergy or intolerance
is the cause of the diarrhea and fussiness.
C. CORRECT: This response by the nurse is an attempt to assess
the infant’s diet to help determine which food triggered
the infant’s behavior change. Parents should introduce one
food at a time to help identify allergies or intolerances.
D. CORRECT: This response by the nurse is an attempt
to assess for other changes caused by the infant’s
diet which could be linked to a food allergy or
intolerance, (vomiting, rash, or constipation).
E. This response by the nurse is nontherapeutic because it
involves stereotyping, and offers false reassurance without
any attempt to understand the infant’s problem.
NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration

CHAPTER 19
UNIT 2 HEALTH PROMOTION PSYCHOSOCIAL DEVELOPMENT
Erikson: autonomy vs. shame and doubt
Toddlers
● Independence is paramount as toddlers attempt to do
CHAPTER 19 everything for themselves.
(1 to 3 Years) ● Separation anxiety continues when parents leave.

● A toddler might show regression (bed-wetting, thumb
sucking) as a response to anxiety or separation.

● Engages in parallel play, but by age 3 begins to play and
communicate with others.
EXPECTED GROWTH AND Moral development
DEVELOPMENT ● Moral development parallels cognitive development.
● Egocentric: Toddlers are unable to see another’s
PHYSICAL DEVELOPMENT perspective; they can only view things from their
point of view.
The anterior fontanel closes by 18 months. ● Punishment and obedience orientation begins with a
WEIGHT: Toddlers grow approximately 1.8 to 2.7 kg (4 to sense that others reward good behavior and punish
6 lb) per year. bad behavior.
HEIGHT: Toddlers grow approximately 7.5 cm Self-concept development: Toddlers progressively see
(3 in) per year. themselves as separate from their parents and increase
their explorations away from them.
CONTRIBUTION TO SELF-CARE ACTIVITIES: dressing,
feeding, toilet-training Body-image changes: Toddlers appreciate the usefulness
of various body parts.
19.1 Motor skills by age
AGE GROSS MOTOR SKILLS FINE MOTOR SKILLS
Walks without help
AGE-APPROPRIATE ACTIVITIES
Uses cup well
Creeps up stairs ● Solitary play evolves into parallel play where
15 months Builds tower of
Assumes standing two blocks toddlers observe other children and then engage in
position activities nearby.
Manages spoon ● Temper tantrums result when toddlers are frustrated
Jumps in place without rotation with restrictions on independence. Providing consistent,
18 months
with both feet Turns pages in book age-appropriate expectations helps them work through
two or three at a time
their frustration.
Walks up and Builds a tower with
2 years ffer choices uice or mil instead of pro iding an
down stairs six or seven blocks
●
opportunity for a yes/no response from the toddler.

Draws circles
Jumps with both feet ● Toilet training can begin with awareness of the
2.5 years Has good
Stands on one foot sensation of needing to urinate or defecate. The toddler
hand-finger
momentarily
coordination should show indications of readiness and parents should
demonstrate patience, consistency, and a nonjudgmental
attitude with toilet training. Nighttime control can
COGNITIVE DEVELOPMENT develop last.
Piaget: Sensorimotor transitions to preoperational ● Discipline should be consistent ith ell de ned
● The concept of object permanence is fully developed. boundaries that help develop acceptable social behavior.
● Toddlers have and demonstrate memories of events that
Appropriate activities
relate to them. ● Filling and emptying containers
● Domestic mimicry is evident (playing house). ● Playing with blocks
● Preoperational thought does not allow toddlers to ● Looking at books
understand other viewpoints, but it does allow them ● Playing with push and pull toys
to symbolize objects and people in order to imitate ● Tossing a ball
activities they have seen.
● By 24 months, most toddlers understand
about 300 words, and can speak in two- to
three-word phrases.
● Ability to comprehend speech outweighs the number of
words and phrases spoken.
FUNDAMENTALS FOR NURSING CHAPTER 19 TODDLERS (1 TO 3 YEARS) 99

HEALTH PROMOTION INJURY PREVENTION
Aspiration
IMMUNIZATIONS ● Avoid small objects (grapes, coins, candy) that can lodge
in the throat.
Follow the latest Centers for Disease Control and ● Keep toys with small parts out of reach.
Prevention immunization recommendations ● Provide age-appropriate toys.
(see www.cdc.gov) for healthy toddlers 12 months to ● Check clothing for safety hazards (loose buttons).
3 years of age. These generally include immunizations ● Keep balloons away from toddlers.
against hepatitis A and B, diphtheria, tetanus, pertussis,
measles, mumps, rubella, aricella, polio, in uen a, Bodily harm
haemophilus in uen a type , and pneumococcal ● Keep sharp objects out of reach.
pneumonia. Recommendations change periodically, so ● eep rearms in a loc ed bo or cabinet.
check them often. ● Do not leave toddlers unattended with animals present.
● Teach stranger safety.
NUTRITION Burns
● Check the temperature of bath water.
● Toddlers are picky eaters with repeated requests for ● Turn down the thermostat on the water heater.
favorite foods. ● Have smoke detectors in the home and replace their
● Toddlers should consume 2 to 3 cups (16 to 24 oz)
batteries regularly.
per day and can switch from drinking whole milk to ● Turn pot handles toward the back of the stove.
drinking low-fat or fat-free milk at 2 years of age. ● Cover electrical outlets.
● Limit juice to 4 to 6 oz a day. ● Use sunscreen when outside.
● Food serving size is 1 tbsp for each year of age.
● Toddlers can be reluctant to try or accept foods Drowning
new to them. ● Do not leave toddlers unattended in the bathtub.
● As toddlers become more autonomous, they tend to ● Keep toilet lids closed.
prefer nger foods. ● Closely supervise toddlers at the pool or any other
● Regular meal times and nutritious snacks best meet body of water.
nutrient needs. ● Teach toddlers to swim.
● Avoid snacks and desserts that are high in sugar, fat,
Falls
or sodium. ● Keep doors and windows locked.
● Avoid foods that pose choking hazards (nuts, grapes, hot ● Keep the crib mattress in the lowest position with the
dogs, peanut butter, raw carrots, tough meats, popcorn).
rails all the way up.
● Supervise toddlers during snacks and mealtimes. ● Use safety gates across stairs.
● Cut food into small, bite-sized pieces to make it easier
to swallow and to prevent choking. Motor-vehicle injuries
● Do not allow toddlers to eat or drink during play ● Use an approved car seat in the back seat, away
activities or while lying down. from air bags.
● Do not use food as a reward or punishment. ● Toddlers should be in a rear-facing car seat at least
● Suggest that parents follow U.S. Department until age 2 or until they exceed the height and weight
of Agriculture nutrition recommendations limit of the car seat. They can then sit in an approved
(www.choosemyplate.gov). for ard facing car seat in the bac seat, using a e point
● Brush teeth and begin dental visits. Do not allow child harness or T-shield until they exceed the manufacturer’s
to use a bottle during naps or bedtime to reduce the risk recommended height and weight for the car seat.
for dental caries. ● Prior to installation, read all car seat safety guidelines.
● Teach toddler not to run or ride a tricycle into the street.
● Never leave a toddler alone in a car, especially in
warm weather.
100 CHAPTER 19 TODDLERS (1 TO 3 YEARS) CONTENT MASTERY SERIES

Poisoning
● Avoid exposure to lead paint.
● Place safety locks on cabinets that contain cleaners and

other chemicals.
● Keep plants out of reach.
● Keep a poison control number handy or program it into
A nurse is explaining to the parents of a 14-month-old
the phone.
toddler what physical and cognitive development
● Keep medications in childproof containers out of the they can expect from now until their child is 3 years
child’s reach. old. Use the ATI Active Learning Template: Growth
● Have a carbon monoxide detector in the home. and Development to complete this item.
Suffocation
PHYSICAL DEVELOPMENT: Identify at least four gross or
● Keep plastic bags out of reach. fine motor skills the parents can expect at specific ages.
● e sure the crib mattress ts tightly.
● Ensure crib slats are no further apart than 6 cm (2.4 in). COGNITIVE DEVELOPMENT: Describe at
● Keep pillows out of the crib. least three parameters the parents can expect
to observe during the toddler stage.
● Remove drawstrings from jackets and other clothing.
1. A nurse is giving a presentation about accident 4. A mother tells the nurse that her 2-year-old toddler
prevention to a group of parents of toddlers. Which has temper tantrums and says “no” every time
of the following accident-prevention strategies the mother tries to help them get dressed. The
should the nurse include? (Select all that apply.) nurse should recognize the toddler is manifesting
A. Store toxic agents in locked cabinets. which of the following stages of development?
B. Keep toilet seats up. A. Trying to increase her independence
C. Turn pot handles toward the back of the stove. B. Developing a sense of trust
D. Place safety gates across stairways. C. Establishing a new identity
E. Make sure balloons are fully inflated. D. Attempting to master a skill
2. A nurse is planning diversionary activities for toddlers 5. A nurse is reviewing nutritional guidelines with
on an inpatient unit. Which of the following activities the parents of a 2-year-old toddler. Which of the
should the nurse include? (Select all that apply.) following parent statements should indicate to
the nurse an understanding of the teaching?
A. Building models
A. “I should keep feeding my son whole
B. Working with clay milk until he is 3 years old.”
C. Filling and emptying containers B. “It’s okay for me to give my son a cup
D. Playing with blocks of apple juice with each meal.”
E. Looking at books C. “I’ll give my son about 2 tablespoons
of each food at mealtimes.”
3. A nurse is teaching the parents of a toddler D. “My son loves popcorn, and I know it
is better for him than sweets.”
about discipline. Which of the following
actions should the nurse suggest?
A. Establish consistent boundaries for the toddler.
B. Place the toddler in a room with the door closed.
C. Inform the toddler how you feel
when he misbehaves.
D. Use favorite snacks to reward the toddler.
FUNDAMENTALS FOR NURSING CHAPTER 19 TODDLERS (1 TO 3 YEARS) 101

1. A. CORRECT: Parents must prevent toddlers from Using the ATI Active Learning Template:
accessing dangerous substances. Growth and Development
B. Easy access to the water in the toilet bowl
PHYSICAL DEVELOPMENT
could result in aspiration or drowning.
C. CORRECT: Turn pot handles toward the back of
●
At 15 months, gross motor skills: walks without help, creeps up stairs
the stove to prevent the toddler from reaching and
●
At 15 months, fine motor skills: uses cup
pulling its contents down on themselves. well, builds tower of two blocks
D. CORRECT: Safety gates at the bottom of a staircase ●
At 18 months, gross motor skills: assumes standing
prevent toddlers from climbing stairs and falling position, jumps in place with both feet
backward. Safety gates placed at the top of a staircase ●
At 18 months, fine motor skills: manages spoon without
prevent toddlers from falling down the stairs. rotation, turns pages in book two or three at a time
E. Toddlers should not have access to balloons. Balloons can ●
At 2 years, gross motor skills: walks up and down stairs
easily burst and toddlers can put fragments of the balloon or ●
At 2 years, fine motor skills: builds a tower with six or seven blocks
the entire deflated balloon in their mouth and asphyxiate. ●
At 2.5 years, gross motor skills: jumps with both
NCLEX® Connection: Safety and Infection Control, feet, stands on one foot momentarily
Accident/Error/Injury Prevention ●
At 2.5 years, fine motor skills: draws circles,
has good hand-finger coordination
2. A. Toddlers are not cognitively or physically COGNITIVE DEVELOPMENT: During toddler stage: object
capable of building models. This play activity is permanence, memories of events that relate to them, domestic
acceptable for school-age children. mimicry (playing house), symbolization of objects and people,
B. Toddlers put small objects into their mouths use of 300 words, use of two- to three-word phrases
and can easily swallow bits of clay. This NCLEX® Connection: Health Promotion and Maintenance,
activity is unacceptable for a toddler. Developmental Stages and Transitions
C. CORRECT: This activity can help a toddler
develop fine motor skills and coordination.
D. CORRECT: This activity can help a toddler
develop fine motor skills.
E. CORRECT: This activity can help a toddler
prepare to learn to read.
3. A. CORRECT: Toddlers need consistent boundaries

for discipline to be effective.
B. Placing a toddler in a room with the door
closed can cause anxiety and fear.
C. A toddler is unable to understand how
another person is feeling.
D. Using favorite foods as rewards can
promote unhealthy eating habits.
4. A. CORRECT: Toddlers express a drive for independence

by opposing the desires of those in authority and
attempting to do everything themselves.
B. Developing trust is a developmental task for infants.
C. Establishing a new identity is the
developmental task of an adolescent.
D. Mastering a skill is a developmental
task of school-age children.
5. A. When toddlers turn 2 years old, the parents should give them
low-fat or fat-free milk, not whole milk. This reduces fat and
cholesterol intake and helps prevent childhood obesity.
B. Toddlers should have 4 to 6 oz of juice per day. Juices
do not have the whole fiber that fruit has, and they
contain sugar, so parents should limit their use.
C. CORRECT: Serving sizes for toddlers should be about
1 tbsp of solid food per year of age, so 2-year-olds
should have about 2 tbsp per serving.
D. Popcorn poses a choking hazard to toddlers.
102 CHAPTER 19 TODDLERS (1 TO 3 YEARS) CONTENT MASTERY SERIES

CHAPTER 20
UNIT 2 HEALTH PROMOTION Time concepts: Preschoolers begin to understand the
SECTION: NURSING THROUGHOUT THE LIFESPAN concepts of past, present, and future. By the end of the
preschool years, they can comprehend days of the week.
CHAPTER 20 Preschoolers Language development: Vocabulary continues to increase,
(3 to 6 Years) and by age 6 contains 8,000 to 14,000 words. Desires and

frustrations are more verbally articulated, and a need to
learn information is expressed through questioning.
Phonetically similar words (eye and I are difficult to
comprehend at this age. Preschoolers speak in sentences,
EXPECTED GROWTH AND identify colors, and enjoy talking. Children who speak
DEVELOPMENT more than one language reach language milestones at the
same time as peers who speak one language.
● Development occurs at a more gradual rate than
PSYCHOSOCIAL DEVELOPMENT
cognitive and psychosocial development. Erikson: Initiative vs. guilt: Preschoolers take on many
● Preschoolers evolve from the characteristically unsteady new experiences, despite not having all of the physical
wide stance and protruding abdomen of toddlers to the abilities necessary to be successful at everything. When
more graceful, posturally erect, and sturdy physicality children are unable to accomplish a task, they can
of this age group. feel guilty and believe they have misbehaved. Guide
● Male preschoolers have a tendency to appear larger with preschoolers to attempt activities within their capabilities
more muscle mass. while setting limits.
WEIGHT: Preschoolers gain about 2 to 3 kg Moral development: Preschoolers continue in the

(4.5 to 6.5 lb) per year. good-bad orientation of the toddler years but begin
to understand behavior in terms of what is socially
HEIGHT: Preschoolers grow about 6.2 to 9 cm
acceptable.
(2.4 to 3.5 in) per year.
Self-concept development: Preschoolers feel good about
FINE AND GROSS MOTOR SKILLS: Preschoolers show an
themselves for mastering skills (dressing and feeding)
impro ement in ne motor s ills copying gures on
that allow independence. During stress, insecurity, or
paper, scribbling, drawing, and dressing themselves).
illness, they tend to regress to previous immature
20.1 Gross motor skills by age behavior or develop habits (nose picking, bed wetting, or
thumb sucking).
3-YEAR-OLD 4-YEAR-OLD 5-YEAR-OLD
Ride a tricycle Skip and hop Jump rope Body-image changes
Jump off on one foot Walk backward ● Mistaken perceptions of reality coupled with
bottom step Throw ball with heel to toe misconceptions in thinking lead to active fantasies and
Stand on one foot overhead Move up and down fears. Preschoolers fear bodily harm, the dark, ghosts,
for a few seconds stairs easily
animals, inclement weather, and medical personnel.
● e role identi cation is typical.
COGNITIVE DEVELOPMENT Social development
Piaget: preoperational phase ● During the preschool time period, children generally do
● Preschoolers are still in the preoperational phase not exhibit stranger anxiety and have less separation
of cognitive development. They participate in anxiety. This leads to exploring their neighborhood
preconceptual thought (from 2 to 4 years of age) and environment and making new friends. However,
intuitive thought (from 4 to 7 years of age). prolonged separation (during hospitalization) can
● Preconceptual thought: Preschoolers make judgments provoke anxiety. Favorite toys and play help ease fears.
based on visual appearances. Misconceptions in ● Pretend play is healthy and allows children to determine
thinking during this stage include: the difference bet een reality and fantasy.
◯ Artificialism: Everything is made by humans. ● Sleep disturbances are common during early childhood,
◯ Animism: Inanimate objects are alive. and problems range from difficulties going to bed to
◯ Imminent justice: A universal code exists that night terrors. Advise parents to:
determines law and order. ◯ Assess whether the bedtime is too early for children
● Intuitive thought: Preschoolers can classify and who still take naps. Preschoolers average about 12 hr
begin to question information and become aware of of sleep a day. Some still require a daytime nap.
cause and effect relationships. ◯ Keep a consistent bedtime routine, and help children
slow down in preparation for bedtime. Avoid media

use or other stimulation before bed.
◯ Use a night light.
◯ Reassure children who are frightened.
◯ Ensure media content the child views is age-
appropriate and nonviolent.
FUNDAMENTALS FOR NURSING CHAPTER 20 PRESCHOOLERS (3 TO 6 YEARS) 103

AGE-APPROPRIATE ACTIVITIES INJURY PREVENTION
Parallel play shifts to associative play during the preschool Bodily harm
years. Play is not highly organized, and preschoolers do ● eep rearms in a loc ed cabinet or container.
not cooperate during play. Activities include the following. ● Teach stranger safety.
● Playing ball ● Wear helmets when riding a bicycle or tricycle
● Putting puzzles together and during any other activities that increase
● Riding tricycles head-injury risk.
● Pretend and dress-up activities ● Wear protective equipment (helmet and pads) during
● Musical toys physical activity.
● Painting, drawing, and coloring ● Remove doors from unused refrigerators or
● Sewing cards other equipment.
● Cooking and housekeeping toys ● Teach preschoolers not to walk in front of swings.
● Looking at illustrated books
Burns
● Technology (video and computer programs) to support ● Reduce the temperature setting on the water heater.
development and learn new skills ● Have smoke detectors in the home and replace the
batteries regularly.
Use sunscreen while outdoors.
HEALTH PROMOTION
●
● Teach preschoolers not to play with matches.
Drowning
IMMUNIZATIONS ● Do not leave children unattended in the bathtub.
Follow the latest Centers for Disease Control and ● Closely supervise children at a pool or any body of water.
Prevention immunization recommendations ● Teach children to swim.
(www.cdc.gov) for healthy preschoolers.
Motor-vehicle injuries
● These generally include immunizations against
Preschoolers must sit in a forward-facing car seat with
diphtheria, tetanus, pertussis, measles, mumps, rubella,
a harness for as long as possible, at least to 4 years of
aricella, seasonal in uen a, and polio.
age. For small sized preschoolers, many rear-facing seats
● Recommendations change periodically, so check
can accommodate a child weighing up to 15.9 Kg (35 lb.).
them often.
All children should sit in a back seat away from airbags.
Children who outgrow the seat before age 4 should use
HEALTH SCREENINGS a seat with a harness approved for higher weights and
heights. Preschoolers whose weight or height exceed
Vision screening is routine in the preschool population as
the forward-facing limit for their car seat should use a
part of the prekindergarten physical examination. It is
belt-positioning booster seat until the vehicle’s seat belt
essential to detect and treat myopia and amblyopia before
ts properly, typically bet een the ages of to .
poor visual acuity impairs the learning environment.
Poisoning
● Avoid exposure to lead paint.
NUTRITION ● Keep plants out of reach.

● Preschoolers who are mildly active, require an estimated ● Place safety locks on cabinets with cleaners and
caloric intake range from 1200 to 1400 calories per day. other chemicals.
● Picky eating remains a problem for some preschoolers, ● Keep a poison control number handy or program it into
but often by age 5 they become a bit more willing to the phone.
sample different foods. ● Keep medications in childproof containers out of reach.
● Preschoolers age 3 need 13 to 19 g of protein daily and ● Have a carbon monoxide detector in the home.
25 g are needed for ages 4 to 5 (2 to 4 oz-equivalents)
in addition to adequate calcium, iron, folate, and
vitamins A and C.
● Parents should provide a balance of nutrients. See
www.choosemyplate.gov for nutritional guidelines
for preschoolers.
104 CHAPTER 20 PRESCHOOLERS (3 TO 6 YEARS) CONTENT MASTERY SERIES

1. A nurse is talking with the guardian of a 4-year-old A nurse is making safety recommendations to the guardians
child who reports that the child is waking up at of two preschoolers. Use the ATI Active Learning Template:
night with nightmares. Which of the following Growth and Development to complete this item.
interventions should the nurse suggest?
INJURY PREVENTION: List at least four key areas of safety
A. Offer the child a large snack before bedtime. and age-appropriate instructions for addressing each area.
B. Allow the child to watch an extra
30 min of TV in the evening.
C. Have the child go to bed at a
consistent time every day.
D. Increase physical activity before bedtime.
2. A nurse is planning diversionary activities for

preschoolers on an inpatient pediatric unit.
Which of the following activities should the
nurse include? (Select all that apply.)
A. Assembling puzzles
B. Pulling wheeled toys
C. Using musical toys
D. Playing with puppets
E. Coloring with crayons
3. A nurse is preparing to administer medications to a

preschooler. Which of the following strategies should
the nurse implement to increase the child’s cooperation
in taking medications? (Select all that apply.)
A. Reassure the child an injection will not hurt.
B. Mix oral medications in a large glass of milk.
C. Offer the child choices when possible.
D. Have the guardians bring in a
favorite toy from home.
E. Engage the child in pretend play
with a toy medical kit.
4. A nurse is reviewing the Centers for Disease

Control and Prevention’s (CDC) immunization
recommendations with the guardians of preschoolers.
Which of the following vaccines should the nurse
include in this discussion? (Select all that apply.)
A. Haemophilus influenzae type B
B. Varicella
C. Polio
D. Hepatitis A
E. Seasonal influenza
5. A nurse is talking with guardians who are

concerned about several issues with their
preschooler. Which of the following issues
should the nurse identify as the priority?
A. “My child mimics the way my partner and I dress.”
B. “My child has temper tantrums every time we tell
them to do something they don’t want to do.”
C. “I think my child truly believes that toys
have personalities and can talk.”
D. “I feel bad when I see my child trying
so hard to button their shirt.”
FUNDAMENTALS FOR NURSING CHAPTER 20 PRESCHOOLERS (3 TO 6 YEARS) 105

1. A. Eating a large snack, especially one that is heavy or has 4. A. The CDC recommends Haemophilus influenzae
a high sugar content, is likely to provide stimulation that type B immunizations during infancy, but not
will make it more difficult for the child to fall asleep. generally beyond 18 months of age.
This will not alleviate the child’s nightmares. B. CORRECT: The CDC recommends a varicella (chickenpox)
B. Watching TV is likely to provide stimulation that will immunization during the preschool years.
make it more difficult for the child to fall asleep. C. CORRECT: The CDC recommends a polio
This will not alleviate the child’s nightmares. immunization during the preschool years.
C. CORRECT: Encourage the guardian to have the child go to D. The CDC recommends hepatitis A immunizations during
bed at the same time every day to promote a bedtime routine. infancy, but not generally beyond 24 months of age.
It is helpful to bathe the child or read a story every night E. CORRECT: The CDC recommends seasonal influenza
before bed to promote consistency, which should provide immunizations during the preschool years.
reassurance and ensure the child gets adequate sleep. NCLEX® Connection: Health Promotion and Maintenance,
D. Increasing physical activity is likely to provide stimulation Health Promotion/Disease Prevention
that will make it more difficult for the child to fall asleep.
This will not alleviate the child’s nightmares.
NCLEX® Connection: Basic Care and Comfort, Rest and Sleep 5. A. Dressing like guardians is nonurgent because it is an
expected response for a preschooler. It is common
for preschoolers to mimic behavior.
2. A. CORRECT: Putting puzzles together helps a preschooler B. CORRECT: When using the urgent vs. nonurgent approach
develop fine motor and cognitive skills. to client care, the priority issue is the problem that reflects
B. Pulling or pushing toys helps toddlers develop a lack of completion of the previous stage of development
large muscles and coordination. and progression to the current stage of development.
C. CORRECT: Playing with musical toys helps a preschooler According to Erikson, it is a task of the toddler stage to
develop fine motor skills and coordination. develop autonomy vs. shame and doubt. This preschooler
D. CORRECT: Playing with puppets helps a preschooler is still acting out with negativism, which is a persistent
develop oral language and actively use their imagination. negative response to requests, often manifested in
E. CORRECT: Using crayons to color on paper or tantrums. They are still struggling with this task and
in coloring books helps a preschooler develop needs assistance in working through that stage.
fine motor skills and coordination. C. The strong imagination of a preschooler is nonurgent
NCLEX® Connection: Health Promotion and Maintenance, because it is expected for preschoolers to have an active
Developmental Stages and Transitions imagination as well as an imaginary friend. It is common
for preschoolers to manifest misperceptions in thinking
(animism [the belief that inanimate objects are alive]).
3. A. Telling the preschooler the injection will not hurt D. Attempting to master activities (dressing themselves)
will cause the child to distrust the nurse. is nonurgent because it is an expected activity for a
B. Oral medications should be mixed in a small amount of fluid preschooler. It is common for preschoolers, who are
to increase the chance of the child taking the entire dosage. in the stage Erikson describes as initiative vs. guilt,
C. Offer the child choices when possible gives the child to face the challenge of mastering activities they can
some control and helps reduce the child’s fears. perform independently (dressing themselves).
D. CORRECT: Having familiar and cherished objects nearby is NCLEX® Connection: Health Promotion and Maintenance,
therapeutic for children during their hospitalization and is Developmental Stages and Transitions
useful as a distraction during uncomfortable procedures.
E. CORRECT: Pretend play helps children determine
the difference between reality and fantasy
(imagined fears), especially with the assistance
of the nurse during hospitalization.

Using the ATI Active Learning Template: Growth and Development
INJURY PREVENTION Drowning
Bodily harm
●
Do not leave children unattended in the bathtub.
●
Keep firearms in a locked cabinet or container.
●
Closely supervise children at a pool or any other body of water.
●
Teach stranger safety.
●
Teach children to swim.
●
Wear helmets when riding a bicycle or tricycle and during
●
any other activities that increase head-injury risk.
●
Use a forward-facing car seat with a harness in the back seat.
●
Wear protective equipment (helmet and pads) during physical activity. ●
If weight or height exceeds the forward-facing
●
Remove doors from unused refrigerators or other equipment. limit, use a belt-positioning booster seat.
●
Teach preschoolers not to walk in front of swings. Poisoning
Burns
●
Avoid exposure to lead paint.
●
Reduce the temperature setting on the water heater.
●
Keep plants out of reach.
●
Have smoke detectors in the home and replace the batteries regularly.
●
Place safety locks on cabinets with cleaners and other chemicals.
●
Use sunscreen while outdoors.
●
Keep a poison control number handy or program it into the phone.
●
Teach preschoolers not to play with matches.
●
Keep medications in childproof containers out of reach.
●
Have a carbon monoxide detector in the home.
NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions
106 CHAPTER 20 PRESCHOOLERS (3 TO 6 YEARS) CONTENT MASTERY SERIES

CHAPTER 21
Erikson: industry vs. inferiority
School-Age Children School-age children’s stage of psychosocial development,

CHAPTER 21 according to Erikson, is industry vs. inferiority.
(6 to 12 Years) ● School-age children develop a sense of

industry through advances in learning.
● Tasks that increase self-worth motivate them.
● Stress is increasingly common in this age
group from parental and peer expectations,
EXPECTED GROWTH AND their environment, or observed violence.
DEVELOPMENT ● Fears of ridicule by peers and teachers over school-related
issues are common. Some children manifest nervous
behavior to deal with stress (nail biting).
Moral development
WEIGHT: Gain about 1.8 to 3.2 kg (4 to 7 lb) per year ● Early on, school-age children might not understand the
HEIGHT: Grow about 5 cm (2 in) per year reasoning behind many rules and ill try to nd ays
around them. Instrumental exchange is in place (“I’ll
FINE AND GROSS MOTOR DEVELOPMENT: Coordination
help you if you help me.”). They want to make the best
continues to improve and movements become
deal and do not consider elements of loyalty, gratitude,
more re ned.
or justice when making decisions.
● Females can exceed the height and weight of males near ● In the latter part of the school years, they move into
the end of school-age years.
a law-and-order orientation, placing more emphasis
● Permanent teeth erupt.
on justice.
● Visual acuity improves to 20/20.
● Auditory acuity and sense of touch fully develop. Self-concept development

● tri e to de elop healthy self respect by nding out in
CHANGES RELATED TO PUBERTY BEGIN:
what areas they excel
● Females ● Need parents to encourage them in educational or
◯ Budding of breasts.
extracurricular successes
◯ Appearance of pubic hair
● Self-esteem developed based on interactions with peers
◯ Menarche
and perceived self-concept

● Males
◯ Enlargement of testicles with changes in the scrotum Body-image changes
◯ Appearance of pubic hair ● ody image solidi es.
● Education should address curiosity about sexuality,
sexual development, and the reproductive process.
COGNITIVE DEVELOPMENT ● School-age children are more modest than
Piaget: Concrete Operations preschoolers and place more emphasis on privacy.
● See weight and volume as unchanging. ● School-age children develop concern
● Understand simple analogies and relationships between about appearance and hygiene.
things and ideas.
Social development
● Understand time (days, seasons). ● Social environment can expand to include
● Classify more complex information.
school, community, and church.
● Understand various emotions. ● Peer groups play an important part in social development.
● Become self-motivated.
Ho e er, peer pressure begins to ta e effect.
● ol e problems and understand cause and effect. ● Friendships begin to form among same-gender
Language development peers. Clubs and best friends are popular.
● De ne many ords and understands rules of grammar. ● Most relationships come from school associations.
● Understand that a word can have multiple meanings. ● Children at this age can rival the same-gender parent.
● Increased ability to connect words into phrases. ● Conformity becomes evident.
● Reason about a word’s meaning rather than the ● School-age children become more
literal translation. independent from parents.
● Understands jokes and riddles.
FUNDAMENTALS FOR NURSING CHAPTER 21 SCHOOL-AGE CHILDREN (6 TO 12 YEARS) 107

AGE-APPROPRIATE ACTIVITIES DENTAL HEALTH
Competitive and cooperative play predominates. ● Ha e the child brush and oss daily.
● Ensure the child get regular check-ups.
6- TO 9-YEAR-OLDS
● Play board, video, and number games.
● Play hopscotch. INJURY PREVENTION
● Jump rope.
Bodily harm
● Collect roc s, stamps, cards, coins, or stuffed animals. ● eep rearms in a loc ed cabinet or bo .
● Ride bicycles. ● Assist with identifying safe play areas.
● Build simple models. ● Teach stranger safety.
● Artistic activities (painting and drawing). ● Teach children to wear helmets and pads when roller
● Play team sports: skill building.
skating, skateboarding, bicycling, riding scooters, skiing,
9- TO 12-YEAR-OLDS and during any other activities that increase injury risk.
● Make crafts. ● Teach children to ear light re ecti e clothing at night.
● Read books.
Burns
● Build models. ● Teach re safety and elimination of potential burn ha ards.
● Develop in hobbies. ● Have working smoke and carbon
● Assemble jigsaw puzzles.
monoxide detectors in the home.
● Play video games. ● Promote sunscreen use.
● Play team sports.
● Learn to play musical instruments. Drowning
● Supervise children when swimming
or near a body of water.
HEALTH PROMOTION ● Teach swimming skills and safety.
IMMUNIZATIONS ● Have children use a car or booster seat
until adult seat belts t correctly.
Follow the latest Centers for Disease Control and Prevention ● Children younger than 13 years of age
immunization recommendations (see www.cdc.gov) for
are safest in the back seat.
healthy school-age children. These generally include
immunizations against diphtheria, tetanus, pertussis, human Substance abuse/poisoning
papillomavirus, hepatitis A and B, measles, mumps, rubella, ● Keep cleaners and chemicals in locked
aricella, seasonal in uen a, polio, meningococcal infections, cabinets or out of reach.
and for some high-risk individuals, pneumococcal infections. ● Teach children to say “no” to use of illicit drugs,
Recommendations change periodically, so check them often. alcohol, or other addictive substances. .
● Teach children about the dangers of smoking.
HEALTH SCREENINGS
● Scoliosis: Screening for idiopathic scoliosis, a lateral
curvature of the spine with no apparent cause, is essential,
especially for females, during the school-age stage.
● Health promotion and maintenance education is essential
to promote healthy choices and prevent illness.
NUTRITION
● By the end of the school-age stage, children eat adult
servings of food and also need nutritious snacks.
● Obesity predisposes school-age children to low
self-esteem, diabetes mellitus, heart disease, and high
blood pressure. Advise parents to:
◯ Not use food as a reward.
◯ Emphasize physical activity.
◯ Provide a balanced diet. See www.choosemyplate.gov
for nutritional guidelines for school-age children.

◯ Teach children to make healthy food selections for
meals and snacks.

◯ Avoid eating meals at fast-food restaurants.
◯ Avoid skipping meals.
108 CHAPTER 21 SCHOOL-AGE CHILDREN (6 TO 12 YEARS) CONTENT MASTERY SERIES

1. A nurse is talking with caregivers of a 12-year-old 4. A nurse is talking with the caregivers of a
child. Which of the following issues verbalized by the 10-year-old child who is concerned that their
caregivers should the nurse identify as the priority? child is becoming secretive, including closing the
A. “We just don’t understand why our child door when showering and dressing. Which of the
can’t keep up with the other kids in simple following responses should the nurse make?
activities like running and jumping.” A. “Perhaps you should try to find out what is
B. “Our child keeps trying to find ways happening behind those closed doors.”
around our household rules. They always B. “Suggest that the door be left
want to make deals with us.” ajar for safety reasons.”
C. “We think our child is trying too hard to excel in C. “At this age, children tend to become
math just to get the top grades in the class.” modest and value their privacy.”
D. “Our child likes to sing and worries it will D. “You should establish a disciplinary
make the other kids want to laugh.” plan to stop this behavior.”
2. A nurse is planning diversionary activities for 5. A nurse is planning a health promotion and primary
school-age children on an inpatient pediatric prevention class for the caregivers of school-age
unit. Which of the following activities should children. Which of the following actions should
the nurse include? (Select all that apply.) the nurse plan to take? (Select all that apply.)
A. Building models A. Provide information about the
B. Playing video games risk of childhood obesity.
C. Reading books B. Discuss the danger of substance use disorders.
D. Using toy carpentry tools C. Promote discussion about sexual issues.
E. Playing board games D. Recommend the school-age child

sit in the front seat of the car.
E. Reinforce stranger awareness.
3. A nurse is evaluating teaching about nutrition
with the guardians of an 11-year-old child. Which
of the following statements should indicate to
the nurse an understanding of the teaching?
A. “Our child wants to eat as much as we do, but
we’re afraid it will lead to becoming overweight.”
B. “Our child skips lunch sometimes, but
we figure it’s okay as long as we eat a
healthy breakfast and dinner.”
C. “We limit fast-food restaurant meals
to three times a week now.”
D. “We reward school achievements with a point
system instead of a pizza or ice cream.”

A nurse is explaining to a group of caregivers in
a community center what cognitive development
characteristics they should expect of their school-age
children. Use the ATI Active Learning Template:
Growth and Development to complete this item.
COGNITIVE DEVELOPMENT: List at least

eight cognitive and language development
expectations during young adulthood.
FUNDAMENTALS FOR NURSING CHAPTER 21 SCHOOL-AGE CHILDREN (6 TO 12 YEARS) 109

1. A. CORRECT: When using the urgent vs. nonurgent Using the ATI Active Learning Template:
approach to client care, the priority issue is the Growth and Development
delay in motor skills, which could indicate an illness
COGNITIVE DEVELOPMENT
and requires further investigation.
B. The failure to understand rules is nonurgent
●
See weight and volume as unchanging.
because it is common for school-age children to
●
Understand simple analogies and relationships
fail to understand the reasoning behind many between things and ideas.
rules and to try to find ways around them. ●
Understand time (days, seasons).
C. The self-motivation to excel is nonurgent because it is ●
Classify more complex information.
common for school-age children, who are in the stage ●
Understand various emotions people experience.
Erikson describes as industry vs. inferiority, to strive to ●
Become self-motivated.
develop a sense of industry through advances in learning. ●
Solve problems and understand cause and effect.
D. The fear of disapproval from peers is nonurgent because it is ●
Define many words and understands rules of grammar.
common for school-age children, who are in the stage Erikson
describes as industry vs. inferiority, to face the challenge
●
Understand that a word can have multiple meanings.
of acquiring new skills and achieving success socially. NCLEX® Connection: Health Promotion and Maintenance,
2. A. CORRECT: Building simple models helps the school-age

child develop fine motor and cognitive skills.
B. CORRECT: Playing video games, especially educational
and nonviolent ones, helps school-age children
develop fine motor and cognitive skills.
C. CORRECT: Reading books helps the school-age child
develop cognitive and communication skills.
D. Using toy carpentry tools helps preschoolers
develop imagination and fine motor skills.
E. CORRECT: Playing board games builds cognitive
skills and promotes social interaction.
3. A. By the end of the school-age stage, guardians should

expect children to eat adult-size portions of food.
B. Skipping meals can lead to unhealthful snacking
and overeating later in the day.
C. Guardians should avoid fast-food restaurants
completely to keep children from eating food
high in sugar, fat, and starches.
D. CORRECT: Guardians should avoid rewarding
children with food for good behavior or
achievements. Associations between food and
feeling good can lead to weight problems.
4. A. This response implies that the child is

doing something wrong.
B. A toddler requires constant supervision. This response
suggests that the school-age child has something to fear in
the home, or that the child requires constant supervision.
C. CORRECT: School-age children develop a need for
privacy. It is important for the caregivers to show trust
in the child and respect the child’s need for privacy.
D. This suggestion sounds like a punishment, and
the caregivers have not presented any evidence
that the child is doing anything wrong.
5. A. CORRECT: Caregivers of school-age children

need to be aware of nutritional strategies for
preventing childhood obesity.
B. CORRECT: Caregivers of school-age children need to
know how to teach children to say no to illicit drugs,
alcohol, and all other harmful or addictive substances.
C. CORRECT: Caregivers should discuss sexual issues with
school-age children to promote healthy behavior.
D. Instruct the caregivers of school-age children
to keep children under 13 years in the back seat
of the car to reduce the risk of injury.
E. CORRECT: Caregivers should reinforce stranger safety
as soon as their children are old enough to understand
it, and throughout all stages of childhood.
110 CHAPTER 21 SCHOOL-AGE CHILDREN (6 TO 12 YEARS) CONTENT MASTERY SERIES

CHAPTER 22
Erikson: identity vs. role confusion
Adolescents
● They develop a sense of personal identity that family
CHAPTER 22 e pectations in uence.
(12 to 20 Years) ● Adolescents strive for independence from guardians and
identify more with peers.
Group identity: They become part of a peer group that

greatly affects behavior.
EXPECTED GROWTH Vocationally: Work habits and plans for college and career
AND DEVELOPMENT begin to solidify.
Sexuality: Sexual identity develops during adolescence,

PHYSICAL DEVELOPMENT with increasing interest in the opposite gender, the same
gender, or arious genders, according to self identi cation
● Adolescents gain the nal to of height
ith se uality. elf identi cation can shift as se ual
during puberty.
maturity progresses.
● Sleep habits change with puberty due to increased
metabolism and rapid growth during the adolescent Health perceptions: Adolescents often feel invincible to
years. Adolescents stay up late, sleep later in the bad outcomes of risky behaviors.
morning, and perhaps sleep longer than they did during
Moral development: conventional law and order.
the school-age years.
Adolescents do not see rules as absolutes, instead
FEMALES looking at each situation and adjusting the rules. Not all
● Grow 5 to 20 cm (2 to 8 in) and gain 7 to 25 kg (15.5 to adolescents attain this level of moral development during
55 lb) during the prepuberty growth spurt these years.
● Stop growing around 16 to 17 years of age
Self-concept development: Adolescents develop a
● Mature sexually in the following order:
◯ Appearance of breast buds
healthy self-concept by having healthy relationships with
◯ Growth of pubic hair (can have hair growth prior to
peers, family, and teachers while striving for emotional
independence. Identifying a skill or talent helps them
breast bud development)
maintain a healthy self-concept. Participation in sports,
◯ Onset of menstruation
hobbies, or the community can have a positive outcome.
MALES
Body-image changes: Adolescents seem particularly
● Grow 10 to 30 cm (4 to 12 in) and gain 7 to 29 kg (15 to
concerned with the body images the media portray.
65 lb) during the prepuberty growth spurt
Changes during puberty result in comparisons between
● Stop growing at around 18 to 20 years of age
adolescents and peers. Guardians also give their input
● Mature in the following order:
◯ Increase in the size of the testes and scrotum
for hair styles, dress, and activity. Adolescents require
◯ Appearance of pubic hair
interventions if depression or eating disorders result from
◯ Rapid growth of genitalia
poor body image.
◯ Growth of axillary hair Social development
◯ Appearance of downy hair on upper lip ● Group relationships are important, as they lead to
◯ Change in voice personal acceptance, approval, and learned behaviors.
● Peer relationships develop as a support system.
Best-friend relationships are more stable and
●
long-lasting than in previous years.

Piaget: Formal operations ● Guardian-child relationships change to allow
● Think at an adult level. more independence.
● Think abstractly and deal with principles and
hypothetical situations.
● Evaluate the quality of their own thinking.
AGE-APPROPRIATE ACTIVITIES
● Have a longer attention span. ● Nonviolent video games, music, movies
● Are highly imaginative and idealistic. ● Sports, social events
● Make decisions through logical operations. ● Caring for a pet
● Are future-oriented. ● Career-training programs
● Are capable of deductive reasoning. ● Reading
● Understand how actions of an individual
in uence others.
Adolescents communicate one way with the peer group
and another way with adults. Use open-ended questions to
communicate and discuss sensitive issues.
FUNDAMENTALS FOR NURSING CHAPTER 22 ADOLESCENTS (12 TO 20 YEARS) 111

HEALTH PROMOTION INJURY PREVENTION
Bodily harm
IMMUNIZATIONS ● eep rearms in a loc ed cabinet or bo .
● Teach proper use of sporting equipment prior to use.
Follow the latest Centers for Disease Control and ● Insist on helmet use and/or pads when roller skating,
Prevention (CDC) immunization recommendations
skateboarding, bicycling, riding scooters, skiing, and
for healthy adolescents. These generally include
during any other activities that increase injury risk.
immunizations against diphtheria, tetanus, pertussis, ● Avoid trampolines.
human papillomavirus, hepatitis A and B, measles, mumps, ● Be aware of changes in mood and monitor for self-harm
rubella, aricella, seasonal in uen a, meningococcal and
in at-risk adolescents. Watch for the following.
polio, and for some high-risk individuals, pneumococcal ◯ Poor school performance
infections. The recommendations change periodically, so ◯ Lack of interest in things of previous interest
check them often. ◯ Social isolation
◯ Disturbances in sleep or appetite
HEALTH SCREENINGS ◯ Expression of suicidal thoughts
Provide health promotion and maintenance education Burns

related to illness prevention. ● Teach re safety.
● Promote sunscreen use.
SCOLIOSIS: Screening for idiopathic scoliosis, a lateral
curvature of the spine with no apparent cause, is essential, Drowning: Teach swimming skills and safety.
especially for females, during the adolescent growth spurt
Motor-vehicle injury
because it is most evident at that time. ● Encourage attendance at drivers’ education courses.
● Emphasize seat belt use.
NUTRITION ● Discourage use of cell phones, including texting,
while driving.
● Rapid growth and high metabolism require increases ● Teach the dangers of combining substance use
in high-quality nutrients. Nutrients that tend to be
with driving.
de cient during this stage of life are iron, calcium, and
vitamins A and C. Substance use
● Eating disorders commonly develop during adolescence ● Monitor at-risk adolescents.
(more in females than in males) due to a fear of being ● Teach adolescents about the dangers of smoking
overweight, fad diets, or as a mechanism of maintaining ● Teach adolescents to say “no” to drugs and alcohol.
control over some aspect of life. ● Present a no-tolerance attitude.
◯ Anorexia nervosa
◯ Bulimia nervosa
Sexually transmitted infections (STIs)
● Identify risk factors through the assessment and
◯ Overeating
interview process.
● Advise guardians to: ● Provide education about prevention of STIs and
◯ Not use food as a reward.
resources for treatment.

◯ Emphasize physical activity.
◯ Provide a balanced diet. See www.choosemyplate.gov Pregnancy prevention

for nutritional guidelines for adolescents. ● Provide education.
◯ Teach adolescents to make healthy food selections for ● For pregnant adolescents, provide resources
meals and snacks. for supervision of pregnancy, nutrition, and
psychological support.
DENTAL HEALTH
● Brush daily.
● Floss daily.
● Get regular check-ups.
112 CHAPTER 22 ADOLESCENTS (12 TO 20 YEARS) CONTENT MASTERY SERIES

1. A nurse is teaching the guardian of a 12-year-old A nurse on a pediatric unit is reviewing with a group of newly
male client about manifestations of puberty. licensed nurses the cognitive developmental milestones to
The nurse should explain that which of the expect from adolescent clients. Use the ATI Active Learning
following physical changes occurs first? Template: Growth and Development to complete this item.
A. Appearance of downy hair on the upper lip COGNITIVE DEVELOPMENT: List at least five cognitive
B. Hair growth in the axillae development expectations during adolescence.
C. Enlargement of the testes and scrotum
D. Deepening of the voice
2. A nurse on a pediatric unit is caring for

an adolescent who has multiple fractures.
the nurse take? (Select all that apply.)
A. Suggest that the guardians bring
in video games to play.
B. Provide a television and movies for
the adolescent to watch.
C. Limit visitors to the adolescent’s immediate family.
D. Involve the adolescent in treatment
decisions when possible.
E. Allow the adolescent to perform morning self-care.
3. A nurse is reviewing the CDC’s immunization

recommendations with the guardians of an adolescent.
Which of the following recommendations should the
nurse include in this discussion? (Select all that apply.)
A. Rotavirus
B. Varicella
C. Herpes zoster
D. Human papilloma virus
E. Seasonal influenza
4. A nurse is talking with an adolescent who

is having difficulty dealing with several
issues. Which of the following issues should
the nurse identify as the priority?
A. “I kind of like this boy in my class,
but he doesn’t like me back.”
B. “I want to hang out with the kids in the
science club, but the jocks pick on them.”
C. “I am so fat, I skip meals to try to lose weight.”
D. “My dad wants me to be a lawyer like
him, but I just want to dance.”
5. A nurse is preparing a wellness presentation for

families about health screening for adolescents.
Which of the following information should
A. Obtain a periodic mental status evaluation.
B. Discuss prevention of sexually
transmitted infections.
C. Regularly screen for tuberculosis.
D. Provide education about drug and alcohol use.
E. Teach monthly breast examinations.
FUNDAMENTALS FOR NURSING CHAPTER 22 ADOLESCENTS (12 TO 20 YEARS) 113

1. A. The emergence of facial hair is a late pubescent 4. A. The client is at risk for developing an altered self-esteem
change. Evidence-based practice indicates due to rejection from their peers. However, another
that another change occurs first. issue is the priority. It is common for adolescents,
B. Hair growth in nongenital areas is a late prepubescent who are in the stage Erikson describes as identity
change. Evidence-based practice indicates vs. role confusion, to face the challenge of forming
that another change should occur first. peer relationships and dating relationships.
C. CORRECT: Using evidence-based practice, the first B. The client is at risk for developing an altered self-esteem
prepubescent change in boys is an increase in the size of due to rejection from their peers. However, another
the testicles and scrotum, and growth of pubic hair. issue is the priority. It is common for adolescents, who
D. Changing vocal quality is the last expected are in the stage Erikson describes as identity vs. role
pubescent change. Evidence-based practice confusion, to face the challenge of becoming part of
indicates that another change occurs first. a peer group and establishing a group identity.
NCLEX® Connection: Health Promotion and Maintenance, C. CORRECT: The greatest risk to the client is injury due to an
Developmental Stages and Transitions eating disorder. The priority issue is to provide counseling
to promote body image and ensure proper nutrition.
D. The client is at risk for developing an altered self-identity
2. A. CORRECT: Nonviolent video games are suitable due to pressure from a guardian; however, another
diversional activities for an adolescent. issue is the priority. It is common for adolescents, who
B. CORRECT: Nonviolent movies are suitable are in the stage Erikson describes as identity vs. role
diversional activities for an adolescent. confusion, to face the challenge of forming an identity
C. An adolescent client forms a strong attachment that will lead to higher education and a career.
to peers. Allowing friends to visit should reduce NCLEX® Connection: Health Promotion and Maintenance,
the adolescent’s feelings of isolation. Developmental Stages and Transitions
D. CORRECT: The adolescent is capable of thinking
through problems. Involving the adolescent in decisions
helps promote independence and control. 5. A. CORRECT: Obtain an occasional mental status evaluation
E. CORRECT: Allowing the adolescent to perform morning is important for the adolescent to reduce the risk for
self-care helps promote a sense of independence suicide, eating disorders, or substance use disorder.
and shows respect for their privacy. B. CORRECT: Discuss prevention of sexually transmitted
NCLEX® Connection: Health Promotion and Maintenance, infections is important for the adolescent to reduce the
Developmental Stages and Transitions risk for developing a sexually transmitted disease.
C. CORRECT: Periodically screen for tuberculosis is
important for the adolescent to reduce the risk
3. A. The CDC recommends rotavirus immunizations during for developing or spreading tuberculosis.
infancy and not generally beyond 8 months of age. D. CORRECT: Providing education about drug and alcohol
B. CORRECT: The CDC recommends varicella use is important for the adolescent to reduce the risk
(chickenpox) immunizations during adolescence. for the use of alcohol and recreational drugs.
C. The CDC recommends herpes zoster (shingles) E. Young adult clients should begin monthly breast
immunizations during middle adulthood, examinations to screen for early breast cancer.
typically one dose at age 60 or beyond. NCLEX® Connection: Health Promotion and Maintenance,
D. CORRECT: The CDC recommends human papilloma virus Health Screening
(genital warts) immunizations during adolescence.
E. CORRECT: The CDC recommends seasonal
influenza immunizations during adolescence.

Using the ATI Active Learning Template: Growth and Development
●
Think at an adult level
●
Think abstractly and deal with principles
●
Evaluate the quality of their own thinking
●
Have a longer attention span
●
Are highly imaginative and idealistic
●
Make decisions through logical operations
●
Are future-oriented
●
Are capable of deductive reasoning
●
Understand how actions of an individual influence others
114 CHAPTER 22 ADOLESCENTS (12 TO 20 YEARS) CONTENT MASTERY SERIES

CHAPTER 23
UNIT 2 HEALTH PROMOTION Social development
SECTION: NURSING THROUGHOUT THE LIFESPAN Young adults might:
Leave home and establish independent living situation.
Young Adults
●
● Establish close friendships (intimacy).

CHAPTER 23
(20 to 35 Years)
● Transition from being single to being a member of a
new family.
● Question their ability to parent.
● Experience increased anxiety and/or depression,
especially after the birth of a child.
EXPECTED GROWTH AND

DEVELOPMENT HEALTH PROMOTION
Young adults are especially at risk for alterations in
PHYSICAL DEVELOPMENT health from:
● Growth has concluded around age 20. ● Substance use disorders
● Physical senses peak. ● Periodontal disease due to poor oral hygiene
● Cardiac output and efficiency pea . ● Unplanned pregnancies: a source of high stress
● Muscles function optimally at ages 25 to 30. ● Sexually transmitted infections (STIs)
● Time for childbearing is optimal. ● Infertility
● Pregnancy-related changes occur. ● Work-related injuries or exposures
● Violent death and injury
Piaget: Formal operations
IMMUNIZATIONS
The young adult years are an optimal time for education, Follow the latest Centers for Disease Control and Prevention
both formal and informal. (CDC) immunization recommendations (see www.cdc.gov).
● Critical thinking skills improve. Primary vaccinations for young adults include annual
● Memory peaks in the 20s. in uen a, as ell as tetanus, diphtheria, and pertussis.
● Ability for creative thought increases. Other vaccines are given to “catch up” the young adult for
● Values/norms of friends (social groups) are relevant. incomplete immunization series, or to provide additional
● Decision ma ing s ills are e ible ith increased protection to high-risk individuals. These include
openness to change. immunizations against hepatitis A and B, measles, mumps,
rubella, varicella, human papillomavirus, and pneumococcal
and meningococcal infections. The recommendations
PSYCHOSOCIAL DEVELOPMENT change periodically, so check them often.
According to Erikson, young adults must achieve
intimacy vs. isolation.
● Young adults can take on more adult commitments
HEALTH SCREENINGS
and responsibilities. ● Young adults should follow age-related guidelines
● Young adults’ occupational choices relate to: for screening.
◯ High goals/dreams. ● Encourage selecting a primary care provider for ongoing,
◯ Exploration/experimentation. routine medical care.
● Provide education about contraception and regular
Moral development
physical activity.
● Young adults can personalize values and beliefs.
● They can base reasoning on ethical fairness principles

(justice). ROUTINE HEALTH CARE VISITS
Self-concept development: In uences on the formation Should include obtaining height, weight, vital signs, and
of a healthy self-concept during the young adult family history; screening for stress; education related to
years include: STIs and substance use disorders; and encouragement of
● Avoidance of substance use disorders good nutrition.
● Formation of a family
Frequency of interactions with family and friends
NUTRITION
●
● Personal choice and response to ethical situations

● Monitor for adequate nutrition and proper physical activity.
Body-image changes ● Monitor calcium intake in females.
● Changes are affected by diet and e ercise patterns. ● See choosemyplate.gov for nutritional recommendations.
● Pregnancy-related body image changes can also occur.
FUNDAMENTALS FOR NURSING CHAPTER 23 YOUNG ADULTS (20 TO 35 YEARS) 115

INJURY PREVENTION
● Avoiding alcohol, tobacco products, and illicit drugs, Active Learning Scenario
which can lead to substance use disorders
● Avoiding driving a vehicle during or after drinking A nurse at a community center is teaching a group of young adults
alcohol or taking substances that impair sensory and what physical and cognitive development characteristics they
motor functions should expect at this stage of life. Use the ATI Active Learning
Template: Growth and Development to complete this item.
● Wearing a seat belt when operating a vehicle
● Wearing a helmet while bike riding, skiing, and other PHYSICAL DEVELOPMENT: List at least five
recreational activities that increase head-injury risk physical development expectations.
● Installing smoke and carbon monoxide detectors
in the home COGNITIVE DEVELOPMENT: List at least three cognitive
development expectations during young adulthood.
● ecuring rearms in a safe location
1. A nurse is instructing a young adult client about 4. A nurse is counseling a young adult who describes
health promotion and illness prevention. Which of having difficulty dealing with several issues.
the following statements indicates understanding? Which of the following statements should the
A. “I already had my immunizations as a nurse identify as the priority to assess further?
child, so I’m protected in that area.” A. “I have my own apartment now, but it’s not
B. “It is important to schedule routine health easy living away from my guardians.”
care visits even if I am feeling well.” B. “It’s been so stressful for me to even
C. “I will just go to an urgent care center think about having my own family.”
for my routine medical care.” C. “I don’t even know who I am yet, and now
D. “There’s no reason to seek help if I am feeling I’m supposed to know what to do.”
stressed because it’s just part of life.” D. “My partner is pregnant, and I don’t think I
have what it takes to be a good parent.”
2. A nurse is reviewing CDC immunization
recommendations with a young adult client. 5. A nurse is reviewing safety precautions with a
Which of the following vaccines should the nurse group of young adults at a community health fair.
recommend as routine, rather than catch-up, Which of the following recommendations should
during young adulthood? (Select all that apply.) the nurse include to address common health
A. Influenza risks for this age group? (Select all that apply.)
B. Measles, mumps, rubella A. Install bath rails and grab bars in bathrooms.
C. Pertussis B. Wear a helmet while skiing.
D. Tetanus C. Install a carbon monoxide detector.
E. Polio D. Secure firearms in a safe location.
E. Remove throw rugs from the home.
3. A charge nurse is explaining the various stages of the
lifespan to a group of newly licensed nurses. Which
of the following examples should the charge nurse
include as a developmental task for a young adult?
A. Becoming actively involved in providing
guidance to the next generation
B. Adjusting to major changes in roles
and relationships due to losses
C. Devoting time to establishing an occupation
D. Finding oneself “sandwiched” between and
being responsible for two generations
116 CHAPTER 23 YOUNG ADULTS (20 TO 35 YEARS) CONTENT MASTERY SERIES

1. A. For protection against a wide variety of communicable 4. A. Living away from home and establishing independent
illnesses, encourage adults to obtain CDC-recommended living is nonurgent because it is an expected
immunizations throughout the lifespan. challenge during a young adulthood. There is another
B. CORRECT: Despite being in relatively good health, statement to identify as the priority.
young adult clients should plan to participate in B. Transitioning from being single to being a member
routine screenings and health care visits. of a new family is nonurgent because it is an
C. Urgent care centers offer limited services, typically expected challenge during young adulthood. There
for acute injuries or problems that cannot wait until a is another statement to identify as the priority.
primary care provider is available. Encourage clients C. CORRECT: When using the urgent vs. nonurgent approach
to establish a relationship with a primary care provider to client care, determine that the counseling priority is the
to consult for nonurgent health problems. problem that reflects a lack of completion of the previous
D. Although it is true that stress is inevitable, chronic stress can stage of development and progression to the current
lead to severe health alterations. Young adults who have stress stage. According to Erikson, it is a task of adolescence
that is recurrent or escalating should seek medical care. to develop identity vs. role confusion. Recognize this
NCLEX® Connection: Health Promotion and Maintenance, young adult is still struggling with this task and needs
Health Promotion/Disease Prevention assistance in working through that dilemma.
D. Considering childbearing and parenting is nonurgent
because it is an expected challenge during young adulthood.
2. A. CORRECT: The CDC recommends an annual There is another statement to identify as the priority.
influenza immunization during adulthood. NCLEX® Connection: Health Promotion and Maintenance,
B. The CDC recommends obtaining the measles, mumps, Developmental Stages and Transitions
and rubella vaccines routinely during childhood.
The series can be administered during adulthood
for individuals who meet certain criteria. 5. A. Although bath rails and grab bars add a measure
C. CORRECT: The CDC recommends a booster dose of safety to bathing activities, this recommendation
of pertussis vaccine during adulthood. addresses health risks common to the older adult
D. CORRECT: The CDC recommends a booster population due to their risk for falls.
dose of diphtheria and ongoing booster B. CORRECT: Encourage the client to wear a helmet while
doses of tetanus during adulthood. skiing to reduce the risk of head injury. Although it
E. The CDC recommends the polio vaccine to be administered applies to other age groups, many young adults engage
routinely during childhood. The series can be administered in winter sports. Therefore, this is an age-appropriate
during adulthood for individuals who meet certain criteria. recommendation for this developmental group.
NCLEX® Connection: Health Promotion and Maintenance, C. CORRECT: Remind the client to install a carbon monoxide
Health Promotion/Disease Prevention detector in the home. This is an essential safety precaution for
young adults as well as for all other developmental stages.
D. CORRECT: Warn the client to secure firearms in a
3. A. Identify active involvement in the next generation safe location to reduce the risk of accidental gunshot
as a developmental task for middle adults. injuries. Although it applies to all age groups, many
B. Identify adjusting to major role changes associated young adults own firearms, so this is an age-appropriate
with loss as a developmental task for older adults. recommendation for this developmental group.
C. CORRECT: Identify exploring career options and E. Although throw rugs can pose a safety hazard, this
then establishing oneself in a specific occupation as recommendation addresses health risks common to the
a major developmental task for a young adult. older adult population due to their risk for falls.
D. Identify assuming responsibility for the previous as well as the NCLEX® Connection: Health Promotion and Maintenance,
next generation as a developmental task for middle adults. Developmental Stages and Transitions

Use the ATI Active Learning Template: Growth and Development
PHYSICAL DEVELOPMENT COGNITIVE DEVELOPMENT
●
Completion of growth ●
Optimal childbearing ●
Improvement in critical thinking
●
Peak in physical senses ●
Pregnancy-related changes ●
Peak in memory
●
Peak in cardiac output, efficiency ●
Increased ability for creative thought
●
Optimal muscle function ●
Relevance of values/norms of friends
FUNDAMENTALS FOR NURSING CHAPTER 23 YOUNG ADULTS (20 TO 35 YEARS) 117

118 CHAPTER 23 YOUNG ADULTS (20 TO 35 YEARS) CONTENT MASTERY SERIES
CHAPTER 24
UNIT 2 HEALTH PROMOTION Self-concept development: Some middle adults have
SECTION: NURSING THROUGHOUT THE LIFESPAN issues related to:
Menopause
Middle Adults
●
● Sexuality
CHAPTER 24
(35 to 65 Years)
● Depression
● Irritability
● Difficulty ith se ual identity
● Job performance and ability to provide support
● Marital changes with the death of a spouse or divorce
EXPECTED GROWTH Body image changes

AND DEVELOPMENT ● Sex drive can decrease as a result of declining
hormones, chronic disorders, or medications.
Changes in physical appearance can
●
raise concerns about desirability.

Decreases in the following: ● FEMALES: Response to menopausal changes can
● Skin turgor and moisture cause role confusion for some clients or a sense
● Subcutaneous fat of excitement related to sexual freedom.
● Melanin in hair (graying) ● MALES
● Hair ◯ Decreasing strength can be frustrating or frightening.
● Visual acuity, especially for near vision ◯ Climacteric occurs.
● Auditory acuity, especially for high-pitched sounds
Social development
● Sense of taste ● Need to maintain and strengthen intimacy
● Skeletal muscle mass ● Empty nest syndrome: experiencing sadness when
● Height
children move away from home
● Calcium/bone density ● Provide assistance to aging parents, adult children,
● Blood vessel elasticity
and grandchildren, giving this stage of life the name
● Respiratory vital capacity
“sandwich generation”
● Large intestine muscle tone
● Gastric secretions
● Decreased glomerular ltration rate HEALTH PROMOTION
● Estrogen/testosterone
Especially at risk for alterations in health due to:
● Glucose tolerance ● Obesity, type 2 diabetes mellitus
● Cardiovascular disease
COGNITIVE DEVELOPMENT ● Cancer
● Substance use disorders (alcohol use disorder)
Piaget: Formal operations ● Psychosocial stressors
● Reaction time and speed of performance slow slightly.
Memory is intact.
IMMUNIZATIONS
●
● Crystallized intelligence remains (stored knowledge).

● Fluid intelligence (how to learn and process new Follow the latest Centers for Disease Control and Prevention
information) declines slightly. (CDC) immunization recommendations (see www.cdc.gov).
Primary vaccinations for middle adults include annual
in uen a immuni ation, as ell as tetanus, diphtheria,
PSYCHOSOCIAL DEVELOPMENT zoster, pneumococcal, and pertussis. Other vaccines are given
According to Erikson, middle adults must achieve to “catch-up” the middle adult for incomplete immunization
generativity vs. stagnation. series, or to provide additional protection to high-risk
Middle adults strive for generativity. individuals. These include immunizations against hepatitis A
● Use life as an opportunity for creativity and productivity. and B, measles, mumps, rubella, varicella, and pneumococcal
● Have concern for others. and meningococcal infections. The recommendations change
● Consider parenting an important task. periodically, so check them often.
● Contribute to the well-being of the next generation.
● Strive to do well in one’s own environment. HEALTH SCREENINGS
● Adjust to changes in physical appearance and abilities.
Middle adults should follow age-related guidelines

Moral development for screening.
● Religious maturity ● Dual-energy x-ray absorptiometry (DXA) screening for
● Spiritual beliefs and religion taking on added importance osteoporosis
● Become more secure in their convictions ● Eye examination for glaucoma and other disorders every 2
● Often have advanced moral development to 3 years or annually depending on provider
● Mental health screening for anxiety and depression
FUNDAMENTALS FOR NURSING CHAPTER 24 MIDDLE ADULTS (35 TO 65 YEARS) 119

NUTRITION
Nutrition counseling for middle adults generally includes:
● Obtaining adequate protein.
● Increasing the consumption of whole grains and fresh
fruits and vegetables.
● Limiting fat and cholesterol.
● Increasing vitamin D and calcium supplementation
(especially for females).
See www.choosemyplate.gov for

nutritional recommendations.
INJURY PREVENTION Active Learning Scenario

● Avoid substances, including alcohol, that can lead to A nurse in a community health center is explaining to
substance use disorders. a group of middle adults what moral and cognitive
● Avoid driving a vehicle during or after drinking development characteristics they should expect at this
alcohol or taking substances that impair sensory and stage of life. Use the ATI Active Learning Template:
motor functions. Growth and Development to complete this item.
● Wear a seat belt when operating a vehicle.
● Wear a helmet while bike riding, skiing, and other
recreational activities that increase head-injury risk. ●
List at least two moral development
● Install smoke and carbon monoxide detectors expectations during middle adulthood.
in the home. ●
List at least four cognitive development
● ecure rearms in a safe location. expectations during middle adulthood.
1. A charge nurse is explaining the various stages of the 3. A nurse is collecting history and physical examination
lifespan to a group of newly licensed nurses. Which data from a middle adult. The nurse should
of the following examples should the nurse include expect to find decreases in which of the following
as a developmental task for middle adulthood? physiologic functions? (Select all that apply.)
A. The client evaluates their behavior A. Metabolism
after a social interaction. B. Ability to hear low-pitched sounds
B. The client states they are learning to trust others. C. Gastric secretions
C. The client wishes to find meaningful friendships. D. Far vision
D. The client expresses concerns E. Glomerular filtration
about the next generation.
4. A nurse is preparing a health promotion

2. A nurse is collecting data to evaluate a middle adult’s course for a group of middle adults. Which
psychosocial development. The nurse should expect of the following strategies should the nurse
middle adults to demonstrate which of the following recommend? (Select all that apply.)
developmental tasks? (Select all that apply.) A. Eye examination every 1 to 3 years
A. Develop an acceptance of diminished strength B. Decrease intake of calcium supplements
and increased dependence on others. C. DXA screening for osteoporosis
B. Spend time focusing on improving D. Increase intake of carbohydrate in the diet
job performance. E. Screening for depressive disorders
C. Welcome opportunities to be
creative and productive.
5. A nurse is counseling a middle adult client who
D. Commit to finding friendship and companionship. describes having difficulty dealing with several issues.
E. Become involved with community Which of the following client statements should the
issues and activities. nurse identify as the priority to assess further?
A. “I am struggling to accept that my parents
are aging and need so much help.”
B. “It’s been so stressful for me to think
about having intimate relationships.”
C. “I know I should volunteer my time for a
good cause, but maybe I’m just selfish.”
D. “I love my grandchildren, but my child
expects me to relive my parenting days.”
120 CHAPTER 24 MIDDLE ADULTS (35 TO 65 YEARS) CONTENT MASTERY SERIES

1. A. Identify evaluating behavior after a social 4. A. CORRECT: Recommend middle adult clients have
interaction as a developmental task that begins an eye examination every 1 to 3 years to screen
during the preschool years. for glaucoma and other disorders.
B. Identify learning to trust others as a developmental task B. Recommend that middle adult clients, especially
of infancy during Erickson’s trust vs. mistrust stage. females, increase intake of vitamin D and
C. Identify finding meaningful friendships as a calcium to prevent osteoporosis.
developmental task for school-aged children. C. CORRECT: Recommend middle adult clients have
D. CORRECT: Erickson’s task for a middle adult as generativity a DXA scan to screen for osteoporosis.
vs. stagnation. Include showing concern for the next D. CORRECT: Recommend middle adult clients
generation as an example for this age group. obtain adequate protein, and consume more
NCLEX® Connection: Health Promotion and Maintenance, fresh fruits, vegetables and whole grains.
Developmental Stages and Transitions E. CORRECT: Recommend screening for anxiety
and depression during middle adulthood.
2. A. Identify acceptance of diminished strength and Nutrition and Oral Hydration
increased dependence as a developmental
task for older adulthood.
B. CORRECT: Psychosocially healthy middle adults strive 5. A. Adjusting to and caring for aging parents is nonurgent
to do well in their environment as part of achieving because it is an expected challenge during middle adulthood.
Erikson’s stage of generativity vs. stagnation. There is another statement to identify as the priority.
C. CORRECT: Psychosocially healthy middle adults B. CORRECT: When using the urgent vs. nonurgent approach
accept life’s opportunities for creativity and to client care, the counseling priority is the problem that
productivity and use these opportunities for achieving reflects a lack of completion of the previous stage and
Erikson’s stage of generativity vs. stagnation. progression to the current stage of development. According
D. Identify seeking and forming friendships as a to Erikson, developing intimacy vs. isolation is a task of
developmental task of young adulthood. young adulthood. This middle adult is still struggling with
E. CORRECT: Psychosocially healthy middle adults work this task and needs assistance in working through searching
to contribute to future generations through community for and developing intimate relationships with others.
involvement and parenting as part of achieving C. Contributing to the community is nonurgent because
Erikson’s stage of generativity vs. stagnation. it is an expected challenge during middle adulthood.
NCLEX® Connection: Health Promotion and Maintenance, There is another statement to identify as the priority.
Health Screening D. Questioning the ability to contribute to future
generations is nonurgent because it is an expected
challenge during middle adulthood. There is
3. A. CORRECT: Expect metabolism to decline, causing another statement to identify as the priority.
weight gain during middle adulthood. NCLEX® Connection: Health Promotion and Maintenance,
B. Expect a decline in the ability to hear high-pitched Developmental Stages and Transitions
sounds during middle adulthood.
C. CORRECT: In middle adulthood, decreases in secretions
of bicarbonate and gastric mucus begin and persist into
older age. This increases the risk of peptic ulcer disease.
D. Expect a decline in near vision (presbyopia)
during middle adulthood.
E. CORRECT: Middle adults begin to lose nephron units,
which results in a decline in glomerular filtration rates.

Using the ATI Active Learning Template:
Growth and Development
Moral development
●
Spiritual beliefs and religion can take on added importance.
●
Middle adults can become more secure in their convictions.
●
Middle adults often have advanced moral development.
Cognitive development
●
Reaction time and speed of performance slow slightly.
●
Memory is intact.
●
Crystallized intelligence remains (stored knowledge).
●
Fluid intelligence (how to learn and process
new information) declines slightly.
FUNDAMENTALS FOR NURSING CHAPTER 24 MIDDLE ADULTS (35 TO 65 YEARS) 121

122 CHAPTER 24 MIDDLE ADULTS (35 TO 65 YEARS) CONTENT MASTERY SERIES
CHAPTER 25
UNIT 2 HEALTH PROMOTION Immune
SECTION: NURSING THROUGHOUT THE LIFESPAN ● Decreased production of antibodies by B cells
Increased production of autoantibodies (antibodies against
Older Adults
●
the host’s body) with increased autoimmune response

CHAPTER 25
(65 Years and Older)
● Decreased core body temperature
● Decreased T-cell function
● Decreased stress response
● Decreased response to immunizations
EXPECTED GROWTH COGNITIVE DEVELOPMENT

AND DEVELOPMENT Piaget: Formal operations
● Many older adults maintain their cognitive function.
PHYSICAL DEVELOPMENT There is some decline in speed of the cognitive function
versus cognitive ability.
Integumentary ● A number of factors in uence older adults abilities to
● Decreased skin turgor, subcutaneous fat, and connective
function (overall health, the number of stressors, and
tissue (dermis), which leads to wrinkles and dry,
lifelong mental well-being).
transparent skin ● Slowed neurotransmission, vascular circulation
● Loss of subcutaneous fat, hich ma es it more difficult
impairment, disease states, poor nutrition, and
for older adults to adjust to cold temperatures
structural brain changes can result in the following
● Thinning and graying of hair, as well as a more
cognitive disorders.
sparse distribution ◯ Delirium: Acute, temporary, and can have a physiologic
● Thic ening of ngernails and toenails
source (infection, sleep deprivation, or pain) or related to
Cardiovascular/pulmonary a change in surroundings (being in an unfamiliar or new
● Decreased chest wall movement, vital capacity, and cilia, en ironment delirium is often the rst manifestation
which increases the risk for respiratory infections of infection (urinary tract infection) in older adults.
● Reduced cardiac output ◯ Dementia: Chronic, progressive, and possibly with an
● Decreased peripheral circulation unknown cause (Alzheimer’s disease, vascular dementia).
● Increased blood pressure ◯ Depression: Chronic, acute, or gradual onset (present
for at least 6 weeks); depression is often due to loss of
Neurologic
a loved one, feelings of isolation, or chronic disease.
● Slower reaction time
● Decreased touch, smell, and taste sensations
● Decline in visual acuity PSYCHOSOCIAL DEVELOPMENT
● Decreased ability for eyes to adjust from light to
Erikson: Integrity vs. despair
dark, leading to night blindness, which is especially
Older adults need to:
dangerous when driving ● Adjust to lifestyle changes related to retirement
● Inability to hear high-pitched sounds (presbycusis)
(decrease in income, living situation, loss of work role).
● Reduced spatial awareness ● Adapt to changes in family structure (can be role
Gastrointestinal reversal in later years).

● Decreased production of saliva ● Adapt to changes in living environment.
● Decreased digestive enzymes ● Deal with multiple losses (death of a spouse,

● Decreased intestinal motility, which can lead to friends, siblings).
increased risk of constipation ● Face death.
● Increased dental problems
Self-concept development: lder adults face difficulties in
Musculoskeletal the area of self-concept.
● Decreased height due to intervertebral disk changes ● Seeing oneself as an aging person
● Decreased muscle strength and tone ● Finding ways to maintain a good quality of life
● Decalci cation of bones ● Becoming more dependent on others for activities of
● Degeneration of joints daily living
Genitourinary Body image changes: An adjustment to decreases in

● Decreased bladder capacity physical strength and endurance is often difficult,
● Prostate hypertrophy in males especially for older adults who are cognitively active and
● Decline in estrogen or testosterone production engaged. Many older adults feel frustrated that their
● Atrophy of breast tissue in females bodies are limiting what they desire to do.
Endocrine Social development

● Decline in triiodothyronine (T3) production, yet overall ● Find ways to remain socially active and to
function remains effecti e overcome isolation.
● Decreased sensitivity of tissue cells to insulin ● Maintain sexual health.
FUNDAMENTALS FOR NURSING CHAPTER 25 OLDER ADULTS (65 YEARS AND OLDER) 123

HEALTH PROMOTION NUTRITION
● In addition to gastrointestinal alterations, other factors
HEALTH RISKS in uence nutrition in older adults.
◯ Difficulty getting to and from the supermar et to
Cardiovascular diseases
shop for food
● Coronary artery disease ◯ Low income
● Hypertension ◯ Impaired mobility
Factors affecting mobility ◯ Depression or dementia
● Arthritis ◯ Social isolation (preparing meals for one person,
● Osteoporosis eating alone)

● Falls ◯ Medications that alter taste or appetite
◯ Prescribed diets that are unappealing
Mental health disorders ◯ Incontinence that can cause the person to limit
● Depression
uid inta e
● Dementia ◯ Constipation
● Suicide ● Metabolic rates and activity decline as individuals age,
● Alcohol use disorder
so total caloric intake should decrease to maintain

● Tobacco use disorder
a healthy weight. With the reduction of total calorie
Other disorders intake, it becomes even more important that the calories
● Stroke older adults consume be of good nutritional value.
● Diabetes mellitus
Go to www.choosemyplate.gov for
● Cancer
nutritional recommendations.
● Incontinence
● Abuse and neglect NUTRITIONAL RECOMMENDATIONS
● Cataracts ● Increase intake of vitamins D, B12, , folate, ber,
● Chronic pain and calcium.
● Issues related to poor dental hygiene (gingivitis, ● Increase uid inta e to minimi e the ris of
missing teeth, gum disease) dehydration and prevent constipation.
● Take a low-dose multivitamin along with
mineral supplementation.
IMMUNIZATIONS ● Limit sodium, fat, re ned sugar, and alcohol inta e.
Follow the latest Centers for Disease Control and
RECOMMENDATIONS FOR IMPROVING NUTRITIONAL
Prevention (CDC) immunization recommendations
INTAKE DURING ACUTE OR LONG-TERM CARE
(www.cdc.gov) for healthy older adults. These ● Allow the client to eat with others, when possible.
generally include:
Socialization can make the meal more enjoyable.
● Immunizations against diphtheria, tetanus, pertussis, ● Make sure food is accessible throughout the day and
aricella, seasonal in uen a, herpes oster, and
nutritional supplements between mealtimes.
pneumococcal infections ● Provide medication or address other physical needs
● Immunizations against, hepatitis A and B, haemophilus
before the meals so the client can be comfortable.
in uen ae type b, and meningococcal infections for ● Allow the client to wash the hands and clean the mouth
high-risk individuals
before meals.
● Avoid mealtime interruptions.
HEALTH SCREENINGS ● Make sure the client has glasses, dentures, or other
assistive devices prior to meals.
Older adults should follow age-related guidelines ● Consult the provider and dietitian about including
for screening.
client-preferred foods that might be outside the
ANNUAL SCREENINGS restrictions of the therapeutic diet, if the client is not
● Hearing eating enough.
● Fecal occult blood test ● Promote physical activity (walking, range-of motion
● Digital rectal and prostate speci c antigen males exercises) to increase the appetite.
● Dual-energy x-ray absorptiometry (DXA) scanning
for osteoporosis
● Eye examination for glaucoma and other disorders
PERIODIC SCREENING
● Mental health screening for depression
● Cholesterol and diabetes screening every 3 years
124 CHAPTER 25 OLDER ADULTS (65 YEARS AND OLDER) CONTENT MASTERY SERIES

PSYCHOSOCIAL INTERVENTIONS INJURY PREVENTION
To improve self-concept and alleviate social isolation: ● Install bath rails, grab bars, and handrails on stairways.
● Therapeutic communication ● Remove throw rugs.
● Touch ● Eliminate clutter from walkways and hallways.
● Reality orientation ● Remove extension and phone cords from walkways
● Validation therapy and hallways.
● Reminiscence therapy ● Properly use mobility aids (walkers, canes).
● Attending to physical appearance ● Practice safe medication use.
● Assistive devices (canes, walkers, hearing aids) ● Ensure adequate lighting.
● Wear eyeglasses and hearing aids if needed.
● Prevent substance use disorders.
Active Learning Scenario ● Avoid driving a vehicle during or after drinking
alcohol or taking substances that impair sensory and
A nurse is reviewing safety precautions for older motor functions.
adults with a group of home health care assistive ● Wear a seat belt when operating a vehicle.
personnel. Use the ATI Active Learning Template: ● Wear a helmet while bike riding, skiing, and other
Growth and Development to complete this item. recreational activities that increase the risk of head injury.
● Install smoke and carbon monoxide detectors in the home.
INJURY PREVENTION: List at least 10 safety
recommendations for older adults.
● ecure rearms in a safe location.
1. A nurse is counseling an older adult who describes 3. A nurse is planning a presentation for a group of
having difficulty dealing with several issues. Which older adults about health promotion and disease
of the following problems verbalized by the client prevention. Which of the following interventions should
should the nurse identify as the priority? the nurse plan to recommend? (Select all that apply.)
A. “I spent my whole life dreaming about A. Human papilloma virus (HPV) immunization
retirement, and now I wish I had my job back.” B. Pneumococcal immunization
B. “It’s been so stressful for me to have to depend C. Yearly eye examination
on my child to help around the house.”
D. Periodic mental health screening
C. “I just heard my friend Al died. That’s
E. Annual fecal occult blood test
the third one in 3 months.”
D. “I keep forgetting which medications
I have taken during the day.” 4. A nurse is talking with an older adult client
about improving nutritional status. Which of
the following interventions should the nurse
2. A nurse is providing teaching for an older recommend? (Select all that apply.)
adult client who has lost 4.5 kg (9.9 lb) since
A. Increase protein intake to increase muscle mass.
the last admission 6 months ago. Which of the
following instructions should the nurse include B. Decrease fluid intake to prevent
in the teaching? (Select all that apply.) urinary incontinence.
A. “Eat three large meals a day.” C. Increase calcium intake to prevent osteoporosis.
B. “Eat your meals in front of the television.” D. Limit sodium intake to prevent edema.
C. ”Eat foods that are easy to eat, E. Increase fiber intake to prevent constipation.
such as finger foods.”
D. ”Invite family members to eat meals with you.” 5. A nurse is collecting data from an older adult client as
E. “Exercise every day to increase appetite.” part of a comprehensive physical examination. Which
of the following findings should the nurse expect
as associated with aging? (Select all that apply.)
A. Skin thickening
B. Decreased height
C. Increased saliva production
D. Nail thickening
E. Decreased bladder capacity
FUNDAMENTALS FOR NURSING CHAPTER 25 OLDER ADULTS (65 YEARS AND OLDER) 125

1. A. The client is at risk for social isolation and Using the ATI Active Learning Template:
loss of independence because of retirement. Growth and Development
However, another issue is the priority.
INJURY PREVENTION
B. The client is at risk for loss of independence and
reduced self-esteem due to dependence upon their
●
Install bath rails, grab bars, and handrails on stairways.
child. However, another issue is the priority.
●
Practice safe medication use.
C. The client is at risk for social isolation due to the loss ●
Remove throw rugs.
of a friend. However, another issue is the priority. ●
Eliminate clutter from walkways and hallways.
D. CORRECT: The greatest risk to this client is injury from ●
Remove extension and phone cords from walkways and hallways.
overdosing or underdosing medications due to loss of ●
Use mobility aids (walkers, canes).
short-term memory. The priority issue is to assist the client ●
Ensure adequate lighting.
to implement safe medication strategies. Assist the client ●
Wear eyeglasses and hearing aids as needed.
to use a pill organizer to help them remember to take their
medications and to keep a list of all current medications.
●
Prevent substance use disorders.
●
Avoid driving a vehicle during or after drinking alcohol or
®
taking substances that impair sensory and motor functions.
Developmental Stages and Transitions ●
Wear a seat belt when operating a vehicle.
●
Wear a helmet while bike riding, skiing, and other
2. A. The client should eat small frequent meals recreational activities that increase head-injury risk.
to increase nutritional intake. ●
Install smoke and carbon monoxide detectors in the home.
B. The client should avoid distractions during ●
Secure firearms in a safe location.
meals to increase nutritional intake.
NCLEX® Connection: Safety and Infection Control, Accident/Error/
C. CORRECT: Encourage the client to eat finger foods because
Injury Prevention
finger foods are easier for the older adult client to eat.
D. CORRECT: Encourage the client to involve
family members with meals. Socialization during
meals promotes nutritional intake.
E. CORRECT: Encourage the client to exercise
daily to increase appetite.
Health Screening
3. A. The HPV vaccine is recommended for female clients

from age 11 to 26 and male clients from age 9 to 26.
It is not a recommendation for older adults.
B. CORRECT: The pneumococcal vaccine is
recommended for older adult clients.
C. CORRECT: A yearly eye examination to screen for glaucoma
and vision changes is recommended for older adults.
D. CORRECT: Periodic mental health assessments
are recommended for older adult clients
to screen for depression.
E. CORRECT: An annual fecal occult blood test
is recommended for older adults.
4. A. CORRECT: Older adults should increase protein intake to

increase muscle mass and improve would healing.
B. Older adults should increase fluid intake to
prevent dehydration and constipation.
C. CORRECT: Older adults should increase calcium
intake to reduce the risk for osteoporosis.
D. CORRECT: Older adults should limit sodium intake
to reduce the risk for edema and hypertension.
E. CORRECT: Older adults should increase
fiber intake to prevent constipation.
5. A. Physiological changes that occur with aging can

include decreased skin turgor, subcutaneous fat,
and connective tissue (dermis), which can cause
wrinkles and dry, thin, transparent skin.
B. CORRECT: Physiological changes that occur
with aging can include loss in height due to
the thinning of intervertebral disks.
C. Physiological changes that occur with aging can
include decreased saliva production, making
xerostomia (dry mouth) a common problem.
D. CORRECT: Physiological changes that occur with aging can
include thickening of the nails of the fingers and toes.
E. CORRECT: Physiological changes that occur with aging
can include a reduced bladder capacity. While young
adults have a bladder capacity of about 500 to 600 mL,
older adults have a capacity of about 250 mL.
126 CHAPTER 25 OLDER ADULTS (65 YEARS AND OLDER) CONTENT MASTERY SERIES

NCLEX® Connections

DEVELOPMENTAL STAGES AND TRANSITIONS:
Compare client development to expected age/
developmental stage and report any deviations.
HEALTH PROMOTION/DISEASE PREVENTION: Perform

health history/health and risk assessments.
TECHNIQUES OF PHYSICAL ASSESSMENT:

Perform comprehensive health assessments.

MOBILITY/IMMOBILITY: Assess the client for
mobility, gait, strength, and motor skills.

CHANGES/ABNORMALITIES IN VITAL SIGNS
Apply knowledge needed to perform related nursing procedures
and psychomotor skills when assessing vital signs.
Assess and respond to changes and/or trends in client vital sign.
SYSTEM SPECIFIC ASSESSMENT: Perform focused assessment.

CHAPTER 26
UNIT 2 HEALTH PROMOTION HEALTH HISTORY COMPONENTS
SECTION: HEALTH ASSESSMENT/DATA COLLECTION
The health history provides subjective data about
Data Collection and health status.

CHAPTER 26
General Survey
DEMOGRAPHIC INFORMATION: Identifying data include:
● Name, address, contact information
● Birth date, age
● Gender
Race, ethnicity
Data collection includes obtaining subjective
●
● Relationship status
and objective information from clients. ● Occupation, employment status
Insurance
The health history provides subjective data.
●
● Emergency contact information

The physical examination and diagnostic tests ● Family, others living at home
Advance directives
provide objective data.
●
SOURCE OF HISTORY
● Client, family members or close friends, other medical
INTERVIEWING TECHNIQUES records, other providers
● Reliability of the historian
Standardized formats are a framework for obtaining
information about clients’ physical, developmental, CHIEF CONCERN: A brief statement in the client’s own
emotional, intellectual, social, and spiritual dimensions. words of the reason for seeking care
Therapeutic techniques for health assessment foster HISTORY OF PRESENT ILLNESS

communication and create an environment that promotes ● A detailed, chronological description of why the client
an optimal health assessment/data collection experience. seeks care
● Details about the manifestation(s), (location, quality,
quantity, setting, timing [onset and duration],
THERAPEUTIC COMMUNICATION precipitating factors, alleviating or aggravating factors,
Therapeutic communication helps develop rapport with associated phenomena [concomitant manifestations])
clients. The techniques encourage a trusting relationship,
PAST HEALTH HISTORY AND CURRENT HEALTH STATUS
whereby clients feel comfortable telling their story. Begin ● Childhood illnesses, both communicable and chronic
with the purpose of the interview, gather information, ● Medical, surgical, obstetrical, gynecological,
and then conclude the interview by summarizing
psychiatric history, including time frames,
the ndings. (26.1)
diagnoses, hospitalizations, treatments
● Introduce yourself and the various parts of the assessment. ● Current immunization status, dates and
● Determine what the client wants you to call them.
results of any screening tests
● Allow more time for responses from older adults.
● Allergies to medication, environment, food
● Make sure the client is comfortable (room ● Current medications including prescription,
temperature, chair).
over-the-counter, vitamins, supplements,
● When possible, start by asking for the health history,
herbal remedies, time of last dose(s)
performing the general survey, and measuring vital ● Habits and lifestyle patterns (interests and social activities)
signs to build rapport prior to moving on to more ● ubstance use alcohol, tobacco, caffeine,
sensitive parts of the examination.
recreational drugs)
● Reduce environmental noises
(TV, radio, visitors talking) to

enhance communication and
eliminate distractions. 26.1 Therapeutic communication techniques
● Ensure understanding by obtaining
interpretive services for clients ACTIVE LISTENING: Show clients that they have your undivided attention.
who have language or other OPEN-ENDED QUESTIONS: Use initially to encourage clients to tell their
communication barriers. story in their own way. Use terminology clients can understand.
● Note the client’s nonverbal CLARIFYING: Question clients about specific details in greater
depth or direct them toward relevant parts of their history.
communication (body language,
eye contact, tone of voice, facial BACK CHANNELING: Use active listening phrases (“Go on” and “Tell me
more”) to convey interest and to prompt disclosure of the entire story.
expressions, posture, gait,
appearance, gestures). PROBING: Ask more open-ended questions (“What else would you
● Avoid using medical or
like to add to that?”) to help obtain comprehensive information.
nursing jargon, giving advice, CLOSED-ENDED QUESTIONS: Ask questions that require yes or no answers
to clarify information (“Do you have any pain when you cannot sleep?”).
ignoring feelings, and offering
false reassurance. SUMMARIZING: Validate the accuracy of the story.
FUNDAMENTALS FOR NURSING CHAPTER 26 DATA COLLECTION AND GENERAL SURVEY 129
FAMILY HISTORY Ears, nose, mouth, and throat
● Health information of grandparents, parents, siblings, ● How well do you hear?
children, grandchildren ● Have you noticed any changes in your hearing?
● Family structure, interaction, support system, function ● Have other people commented that you aren’t hearing
● Current ages or age at death, acute and chronic what they say?
disorders of family members ● Do you wear hearing aids?
● Do you ever have ringing or buzzing in your ears,
PSYCHOSOCIAL HISTORY: Relationships, support systems,
drainage, dizziness, or pain?
concerns about li ing or or situations, nancial status, ● Have you had ear infections?
ability to perform activities of daily living, spiritual health ● How do you clean your ears?
HEALTH PROMOTION BEHAVIORS ● Are you ha ing any pain, stuffiness, or uid draining
● Exercise/activity, diet, wearing of safety equipment, use from your nose?
of health resources, stress prevention and management, ● Do you have nosebleeds?
adequate sleep patterns, positive coping measures ● Do you ha e any difficulty breathing through your nose
● Awareness of risks for heart disease, cancer, diabetes ● Have you noticed any change in your sense of
mellitus, stroke smell or taste?
● Prevention of exposure to substances, harmful ● How often do you go to the dentist?
environment, excessive sunlight ● Do you have dentures or retainers?
● Do you have any problems with your gums, like bleeding
or soreness?
REVIEW OF SYSTEMS ● Do you ha e any difficulty s allo ing or problems ith
hoarseness or a sore throat?
An extensive review of systems ascertains information ● Do you have allergies?
about the functioning of all body systems and ● Do you use nasal sprays?
health problems ● Do you know if you snore?
Breasts
QUESTIONS TO ASK ● Do you perform breast self-examinations? How often,
Integumentary system and when do you perform them?
● Do you have any skin diseases? ● Do you have any tenderness, lumps, thickening, pain,
● Do you have any itching, bruising, lumps, hair loss, nail drainage, distortion, or change in breast size, or any
changes, or sores? retraction or scaling of the nipples?
● Do you have any allergies? ● Has anyone in your family had breast cancer?
● How do you care for your hair, skin, and nails? ● Are you aware of breast cancer risks?
● Do you use lotions, soaps, or sunscreen or wear ● For clients over 40: How often do you get a mammogram?
protective clothing?
Respiratory system
Head and neck ● Do you ha e any difficulties breathing
● Do you get headaches? If so, how often? (Ask about and ● Do you breathe easier in any particular position?
note onset, precipitating factors, duration, character, ● Are you ever short of breath?
pattern, and presence of other manifestations.) ● Have you recently been around anyone who has a cough,
● What do you do to relieve the pain? cold, or in uen a
● Have you ever had a head injury? ● Do you recei e an in uen a accine e ery year
● Can you move your head and shoulders with ease? ● Have you had the pneumonia vaccine?
● Are any of your lymph nodes swollen? (If so, ask about ● Do you smoke or use other tobacco products? If yes, for
recent colds or viral infections.) how long and how much? Are you interested in quitting?
● Have you noticed any unusual facial movements? ● Are you around second-hand smoke?
● Does anyone in your family have thyroid disease? ● Do you have environmental allergies?
● Has anyone in your family had lung cancer or tuberculosis?
Eyes ● Have you ever been around anyone who has tuberculosis?
● How is your vision? ● Have you had a tuberculosis test?
● Have you noticed any changes in your vision?
● Do you e er ha e any uid draining from your eyes
● Do you wear eyeglasses? Contact lenses?
● When was your last eye examination?
● Does anyone in your family have any eye disorders?
● Do you have diabetes?
130 CHAPTER 26 DATA COLLECTION AND GENERAL SURVEY CONTENT MASTERY SERIES
Cardiovascular system Mental health
● Do you have any problems with your heart? ● What are the sources of stress in your life (family, career,
● Do you take any medications for your heart? school, peers) and what stresses do you deal with?
● Do you ever have pain in your chest? Do you ● Are you having any problems with depression or
also feel it in your arms, neck, or jaw? changes in mood?

● Do you know if you have high cholesterol ● Have you had any recent losses?
or high blood pressure? ● Are you having any problems concentrating?
● Do you have any swelling in your feet and ankles?

Endocrine system
● Do you cough frequently? ● Have you noticed any change in urination patterns?
● Are you familiar with the risk factors for heart disease?
● Have you noticed any change in your energy level?
Gastrointestinal system ● Have you noticed any change in your ability to
● Do you have any problems with your stomach handle stress?
(nausea, vomiting, heartburn, or pain)? ● Have you had any change in weight or appetite?
● Do you have any problems with your ● Have you had any visual disturbances?
bowels (diarrhea or constipation)? ● Have you had any palpitations?
● When was your last bowel movement?
Allergic/immunologic system
● Do you ever use laxatives or enemas? ● Do you have any allergies to medications, foods, or
● Have you had any black or tarry stools?
environmental substances?
● Do you take aspirin or ibuprofen? If so, how often? ● Have you ever received a blood transfusion? If so, did
● Do you have any abdominal or lower
you have any adverse reactions?
back pain or tenderness?
● Have you had any recent weight changes?
● Do you ha e any s allo ing difficulties PHYSICAL ASSESSMENT TECHNIQUES
● Do you drink alcohol? If so, how much?
● For clients over 50: Have you had a colonoscopy? If so, Preparation/Preparing for a physical examination
when was your last one? ● Provide adequate lighting.
● Do you know the indications and ● eep the ngernails nails short.
manifestations of colon cancer? ● Ensure a quiet, private environment.
● hat is your typical day s inta e of food and uid ◯ Have necessary equipment ready.
● Do you have any dietary restrictions, food ◯ Invite the client to use the bathroom before beginning
intolerances, or special practices?

the physical examination. Collect urine or fecal
Genitourinary system specimens at this time.
Do you ha e any difficulties ith urination burning,
During a physical examination
●
leakage or loss of urine, urgency, frequency, waking up at

night to urinate, or hesitancy)? ● Maintain a comfortable environment.
● Have you noticed any change in the color of your urine? ● Provide privacy, using a gown or draping the client with
● Have you noticed any changes in your menstrual cycle? a sheet and visualizing only one section of the body
● Have you had pain during intercourse? at a time.
● Have you had any sexual problems? ● Explain the various assessment/data collection
● Have you had any pain in your scrotum or testes? techniques you will use.
● Look and observe before touching.
Musculoskeletal system ● Keep hands and stethoscope warm.
● Have you noticed any pain in your joints or muscles? ● Do not feel or listen through clothing. (Clothing can
● Do you have any weakness or twitching?
obscure or create sounds.)
● Have you had any recent falls? ● Use standard precautions when in contact with body
● Are you able to care for yourself?
uids, ound drainage, and open lesions.

● Do you exercise or participate in sports?
● For postmenopausal clients: What was your ADDITIONAL GUIDELINES FOR OLDER ADULT CLIENTS
maximum height? ● Allow adequate time for the interaction. Mobility issues
● For postmenopausal clients: Do you take can increase the time required for some older adults
calcium supplements? to change positions. Older adult clients have more
information to relay regarding their history because of
Neurologic system
having lived longer. For some clients, cognitive issues
● Have you noticed any change in your vision, speech,
can lengthen the time required for communication.
ability to think clearly, or loss of or change in memory? ● Watch for indications the client is getting tired
● Do you have any dizziness or headaches?
(slumped shoulders, grimacing or sighing,
● Do you ever have seizures? If so, what triggers them?
or leaning against object for support.
● Do you ever have any weakness, tremors, numbness, or ● Be aware that topics of conversation related
tingling anywhere? If so, where?
to a loss or possible loss of independence
might be difficult for the client to discuss.
● Make sure older adults who use sensory aids
(eyeglasses, hearing aids) have them available for use.
EXAMINATION SEQUENCE Auscultation
or most body systems, follo the se uence of rst Auscultation is the process of listening to sounds the
inspecting, the palpating, followed by percussion, and body produces to identify une pected ndings. ome
nally auscultation. sounds are loud enough to hear unaided (speech and
coughing), but most sounds require a stethoscope or a
The exception is the abdomen; inspect,
Doppler technique (heart sounds, air moving through
auscultate, percuss, and palpate in that
the respiratory tract, blood moving through blood
order to avoid altering bowel sounds.
vessels). Learn to isolate the various sounds to collect
data accurately.
Inspection ● Evaluate sounds for amplitude or intensity (loud or soft),
Inspection begins ith the rst interaction and continues pitch or frequency (high or low), duration (time the
throughout the examination. sound lasts), and quality (what it sounds like).
● A penlight, an otoscope, an ophthalmoscope, or another ● Use the diaphragm of the stethoscope to listen to
lighted instrument can enhance the process. high-pitched sounds (heart sounds, bowel sounds,
● Inspection involves using the senses of vision, smell lung sounds).
(olfaction), and hearing to observe and detect any
Place the diaphragm firmly on the body part.
e pected or une pected ndings. Inspect for si e, shape,
color, symmetry (comparing both sides of the body), ● Use the bell of the stethoscope to listen to low-pitched
and position. sounds (unexpected heart sounds, bruits).
● alidate ndings ith the client.
Place the bell lightly on the body part.
Palpation
Palpation is the use of touch to determine the size, EQUIPMENT FOR SCREENING
consistency, texture, temperature, location, and EXAMINATION
tenderness of the skin, underlying tissues, an organ, or a ● Gown
body part. Palpate tender areas last. ● Drapes
● Use light palpation (less than 1 cm [0.4 in]) for most ● Scale with height measurement device
body surfaces. Use deeper palpation (4 cm [1.6 in]) to ● Thermometer
evaluate abdominal organs or masses. ● Stethoscope with diaphragm and bell
● arious parts of your hands detect different sensations. ● Sphygmomanometer
◯ The dorsal surface is the most sensitive
● Reading/eye chart
to temperature. ● Otoscope, ophthalmoscope, nasal speculum
◯ The palmar surface and base of the fingers are
● Penlight or ophthalmoscope
sensitive to vibration. ● Cotton balls
◯ Fingertips are sensitive to pulsation, position, texture,
● Sharp and dull objects
turgor, size, and consistency. ● Tuning fork
◯ The fingers and thumb are useful for grasping an
● Glass of water
organ or mass. ● Items to test smell and taste
● Starting with light palpation, be systematic, calm, ● Clean gloves
and gentle. Proceed to deep palpation if necessary ● Tongue depressor
unless contraindicated. ● e e hammer
Pulse oximeter
Percussion
●
● Marking pen
Percussion in ol es tapping body parts ith ngers, ● easuring tape and clear, e ible ruler ith
sts, or small instruments to ibrate underlying tissues measurements in centimeters
to determine the size and location; detect tenderness or ● Watch or clock to measure time in seconds
abnormalities, and to check for the presence or absence
of uid or air in the tissues. The denser the tissue, the
uieter the sound. An understanding of the effect of
various densities on sound can help you locate organs or 26.2 Sample documentation
masses, nd their edges, and estimate their si e.
Client: 16-year-old male, alert and oriented x 3. No
TECHNIQUES FOR PERCUSSION distress. Personal hygiene and grooming slightly unkempt
but appropriate for age. Weight appropriate for height,
● Direct percussion, which involves striking the body to erect posture, and steady gait. Full range of motion. Does
elicit sounds not maintain eye contact. Volunteers no information but
● Indirect percussion, which involves placing your hand answers questions appropriately. No gross abnormalities.
atly on the body, as the stri ing surface, for sound
production
● Fist percussion, which helps identify tenderness over
the kidneys, liver, and gallbladder
GENERAL SURVEY Application Exercises
The general survey is a written summary or appraisal
of overall health. Gather this information from the 1. A nurse provides an introduction to a client as the
rst encounter ith the client and continue to ma e first step of a comprehensive physical examination.
observations throughout the assessment process. (26.2) Which of the following strategies should the nurse
use with this client? (Select all that apply.)
Assess/collect data about the following.
A. Address the client with the appropriate
PHYSICAL APPEARANCE title and their last name.
● Age B. Use a mix of open- and closed-ended questions.
● Sex C. Reduce environmental noise.
● Race and/or ethnicity
D. Have the client complete a printed history form.
● Level of consciousness
● Color of skin E. Perform the general survey before the examination.
● Facial features
● Indications of distress (pallor, labored breathing, 2. A nurse in a provider’s office is documenting
guarding, anxiety) findings following an examination performed for a
● Indications of possible physical abuse or neglect client new to the practice. Which of the following
● Indications of substance use disorders parameters should the nurse include as part of
the general survey? (Select all that apply.)
BODY STRUCTURE
A. Posture
● Body build, stature, height, and weight
● Nutritional status B. Skin lesions
● Symmetry of body parts C. Speech
● Posture and usual position D. Allergies
● Gross abnormalities (skin lesions, amputations) E. Immunization status
MOBILITY
● Gait 3. A nurse is collecting data for a client’s comprehensive
● Movements (purposeful, tremulous) physical examination. After inspecting the client’s
● Range of motion abdomen, which of the following skills of the physical
● Motor activity examination process should the nurse perform next?
BEHAVIOR A. Olfaction
● Facial expression and mannerisms B. Auscultation
● ood and affect C. Palpation
● Speech D. Percussion
● Dress, hygiene, grooming, and odors (body, breath)
VITAL SIGNS 4. A nurse is preparing to perform a comprehensive

● Temperature physical examination of an older adult client. Which
● Pulse of the following interventions should the nurse use in
● Respirations consideration of the client’s age? (Select all that apply.)
● Blood pressure A. Expect the session to be shorter
● Oxygen saturation than for a younger client.
● Pain (often considered an additional vital sign) B. Plan to allow plenty of time for position changes.
C. Make sure the client has any essential
Active Learning Scenario sensory aids in place.
D. Tell the client to take their time
A nurse is reviewing the data to collect from a client for a answering questions.
comprehensive health history prior to the systems review. Use the E. Invite the client to use the bathroom
ATI Active Learning Template: Basic Concept to complete this item. before beginning the examination.
RELATED CONTENT: List at least six general categories to

cover and the essential data to include in each category. 5. A nurse in a provider’s office is performing a
physical examination of an adult client. Which part
of the hands should the nurse use during palpation
for optimal assessment of skin temperature?
A. Palmar surface
B. Fingertips
C. Dorsal surface
D. Base of the fingers
1. A. Ask for the client’s preference on how to be addressed. Using the ATI Active Learning Template: Basic Concept
B. CORRECT: Open-ended questions help the client RELATED CONTENT
tell a story in their own words. Closed-ended ●
Demographic information
questions are useful for clarifying and verifying
information gathered from the client’s story. Name, address, contact information
◯
C. CORRECT: A quiet, comfortable environment Birth date, age

◯
eliminates distractions and helps the client focus Sex

◯
on the important aspects of the interview. Race, ethnicity

◯
D. Having the client fill out a printed history form might deter Relationship status
◯
the establishment of a therapeutic relationship. When asking Occupation, employment status

◯
about history, the client might feel they are wasting time Insurance
◯
because that information was already written on the form.

Emergency contact information
◯
E. CORRECT: The general survey is noninvasive and, along

with the health history and vital sign measurement, Family, others living at home
◯
can help put the client at ease before the more Advance directives
◯
sensitive parts of the process (the examination). ●

Source of history
NCLEX® Connection: Health Promotion and Maintenance, Client, family members or close friends, other
◯
Techniques of Physical Assessment medical records, other providers

Reliability of the historian
◯
●
Chief concern: Brief statement in the client’s
2. A. CORRECT: Posture is part of the body structure or general own words of why they are seeking care
appearance portion of the general survey. ●
History of present illness
B. CORRECT: Skin lesions are part of the body structure or Detailed, chronological description of why the client seeks care
◯
general appearance portion of the general survey. Details about the manifestation(s) (location, quality, quantity,
◯
C. CORRECT: Speech is part of the behavior setting, timing [onset and duration], precipitating factors,
portion of the general survey. alleviating or aggravating factors, associated manifestations)
D. Allergies are part of the health history, ●
Past health history and current health status
not the general survey.
E. Immunization status is part of the health Childhood illnesses, both communicable and chronic
◯
history, not the general survey. Medical, surgical, obstetrical, gynecological, psychiatric history
◯
including time frames, diagnoses, hospitalizations, treatments

Current immunization status, dates and
◯

results of any screening tests
Allergies to medication, environment, food
◯
3. A. Olfaction is the use of the sense of smell to detect Current medications including prescription, over-the-counter,
◯
any unexpected findings that cannot be detected via vitamins, supplements, herbal remedies, time of last dose(s)
other means (a fruity breath odor). Unless there is an Habits and lifestyle patterns (alcohol, tobacco,
◯
open lesion on the client’s abdomen, this is not the caffeine, recreational drugs)
next step in an abdominal examination. ●
Family history
B. CORRECT: Because palpation and percussion can alter the Health information of grandparents, parents,
◯
frequency and intensity of bowel sounds, auscultate the siblings, children, grandchildren
abdomen next and before using those two techniques. Family structure, interaction, support system, function
◯
C. Palpation is the next step in examining other

Current ages or age at death, acute and
◯
areas of the body, but not the abdomen.

chronic disorders in family members
D. Percussion is important for detecting gas, fluid,
and solid masses in the abdomen, but it is not the
●
Psychosocial history: Relationships, support systems,
next step in an abdominal assessment. concerns about living or work situations, financial status,
ability to perform activities of daily living, spiritual health
NCLEX® Connection: Reduction of Risk Potential, ●
Health promotion behavior
Exercise/activity, diet, wearing of safety equipment, use
◯
of health resources, stress prevention and management,

4. A. Expect the session to take longer than for most clients, sleep patterns, positive coping measures
and allow adequate time. The older adult client might Prevention of exposure to substances, harmful
◯
have had more medial conditions and has a more environment, excessive sunlight
complex social and functional history. Awareness of risks for heart disease, cancer, diabetes
◯
B. CORRECT: Because many older adults have mobility mellitus, and cerebrovascular accident
challenges, plan to allow extra time for position changes. NCLEX® Connection: Health Promotion and Maintenance,
C. CORRECT: Make sure clients who use sensory aids have Techniques of Physical Assessment
them available for use. The client has to be able to hear
the nurse and see well enough to avoid injury.
D. CORRECT: Some older clients need more time to collect
their thoughts and answer questions, but most are reliable
historians. Feeling rushed can hinder communication.
E. CORRECT: This is a courtesy for all clients, to avoid
discomfort during palpation of the lower abdomen
for example, but this is especially important for older
clients who have a smaller bladder capacity.
5. A. The palmar surface of the hands is especially

sensitive to vibration, not temperature.
B. The fingertips are sensitive to pulsation, position,
texture, size, and consistency, not temperature.
C. CORRECT: The dorsal surface of the hand is
the most sensitive to temperature.
D. The base of the fingers is especially sensitive
to vibration, not temperature.
CHAPTER 27
UNIT 2 HEALTH PROMOTION
Temperature
CHAPTER 27 Vital Signs PHYSIOLOGIC RESPONSES
● The neurologic and cardiovascular systems work
together to regulate body temperature. Disease or
Vital signs are measurements of the body’s most trauma of the hypothalamus or spinal cord will alter
temperature control.
basic functions and include temperature, pulse, ● The rectum, tympanic membrane, temporal artery,
respiration, and blood pressure. Many facilities pulmonary artery, esophagus, and urinary bladder are
core temperature measurement sites.
also consider pain level and oxygen saturation ● The skin, mouth, and axillae are surface temperature
vital signs. (SEE CHAPTER 41: PAIN MANAGEMENT, CHAPTER measurement sites.
53: AIRWAY MANAGEMENT, MATERNAL NEWBORN CHAPTER
23: NEWBORN ASSESSMENT, AND NURSING CARE OF CHILDREN

HEAT PRODUCTION AND LOSS
Heat production results from increases in basal metabolic
CHAPTER 2: PHYSICAL ASSESSMENT FINDINGS.)
rate, muscle activity, thyroxine output, testosterone, and
sympathetic stimulation, which increases heat production.
Temperature reflects the balance between heat
Heat loss from the body occurs through:
the body produces and heat lost from the body ● Conduction: Transfer of heat from the body directly
to the environment. to another surface (when the body is immersed in
cold water).
Pulse is the measurement of heart rate and ● Convection: Dispersion of heat by air currents (wind
blowing across exposed skin).
rhythm. Pulse corresponds to the bounding ● Evaporation: Dispersion of heat through water
of blood flowing through various points in the vapor (perspiration).
Radiation: Transfer of heat from one object to another
circulatory system. It provides information about
●
object without contact between them (heat lost from the

circulatory status. body to a cold room).
● Diaphoresis: Visible perspiration on the skin.
Respiration is the body’s mechanism for
exchanging oxygen and carbon dioxide between ASSESSMENT/DATA COLLECTION
the atmosphere and the blood and cells of the
body, which is accomplished through breathing EXPECTED TEMPERATURE RANGES
and recorded as the number of breaths per minute. ● An oral temperature range of 36° to 38° C (96.8° to
100.4° F) is acceptable. The average is 37° C (98.6° F).
Blood pressure (BP) reflects the force the blood ● Rectal temperatures are usually 0.5° C (0.9° F) higher
than oral and tympanic temperatures.
exerts against the walls of the arteries during ● Axillary temperatures are usually 0.5° C (0.9° F) lower
cardiac muscle contraction (systole) and relaxation than oral and tympanic temperatures.
Temporal temperatures are close to rectal, but they
(diastole). Systolic blood pressure (SBP) occurs
●
are nearly 0.5° C (1° F) higher than oral, and 1° C (2° F)

during ventricular systole, when the ventricles force higher than axillary temperatures.
A client’s usual temperature serves as a baseline
blood into the aorta and pulmonary artery, and it
●
for comparison.
represents the maximum amount of pressure
exerted on the arteries when ejection occurs.
Diastolic blood pressure (DBP) occurs during
ventricular diastole, when the ventricles relax and
exert minimal pressure against arterial walls, and
represents the minimum amount of pressure
exerted on the arteries.
FUNDAMENTALS FOR NURSING CHAPTER 27 VITAL SIGNS 135

CONSIDERATIONS PROCEDURES FOR TAKING TEMPERATURE
Age Perform hand hygiene, provide privacy, and apply
● Newborns have a large surface-to-mass ratio, so they clean gloves.
lose heat rapidly to the environment. A newborn’s
temperature should be between 36.5° and 37.5° C (97.7° Oral
and 99.5° F). By age 5, children should be able to ● Gently place the oral probe (with cover) of the
maintain an average temperature of 37° C (98.6° F).
thermometer under the tongue in the posterior
● Older adult clients experience a loss of subcutaneous fat
sublingual pocket lateral to the center of the lower jaw.
that results in lower body temperatures and feeling cold. ● Leave it in place until the reading is complete.
Their average body temperature is 35° to 36.1° C (95.9° to
99.5° F). Older adult clients are more likely to develop AGE-SPECIFIC: Use this site for clients who are 4 years of
ad erse effects from e tremes in en ironmental age and older.
temperatures (heat stroke, hypothermia). It also takes
Note: Do not obtain oral temperature readings for
longer for body temperature to register on a
clients who breathe through their mouth or have
thermometer due to changes in temperature
experienced trauma to the face or mouth.
regulation.
Hormonal changes can in uence temperature. In general, Rectal

temperature rises slightly with ovulation and menses. ● Rectal measurement of temperature is more accurate
At ovulation, body temperature can increase by 0.3° to
than axillary.
0.6° C (0.5° to 1.0° F) above the client’s baseline. During ● Assist the client to Sims’ position with the upper leg
menopause hen the client is e periencing a hot ash,
e ed. earing glo es, e pose the anal area hile
skin temperature can increase up to 4° C (7.2° F).
keeping other body areas covered. Spread the buttocks
Exercise, activity, and dehydration can contribute to the to expose the anal opening.
development of hyperthermia. ● Ask the client to breathe slowly and relax. Insert
the rectal probe (with cover and lubrication) of the
Illness and injury can cause elevations in temperature.
thermometer into the anus in the direction of the
Fever is the body’s response to infectious and
umbilicus 2.5 to 3.5 cm (1 to 1.5 in) for an adult. If you
in ammatory processes. e er causes an increase in the
encounter resistance, remove it immediately. Once
body’s immune response by:
inserted, hold the thermometer in place until the
● Increasing WBC production.
reading is complete.
● Decreasing plasma iron concentration to reduce ● Clean the anal area to remove feces or lubricant.
bacteria growth. ● Use the rectal site to verify the temperature for any
● Stimulating interferon to suppress virus production.
reading obtained through another site that is greater
Recent food or fluid intake and smoking can interfere with than 37.2º C (99º F).
accurate oral measurement of body temperature, so it is best
SAFETY MEASURE: Do not obtain rectal temperatures for
to wait 20 to 30 min before measuring oral temperature.
clients who have diarrhea, are on bleeding precautions
Circadian rhythm, stress, and environmental conditions (those who have a low platelet count), or have rectal
can also affect body temperature. disorders.
AGE-SPECIFIC: The American Academy of Pediatrics

recommends not measuring rectal temperatures on
NURSING INTERVENTIONS infants younger than 3 months.
Note: Stool in the rectum can

EQUIPMENT cause inaccurate readings.
Electronic thermometers use a probe to measure oral,
rectal, tympanic, temporal artery, or axillary temperature. Axillary
Electronic thermometers require the use of a probe cover or ● Place the oral probe of the thermometer (with cover)
probe cleaning with each use (per the manufacturer) and
in the center of the client’s clean, dry axilla. Lower the
can be set to play a signal when the reading is complete.
arm over the probe.
Tympanic or temporal arterial temperatures require a ● Hold the arm down, keeping the thermometer in
de ice speci cally for measuring temperature at that site.
position until the reading is complete.
Disposable, single-use thermometers are for oral, axillary,
and rectal temperature measurement. They reduce the
risk of cross-infection. These can include single-use
thermometer strips or patches that have an adhesive side,
and can be applied to the forehead or abdomen.
136 CHAPTER 27 VITAL SIGNS CONTENT MASTERY SERIES

Tympanic Hypothermia
● Pull the ear up and back (for an adult) or down and back Hypothermia is a body temperature less than 35º C (95° F).
(for a child who is younger than 3 years old).
NURSING ACTIONS
● Place the thermometer probe (with cover) snugly into ● Provide a warm environmental temperature, heated
the client’s outer ear canal and press the scan button.
humidi ed o ygen, arming blan et, and or armed
● Leave it in place until the reading is complete.
oral or I uids.
● Carefully remove the thermometer from the ear canal ● Keep the head covered.
and read the temperature. ● Provide continuous cardiac monitoring.
● Ambient temperature can affect readings. ● Have emergency resuscitation equipment on standby.
AGE-SPECIFIC: The American Academy of Pediatrics
advises against the use of electronic ear thermometers for
infants 3 months old and younger due to the inaccuracy
of readings.
Pulse
Note: Excess earwax can alter the reading.
If noted, use the other ear or select another
PHYSIOLOGIC RESPONSES
site for temperature assessment. Autonomic nervous system controls the heart rate.
Parasympathetic nervous system lowers the heart rate.

Temporal
Sympathetic nervous system raises the heart rate.
● Remove the protective cap and wipe the lens of the
scanning device with alcohol to make sure it is clean.
Hold the probe at against the forehead and press the
●
scan button. Continue holding the button and keeping

the probe ush ith the s in o er the temporal artery.
Then lift the thermometer and touch the probe to the EXPECTED HEART RATE RANGE
skin behind the earlobe. ● The expected reference range for an adult client’s pulse
● Release the scan button to display the
is 60 to 100/min at rest.
temperature reading. ● Assess the wave-like sensations or impulses you feel in
a peripheral arterial vessel or over the apex of the heart
COMPLICATIONS as a gauge of cardiovascular status.
Rate: The number of times per minute you feel or hear

Fever
the pulse.
Usually not harmful unless it exceeds 39° C (102.2° F).
Rhythm: The regularity of impulses. A premature, late, or
missed heart beat can result in an irregular interval between
Hyperthermia
impulses and can indicate altered electrical activity of the
Hyperthermia is an abnormally elevated body temperature heart. A regular pulse is the e pected nding.
(greater than 40° C [104° F]) due to a failure of the
Strength (amplitude or pulse volume): e ects the olume
thermoregulatory mechanisms of the body.
of blood ejected against the arterial wall with each heart
NURSING ACTIONS contraction and the condition of the arterial vascular
● Obtain specimens for blood, urine, sputum, or wound system. The strength of the impulse should be the same
cultures as needed. from beat to beat. Grade strength on a scale of 0 to 4.
● Assess/monitor white blood cell counts, sedimentation ● 0 = Absent, unable to palpate
rates, and electrolytes. ● 1+ = Diminished, weaker than expected
● Ensure prescribed cultures are obtained before ● 2+ = Brisk, expected
administering prescribed antibiotics, to promote ● 3+ = Increased, strong
test accuracy. ● 4+ = Full volume, bounding
● Pro ide uids and rest. inimi e acti ity. se a
cooling blanket. Equality: Peripheral pulse impulses should be symmetrical
● Children and older adults are at particular ris for uid in quality and quantity on both sides of the body at the
olume de cit. same location. Assess strength and equality to evaluate
● Provide antipyretics (aspirin, acetaminophen, ibuprofen). the adequacy of the vascular system. An inequality or
Do not give aspirin to manage fever for children absence of pulse on one side of body can indicate a disease
and adolescents ho ha e a iral illness in uen a, state (thrombus, aortic dissection).
chickenpox) due to the risk of Reye’s syndrome.
● Prevent shivering, as this increases energy demand.
● ffer blan ets during chills and remo e them hen the
client feels warm.
● Provide oral hygiene and dry clothing and linens.
● Keep environmental temperature between 21° and 27° C
(70° to 80° F).

CONSIDERATIONS PROCEDURE
Dysrhythmia: An irregular heart rhythm, generally with ● Perform hand hygiene and provide privacy.
an irregular radial pulse. ● Locate the radial pulse on the radial- or thumb-side of
the forearm at the wrist. (27.1)
Pulse deficit: The difference bet een the apical rate and ◯ Place the inde and middle nger of one hand gently
the radial rate. With dysrhythmias, the heart can contract
but rmly o er the pulse. Assess the pulsation for
ineffecti ely, resulting in a beat at the apical site ith no
rate, rhythm, amplitude, and quality.
pulsation at the radial pulse point. To determine the pulse ◯ If the peripheral pulsation is regular, count the
de cit accurately, t o clinicians should measure the apical
rate for 30 sec and multiply by 2. If the pulsation is
and radial pulse rates simultaneously.
irregular, count for a full minute and compare the
Age: The expected pulse rate for a 1-week-old infant is 90 result to the apical pulse rate.
to 160/min, depending on activity level. The rate gradually ● Measure the temporal, carotid, brachial, femoral,
decreases as the child grows older. From age 10 through popliteal, posterior tibial or dorsal pedal pulses using
adolescence, the expected pulse rate is 50 to 100/min, the same technique.
depending on activity. The strength of the pulsation can ● Locate the apical pulse at the fth intercostal space at
weaken in older adult clients due to poor circulation or the left midclavicular line. (27.2)
cardiac dysfunction, which can make the peripheral pulses ◯ Use this site for assessing the heart rate of an infant,
difficult to palpate. checking a heart rate prior to the administration of
cardiac medications, or to validate the precise rate
when a rapid (greater than 100/min) or irregular pulse
NURSING INTERVENTIONS is detected.
◯ Place the diaphragm of a stethoscope on the chest at
the fth intercostal space at the left midcla icular
EQUIPMENT line. If the rhythm is regular, count for 30 sec and
A device (clock) that allows for counting seconds multiply by 2. If the rhythm is irregular or the client
is receiving cardiovascular medications, count for
Stethoscope
1 full min.
COMPLICATIONS
Tachycardia
A rate greater than the expected range or greater
than 100/min.
FACTORS LEADING TO TACHYCARDIA

● Exercise
● Fever, heat exposure
● Medications: epinephrine, levothyroxine
beta2-adrenergic agonists (albuterol)
27.1 Pulse points ● Changing position from lying down to sitting
or standing
27.2 Apical pulse

● Acute pain ASSESSMENT/DATA COLLECTION
● Hyperthyroidism
Anemia, hypoxemia
EXPECTED RESPIRATORY RATE RANGE
●
● Stress, anxiety, fear

● Hypovolemia, shock, heart failure, hemorrhage ● The expected reference range for an adult client’s
respiratory rate is 12 to 20/min.
NURSING ACTIONS ● Accurate assessment of respiration involves observing
● Monitor for pain, anxiety, restlessness, and
the rate, depth, and rhythm of chest-wall movement
manifestations of low cardiac output (fatigue, dizziness,
during inspiration and expiration. Do not inform the
hypotension, chest pain, low oxygen saturation).
client that you are measuring respirations so the client
● onitor for potential ad erse effects of medications.
will remain relaxed and not alter the breathing pattern.
● Protect the client from injury.
Rate: The number of full inspirations and expirations in
Bradycardia 1 min. Determine this by observing the number of times
the client’s chest rises and falls.
A rate less than the expected range or slower than 60/min.
Depth: The amount of chest wall expansion that occurs
FACTORS LEADING TO BRADYCARDIA
with each breath. Altered depths are deep or shallow.
● Long term physical tness
● Hypothermia Rhythm: The observation of breathing intervals. For
● Medications: digoxin, beta-blockers (propranolol), adults, expect a regular rhythm (eupnea) with an
calcium channel blockers (verapamil) occasional sigh.
● Changing position from standing or sitting to
lying down
● Chronic severe pain
CONSIDERATIONS
● Hypothyroidism Age: Respiratory rate decreases with age. Newborns have
● Relaxation an expected respiratory rate of 30 to 60/min and can
experience short apneic spells during REM sleep (less than
NURSING ACTIONS
15 seconds duration). Children 3 to 5 years old have an
● Monitor for manifestations of low cardiac output
expected respiratory rate of 20 to 25/min.
(dizziness, hypotension, chest pain, syncope,
diaphoresis, dyspnea, altered mental state). Sex: Males and children are diaphragmatic breathers, and
● onitor for potential ad erse effects of medications. abdominal movements are more noticeable. Women use
● Protect the client from injury. more thoracic muscles, and chest movements are more
pronounced when they breathe.
Respirations
Pain in the chest wall area can decrease the depth of
respirations. At the onset of acute pain, the respiration
rate increases but stabilizes over time.
PHYSIOLOGICAL RESPONSES Anxiety increases the rate and depth of respirations.
Chemoreceptors in the carotid arteries and the aorta Smoking causes the resting rate of respirations to
primarily monitor carbon dioxide (CO2) levels of the blood. increase.
Rising CO2 levels trigger the respiratory center of the brain
Body position: Upright positions allow the chest wall to
to increase the respiratory rate. The increased respiratory
expand more fully.
rate rids the body of excess CO2. For clients who have
chronic obstructive pulmonary disease (COPD), a low Medications (opioids, sedatives, bronchodilators, and
oxygen level becomes the primary respiratory drive. general anesthetics) decrease respiratory rate and depth.
espiratory depression is a serious ad erse effect of these
medications. Amphetamines and cocaine increase rate and
PROCESSES OF RESPIRATION depth.
Ventilation: The exchange of oxygen and carbon dioxide
Neurologic in ury to the brainstem decreases respiratory
in the lungs through inspiration and expiration. Measure
rate and rhythm.
ventilation with the respiratory rate, rhythm, and depth.
Illnesses can affect the shape of the chest all, change
Diffusion: The exchange of oxygen and carbon dioxide
the patency of passages, impair muscle function, and
between the alveoli and the red blood cells. Measure
diminish respiratory effort. ith these conditions, the
diffusion ith pulse o imetry.
use of accessory muscles (the intercostal muscles) and the
Perfusion: The o of red blood cells to and from respiratory rate increase.
the pulmonary capillaries. Measure perfusion with
Impaired oxygen-carrying capacity of the blood that
pulse oximetry.
occurs with anemia or at high altitudes can result
in increased depth and respiratory rate in order to
compensate.

NURSING INTERVENTIONS Pulse oximetry
EQUIPMENT: A watch or clock that allows for
This is a noninvasive, indirect measurement of the oxygen
counting seconds.
saturation (SaO2) of the blood (the percent of hemoglobin
PROCEDURE that is bound with oxygen in the arteries is the percent of
● Perform hand hygiene and provide privacy. saturation of hemoglobin).
● Place the client in semi-Fowler’s position, being sure
the chest is visible.
● Have the client rest an arm across the abdomen, or place
a hand directly on the client’s abdomen.
● Observe one full respiratory cycle, look at the timer, and
EXPECTED PULSE OXIMETRY RANGE
then begin counting the rate. The expected reference range is 95% to 100%, although
● Count a regular rate for 30 seconds and multiply by 2. clients who have chronic lung disease might tolerate a
Count the rate for 1 min if irregular, faster than 20/min, level as low as 85%. The provider can prescribe an
or slower than 12/min. Note depth (shallow, normal, or acceptable range for the client.
deep) and rhythm (regular or irregular).
CONSIDERATIONS
The same factors that affect respiratory rate can affect
COMPLICATIONS pulse oximetry measurement.
Ineffecti e breathing patterns cause decreased diffusion of
oxygen and decreased perfusion to the tissues, and require
further data collection with possible rapid intervention.
Alterations in ventilatory patterns include the following: EQUIPMENT: Pulse oximeter with digit probe, earlobe
probe, or disposable sensor pad
Bradypnea: Regular breathing pattern with a rate less
than 12/min. PROCEDURE
● Choose an intact, nonedematous site for probe or
Hypoventilation: Shallow breathing pattern with an
sensor placement.
abnormally low rate. ● Place the digit probe on the client s nger.
Apnea: periods where there is no breathing. Ongoing ● Use earlobe or bridge of nose for clients who have
apneic spells can lead to respiratory arrest. peripheral vascular disease.
● A disposable sensor pad can be applied to the sole of an
Tachypnea: regular breathing pattern with a rate greater
infant’s foot.
than 20/min. ● When the readout on the pulse oximeter is stable, record
Hyperventilation: Deep breathing pattern with an this value as the oxygen saturation.
increased rate; leads to decreased levels of carbon dioxide
Blood pressure
and hyperoxygenation.
Hyperpnea: Respiratory rate, depth, and work of breathing

are increased; common during exercise.
Cheyne-Stokes respirations: Irregular rate and depth of

PHYSIOLOGICAL RESPONSES
respirations that follow a cyclical pattern. The client will The principal determinants of blood pressure are cardiac
experience shallow breaths that progress to a normal output (CO) and systemic (peripheral) vascular
pattern, and increased rate, then the rate begins to slow resistance (SVR).
again, ending with an apneic period.
BP = CO × SVR
Kussmaul respirations: Increased respiratory rate, regular
pattern, but abnormally deep. Cardiac output
● CO is determined by
◯ Heart rate
◯ Contractility
◯ Blood volume
◯ Venous return
● Increases in any of these increase CO and BP
● Decreases in any of these decrease CO and BP
Systemic vascular resistance

● re ects the amount of constriction or dilation of
the arteries, and diameter of blood vessels.
● Increases in SVR increase BP
● Decreases in SVR decrease BP

ASSESSMENT/DATA COLLECTION Medications (opiates, antihypertensives, and cardiac
medications) can lower BP. Cocaine, nicotine, cold
medications, oral contraceptives, alcohol, and
CLASSIFICATIONS OF BLOOD PRESSURE antidepressants can raise BP.
27.3 BP classifications Exercise can cause a decrease in BP for several hours
according to the updated guidelines of the afterward.
Eighth Report of the Joint National Committee
on Prevention, Detection, Evaluation, and Obesity is a contributing factor to hypertension.
Treatment of High Blood Pressure
SYSTOLIC BP DIASTOLIC BP Family history of hypertension, lack of exercise, high
(mm Hg) (mm Hg) sodium intake, and continuous stress can increase the risk
NORMAL less than 120 and less than 80 of hypertension.
ELEVATED 120 to 129 and less than 80
STAGE 1 HYPERTENSION 130 to 139 or 80 to 89
greater than
greater than
STAGE 2 HYPERTENSION or equal or Implement interventions to ensure an accurate blood
or equal to 90
to 140
pressure measurement.
● ase the classi cation on the highest reading systolic
The client should
or diastolic). A client who has a BP of 124/92 mm Hg has ● Not use nicotine or drin any caffeine for min prior
stage 2 hypertension because the DBP places the client
to measurement.
in that category. A client who has a BP of 146/82 mm Hg ● Rest for 5 min before measurement.
also has stage 2 hypertension because the SBP places the ● it in a chair, ith the feet at on oor, the bac and
client in that category.
arm supported, and the arm at heart level.
● If the client’s average SBP or DBP (following two BP
measurements) is elevated, they should have readings The nurse should
performed on at least other days. If the ndings are ● Use the auscultatory method with a properly calibrated
elevated on at least three separate occasions over and validated instrument.
several weeks, the client has hypertension. ● Not measure BP in an arm with an IV infusion
in progress or on the side where the client had a
Hypotension is a blood pressure below the expected
mastectomy or an arterio enous shunt or stula.
reference range (systolic less than 90 mm Hg) and can be ● Average two or more readings, taken at least 2 min
a result of uid depletion, heart failure, or asodilation.
apart. If they differ by more than mm Hg, obtain
Pulse pressure is the difference bet een the systolic and additional readings and average them.)
the diastolic pressure readings. ● After initial readings, measure BP and pulse with the
client standing.
Orthostatic (postural) hypotension is a blood pressure
that decreases when a client changes position from lying
to sitting or standing, and it can result from various EQUIPMENT
causes (peripheral vasodilation, medication adverse
effects, uid depletion, anemia, prolonged bed rest . Auscultatory method
● Sphygmomanometer with a pressure manometer
CONSIDERATIONS aneroid or mercury and a correctly si ed cuff
◯ The idth of the cuff should be of the arm
Age
circumference at the point here the cuff is rapped.
● Infants have a low BP that gradually increases with age. ◯ The bladder inside the cuff should surround of
● Older children and adolescents have varying BP based on
the arm circumference of an adult and the whole arm
body size. Larger children have a higher BP.
for a child.
● Adults’ BP can increase with age. ◯ Cuffs that are too large gi e a falsely lo reading, and
● Older adult clients can have a slightly elevated systolic
cuffs that are too small gi e a falsely high reading.
pressure due to decreased elasticity of blood vessels. ● Stethoscope
Circadian (diurnal) rhythms affect P, ith P usually
lowest in the early morning hours and peaking during the Automatic blood pressure devices
later part of the afternoon or evening.
Use when available for monitoring clients who require
Stress associated with fear, emotional strain, and acute fre uent e aluation. easure P rst using the
pain can increase BP. auscultatory method to make sure the automatic device
readings are valid.
Ethnicity: African Americans have a higher incidence of
hypertension in general and at earlier ages.
Sex: Adolescent to middle-age males have higher blood

pressures than females of the same age. Postmenopausal
clients have higher blood pressures than males of the
same age.

PROCEDURE (AUSCULTATORY METHOD) COMPLICATIONS
Perform hand hygiene and provide privacy.
Orthostatic (postural) hypotension
●
● Initially measure P in both arms. If the difference

is more than 10 mm Hg, use the arm with the higher NURSING ACTIONS
reading for subse uent measurements. This difference ● Assess for dizziness, weakness, and fainting. Advise the
can indicate a vascular problem. client to sit or lie down if these manifestations occur.
● Apply the P cuff . cm in abo e the antecubital ● Instruct the client to activate the call light and not to
space with the brachial artery in line with the marking get out of bed without assistance.
on the cuff. ● Have the client sit at the edge of the bed for at least
● Use a lower extremity if the brachial artery is 1 min before standing up, and to move slowly when
not accessible. changing position.
● Estimate systolic pressure by palpating the radial pulse ● Assist with ambulation.
and in ating the cuff until the pulse disappears. In ate
the cuff another mm Hg, and slo ly release the Hypertension
pressure to note when the pulse is palpable again (the
NURSING ACTIONS
estimated systolic pressure). ● Assess/monitor for tachycardia, bradycardia, pain,
● De ate the cuff and ait min.
and anxiety. Primary hypertension is usually
● Position the stethoscope over the brachial artery.
without manifestations.
● Close the pressure bulb by turning the valve clockwise ● Assess for identi able causes of hypertension idney
until tight.
disease, thyroid disease, medication).
● uic ly in ate the cuff to mm Hg abo e the palpated ● Administer pharmacological therapy.
systolic pressure. ● Encourage the client to follow up with the provider.
● Release the pressure no faster than 2 to 3 mm Hg ● ncourage lifestyle modi cations.
per second. ◯ Cessation of smoking or use of smokeless tobacco
● The le el at hich you hear the rst clear sounds is the ◯ Weight control
systolic pressure. ◯ odi cation of alcohol inta e
● Continue to de ate the cuff until the sounds mu e and ◯ Physical activity
disappear and note the diastolic pressure. ◯ Stress reduction
● Record the systolic over the diastolic pressure ◯ Dietary modi cations
(110/70 mm Hg). ■ Dietary Approaches to Stop Hypertension (DASH) diet
● Assess orthostatic changes by taking the client’s BP and ■ Restrict sodium intake.
heart rate (HR) after the client has been in the supine ■ Consume adequate potassium, calcium, and
position for 3 to 10 min. Next, have the client change
magnesium, which help lower BP.
to the sitting or standing position and immediately ■ Restrict cholesterol and saturated fat intake.
reassess BP and HR. Wait an additional 3 min and repeat
BP and HR. The client has orthostatic hypotension if
the SBP decreases more than 20 mm Hg and/or the DBP
decreases 10 mm Hg or more with an increase in HR. Do
not delegate this procedure to an assistive personnel.
● Recall that initial blood pressures can be higher due to
the stress of the clinical setting.
● De ate the cuff completely bet een attempts. ait at
least full min before rein ating the cuff. Air trapped in
the bladder can cause a falsely high reading.

1. A nurse is caring for a client in the emergency A nurse is explaining to a group of newly licensed
department who has an oral body temperature nurses the various factors that can affect a client’s
of 38.3° C (101° F), pulse rate 114/min, and heart rate. Use the ATI Active Learning Template:
respiratory rate 22/min. The client is restless with Basic Concept to complete this item.
warm skin. Which of the following interventions
should the nurse take? (Select all that apply.) UNDERLYING PRINCIPLES: List at least five
factors that can cause tachycardia and at least
A. Obtain culture specimens before five factors that can cause bradycardia.
initiating antimicrobials.
B. Restrict the client’s oral fluid intake.
C. Encourage the client to rest and limit activity.
D. Allow the client to shiver to dispel excess heat.
E. Assist the client with oral hygiene frequently.
2. A nurse is instructing an assistive personnel (AP)

about caring for a client who has a low platelet
count. Which of the following instructions is the
priority for measuring vital signs for this client?
A. “Do not measure the client’s temperature rectally.”
B. “Count the client’s radial pulse for
30 seconds and multiply it by 2.”
C. “Do not let the client know you are
counting their respirations.”
D. “Let the client rest for 5 minutes before
you measure their blood pressure.”
3. A nurse is instructing a group of assistive

personnel in measuring a client’s respiratory
rate. Which of the following guidelines should
A. Place the client in semi-Fowler’s position.
B. Have the client rest an arm across the abdomen.
C. Observe one full respiratory cycle
before counting the rate.
D. Count the rate for 30 sec if it is irregular.
E. Count and report any sighs the client demonstrates.
4. A nurse is measuring the blood pressure of a

client who has a fractured femur. The blood
pressure reading is 140/94 mm Hg, and the client
denies any history of hypertension. Which of the
following actions should the nurse take first?
A. Request a prescription for an
antihypertensive medication.
B. Ask the client if they are having pain.
C. Request a prescription for an
antianxiety medication.
D. Return in 30 min to recheck the
client’s blood pressure.
5. A nurse is performing an admission assessment on a

client. The nurse determines the client’s radial pulse
rate is 68/min and the simultaneous apical pulse
rate is 84/min. What is the client’s pulse deficit?

1. A. CORRECT: The provider can prescribe cultures to Using the ATI Active Learning Template: Basic Concept
identify any infectious organisms causing the fever. UNDERLYING PRINCIPLES
The nurse should obtain culture specimens before
initiating antimicrobial therapy to prevent interference Tachycardia
with the detection of the infection. ●
Exercise
B. Increase oral fluid intake to replace the loss of ●
Fever
body fluids from the diaphoresis and increased ●
Medications: epinephrine, levothyroxine, beta 2
metabolic rate the fever can cause. adrenergic agonists (albuterol )
C. CORRECT: Rest helps conserve energy and decreases ●
Changing position from lying down to sitting or standing
metabolic rate. Activity can increase heat production. ●
Acute pain
D. Provide interventions to prevent shivering, because ●
Hyperthyroidism
shivering increases energy demands.
E. CORRECT: Oral hygiene helps prevent cracking of
●
Anemia, hypoxemia
dry mucous membranes of the mouth and lips.
●
Stress, anxiety, fear
●
Hypovolemia, shock, heart failure
Changes/Abnormalities in Vital Signs Bradycardia
●
Long-term physical fitness
●
Hypothermia
2. A. CORRECT: The greatest risk to a client who has a low ●
Medications: digoxin, beta-blockers (propranolol),
platelet count is an injury that results in bleeding. Using
calcium channel blockers (verapamil )
a thermometer rectally poses a risk of injury to the
rectal mucosa. The low platelet count contraindicates
●
Changing position from standing or sitting to lying down
the use of the rectal route for this client.
●
Chronic, severe pain
B. The AP should count the radial pulse, unless it is ●
Hypothyroidism
irregular, for 30 seconds and then multiply by 2 NCLEX® Connection: Reduction of Risk Potential, Changes/
to obtain the number of pulsations per minute. Abnormalities in Vital Signs
However, this is not the highest priority.
C. The AP should avoid letting the client know about counting
respirations as this awareness can sometimes alter the
respiratory rate. However, this is not the highest priority.
D. The AP should let the client rest for 5 min before
measuring blood pressure as activity can alter the
reading. However, this is not the highest priority.
Changes/Abnormalities in Vital Signs
3. A. CORRECT: Having the client sit upright facilitates full

ventilation and gives the assistive personnel a clear
view of chest and abdominal movements.
B. CORRECT: With the client’s arm across the abdomen or lower
chest, it is easier for the AP to see respiratory movements.
C. CORRECT: Observing for one full respiratory
cycle before starting to count assists the AP
in obtaining an accurate count.
D. The AP should count the rate for 1 min if it is irregular.
E. An occasional sigh is an expected finding in adults and can
assist to expand airways. AP do not need to count sighs.
4. A. Request a prescription for an antihypertensive medication

if the client’s blood pressure remains elevated after the
nurse implements other interventions to reduce it. However,
there is another action the nurse should take first
B. CORRECT: The first action that should be taken using the
nursing process is to assess the client for pain which can
cause multiple complications, including elevated blood
pressure. Therefore, the priority is to perform a pain
assessment. If the client’s blood pressure is still elevated
after pain interventions, report this finding to the provider.
C. Request a prescription for an anti-anxiety medication if the
client’s blood pressure remains elevated after the nurse
implements other interventions to reduce it. However,
D. Recheck the client’s blood pressure in 30 min and
periodically thereafter if it remains elevated after the nurse
implements other interventions to reduce it. However,
5. 16/min
The pulse deficit is the difference between the apical and
radial pulse rates. It reflects the number of ineffective
or nonperfusing heartbeats that do not transmit
pulsations to peripheral pulse points. 84-68 = 16

CHAPTER 28
UNIT 2 HEALTH PROMOTION Face
EXPECTED FINDINGS
Head and Neck

● Symmetry of facial features (If there is asymmetry, note
CHAPTER 28 if all features on one side of face are affected, or only
some of the features)
● Symmetry of expressions
This examination includes the head, neck, eyes, ● No involuntary movements
Proportionate features (no thickening as with acromegaly)
ears, nose, mouth, and throat.
●
● CN V
◯ MOTOR: Test the strength of the muscle contraction
by asking the client to clench their teeth while you
Head and neck palpate the masseter and temporal muscles, and then
the temporomandibular joint. Joint movement should
● This examination includes the skull, face, hair, neck, be smooth.
shoulders, lymph nodes, thyroid gland, trachea position, ◯ SENSORY: Test light touch by having the client close
carotid arteries, and jugular veins. their eyes while you touch the face gently with a wisp
● Use the techniques of inspection, palpation, and of cotton. Ask the client to tell you when they feel
auscultation to examine the head and neck. the touch.
● ne pected ndings include palpation of a mass, ● CN VII: MOTOR: Test facial movement and symmetry
limited range of motion of the neck, and enlarged by ha ing the client smile, fro n, puff out the chee s,
lymph nodes. raise the eyebrows, close their eyes tightly, and show
● If the client’s head size appears abnormal, compare their teeth.
the circumference to a chart, taking into account the
client’s sex, age, and racial background. Equipment Neck
includes a stethoscope.
EXPECTED FINDINGS
● Test the following cranial nerves (CN) during the head ● Muscles of the neck symmetric.
and neck examination. ● Shoulders equal in height and with average
◯ CN V (trigeminal): Assess the face for strength
muscle mass.
and sensation. ◯ RANGE OF MOTION (ROM): Moving the head smoothly
◯ CN VII (facial): Assess the face for
and without distress in the following directions:
symmetrical movement. ■ Chin to chest e ion .
◯ CN XI (spinal accessory): Assess the head and ■ ar to shoulder bilaterally lateral e ion .
shoulders for strength. ■ Chin up (hyperextension).
◯ CN XI: Place your hands on the client’s shoulders and
ask them to shrug their shoulders against resistance;
HEALTH HISTORY: REVIEW OF SYSTEMS then turn the head against resistance of your hand.
QUESTIONS TO ASK
● Do you get headaches? If so, how often? Would you Lymph nodes
point to the exact location? Do you have any other ● Chains of lymph nodes extend from the lower half of
manifestations related to your headaches (nausea and
the head down into the neck. Palpate each node for
vomiting)? What do you do to relieve the pain?
enlargement, in the following sequence.
● Have you ever had a head injury? ◯ Occipital nodes: Base of the skull
● Do you have any pain in your neck? ◯ Postauricular nodes: Over the mastoid
● Can you move your head and shoulders with ease? ◯ Preauricular nodes: In front of the ear
● Have you noticed any unusual facial movements? ◯ Tonsillar (retropharyngeal) nodes: Angle of
● Are any of your lymph nodes swollen?
the mandible
● Does anyone in your family have thyroid disease? ◯ Submandibular nodes: Along the base of the mandible
◯ Submental nodes: Midline under the chin
Anterior cervical nodes: Along the
INSPECTION, PALPATION,
◯
sternocleidomastoid muscle
AND AUSCULTATION ◯ Posterior cervical nodes: Posterior to the
sternocleidomastoid muscle
Skull ◯ Supraclavicular nodes: Above the clavicles
EXPECTED FINDINGS ● Lymph nodes are usually difficult to palpate and not
● Size (normocephalic) tender or visible.
● No depressions, deformities, masses, tenderness ● se the pads of the inde and middle ngers and mo e
● Overall contour and symmetry the skin over the underlying tissue in a circular motion to
try to detect enlarged nodes. Compare from side
to side.
● Evaluate any enlarged nodes for location, tenderness,
size, shape, consistency, mobility, and warmth.
FUNDAMENTALS FOR NURSING CHAPTER 28 HEAD AND NECK 145

Thyroid gland HEALTH HISTORY: REVIEW OF SYSTEMS
The thyroid gland has t o lobes and is ed to the QUESTIONS TO ASK
trachea. It lies in front of the trachea and extends to ● How is your vision? Have you noticed any changes?
both sides. ● Do you ever have blurry or double vision? Do you ever
see spots or halos?
Examine the gland by ● Do you have any eye pain, sensitivity to light, burning,
● First, inspecting the lower half of the neck to see any
itching, dryness, or excessively watery eyes?
enlargement of the gland. An average-size thyroid ● Do you ever have drainage or crusting from your eyes?
gland is not visible. Having the client hyperextend ● Do you wear eyeglasses? Contact lenses?
the neck helps makes the skin taut and allows ● When was your last eye examination?
better visualization. ● Have you ever been diagnosed with an eye disorder?
● Instructing the client to take a sip of water and feeling ● Does anyone in your family have any eye disorders?
the thyroid gland as it moves up with the trachea. ● Do you have diabetes mellitus?
● Palpating the thyroid gland on both sides of the trachea
for size, masses, and smoothness.
AUSCULTATION: If the thyroid is enlarged, auscultate the

INSPECTION
gland using a stethoscope. A bruit indicates an increase in
Visual acuity: CN II
blood o to the area, possibly due to
hyperthyroidism. Measure the client’s ability to see small details.
● If the client can read, use a Snellen chart, Rosenbaum
Trachea chart, or newspaper to measure visual acuity.
● If the client has eyeglasses or contact lenses, have the
Inspect and palpate the trachea for any deviation from
client use them during the test.
midline above the suprasternal notch. Masses in the neck ● Ensure reading material is in the client’s language.
or mediastinum and pulmonary abnormalities cause
lateral displacement. Snellen chart: Use to screen for myopia (impaired
far vision). The Snellen (E) chart is used for clients who
cannot read.
Eyes ●
●
Have the client stand 20 feet from the Snellen chart.
Evaluate both eyes and then each eye separately with
● This examination includes the external and internal and without correction.
anatomy of the eye, isual path ays, elds, isual ● For each eye, cover the opposite eye.
acuity, e traocular mo ements, and re e es. ● Ask the client to read the smallest line of print visible.
● The primary technique for examination of the eyes is ● Note the smallest line the client can read correctly.
inspection, with a limited amount of palpation that ● The rst number is the distance in feet the client
requires gloves. stands from the chart. The second number is the
● ne pected ndings include loss of isual elds, distance at which a visually unimpaired eye can see the
asymmetric corneal light re e , periorbital edema, same line clearly.
conjunctivitis, and corneal abrasion.
For example: A 20/30 vision means a client can
● Perform the eye examination in the following sequence,
read a line from 20 feet away that a person who
using the correct equipment.
has unimpaired vision can read from 30 feet away.
◯ Visual acuity
■ Distant vision: Snellen and Rosenbaum charts, eye Rosenbaum eye chart: Hold 14 inches from the client’s
cover, Ishihara test for color blindness face to screen for presbyopia (impaired near vision or
■ Near vision: hand-held card farsightedness). Readings correlate with the Snellen chart.
◯ Extraocular movements (EOMs): Penlight or
Color vision: Assess using the Ishihara test. The client
ophthalmoscope light, eye cover
should be able to identify the various shaded shapes.
◯ isual elds ye co er
◯ External structures: Penlight or ophthalmoscope
light, gloves
◯ Internal structures: Ophthalmoscope
● Test cranial nerves during the eye examination.
◯ CN II optic isual acuity, isual elds
◯ CN III (oculomotor), CN IV (trochlear), CN VI
(abducens): extraocular movements
◯ CN III (oculomotor): pupillary reaction to light
◯ CN corneal light re e
146 CHAPTER 28 HEAD AND NECK CONTENT MASTERY SERIES

Extraocular movements: CN III, IV, VI PERRLA (CN II, CN III)
● P: Pupils clear
Assess EOMs to determine the coordination of the eye ● E: Equal and between 3 to 7 mm in diameter
muscles using three different tests CN III, CN I , CN I . ● R: Round
● Assess for parallel eye movement, the position of the upper ● RL: Reactive to light both directly and consensually
eyelid, and the presence of abnormal eye movements while
when you direct light into one pupil and then the other
the client looks in each direction (28.1). ● A: Accommodation of the pupils when they dilate to look
● Test the corneal light re e by directing a light onto the
at an object far away and then converge and constrict to
eyes and loo ing to see if the re ection is symmetric on
focus on a near object
the corneas.
Screen for strabismus with the cover/uncover test.
Internal structures
●
While covering one eye, ask the client to look in another

direction. Remove the cover and expect both eyes to be Examine by
gazing in the same direction. ● Darken the room.
● The six cardinal positions of gaze require the client to ● Turn on the ophthalmoscope, and use the lens selector
follo your nger ith his eyes ithout mo ing his disc to nd the large hite disc.
head. o e your nger in a ide H pattern about ● The diopter is set at 0. You can change the setting to
20 to 25 cm (7.9 to 9.8 in) to from the client’s eyes. bring structures into focus during the examination.
Expect smooth, symmetric eye movements with no ● Use your right eye to examine the client’s right eye and
jerky or tremor-like movements (nystagmus). vice versa.
● Instruct the client to stare at a point somewhere
Visual fields: CN II behind you.
● Start slightly lateral and 25 to 30 cm from the client,
Evaluate by facing the client at a distance of 60 cm (2 ft).
nding and follo ing the red re e , to ithin a
The client covers one eye while you cover your direct
distance of 2 to 3 cm of the client’s eye.
opposite eye (client’s right eye and your left eye). Ask
the client to look at you and report when she can see the EXPECTED FINDINGS
ngers on your outstretched arm coming in from four ● The optic disc is light pink or more yellow than the
directions (up, down, temporally, nasally). The expected surrounding retina.
nding is that the client sees your ngers at the same ● The retina is without lesions. The color will be dark pink
time you do. in those with a dark complexion and light pink in those
who have fair skin.
External structures ● The arteries and veins have a 2:3 ratio with no nicking.
● Without pupil dilation, you might only glimpse the
EXPECTED FINDINGS
macula brie y hen the client loo s directly at
● Eyes parallel to each other without bulging
the light.
(exophthalmos) or crossing (strabismus)
● Eyebrows symmetric from the inner to the outer
canthus: can raise and lower symmetrically PALPATION
● Eyelids closing completely and opening to show the
Palpate the lacrimal apparatus to assess for tenderness
lower border and most of the upper portion of the iris
and to express any discharge from the lacrimal duct.
without ptosis (the upper eyelid covering the pupil)
pected ndings include no tenderness, no discharge,
● yelashes cur ing out ard ith no in ammation
and clear uid tears .
around any of the hair follicles
● No edema or redness in the area of the lacrimal glands.
● Conjunctiva
◯ Palpebral pink
◯ Bulbar transparent
● The sclerae will be white in those
who have fair skin and light yellow
with possible brown macules in 28.1 Extraocular movements
clients who have a dark complexion.
● Corneas clear, shiny, and smooth.
● Lenses clear, cloudy with cataracts
● Irises round and illuminating fully
when you shine a light across from
the side. A partially illuminated iris
indicates glaucoma. Note the color of
the irises.

Ears, nose, mouth, and throat INSPECTION AND PALPATION
This examination includes the external, middle, and Ears
internal ear; evaluation of hearing; the nose and sinuses;
EXTERNAL EAR EXPECTED FINDINGS
and the mouth and throat. ● Alignment: The top of the auricles meeting an
● Use the techniques of inspection and palpation to
imaginary horizontal line that extends from the outer
examine the ears, nose (sinuses), mouth, and throat.
canthus of the eye. The auricles should be of equal size
● ne pected ndings include otitis e terna, osteoma,
and level with one another.
polyp, retracted drum, decreased hearing acuity, ● Ear color matching face color
and lateralization. ● No lesions, deformities, or tenderness
● Test the following cranial nerves during the ears, nose, ● No foreign bodies or discharge
mouth, and throat examination. ● Presence of a small amount of cerumen
◯ CN I (olfactory): Assess the nose for smell.
◯ CN VII (facial) and CN IX (glossopharyngeal): Assess INTERNAL EAR
the mouth for taste. Straighten the ear canal by pulling the auricle up and
◯ CN VIII (auditory): Assess the ears for hearing. back for adults and older children, and down and back for
◯ CN IX (glossopharyngeal) and CN X (vagus): Assess younger children. Using the otoscope, insert the speculum
the mouth for movement of the soft palate and the slightly down and forward 1 to 1.5 cm (0.4 to 0.6 in)
gag re e . Assess s allo ing and speech uality. following, but not touching, the ear canal to visualize:
◯ CN XII (hypoglossal): Assess the tongue for movement ● Tympanic membranes that are pearly gray and intact,
and strength. taut, and free from tears.
● A light re e that is isible and in a ell de ned
EQUIPMENT
cone shape.
● Otoscope ● Umbo and manubrium landmarks are readily visible.
● Wristwatch or clock to measure time in seconds ● External ear canal color can vary but is consistent with
● Tuning fork
the client’s skin color.
● Nasal speculum ● Cerumen might be present in the ear canal. Moist
● Tongue blade
cerumen is light brown to gray. Asian or Native
● Penlight
American heritage is associated with dry cerumen.
● Gauze square
● Cotton-tipped applicators AUDITORY SCREENING TESTS
● Whisper test (CN VIII)
◯ TECHNIQUE
HEALTH HISTORY: REVIEW OF SYSTEMS Occlude one ear and test the other to see if the
■
client can hear whispered sounds without seeing

QUESTIONS TO ASK
your mouth move.
● How well do you hear? ■ Repeat with the other ear.
● Have you noticed any changes in your hearing? Do you ◯ EXPECTED FINDING: The client can hear you whisper
wear hearing aids?
softly from 30 to 60 cm (1 to 2 ft) away.
● Have other people commented that you aren’t hearing ● Rinne test (28.2)
what they say? ◯ TECHNIQUE
● Do you ever have ringing or buzzing in your ears,
Place a ibrating tuning for
■ rmly against the
drainage, dizziness, itching, or pain? Do you have a
mastoid bone. Have the client state when he can no
history of ear infections?
longer hear the sound. Note the length of time that
● Are you routinely exposed to loud noises
the client heard the sound (bone conduction).
(work, recreation)? ■ Then move the tuning fork in front of the ear canal.
● How do you clean your ears?
When the client can no longer hear the tuning fork
● Do you e er ha e pain, stuffiness, or uid draining from
sound, note the length of time the sound was heard
your nose?
(air conduction).
● Ha e you e er suffered an in ury to your nose ◯ EXPECTED FINDING: Air conduction (AC) sound longer
● Do you ever have nosebleeds?
than bone conduction (BC) sound; 2:1 ratio.
● Have you noticed any change in your senses of ● Weber test (28.3)
smell or taste? ◯ TECHNIQUE: Place a vibrating tuning fork on top of
● Do you use nasal sprays?
the client’s head. Ask whether the client can hear
● Do you snore or ha e difficulty breathing through
the sound best in the right ear, the left ear, or both
your nose?
ears equally.
● How often do you go to the dentist? Do you have ◯ EXPECTED FINDING: The client hears sound equally in
dentures? Retainers? Do you have any problems with
both ears (negative Weber test).
your gums?
● Do you ha e any difficulty s allo ing or problems ith
hoarseness or sore throat?

Nose ● Hard palate: hitish, intact, symmetric, rm,
and concave.
EXPECTED FINDINGS ● Soft palate: Light pink, intact, smooth, symmetric, and
● The nose is midline, symmetrical, and the same color
moves with vocalization (CN IX, CN X).
as the face. Observe for tenderness, swelling, masses, ● Uvula: Pink, midline, intact, and moves
or deviations.
with vocalization.
● ach naris nostril is patent ithout e cessi e aring. ● Tonsils: The same color as the surrounding mucosa and
The structure of the nose is rm and stable.
vary in size and visibility.
● To examine internal structures, insert a nasal speculum ◯ +1: Barely visible
just barely into each naris as the client tips their ◯ +2: Halfway to the uvula
head back. ◯ +3: Touching the uvula
◯ Septum is midline and intact. ◯ +4: Touching each other or midline
◯ Mucous membranes are redder than the oral mucosa ● Gag reflex: Elicit by using a tongue blade to stimulate
and moist with no discharge or lesions.
the back of the throat (CN IX, CN X). Explain
● Assess smell (CN I) by asking the client to close their
the procedure to the client prior to performing
eyes, occlude one naris at a time, and identify a familiar
this assessment.
smell with the eyes closed. ● Speech: Clear and articulate.
Mouth and throat

EXPECTED FINDINGS
● Lips: Darker pigmented skin than the face and are
moist, symmetric, smooth, soft with no lesions, and
nontender. Lip color can range from pink in clients who
have pale skin to plum for clients who have
dark skin.
● Gums: Tight against the teeth with no bleeding on
gloves from palpation. Uniform in pink color; dark-
skinned clients can have bluish or brown patches
of pigmentation. 28.2 Rinne test
● Mucous membranes: Pink and moist with no lesions
and some freckled brown pigmentation for dark-
skinned clients. Hyperpigmentation can occur after
age 50 years.
● Tongue: Use a gauze pad to hold the tip and move the
tongue from side to side. The dorsal surface is pink,
with the presence of papillae, and symmetric. The
underside of the tongue is smooth with a symmetric
vascular pattern. Assess taste (CN VII, CN IX) by having
the client close their eyes and identify foods you place
on the tongue. Ask the client to move the tongue
up, down, and side to side. Test strength (CN XII)
by applying resistance against each cheek while the
client sticks the tongue into each cheek. The tongue is
midline, moist, free of lesions, and moves freely.
● Teeth: Shiny, white, and smooth. Check for
malocclusions by asking the client to clench their
teeth. Note any missing or loose teeth, as well as any 28.3 Weber test
discoloration. Yellow or darkened teeth are common in
older adults because of long-term wear.

Sinuses SAMPLE DOCUMENTATION
TECHNIQUE Client reports no pain in head or neck region.
● Palpate the frontal sinuses by pressing upward with the
Skull normocephalic, symmetrical, and nontender.
thumbs from just below the eyebrows on either side of
Symmetric facial features, movements. Trachea
the bridge of the nose.
midline. Thyroid lobes palpable but not enlarged;
● Palpate the maxillary sinuses by pressing upward at the
no nodules. Neck supple with no palpable lymph
skin crevices that run from the sides of the nose to the
nodes. Full range of motion of the neck.
corner of the mouth.
Visual acuity 20/30 in the left eye, 20/20 in the
EXPECTED FINDING: Nontender
right eye, 20/20 in both eyes without correction.
EOMs symmetric with no strabismus or nystagmus.
Peripheral fields full bilaterally. Eyebrows evenly
For all systems in this chapter distributed. Eyelids close completely with no ptosis.
No discharge. Bulbar conjunctiva clear, palpebral
conjunctiva pink, sclerae white, irises blue bilaterally.
EXPECTED CHANGES WITH AGING Corneas and lenses clear. PERRLA intact bilaterally.
Red reflex bilaterally. Retinas yellowish orange
Eyes: Decreased visual acuity, decreased peripheral vision,
with no nicking or hemorrhaging of vessels.
diminishing ability to see close objects or read small print
(presbyopia), decreased ability to accommodate extreme No lesions or tenderness on external ears. Top of
changes in light glare, dar ness , difficulty distinguishing ears align with outer canthus of eyes. Tympanic
colors, intolerance to glare, delayed pupillary reaction membranes pearly gray and translucent with
to light, yellowing of the lens, thin gray-white ring well-defined cone of light. Light yellow cerumen
surrounding the cornea (arcus senilis), loss of lateral third in ear canals bilaterally. Auditory acuity intact to
of eyebrows, decrease in lens opacity (cataracts) whispered voice bilaterally. Negative Weber test
and AC > BC bilaterally. Nose midline, symmetrical.
Ears: Hearing loss, loss of acuity for high-frequency tones
Nares patent. Nasal mucosa pink, septum intact
(presbycusis), loss of acuity at all frequencies (strial), or
and midline, no discharge. No sinus tenderness.
loss of acuity at all but worse at high frequency (cochlear
Lips darker pink and intact, symmetric. Oral
conductive loss), cerumen accumulation in the ear canal,
mucosa pink, no dental caries, no missing teeth.
thickening of the tympanic membrane
Tongue pink and midline. Papillae on dorsum,
Mouth: Decreased sense of taste due to reduced number symmetrical vascular pattern on the underside
of taste buds, tooth loss, pale gums, gum disease due to of the tongue. Gums tight against the teeth with
inadequate oral hygiene, darkening of teeth, decreased no bleeding. Hard and soft palates intact with
salivation no lesions. Uvula midline. Gag reflex present.
Tonsils +1 bilaterally. Taste and smell sensations
Voice: Rise in pitch, loss of power and range
intact. Speech clear. CN I through XII intact.
Nose: Decreased sense of smell

1. A nurse in a provider’s office is preparing to test A nurse is assessing a client’s lymph nodes as part of a
a client’s cranial nerve function. Which of the comprehensive physical examination. Use the ATI Active
following directions should the nurse include when Learning Template: Nursing Skill to complete this item.
testing cranial nerve V? (Select all that apply.)
DESCRIPTION OF SKILL: List the nine chains
A. “Close your eyes.” of lymph nodes and the location of each, in the
B. “Tell me what you can taste.” appropriate sequence for palpating them.
C. “Clench your teeth.”
D. “Raise your eyebrows.”
E. “Tell me when you feel a touch.”
2. A nurse is assessing a client’s thyroid gland as

part of a comprehensive physical examination.
Which of the following findings should the
nurse expect? (Select all that apply.)
A. Palpating the thyroid in the lower half of the neck
B. Visualizing the thyroid on inspection of the neck
C. Hearing a bruit when auscultating the thyroid
D. Feeling the thyroid ascend as the client swallows
E. Finding symmetric extension off the
trachea on both sides of the midline
3. A nurse is assessing an adult client’s internal ear

canals with an otoscope as part of a head and
neck examination. Which of the following actions
should the nurse take? (Select all that apply.)
A. Pull the auricle down and back.
B. Insert the speculum slightly down and forward.
C. Insert the speculum 2 to 2.5 cm (0.8 to 1 in).
D. Make sure the speculum does
not touch the ear canal.
E. Use the light to visualize the tympanic
membrane in a cone shape.
4. A nurse is caring for a client who asks what

their Snellen eye test results mean. The client’s
visual acuity is 20/30. Which of the following
responses should the nurse make?
A. “Your eyes see at 20 feet what visually
unimpaired eyes see at 30 feet.”
B. “Your right eye can see the chart clearly
at 20 feet, and your left eye can see
the chart clearly at 30 feet.”
C. “Your eyes see at 30 feet what visually
unimpaired eyes see at 20 feet.”
D. “Your left eye can see the chart clearly
at 20 feet, and your right eye can see
the chart clearly at 30 feet.”
5. A nurse is performing a head and neck examination for

an older adult client. Which of the following age-related
findings should the nurse expect? (Select all that apply.)
A. Reddened gums
B. Lowered vocal pitch
C. Tooth loss
D. Glare intolerance
E. Thickened eardrums

1. A. The first step of testing cranial nerve I, the Using the ATI Active Learning Template: Nursing Skill
olfactory nerve, is to have the client close DESCRIPTION OF SKILL
their eyes prior to testing the sense of smell. ●
Occipital nodes: base of the skull
B. Testing the sensory function of cranial nerve VII, the facial
nerve, involves testing the mouth for taste sensations.
●
Postauricular nodes: over the mastoid
C. CORRECT: Testing cranial nerve V, the trigeminal
●
Preauricular nodes: in front of the ear
nerve, involves testing the strength of muscle ●
Tonsillar (retropharyngeal) nodes: angle of the mandible
contraction by asking the client to clench their teeth ●
Submandibular nodes: along the base of the mandible
while the nurse palpates the masseter and temporal ●
Submental nodes: midline under the chin
muscles, and then the temporomandibular joint. ●
Anterior cervical nodes: along the sternocleidomastoid muscle
D. Testing cranial nerve VII, the facial nerve, involves ●
Posterior cervical nodes: posterior to the sternocleidomastoid muscle
testing for a range of facial expressions by having ●
Supraclavicular nodes: above the clavicles
the client smile, raise their eyebrows, puff out the
cheeks, and perform other facial movements. NCLEX® Connection: Health Promotion and Maintenance,
E. CORRECT: Testing cranial nerve V, the trigeminal Techniques of Physical Assessment
nerve, involves testing light touch by having
the client tell the nurse when they feel a gentle
touch on the face from a wisp of cotton.
Diagnostic Tests
2. A. CORRECT: The thyroid gland lies in the anterior portion of

the lower half of the neck, just in front of the trachea.
B. An average-size thyroid gland is not visible on
inspection. Visualization of the thyroid under the
skin could indicate a thyroid disorder.
C. A bruit indicates increased blood flow,
possibly due to hyperthyroidism.
D. CORRECT: When the client swallows a sip of water, the nurse
should feel the thyroid move upward with the trachea.
E. CORRECT: The thyroid gland lies in front of the trachea
and extends symmetrically to both sides of the midline.
3. A. The nurse should pull the auricle up and back for adults and
down and back for children younger than 3 years.
B. CORRECT: Inserting the speculum slightly down and
forward follows the natural shape of the ear canal.
C. Insert the speculum 1 to 1.5 cm (0.4 to 0.6 in).
D. CORRECT: The lining of the ear canal is sensitive.
Touching it with the speculum could cause pain.
E. CORRECT: Due to the angle of the ear canal, the nurse
can only visualize the light reflecting off of the tympanic
membrane as a cone shape rather than a circle.
Diagnostic Tests
4. A. CORRECT: The first number is the distance (in

feet) the client stands from the chart. The second
number is the distance at which a visually unimpaired
eye can see the same line clearly.
B. Each eye has its own visual acuity, which
includes both numbers.
C. The numerator of visual acuity results is a constant. It
does not change with a client’s ability to see clearly.
D. Each eye has its own visual acuity, which
includes both numbers.
5. A. Expect an older adult’s gums to be pale.

B. Expect an older adult’s vocal pitch to rise.
C. CORRECT: Tooth loss and gum disease
are common in older adults.
D. CORRECT: Older adults tend to become intolerant of glaring
lights and also lose some ability to distinguish colors.
E. CORRECT: Tympanic membranes (eardrums)
thicken in older adults, and they tend to
accumulate cerumen in their ear canals.

CHAPTER 29
UNIT 2 HEALTH PROMOTION HEALTH HISTORY: REVIEW OF SYSTEMS
QUESTIONS TO ASK
Thorax, Heart,
● Do you perform breast self-examinations? How often?
CHAPTER 29 Have you noticed any tenderness or lumps? For
and Abdomen
●
menstruating clients: Does this change with your

menstrual cycle?
● Do you have any thickening, pain, drainage, distortion,
or change in breast size, or any retraction or scaling of
This examination includes the thorax the nipples?
Have you ever had a mammogram? If so,
(breast tissue and lungs), heart, and abdomen.
●
how frequently?
● Has anyone in your family had breast cancer?
● Are you aware of the risks for breast cancer?
Breasts ● Are you ta ing medications that ould affect your

breast tissue?
● For clients who have had a mastectomy, breast
augmentation, or reconstruction, palpate the incisional
lines. Look for lymphedema in clients who have INSPECTION
impaired lymphatic drainage on the affected side.
Position client
● Instruct clients to become self-aware of the breast ● WOMEN: Four positions (sitting or standing)
tissue to detect changes. ◯ Arms at the side
● Clients can perform monthly breast self-examination ◯ Arms above the head
(BSE) to inspect their breasts in front of a mirror and ◯ Hands on the hips pressing rmly
palpate them during a shower. Clients who are pregnant ◯ Leaning forward (arms out in front or on hips)
or postmenopausal should perform BSE on the same day ● MEN: In sitting or lying position (with arms at the
of each month. The optimal time to conduct a BSE is 4
side only)
to 7 days after menses begins, or right after
menstruation ends. Inspect for
● Perform breast examinations on female and ● Size, symmetry (One breast is often slightly larger than
male clients. the other.)
● Use the techniques of inspection and palpation to ● Shape (convex, conical, pendulous)
examine the breasts. ● Symmetric venous patterns and consistency of
skin color
EQUIPMENT ● No lesions, edema, erythema (Rashes and ulcerations
● Gloves
are une pected ndings.
● Drape ● Round or oval shape of areola
● Small pillow or folded towel ● Darker-pigmented areola and nipple. Color ranges
DOCUMENTATION OF NODULES from pink for clients who have pale skin to brown
● Location (quadrant or clock method) for clients who have dark skin. The areola darkens
● Size (centimeters) during pregnancy.
● Shape ● Direction of nipples (Nipples are usually everted; recent
● Consistency soft, rm, or hard inversion is unexpected.)
● Discreteness ell de ned borders of mass ● Bleeding or discharge from the nipples
● Tenderness ● Excoriation under the breasts
● Erythema
● Dimpling or retraction over the mass
● Lymphadenopathy
● Mobility
FUNDAMENTALS FOR NURSING CHAPTER 29 THORAX, HEART, AND ABDOMEN 153

Online Animation: Lung Landmarks
PALPATION Thorax and lungs

Palpate axillary and clavicular lymph nodes with the ● This examination includes the anterior and posterior
client sitting with their arms at both sides. Expect them to
thorax and lungs.
be nonpalpable with no tenderness. ● Use the techniques of inspection, palpation, percussion,
and auscultation.
Breast examination
EQUIPMENT
● Wear gloves if skin is not intact. Feel for lumps using ● Stethoscope
the nger pads of your three middle ngers. The best ● Centimeter ruler
position is for the client to be lying down with the ● Wristwatch or clock that allows for counting seconds
arm up by the head and a small pillow or folded towel
under the shoulder of the side you are examining. This POSITIONING: Assess the posterior thorax with the client
position spreads the breast tissue more evenly over the sitting or standing. Assess the anterior thorax with the
chest wall, allowing for easier palpation. client sitting, lying, or standing.
● Palpate each breast from the sternum to the posterior
ANATOMICAL REMINDER: The right lung has three lobes;
axillary line, and from the clavicle to the bra line
the left lung has two lobes. Auscultate the right middle
(including the areola, nipple, and tail of Spence) using
lobe via the axillae.
one of three techniques.
◯ Circular pattern VERTICAL CHEST LANDMARKS: Use the following
◯ Wedge pattern landmar s to perform assessments and describe ndings.
◯ Vertical strip pattern ● The midsternal line is through the center of
● Compress the nipples carefully between your thumb the sternum.
and inde nger to chec for discharge une pected in ● The midclavicular line is through the midpoint of
nonlactating women). Note the color, consistency, and the clavicle.
odor of any discharge. ● The anterior axillary line is through the anterior
● For pendulous breasts, use one hand to support the axillary folds.
lower portion of the breast while using your other hand ● The midaxillary line is through the apex of the axillae.
to palpate breast tissue against the supporting hand. ● The posterior axillary line is through the posterior
axillary fold.
EXPECTED FINDINGS ● The right and left scapular lines are through the
● FEMALES
inferior angle of the scapula.
◯ reasts rm, dense, elastic, and ithout lesions ● The vertebral line is along the center of the spine.
or nodules
◯ Breast tissue granular or lumpy bilaterally in PERCUSSION AND AUSCULTATORY SITES are in the
some females intercostal spaces (ICSs). The number of the ICSs
● MALES corresponds to the rib above it.
◯ No edema, masses, nodules, or tenderness ● Posterior thorax: The sites are between the scapula
◯ Areolas round and darker pigmented and the vertebrae on the upper portion of the back.
Below the scapula, the sites are along the right and left
UNEXPECTED FINDINGS
scapular lines.
● FEMALES: Fibrocystic breast disease: tender cysts often ● Anterior thorax: The sites are along the midclavicular
more prominent during menstruation
lines bilaterally, with several sites at the anterior/
● MALES: Unilateral or bilateral (but asymmetrical)
midaxillary lines bilaterally in the lower portions of the
gynecomastia in adolescent boys or
chest wall and on either side of the sternum following
bilateral gynecomastia in older adult males, with the
along the rib cage. Observe for accessory muscle use.
exception of male clients who take estrogen therapy to ● Percussing and auscultating in a systemic pattern
augment breast tissue.
allows side-to-side comparisons.
● Maximize sounds by:
◯ Having the client take deep breaths with an open
mouth each time you move the stethoscope.
◯ Placing the diaphragm stethoscope directly on the
s in to pre ent mu ing or distortion of sounds.
◯ Facilitating breathing by medicating for pain,
giving clear directions, and assisting the client to a
sitting position.
154 CHAPTER 29 THORAX, HEART, AND ABDOMEN CONTENT MASTERY SERIES

HEALTH HISTORY: REVIEW OF SYSTEMS Vocal (tactile) fremitus
QUESTIONS TO ASK ● Palpate the chest wall using the palms of both hands,
● Do you have any chronic lung conditions (asthma or comparing side to side from top to bottom.
emphysema)? Do you take any medications for your ● Ask the client to say “99” each time you move your hands.
respiratory problems?
EXPECTED FINDINGS: Vibration is symmetric and more
● Have you ever had pneumonia? If so, when?
pronounced at the top, near the level of the tracheal
● Do you get coughs and colds frequently?
bifurcation.
● Do you have environmental allergies?
● Do you e er ha e shortness of breath or difficulty UNEXPECTED FINDINGS: Increased fremitus (pneumonia)
breathing with activity? or decreased to absent fremitus (pneumothorax).
● Do you have a cough now? Do you cough up sputum? If
so, what does it look like?
● Do you currently or have you ever smoked? If you no PERCUSSION
longer smoke, when did you quit? How long did you ● Compare sounds from side to side.
smoke? If you do currently smoke, when did you start and ● Percussion of the thorax elicits resonance.
how much do you smoke? Are you interested in quitting?
● Are you exposed to secondhand smoke? UNEXPECTED FINDINGS AND SIGNIFICANCE
● Are you exposed to environmental pollutants in your ● Dullness: In uid or solid tissue, this can indicate
work area or residence? pneumonia or a tumor.
● Has anyone in your family had lung cancer or ● Hyperresonance: In the presence of air, this can indicate
tuberculosis? Have you had any exposure to tuberculosis? pneumothorax or emphysema.
● Do you recei e an in uen a accine e ery year
● Have you received a pneumonia vaccine?
● Have you had a TB test? AUSCULTATION
INSPECTION EXPECTED SOUNDS
SHAPE: The anteroposterior diameter is one third to one
Bronchial: Loud, high-pitched, hollow quality, expiration
half of the transverse diameter.
longer than inspiration over the trachea
SYMMETRY: The chest is symmetric with no deformities
Bronchovesicular: Medium pitch, blowing sounds and
of the ribs, sternum, scapula, or vertebrae, and equal
intensity with equal inspiration and expiration times over
movements during respiration.
the larger airways
ICS: No excessive retractions.
Vesicular: Soft, low-pitched, breezy sounds, inspiration
RESPIRATORY EFFORT three times longer than expiration over most of the
● Rate and pattern: 12 to 20/min and regular peripheral areas of the lungs
● Character of breathing (diaphragmatic,
abdominal, thoracic)
● Use of accessory muscles
UNEXPECTED OR ADVENTITIOUS SOUNDS
● Chest wall expansion Crackles or rales: Fine to coarse bubbly sounds (not
● Depth of respirations: unlabored, quiet breathing cleared ith coughing as air passes through uid or
re-expands collapsed small airways
COUGH: If productive, note the color and consistency
of sputum. Wheezes: High-pitched whistling, musical sounds as air
passes through narrowed or obstructed airways, usually
TRACHEA: Midline.
louder on expiration
PALPATION Rhonchi: Coarse, loud, low-pitched rumbling sounds

during either inspiration or e piration resulting from uid
● Surface characteristics include tenderness, lesions,
or mucus, can clear with coughing
lumps, and deformities. Tenderness is an unexpected
nding. A oid deep palpation if the client reports pain Pleural friction rub: Dry, grating, or rubbing sound as
or tenderness. the in amed isceral and parietal pleura rub against each
● Chest excursion or expansion of the posterior thorax: other during inspiration or expiration
With thumbs aligned parallel along the spine at the
Absence of breath sounds: From collapsed or surgically
le el of the tenth rib and the hands attened around the
removed lobes
client’s back, instruct the client to take a deep breath.
Move your thumbs outward approximately 5 cm (2 in)
when the client takes a deep inspiration.

Online Image: Cardiac Landmarks
Heart HEALTH HISTORY: REVIEW OF SYSTEMS

QUESTIONS TO ASK
This examination includes measuring heart rate and blood ● Do you have any problems with your heart? Do you take
pressure, examining the jugular veins, and auscultating
any medications for your heart?
heart sounds. ● Have you had any history of heart trouble, preexisting
EQUIPMENT diabetes, lung disease, obesity, or hypertension?
● Stethoscope ● Do you have high blood pressure or high cholesterol?
● lood pressure cuff ● Do your feet and ankles ever swell?
● Wristwatch or clock that allows for counting seconds ● Do you cough frequently?
● Two rulers ● Do you have chest pain? When? How long does it last?
How often does it occur? Describe the pain. Do you also
Cardiac cycle and heart sounds feel it in your arms, neck, or jaw?
● What are you doing before the pain begins?
● Closure of the mitral and tricuspid valves signals the ● Do you have any nausea, shortness of breath, sweating,
beginning of ventricular systole (contraction) and
dizziness, or any other problems when the pain occurs?
produces the S1 sound (lub). Place the diaphragm of the ● What have you tried to relieve the pain? Does it work?
stethoscope at the apex. ● Describe your energy level. Are you frequently tired? Do
● Closure of the aortic and pulmonic valves signals the
you have unusual fatigue?
beginning of ventricular diastole (relaxation) and ● Do you have fainting spells or dizziness? If so, how
produces the S2 sound (dub). Place the diaphragm of the
often? When was the last time?
stethoscope at the aortic area. ● What is your stress level?
● An S3 sound (ventricular gallop) indicates rapid ● Do you currently or have a history of smoking,
entricular lling and can be an e pected nding
drin ing alcohol, using caffeine, using prescripti e or
in children and young adults. Use the bell of
recreational drugs?
the stethoscope. ● Describe your exercise habits.
● An S4 sound re ects a strong atrial contraction and can ● Describe your dietary pattern and intake.
be an e pected nding in older and athletic adults and ● Are you familiar with the risk factors for heart disease?
children. Use the bell of the stethoscope. ● Does anyone in your family have health problems
● Dysrhythmias occur when the heart fails to beat at
related to the heart?
regular successive intervals.
● Gallops are extra heart sounds. Use the bell of
the stethoscope.
◯ Ventricular gallop occurs after S2, sounds like
INSPECTION AND PALPATION
“Ken-tuck’-y” VITAL SIGNS: Pulse and blood pressure re ect
◯ Atrial gallop occurs before S1, sounds like cardiovascular status.
“Ten’-es-see”
● Murmurs are audible when blood volume in the heart Peripheral vascular system
increased or its o is impeded or altered. se the bell
Inspect jugular veins with the client in bed with the head
of the stethoscope to hear the characteristic blowing or
of the bed at a 30° to 45° angle to assess for right-sided
s ishing sound. Can be asymptomatic or a nding of
heart failure.
heart disease.
◯ Systolic murmurs occur just after S1. APPEARANCE: No neck vein distention
◯ Diastolic murmurs occur just after S2.
JUGULAR VENOUS PRESSURE (JVP): Measure at less than
● Thrills are a palpable vibration that can accompany
2.5 cm (1 in) above the sternal angle using the following
murmurs or cardiac malformation.
technique:
● Bruits are blowing or swishing sounds that indicate ● Place one ruler vertically at the sternal angle.
obstructed peripheral blood o . se the bell of ● Locate the pulsation in the external jugular vein and
the stethoscope.
place the straight edge of another ruler parallel to the
oor at the le el of the pulsation.
Auscultatory sites for the heart ● Line up the two rulers as a T square, keeping the
Aortic: Just right of the sternum at the second ICS horizontal ruler at the level of pulsation.
● Measure JVP at the level where the horizontal ruler
Pulmonic: Just left of the sternum at the second ICS
intersects the vertical ruler.
Erb’s point: Just left of the sternum at the third ICS ● Bilateral pressures greater than 2.5 cm (1 in) are
considered ele ated, and a nding of right sided
Tricuspid: Just left of the sternum at the fourth ICS
heart failure. One-sided pressure elevation
Apical/mitral: Left midcla icular line at the fth IC indicates obstruction.
◯ Examine one carotid artery at a time. If you occlude
both arteries simultaneously during palpation, the
client loses consciousness as a result of inadequate
circulation to the brain.

Heart
Abdomen
APICAL PULSE OR POINT OF MAXIMAL IMPULSE (PMI) ● This examination includes observing the shape of the
● Can be visible just medial to the left midclavicular line
abdomen, palpating for masses, and auscultating for
at the fourth or fth IC . ith clients ho ha e large
vascular sounds.
breast tissue, displace the breast with one hand to ● Use the techniques of inspection, auscultation,
locate the PMI.
percussion, and palpation. Note that this changes the
● Palpate where you visualized it. Otherwise, try to
usual order of assessment techniques. Auscultate just
palpate the location to feel the pulsations.
after inspection, because percussion and palpation can
HEAVES (OR LIFTS) are unexpected, visible elevations of alter bowel sounds.
the chest wall that indicate heart failure, and are often ● EQUIPMENT
along the left sternal border or at the PMI. ◯ Stethoscope
◯ Tape measure or ruler
THRILLS: Use the palm of the hand to feel for vibration ◯ Marking pen
similar to that of a purring kitten. This is an ● Ask the client to urinate before the abdominal
une pected nding.
examination. Have the client lie supine with arms at
both sides and knees slightly bent.
Imagine vertical and horizontal lines through the
AUSCULTATION
●
umbilicus to divide the abdomen into four quadrants

with the xiphoid process as the upper boundary and the
Heart
symphysis pubis as the lower boundary.
● Positioning the client in three different ays allo s for ◯ Right upper quadrant
optimal assessment of heart sounds, as some positions ◯ Left upper quadrant
amplify extra or abnormal sounds. ◯ Right lower quadrant
◯ Sitting, leaning forward ◯ Left lower quadrant
◯ Lying supine
◯ Turned toward the left side (best position for
auscultating extra heart sounds or murmurs) HEALTH HISTORY: REVIEW OF SYSTEMS
● Use both the diaphragm and the bell of the stethoscope
QUESTIONS TO ASK
in a systematic manner to listen at all of the ● Do you ever have nausea, vomiting, or cramping?
auscultatory sites. ● Have you had any change in your appetite? Do you have
● To measure the heart rate, listen and count for 1 min.
any food intolerances? Any recent weight changes?
Determine if the rhythm is regular. If a dysrhythmia ● Do you ha e any difficulty ith s allo ing,
e ists, chec for a pulse de cit radial pulse slo er than
belching or gas?
apical pulse . eport a difference in pulse rates to the ● Have you had any vomit containing blood?
provider immediately. ● What problems, if any, do you have with your bowels?
When was your last bowel movement? Do you often use
Peripheral vascular system
laxatives or enemas?
LOCATIONS TO ASSESS FOR BRUITS ● Have you had any black or tarry stools?
● Carotid arteries: Over the carotid pulses ● Do you take aspirin or ibuprofen? If so, how often?
● Abdominal aorta: Just below the xiphoid process ● Do you ever have heartburn? When? How often?
● Renal arteries: Midclavicular lines above the umbilicus ● Have you had any low abdominal or back pain? Any
on the abdomen tenderness in these areas?
● Iliac arteries: Midclavicular lines below the umbilicus ● Have you had any abdominal surgery, injuries, or
on the abdomen diagnostic tests in this area?
● Femoral arteries: Over the femoral pulses ● Has anyone in your family had colon cancer?
● For clients over 50 years of age: Do you have
routine colonoscopies?
● Are you aware of changes that could indicate
colon cancer?
● Do you drink alcohol? If so, how much?
● What do you eat and drink on a typical day?
● For clients who are pregnant, when was your last
menstrual period?

INSPECTION AUSCULTATION
● Note any guarding or splinting of the abdomen. Bowel sounds result from the mo ement of air and uid
● Inspect the umbilicus for position, shape, color, in the intestines. The most appropriate time to auscultate
in ammation, discharge, and masses. bowel sounds is in between meals.
● TECHNIQUE: Listen with the diaphragm of the
ASSESS THE SKIN FOR
stethoscope in all four quadrants.
● Lesions: Bruising, rashes, or other primary lesions ● EXPECTED SOUNDS: High-pitched clicks and gurgles
● Scars: Location and length
5 to 35 times/min. To make the determination of absent
● Silver striae or stretch marks e pected ndings
bowel sounds, you must hear no sounds after listening
● Dilated veins: An une pected nding possibly re ecting
for a full 5 min.
cirrhosis or inferior vena cava obstruction ● UNEXPECTED SOUNDS: Loud, growling sounds
● Jaundice, cyanosis, or ascites: Possibly
(borborygmi) are hyperactive sounds and indicate
re ecting cirrhosis
increased gastrointestinal motility. Possible causes
SHAPE OR CONTOUR include diarrhea, an iety, bo el in ammation, and
● Flat: In a horizontal line from the xiphoid process to the reactions to some foods.
symphysis pubis
Friction rubs result from the rubbing together of in amed
● Convex: Rounded
layers of the peritoneum.
● Concave: A sunken appearance ● Listen with the diaphragm over the liver and spleen.
● Distended: A large protrusion of the abdomen due ● Ask the client to take a deep breath while you listen for
to fat, uid, or atus. easure the abdomen at the
any grating sounds (like sandpaper rubbing together).
umbilicus to monitor for changes in clients who have
uid retention.
Fat: The client has rolls of fat tissue along both sides,
PERCUSSION
◯
and the skin does not look taut.

◯ Fluid: The an s also protrude, and hen the client ● Expect to hear tympany over most of the abdomen. A
turns onto one side, the protrusion moves to the lower-pitch tympany over the gastric bubble in the left
dependent side. upper quadrant is common.
◯ Flatus: The protrusion is mainly midline, and there is ● Expect dullness over the liver or a distended bladder.
no change in the an s. ● The liver span is a measurement of liver size at the
◯ Hernias: Protrusions through the abdominal muscle right midcla icular line. The e pected nding is
all are isible, especially hen the client e es the 6 to 12 cm (2.4 to 4.7 in). Findings outside this range
abdominal muscles. indicate hepatomegaly.
● Assess for idney tenderness by st percussion o er the
MOVEMENT OF THE ABDOMINAL WALL
costovertebral angles at the scapular lines on the back.
● Peristalsis: Wavelike movements visible in thin adults
The e pected nding is no tenderness.
or in clients who have intestinal obstructions.
● Pulsations: Regular beats of movement midline above
the umbilicus are e pected ndings in thin adults, but a
pulsating mass is unexpected.
PALPATION
Palpate tender areas last.
Light
29.1 Abdominal assessment ● se the nger pads on one hand to palpate to a depth of
1.3 cm (0.5 in) in each quadrant.
● Expect softness, no nodules, and no guarding.
● The bladder is palpable if full; otherwise, it
is nonpalpable.
Deep
Deep palpation may be reserved for advanced or
experienced practitioners.
TWO-HANDED APPROACH: The top hand depresses the

bottom hand 2.5 to 7.5 cm (1 to 3 in) in depth. The bottom
hand assesses for organ enlargement or masses.
EXPECTED FINDINGS: The stool can be palpable in the

descending colon.

Rebound tenderness (Blumberg’s sign) Abdomen
An indication of irritation or in ammation some here ● Weaker abdominal muscles declining in
in the abdominal cavity. Use the following technique in tone and more adipose tissue result in a
all four quadrants. Some facilities might limit this test to rounder, more protruding abdomen.
advanced practitioners. ● Peritoneal in ammation is more difficult to detect due
● Apply rm pressure for seconds ith the hand at a to less pain, guarding, fever, and rebound tenderness.
angle and ith the ngers e tended. ● Saliva, gastric secretions, and
● After releasing the pressure, observe the client’s pancreatic enzymes decrease.
response to see if releasing the pressure caused pain. ● Esophageal peristalsis and
● Ask about pain and tenderness. small-intestine motility decrease.
● Never palpate an abdominal mass, tender organs, or
surgical incisions deeply.
SAMPLE DOCUMENTATION
Breasts conical, symmetric in size, and without
For all systems in this chapter masses or lesions. Nipples and areolae darker
pigmented and symmetric. Everted nipples
without discharge. No palpable axillary or
EXPECTED CHANGES WITH AGING clavicular lymph nodes. No pain or tenderness.
Respiratory rate 16/min and regular. Respirations
Breasts
easy and unlabored. Thorax has a greater transverse
● With menopause, glandular tissue atrophies. Adipose than AP diameter. No chest wall deformities.
tissue replaces it, making it feel softer and more Trachea midline. Movement symmetric with 5 cm
pendulous. The atrophied ducts can feel like thin of expansion. Equal tactile fremitus. Resonant
strands and tissue can feel nodular. sounds throughout. Vesicular sounds primarily over
● Nipples no longer have erectile ability and can invert. the bases bilaterally. No adventitious sounds. No
cough, shortness of breath, difficulty breathing.
Lungs
Heart rhythm and rate regular at 72/min. Blood
● Chest shape changes so that the AP diameter pressure 118/76 mm Hg. No thrills or heaves.
becomes similar to the transverse diameter (barrel PMI approximately 1 cm at the fifth ICS left
chest), resulting in decreased vital capacity. midclavicular line. S1 louder at the apex than S2.
● Chest excursion or expansion diminishes. S2 loudest in the pulmonary area on inspiration.
● Cough re e diminishes. No extra heart sounds, murmurs, or bruits. JVP
● Cilia ineffecti ely remo es dust and 2 cm bilaterally. No chest pain or discomfort.
irritants from the airways.
Abdomen flat with active bowel sounds every 10 to
● Alveoli dwindle, airway resistance increases, and
20 seconds in all four quadrants. No bruits or friction
the risk of pulmonary infection increases.
rubs. Abdomen soft, nontender, and without masses
● Kyphosis, an increased curvature of the thoracic spine
or enlargement of spleen or liver. No costovertebral
due to osteoporosis and weakened cartilage, results in
angle tenderness. Bladder not palpable. No
ertebral collapse and impairment of respiratory effort.
pain or discomfort in abdominal region.
Cardiovascular system
● Systolic hypertension (widened pulse pressure)
is a common nding ith atherosclerosis.
● The P I becomes more difficult to palpate
because the AP diameter of the chest widens.
● Coronary blood vessel walls thicken and
become more rigid with a narrowed lumen.
● Cardiac output decreases and strength of
contraction leads to poor activity tolerance.
● Heart al es stiffen due to calci cation.
● The left ventricle thickens.
● Pulmonary vascular tension increases.
● Systolic blood pressure rises.
● Peripheral circulation diminishes.

1. A nurse in a provider’s office is preparing to perform A nurse is teaching a group of newly licensed nurses about
a breast examination for an older adult client who identifying chest landmarks to help them find the optimal
is postmenopausal. Which of the following findings locations for auscultation of the thorax. Use the ATI Active
should the nurse expect? (Select all that apply.) Learning Template: Basic Concept to complete this item.
A. Smaller nipples UNDERLYING PRINCIPLES: List the seven key chest

B. Less adipose tissue landmarks, along with their locations on the thorax.
C. Nipple discharge
D. More pendulous
E. Nipple inversion
2. A nurse in a provider’s office is preparing to auscultate

and percuss a client’s thorax as part of a comprehensive
physical examination. Which of the following findings
A. Rhonchi
B. Crackles
C. Resonance
D. Tactile fremitus
E. Bronchovesicular sounds
3. During an abdominal examination, a nurse in a

provider’s office determines that a client has abdominal
distention. The protrusion is at midline, the skin over
the area is taut, and the nurse notes no involvement
of the flanks. Which of the following possible
causes of distention should the nurse suspect?
A. Fat
B. Fluid
C. Flatus
D. Hernias
4. During a cardiovascular examination, a nurse in

a provider’s office places the diaphragm of the
stethoscope on the left midclavicular line at the fifth
intercostal space. Which of the following data is the
nurse attempting to auscultate? (Select all that apply.)
A. Ventricular gallop
B. Closure of the mitral valve
C. Closure of the pulmonic valve
D. Apical heart rate
E. Murmur
5. A nurse in a provider’s office is preparing to

auscultate and percuss a client’s abdomen as
part of a comprehensive physical examination.
Which of the following findings should the
nurse expect? (Select all that apply.)
A. Tympany
B. High-pitched clicks
C. Borborygmi
D. Friction rubs
E. Bruits

1. A. CORRECT: In older adulthood, the nipples Using the ATI Active Learning Template: Basic Concept
become smaller and flatter. UNDERLYING PRINCIPLES
B. Older adults have more adipose tissue and ●
Midsternal line: through the center of the sternum
less glandular tissue in their breasts.
C. Older adults have no nipple discharge, unless
●
Midclavicular line: through the midpoint of the clavicle
there is some underlying pathophysiology.
●
Anterior axillary line: through the anterior axillary folds
D. CORRECT: In older adulthood, breasts ●
Midaxillary line: through the apex of the axillae
become softer and more pendulous. ●
Posterior axillary line: through the posterior axillary fold
E. CORRECT: Nipple inversion is common among older ●
Right and left scapular lines: through the inferior angle of the scapula
adults, due to fibrotic changes and shrinkage. ●
Vertebral line: along the center of the spine
NCLEX® Connection: Physiological Adaptation, Pathophysiology NCLEX® Connection: Health Promotion and Maintenance,
2. A. Rhonchi are coarse sounds that result from
fluid or mucus in the airways.
B. Crackles are fine to coarse popping sounds
that result from air passing through fluid or
re-expanding collapsed small airways.
C. CORRECT: Resonance is the expected percussion
sound over the thorax. It is a hollow sound
that indicates air inside the lungs.
D. Tactile fremitus is an expected vibration the nurse can
expect to feel or palpate as the client vocalizes. Speech
creates sound waves, the vibrations of which travel from
the vocal cords through the lungs and to the chest wall.
E. CORRECT: Bronchovesicular sounds are expected
breath sounds of medium pitch and intensity and of
equal inspiration and expiration time. The nurse can
expect to hear them over the larger airways.
3. A. With fat, there are rolls of adipose tissue along the

sides, and the skin does not look taut.
B. With fluid, the flanks also protrude, and when the client turns
onto one side, the protrusion moves to the dependent side.
C. CORRECT: With flatus, the protrusion is mainly
midline, and there is no change in the flanks.
D. With hernias, protrusions through the abdominal
muscle wall are visible, especially when the
client flexes the abdominal muscles.
4. A. To auscultate a ventricular gallop (an S3 sound), place the bell

of the stethoscope at each of the auscultatory sites.
B. CORRECT: To auscultate the closure of the mitral
valve, place the diaphragm of the stethoscope over
the apex, or apical/mitral site, which is on the left
midclavicular line at the fifth intercostal space.
C. To auscultate the closure of the pulmonic valve,
place the diaphragm of the stethoscope over
the aortic area, which is just to the right of the
sternum at the second intercostal space.
D. CORRECT: To auscultate the apical heart rate,
place the diaphragm of the stethoscope over the
apex of the heart, which is on the left midclavicular
line at the fifth intercostal space.
E. To auscultate a murmur, place the bell of the
stethoscope at various auscultatory sites.
5. A. CORRECT: Tympany is the expected drumlike percussion

sound over the abdomen. It indicates air in the stomach.
B. CORRECT: Typical bowel sounds are high-pitched
clicks and gurgles occurring about 35 times/min.
C. Borborygmi are unexpected loud, growling sounds
that indicate increased gastrointestinal motility.
Possible causes include diarrhea, anxiety, bowel
inflammation, and reactions to some foods.
D. Friction rubs result from the rubbing together of inflamed
layers of the peritoneum and are unexpected findings.
E. Bruits indicate narrowed blood vessels
and are unexpected findings.

CHAPTER 30 View Video: Skin Turgor
UNIT 2 HEALTH PROMOTION INSPECTION AND PALPATION

Skin
CHAPTER 30 Integumentary Provide adequate lighting for inspecting the client’s skin.
and Peripheral Natural light is best for detecting subtle color changes,
especially for clients who have dark skin tones. Use
Vascular Systems uorescent lighting hen natural light is not an option.

Use a penlight to visualize the inside of the mouth.
● Ensure the room temperature is comfortable so that
the client does not become cold (causing bluing around
Assess the integumentary (skin, hair, scalp, and the lips and nail beds) or too hot (causing a general
nails) and peripheral vascular systems at the reddened undertone).
If the client is wearing a wig or other hair covering, ask
same time.
●
them to remove it to examine the head and scalp properly.

Use inspection with palpation to examine areas of skin
First, examine the upper extremities while the
●
where tattoos are present. Tattoos can mask rash or

client is sitting or recumbent. Then remove color changes. Skin cancer is more common in locations
where tattoos have been removed.
stockings/socks, and drape the client to expose ● Assess the color of the hair, nails, and skin for uniformity.
the entire lower extremity at once. Make ● Typically, s in color is in uenced by genetics and aries
from black, dark to light brown, or light pink to ivory,
side-to-side comparisons to evaluate for and can have olive or reddish undertones. Skin color
variations of symmetry. Examine lesions should be consistent over most areas of the body, with
darker pigmented areas in sun-exposed regions.
individually. Use the Braden scale or a similar ● Clients who have dark skin tones typically have lighter
assessment tool to predict pressure-ulcer risk. pigmentation on the palms, lips, nail beds, and soles of
the feet. After in ammation resol es, s in pigmentation
Inspect and palpate simultaneously. might turn darker.
Note cleanliness of the hair, skin, and nails, as well
Equipment includes adequate lighting, gloves
●
as any odors. After puberty, most clients have some

for palpating open or draining lesions, a flexible body odor; clients of Native American or Asian descent
usually do not. Other skin odors could indicate infection.
ruler or tape measure to measure the size and ● Expect skin color of the extremities to be symmetric
depth of lesions in centimeters, and a gown or and similar to the rest of the body.
◯ Brown pigmentation changes with
drape to cover the client. enous insufficiency.

◯ Shiny and translucent skin without hair on the toes
and foot indicates arterial insufficiency.

HEALTH HISTORY: REVIEW OF SYSTEMS ● Palpate the temperature of the skin with the dorsal part
QUESTIONS TO ASK of the hand and assess for symmetry of temperature,
● Have you noticed any change in your skin color? If so, is and e pect armth. Note changes re ecting circulation
the change widespread or just in one area? impairment or environmental temperature. Slightly
● Do you have a rash? Where? Does it itch? How long have cooler temperatures of the hands or feet are acceptable.
you had it? What have you used to treat the rash? ● Expect smooth, soft, even skin. Hair can be smooth,
● Is your skin excessively dry or oily? Does this change coarse, or ne. Thic er s in of the palms and soles of
with the seasons? Do you use anything to treat it? the feet is an e pected nding.
● Have you developed any new moles or lesions? Have ● Assess skin turgor by lifting and releasing a fold of
any of the moles or lesions changed in any way (color, skin on the forearm or sternum of an adult, or on the
borders, size)? abdomen of an infant, to verify that it returns quickly
● How often are you out in the sun? Do you use sunscreen into place. Tenting is a delay in the skin returning to its
or wear protective clothing and a hat? usual place. Poor turgor indicates possible dehydration,
● Do you have any swelling? If in your legs, is it in both increasing the risk for skin breakdown.
legs? Does the swelling cause pain? What do you do ● Skin turgor measurement is not always reliable for older
to relieve the swelling? Does it occur at any particular adult clients, who might exhibit decreased skin turgor
time of day? as part of age-related changes.
● Do you have a family history of skin cancer or other ● Moisture in the axillae and in skin folds is an expected
skin conditions? nding. ther ise, the s in should be dry. Note
diaphoresis, oiliness, or e cessi e dryness ith a ing
or scaling. Check skin folds for presence of rash
or infection.
FUNDAMENTALS FOR NURSING CHAPTER 30 INTEGUMENTARY AND PERIPHERAL VASCULAR SYSTEMS 163
View Video: Capillary Refill
COLOR CHANGES Nails

Color changes are more difficult to notice in dar s inned ● pect rm nail bases and nail angles to be
clients. The palms, soles of feet, lisp, tongue, and nail
approximately 160°. Note the curvature of the nail plate
beds are the best places to detect color changes. Vary the
in relationship to the tissue just before the cuticle.
assessment technique as needed to ensure proper ◯ Clubbing, an angle of the nail greater than 160°, can
evaluation of the client’s skin.
result from chronic low oxygen saturation related
Pallor: loss of color; in black skin tones, a change to gray, to heart and lung disease (emphysema, chronic
particularly in the mucous membranes; in brown skin bronchitis). The angle of the nail and base can
tones, a change to yellow-brown; in pale skin tones, a loss eventually exceed 180°.
of red undertones ● Expect symmetric nail beds with uniform color, ranging
● LOCATION: face, conjunctivae, nail beds, palms, lips, from pink with pale skin tones to reddish, bluish, or
buccal mucosa brown to black for dark skin tones, with possible
● INDICATION Anemia, shoc , or lac of blood o longitudinal color strea s. Capillary re ll assesses
circulation to the periphery. Assess capillary re ll by
Cyanosis: bluish for light skin tones in general, and on
applying rm pressure to the nail bed to blanch it. uic
the palms and soles for darker skin tones; for brown skin
release of the pressure should result in a brisk return of
tones, a change to yellow-brown; for darker skin tones,
color less than seconds . Alterations in capillary re ll
black pigmented skin turns grayish
should be compared to other ndings to determine the
● LOCATION: nail beds, lips, mouth mucosa, skin, palms
clinical signi cance.
● INDICATION: Hypoxia or impaired venous return
Jaundice: yellow to orange Hair
● LOCATION: skin, sclera, mucous membranes; changes ● Expect even hair distribution patterns and symmetric
best detected in the sclera for light skin tones and
hair loss, as with male pattern baldness. Females
oral mucous membranes or hard palate for darker skin
can develop male hair pattern distribution following
tones. A slight yello tinge can be an e pected nding
menopause, or it can be caused by other hormone
for clients who have dark skin. For clients who have
changes. Note any infestations of the hair or skin. Hair
darker skin tones, a yellow coloring of the sclera can be
color can vary due to dyes or from aging changes.
an e pected nding. Compare to the posterior hand to ◯ Alopecia can result from endocrine disorders and
detect yellow color change.

poor nutrition.
● INDICATION: Liver dysfunction, red blood-cell ◯ Hirsutism, or hair growth on the face, shoulders,
destruction
or chest for females, can be the result of endocrine
Erythema: redness. For clients who have darker skin, disorders. It can occur with aging.
erythema can be difficult to see. Palpate the s in for ● Pubic hair can range from curly to straight and can
armth, compared to other sections of s in in amed be more coarse depending on the client’s genetic
areas can feel more rm or ood li e and be tender. background. It grows in a diamond shape among males
● LOCATION: face, skin, trauma and pressure sore areas or inverted triangle for females. A varied growth pattern
● INDICATION In ammation, locali ed asodilation, can indicate hormone alterations.
substance use, sun exposure, rash, elevated
body temperature Peripheral arteries
● Bleeding or bruising can appear reddish or bluish in pale ● Palpate the peripheral pulses for strength (amplitude)
skin. Ecchymoses appear as darkened areas in clients
and equality (symmetry).
who have dark skin. Bleeding might be best detected in ◯ Strength (amplitude): The same from beat to beat
dark skin by swelling or warmth. ◯ Grade strength as
■ 0 = Absent, unable to palpate
■ 1+ = Diminished, weaker than expected
■ 2+ = Brisk, expected
■ 3+ = Increased
■ 4+ = Full volume, bounding
◯ Equality: Symmetric in quality and quantity from the

right side of the body to the left
● With the exception of the carotid arteries, palpate pulse
sites bilaterally to make comparisons.
◯ Carotid pulse: On either side of the trachea, just
medial to the sternocleidomastoid muscle on the neck
◯ Radial pulse: On the radial (or thumb) side of
each wrist
◯ Brachial pulse: In the antecubital fossa
above the elbow
◯ Femoral pulse: Midway between the symphysis pubis
and the anterosuperior iliac spine
164 CHAPTER 30 INTEGUMENTARY AND PERIPHERAL VASCULAR SYSTEMS CONTENT MASTERY SERIES
◯ Popliteal pulse: Behind the knee, deep in the popliteal ● Atrophy
fossa, just lateral to midline ◯ Thinning of skin with loss of normal skin furrow.
◯ Dorsalis pedis pulse: On the top of the foot, along Skin is shiny and translucent.
a line ith the groo e bet een the rst toe and the ◯ EXAMPLE: Arterial insufficiency
extensor tendons of the great toe
Secondary lesions result from a change in a primary
◯ Posterior tibial pulse: Behind and below the medial
lesion. Common examples include the following.
malleolus of the ankles ● Erosion
● Inspect peripheral veins for varicosities, redness, ◯ Lost epidermis, moist surface, no bleeding
and swelling. ◯ EXAMPLE: Ruptured vesicle

Crust
Edema
●
◯ Dried blood, serum, or pus
dema is an accumulation of uid in the tissues most ◯ EXAMPLE: Scab

often from direct trauma or impaired venous return. ● Scale
The presence of edema causes swelling with the skin ◯ Flakes of skin that exfoliate
appearing shiny and tight. ◯ EXAMPLES: Dandruff, psoriasis, ec ema

● Assess the swelling for discoloration, location, ● Fissure
and tenderness. In the extremities, measure the ◯ Linear crack
circumference of the swollen body area and compare ◯ EXAMPLE: Tinea pedis
both sides. ● Ulcer
● Evaluate pitting by compressing the skin for at least ◯ Loss of epidermis and dermis with possible
5 seconds over a bony prominence (behind the medial bleeding, scarring

malleolus, the dorsum of foot, or over the shin) ◯ EXAMPLES: Venous stasis ulcer, pressure ulcer
and then assess. The depth of pitting re ects the ● Check lesions using the ABCDE system to detect possible
degree of edema. skin cancer.
◯ 1+ = Trace, 2 mm, rapid skin response ◯ A = asymmetry of shape
◯ 2+ = Mild, 4 mm, 10- to 15-second skin response ◯ B = border irregularity
◯ 3+ = Moderate, 6 mm, prolonged skin response ◯ C = color variation within one lesion
◯ 4+ = Severe, 8 mm, prolonged skin response ◯ D = diameter greater than 6 mm
◯ E = evolving or change in color, elevation, shape, size,
Lesions or development of itching, crusting, or bleeding

● elanoma can appear under the ngernails and on the
Examine skin lesions for size, color, shape, consistency,
palms and soles of the feet; this is more common among
ele ation, location, distribution, con guration, tenderness,
clients of African descent.
uid, and drainage. easure the height, idth, and depth
of lesions. Observe a lesion for any odor, exudate, the Common examples of skin lesions in various age groups
amount and consistency of the exudate, and include the following.
document. ● CHILDREN
◯ Diaper dermatitis
Primary lesions arise from healthy skin tissue. Common ◯ Intertrigo
examples include the following. ◯ Impetigo
● Macule ◯ Atopic dermatitis (eczema)
◯ Nonpalpable, skin color change, smaller than 1 cm
● ADULTS
◯ EXAMPLES: Freckle, petechiae ◯ Primary contact dermatitis
● Papule ◯ Tinea pedis (ringworm of the foot)
◯ Palpable, circumscribed, solid elevation of skin,
◯ Psoriasis
smaller than 1 cm ◯ Labial herpes simplex (cold sores)
◯ EXAMPLE: Elevated nevus ● OLDER ADULTS
● Nodule ◯ Lentigines (liver spots)
◯ Palpable, circumscribed, deep, rm, to cm ◯ Seborrheic keratosis
◯ EXAMPLE: Wart ◯ Dermatosis papulosa nigra, a form of seborrheic
● Vesicle
keratosis, with possible tag-like lesions. Appears
◯ erous uid lled, smaller than cm
mainly on the face and is common among darkly
◯ EXAMPLES: Blister, herpes simplex, varicella
pigmented skin.
● Pustule ◯ Acrochordons (skin tags)
◯ Pus lled, aries in si e ◯ Sebaceous hyperplasia
◯ EXAMPLE: Acne
● Tumor Vascular lesions result from aging changes or
◯ Solid mass, deep, larger than 1 to 2 cm blood-vessel damage in or near the skin. Common
◯ EXAMPLE: Epithelioma examples include the following.
● Wheal ● Spider angioma: Red center with radiating red legs, up
◯ Palpable, irregular borders, edematous to 2 cm, possibly raised
◯ EXAMPLE: Insect bite ● Cherry angioma: Red, 1 to 3 cm, round, possibly raised
● Spider vein: Bluish, spider-shaped or linear, up to Application Exercises
several inches in size
Petechiae/purpura: Deep reddish purple, at, petechiae
1.
●
A nurse in a provider’s office is preparing to assess

1 to 3 mm, purpura larger than 3 mm
a client’s skin as part of a comprehensive physical
● Ecchymosis: Purple fading to green or yellow over time,
examination. Which of the following findings
ariable in si e, at should the nurse expect? (Select all that apply.)
● Hematoma: Raised ecchymosis
A. Capillary refill less than 3 seconds
B. 1+ pitting edema in both feet
EXPECTED CHANGES WITH AGING C. Pale nail beds in both hands
D. Thick skin on the soles of the feet
Integumentary system E. Numerous macules on the face darker
than the surrounding skin color
● Skin thin and translucent, drier, tears easily, loss of
elasticity and increased wrinkling; leathery appearance
● Thinning of hair, hair loss on the scalp or pubic area 2. A nurse is assessing an older adult client who has
● Slow growth of nails with thickening significant tenting of the skin over the forearm. Which
● Decline in glandular structure and function (less oil, of the following factors should the nurse consider
moisture, sweat) as a cause for this finding? (Select all that apply.)
● Uneven pigmentation A. Thin, parchment-like skin
● Slow wound healing B. Loss of adipose tissue
● Little subcutaneous tissue over bony prominences
C. Dehydration
● Increased presence of vitiligo, possibly from
D. Diminished skin elasticity
autoimmune changes
E. Excessive wrinkling
Peripheral vascular system
● Thicker, more rigid peripheral blood vessel walls with a 3. A nurse is assessing postoperative circulation
narrowed lumen leading to poor peripheral circulation of the lower extremities for a client who had
● Higher systolic blood pressure knee surgery. The nurse should test which
of the following? (Select all that apply.)
A. Range of motion
SAMPLE DOCUMENTATION B. Skin color
C. Edema
Skin dark brown, warm, and dry. Turgor brisk, skin
elastic. Rough, thickened skin over heels, elbows, D. Skin lesions
and knees; otherwise, smooth. A 0.5 cm dark E. Skin temperature
papule on right forearm and a 2.5 cm scar on left
knee. Scalp dry with slight dandruff. Hair brown,
clean, smooth, curly, evenly distributed on the
4. A nurse is performing skin assessments on a group
of clients. Which of the following lesions should the
head. Axillary and pubic hair evenly distributed nurse identify as vesicles? (Select all that apply.)
with no infestations. Nails short and firm with no
A. Acne
clubbing. Capillary refill < 3 seconds. No edema.
Pulses palpable, 2+, and equal bilaterally. B. Warts
C. Psoriasis
D. Herpes simplex
E. Varicella

5. A nurse is performing an integumentary
A nurse is reviewing the questions to ask when interviewing assessment for a group of clients. Which of the
clients as part of an integumentary and peripheral following findings should the nurse recognize
vascular assessment. Use the ATI Active Learning as requiring immediate intervention?
Template: Basic Concept to complete this item. A. Pallor
B. Cyanosis
NURSING INTERVENTIONS: Identify at least five
questions to ask prior to beginning the inspection C. Jaundice
and palpation portions of the assessment. D. Erythema
1. A. CORRECT: Expect capillary refill in less than Using the ATI Active Learning Template: Basic Concept
3 seconds as an expected finding. NURSING INTERVENTIONS
B. Do not expect pitting edema, which can reflect excess ●
Have you noticed any changes in your skin color? If so,
fluid that has accumulated in body tissues.
is the change widespread or just in one area?
C. Do not expect pallor in the nail beds, which can
reflect anemia or impaired circulation.
●
Do you have a rash? Where? Does it itch? How long have
D. CORRECT: Expect thicker skin on the palms of you had it? What have you used to treat the rash?
the hands and the soles of the client’s feet. ●
Is your skin excessively dry or oily? Does this change
E. CORRECT: Macules on the face that are darker than the skin with the seasons? Do you use anything to treat it?
color indicate freckles, which are an expected finding. ●
Have you developed any new moles or lesions? Have any of the
NCLEX® Connection: Physiological Adaptation, Pathophysiology moles or lesions changed in any way (color, borders, size)?
●
How often are you out in the sun? Do you use
sunscreen or wear protective clothing and a hat?
2. A. The older adult client, as aging occurs, will have ●
Do you have any swelling? If in your legs, is it in both legs?
skin that becomes thin and translucent and is Does the swelling cause pain? What do you do to relieve the
not a factor for tenting of the skin. swelling? Does it occur at any particular time of day?
B. CORRECT: Tenting is a delay in the skin returning NCLEX® Connection: Reduction of Risk Potential,
to its normal place after pinching. Tenting is a System Specific Assessments
manifestation of aging skin and loss of subcutaneous
tissue that provides recoil in younger skin.
C. CORRECT: Tenting is a delay in the skin returning to its
normal place after pinching. Dehydration can cause the skin
to tent, which can easily develop in the older adult client.
D. CORRECT: Tenting is a delay in the skin returning to its
normal place after pinching. Tenting in the older adult client
is a manifestation of aging skin and loss of elasticity.
E. The older adult client who has aging skin does become
wrinkled, but is not a factor for tenting of the skin.
3. A. Determining range of motion helps with evaluating

joint function, not circulation.
B. CORRECT: Assess the peripheral vascular system to verify
adequate circulation to the client’s legs, which includes skin
color. Pallor and cyanosis reflect inadequate circulation.
C. CORRECT: Assess the peripheral vascular system to verify
adequate circulation to the client’s legs, which includes
edema. Edema reflects inadequate venous circulation.
D. Inspecting for skin lesions is part of an integumentary
assessment, but it does not evaluate circulation. Some skin
lesions do reflect inadequate circulation, but they would not
have developed in the immediate postoperative period.
E. CORRECT: Assess the peripheral vascular system to verify
adequate circulation to the client’s legs, which includes skin
temperature. Coolness of the extremity compared with the
nonoperative extremity indicates inadequate circulation.
Illness Management
4. A. Acne lesions are pustules, not vesicles.

B. Warts are nodules, not vesicles.
C. Psoriasis lesions are scales, not vesicles.
D. CORRECT: Herpes simplex lesions are vesicles, which
are circumscribed fluid-filled skin elevations. Eczema and
impetigo also cause vesicles to appear on the skin.
E. CORRECT: Varicella (chickenpox) lesions are vesicles, which
are circumscribed fluid-filled skin elevations. Eczema and
impetigo also cause vesicles to appear on the skin.
5. A. Report pallor, which can indicate anemia

or circulation difficulties. However, another
assessment finding is the priority.
B. CORRECT: The priority finding when using the airway,
breathing, circulation (ABC) approach to care is cyanosis,
which an indication of hypoxia (inadequate oxygenation).
Therefore, immediately report this finding to the provider.
C. Report jaundice, which can indicate liver dysfunction
or red blood cell destruction. However, another
assessment finding is the priority.
D. Report erythema, which can indicate inflammation.
However, another assessment finding is the priority.
Illness Management
CHAPTER 31
UNIT 2 HEALTH PROMOTION EXPECTED RANGE OF MOTION OF JOINT MOVEMENT
SECTION: HEALTH ASSESSMENT/DATA COLLECTION ● Flexion: Movement that decreases the angle between
two adjacent bones
CHAPTER 31 Musculoskeletal and ● Extension: Movement that increases the angle between
Neurologic Systems
two adjacent bones
● Hyperextension: Movement of a body part beyond its
normal extended position
● Supination: Movement of a body part so the ventral
(front) surface faces up
This examination includes muscles, joints, range ● Pronation: Movement of a body part so the ventral
of motion, mental status, cranial nerves, and (front) surface faces down
Abduction: Movement of an extremity away from the
motor and sensory function.
●
midline of the body

● Adduction: Movement of an extremity toward the
midline of the body
Musculoskeletal system ●
●
Dorsiflexion: Flexing the foot and toes upward
Plantar flexion: Bending the foot and toes downward
● Examination of the musculoskeletal system includes ● Eversion: Turning a body part away from midline
assessing both its structure and function. ● Inversion: Turning a body part toward the midline
● Assessment involves examining each joint, muscle, and ● External rotation: Rotating a joint outward
the surrounding tissues bilaterally and comparing ● Internal rotation: Rotating a joint inward
ndings for symmetry.
● Use the techniques of inspection and palpation to assess
the musculoskeletal system. HEALTH HISTORY: REVIEW OF SYSTEMS
EQUIPMENT QUESTIONS TO ASK
● Tape measure ● Do you have any pain in your joints or muscles?
● Drape or cover for privacy ● Do you ha e any stiffness, ea ness, or t itching
● Have you fallen recently?
ASSESS ● Are you able to care for yourself?
● Gait: Manner or style of walking ● Do you have any physical problems that limit
● Alignment: Position of the joints, tendons, muscles, and
your activities?
ligaments while sitting, standing, and lying ● Do you exercise or participate in sports on a regular basis?
● Symmetry, muscle mass ● For postmenopausal women: What was your maximum
● Muscle tone: Normal state of balanced muscle tension
height? Do you take calcium or vitamin D supplements?
allowing one to maintain positions (sitting or standing) ● Have you ever had bone, muscle, or joint problems?
● Range of motion (ROM): Maximum amount of
movement of a joint – sagittal (left or right), transverse
(side to side), and frontal (front to back)
● Any involuntary movements
INSPECTION
● Indications of inflammation: Redness, swelling, SYMMETRY: Observe and compare both sides of the body
warmth, tenderness, loss of function for symmetry.
● Gross deformities
HEIGHT: Measure for comparison over time. Gradual
height loss is a common nding as a person ages.
POSTURE: Observe when the client is unaware. Expected

nding client standing ith head erect ith both
shoulders and hips at equal heights bilaterally.
SPINE: Inspect from the side. Note the following curvatures:

Expected curvatures (posteriorly)
● Concave cervical spine
● Convex thoracic spine
● Concave lumbar spine
● Convex sacral spine
UNEXPECTED FINDINGS
● Kyphosis: exaggerated curvature of the thoracic spine
(common among older adults)
● Lordosis: exaggerated curvature of the lumbar spine
(common during the toddler years and pregnancy)
● Scoliosis: exaggerated lateral curvature
FUNDAMENTALS FOR NURSING CHAPTER 31 MUSCULOSKELETAL AND NEUROLOGIC SYSTEMS 169

INSPECTION AND PALPATION Neurologic system
Expect equal range of motion (ROM) in the joints bilaterally. ● A neurologic screening examination can evaluate the
● Assess passive ROM by moving the client’s joints
major indicators of neurologic function and assist with

through their full range of movements. Do not move a
recognition of areas of dysfunction.
joint past the point of pain or resistance. ● Integrate neurologic testing throughout the data
● Assess active ROM by having the client repeat the
collection process.
movements the nurse demonstrates.
● Assess oints for armth, in ammation, edema, EXAMINATION COMPONENTS
stiffness, crepitus, deformities, tenderness, limitations, ● Mental status examination to test cerebral function
and instability. Assess the following joints. ● Assessment of cranial nerves
◯ Temporomandibular joint ● Motor function to test cerebellar function
◯ Shoulders ● Sensory function
◯ Elbows ● e e es
◯ Wrists and hands
◯ Spine (scoliosis)
EQUIPMENT
● Snellen and Rosenbaum eye charts
◯ Hips
● Aromatic substances
◯ Knees
● Tongue blades
◯ Ankles, feet
● Penlight
uscles should be rm, symmetric, and ha e e ual ● Sugar and salt
strength bilaterally. The dominant side is usually slightly ● Tuning fork
larger less than a cm difference is not signi cant. ● e e hammer
● Size variations ● Cotton balls
◯ Hypertrophy: Enlargement of muscle due to ● Two test tubes containing water (one cold, one warm)
strengthening ● Pencil
◯ Atrophy: Decrease in muscle size due to disuse; feels ● Paper clips
soft and boggy ● Key
● During ROM, assess tone: slight resistance of the
muscles during relaxation.
● Assess the strength of muscle groups by asking the HEALTH HISTORY: REVIEW OF SYSTEMS
client to push or pull against resistance. Expected
QUESTIONS TO ASK
nding strength e ual, or slightly stronger on the ● Do you have any dizziness or headaches?
dominant side of the body. ● Do you ever have seizures? If so, what triggers them?
● Assess for muscle tremors.
● Have you ever had a head injury or any loss
Inspect and palpate the spine from the back for any lateral of consciousness?
deviations or scoliosis. ● Have you noticed any change in your vision, speech,
● Instruct the client to bend at the waist with the arms ability to think clearly, loss of memory, or change in
reaching for the toes. memory or behavior?
● Inspect and palpate down the spine using the thumb ● Do you have any weakness, numbness, tremors, or
and fore nger. tingling? If so, where?
● Inspect and palpate the spine again with the
client standing.
● pected nding No tenderness, ith spinal ertebrae
that are midline.
170 CHAPTER 31 MUSCULOSKELETAL AND NEUROLOGIC SYSTEMS CONTENT MASTERY SERIES

INSPECTION ● Assess cognitive and intellectual processes.
◯ Memory, both recent and remote.
Mental status ■ Recent: Ask the client to repeat a series of numbers
or a list of objects.
● Describe levels of consciousness and observed behavior ■ Remote: Ask the client to state their birth date or
with the following terms.

mother s maiden name eri able .
◯ Alert: The client is responsive and able to open
◯ Level of knowledge: Ask the client what they know
their eyes and answer questions spontaneously
about their current hospitalization or illness.
and appropriately. ◯ Ability for calculation: Ask the client to count
◯ Lethargic: The client is able to open their eyes and
backward from 100 in serials of 7.
respond but is drowsy and falls asleep readily. ◯ Abstract thinking: Ask the client the interpretation
◯ Obtunded: The client responds to light shaking but
of a cliché (“A bird in the hand is worth two in
can be confused and slow to respond.
the bush.”) This demonstrates a higher level of
◯ Stuporous: The client requires painful stimuli
thought processes.
(pinching a tendon or rubbing the sternum) to achieve ◯ Insight: Perform an objective assessment of the
a brief response. The client might not be able to

client’s perception of illness.
respond verbally. ◯ Judgment: Ask the client about the solution to a
◯ Comatose: There is no response to repeated
speci c dilemma. hat ould you do if you loc ed
painful stimuli. Abnormal posturing in clients who
your keys in your car?”)
are comatose: ◯ Thought process: Note processing differences a rapid
■ Decorticate rigidity: Flexion and internal rotation
change of topic ight of ideas and use of nonsense
of upper extremity joints and legs
words [“hipsnippity”]).
■ Decerebrate rigidity: Neck and elbow extension, ◯ Thought content: Note the presence of delusions,
ith the rists and ngers e ed

hallucinations, and other ideas the client presents
● Assess appearance by observing hygiene, grooming, and
during the interview.
clothing choice. EXPECTED FINDINGS: client is clean ● Expect speech and language rate and features (quality,
and dressed appropriately for the environment or
quantity, and volume) to be articulate and responses
situation. Consider cultural preferences.
meaningful and appropriate.
● Assess mood by inspecting mannerisms and actions
during interactions. EXPECTED FINDINGS: client
makes eye contact, and emotions correspond to the
conversation and situation.
31.1 Cranial nerve testing throughout data collection

EARS, NOSE,
MOUTH, HEAD
AND THROAT EYES AND NECK
✔ I (Olfactory) SENSORY: smell
✔ II (Optic) SENSORY: visual acuity, visual fields
III (Oculomotor),
✔ IV (Trochlear), and MOTOR: PERRLA, six cardinal positions of gaze
VI (Abducens)
SENSORY: light touch sensation to the
✔ V (Trigeminal) face (forehead, cheek, jaw)
MOTOR: jaw opening, clenching, chewing
SENSORY: taste (salt/sweet) on anterior
✔ VII (Facial) two thirds of the tongue
MOTOR: facial movements
✔ VIII (Auditory) SENSORY: hearing and balance
SENSORY: taste (sour/bitter) on posterior third of the tongue

✔ IX (Glossopharyngeal) MOTOR: swallowing, speech sounds, gag reflex
SENSORY: gag reflex

✔ X (Vagus) MOTOR: swallowing, speech quality
✔ XI (Spinal accessory) MOTOR: turning head, shrugging shoulders
✔ XII (Hypoglossal) MOTOR: tongue movement

STANDARDIZED SCREENING TOOLS ● Assess vibration by having the client report when and
● Use the Mini-Mental State Examination to assess where they feel the handle of the vibrating tuning fork
cognitive status objectively. The tool evaluates: on their skin.
◯ Orientation to time and place ● Assess position by repositioning the client’s appendages
◯ Attention and calculation of counting and asking them to report whether each is positioned
backward by sevens up or down.
◯ Registration and recalling of objects ● Assess discrimination by using one of the following.
◯ Language, including naming of objects, following of ◯ Two-point discrimination: Use open paper clips to
commands, and ability to write determine the smallest distance between the two
◯ Reading points at which the client can still feel the two points
● Use the Glasgow Coma Scale to obtain a baseline on his skin and not just one. Compare bilaterally.
assessment of the client’s level of consciousness and for Minimal distance varies with the body part.
ongoing assessment. ◯ Stereognosis: Place a familiar object (key, cotton ball)
◯ This assessment looks at eye, verbal, and motor in the client’s hand, and ask them to identify it.
response, and assigns a number value based on the ◯ Graphesthesia: Trace a number on the client’s
client’s response. palm with the blunt end of a pencil and ask them to
◯ The highest value possible is 15, indicating identify it.
full consciousness.
Deep‑tendon reflexes (DTRs)
Motor function
sing a re e hammer, assess DT s bilaterally and
● Assess coordination by asking the client to extend compare results for symmetry.
the arms and rapidly touch one nger to the nose,
Biceps
alternating hands, and then doing it with the ● Flex arm 45°.
eyes closed. EXPECTED FINDINGS include smooth, ● Place the thumb on the tendon in antecubital fossa.
coordinated movements. ● tri e the thumb ith a re e hammer.
● Assess gait when the client is unaware of the ● EXPECTED RESPONSE: Flexion of the elbow
assessment. EXPECTED FINDING: Gait is steady, smooth,
and coordinated. Brachioradialis
● Assess balance using the following tests. ● Rest a forearm on the examiner’s forearm with the wrist
◯ Romberg test: Ask the client to stand with the feet slightly pronated.
together, arms at both sides, and the eyes closed. ● Strike the tendon 2.5 to 5 cm above the wrist.
EXPECTED FINDING: The client stands with minimal ● EXPECTED RESPONSE: Pronation of the forearm and
swaying for at least 5 seconds. e ion of the elbo
◯ Heel-to-toe walk: Ask the client to place the heel
Triceps
of one foot in front of the toes of the other foot as ● Support the upper arm with the forearm hanging at a
they walk in a straight line. EXPECTED FINDING:
90° angle.
The client walks in a straight line without losing ● Strike the tendon above the elbow.
their balance. ● EXPECTED RESPONSE: Extension of the elbow
● Muscle strength: Assess the strength of muscle groups
by asking the client to push or pull against resistance. Patellar
EXPECTED FINDING: Strength is equal or slightly ● With the upper leg supported and the lower leg dangling
stronger on the dominant side of the body. freely, strike the tendon below the knee.
● EXPECTED RESPONSE: Extension of the lower leg
Sensory function
Achilles
Perform tests on all four extremities with the client’s ● le the nee, dorsi e the foot, and stri e the tendon
eyes closed. above the heel.
● Assess pain sensation by alternating sharp (broken end ● EXPECTED RESPONSE: Plantar e ion of the foot
of tongue blade) and dull (smooth end of tongue blade)
Grade DTR responses as
objects on the skin and asking the client to report what ● 4+ = Very brisk with clonus
they feel. ● 3+ = More brisk than average

● Assess temperature by using two test tubes containing
● 2+ = Expected
water (one warm and one cold), and ask the client to ● 1+ = Diminished
identify which they feel. ● 0 = No response

● Assess light touch by asking the client to report when
and where they feel a cotton ball touching their skin.

For all systems in this chapter Application Exercises
EXPECTED CHANGES WITH AGING 1. A nurse in a provider’s office is preparing to

assess a young adult client’s musculoskeletal
system as part of a comprehensive physical
Musculoskeletal system examination. Which of the following findings
● Reduced muscle mass should the nurse expect? (Select all that apply.)
● Declines in speed, strength, resistance to fatigue, A. Concave thoracic spine posteriorly
reaction time, coordination B. Exaggerated lumbar curvature
● Decalci cation of bones, leading to loss of bone mass C. Concave lumbar spine posteriorly
and height, increasing risk for osteoporosis
D. Exaggerated thoracic curvature
● Degenerative alterations in joints
● Limited range of motion E. Muscles slightly larger on the dominant side
● Thinning intervertebral discs, kyphosis (with height
loss), wider stance altering posture 2. A nurse, who is assessing a client’s neurologic
system, should ask the client to close their eyes
Neurologic system and identify which of the following items?
● Some short-term memory decline A. A word the nurse whispers 30 cm from the ear
● Diminished slo ed re e and reaction times B. A number the nurse traces on the palm of the hand
● Altered vibration, position, hearing, vision, smell, and C. The vibration of a tuning fork the
deep pain and temperature sensation nurse places on the foot
● lo er ne nger mo ement D. A familiar object the nurse places in the hand
● Increased difficulty learning comple or abstract data
Fewer brain cells, smaller brain volume, deteriorating
3.
●
nerve cells, fewer neurotransmitters A nurse is caring for a client who reports pain
with internal rotation of the right shoulder.
● Impaired balance
This discomfort can affect the client’s ability to
● Decreased touch sensation
perform which of the following activities?
A. Exercising the deltoid muscle
when using hand weights
SAMPLE DOCUMENTATION
B. Brushing the hair on the back of the head
Full range of motion without pain in all joints and C. Fastening or zipping closures on
spine. No joint deformities, warmth, or swelling. the back while dressing
Posture erect. Spine midline with expected cervical,
D. Reaching into a cabinet above the sink
thoracic, and lumbar curvatures. No scoliosis.
Muscle strength equal and strong bilaterally.
4. A nurse is performing a neurologic examination
for a client. Which of the following assessments
should the nurse perform to test the client’s
balance? (Select all that apply.)
A. Romberg test
B. Heel-to-toe walk
C. Snellen test
D. Spinal accessory function
E. Rosenbaum test
5. A nurse is collecting data from an older adult client

as part of a neurologic examination. Which of the
Active Learning Scenario following findings should the nurse expect as changes
associated with aging? (Select all that apply.)
A nurse is reviewing the expected range of motion A. Slower light touch sensation
of joint movement with a group of newly licensed
nurses. What information should the nurse include B. Some vision and hearing decline
in the review? Use the ATI Active Learning Template: C. Slower fine finger movement
Basic Concept to complete this item. D. Some short-term memory decline
RELATED CONTENT: List the 13 common types of E. Decreased risk of depression

motion along with the actions that demonstrate them.

1. A. Expect the client to have a convex Using the ATI Active Learning Template: Basic Concept
thoracic spine posteriorly. RELATED CONTENT
B. Although lordosis (an exaggerated lumbar curvature) is ●
Flexion: a movement that decreases
common among toddlers and pregnant clients, do not
the angle between two adjacent bones
expect this finding in a young adult male client.
C. CORRECT: Expect the client to have a
●
Extension: a movement that increases
concave lumbar spine posteriorly. the angle between two adjacent bones
D. Although kyphosis (an exaggerated lumbar
●
Hyperextension: movement of a body part
curvature) is common among older adults, do not beyond its normal extended position
expect this finding in a young adult client. ●
Supination: movement of a body part so the
E. CORRECT: Expect the client to have muscle size equal ventral (or front) surface faces up
on both sides or slightly larger on the dominant side. ●
Pronation: movement of a body part so the
NCLEX® Connection: Physiological Adaptation, Pathophysiology ventral surface (or front) faces down
●
Abduction: the movement of an extremity
away from the midline of the body
2. A. Identifying a whispered word confirms that ●
Adduction: the movement of an extremity
cranial nerve VIII is intact. toward the midline of the body
B. Identifying a tracing on the palm confirms the client’s ●
Dorsiflexion: flexing the foot and toes upward
sense of graphesthesia, which is the ability to use only the ●
Plantar flexion: bending the foot and toes downward
sensation of touch to recognize writing on the skin. ●
Eversion: turning the body part away from the midline
C. Identifying the vibration of a tuning fork ●
Inversion: turning the body part toward the midline
confirms the client’s vibratory sense.
D. CORRECT: Identifying a familiar object in the
●
External rotation: rotating a joint outward
hand confirms the client’s sense of stereognosis,
●
Internal rotation: rotating a joint inward
which is tactile recognition. NCLEX® Connection: Physiological Adaptation, Pathophysiology
3. A. Exercising the deltoid muscle results in

shoulder flexion and extension.
B. Brushing the back of the hair requires
external rotation of the shoulder.
C. CORRECT: Fastening closures on the back
while dressing requires internal rotation of the
shoulder, so this activity will elicit pain.
D. Reaching for something up high requires
external rotation of the shoulder.
4. A. CORRECT: For the Romberg test, the client stands with

their eyes closed, arms at both side, and feet together.
The nurse verifies balance if the client can stand with
minimal swaying for at least 5 seconds.
B. CORRECT: For the heel-to-toe walk, the client places the
heel of one foot in front of the toes of the other foot as they
walk in a straight line. The nurse verifies balance if the client
can walk in a straight line without losing his balance.
C. A Snellen eye chart tests visual acuity, not balance.
D. Testing spinal accessory function verifies that cranial
nerve XI is intact by asking the client to shrug their
shoulders and turn the head against resistance.
E. A Rosenbaum eye chart tests visual acuity, not balance.
Diagnostic Tests
5. A. CORRECT: Touch sensation decreases

for the client who is aging.
B. CORRECT: Losses in vision, hearing, taste, and
smell decline for the client who is aging.
C. CORRECT: Fine finger movement slows, along with some
reflex and motor responses, for the client who is aging.
D. CORRECT: Minimal decline in short-term memory is
an expected finding for the client who is aging.
E. The risk for depression typically increases
for the client who is aging.

NCLEX® Connections

SELF-CARE: Consider client self-care needs
before developing or revising care plan.
Psychosocial Integrity
COPING MECHANISMS
Assess client's ability to cope with life changes and provide support.
Identify situations which may necessitate role changes for a client.
CULTURAL AWARENESS/CULTURAL INFLUENCES ON HEALTH

Incorporate client cultural practices and beliefs
when planning and providing care.
Respect cultural backgrounds/practices of the client.
END OF LIFE CARE: Provide end-of-life care and education to clients.
GRIEF AND LOSS

Provide care for a client experiencing grief or loss.
Inform the client of expected reactions to gried and loss.
RELIGIOUS AND SPIRITUAL INFLUENCES ON HEALTH

Identify the emotional problems of client or client needs
that are related to religious/spiritual beliefs.
Assess and plan interventions that meet the
client's emotional and spiritual needs.
THERAPEUTIC COMMUNICATION
Allow time to communicate with the client.

PERSONAL HYGIENE: Perform postmortem care.

CHAPTER 32
UNIT 3 PSYCHOSOCIAL INTEGRITY FUNCTIONAL COMPONENTS
CHAPTER 32 Therapeutic Referent: The incentive or motivation for communication
Communication
between two people
Sender: The person who initiates and transmits the message
Receiver: The person to whom the sender aims the

message and who interprets the sender’s message
Communication is a complex process of sending,
Message: The verbal and nonverbal information the sender
receiving, and comprehending messages
expresses and intends for the receiver
between two or more people. It is a dynamic and
Channel: The method of transmitting and receiving
ongoing process that creates a unique experience a message (sight, hearing, touch, facial expression,
body language)
for the participants. When communication breaks
Environment: The emotional and physical climate in
down, the result can be workplace errors and the
which the communication takes place
loss of professional credibility.
Feedback: Can be verbal, nonverbal, positive, negative
The message the receiver returns to the sender that
Communicating effectively is a skill that nurses
●
indicates the receipt of the message

must develop. Nurses use communication when ● An essential component of ongoing communication
providing care to demonstrate caring, establish Interpersonal variables: actors that in uence
communication between the sender and the receiver
therapeutic relationships, obtain and deliver
(educational and developmental levels)
information, and assist with changing behavior.
Therapeutic communication is foundational to the METHODS OF COMMUNICATION

nurse-client relationship. Effective communication Verbal communication
is key to ensuring clients’ safety. Vocabulary
● These are the words that communicate a message the
sender writes or speaks.
BASIC COMMUNICATION ● Limited ocabulary or spea ing a different language can
ma e it difficult for nurses to communicate ith clients.
Using medical or nursing jargon can decrease clients’
LEVELS OF BASIC COMMUNICATION understanding. Children and adolescents tend to use words
Intrapersonal communication: Communication within differently than adults do.
an individual. It is each person’s “self-talk,” the internal
Credibility
discussion when thinking but not outwardly verbalizing ● Trustworthiness and reliability of the individual. Nurses
thoughts. It helps nurses assess clients and situations and
must be no ledgeable, consistent, honest, con dent,
think critically about them before communicating verbally.
and dependable.
Interpersonal communication: Communication ● Lack of credibility creates a sense of uncertainty for clients.
between two people. This form of communication is
Denotative and connotative meaning
the most common in nursing and requires an exchange ● When communicating, participants must share meanings.
of information with another individual. However, ● Words that have multiple meanings can cause
messages the recei er percei es can differ from hat the
miscommunication if people interpret them differently.
sender intended.
Clarity and brevity
Public communication: Communication to, within, or ● The shortest, simplest communication
between large groups of people. Using this type of
is usually most effecti e.
communication, many nurses teach, give community ● Long and complex communication
presentations, or write about nursing or health care topics
can be difficult to understand.
and issues.
Small group communication: Communication within a

group of people, often working toward a mutual goal (in
committees, research teams, and support groups).
FUNDAMENTALS FOR NURSING CHAPTER 32 THERAPEUTIC COMMUNICATION 177

View Video: Therapeutic Communication
Timing and relevance THERAPEUTIC COMMUNICATION

● Knowing when to communicate makes the receiver
Therapeutic communication is the purposeful use of
more attentive to the message.
communication to build and maintain helping
● When clients are uncomfortable or distracted, it can be
relationships ith clients, families, and signi cant others.
difficult to con ey the message. ● Nurses use interactive, purposeful
Pacing communication skills to
● The rate of speech can communicate a meaning the ◯ Elicit and attend to clients’ thoughts, feelings,
speaker did not intend. concerns, and needs.

● Speaking rapidly can suggest not having time for ◯ Express empathy and genuine concern for clients’ and
the clients. families’ issues.

◯ Obtain information and give feedback about
Intonation
clients’ status.
● The tone of voice can communicate a variety of feelings. ◯ Intervene to promote functional behavior and
● Nurses communicate feelings (acceptance, judgment,
effecti e interpersonal relationships.
and dislike) through their tone of voice. ◯ Evaluate clients’ progress toward desired goals
and outcomes.
Nonverbal communication ● Children and older adults often re uire speci c,
Nurses should be aware of how they communicate age-appropriate techniques to enhance communication.
nonverbally and determine the meaning of clients’ ● Use of the nursing process depends on therapeutic
nonverbal communication. Nonverbal communication can communication among the nurse, client, family,
often ha e a greater effect on a message than the ords signi cant other, and the interprofessional health
do. Culture also affects interpretation. Attention to the care team.
following in both the communicator and the receiver is
CHARACTERISTICS
necessary. ● Client-centered: Not social or reciprocal
Appearance, posture, gait: Physical characteristics can ● Purposeful, planned, and goal-directed
convey professionalism. Body language and posture can
demonstrate comfort and ease in the situation. The rst
impression is very important.
ESSENTIAL COMPONENTS
Time: Plan for and allow adequate time to communicate
Facial expressions, eye contact, gestures: Facial
with others.
expressions can reveal feelings that clients can easily
misinterpret. Eye contact typically conveys interest and Attentive behavior or active listening: Use this as a means
respect but varies with culture and the situation. Gestures of conveying interest, trust, and acceptance.
can enhance verbal communication or create their
Caring attitude: Show concern and facilitate an emotional
own messages.
connection and support among nurses and clients,
Sounds: Crying or moaning can have multiple meanings, families, and signi cant others.
especially when other nonverbal communication
Honesty: Be open, direct, truthful, and sincere.
accompanies it.
Trust: Demonstrate to clients, families, and signi cant
Territoriality, personal space: Lack of awareness of
others that they can rely on nurses without doubt,
territoriality (right to space) and personal space (the area
question, or judgment.
around an individual) can make clients perceive a threat
and react defensively. Empathy: Convey an objective awareness and
understanding of the feelings, emotions, and behavior of
Electronic communication clients, families, and signi cant others, including trying
to envision what it must be like to be in their position.
Some facilities permit nurses to communicate with
clients via email. An email encryption system is essential Nonjudgmental attitude: A display of acceptance of clients,
for assuring con dentiality. These facilities must also families, and signi cant others encourages open, honest
have guidelines that address when and how to use email communication.
and what information nurses can convey. Many clients
welcome the use of technology in this way; for all clients,
nurses must have their permission to communicate
electronically and must respect their preferences.
Email communication becomes part of the clients’
medical record.
178 CHAPTER 32 THERAPEUTIC COMMUNICATION CONTENT MASTERY SERIES

NURSING PROCESS IMPLEMENTATION
● Establish a trusting nurse-client relationship. Clients
ASSESSMENT/DATA COLLECTION feel more at ease during the implementation phase
when nurses establish a helping relationship.
● Determine verbal and nonverbal communication needs ● Provide empathetic responses and explanations by using
for client-centered care.
observations, giving information, conveying hope, and
◯ Clients who have hearing, vision, or cognitive losses,
using humor.
are unresponsive, are aphasic, or do not speak the ● Manipulate the environment to decrease distractions.
same language as the staff. ● Make sure verbal communication and nonverbal
● Consider physical status.
communication are congruent.
● Consider the developmental level, and alter ● Demonstrate an empathic presence by appearing relaxed
communication accordingly.
and comfortable, facing the client, having an open
◯ CHILDREN
posture, leaning toward the client, and maintaining
■ Use simple, straightforward language.
good eye contact unless cultural norms discourage it.
■ Be aware of nonverbal messages because children
are especially sensitive to nonverbal communication.
Enhance communication by being at the child’s
EFFECTIVE SKILLS AND TECHNIQUES
■
eye level.
■ Incorporate play in interactions. Silence: This allo s time for meaningful re ection.
◯ OLDER ADULT CLIENTS
Presenting reality: This helps the client distinguish
■Recognize that many older adults require
what is real from what is not and to dispel delusions,
ampli cation of sound.
hallucinations, and faulty beliefs.
■ Make sure assistive devices (glasses and hearing
aids) are available for clients who need them. Active listening: This helps the nurse hear, observe,
■ Minimize distractions, and face clients and understand what the client communicates and
when speaking. provide feedback.
■ Speak in short and simple sentences.
■ Allow plenty of time for clients to respond.
Asking questions: This is a way to seek additional
■ Ask for input from caregivers or family to
information.
determine the e tent of any communication de cits Open-ended questions: This facilitates spontaneous
and how best to communicate. responses and interactive discussion. It encourages the
● Identify any cultural considerations that client to explore feelings and thoughts and avoids yes or
affect communication. no answers.
◯ Provide an interpreter.
◯ Address the client directly when the interpreter

Clarifying techniques: This helps the nurse determine
whether the message the client received was accurate:
is present. ● Restating: Uses the client’s exact words
◯ Provide educational materials and instructions in the
● Reflecting: Directs the focus back to the client for them
client’s language.
to examine their feelings
● Paraphrasing: Restates the client’s feelings and
PLANNING thoughts for them to con rm hat they ha e
communicated
● Minimize distractions. ● Exploring: Allows the nurse to gather more information
● Provide privacy.
about important topics the client mentioned
● Identify mutually agreed-upon outcomes.
● Set priorities according to the clients’ needs. Offering general leads, broad opening statements: This
● Collaborate with other health care professionals encourages the client to start and to continue talking.
when necessary.
Showing acceptance and recognition: This acknowledges
● Plan adequate time for interventions.
the nurse’s interest and nonjudgmental attitude.
Focusing: This helps the client concentrate on what

is important.
Giving information: This provides factual details that the

client might need for decision-making.
Summarizing: This emphasizes important points and

reviews what the nurse and the client have discussed.
Offering self: This demonstrates a willingness to spend

time with the client. The nurse can share limited personal
information, but the focus should return to the client as
soon as possible. Relevant self-disclosure by the nurse
helps the client see that others share their experience and
understand.

Touch: If appropriate, touch can communicate caring and Application Exercises
provide comfort.
Sharing feelings: Ask clients to express feelings and help 1. A nurse is caring for a client who states, “I have to check
them identify their feelings. Plan to discuss negative or with my partner and see if they think I am ready to go
angry feelings with peers or other support persons rather home.” The nurse replies, “How do you feel about
than the client. The nurse can also share feelings of caring going home today?” Which clarifying technique is the
and concern with the client, which can promote rapport nurse using to enhance communication with the client?
with the client. A. Pacing
B. Reflecting
C. Paraphrasing
BARRIERS TO EFFECTIVE D. Restating
COMMUNICATION
Asking irrelevant personal questions
2.
●
Which of the following actions should the

● ffering personal opinions
nurse take when demonstrating an empathic
● Stereotyping presence to a client? (Select all that apply.)
● Giving advice
A. Use an open posture.
● Giving false reassurance
● Minimizing feelings B. Write down what the client says
to avoid forgetting details.
● Changing the topic
● Asking “why” questions or asking for explanations C. Establish and maintain eye contact.
● Challenging D. Nod in agreement with the client
● ffering alue udgments throughout the conversation.
● Asking questions excessively (probing) E. Sit facing the client.
● Responding approvingly or disapprovingly (refusing)
Being defensive
3.
●
A nurse is caring for a client who is concerned

● Testing
about being discharged to home with a new
● Judging
colostomy because of being an avid swimmer.
● ffering sympathy Which of the following statements should
● Arguing the nurse make? (Select all that apply.)
● Making automatic responses
A. “You will do great! You just have to get used it.”
● Reacting with passive or aggressive responses
B. “Why are you worried about going home?”
C. “Your daily routines will be different
COMMUNICATION AMONG when you get home.”
HEALTH PROFESSIONALS D. “Tell me about the support system you’ll
have after you leave the hospital.”
Nurses must communicate clearly, respectfully, and
E. “It sounds like you are not sure how having
professionally ith all staff members. a colostomy will affect swimming.”
Faulty communication among the members of the
health care team can ha e a negati e effect on the or
4. Which of the following strategies should a nurse use
environment and on clients’ outcomes. to establish a helping relationship with a client?
● Incivility: Rude dialogue or actions (sarcasm,
A. Make sure the communication is equally distributed
eye rolling)
between the nurse’s and client’s desires.
● Bullying: Repeated words or acts of intimidation
B. Encourage the client to communicate
● Lateral violence: Abusive words or actions of peers
their thoughts and feelings.
(gossiping, exclusion of information, threats of harm,
actual harm) C. Give the nurse-client communication no time limits.
D. Allow communication to occur spontaneously
throughout the nurse-client relationship.

5. A nurse is caring for a school-age child who is sitting
A nurse manager is reviewing nonverbal communication in a chair. To facilitate effective communication, which
with staff members. Use the ATI Active Learning of the following actions should the nurse take?
Template: Basic Concept to complete this item. A. Touch the child’s arm.
RELATED CONTENT: List at least four examples B. Sit at eye level with the child.
of nonverbal communication. C. Stand facing the child.
UNDERLYING PRINCIPLES: Explain their D. Stand with a relaxed posture.

effect on the communication.

1. A. Pacing is a characteristic of verbal communication, Using the ATI Active Learning Template: Basic Concept
not a clarifying technique. RELATED CONTENT
B. CORRECT: Reflecting directs the focus of the ●
Appearance, posture, gait
conversation back to the client so that they
can further explore their own feelings.
●
Facial expressions, eye contact, gestures
C. Paraphrasing restates the client’s feelings for them to
●
Sounds
confirm what they have communicated. In this scenario, ●
Territoriality, personal space
the client did not verbalize their feelings to the nurse. UNDERLYING PRINCIPLES
D. Restating uses the client’s exact words. In this scenario, ●
Appearance, posture, gait: Physical characteristics
the nurse did not restate what the client stated.
convey professionalism and can demonstrate
NCLEX® Connection: Psychosocial Integrity, comfort and ease in the situation.
Therapeutic Communication ●
Facial expressions: Facial expressions can reveal
feelings that clients could misinterpret.
●
Eye contact: Eye contact conveys interest and respect
2. A. CORRECT: Having an open posture, facing the
but varies with culture and the situation.
client, and leaning forward are ways that can
demonstrate an empathic presence.
●
Gestures: Gestures can enhance verbal
B. Writing down everything the client says can interfere communication or create their own messages.
with the ability to convey full attention and interest.
●
Sounds: Crying or moaning can have multiple meanings when
C. CORRECT: Establishing and maintaining eye contact are clients also convey other nonverbal communication.
ways that can demonstrate an empathic presence. ●
Territoriality, personal space: Lack of awareness of territoriality
D. If the nurse nods in agreement throughout the conversation, (right to space) and personal space (the area around an individual)
the client could interpret that as agreement with what the can make clients perceive a threat and react defensively.
client is saying when instead the nurse meant to convey NCLEX® Connection: Psychosocial Integrity,
attending to and understanding what they are saying. Therapeutic Communication
E. CORRECT: Sitting while facing the client directly can
demonstrate an empathic presence. It also helps clients who
have a hearing loss understand verbal communication.
NCLEX® Connection: Psychosocial Integrity,
Therapeutic Communication
3. A. Giving false reassurance and minimizing the client’s feelings

are both barriers to effective communication.
B. Although this might appear to help the client
discuss their feelings, asking a “why” question is
a barrier to effective communication, because it
could make the client react defensively.
C. CORRECT: Presenting reality is an effective communication
technique that can help the client focus on what will really
happen after the changes the surgery has made.
D. CORRECT: Asking open-ended questions and
offering general leads and broad opening statements
are effective communication techniques that
encourage the client to express feelings through
dialogue and offer additional information.
E. CORRECT: Focusing is an effective communication technique
that clearly directs the interaction to the relevant point.
4. A. The communication should not be

reciprocal but client-focused.
B. CORRECT: Therapeutic communication facilitates a
helping relationship that maximizes the client’s ability
to express their thoughts and feelings openly.
C. Limit therapeutic communication to the boundaries
of the therapeutic relationship, including time.
D. Plan therapeutic communication.
5. A. Touching can intimidate the child and

block communication.
B. CORRECT: Be at the same eye level as the
child to facilitate communication.
C. Standing can appear domineering and intimidating.
D. Standing can appear domineering and
intimidating, even with a relaxed posture.

CHAPTER 33
UNIT 3 PSYCHOSOCIAL INTEGRITY
Adaptation
CHAPTER 33 Coping Coping behavior that describes how an individual handles
demands imposed by the environment.
General adaptation syndrome (GAS)

Coping describes how an individual deals with
Also known as “stress syndrome.” Hans Selye developed a
problems (illness and stress). Factors involved in theory of adaptation that describes the stress reaction in
three stages.
coping and adaptation include the client’s family ● Alarm stage: Body functions are heightened to respond
dynamics, adherence to treatment regimens, to stressors, also called ght or ight response.
Hormones (epinephrine, norepinephrine, cortisone) are
and the role an individual can play in important released, which cause elevated blood pressure and heart
relationships. rate, heightened mental alertness, increased secretion
of epinephrine and norepinephrine, and increased blood
o to muscles.
Stress, coping, adaptation,

● Resistance stage: Body functions normalize while
responding to the stressor. The body attempts to
and adherence cope with the stressor and return to homeostasis.
Stabilization of blood pressure, heart rate, and
hormones will occur.
Stress ● Exhaustion stage: Body functions are no longer
● Stress describes changes in an individual’s state of able to maintain a response to the stressor and the
balance in response to stressors, the internal and client cannot adapt. The end of this stage results in
external forces that disrupt that state of balance. Any recovery or death.
stressor, whether it is perceived as “good” or “bad,”
produces a similar biological response in the body. Adherence
● Stress can be situational (adjusting to a chronic disease ● The commitment and ability of the client and family to
or a stressful job change).
follow a given treatment regimen.
● Stress can be developmental (varying with life stage). ● Commitment to the regimen increases adherence.
Adult stressors can include losing parents, having a ● Complicated regimen interferes with adherence.
baby, and getting married. ● In ol ement of the client and signi cant support people
● Stress can be caused by sociocultural factors, including
in the planning stage increases adherence.
substance use, lack of education, and prolonged poverty. ● Ad erse effects of medications diminish adherence.
● Stress not only impairs and weakens the immune ● Negative coping mechanisms (denial) can cause
system also is a causal factor in numerous
nonadherence; positive coping mechanisms can
health conditions.
increase adherence.
● The presence of stressors delays a client’s return to ● Available resources increase adherence.
health in the same way that the presence of a foreign
body or infection delays the healing of a wound.
Coping
● Ask the client questions related to:
● Coping describes how an individual deals with problems ◯ Current stress, perception of stressors, and
and issues. It is the beha ioral and cogniti e efforts of
ability to cope
an individual to manage stress. ◯ Support systems
● actors in uencing an indi idual s ability to cope ◯ Adherence to healthy behaviors and/or the
include the number, duration, and intensity of stressors;

treatment regimen
the individual’s past experiences; the current support ◯ Sleep patterns
system; and available resources. ◯ Altered elimination patterns, changes in appetite, and
● Coping strategies are unique to an individual and can
weight loss or gain
vary greatly with each stressor. ● Observe the client’s appearance and eye contact, verbal,
● Ego defense mechanisms: assist a person during
motor, and cognitive status during the assessment.
a stressful situation or crisis by regulating ● Measure vital signs.
emotional distress. ● Observe for irritability, anxiety, and tension.
FUNDAMENTALS FOR NURSING CHAPTER 33 COPING 183

PATIENT-CENTERED CARE Family systems and
NURSING CARE
family dynamics
● amily is de ned by the client, and it consists of the
Stress individual structures and roles. It is typically two or
more people whose relationships create a bond and
● Encourage health promotion strategies (regular exercise,
in uence their mutual de elopment, support, goals,
optimal nutrition, adequate sleep and rest).
and resources.
● Assist with time management and determining ● Consider e realms of processes in ol ed in family
priority tasks.
function during a family assessment: interactive,
● Encourage appropriate relaxation techniques, (breathing
developmental, coping, integrity, and health.
exercises, massage, imagery, yoga, meditation). ● Families and clients are not mutually exclusive;
● Listen attentively, and take the time to understand the
family-centered care creates a holistic approach to
client’s perspective.
nursing care.
● Control the environment to reduce the number of ● Family dynamics are constantly evolving due to the
external stressors, including noise and breaks in the
processes of family life and developmental stages of the
continuity of care.
family members.
● Identify available support systems.
● Educate the client on available training to manage
stress (journal writing, assertiveness training, stress
management in the workplace, mindfulness-based
CURRENT TRENDS
stress reduction). FASTEST-GROWING POPULATION: Those older than
● The optimal time to teach a client about 65 years, leading to caregiver issues
stress-management skills is after coping with
DECLINING ECONOMIC STATUS OF FAMILIES (increased
crisis successfully.
unemployment)
● se effecti e communication techni ues to foster the
expression of feelings. FAMILY VIOLENCE and its endless cycle
ANY ACUTE OR CHRONIC ILLNESS THAT DISRUPTS THE
Coping
FAMILY UNIT (can include end-of-life care issues)
● Be empathetic in communication, and encourage the
HOMELESSNESS: Lac of stable en ironment, nancial
client to verbalize feelings.
issues, inadequate access to health care (fastest-growing
● Identify the client’s and family’s strengths and abilities.
homeless population is families with children).
● Encourage client’s autonomy with decision-making.
The homeless population is increasing due to lack of
● Discuss the client’s and family’s abilities to deal with
affordable housing.
the current situation.
● Encourage the client to describe coping skills used
effecti ely in the past.
● Identify available community resources, and refer the
ATTRIBUTES OF FAMILIES
client for counseling if needed. ● Structure dictates the family’s ability to cope.
◯ Rigid structure is dictatorial and strict.
Adherence ◯ Open structure includes few or no boundaries,

consistent behavior, or consequences.
● Put instructions in writing. ◯ Either structure can provide positive or
● Allow the client to give input into the
negative outcomes.
treatment regimen. ● Function describes the course of action the family uses
● Simplify treatment regimens as much as possible.
to reach its goals, including members’ communication
● Follow up with the client to address any questions
skills, problem-solving abilities, and available resources.
or problems.
184 CHAPTER 33 COPING CONTENT MASTERY SERIES

ASSESSMENT/DATA COLLECTION Situational role changes
● Assess all clients within the context of the family. ● A role is the function a person adopts within their
● Assess a family by looking at its structure and function.
life. Seldom is it limited to one role, but rather is
● Assessment of a family can focus on family as a context,
multidimensional and is often relative to the role
a client, or a system.
of others.
● Identify who is a family member, what role each family ◯ Grandparent
member has, and the dynamic interactions within ◯ Parent
the family. ◯ Dependent child

● Listen attentively, and use the therapeutic ◯ Employee/employer
communication techni ues of re ection and restatement ◯ Committee member

to clarify the family’s concerns. ◯ Community activist
● Cultural ariables all of hich can differ bet een and ● tress affects roles in many ays.
within generations ● Illness causes role stress by creating a situation in
◯ Perception of events
hich roles can change simply due to the effect and

◯ Rites and rituals
progression of the illness.

◯ Health beliefs
● Nurses must be aware of a client’s roles in life, as well
as how the situation of illness might change these roles,
either temporarily or permanently.
PATIENT-CENTERED CARE ● A basic assumption is that a client can either advance or
regress in the face of a situational role change.
NURSING CARE
Assist the family to adapt their strengths to
TYPES OF ROLE PROBLEMS
●
perceived stressors.
◯ Communication Role conflict: This develops when a person must assume
◯ Adaptability opposing roles with incompatible expectations. Role
◯ Nurturing con icts can be interpersonal hen parents e pect
◯ Crisis as a growth element adolescents to participate in sports and perform household
◯ Parenting skills tasks) or inter-role (when a mother wants to stay at home
◯ Resiliency ith her infant, but family nances re uire her to or .
● Set realistic goals with the family.
Sick role: Expectations of others and society regarding
● Provide information about support networks and
how one should behave when sick (caring for self while
community resources.
sick and continuing to provide childcare to grandchildren).
◯ Child and adult day care
◯ Caregiver support groups Role ambiguity: Uncertainty about what is expected when
● Promote family unity. assuming a role; creates confusion.
● Ensure safety for families at risk for violence.
Role strain: The frustration and anxiety that occurs when
● ncourage con ict resolution.
a person feels inadequate for assuming a role (caring for a
● inimi e family process disruption effects.
parent with dementia). Caregiver burden results from the
● Remove barriers to health promotion.
accumulated stress of caring for someone else over time.
● Increase family members’ abilities to participate.
● Perform interventions that the family cannot perform. Role overload: More responsibility and roles than are
● Evaluate goals within the context of the family by manageable; very common (assuming the role of student,
checking back to ensure that goals were realistic employee, and parent).
and achievable.
● Protect clients experiencing crisis from self-harm, and
initiate referral to mental health services for crisis SITUATIONAL ROLE CHANGES
intervention. ● Caused by situations other than physical growth and
development (marriage, job changes, divorce)
● Can disrupt one or more of the client’s roles in life (with
illness or hospitalization)
● With resolution, can contribute to healing in the
physical, mental, and spiritual realms
TEMPORARY ROLE CHANGES: The client will resume the

role when illness resolves.
PERMANENT ROLE CHANGES: Illness has altered the level

of the client’s health to a point that previous roles are no
longer available.

ASSESSMENT/DATA COLLECTION Application Exercises
● Identify the client’s roles as perceived as owning and by
signi cant others. 1. A nurse is caring for a client whose partner passed away 4
● Assess e realms of family life interacti e processes, months ago. The client has a recent diagnosis of diabetes
mellitus. The client is tearful and states, “How could you
developmental processes, coping processes, integrity
possibly understand what I am going through?” Which
processes, health processes).
of the following responses should the nurse make?
● Validate any discrepancies.
A. “It takes time to get over the loss of a loved one.”
● Identify the effect that the loss or addition of a role is
B. “You are right. I cannot really understand.
having on the client (grieving the loss of a role).
Perhaps you’d like to tell me more
● Identify who will now take on the client’s role while the
about what you’re feeling.”
client cannot, and make referrals as appropriate.
C. “Why don’t you try something to take your mind
● Findings of caregiver burden or role strain include off your troubles, like watching a funny movie.”
fatigue, difficulty sleeping, and illness hypertension, D. “I might not share your exact situation,
mental health issues). but I do know what people go through
when they deal with a loss.”
PATIENT-CENTERED CARE 2. A nurse is caring for a client awaiting transport to the

surgical suite for a coronary artery bypass graft. Just as
NURSING CARE the transport team arrives, the nurse takes the client’s
vital signs and notes an elevation in blood pressure and
● Educate family members on potential stressors (social heart rate. The nurse should recognize this response as
isolation, physical demands) and the resources available which part of the general adaptation syndrome (GAS)?
in the community. A. Exhaustion stage
● Provide short-term care to provide relief for the B. Resistance stage
family caregiver. C. Alarm stage
● Provide encouragement during times of stress. D. Recovery stage
● Seek congruence among perceived roles.
Prepare the client for the anticipated situational crisis.
3.
●
A nurse is caring for a client who has left-sided
● Anticipate role con ict or o erload on the client s part. hemiplegia resulting from a cerebrovascular accident.
● Impro e relationships by supplementing speci c The client works as a carpenter and is now experiencing
role behaviors. a situational role change based on physical limitations.
● Explore which roles the client can relinquish. The client is the primary wage earner in the family. Which
● Help the client improve personal judgment of self-worth of the following describes the client’s role problem?
given the current situational role change. A. Role conflict
● Provide counseling about roles that are B. Role overload
permanently altered. C. Role ambiguity
● Make referrals to community services for outpatient D. Role strain
adaptation to lost or new roles.
● Make referrals to social services for assistance in 4. A nurse is caring for a client who has a new
some roles. diagnosis of type 2 diabetes mellitus. Which of the
● Evaluate the client after acceptance of the role change(s) following nursing interventions for stress, coping,
to assess adaptation. and adherence to the treatment plan should the
nurse initiate at this time? (Select all that apply.)
A. Suggest coping skills for the client
Active Learning Scenario to use in this situation.
B. Allow the client to provide input
A nurse manager is reviewing coping factors with the in the treatment plan.
members of the team. Use the ATI Active Learning C. Assist the client with time management,
Template: Basic Concept to complete this item. and address the client’s priorities.
D. Provide extensive instructions on the
RELATED CONTENT: List at least four factors client’s treatment regimen.
that influence an individual’s ability to cope.
E. Encourage the client in the expression
NURSING INTERVENTIONS: List three interventions of feelings and concerns.
the nurse can take to assist the client in coping
with a stressful event or situation. 5. A nurse is caring for a family who is experiencing
a crisis. Which of the following approaches should
the nurse use when working with a family using
an open structure for coping with crisis?
A. Prescribing tasks unilaterally
B. Delegating care to one member
C. Speaking to the primary client privately
D. Convening a family meeting

1. A. Telling the client it will take more time to heal belittles Using the ATI Active Learning Template: Basic Concept
the client’s feelings and gives false reassurance. RELATED CONTENT
B. CORRECT: By stating there is a lack of understanding, the ●
Number of stressors
nurse is using the therapeutic communication technique
of validation, whereby a person shows sensitivity to
●
Duration of the stressors
the meaning behind a behavior. The nurse is also
●
Intensity of the stressors
creating a supportive and nonjudgmental environment, ●
Individual’s past experiences
and inviting the client to express frustrations. ●
Current support system
C. Telling the client to try a distraction dismisses the client’s ●
Available resources
feelings and gives common advice instead of expert advice.
D. Saying the nurse knows what clients feel is NURSING INTERVENTIONS
presumptive and inappropriate.
●
Be empathetic in communication, and encourage
the client to verbalize feelings.
NCLEX® Connection: Psychosocial Integrity, ●
Identify the client’s and family’s strengths and abilities.
Discuss the client’s and family’s abilities to
deal with the current situation.
2. A. Although the exhaustion stage is a component ●
Encourage the client to describe coping
of GAS, body functions are no longer able to skills used effectively in the past.
respond to the stressor in this stage. ●
Identify available community resources, and
B. Although the resistance stage is a component refer the client for counseling if needed.
of GAS, body functions normalize in an attempt
NCLEX® Connection: Psychosocial Integrity, Coping Mechanisms
to cope with the stressor in this stage.
C. CORRECT: In the alarm stage of GAS, body
functions (blood pressure and heart rate) are
heightened in order to respond to stressors.
D. Although not technically a component of GAS, recovery stage
is an alternative to the exhaustion stage, but it would not
account for an elevation in blood pressure and heart rate.
3. A. CORRECT: The client is experiencing role conflict

because their career is extremely physical, and they
can no longer perform the job duties. However, the
client is the primary wage earner in the family.
B. Although the client can feel overloaded and
overwhelmed, role overload occurs when the
client is trying to juggle too many roles.
C. The client is not experiencing role ambiguity because their
job duties and physical limitations are quite clear.
D. The client is not experiencing role strain. That occurs
when one feels inadequate for assuming a role.
4. A. Although it can seem helpful to suggest specific coping

skills for the client, it is best to allow the client to discuss
coping skills that have worked in the past.
B. CORRECT: Allowing the client to contribute to the
treatment plan allows for greater adherence to the plan.
C. CORRECT: Helping the client to prioritize is an
intervention that can reduce levels of stress for
the client because many times time management
is extremely difficult in times of stress.
D. Although it is necessary to provide complete information on
treatment plans, simplifying treatment regimens as much as
possible allows for greater adherence to the treatment plan.
E. CORRECT: By using effective communication
techniques, encouraging the client to verbalize feelings
is an intervention for stress, coping, and adherence
that allows the client to reduce stress, validate
emotions, and start planning for valid concerns.
5. A. Prescribing tasks is too rigid for acceptance by

a family with an open structure.
B. Delegating care is too rigid for acceptance
by a family with an open structure.
C. Speaking to the primary client privately excludes the family.
D. CORRECT: An open structure is loose, and convening
a family meeting would give all family members input
and an opportunity to express their feelings.

CHAPTER 34
UNIT 3 PSYCHOSOCIAL INTEGRITY Body image
CHAPTER 34 Self-Concept ● Body image changes with cognitive growth and
and Sexuality
physical development.
◯ During adolescence, hormonal changes include the
development of secondary sex characteristics that

in uence body image.
◯ Among older adults, changes in mobility, thinning
Self-concept is the way individuals feel and and graying of hair, and decreased visual and hearing
view themselves. This involves conscious and acuity can affect body image.
tressors that affect body image include loss of body parts
unconscious thoughts, attitudes, beliefs, and
●
due to an amputation, mastectomy, or hysterectomy; loss

perceptions. Body image, a component of of body function due to arthritis, spinal cord injury, or
stroke; and an unattainable body ideal.
self-concept, refers to the way individuals perceive ● ternal in uences media, others perceptions and
their appearance, size, and body structure/function. responses, cultural standards, societal attitudes) can
affect body image.
Sexuality and sexual orientation are integrated ● Clients who have a negative body-image perception tend
to be at risk for suicidal ideation.
into individuals’ personalities as well as their
general health. Sexuality encompasses physical Identity
and emotional connections with others. ● Identity is an inner sense of individuality that implies
the person’s uniqueness as compared with others.
Individuals’ sexuality and sexual health are ● Achievement of identity is important for maintaining
intimate relationships.
influenced by self-concept, body image, gender
identity, and sexual orientation. Sexuality
Sexuality and sexual health are vital components of
Nurses should assess their own comfort levels
●
general health and part of a nursing assessment.

with issues related to sexuality because clients ● Sexuality is an integral part of identity. Its focus
changes during various stages of the lifespan.
can sense nurses’ discomfort. Nurses should ● Sexual health is physical, mental, emotional, and social
have a knowledge of sexual growth and well-being regarding sexuality and sexual activity.
Aspects of sexual health include knowledge
development and an understanding of how
●
of sexual behavior, understanding of expected

health problems and treatments affect sexuality. growth and development, and access to appropriate
health care resources for preventing and
Self-concept treating problems related to sexual health.
● e uality is affected by each de elopmental stage.
● Self-concept is how one values oneself.
For example, during adolescence, primary and
● Self-concept is subjective and includes self-identity, body
secondary sex characteristics develop, menarche
image, attitudes, role performance, and self-esteem.
occurs, relationships involving sexual activity
◯ Individuals who have high self-esteem are better
can develop, and masturbation is common.

equipped to cope successfully with life’s stressors. ● Sexual orientation can include a wide range of
◯ tressors that affect self concept include unrealistic
attractions and can change over the lifespan.
expectations, surgery, chronic illness, and changes in ● e uality is in uenced by culture. Cultures can ie
role performance.
premarital se , homose uality, and polygamy differently.
● Individuals who have a positive self-concept ● e uality affects health status. ome conditions can alter
tend to feel good about themselves.
sexual expression. For example, the presence of a sexually
● Individuals who have positive self-esteem
transmitted infection can cause fear of transmission to a
feel capable and competent.
partner, leading to a decrease in sexual desire.
● Physical, spiritual, emotional, sexual, ● ome medications affect se ual functioning. Diuretics
familial, and sociocultural stressors can
decrease vaginal lubrication, cause erectile dysfunction,
ha e an ad erse effect on self concept.
and reduce sexual desire. Antidepressant medications
can cause erectile dysfunction and reduced libido.
FUNDAMENTALS FOR NURSING CHAPTER 34 SELF-CONCEPT AND SEXUALITY 189

ASSESSMENT/DATA COLLECTION PATIENT-CENTERED CARE
Observe for the following.
Self-concept
●
◯ Posture
◯ Appearance ● Encourage a healthy lifestyle (exercise, diet,

◯ Demeanor stress management).
◯ Eye contact ● Encourage the client to verbalize fears or anxieties.
◯ Grooming ● Use therapeutic communication skills to assist the client
◯ Unusual behavior with self-awareness.
● Discuss the client’s feelings about body image, self- ● ncourage the use of effecti e coping s ills.
concept, or sexuality. For example, a refusal to look at or ● Reinforce successes and strengths.
care for incisions or ostomies after surgical alterations
can indicate a body-image disturbance. Body image
● Obtain a sexual history from clients who report ● Establish a therapeutic relationship with the client. A
sexual problems or are receiving care for relevant
caring and nonjudgmental manner puts the client at
conditions (pregnancy, contraception, STI, infertility),
ease and fosters meaningful communication.
and for clients who might experience a change in ● nsure pri acy and con dentiality. Let the client no
sexual functioning due a condition or treatment
that sensitive issues are safe to discuss.
(diabetes mellitus, heart disease, cancer of the ● Identify individuals who can be at risk for
reproductive organs).
body-image disturbances.
● Ask about sexual orientation and preferred pronouns or ● Acknowledge anger, depression, and denial as feelings
terminology related to sexual self-concept or identity.
to be expected when adjusting to body changes.
● Ask if the client is sexually active and whether there are ● Arrange for a visit from a volunteer who has
any concerns about sexual function, discomfort, or pain
experienced a similar body-image change.
during sexual activity. ● einforce clients strengths and help them nd the
● Use the PLISSIT assessment tool for sexuality.
assistance they need.
◯ P: Permission (obtaining permission to discuss this
with the client)
Sexuality
◯ LI: Limited information (related to sexual
health patterns) ● Allow the client to discuss issues and concerns related
◯ SS: Specific suggestions (using assessment data to to sexuality.
make appropriate suggestions) ● Be straightforward with questions in a relaxed manner.
◯ IT: Intensive therapy (more referral if needed) (“Are you, or have you been, concerned about sexual
functioning since your surgery?”)
OTHER FACTORS TO CONSIDER INCLUDE ● As the client to describe factors that in uence
● Cultural background
sexual desire.
● Quality of relationships ● Educate clients about enhancing sexual health.
● Coping mechanisms helpful in the past ● Determine the client’s current knowledge base
● Evaluation of self-worth
regarding sexuality, and provide developmentally-
appropriate education (contraception, prevention of
sexually transmitted infections, immunizations). Teach
ways to make sexual activity safer (barrier methods,
including condoms or dental dams).
● Incorporate knowledge from nursing and other
disciplines in understanding sexuality.
● Acute care: Increase awareness by introducing or
clarifying information and referring the client for
counseling if necessary.
● Inform the client of available resources and
support groups.
● Never assume that sexual function is not a concern.
● Discuss alternative means of sexual expression
(hugging, cuddling) if the client experiences a change in
body functioning or structure.
190 CHAPTER 34 SELF-CONCEPT AND SEXUALITY CONTENT MASTERY SERIES

1. A nurse in an ambulatory care clinic is caring for a 4. A nurse is caring for a client who is recovering
client who had a mastectomy 6 months ago. The from a myocardial infarction and a cardiac
client tells the nurse that there has been a decreased catheterization. The client states, “I am concerned
desire for sexual relations since the surgery, that things might be a little, you know, ‘different’
stating, “My body is so different now.” Which of with my partner when I get home.” Which of the
the following responses should the nurse make? following statements should the nurse make?
A. “Really, you look just fine to me. There’s A. “Sounds like something you should discuss
no need to feel undesirable.” with them when you get home.”
B. “I’m interested in finding out more B. “It sounds like you are concerned about sexual
about how your body feels to you.” functioning. Let’s discuss your concerns.”
C. “Consider an afternoon at a spa. A facial C. “Oh, I wouldn’t be too concerned. Things
will make you feel more attractive.” will be fine as soon as we get you home.”
D. “It’s still too soon to expect to feel D. “Just make sure you take your medication
normal. Give it a little more time.” as directed, and you should be fine.”
2. A nurse is caring for a group of clients on a 5. A nurse is teaching a group of clients how to
medical-surgical unit. Which of the following care for their colostomies. Which of the following
clients are at increased risk for body-image statements indicates an issue with self-concept?
disturbances? (Select all that apply.) A. “I was having difficulty with attaching the appliance
A. A client who had a laparoscopic appendectomy at first, but my partner was able to help.”
B. A client who had a mastectomy B. “I’ll never be able to care for this at home.
C. A client who had a left above-the-knee amputation Can’t you just send a nurse to the house?”
D. A client who had a cardiac catheterization C. “I met a neighbor who also has a colostomy,
E. A client who had a stroke with and they taught me a few things.”
right-sided hemiplegia D. “It can take me a while to get the hang of
this. I have to admit, I am pretty nervous.”
3. A nurse is caring for a client who is 3 days postoperative

following a below-the-knee amputation as a result of a
motor-vehicle crash. Which of the following statements
indicates that the client has a distorted body image?
A. “I’ll be able to function exactly as
I did before the accident.”
B. “I just can’t stop crying.”
C. “I am so mad at that guy who hit
us. I wish he lost a leg.”
D. “I don’t even want to look at my leg.
You can check the dressing.”

A nurse manager is reviewing self-concept assessment
findings with their staff. Use the ATI Active Learning
Template: System Disorder to complete this item.
EXPECTED FINDINGS: List at least six.
FUNDAMENTALS FOR NURSING CHAPTER 34 SELF-CONCEPT AND SEXUALITY 191

1. A. Telling the client they look fine is using the nontherapeutic Using the ATI Active Learning Template: System Disorder
communication technique of giving an opinion. Assuming
EXPECTED FINDINGS
the client feels undesirable is using the nontherapeutic
communication technique of interpreting.
●
Cultural background
B. CORRECT: Showing interest in the client is applying
●
Quality of relationships
the therapeutic communication technique of offering ●
Feelings related to recent body image changes,
self. Asking more about how the client feels is self-concept, and issues of sexuality
applying the therapeutic communication technique ●
Coping mechanisms used in the past
of encouraging a description of perception. ●
Expectations
C. Suggesting a facial is using the nontherapeutic ●
Posture
communication technique of giving advice. ●
Appearance
D. Telling the client it is too soon to feel normal ●
Demeanor
and to give it more time is belittling the client’s
feelings and giving false reassurance.
●
Eye contact
●
Grooming
NCLEX Connection: Psychosocial Integrity, Coping Mechanisms
®
●
Unusual behavior
2. A. According to the concept of body image, an
appendectomy would not place a client at high
risk for a body-image disturbance.
B. CORRECT: Having a mastectomy involves a change
in the physical appearance and can lead to body-
image disturbances related to sexuality.
C. CORRECT: Having an above-the-knee amputation involves a
change in physical appearance and can lead to body-image
disturbances related to function, health, and strength.
D. Depending on the prognosis postcatheterization,
the client can have some limitations. However, in
general, a cardiac catheterization would not place a
client at high risk for a body-image disturbance.
E. CORRECT: Having right-sided hemiplegia involves a
change in physical appearance and can lead to body-image
disturbances related to function, health, and strength.
3. A. Denial is a normal and expected reaction

when adjusting to body changes.
B. Depression and sadness are normal and expected
reactions when adjusting to body changes.
C. Anger is a normal and expected reaction
when adjusting to body changes.
D. CORRECT: Refusing to look at the leg or the
dressing indicates that the client is having difficulty
acknowledging the fact that the leg has been amputated.
This would imply a distorted body image.
4. A. Allow the client to discuss issues and concerns related

to sexuality and not dismiss their concerns.
B. CORRECT: Acknowledge and allow the client to discuss
their concerns regarding sexual functioning.
C. Do not give the client false reassurance. The client has valid
concerns. This statement is dismissing the client’s feelings.
D. This statement is not allowing the client to express their
feelings and is displaying false reassurance, which is
inappropriate because the client has valid concerns.
5. A. Although the client was having difficulty at first,

the client expressed how resources would be
used, resulting in a positive outcome, and does
not show signs of self-concept issues.
B. CORRECT: This client is displaying a lack of interest in
learning how to care for the colostomy and preferring
dependence on others to perform the care. Suspect
issues with self-concept with this client.
C. This client is displaying a positive self-concept by
reaching out and using resources to learn additional
information regarding the colostomy.
D. Expression of feelings is an indication of a positive
self-concept even if the client admits to anxiety or
hesitance about caring for the colostomy.
192 CHAPTER 34 SELF-CONCEPT AND SEXUALITY CONTENT MASTERY SERIES

CHAPTER 35
UNIT 3 PSYCHOSOCIAL INTEGRITY ● When exposed to a new culture, individuals can undergo
Cultural the process of acculturation and adopt some of the cultural

CHAPTER 35 practices of the predominant group. The individual might
and Spiritual adopt the predominant culture and form a new cultural

identity through the process of assimilation.
Nursing Care ● Indi iduals are multicultural, or in uenced by more

than one cultural group, adopting preferences and
shared values from more than one origin.
The study of culture includes understanding general
Cultural and spiritual backgrounds and belief
●
facts about cultural groups. Avoid stereotyping behavior,

systems can vary widely among clients. which assumes that group generalizations are true for
each individual in the group.
Individuals and families might identify with more
than one cultural or spiritual group, and choose EVOLUTION OF CULTURE
whether to adhere to the traditions, values, and Culture evolves as the following.
practices for the groups they are connected to. ● Knowledge
Values
Transcultural nursing involves learning about and
●
◯ Values guide decision-making and behavior. For
comparing cultures in order to provide care that example, if health promotion and maintenance are
valued, monthly breast self-examinations are done.
aligns with cultural patterns, beliefs, and values. ◯ Values develop unconsciously during childhood.
Beliefs
Spirituality relates to whatever an individual uses
●
● Morals and law

or does for self-discovery, coping, and health ● Customs and habits
maintenance. Spirituality is personal and subjective.

CULTURALLY RESPONSIVE NURSING CARE
CULTURE ● Culturally responsive nursing care involves the delivery
of care that transcends cultural boundaries and
Culture involves the similarities shared among members
considers a client s cultural beliefs as they affect health,
of a group. These similarities include ways of thinking
illness, and lifestyle. By encouraging client decision-
(values, norms, beliefs about health and illness), language
making, the nurse fosters respect and promotes sensitive
and communication, and customs (art, dress, music).
and effecti e care. The client s needs are met, and the
Culture is transmitted generationally (heritage) or across
client is more likely to adhere to the treatment plan.
groups. Cultural groups can be linked by a common ● Within the context of culturally responsive nursing care
ethnicity, race, nationality, language, religion, location,
is terminology that describes how nurses approach
sexual orientation, class, or gender.
clients’ cultures.
● Ethnicity (the shared identity, bond, or kinship people ◯ Cultural awareness involves self-awareness for the
feel with their country of birth or place of ancestral
nurse, examining personal attitudes related to various
origin affects culture.
aspects of culture, to identify possible bias.
● Race has traditionally been linked to biological or ◯ Cultural sensitivity means that nurses are
genetic traits, or shared origin or background. While
knowledgeable about the cultures prevalent in their
genetic discoveries have shown that races cannot be
area of practice.
identi ed scienti cally, race continues to be used as a ◯ Cultural appropriateness means that nurses apply their
way to identify groups of individuals (when individuals
knowledge of a client’s culture to their care delivery.
self-identify on the U. S. census). ◯ Culturally competence means that nurses understand
● Culture in uences health beliefs health practices and
and address the entire cultural context of each client
manifestations of, responses to, and treatment of illness or
within the realm of the care they deliver. Competence
injury. Culture evolves over time and is shared by members
is developed over a lifetime as the nurse continues to
of a group who have similar needs and life experiences.
attain knowledge and develop cultural skill through
● Many cultures consider the mind-body-spirit to be a
varied client encounters.
single entity. Therefore, no distinction is made between ◯ Cultural imposition is similar to ethnocentrism and
physical and mental illness.
occurs when a nurse imposes the rules of their culture
● Although everyone within a culture shares cultural
onto another person. This is sometimes referred to a

values, diversity exists, forming subcultures. These
cultural blindness.
subcultures can be formed by factors (shared social ● Accommodate each client’s cultural beliefs and values
values, ethnicity, or occupation).
hene er possible, unless they are in direct con ict
with essential health practices. The goal is to provide
culturally competent care.
FUNDAMENTALS FOR NURSING CHAPTER 35 CULTURAL AND SPIRITUAL NURSING CARE 193

● National Culturally and Linguistically Appropriate SPIRITUALITY
Services (CLAS) should guide health care delivery. Care
Spirituality can play an important role in clients’ abilities
must be respectful and effecti e for clients of any
to achieve balance in life, maintain health, seek health
language or culture. This includes the following.
care, and deal with illness and injury. It is associated
◯ Providing language assistance to clients who have
with an awareness of inner self, belief of a higher being,

communication needs limited nglish pro ciency
or some connection to a purpose greater than oneself.
◯ Informing clients of language services verbally and
Hope, faith, and transcendence are integral components of

in writing
spirituality.
◯ Providing competent, trained interpreters
◯ Giving the client learning materials (videos, handouts) Connectedness helps clients nd comfort and
and having signs in all languages common among the empowerment despite life’s stressors.
population members in the area the facility serves ◯ Intrapersonal: within one’s self
◯ Interpersonal: with others and the environment
◯ Transpersonal: with an unseen higher power
BARRIERS TO CULTURALLY
RESPONSIVE NURSING CARE Faith is a belief in something or a relationship with
a higher po er. aith can be de ned by a culture or
● Language, communication, and perception of
a religion.
time differences.
● Culturally inappropriate tests and tools that lead Hope is a concept that includes anticipation and optimism
to misdiagnosis. and provides comfort during times of crisis.
● Ethnic variations in drug metabolism related to genetics.
Transcendence is the belief in a force outside the person
● Ethnocentrism is the belief that one’s culture is
and material world that is superior.
superior to others. Ethnocentric ideas interfere with the
provision of cultural nursing care. Self-transcendence is an authentic connection with the
● Poor access to health care. Low-income and middle- inner self.
income groups have less accessibility to health care ● Spiritual well-being can include personal connectedness
compared to high-income groups. to a higher power and connections with others.
● Prejudice involves making assumptions without full ● When faced with health care issues (acute, chronic, or
information, which often results in taking wrong life limiting illness , clients often nd ays to cope
actions. A nurse might assume a client does not need through the use of spiritual practices. Clients who
nancial assistance and not offer help, or assume a begin to question their belief systems and are unable to
client is uneducated and speak to the client in a way nd support from those belief systems can e perience
that is offensi e. spiritual distress.
● Discrimination involves unfair treatment of individuals, ● Spiritual distress is a challenge to belief systems
affecting rights and opportunities based on their or spiritual well-being. It often arises as a result of
association with a certain group. catastrophic events. The client can display hopelessness
● Health disparities, or differences in health status, ha e and decreased interactions with others.
been linked to cultural groups, including distinctions ● Nursing inter entions are directed at identi cation,
of poorer health associated with lower socioeconomic restoration, and/or reconnection of clients and families
status, older age, and minority status. These groups to spiritual strength.
often face health care disparities of reduced access to
Religion is a system of beliefs practiced outwardly to
health care.
express one’s spirituality, typically related to a particular
Example: Clients related to Amish or Mennonite form of worship, sect, or spiritual denomination.
groups are likely to not have health insurance. Spirituality can include religious practices, but does not
always.
● Religious practice can include reading sacred texts,
having sacred symbols, prayer, meditation, connecting
with spiritual leaders and a community of other
followers, and observing holy days.
● Religions often dictate guidelines related to dress, diet,
modesty, birth, and death, although individuals from
the same religion might adhere to different practices
from each other.
SPIRITUAL RITUALS AND OBSERVANCES

Spiritual and religious groups often adopt practices related
to health care, birth, death, diet, and other rituals. Always
ask the client about personal adherence to group practices
and do not make assumptions.
194 CHAPTER 35 CULTURAL AND SPIRITUAL NURSING CARE CONTENT MASTERY SERIES

Buddhism Sikhism
HEALTH AND ILLNESS HEALTH AND ILLNESS
● Health care beliefs often correlate ● Health care beliefs often correlate with modern
with modern medical science. medical science.
● Illness can be the result of nonhuman ● Female clients often prefer to be examined by females.
spirits invading the body. ● Having to remove undergarments can be very
● Do not typically allow euthanasia. distressing for some clients.
● ight not ta e time off or a ay from
RITUALS
responsibilities when ill. ● Clients can use religious symbols or devotional prayer.
● Maintain good health through good deeds. ● Clients might not permit cutting or shaving of the hair.
● Medications can be seen as harmful
because they are chemical substances.
Navajo
● Can refer treatment by a health care
worker of the same gender. HEALTH AND ILLNESS
● Might decline bovine-derived medications. ● Health concepts can be part of humanity and relate to
the place of humans in the universe.
DIETARY RITUALS ● Clients often view health holistically.
● Some clients are vegetarians. ● Clients might adhere more to wellness interventions
● Some clients avoid alcohol and tobacco.
than disease prevention.
● Clients might fast on holy days. ● Clients can attempt to correct poor health using
DEATH RITUALS symbols, stories, songs, rituals, prayers, and paintings
● Brain death might not be considered (a practice known as blessingway).
as a requirement for death.
● Death is seen as a stage of life and can advocate Hinduism
withdrawal of life sustaining measures.
Views can vary across castes.
● Many prefer for death to occur at home.
● The body is prepared by a male. HEALTH AND ILLNESS
● Mourners are quiet and peaceful, and avoid touching the ● Health care beliefs often correlate
body but might touch the head and stand nearby, praying. with modern medical science.
● Many use cremation. ● Illness can be a cause of past sins.
● Decisions might be made by the community,
Christianity especially by senior family. Females defer to
a spouse or family to make decisions.
There are many denominations of Christianity and ● Life-prolonging therapies might be discouraged.
varied beliefs. ● Clients might decline porcine-derived medications.
HEALTH AND ILLNESS
DIETARY RITUALS: Some clients are vegetarians due to
● Health care beliefs often correlate
an adherence to the concept of ahimsa (nonviolence as
with modern medical science.
applicable to food).
● Clients often use alternative or complementary practices.
● There is a common belief in faith healing; can DEATH RITUALS
use “laying on of hands” during prayer. ● Clients might ant to lie on the oor hile
● Clients might wish to anoint a client who is ill or dying, or the body might be placed on the oor
near death (Catholicism; Sacrament of the Sick). following death with the head facing north.
● Organ donation is generally allowed. ● Clients prepare for death, when possible,
● Many believe in health maintenance. with prayer and meditations.
● Care of the body should be by those of the same gender.
DIETARY RITUALS ● Cremation can be used as a way to
● ome a oid alcohol, tobacco, and caffeine.
purify the body following death.
● Clients might fast during Lent.
RELIGIOUS RITUALS
DEATH RITUALS: Most believe in continuing hydration and ● Clients can use rituals for purity and prayer.
nutrition therapies as long as possible. ● Clients can use amulets or other symbols.
RELIGIOUS RITUALS
● Some clients practice Holy Communion.
● Clients often have visits from spiritual leaders (clergy).

Islam Judaism
HEALTH AND ILLNESS HEALTH AND ILLNESS
● Clients’ view of health can be fatalistic, at times. ● Clients often in balance between God and medicine.
● Clients often have a belief in faith healing. ● Clients can have an obligation to avoid
● Clients can avoid discussions about death, and see death substance use and stay healthy.
as predetermined. ● Clients might refuse treatment on the Sabbath.
● Clients might permit withdrawal of life-support ● Clients can feel an obligation to visit the ill.
measures but continue hydration and nutrition therapies. ● Euthanasia is often not permitted.
● Clients often avoid euthanasia and organ transplantation. ● Life support measures can be discouraged. Views vary
● Spirituality is often connected to health. regarding hydration and nutrition at the end of life.
● Clients often make decisions within families, and might
BIRTH RITUALS AND HEALTH CARE DECISIONS
prefer for new information to be discussed in this manner. ● On the eighth day after birth, males are
● Clients can view pain as cleansing.
usually circumcised.
● Clients might decline porcine-derived medications. ● Observing Sabbath is often important.
DIETARY RITUALS ● It is often an obligation to visit the sick.
● Clients often avoid alcohol and pork.
DIETARY RITUALS: Some clients practice a kosher diet.
● Clients can fast during Ramadan.
DEATH RITUALS
DEATH RITUALS ● Someone often stays with the body.
● The face can be turned towards Mecca. ● Orthodox clients often have the body prepared by the
● The body can be washed and wrapped in a cloth by
Jewish Burial Society and do not typically permit autopsy.
someone of the same gender. The client might wish for ● Burial often occurs within 24 hr, unless this is during
a person from the mosque to do this.
the Sabbath.
● A prayer is often said. ● Cremation and embalming are generally not permitted.
● Autopsy might not be permitted.
Burial is often preferred to cremation.
Mormonism
●
● Clients often value having loved ones close by.

HEALTH AND ILLNESS: Many clients avoid alcohol, tobacco
RELIGIOUS RITUALS
use, and caffeine.
● Clients might practice Five Pillars of Islam.
● Clients often nd strength in group prayer. BIRTH RITUALS AND HEALTH CARE DECISIONS: Children
● any clients pray e times a day facing ecca. are usually baptized at age 8 by immersion.
DIETARY RITUALS: Many clients avoid alcohol, tobacco,

Jehovah’s Witnesses
and caffeine.
HEALTH AND ILLNESS: Clients might not accept blood
DEATH RITUALS
transfusions, even in life-threatening situations. ● Clients might recite a confessional or affirmation near
DIETARY RITUALS: Clients might avoid foods having or death (the Shema).
prepared with blood. ● The dying client is usually not left alone.
● Last rites can include wearing temple clothes for burial.
DEATH RITUALS: Clients can choose burial or cremation. ● Burial is often preferred.
RITUALS
● Clients often have visit from spiritual leaders (local
elders) for blessing.
● Clients might prefer to wear temple undergarments.
Christian Science
HEALTH AND ILLNESS: Clients often rely on Christian
Science practitioners, avoiding Western medicine and
interventions.

ASSESSMENT/DATA COLLECTION OTHER QUESTIONS
● When did the problem start?
To meet a client s cultural needs, a nurse must rst perform ● What does the illness do to you? How does it work?
a cultural assessment to identify those needs. ● What makes it better or worse?
Cultural background and acculturation ● How severe is the illness?
● What treatments have you tried? How do you think it
Example: The client was born in Central America
should be treated?
and has been a resident of New York for 2 years. ● What are the chief problems the illness has caused you?
Health and wellness beliefs/practices ● What do you fear most about the illness?
Example: The client relies on folk medicine to treat

or prevent illness. Folk practices are those that NONVERBAL BEHAVIOR
are linked to tradition rather than scientific basis. ● Understand that nonverbal behaviors vary among
Family patterns cultures.
● Assess the client s gestures, ocal tones, and in ections.
Example: The client is from a patriarchal
Observing the client’s interactions with visitors
culture where the oldest male family member
can provide the nurse cues to the client’s nonverbal
makes decisions for all family members.
communication style.
Verbal and nonverbal communication ● Be aware of personal nonverbal behaviors, and consider
how the client might interpret them.
Example: Within the client’s culture, it is
disrespectful to make direct eye contact.
Tone of voice
Space and time orientation
ASIAN: Many use a soft tone of voice to convey respect.
Example: Within the client’s culture, little importance
ITALIAN AND MIDDLE EASTERN: Many use a loud
is placed on how past behavior affects future health.
tone of voice.
Nutritional patterns
Eye movement
Example: The client believes that some
foods have healing properties. Most Western cultures value direct eye contact as an
indication of attentiveness and respect, as well as self-
Meaning of pain
con dence. Lac of eye contact can be interpreted as an
Example: Within the client’s culture, pain is indication of possible mental illness, guilts or secrecy.
viewed as a punishment for misbehavior or sin.
Other cultures consider direct eye contact an invasion of
Death rituals privacy, or disrespect. Eye contact might be intermittent.
Example: Within the client’s Directing the gaze of the eyes downward towards a client
culture, suicide is acceptable. can be interpreted as demonstrating authority; sitting and
looking at the client at the same eye level is more respectful.
Care of ill family members
Example: The client expects the entire family to Facial expression

remain at the client’s bedside during an illness.
Some cultures are more stoic, showing few emotions as
Health literacy facial expressions. In others, facial expressions are used
as a main way to convey feelings, or to hide feelings. The
Example: The client has access to health
amount of emotion displayed through facial expression
information, but does not understand it. This
can vary, depending on how well the client knows the
decreases the client’s likelihood of adopting
individual with whom they are interacting.
scientific health practices or adhering
to provider prescribed treatment. Be aware of personal facial expressions and how the client
might interpret them.
Perform the cultural assessment in a language
that is common to both nurse and client, or use a
Touch
facility-approved medical interpreter. Inform the
interpreter of questions that might be asked. Cultural values dictate what forms of touch are acceptable.
Western cultures often value a strong handshake, while in
other cultures only speci c people are allo ed to touch.
4 C’S CULTURAL ASSESSMENT
Always ask the client’s permission before touching them.
Nurses can use the 4 C’s of Culture by Slavin, Galanti, and
Watch to see how the client reacts to touch.
Kuo (2012).
● What do you call the problem you are having now?
● How do you cope with the problem?
● What are your concerns regarding the problem?
● What do you think caused the problem?

Use of space SPIRITUAL ASSESSMENT
Some cultures value a large amount of personal space while ● A spiritual assessment includes several components.
others value closeness. The amount of space acceptable can ◯ Primary: self re ection nurses on personal beliefs
vary with the type of interaction. Try to mirror the client’s and spirituality
use of distance during interactions, and get consent from ◯ Initial: identifying the client’s religion, if any
the client before moving close into the body. ◯ Focused: ongoing, as nurses identify the clients at
risk for spiritual distress

Use of silence ● Spirituality is a highly subjective area requiring the
development of rapport and trust among the client,
Some cultures value silence, sometimes for long periods of
family, and provider.
times. It can indicate respect, agreement, provide privacy
for the other individual. In some cultures, interrupting ASSESSMENT OF THE CLIENT
someone else while speaking is acceptable. ● Faith/beliefs
● Perception of life and self-responsibility
Use of the body ● Satisfaction with life
● Culture
Posture and gesturing can vary across cultures. ● Fellowship and the client’s perceived
● Avoid using hand symbols (a thumbs-up or “okay” sign)
place in the community

unless you have seen the client make the gestures, as they ● Rituals and practices
could be interpreted offensi ely by the client. ● Incorporation of spirituality within profession or workplace
● In some cultures, an erect posture indicates self ● Client expectations for health care in relation
con dence a more slouched posture could be
to spirituality (traditional vs. alternative
interpreted as the opposite or as an indication of a
paths [shamans, priests, prayer])
physical problem. Observe posture, and consider the
client’s culture before making assumptions. Use the FICA tool to guide a spiritual assessment for
● Observe the client’s body posture when lying, sitting the client.
and interacting with friends.
Faith or beliefs
Example: “Can you tell me what gives

METHODS FOR ASSESSING CULTURE you a sense of purpose, or what guides
Observation: Study the client and their environment for your life and how you handle it.”
examples of cultural relevance.
Implications, importance and influence
Interview
Example: “How do your beliefs affect how
● Establish a therapeutic relationship with the client. This
you make life decisions? How do these
can be hindered by misinterpretations of communication.
beliefs impact your current situation.”
Nurses should develop transcultural
communication skills. Community
● Use focused, open-ended, nonjudgmental questions.
Example: “Is there a group of people you meet or
● Paraphrasing the client’s communication will
interact with regularly, who share these beliefs?”
decrease misinterpretations.
Address
Participation
● Become involved in culturally-related activities outside of Example: “How would you like these personal
the health care setting. beliefs to affect your health care? Will it
● Maintain awareness of population demographics (review affect how you make treatment choices?”
census data).
◯ Number of members in a practice area
◯ Average educational and economic levels
◯ Typical occupations
◯ Commonly-practiced religious spiritual beliefs

◯ Prevalence of illnesses/health issues
◯ Most commonly held health, wellness, illness, and
death beliefs
◯ Social organization

PATIENT-CENTERED CARE Family patterns and gender roles
● Care should promote health equity, or the best health for Communicate with and include the person who has the
all individuals and groups. authority to make decisions in the family. Ask about the
● Always consider the client’s preference, and accommodate roles of members of the family.
that as much as possible when providing care.
● The LEARN assessment tool is a common communication Culture and life transitions
tool used to promote culturally competent care.
Assist families as they mark rituals (rites of passage) that
◯ Listen actively to the client describing the current
symbolize cultural values. Common events expressed with
problem. Use empathy and try to understand the
cultural rituals are puberty, pregnancy, childbirth, dying,
client’s perception.
and death.
◯ Explain the health care professional’s perception of
the problem, which can be cultural, psychological,
Repatterning
spiritual, or physiological.
◯ Acknowledge differences and similarities bet een the Changing one s lifestyle for a ne and bene cial one
professional’s and client’s perceptions. ● Accommodate clients’ cultural beliefs and values as
◯ Recommend treatments, including the client’s choices. much as possible.

◯ Negotiate with the client to involve medical ● Attempt to repattern that belief to one that is
recommendations and client preference. compatible with health promotion, when a cultural
value or behavior hinders a client’s health and wellness.
Death rituals ● Plan and implement appropriate interventions, with
no ledge of cultural differences and respect for the
Death rituals vary among cultures. Facilitate practices and
client and family.
offer appropriate spiritual care hene er possible.
Using an interpreter
Pain
The Joint Commission requires that an interpreter
● Recognize that how clients react to, display, and relieve
be available in health care facilities in the client’s
pain varies by culture.
language (2010).
● Use an alternative to the pain scale (0 to 10) because it ● Use only a facility-approved medical interpreter. Do not
might not appropriately re ect pain for all cultures.
use the client’s family or friends, or a nondesignated
● plore religious beliefs that in uence the meaning of pain.
employee to interpret.
Inform the interpreter about the reason for and the type
Nutrition
●
of questions that will be asked, the expected response

● Provide food choices and preparation consistent with (brief or detailed), and with whom to converse.
cultural beliefs. ● Allow time for the interpreter and the family to be
● When possible, allow the client’s family/caregiver to introduced and become acquainted before starting
bring in food (as long as it meets the client’s dietary the interview.
restrictions), and allow clients to consume foods that ● Speak clearly and slowly; avoid using metaphors.
they view as a treatment for illness. ● Direct the questions to the client, not to the interpreter.
● Communicate ethnicity-related food intolerances/ ● Observe the client’s verbal and nonverbal behaviors
allergies to the dietary staff. during the conversation.
● Get feedback from the client throughout the conversation.
Communication ● Do not interrupt the interpreter, the client, or the family
as they talk.
● Improve nurse-client communication when cultural ● If the conversation doesn’t seem to go well, stop the
variations exist by establishing rapport with the client
conversation and address it with the interpreter.
and family.
Use facility-approved interpreters when the
Communicating with clients who have limited
●
communication barrier is signi cant enough to affect the

English proficiency
exchange of information between the nurse and the client.
● Use nonverbal communication with caution because it can ● Use gestures to increase understanding, recalling the
ha e a different meaning for the client than for the nurse. client’s nonverbal communication values.
● Apologize if cultural traditions or beliefs are violated. ● Speak slowly at normal volume, avoiding abbreviations
● Explanation: encourage the client to express their and slang. Use layman’s terminology.
perception of the problem. ● Determine client understanding throughout
● Treatment: discuss the types of approach or treatment the conversation. Smiling and nodding can be
the client tried. demonstrations of respect, not understanding.
● Healers: alternate type of practitioners sought ● Use printed materials suited to the client’s level
for treatment. of understanding.
● Negotiate: options are mutually agreed upon.
● Intervention: incorporate a possible alternate treatment.
● Collaboration: include client, family, health team
members, healers, and available resources.

Addressing spirituality ● Establish a caring presence in being with the client and
family rather than merely performing tasks for them.
● Identify the client’s perception of the existence of a ● Support all healing relationships.
higher power. ◯ Using a holistic approach to care: seeing the large
● Facilitate growth in the client’s abilities to connect with
picture for the client
a higher power. ◯ sing client identi ed spiritual resources and needs
● Look for environmental, behavioral, or verbal cues to ● Be aware of diet therapies included in spiritual beliefs.
assess a client’s spirituality (a sacred text at bedside ● Support religious rituals.
[Bible, Quran, Rig Veda], praying at bedtime, or talking ◯ Icons
about God, gods, or other higher power). ◯ Statues

● Assist the client to feel connected or reconnected to a ◯ Prayer rugs
higher power. ◯ Devotional readings

◯ Allow time and/or resources for the practice of
◯ Music
religious rituals. ● Support restorative care.

◯ Provide privacy for prayer, meditation, or the reading
◯ Prayer
of religious materials. ◯ Meditation

● Use facility’s pastoral care department if appropriate. ◯ Grief work
● Facilitate development of a positive outcome in a ● Evaluation of care is ongoing and continuous, with a
particular situation.
need for e ibility as the client and family process the
● Provide stability for the client experiencing a
current crisis through their spiritual identity.
dysfunctional spiritual mood.

1. A nurse is using an interpreter to communicate 4. A nurse is discussing the plan of care for a client
with a client. Which of the following actions should who reports following Islamic practices. Which of
the nurse use when communicating with a client the following statements by the nurse indicates
and family members? (Select all that apply.) culturally responsive care to the client?
A. Talk to the interpreter about the family A. “I will make sure the menu
while the family is in the room. includes kosher options.”
B. Determine client understanding several B. “I will ask the client if they want to schedule
times during the conversation. some times to pray during the day.”
C. Look at the interpreter when C. “I will avoid discussing care when
asking the family questions. the client’s family is around.”
D. Use lay terms if possible. D. “I will make sure daily communion
E. Do not interrupt the interpreter is available for this client.”
and the family as they talk.
5. A nurse is caring for a client who tells the nurse
2. A nurse is caring for two clients who report that based on religious values and mandates,
following the same religion. Which of the a blood transfusion is not an acceptable
following information should the nurse consider treatment option. Which of the following
when planning care for these clients? responses should the nurse make?
A. Members of the same religion share A. “I believe in this case you should really make an
similar feelings about their religion. exception and accept the blood transfusion.”
B. A shared religious background generates B. “I know your family would approve of your
mutual regard for one another. decision to have a blood transfusion.”
C. The same religious beliefs can C. “Why does your religion mandate that you
influence individuals differently. cannot receive any blood transfusions?”
D. The nurse and client should discuss the D. “Let’s discuss the necessity for a blood
differences and commonalities in their beliefs. transfusion with your religious and spiritual
leaders and come to a reasonable solution.”
3. A nurse enters the room of a client who is crying while

reading from a religious book and asks to be left alone.
Which of the following actions should the nurse take?
A. Contact the hospital’s spiritual services.
B. Ask what is making the client cry.
C. Ensure no visitors or staff enter the
room for a short time period.
D. Turn on the television for a distraction.

A nurse at a clinic is talking with a client and family.
The client has a new diagnosis of diabetes mellitus
type 2. Use the ATI Active Learning Template:
RELATED CONTENT: List the components

of the LEARN assessment tool.
NURSING INTERVENTIONS: List possible

statements the nurse could make during the
interview using the LEARN assessment tool.

1. A. Talking to the interpreter about the family while the Using the ATI Active Learning Template: Basic Concept
family is in the room would hinder communication RELATED CONTENT
between the family and the nurse/interpreter. ●
Listen actively to the client describing the problem,
B. CORRECT: Determining client understanding throughout the
trying to understand the client’s perception.
conversation ensures the client comprehends the information
and the nurse will know how to direct the conversation.
●
Explain the health care professional’s perception of the problem.
C. Looking at the interpreter instead of the family while ●
Acknowledge differences and similarities between the perceptions.
the family is in the room would hinder communication ●
Recommend treatments, including the client’s choices.
between the family and the nurse/interpreter. ●
Negotiate the treatment plan with the client.
D. CORRECT: Using lay terms will promote
effective communication between the
family and the nurse/interpreter.
●
Listen
E. CORRECT: Not interrupting will promote ”Tell me what you think is going on in your body.”
◯
effective communication between the ”What do you think caused you to feel the way you are feeling?”
◯
family and the nurse/interpreter. ●

Explain: ”We use scientific tests to measure the sugar
NCLEX® Connection: Psychosocial Integrity, level in your body. The tests show that the levels are too
Cultural Awareness/Cultural Influences on Health high, which makes you lose extra fluid and feel tired.”
●
Acknowledge
”Our way of understanding the cause of your illness is different.”
◯
2. A. It would be stereotyping to assume that all members ”Even though we think about your illness in different
◯
of a specific religion had the same beliefs. Feelings ways, we both want you to feel better.”
and ideas about religion and spiritual matters can be ●
Recommend
quite diverse, even within a specific culture. “The provider would like for someone to check your
◯
B. Mutual regard does not necessarily follow blood sugar level four times a day. Would you prefer
a shared religious background. to learn to do this, or someone in your family?”
C. CORRECT: Members of any particular religion should
“This condition means you might have to change what you
◯
be assessed for individual feelings and ideas.

eat. Please tell me about what and how often you eat.”
D. Due to boundary issues, the nurse’s beliefs are
not part of a therapeutic client relationship. It is
●
Negotiate
the client’s beliefs that are important. “You would like to continue having a glass of alcohol at bedtime,
◯
so let’s find ways we can remove calories from your dinner.”

“If you do not want to have to go to a hospital for a
◯
Religious Influences on Health

class to learn about your illness, we could arrange
for someone to come to your home instead.”
3. A. Contacting the hospital’s spiritual services presumes NCLEX® Connection: Psychosocial Integrity,
there is a problem and should not be done Cultural Awareness/Cultural Influences on Health
without asking the client’s permission.
B. Asking the client about the crying could be interpreted as
discounting or being disrespectful of the client’s beliefs.
C. CORRECT: Providing privacy and time for the reading of
religious materials supports the client’s spiritual health.
D. Providing a distraction could be interpreted as discounting
or being disrespectful of the client’s beliefs.
Religious Influences on Health
4. A. Jewish culture, not Islam, requires food to be kosher.

B. CORRECT: Islamic practices include praying five times
per day. Work with the client to establish a schedule for
the day, noting which times the client prefers to pray, and
scheduling treatments around those times when possible.
C. American culture appreciates direct eye contact. In
Middle Eastern cultures, direct eye contact can be
perceived as rude, hostile, or sexually aggressive.
D. Daily communion is a ritual to consider for a
Catholic client, not for a Muslim client.
Cultural Awareness/Cultural Influences on Health
5. A. Do not impose an opinion onto the client and ask

them to go against their religious beliefs.
B. Do not make an assumption on behalf of the client’s family.
C. Asking a “why” question can appear
judgmental or accusatory.
D. CORRECT: Involving the client’s religious and spiritual
leaders is a culturally responsive action at this point.
Alternative forms of blood products can be discussed,
and a plan reasonable to all can be reached.
Cultural Awareness/Cultural Influences on Health

CHAPTER 36
UNIT 3 PSYCHOSOCIAL INTEGRITY THEORIES OF GRIEF
CHAPTER 36 Grief, Loss, and KÜBLER-ROSS MODEL
Palliative Care Denial: The client has difficulty belie ing in an e pected
or actual loss.
Clients experience loss in many aspects of their Anger: The client directs anger toward the self, others, a
deity, objects, or the current circumstances.
lives. Grief is the inner emotional response to
Bargaining: The client negotiates for more time or a cure.
loss and is exhibited through thoughts, feelings,
Depression: The client is overwhelmingly saddened by the
and behaviors. Bereavement includes both
inability to change the situation.
grief and mourning (the outward display of
Acceptance: The client acknowledges what is happening
loss) as the individual deals with the death of a and plans for the future by moving forward.
significant individual. Clients might not experience these

stages in order, and the length of each
Palliative or end-of-life care is an important stage varies from person to person.
aspect of nursing care and attempts to meet
the client’s physical, spiritual, and psychosocial FACTORS INFLUENCING LOSS,
needs. End-of-life issues include decision-making GRIEF, AND COPING ABILITY
Current stage of development
in a highly stressful time during which nurses
●
● Gender
must consider the desires of the client and the ● Interpersonal relationships, social support networks
Type, signi cance of the loss
family. Decisions are shared with other health care
●
● Culture, ethnicity
personnel for a smooth transition during this time ● Spiritual, religious beliefs and practices
Prior experience with loss
of stress, grief, and bereavement.
●
● Socioeconomic status
● Coping strategies
ADVANCE DIRECTIVES FACTORS THAT CAN INCREASE AN INDIVIDUAL’S RISK FOR
Advance directives: Legal documents that direct DYSFUNCTIONAL GRIEVING
end-of-life issues ● Being exceptionally dependent on the deceased
● Living will: Directive documents for medical treatment ● Unexpected death at a young age, through violence or in
per clients’ wishes a socially unacceptable manner
● Health care proxy (also known as durable power of ● Inadequate coping skills, lack of social supports
attorney for health care): A document that appoints ● Lack of hope or preexisting mental health issues
someone to make medical decisions when clients are no (depression, substance use disorder)
longer able to do so on their own behalf
TYPES OF LOSS ASSESSMENT/DATA COLLECTION

Necessary loss: A loss related to a change that is part of
the cycle of life and is anticipated but still can be intensely MANIFESTATIONS OF GRIEF REACTIONS
felt. This type of loss can be replaced by something
different or better. Normal grief
Actual loss: Any loss of a valued person, item, or status ● This grief is considered uncomplicated.
(loss of a job) that others can recognize ● Emotions can be negative, (anger, resentment,
withdrawal, hopelessness, and guilt) but
Perceived loss: Anything clients de ne as loss but that is
should change to acceptance with time.
not ob ious or eri able to others ● Some acceptance should be evident
Maturational or developmental loss: Any loss normally by 6 months after the loss.
expected due to the developmental processes of life. These ● Somatic complaints can include chest pain, palpitations,
losses are associated with normal life transitions and help headaches, nausea, changes in sleep patterns, and fatigue.
people develop coping skills (a child leaving home for
college).
Situational loss: Any unanticipated loss caused by an

external event (a family loses their home during tornado)
Anticipatory loss: Experienced before the loss happens
FUNDAMENTALS FOR NURSING CHAPTER 36 GRIEF, LOSS, AND PALLIATIVE CARE 203
Anticipatory grief INTERPROFESSIONAL COLLABORATION
● This grief implies the “letting go” of an object or person ● Encourage attendance at bereavement or grief
before the loss, as in a terminal illness. support groups. Provide information about available
● Individuals have the opportunity to start the grieving community resources.
process before the actual loss. ● Initiate referrals for individual psychotherapy for clients
ho ha e difficulty resol ing grief.
Complicated grief ● Ask the client whether contacting a spiritual advisor
would be acceptable, or encourage the client to do so.
● Types of complicated grief include chronic, exaggerated, ● Participate in debrie ng ith professional grief and
masked, and delayed grief.
mental health counselors.
● Complicated grief in ol es difficult progression through
the expected stages of grief.
Palliative care
● Usually, the work of grief is prolonged. The manifestations
of grief are more severe, and they can result in depression
or exacerbate a preexisting disorder. ● The nurse serves as an advocate for the client’s sense of
● The client can develop suicidal ideation, intense feelings
dignity and self-esteem by providing palliative care at
of guilt, and lowered self-esteem.
the end of life.
● Somatic complaints persist for an extended period of time. ● Goal is to learn to live fully with an incurable condition.
Palliative care improves the quality of life of clients and
Disenfranchised grief
●
their families facing end-of-life issues.

This grief entails an experienced loss that cannot be publicly ● Palliative care interventions are primarily used when
shared or is not socially acceptable (suicide and abortion). caring for clients who are dying and family members
who are grieving but can be used for any client who has
a chronic or curable illness, regardless of the stage of
NURSING INTERVENTIONS the disease process. Assessment of the client’s family is
very important as well.
Palliative care interventions focus on the relief of
FACILITATE MOURNING
●
physical manifestations (pain) as well as addressing

● Allow time for the grieving process. spiritual, emotional, and psychosocial aspects of the
● Identify expected grieving behaviors (crying, somatic client’s life.
manifestations, and anxiety). ● An interprofessional team of physicians, nurses, social
● Use therapeutic communication related to the client’s workers, physical therapists, massage therapists,
stage of grief. Name the emotion the client is feeling. For occupational therapists, music/art therapists, touch/
example, the nurse can say, “You sound as though you energy therapists, and spiritual support staff pro ide
are angry. Anger is a normal feeling for someone who has palliative care.
lost a loved one. Tell me about how you are feeling.” ● Hospice care is comprehensive care delivered in a variety
● Use active listening, open-ended questions, of settings, and can be implemented when a client is not
paraphrasing, clarifying, and summarizing, expected to live longer than 6 months. Further medical
while using therapeutic communication. care aimed toward a cure is stopped, and the focus
● Use silence and personal presence to facilitate mourning. becomes enhancing quality of life and supporting the
● Avoid communication that inhibits the open client to ard a peaceful and digni ed death.
e pression of feelings offering false reassurance,
giving advice, changing the subject, and taking
the focus away from the grieving individual). ASSESSMENT/DATA COLLECTION
● Assist the grieving individual to ● Determine the client’s sources of strength and hope.
accept the reality of the loss. ● Identify the desires and expectations of the client and
● upport efforts to mo e on in the face of the loss.
family for end-of-life care.
● Encourage the building of new relationships.
● Provide continuing support. Encourage CHARACTERISTICS OF DISCOMFORT
the support of family and friends. ● Pain
● Assess for e idence of ineffecti e coping a client refusing ● Anxiety
to leave the home months after the death of a partner). ● Restlessness
● Share information about the tasks and stages of mourning ● Dyspnea
and grieving with the client, who might not realize that ● Nausea, vomiting
feelings (anger toward the deceased) are expected. ● Dehydration
● When relating to someone who is bereaved, avoid cliches ● Diarrhea, constipation
(“They are in a better place now.”). Rather, encourage ● Urinary, fecal incontinence
the individual to share memories about the deceased. ● Inability to perform ADLs
● Provide information on available community resources.
204 CHAPTER 36 GRIEF, LOSS, AND PALLIATIVE CARE CONTENT MASTERY SERIES
MANIFESTATIONS OF APPROACHING DEATH PSYCHOSOCIAL CARE
● Decreased level of consciousness ● Use an interprofessional approach.
● Loss of muscle tone, with obvious relaxation of the face ● Provide care and foster support to the client and family.
● Labored breathing (dyspnea, apnea, Cheyne-Stokes ● Use volunteers when appropriate to provide
respirations), “death rattle”
nonmedical care.
● Touch diminished, but client is able to feel the ● Use therapeutic communication to develop and maintain
pressure of touch
and facilitate communication between the client, family,
● Mucus collecting in large airways
and the provider.
● Incontinence of bowel and/or bladder ● Facilitate the understanding of information regarding
● Mottling, cyanosis occurring with poor circulation
disease progression and treatment choices.
● Pupils no longer reactive to light ● Facilitate communication between the client, the family,
● Pulse slow and weak, blood pressure dropping
and the provider.
● Cool extremities ● Encourage the client to participate in religious or other
● Perspiration
practices that bring comfort and strength, if appropriate.
● Decreased urine output ● Assist the client in clarifying personal values in order to
● Inability to swallow
facilitate effecti e decision ma ing.
● Encourage the client to use coping mechanisms that
have worked in the past.
NURSING INTERVENTIONS ● Be sensitive to comments made in the presence of
● Promote continuity of care and communication by clients who are unconscious because hearing is the last
limiting assigned staff changes. sensation lost.
● Assist the client and family to set priorities for ● Discuss speci c concerns the client and family might
end-of-life care. ha e nancial, role changes . Initiate a social ser ices
or other referral as needed.”
PHYSICAL CARE
i e priority to controlling ndings.
PREVENTION OF ABANDONMENT
AND ISOLATION
●
● Administer medications (morphine) that manage pain,

air hunger, and anxiety. ● Prevent the fear of dying alone.
● Perform ongoing assessment to determine the ● Make your presence known by answering call lights in a
effecti eness of treatment and the need for timely manner and making frequent contact.
modi cations of the treatment plan lo er or higher ● Keep the client informed of procedure and
doses of medications). assessment times.
● anage ad erse effects of medications. ● Allow family members to stay overnight.
● Reposition the client to maintain airway patency ● Determine where the client is most comfortable (in a
and comfort. room close to the nurses’ station).
● Maintain the integrity of skin and mucous membranes. ● If the client chooses to be at home, consider moving the
● Provide caring touch (holding the client’s hand). client’s bed to a central location in the home rather than
● Provide an environment that promotes dignity and an isolated bedroom.
self-esteem.
Remove products of elimination as soon as possible to
SUPPORT FOR THE GRIEVING FAMILY
◯
maintain a clean and odor-free environment.

◯ ffer comfortable clothing. ● Suggest that family members plan visits to promote the
◯ Provide careful grooming for hair, nails, and skin. client’s rest.
◯ Encourage family members to bring in comforting ● Ensure that the family receives appropriate information
possessions to make the client feel at home. as the treatment plan changes.
● If appropriate, encourage the use of relaxation ● Provide privacy so family members have the opportunity
techniques (guided imagery and music). to communicate and express feelings among themselves
● Promote decision-making in food selection, activities, without including the client.
and health care to give the client as much control ● Determine family members’ desire to provide physical
as possible. care while maintaining awareness of possible caregiver
● Encourage the client to perform ADLs as able and fatigue. Provide instruction as necessary.
willing to do so. ● Educate the family about physical changes to expect as
the client moves closer to death.
● Allow families to express feelings
Online Video: Postmortem Care
Postmortem care ORGAN/TISSUE DONATION

● Recognize that requests for tissue and organ donations
● Nurses are responsible for following federal and state
must be made by speci cally trained personnel.
laws regarding requests for organ or tissue donation, ● Provide support and education to family members as
obtaining permission for autopsy, ensuring the
decisions are being made. Use private areas for any
certi cation and appropriate documentation of the
family discussions concerning donation.
death, and providing postmortem (after-death) care. ● e sensiti e to cultural and religious in uences.
● After postmortem care is completed, the client’s family ● Maintain ventilatory and cardiovascular support for
becomes the nurse’s primary focus.
vital organ retrieval.
NURSING INTERVENTIONS AUTOPSY CONSIDERATIONS

● The provider typically approaches the family about
CARE OF THE BODY performing an autopsy.
● The nurse’s role is to answer the family members’
● Provide care with respect and compassion while
questions and support their choices.
attending to the desires of the client and family per ● Autopsies can be conducted to ad ance scienti c
their cultural, religious, and social practices. Check the
knowledge regarding disease processes, which can lead
client’s religion and make attempts to comply.
to the development of new therapies.
● ecogni e that the pro ider certi es death by ● The law can require an autopsy to be performed if the
pronouncing the time and documenting therapies used,
death is due to homicide, suicide, or accidental death, or
and actions taken prior to the death.
if death occurs within 24 hr of hospital admission.
● Elevate the client’s head to prevent facial discoloration ● Most facilities require that all tubes remain in place for
by raising the head of the bed and placing a pillow
an autopsy.
under the head and shoulders. Do this as soon as ● Documentation and completion of forms following
possible after the client’s death.
federal and state laws typically includes the following.
PREPARING THE BODY FOR VIEWING ◯ Who pronounced the death and at what time
● Maintain privacy. ◯ Consideration of and preparation for organ donation
● Remove all tubes (unless organs are to be donated or ◯ Description of any tubes or lines left in or on the body
this is a medical examiner’s case). ◯ Disposition of personal articles
● Remove all personal belongings to be given to ◯ ho as noti ed, and any decisions made
the family. ◯ Location of identi cation tags
● Cleanse and align the body supine with a pillow under ◯ Time the body left the facility and the destination
the head, arms with palms of hand down outside the
sheet and blanket, dentures in place, and eyes closed.
● Apply fresh linens with absorbent pads on bed
CARE OF NURSES WHO ARE GRIEVING
and a gown. ● Caring long-term for clients can create personal
● Brush/comb the client’s hair. Replace any hairpieces. attachments for nurses.
● Remove excess supplies, equipment, and soiled linens ● Nurses can use coping strategies (with consideration of
from the room. professional boundaries).
● Dim the lights and minimize noise to provide a ◯ Going to the client’s funeral
calm environment. ◯ Communicating in writing to the family
◯ Attending debrie ng sessions ith colleagues
VIEWING CONSIDERATIONS ◯ Using stress management techniques
● Ask the family whether they would like to visit with the ◯ Talking with a professional counselor
body, honoring any decision.
● Clarify where the client’s personal belongings should go:
with the body or to a designated person.
● Adhere to the same procedures when the client is an
infant, with the following exceptions.
◯ Swaddle the infant’s body in a clean blanket.
◯ Transport the infant in the nurse’s arms or in an
infant carrier based on facility protocol.
◯ ffer mementos of the infant identi cation bracelets,
footprints, the cord clamp, a lock of hair, photos).
POSTVIEWING
● Apply identi cation tags according to facility policy.
● Complete documentation.
● emain a are of isitor and staff sensibilities
during transport.
1. A nurse is caring for a client who has terminal lung A nurse educator is teaching a module on palliative care
cancer. The nurse observes the client’s family assisting to a group of newly licensed nurses. Use the ATI Active
with all ADLs. Which of the following rationales for Learning Template: Basic Concept to complete this item.
self-care should the nurse communicate to the family?
NURSING INTERVENTIONS: List five physical care
A. Allowing the client to function independently
interventions and five psychological care interventions
will strengthen muscles and promote healing.
appropriate for the care of a client who is dying.
B. The client needs privacy at times for
self-reflecting and organizing life.
C. The client’s sense of loss can be lessened
through retaining control of some areas of life.
D. Performing ADLs is a requirement prior to
discharge from an acute care facility.
2. A nurse is caring for a client who has stage IV lung

cancer and is 3 days postoperative following a
wedge resection. The client states, “I told myself
that I would go through with the surgery and quit
smoking, if I could just live long enough to attend my
child’s wedding.” Based on the Kübler-Ross model,
which stage of grief is the client experiencing?
A. Anger
B. Denial
C. Bargaining
D. Acceptance
3. A nurse is consoling the partner of a client who

just died after a long battle with liver cancer.
The grieving partner states, “I hate them for
leaving me.” Which of the following statements
should the nurse make to facilitate mourning
for the partner? (Select all that apply.)
A. “Would you like me to contact the chaplain
to come and speak with you?”
B. “You will feel better soon. You have been
expecting this for a while now.”
C. “Let’s talk about your children and
how they are going to react.”
D. “You know, it is quite normal to feel anger
toward your loved one at this time.”
E. “Tell me more about how you are feeling.”
4. A nurse is caring for a client who has a terminal

illness. Death is expected within 24 hr. The
client’s family is at the bedside and asks the
nurse what to expect at this time. Which of the
following findings should the nurse include?
A. Regular breathing patterns
B. Warm extremities
C. Increased urine output
D. Decreased muscle tone
5. A nurse is about to perform postmortem

care of a client. The family wishes to view the
body. Which of the following actions should
the nurse take? (Select all that apply.)
A. Remove the dentures from the body.
B. Make sure the body is lying completely flat.
C. Apply fresh linens and place a
clean gown on the body.
D. Remove all equipment from the bedside.
E. Dim the lights in the room.
1. A. Strengthening of muscles is not a Using the ATI Active Learning Template: Basic Concept
priority of palliative care. NURSING INTERVENTIONS
B. Privacy for periods of self-reflection can be achieved
at times apart from performance of ADLs. Physical care
C. CORRECT: Allowing the client as much control as ●
Give priority to controlling findings.
possible maintains dignity and self-esteem. ●
Administer medications that manage pain, air hunger, and anxiety.
D. Performance of ADLs is not a criterion for ●
Perform ongoing assessment to determine the effectiveness
discharge from an acute care facility. of treatment and the need for modifications of the
NCLEX® Connection: Psychosocial Integrity, End of Life Care treatment plan (lower or higher doses of medications).
●
Manage adverse effects of medications.
●
Reposition the client to maintain airway patency and comfort.
2. A. This statement does not reflect anger. ●
Maintain the integrity of skin and mucous membranes.
B. The client is not denying the severity of ●
Provide an environment that promotes dignity and self-esteem.
the diagnosis and prognosis.
C. CORRECT: The client is bargaining by attempting to
●
Remove products of elimination as soon as possible
negotiate more time to live to see the child get married. to maintain a clean and odor-free environment.
D. Although the client might have accepted his
●
Offer comfortable clothing.
diagnosis and prognosis, this statement does not ●
Provide careful grooming for hair, nails, and skin.
convey coming to terms with the situation. ●
Encourage family members to bring in comforting
NCLEX® Connection: Psychosocial Integrity, End of Life Care possessions to make the client feel at home.
●
If appropriate, encourage the use of relaxation
techniques, (guided imagery and music).
3. A. CORRECT: Asking whether the grieving individual ●
Promote decision-making in food selection, activities, and
desires spiritual support at this time is an acceptable health care to give the client as much control as possible.
nursing intervention to facilitate mourning. ●
Encourage the client to perform ADLs as able and willing to do so.
B. Avoid giving false reassurance and offering assumptions
while intervening to facilitate mourning. Psychosocial care
C. Avoid changing the subject and bringing the
●
Use an interprofessional approach.
focus away from the grieving individual while ●
Provide care to the client and family.
intervening to facilitate mourning. ●
Use volunteers when appropriate to provide nonmedical care.
D. CORRECT: Educate the grieving individual about the ●
Use therapeutic communication to develop and
grieving process and emotions to expect at this time. maintain a nurse-client relationship.
E. CORRECT: Encourage the open communication of feelings ●
Facilitate the understanding of information regarding
by using therapeutic communication to facilitate mourning. disease progression and treatment choices.
Facilitate communication between the client, family, and provider.
Encourage the client to participate in religious or other
practices that bring comfort and strength, if appropriate.
●
Assist the client in clarifying personal values in
4. A. Labored breathing and irregular patterns order to facilitate effective decision-making.
indicate imminent death. ●
Encourage the client to use coping mechanisms
B. Cool extremities indicate imminent death.
that have worked in the past.
C. Decreased urine output indicates of imminent death.
D. CORRECT: Muscle relaxation is an expected
●
Be sensitive to comments made in the presence of clients who
finding when a client is approaching death. are unconscious because hearing is the last sensation lost.
NCLEX® Connection: Psychosocial Integrity, End of Life Care NCLEX® Connection: Basic Care and Comfort,
Non-Pharmacological Comfort Interventions
5. A. Insert the client’s dentures so that the face

looks as natural as possible.
B. The body should not be completely flat. Place
one pillow under the head and shoulders to
prevent discoloration of the face.
C. CORRECT: The body and the environment should be as
clean as possible. This includes washing soiled areas of
the body and applying fresh linens and a clean gown.
D. CORRECT: The environment should be as
clutter-free as possible. The nurse should remove
all equipment and supplies from the bedside.
E. CORRECT: Dimming the lights helps provide
a calm environment for the family.
NCLEX® Connection: Basic Care and Comfort, Personal Hygiene
NCLEX® Connections

STANDARD PRECAUTIONS/TRANSMISSION-BASED PRECAUTIONS/
SURGICAL ASEPSIS: Apply principles of infection control.

HEALTH PROMOTION/DISEASE PREVENTION:
Integrate complementary therapies into health
promotion activities for the well client.
Client Needs: Basic Care and Comfort

ASSISTIVE DEVICES
Assess the client’s use of assistive devices.
Assist client to compensate for a physical or sensory impairment.
ELIMINATION: Provide skin care to clients who are incontinent.
MOBILITY/IMMOBILITY
Apply knowledge of nursing procedures and psychomotor
skills when providing care to clients with immobility.
Identify complications of immobility.
NON-PHARMACOLOGICAL COMFORT INTERVENTIONS

Recognize complementary therapies and
identify potential contraindications.
ecogni e differences in client perception and response to pain.
NUTRITION AND ORAL HYDRATION

Evaluate client intake and output and intervene as needed.
Apply knowledge of mathematics to client nutrition.
Monitor the client's nutritional status.
PERSONAL HYGIENE: Assess the client for

personal hygiene habits/routine.
REST AND SLEEP: Schedule client care

activities to promote adequate rest.

Pharmacological and Parenteral Therapies
PHARMACOLOGICAL PAIN MANAGEMENT: Evaluate and
document the client's use and response to pain medications.

POTENTIAL FOR COMPLICATIONS OF DIAGNOSTIC
TESTS/TREATMENTS/PROCEDURES: Intervene to
manage potential circulatory complications.

CHAPTER 37
UNIT 4 PHYSIOLOGICAL INTEGRITY Eye and ear care
SECTION: BASIC CARE AND COMFORT
● Use a clean, moist washcloth without any soap to
Hygiene wipe gently across the eyelids from the inner to the
CHAPTER 37 outer canthus.
● Rotate the end of a clean, moist washcloth gently into
the ear canal.
Personal hygiene needs vary with clients’ health
Oral hygiene
status, social and cultural practices, and the
Proper oral hygiene helps decrease the risk of infection for
daily routines they follow at home. For most clients living in long-term care facilities, especially from
clients, personal hygiene includes bathing, oral the transmission of pathogens that can cause pneumonia.
Other populations who require meticulous oral hygiene
care, nail and foot care, perineal care, hair care, include those who are seriously ill, injured, unconscious,
and shaving (especially for men). dehydrated, or have an altered mental status or limited
upper body mobility.
Because personal hygiene has a profound effect
Foot care
on overall health, comfort, and well-being, it
Foot care prevents skin breakdown, pain, and infection.
is an integral component of individualized
●
● Foot care is extremely important for clients who have

nursing care plans. When clients become ill, diabetes mellitus, and a uali ed professional must
perform it.
have surgery, or are injured and are unable to
manage their own personal hygiene needs, it Perineal care
becomes the nurse’s responsibility to meet Perineal care helps maintain skin integrity, relieve
discomfort, and prevent transmission of micro-organisms
those needs. (catheter care).
Before beginning any personal care delivery, it

is important to evaluate the client’s ability to CULTURAL AND SOCIAL PRACTICES
Clients vary in their hygiene preferences and practices.
participate in personal hygiene. Encourage
●
These include bathing routines, oral care, grooming

clients to participate in any way they can. preferences, and health beliefs.
Culture also plays an important role, because some
Integrate assessment, range-of-motion
●
cultures have unique hygiene practices. Be sure to

exercises, and dressing changes while providing be respectful and obser ant of each client s speci c
cultural needs.
hygiene care. ● Consider the client’s personal preference regarding
hygiene practices.
ocioeconomic status can affect clients hygiene status.
HYGIENE CARE
●
If a client is homeless, alter discharge instructions and

follow-up care accordingly.
Bathing ● Respect each client’s dignity. Many clients are dealing
● Bathe clients to cleanse the body, stimulate circulation, with a loss of control when others must provide their
provide relaxation, and enhance healing. hygiene care. Reassure clients and allow them to have
● Bathing clients is often delegated to the assistive as much control as possible.
personnel. However, the nurse is responsible for data
collection and client care.
● Bathe clients whose health problems have exhausted
SAFETY
them or limited their mobility. ● Before starting any care, understand how to complete
◯ Give a complete bath to clients who can tolerate it and each task to avoid injuring the client. This includes
whose hygiene needs warrant it. knowing the equipment and what the proper techniques
◯ Allow rest periods for clients who become tired are for each hygiene procedure.
during bathing. ● Never leave clients in a position where injury could
◯ Partial baths are useful when clients cannot tolerate occur during routine hygiene care. For example, avoid
a complete bath, need particular cleansing of odorous leaving a client who is at risk for aspiration alone with
or uncomfortable areas, or can perform part of the oral hygiene supplies.
bath independently. ● Adjust the bed to a comfortable working height and
◯ Therapeutic baths are used to promote comfort and lower the bed upon completion of the task.
provide treatment (soothing itchy skin).
FUNDAMENTALS FOR NURSING CHAPTER 37 HYGIENE 211

CONSIDERATIONS FOR OLDER ADULTS PATIENT-CENTERED CARE
● Older adults’ skin is drier, thinner, and will not tolerate
as much bathing as younger adults’ skin. NURSING CONSIDERATIONS
● Older adults have higher incidences of infection and
periodontal disease due to the weakening of the Giving a bed bath
periodontal membrane. ● Collect supplies, provide for privacy, and explain the
● Dentures must t correctly, or they can cause digesti e
procedure to the client.
issues, pain, and discomfort. Dentures are a client’s ● Apply gloves.
personal property. Never leave them on a meal tray or in ● Lock the wheels on the bed.
a place where they could be damaged or lost. ● Adjust the bed to a comfortable working position.
● Dry mouth is common in older adults due to decreased ● Place a bath blanket over the client, and remove the
saliva production and the use of certain medications
client’s gown.
antihypertensi es, diuretics, anti in ammatory ● Obtain warm bath water.
agents, antidepressants). ● ash the client s face rst. Allo the client to perform
● Poor nutritional status is often due to dental problems,
this task if able.
socioeconomic status, or a limited ability to prepare ● Perform the bath systematically by starting with the
healthful foods.
client’s trunk and upper extremities and continuing
to the client’s lower extremities. Keep cleaned areas
covered with a blanket or towel.
ASSESSMENT/DATA COLLECTION ● ash ith long, rm stro es from distal to pro imal.
● Inspect the skin for color, hydration, texture, turgor, Use light strokes over lower extremities for clients who
and any lesions or other impaired integrity. have a history of deep vein thrombosis.
● Check the condition of the gums and teeth for dryness ● Apply lotion and powder (if the client has no
or in ammation of the oral mucosa. Does the client contraindications for these products), and a clean gown.
report any pain? ● Replace the water if it becomes cool, and use fresh water
● Assess the skin surfaces, including the feet and to perform perineal care.
nails, and note the shape and size of each foot, any ● Document skin assessment, type of bath, and the
lesions, and areas of dryness or in ammation. client’s response.
igni cant alterations can indicate neuropathy and or
TO CHANGE LINENS ON AN OCCUPIED BED
ascular insufficiency. Are all pulses palpable and ● Adjust the bed to a comfortable working height.
equal bilaterally? ● Don gloves.
● Identify hygiene preferences to understand how clients ● Roll the bottom linens up in the bottom sheet or
perform hygiene at home and what additional education
mattress pad under the client who is turned to one side,
and care to provide.
facing the opposite direction. For safety purposes, adjust
● Monitor for safety issues (altered positioning, decreased
and lower side rails accordingly.
mobility) and the ability to participate in self-care. Alter ● Apply clean bottom linens to the bed (draw sheets are
the plan of care according to the client’s capabilities.
optional), and extend them to the middle of the bed
with the remainder of the linen fan-folded underneath
the client.
● Have the client roll over the linens and face the opposite
direction, then remove the used linens (keep them away
from your uniform) and apply the clean linens. Make
sure the linens are free from wrinkles.
● Apply the upper sheet and blanket.
● To remove the pillowcase, insert one hand into the
opening, grab the pillow, and turn the pillowcase
inside-out.
● Apply the clean pillowcase by grasping the center of
the closed end, turning the case inside out, tting the
pillow into the corner of the case, and pulling the case
until it is right-side out over the pillow.
212 CHAPTER 37 HYGIENE CONTENT MASTERY SERIES

Foot care Oral hygiene
● It is important to prevent any infection or pain that ● Check for aspiration risk, impaired swallowing, and a
can interfere ith gait. A uali ed professional should decreased gag re e .
perform foot care for clients who have diabetes mellitus, ● Clients who have fragile oral mucosa require gentle
peripheral vascular disease, or immunosuppression to brushing and ossing.
evaluate the feet and prevent injury. ● Have suction apparatus ready at the bedside when
● Instruct clients at risk for injury to do the following. providing oral hygiene to clients who are unconscious to
◯ Inspect the feet daily, paying speci c attention to the help pre ent aspiration. Do not place your ngers into
area between the toes. an unconscious client’s mouth because the client could
◯ Use lukewarm water, and dry the feet thoroughly. bite do n on your ngers. Position the client on one
◯ Apply moisturizer to the feet, but avoid applying it side with the head turned toward you in either a
between the toes. semi o ler s position, or ith the head of the bed at.
◯ Avoid over-the-counter products that contain alcohol This ill allo uid and oral secretions to collect in the
or other strong chemicals. dependent side of the client’s mouth and drain out.
◯ Wear clean cotton socks daily. ● Perform denture care for clients who are unable to do so
◯ Check shoes for any objects, rough seams, or edges themselves. Dentures are very fragile, so handle them
that can cause injury. with care.
◯ Cut the nails straight across, and use an emery board ◯ Remove the dentures with a gloved hand, pulling
to le nail edges. down and out at the front of the upper denture, and
◯ Avoid self-treating corns or calluses. lifting up and out at the front of the lower denture.
◯ Wear comfortable shoes that do not ◯ Place the dentures in a denture cup, emesis basin, or
restrict circulation. on a washcloth in the sink.

◯ Do not apply heat unless prescribed. ◯ Brush in a horizontal back-and-forth motion with a
◯ Contact the provider if any indications of infection or soft brush and denture cleaner.
in ammation appear. ◯ Rinse dentures in tepid water.
◯ Store the dentures in a denture cup. Label the cup
Perineal care with the client’s name.

◯ Place the dentures in the cup with water to keep them
It is important to maintain skin integrity to relieve

moist, or to help the client reinsert the dentures.
discomfort and prevent transmission of infection
(catheter care).
Nail care
PRINCIPLES OF PERINEAL CARE ● Observe the size, shape, and condition of the nails and
nail beds.
● Maintain a professional demeanor. ● Check for cracking, clubbing, and fungus.
● Remove any fecal material from the skin. ● Before cutting any client’s nails, check the facility’s
● Cleanse the perineal area from front to back (perineum
policy. Some require a prescription from the provider,
to rectum).
hile others allo only a podiatrist or other uali ed
● Dry thoroughly.
professional to cut some or all clients’ nails.
● Retract the foreskin of male clients to wash the tip of ● Foot and nail care vary from the standard when caring
the penis, clean from the meatus outward in a circular
for a client who has diabetes mellitus or peripheral
motion, then replace the foreskin.
vascular disease. Do not soak the feet due to the risk of
infection, and do not cut the nails. Instead, le nails
using a nail le. Do not apply lotion bet een the ngers
or toes because the moisture can cause skin irritation
and breakdown.

Hair care Shaving
● Caring for the hair and scalp is important for clients’ ● Safety is important. Clients who are prone to bleeding,
appearance and sense of well-being, and is an essential are receiving anticoagulants, or have low platelet counts
component of personal hygiene. Take into consideration should use an electric razor.
the client’s cultural and personal preferences. ● Soften the skin with warm water.
● Brush or comb the hair daily to remove tangles, ● Apply liquid soap or shaving cream.
massage the scalp, stimulate circulation to the scalp, ● Hold the skin taut.
and distribute natural oils along the shaft of the hair. ● Move the razor over the skin in the direction of hair
Use a soft-bristled brush to prevent injury or trauma to growth using long strokes on large areas of the face and
the scalp and a wide-toothed comb or hair pick to comb short strokes around the chin and lips.
through tightly curled hair. ● Be sure to communicate with clients about personal
● For clients who cannot shower but can sit in a chair and shaving preferences.
lean back, shampoo the hair at the sink. For clients who
require bed rest, use a plastic shampoo trough. Dry or
no-rinse shampoos and shampoo caps are also options Active Learning Scenario
for clients who require bed rest.
● Start shampooing the hair at the hairline and work A nurse is about to perform perineal care for a client whose
toward the neck. To wash the hair on the back of the ability to assist with care is limited. Use the ATI Active
head, gently lift the head with one hand and shampoo Learning Template: Nursing Skill to complete this item.
with the other.
● Place a folded or rolled towel behind the neck to pad the DESCRIPTION OF SKILL: List the steps the nurse
edge of the sink. Then rinse, comb, and dry the hair. should take to perform this procedure.
1. A nurse is performing mouth care for a 4. A nurse is beginning a complete bed bath for
client who is unconscious. Which of the a client. After removing the client’s gown and
following actions should the nurse take? placing a bath blanket over the body, which of the
A. Turn the client’s head to the side. following areas should the nurse wash first?
B. Place two fingers in the client’s mouth to open it. A. Face
C. Brush the client’s teeth once per day. B. Feet
D. Inject a mouth rinse into the center C. Chest

of the client’s mouth. D. Arms
2. A nurse is instructing a client who has diabetes mellitus 5. A nurse is preparing to perform denture
about foot care. Which of the following guidelines care for a client. Which of the following
should the nurse include? (Select all that apply.) actions should the nurse plan to take?
A. Inspect the feet daily. A. Pull down and out at the back of the
B. Use moisturizing lotion on the feet. upper denture to remove.
C. Wash the feet with warm water and let them air dry. B. Brush the dentures with a toothbrush
and denture cleaner.
D. Use over-the-counter products to treat abrasions.
C. Rinse the dentures with hot water
E. Wear cotton socks. after cleaning them.
D. Place the dentures in a clean, dry storage
3. A nurse is planning care for a client who develops container after cleaning them.
dyspnea and feels tired after completing morning
care. Which of the following actions should the
nurse include in the client’s plan of care?
A. Schedule rest periods during morning care.
B. Discontinue morning care for 2 days.
C. Perform all care as quickly as possible.
D. Ask a family member to come in to bathe the client.

1. A. CORRECT: Position the client’s head on the side, Using the ATI Active Learning Template: Nursing Skill
unless there is a contraindication for this position,
to reduce the risk of aspiration. DESCRIPTION OF SKILL
B. Do not insert fingers into the client’s mouth because ●
Provide privacy.
the client might bite down on the fingers. ●
Maintain a professional demeanor.
C. Brush the client’s teeth at least twice per day. ●
Remove any fecal material from the skin.
D. Gently inject a mouth rinse into the side of the ●
Cleanse the perineal area from front to back.
client’s mouth to reduce the risk for aspiration.
●
Dry skin thoroughly
NCLEX Connection: Reduction of Risk Potential, Potential for
®
●
Retract the foreskin of male clients to wash the tip of the penis, clean
Complications of Diagnostic Tests/Treatments/Procedures from the meatus outward in a circular motion, then replace the foreskin.
2. A. CORRECT: Clients who have diabetes mellitus are at Standard Precautions/Transmission-Based Precautions/Surgical Asepsis.
increased risk for infection and diminished sensitivity
in the feet, so they should inspect them daily.
B. CORRECT: The client should use moisturizing lotions (but not
between the toes) to help keep the skin smooth and supple.
C. The client should wash the feet with lukewarm
water and dry the feet thoroughly.
D. Over-the-counter products often contain harmful
chemicals that can cause skin impairment.
E. CORRECT: The client should wear clean
cotton socks each day.
Potential for Alterations in Body Systems
3. A. CORRECT: Planning for rest periods during

morning care will help prevent fatigue and
continue to foster independence.
B. Fatigue and dyspnea do not eliminate
the need for morning care.
C. Performing all of the client’s care quickly might affect the
client’s self-esteem and reduce their independence.
D. Having a family member bathe the client reduces
their self-esteem and independence, and
does not reduce the client’s fatigue.
NCLEX® Connection: Basic Care and Comfort, Rest and Sleep
4. A. CORRECT: The greatest risk to a client during bathing

is the transmission of pathogens from one area of the
body to another. Begin with the cleanest area of the
body and proceed to the least clean area. The face is
generally the cleanest area, and washing it first follows a
systematic head-to-toe approach to client care.
B. The client is at risk for infection from pathogens on the
client’s feet. Therefore, wash another area first.
C. The client is at risk for infection from pathogens on the
client’s chest. Therefore, wash another area first.
D. The client is at risk for infection from pathogens on the
client’s arms. Therefore, wash another area first.
5. A. Remove the upper dentures with a gloved hand, pulling

down and out at the front of the upper denture.
B. CORRECT: Brushing the dentures thoroughly with
a toothbrush and denture cleaner removes debris
that accumulate on and between the teeth.
C. Using hot water to rinse dentures can damage some
denture materials. Use tepid water to rinse dentures.
D. Dentures should be moist when not in use to prevent
warping and to facilitate insertion. Store them in water in a
denture cup with the client’s identification on the cup.
NCLEX® Connection: Basic Care and Comfort, Assistive Devices

CHAPTER 38
UNIT 4 PHYSIOLOGICAL INTEGRITY SLEEP DURATION
Sleep averages vary with the developmental stage, with
Rest and Sleep infants and toddlers averaging 9 to 15 hr/day. This

CHAPTER 38 declines gradually throughout childhood, with adolescents
averaging 9 to 10 hr/day and adults 7 to 8 hr/day.
Adequate amounts of sleep and rest promote COMMON SLEEP DISORDERS

health. Too little sleep leads to an inability
Insomnia
to concentrate, poor judgment, moodiness,
The most common sleep disorder, this is the inability
irritability, and increased risk for accidents.
●
to get an adequate amount of sleep and to feel rested.

It might mean difficulty falling asleep, difficulty
Chronic sleep loss can increase risks of obesity, staying asleep, awakening too early, or not getting
depression, hypertension, diabetes mellitus, refreshing sleep.
Acute insomnia lasts a few days possibly due to
heart attack, and stroke.
●
personal or situational stressors.

● Chronic insomnia lasts a month or more.
Some people have intermittent insomnia, sleeping well
SLEEP CYCLE
●
for a few days and then having insomnia for a few days.
The sleep cycle consists of three stages of non-rapid ● Women and older adults are more prone to insomnia.
eye movement (NREM) sleep and a period of rapid eye
movement (REM) sleep. Typically, people cycle through Sleep apnea
the stages of sleep in various patterns several times. REM ● ore than e breathing cessations lasting longer than
sleep accounts for 20% to 25% of sleep time.
10 seconds per hour during sleep, resulting in decreased
arterial oxygen saturation levels.
Stage 1 NREM ● Sleep apnea can be a single disorder or a mixture of
● Very light sleep the following.
● Only a few minutes long ◯ Central: Central nervous system dysfunction in the
● Muscle relaxation respiratory control center of the brain that fails to
● Loss of awareness of surroundings trigger breathing during sleep.
● Vital signs and metabolism beginning to decrease ◯ Obstructive: Structures in the mouth and throat relax
● Awakens easily during sleep and occlude the upper airway.
● Feels relaxed and drowsy
Narcolepsy
Stage 2 NREM ● Sudden attacks of sleep that are often uncontrollable
● Deeper sleep ● Often happens at inappropriate times and increases the
● 10 to 20 min long risk for injury
● Vital signs and metabolism continuing to slow
● Requires slightly more stimulation to awaken Hypersomnolence disorder
● Increased relaxation ● Excessive daytime sleepiness lasting at least 3 months
Impairs social and vocational activities
Stage 3 NREM
●
● Increased risk for accident or injury related to sleepiness

● Slow wave sleep or delta sleep
● Vital signs decreasing
● ore difficult to a a en ASSESSMENT/DATA COLLECTION
● Psychological rest and restoration ● Ask about sleep patterns, history, and any
● Reduced sympathetic activity
recent changes.
Identify the usual sleep requirements.
REM
●
● Ask about sleep problems (type, manifestations, timing,

● Vivid dreaming seriousness, related factors, aftereffects .
● About 90 min after falling asleep, recurring ● Use a linear or visual scale with “best sleep” on one
every 90 min end and “worst sleep” on the opposite end and ask for a
● Longer with each sleep cycle sleep rating on a 0 to 10 scale.
● Average length 20 min ● Check for common factors that interfere with sleep.
● Varying vital signs
● ery difficult to a a en
● Cognitive restoration
FUNDAMENTALS FOR NURSING CHAPTER 38 REST AND SLEEP 217

FACTORS THAT INTERFERE WITH SLEEP CLIENT EDUCATION
Physiologic disorders: Can require more sleep or disrupt ● Exercise regularly at least 2 hr before bedtime.
sleep (sleep apnea, nocturia) ● Establish a bedtime routine and a regular sleep pattern.
● Arrange the sleep environment for comfort.
Current life events: Traveling more, change in work hours ● Limit alcohol, caffeine, and nicotine at least hr
Emotional stress or mental illness: Anxiety, fear, grief before bedtime.
● Limit uids to hr before bedtime.
Diet: Caffeine consumption, hea y meals before bedtime ● Engage in muscle relaxation if anxious or stressed.
Exercise: Promotes sleep if at least 2 hr before bedtime,
For narcolepsy
otherwise can disrupt sleep ● Exercise regularly.
Fatigue: Exhausting or stressful work makes falling ● Eat small meals that are high in protein.
asleep difficult. ● Avoid activities that increase sleepiness (sitting too long,
warm environments, drinking alcohol).

Sleep environment: Too light, the wrong temperature, or ● Avoid activities that could cause injury should the client
too noisy (children, pets, loud noise, snoring partner)

fall asleep (driving, heights).
Medications: Some can induce sleep but interfere ● Take naps when drowsy or when narcoleptic events
with restorative sleep. Others (bronchodilators, are likely.
antihypertensives) cause insomnia. ● Take prescribed stimulants.
Substance use: Nicotine and caffeine are stimulants. For hypersomnolence disorder
Caffeine and alcohol tend to cause night a a enings. ● Maintain a regular sleep-wake schedule.
● Provide ample sleep opportunities.
● Take prescribed stimulants.
NURSING ACTIONS
● Help clients establish and follow a bedtime routine.
● Limit waking clients during the night.
● Promote a quiet hospital environment.
● Help with personal hygiene needs or a back rub prior to
sleep to increase comfort.
● Consider continuous positive airway pressure (CPAP)
devices for clients who have sleep apnea.
● Consult the provider about trying sleep-promoting
over-the-counter products (melatonin, valerian,
chamomile).
● As a last resort, suggest that the provider prescribe
a pharmacological agent. Medications of choice for
insomnia are benzodiazepine-like medications, which
include the sedative-hypnotics zolpidem, eszopiclone,
and zaleplon.
● Adjust inpatient routines when possible to conform with
clients’ home routines (bathing, bedtime).
218 CHAPTER 38 REST AND SLEEP CONTENT MASTERY SERIES

1. A nurse in a provider’s office is caring for a client A nurse on a medical unit is collecting data from a client who
who states that, for the past week, “I have felt reports a persistent inability to sleep. Use the ATI Active
tired during the day and cannot sleep at night.” Learning Template: Basic Concept to complete this item.
Which of the following responses should the
UNDERLYING PRINCIPLES: List at least three common
nurse ask when collecting data about the client’s
factors that might be interfering with the client’s sleep.
difficulty sleeping? (Select all that apply.)
A. “Have your working hours changed recently?” NURSING INTERVENTIONS: List at least three
B. “Do you feel confused in the late afternoon?” strategies the nurse can implement to help
the client sleep while in the hospital.
C. “Do you drink coffee, tea, or other caffeinated
drinks? If so, how many cups per day?”
D. “Has anyone ever told you that you seem to stop
breathing for a few seconds while you are asleep?”
E. “Tell me about any personal stress
you are experiencing.”
2. A nurse is talking with a client about ways to

help sleep and rest. Which of the following
recommendations should the nurse give to the client
to promote sleep and rest? (Select all that apply.)
A. Practice muscle relaxation techniques.
B. Exercise each morning.
C. Take an afternoon nap.
D. Alter the sleep environment for comfort.
E. Limit fluid intake at least 2 hr before bedtime.
3. A nurse is caring for a client who has been following

the facility’s routine and bathing in the morning.
However, at home, the client always takes a
warm bath just before bedtime. Now the client is
having difficulty sleeping at night. Which of the
A. Rub the client’s back for 15 min before bedtime.
B. Offer the client warm milk and crackers at 2100.
C. Allow the client to take a bath in the evening.
D. Ask the provider for a sleeping medication.
4. A nurse is preparing a presentation at a local

community center about sleep hygiene. When
explaining rapid eye movement (REM) sleep,
which of the following characteristics should
A. REM sleep provides cognitive restoration.
B. REM sleep lasts about 90 min.
C. It is difficult to awaken a person in REM sleep.
D. Sleepwalking occurs during REM sleep.
E. Vivid dreams are common during REM sleep.
5. A nurse is instructing a client who has

narcolepsy about measures that might help
with self-management. Which of the following
statements should the nurse identify as an indication
that the client understands the instructions?
A. “I’ll add plenty of carbohydrates to my meals.”
B. “I’ll take a short nap whenever I feel a little sleepy.”
C. “I’ll make sure I stay warm when
I am at my desk at work.”
D. “It’s okay to drink alcohol as long as
I limit it to one drink per day.”
FUNDAMENTALS FOR NURSING CHAPTER 38 REST AND SLEEP 219

1. A. CORRECT: Job changes, including roles and working Using the ATI Active Learning Template: Basic Concept
hours, can affect the quality and quantity of sleep. UNDERLYING PRINCIPLES
B. Chronic sleep deprivation or lack of rapid eye movement ●
Illness
sleep can cause confusion, but sleep difficulties
for 1 week should not result in confusion.
●
Current life events (travel, change in work hours)
C. CORRECT: Caffeinated drinks act as a
●
Emotional stress or mental illness (anxiety, fear)
stimulant and can interfere with sleep. ●
Caffeine consumption
D. CORRECT: Periods of apnea warrant a prompt ●
Heavy meals before bedtime
referral for diagnostic sleep studies. ●
Exercise within 2 hr of bedtime
E. CORRECT: Emotional stress is a common ●
Sleep environment that is noisy, too light, or the wrong temperature
cause of short-term sleep problems. ●
Medications that cause insomnia
●
Help clients establish and follow a bedtime routine.
2. A. CORRECT: Relaxation techniques, especially muscle ●
Limit waking clients during the night.
relaxation, can help promote sleep and rest. ●
Promote a quiet hospital environment.
B. CORRECT: Following an exercise routine regularly, at least ●
Assist with personal hygiene needs.
2 hr prior to bedtime, can help promote rest and sleep. ●
Offer a back rub.
C. Napping during the day can keep some people from getting ●
Request a prescription for a sleep medication from the provider.
the sleep they need during their usual sleeping hours.
D. CORRECT: For example, rather than trying to NCLEX® Connection: Basic Care and Comfort, Rest and Sleep
sleep with a restless pet at the foot of the bed,
move the pet to another sleep area.
E. CORRECT: Limiting fluids for a few hours before
bedtime helps minimize getting up to urinate.
3. A. Rubbing the client’s back can help promote sleep,

but there is another option to try first.
B. Offering the client warm milk and crackers can help
promote sleep, but there is another option to try first.
C. CORRECT: When providing care, first use the least
restrictive intervention. Of these options, allowing the
client to follow their usual bedtime routine represents
the least change, so it is the first intervention to try.
D. Asking for a prescription for sleep medication can help
induce sleep, but there is another option to try first.
4. A. CORRECT: Cognitive and brain tissue

restoration occur during REM sleep.
B. REM sleep lasts an average of 20 min. It typically
begins about 90 min after falling asleep.
C. CORRECT: In this stage, awakening is difficult. Awakening
is relatively easy in stages 1 and 2 of non-REM sleep.
D. Sleepwalking and sleep talking tend to occur
during stage 3 of non-REM sleep.
E. CORRECT: Dreaming does occur in other stages,
but it is less vivid and possibly less colorful.
5. A. Clients who have narcolepsy should eat

light, high-protein meals.
B. CORRECT: Clients who have narcolepsy should take
short naps to reduce feelings of drowsiness.
C. Clients who have narcolepsy should avoid sitting for
prolonged periods in warm environments.
D. Clients who have narcolepsy should avoid ingesting any
substance that could increase drowsiness (alcohol).
220 CHAPTER 38 REST AND SLEEP CONTENT MASTERY SERIES

CHAPTER 39
UNIT 4 PHYSIOLOGICAL INTEGRITY BASIC NUTRIENTS THE BODY REQUIRES
Carbohydrates provide most of the body’s energy and
Nutrition and ber. ach gram produces cal. They pro ide glucose,
CHAPTER 39 hich burns completely and efficiently ithout end
Oral Hydration products to excrete. Sources include whole grain breads,

baked potatoes, brown rice, and other plant foods.
Fats provide energy and vitamins. No more than 35% of

caloric intake should be from fat. Each gram produces
Nutrients provide energy for cellular metabolism,
9 kcal. Sources include olive oil, salmon, and egg yolks.
tissue maintenance and repair, organ function,
Proteins contribute to the growth, maintenance, and
growth and development, and physical activity. repair of body tissues. Each gram produces 4 kcal. Sources
of complete protein include beef, whole milk, and poultry.
Water, the most basic of all nutrients, is crucial
Vitamins are necessary for metabolism. The fat-soluble
for all body fluid and cellular functions.
vitamins are A, D, E, and K. The water-soluble vitamins
include C and the B complex (eight vitamins).
The proper balance of nutrients and fluid
Minerals complete essential biochemical reactions in the
along with consideration of energy intake body (calcium, potassium, sodium, iron).
and requirements is essential for ensuring
Water is critical for cell function and replaces uids
adequate nutritional status. Early recognition the body loses through perspiration, elimination,
and respiration.
and treatment of clients who are malnourished
or at risk can have a positive influence on
client outcomes. FACTORS AFFECTING NUTRITION
AND METABOLISM
A nutritional assessment helps identify areas Religious and cultural practices guide food preparation
and choices.
to modify, either through adding or avoiding
Financial issues prevent some clients from buying foods
specific nutrients or by increasing or decreasing that are high in protein, vitamins, and minerals.
caloric intake.
Appetite decreases with illness, medications, pain,
depression, and unpleasant environmental stimuli.
When planning a nutritional or hydration
Negative experiences with certain foods or familiarity
intervention, it is important to consider beliefs
with foods clients like help determine preferences.
and culture, the environment, and the
Environmental factors (sedentary lifestyles, work
presentation of the food, as well as any illnesses schedules, and widespread access to less healthy foods)
contribute to obesity.
or allergies clients might have.
Disease and illness can affect the functional ability to
prepare and eat food.
Medications can alter taste and appetite and can interfere

with the absorption of certain nutrients.
Age affects nutritional re uirements.
FUNDAMENTALS FOR NURSING CHAPTER 39 NUTRITION AND ORAL HYDRATION 221

AGE Bulimia nervosa: a cycle of binge eating followed by
purging (vomiting, using diuretics or laxatives, exercising
Newborns and infants (birth to 1 year)
excessively, fasting)
● High energy requirements ● Lack of control during binges
● Breast milk (ideally) or formula to provide: ● Average at least one cycle of binge eating and purging
◯ cal g of eight the rst months
per week for at least 3 months
◯ 98 kcal/kg of weight the second 6 months
● Solid food starting at 4 to 6 months of age Binge-eating disorder: repeated episodes of binge eating
● No co s mil or honey for the rst year ● Feels a loss of control when binge eating, followed by an
emotional response (guilt, shame, or depression)
Toddlers (12 months to 3 years) and preschoolers ● Does not use compensatory behaviors (purging)
(3 to 6 years) ● Binge-eating episodes can range from one to multiple
● Toddlers and preschoolers need fewer calories per kg of
times per week.
weight than infants do. ● Clients are often overweight or obese.
● Toddlers and preschoolers need increased protein from
sources other than milk.
● Calcium and phosphorus are important for bone health.
Nutrient density is more important than quantity.
OBESITY
●
School-age children (6 to 12 years)

A BMI of 25 is the upper boundary of a healthy weight, 25
● School-age children need supervision to consume
to 29.9 is overweight, 30 to 34.9 is obesity class 1, 35 to
adequate protein and vitamins C and A.
39.9 is obesity class 2, and 40 and above is obesity class 3.
● They tend to eat foods high in carbohydrates, fats, and salt.
● They grow at a slower and steadier rate, with a gradual
decline in energy requirements.
Adolescents (12 to 20 years)

● Metabolic demands are high and require more energy.
● Protein, calcium, iron, iodine, folic acid, and vitamin B Dietary history should include the following.
needs are high. ● Number of meals per day
● One-fourth of dietary intake comes from snacks. ● Fluid intake
● Increased water consumption is important for ● Food preferences, amounts
active adolescents. ● Food preparation, purchasing practices, access
● Body image and appearance, fast foods, peer pressure, ● History of indigestion, heartburn, gas
and fad diets in uence adolescents diet. ● Allergies
● Taste
Young adults (20 to 35 years) and ● Chewing, swallowing
middle adults (35 to 65 years) ● Appetite
● There is a decreased need for most nutrients (except ● Elimination patterns
during pregnancy). ● Medication use
● Calcium and iron are essential minerals for women. ● Activity levels
● Good oral health is important. ● Religious, cultural food preferences and restrictions
Older adults (over 65 years) ● Nutritional screening tools
● A slower metabolic rate requires fewer calories.
Thirst sensations diminish, increasing the risk

CLINICAL MEASURES
●
for dehydration.
● Older adults need the same amount of most vitamins ● Height, weight to calculate BMI and ideal body weight
and minerals as younger adults.
BMI = weight (kg) ÷ height (m2)
● Calcium is important for both men and women.
● Many older adults require carbohydrates that provide Step 1: Determine the client’s
ber and bul to enhance gastrointestinal function. weight in kg and height in m.
Step 2: Multiply the client’s height by
EATING DISORDERS itself to determine the m2 value.
Anorexia nervosa
Step 3: Divide the weight in kg by the height
● igni cantly lo body eight for gender, age,
value from step 2. The result is the client’s BMI.
developmental level, and physical health.
● Fear of being fat ● Skin fold measurements
● Self-perception of being fat ● Laboratory values of cholesterol, triglycerides,
● Consistent restriction of food intake or repeated hemoglobin, electrolytes, albumin, prealbumin,
behavior that prevents weight gain transferrin, lymphocyte count, nitrogen balance
222 CHAPTER 39 NUTRITION AND ORAL HYDRATION CONTENT MASTERY SERIES

INTAKE AND OUTPUT ● Assist ith pre enting aspiration.
◯ Position in high o ler s position or in a chair.
● Record I&O. ◯ upport the upper bac , nec , and head.
● onitor I for clients ho ha e uid or ◯ Ha e clients tuc their chin hen s allo ing to help
electrolyte imbalances.
propel food do n the esophagus.
◯ easure and calculate all inta e and output in mL ◯ A oid the use of a stra .
o mL . ◯ bser e for aspiration and poc eting of food in the
◯ Inta e includes all li uids oral uids, food that
chee s or other areas of the mouth.
li uefy at room temperature, I uids, I ushes, ◯ bser e for indications of dysphagia coughing,
I medications, enteral feedings, uid instillations,
cho ing, gagging, and drooling of food .
catheter irrigants, tube irrigants . ◯ eep clients in semi o ler s position for at least hr
◯ utput includes all li uids urine, blood, emesis,
after meals.
diarrhea, tube drainage, ound drainage, stula ◯ Pro ide oral hygiene after meals and snac s.
drainage . ● Pro ide therapeutic diets.
● eigh clients each day at the same time, after oiding, ◯ NPO (nil per os): no food or uid at all by mouth, not
and hile earing the same type of clothes.
e en ice chips, re uiring a pro ider s prescription
● If using bed scales, use the same amount of linen each
before resuming oral inta e
day, and reset the scale to ero if possible. ◯ Clear liquid: li uids that lea e little residue clear
fruit uices, gelatin, broth
EXPECTED FINDINGS OF ◯ Full liquid: clear li uids plus li uid dairy products, all
POOR NUTRITION uices. ome facilities include pureed egetables in a

full li uid diet.
● Nausea, omiting, diarrhea, constipation ◯ Pureed: clear and full li uids plus pureed meats,
● laccid muscles
fruits, and scrambled eggs
● ental status changes ◯ Mechanical soft: clear and full li uids plus diced or
● Loss of appetite
ground foods
● Change in bo el pattern ◯ Soft/low-residue: foods that are lo in ber and easy
● pleen, li er enlargement
to digest dairy products, eggs, ripe bananas
● Dry, brittle hair and nails ◯ High‑fiber: hole grains, ra and dried fruits
● Loss of subcutaneous fat ◯ Low sodium: no added salt or to g sodium
● Dry, scaly s in ◯ Low cholesterol: no more than mg day of dietary
● In ammation, bleeding of gums
cholesterol
● Poor dental health ◯ Diabetic: balanced inta e of protein, fats, and
● Dry, dull eyes
carbohydrates of about , calories
● nlarged thyroid ◯ Dysphagia: pureed food and thic ened li uids
● Prominent protrusions in bony areas ◯ Regular: no restrictions
● ea ness, fatigue ● Administer and monitor enteral feedings ia nasogastric,
● Change in eight
gastrostomy, or e unostomy tubes.
● Poor posture ● Administer and monitor parenteral nutrition to clients
ho are unable to use their gastrointestinal tract
to ac uire nutrients. Parenteral nutrients include
NURSING INTERVENTIONS lipids, electrolytes, minerals, itamins, de trose, and
● Assist in ad ancing the diet as the pro ider prescribes. amino acids.
● Instruct clients about the appropriate diet regimen. ● aintain uid balance.
● Pro ide inter entions to promote appetite good oral ◯ Administer I uids.
hygiene, fa orite foods, minimal en ironmental odors . ◯ estrict oral uid inta e maintaining strict I .
● ducate clients about medications that can affect ■ emo e the ater pitcher from the bedside.
nutritional inta e. ■ Inform the dietary staff of the amount of uid to
● Assist clients ith feeding to promote serve with each meal tray.
optimal independence. ■ Inform the staff of each shift of the amount of uid
● Indi iduali e menu plans according to clients clients may have in addition to what they receive
preferences. with each meal tray.
■ ecord all oral inta e, and inform the family of
the restriction.
◯ ncourage oral inta e of uids.
■ Pro ide fresh drin ing ater.
■ emind and encourage a consistent uid inta e.
■ As about be erage preferences.

1. A nurse is caring for a client who is at high A nurse is preparing a presentation in a community
risk for aspiration. Which of the following center on eating disorders that affect adolescents
actions should the nurse take? and young adults. Use the ATI Active Learning
A. Give the client thin liquids.
B. Instruct the client to tuck their RELATED CONTENT: List two common eating
chin when swallowing. disorders and their characteristics.
C. Have the client use a straw.
D. Encourage the client to lie down
and rest after meals.
2. A nurse is preparing a presentation about basic

nutrients for a group of high school athletes. She
should explain that which of the following nutrients
provides the body with the most energy?
A. Fat
B. Protein
C. Glycogen
D. Carbohydrates
3. A nurse is caring for a client who requires a low-residue

diet. The nurse should expect to see which of
the following foods on the client’s meal tray?
A. Cooked barley
B. Pureed broccoli
C. Vanilla custard
D. Lentil soup
4. A nurse is caring for a client who weighs 80 kg

(176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate
the body mass index (BMI) and determine
whether this client’s BMI indicates a healthy
weight, underweight, overweight, or obese.
5. A nurse in a senior center is counseling a group

of older adults about their nutritional needs and
considerations. Which of the following information
A. Older adults are more prone to
dehydration than younger adults are.
B. Older adults need the same amount of most
vitamins and minerals as younger adults do.
C. Many older men and women need
calcium supplementation.
D. Older adults need more calories than
they did when they were younger.
E. Older adults should consume a
diet low in carbohydrates.

Application Exercises Key Active Learning Scenario Answer
1. A. Thin liquids increase the client’s risk for aspiration. Using the ATI Active Learning Template: Basic Concept
B. CORRECT: Tucking the chin when swallowing allows RELATED CONTENT
food to pass down the esophagus more easily.
C. Using a straw increases the client’s risk for aspiration. Anorexia nervosa
D. Sitting for an hour after meals helps prevent ●
Significantly low body weight for gender, age,
gastroesophageal reflux and possible aspiration developmental level, and physical health.
of stomach contents after a meal. ●
Fears being fat
NCLEX® Connection: Reduction of Risk Potential, Potential for ●
Self-perception of being fat
Complications of Diagnostic Tests/Treatments/Procedures ●
Consistent restriction of food intake or repeated
behavior that prevents weight gain
2. A. Although the body gets more than half of its energy supply Bulimia nervosa
from fat, it is an inefficient means of obtaining energy. It
●
Cycle of binge eating followed by purging (vomiting,
produces end products the body has to excrete, and it using diuretics or laxatives, exercise, fasting)
requires energy from another source to burn the fat. ●
Lack of control during binges
B. Protein can supply energy, but it has other very essential ●
Average of at least one cycle of binge eating and
and specific functions that only it can perform. So purging per week for at least 3 months
it is not the body’s priority energy source.
Binge-eating disorder
C. Glycogen, which the body stores in the liver, is a backup
source of energy, not a primary or priority source.
●
Repeated episodes of binge eating
D. CORRECT: Carbohydrates are the body’s greatest energy
●
Feels a loss of control when binge eating, followed by an
source; providing energy for cells is their primary function. emotional response (guilt, shame, or depression)
They provide glucose, which burns completely and efficiently ●
Does not use compensatory behaviors (purging)
without end products to excrete. They are also a ready ●
Binge-eating episodes can range from 1
source of energy, and they spare proteins from depletion. to more than 14 times per week.
NCLEX® Connection: Health Promotion and Maintenance, ●
Clients are often overweight or obese.
Health Promotion/Disease Prevention NCLEX® Connection: Health Promotion and Maintenance, Health
Promotion/Disease Prevention
3. A. Whole grains (barley and oats) are high in fiber and thus
inappropriate components of a low-residue diet.
B. Raw and gas-producing vegetables (broccoli and
the cabbage in coleslaw) are high in fiber and thus
inappropriate components of a low-residue diet.
C. CORRECT: A low-residue diet consists of foods that are low
in fiber and easy to digest. Dairy products and eggs (custard
and yogurt) are appropriate for a low-residue diet.
D. Legumes (lentils and black beans) are high in fiber and
thus inappropriate components of a low-residue diet.
4. BMI = weight (kg) ÷ height (m2).

Step 1: Client’s weight (kg) and height (m) = 80 kg and 1.6 m
Step 2: 1.6 × 1.6 = 2.56 m2
Step 3: 80 ÷ 2.56 = 31.25
A BMI greater than 30 identifies obesity.
5. A. CORRECT: Sensations of thirst diminish with age, leaving

older adults more prone to dehydration.
B. CORRECT: These requirements do not change from
middle adulthood to older adulthood. However, some
older adults need additional vitamin and mineral
supplements to treat or prevent specific deficiencies.
C. CORRECT: If older adults ingest insufficient calcium
in the diet, they need supplements to help prevent
bone demineralization (osteoporosis).
D. Older adults have a slower metabolic rate, so
they require less energy (unless they are very
active), and therefore need fewer calories.
E. Many older adults need more carbohydrates for the fiber and
bulk they contain. They should, however, reduce their intake
of fats and of “empty” calories (pastries and soda pop).

CHAPTER 40
UNIT 4 PHYSIOLOGICAL INTEGRITY SYSTEMIC EFFECTS OF IMMOBILITY
Integumentary
CHAPTER 40 Mobility and Increased pressure on skin, which is aggravated by
Immobility
●
metabolic changes
● Decreased circulation to tissue causing ischemia, which
can lead to pressure injury
Mobility is freedom and independence in Respiratory

purposeful movement. Mobility refers to ● Decreased respiratory movement resulting in decreased
oxygenation and carbon dioxide exchange
adapting to and having self-awareness of the ● Stasis of secretions and decreased and weakened
environment. Functional musculoskeletal and respiratory muscles, resulting in atelectasis and
hypostatic pneumonia
nervous systems are essential for mobility. ● Decreased cough response
Immobility is the inability to move freely and Cardiovascular

independently at will. The risk of complications ● Orthostatic hypotension
increases with the degree of immobility and ● Less uid olume in the circulatory system
Stasis of blood in the legs
the length of time of immobilization. Periods
●
● Diminished autonomic response

of immobility or prolonged bed rest can cause ● Decreased cardiac output, leading to poor
cardiac effecti eness, hich results in increased
major physiological and psychosocial effects. cardiac workload
Increased oxygenation requirement
Cutaneous stimulation in the form of cold
●
● Increased risk of thrombus development

and heat applications helps relieve pain and
Metabolic
promotes healing. Promoting venous return
Altered endocrine system
is another key component of reducing the
●
● Decreased basal metabolic rate

complications of immobility. ● Changes in protein, carbohydrate, and fat metabolism
● Decreased appetite with altered nutritional intake
● Negative nitrogen balance
Mobility and immobility

● Decreased protein resulting in loss of muscle
● Loss of weight
● Alterations in calcium, uid, and electrolytes
Immobility can be the following. ● Resorption of calcium from bones
● Temporary (following knee arthroplasty) ● Decreased urinary elimination of calcium, resulting
● Permanent (paraplegia)
in hypercalcemia
● Sudden onset (a fractured arm and leg following a
motor-vehicle crash)
Elimination
● Slow onset (multiple sclerosis)
GENITOURINARY
Body mechanics involves coordination between the ● Urinary stasis
musculoskeletal and nervous systems, and the use of ● Change in calcium metabolism with hypercalcemia,
alignment, balance, gravity, and friction.
resulting in renal calculi
Movement depends on an intact skeletal system, skeletal ● Decreased uid inta e and increased use of ind elling
muscles, and nervous system. urinary catheters, resulting in urinary tract infections
Assessment focuses on mobility, range of motion GASTROINTESTINAL

(ROM), gait, exercise status, activity tolerance, and body ● Decreased peristalsis
alignment while standing, sitting, and lying. ● Decreased uid inta e
● Constipation, increasing the risk for fecal impaction
FACTORS AFFECTING MOBILITY
● Alterations in muscles
● Injury to the musculoskeletal system
● Poor posture
● Impaired central nervous system
● Health status and age
FUNDAMENTALS FOR NURSING CHAPTER 40 MOBILITY AND IMMOBILITY 227

Musculoskeletal ASSESSMENT/DATA COLLECTION
● Decreased muscle endurance, strength, and mass
AND PATIENT-CENTERED CARE
Impaired balance
Integumentary
●
● Atrophy of muscles
● Decreased stability Maintain intact skin.
● Altered calcium metabolism
ASSESSMENT
● Osteoporosis ● Observe the skin for breakdown, warmth, and
● Pathological fractures
change in color.
● Contractures ● Look for pallor or redness in fair-skinned clients, and
● Foot drop
purple or blue discoloration in dark-skinned clients.
● Altered joint mobility ● Observe bony prominences.
Check skin turgor.
Neurologic/Psychosocial
●
● Use a pressure injury risk scale (Norton or Braden).

● Altered sensory perception ● Assess at least every 2 hr.
● Ineffecti e coping ● Observe for urinary or bowel incontinence.
CHANGES IN EMOTIONAL STATUS: Depression, alteration NURSING INTERVENTIONS

in self-concept, and anxiety ● Identify clients at risk for pressure injury development.
● Position using corrective devices (pillows, foot boots,
BEHAVIORAL CHANGES: Withdrawal, altered sleep/wake
trochanter rolls, splints, wedge pillows).
pattern, hostility, inappropriate laughter, and passivity ● Turn every 1 to 2 hr, and use devices for support or
per protocol.
Developmental ● Teach clients who can move independently to turn at
INFANTS, TODDLERS, AND PRESCHOOLERS least every 15 min.
● Slower progression in gross motor skills and intellectual ● Provide clients who are sitting in a chair with a device
and musculoskeletal development to decrease pressure.
● Body aligned with line of gravity, resulting in ● Limit sitting in a chair to 1 hr. Instruct clients to shift
unbalanced posture their weight every 15 min.
● Use a therapeutic bed or mattress for clients in bed for
ADOLESCENTS
an extended time.
● Imbalanced growth spurt possibly altered with immobility ● Monitor nutritional intake.
● Delayed development of independence ● Provide skin and perineal care.
● Social isolation
ADULTS Respiratory
● Alterations in every physiological system
Maintain airway patency, achieve optimal lung expansion
● Alterations in family and social systems
and gas exchange, and mobilize airway secretions.
● Alterations in job identity and self-esteem
ASSESSMENT
OLDER ADULTS
Complete every 2 hr.
● Alterations in balance resulting in a major risk for falls ● Observe chest wall movement for symmetry.
and injuries ● Auscultate lungs and identify diminished breath sounds,
● Steady loss of bone mass resulting in weakened bones
crackles, or wheezes.
● Decreased coordination ● Observe for productive cough, and note the color,
● Slower walk with smaller steps
amount, and consistency of secretions.
● Alterations in functional status
● Increased dependence on staff and family, hich can NURSING ACTIONS
become long-term ● Reposition every 1 to 2 hr.
● Remove abdominal binders every 2 hr and replace correctly.
● Use chest physiotherapy.
● Auscultate the lungs to determine the effecti eness of
chest physiotherapy or other respiratory therapy.
● Monitor the ability to expectorate secretions.
● Use suction if unable to expectorate secretions.
CLIENT EDUCATION
● Turn, cough, and breathe deeply every 1 to 2 hr
while awake.
● Yawn every hour while awake.
● Use an incentive spirometer while awake.
● Consume at least , mL uid per day, unless inta e
is restricted.
228 CHAPTER 40 MOBILITY AND IMMOBILITY CONTENT MASTERY SERIES

Cardiovascular Elimination
Maintain cardiovascular function, increase activity Maintain urinary and bowel elimination.
tolerance, and prevent thrombus formation.
ASSESSMENT
ASSESSMENT ● Assess I&O.
● Measure orthostatic blood pressure and pulse (lying to ● Assess the bladder for distention.
sitting to standing), and assess for dizziness. ● Observe urine for color, amount, clarity, and frequency.
● Palpate the apical and peripheral pulses. ● Auscultate bowel sounds.
● Auscultate the heart at the apex for S3 (an early ● Observe feces for color, amount, frequency,
indication of heart failure). and consistency.
● Palpate for edema in the sacrum, legs, and feet.
NURSING ACTIONS
● Palpate the skin for warmth in peripheral areas to ● aintain hydration at least , mL day unless uid
include the nose, ear lobes, hands, and feet.
is restricted).
● Assess for deep-vein thrombosis by observing the calves ● Give a stool softener, laxative, or enema as needed.
for redness and palpating for warmth and tenderness. ● Provide perineal care.
● Measure the circumference of both calves and thighs ● Teach bladder and bowel training.
and compare in size. ● Insert a straight or indwelling catheter to relieve or
NURSING ACTIONS manage bladder distention.
● Increase activity as soon as possible by dangling feet on ● Promote urination by pouring warm water over the
side of bed or transferring to a chair. perineal area.
● Change position as often as possible.
CLIENT EDUCATION: Consume a diet that includes fruits
● Move the client gradually during position changes.
and egetables and is high in ber.
● Instruct clients to avoid the Valsalva maneuver.
Give a stool softener to prevent straining.
Musculoskeletal
●
● Teach range of motion (ROM) and antiembolic exercises

an le pumps, foot circles, nee e ion . Maintain or regain body alignment and stability, decrease
● Use elastic stockings. skin and musculoskeletal system changes, achieve full or
● Use sequential compression devices (SCDs). optimal ROM, and prevent contractures.
● Increase uid inta e if no restrictions.
ASSESSMENT
● Administer low-dose heparin or enoxaparin ● Assess ROM capability.
subcutaneously prophylactically. ● Assess muscle tone and mass.
● Contact the provider immediately if there is absence of a ● Observe for contractures.
peripheral pulse in the lower extremities or assessment ● Monitor gait.
data that indicates venous thrombosis. ● Monitor nutritional intake of calcium.
CLIENT EDUCATION ● Monitor use of assistive devices to assist with ADLs.
● Perform isometric exercises to increase activity tolerance.
NURSING ACTIONS
● Avoid placing pillows under the knees or lower extremities, ● Make sure clients change position in bed at least every 2 hr
crossing the legs, wearing tight clothes around the
and perform weight shifts in the wheelchair every 15 min.
waist or on the legs, sitting for long periods of time, and ● Encourage active or provide passive
massaging the legs.
ROM two or three times/day.
A continuous passive motion (CPM) device might
Metabolic
●
be prescribed. Develop an individualized program

Reduce skin injury and maintain metabolism. for each client. Older adult clients can require a
program that addresses the aging process.
ASSESSMENT ● Cluster care to promote a proper sleep-wake cycle.
● Record anthropometric measurements of height, weight, ● Request physical therapy for clients
and skin folds.
who have decreased mobility.
● Assess I&O. ● Assist client with ambulation. Use assistive devices
● Assess food intake.
(gait belts, walkers, canes, or crutches) as needed.
● Review urinary and bowel elimination status.
● Assess wound healing. CLIENT EDUCATION
● Auscultate bowel sounds. ● Perform ROM while bathing, eating, grooming,
● Check skin turgor. and dressing.
● Review laboratory values for electrolytes, blood total
protein, and BUN.
NURSING ACTIONS
● Provide a high-calorie, high-protein diet with vitamin B
and C supplements.
● Monitor and evaluate oral intake. For clients who
cannot eat or drink, provide enteral or parenteral
nutritional therapy.

Cane instructions ● Involve clients in daily care.
● Maintain two points of support on the ground at all times. ● Provide stimuli (books, crafts, television,
● Keep the cane on the stronger side of the body. newspapers, radio).
● Support body weight on both legs. ● Help clients maintain body image by performing or
● Move the cane forward 15 to 25 cm (6 to 10 in). assisting with hygiene and grooming tasks (shaving or
● Next, move the weaker leg forward toward the cane. applying makeup).
● Finally, advance the stronger leg past the cane. ● Ha e nurses and other staff interact on a routine and
informal social basis.
Crutch instructions ● Recommend a referral for consultation (psychological,
● Do not alter crutches after tting.
spiritual, or social worker) for clients who are not
● Follow the prescribed crutch gait.
coping well.
● Support body weight at the hand grips with elbows
e ed at to .
Developmental
● Hold the crutches in one hand and grasp the arm of the
chair with the other hand for balance while sitting and Continue expected development and achieve physical and
rising from a chair. mental stimulation.
● The tripod position is the basic crutch stance. The client
Infancy through school age
should place the crutches 15 cm (6 in) in front of and ● ASSESSMENT
15 cm (6 in) to the side of each foot to provide a wide ◯ Gross motor skills, and intellectual and
base of support.
musculoskeletal development
● Crutch gait: client alternates weight from one leg to the ◯ Body alignment and posture
other as well as on the crutches. ◯ De elopmental tas s speci c to age
● The client should stand with a straight back, hips, head ● NURSING ACTIONS
and neck and should not place any weight on the axillae. ◯ Implement activities that stimulate physical and
● Types of gaits
psychosocial systems. Increase mobility, and involve
◯ Four-point gait requires the client to bear weight
play therapists in age-appropriate activities.

on both legs. The client alternates each leg with the ◯ Use measures to prevent falls.
opposite crutch so three points of support are on the ◯ Develop strategies for maintaining or enhancing the
oor at all time.
developmental process.
◯ Three-point gait requires the client to bear all weight
◯ Teach families that their perception of immobility can
on one foot hile using both crutches. The affected
affect progress and ability to cope.
leg should never bear weight or touch the ground. ◯ Encourage parents to stay with children.
◯ Two-point gait requires the client to have partial
◯ Incorporate children’s involvement, if age-appropriate,
weight bearing on both feet. The client moves a
in their treatments.
crutch while moving the opposite leg at the same ◯ Place children in a room with others who are age-
time. This is to mirror the movements of normal arm
appropriate.
and leg motion during walking.
Adolescents
Psychosocial ● ASSESSMENT
◯ ro th and de elopment speci c to age
Maintain an acceptable sleep/wake pattern, achieve ◯ Level of independence
socialization, and complete self-care independently. ◯ Social activities
ASSESSMENT ● NURSING ACTIONS
● Assess emotional status. ◯ Initiate care that facilitates independence.
● Assess mental status. ◯ Involve adolescents in decision-making for ADLs.
● Assess behavior and decision-making skills. ◯ Provide stimuli to promote socialization (interaction
● Monitor mobility status. with peers, use of adolescents’ activity room).
● Observe for unusual alterations in sleep/wake pattern.
Adults
● Assess coping skills, especially for loss. ● ASSESSMENT
● Monitor activities of daily living (ADLs). ◯ All physical systems
● Assess for family support and relationships. ◯ Family relationships
● Monitor social activities. ◯ Social status
NURSING ACTIONS ◯ Meaning of career/job
● Assist in using usual coping skills or in developing new ● NURSING ACTIONS
coping skills. ◯ Provide care that promotes activity in all
● Maintain orientation to time (clock and calendar with physical systems.
date), person (call by name and introduce self), and ◯ Discuss with families the importance of interaction
place (talk about treatments, therapy, length of stay). with clients.
● Develop a schedule of therapies, and place it on a ◯ Discuss social involvement.
calendar for clients. ◯ Discuss the meaning of career/job.
● Arrange for clients who have limited mobility to be in a
semiprivate room with an alert roommate.

Older adults ● Make sure the provider has written a prescription that
● ASSESSMENT includes the following.
◯ Balance ◯ Location
◯ Coordination ◯ Duration and frequency
◯ Gait ◯ peci c type moist or dry

◯ Functional status ◯ Temperature to use
◯ Level of independence
HEAT
◯ Social isolation ● Monitor bony prominences carefully because they are
● NURSING ACTIONS
more sensitive to heat applications.
◯ Plan care with clients and families to increase ● Avoid the use of heat applications over metal devices
independence with ADLs and decision-making skills.
(pacemakers, prosthetic joints) to prevent deep
◯ Teach the staff to facilitate clients independence in
tissue burns.
all activities. ● Do not apply heat to the abdomen of a client who is
◯ Provide stimuli (a clock, newspaper, calendar,
pregnant to prevent harm to the fetus.
weather status). ● Do not place a heat application under a client who is
◯ Encourage families to visit to maintain socialization.
immobile because this can increase the risk of burns.
◯ Plan for staff to spend some time tal ing and ● Do not use heat applications during the rst hr after
listening to clients.
a traumatic in ury, for acti e bleeding, nonin ammatory
edema, or some skin disorders.
Application of heat and cold SUPPLIES

THERAPEUTIC EFFECTS Heat application
Heat MOIST
● Increases blood o ● Warm compresses: towel, bath thermometer, hot water,
● Increases tissue metabolism plastic covering, hot pack or aquathermia pad (with
● Relaxes muscles distilled water), tape
● ases oint stiffness and pain ● Warm soaks: water, bath thermometer, basin, waterproof pads
● it baths speci c chair, tub, or basin disposable or
Cold
built-in), bath thermometer, bath blanket, towels
● Decreases in ammation
● Prevents swelling DRY
● Reduces bleeding ● Hot pack (disposable or reusable) or an aquathermia pad
● Reduces fever with distilled water, and a pillowcase
● Diminishes muscle spasms ● Warming blanket
● Decreases pain by decreasing the velocity of nerve
conduction Cold application
MOIST
Cold water compresses
PATIENT-CENTERED CARE
●
● Cold soaks
DRY
CONSIDERATIONS ● Ice bag, ice collar, ice glove, or a cold pack
FOR CLIENTS AT RISK FOR INJURY FROM HEAT/COLD ● Cooling blanket
● Use extreme caution with clients who are very young or
fair-skinned, and older adults because they have
fragile skin.
NURSING ACTIONS
● Clients who are immobile might not be able to move away ● Apply to the area.
from the application if it becomes uncomfortable. They are ● Make sure the call light is within reach, and instruct
at increased risk for skin injuries. clients to report any discomfort.
● Clients who have impaired sensory perception might not ● Assess the site every 5 to 10 min to check for
feel numbness, pain, or burning. the following.
● Use minor temperature changes and short-term ◯ Redness or pallor
applications of heat or cold for best results. ◯ Pain or burning
● Avoid long applications of either heat or cold because ◯ Numbness
this can result in tissue damage, burns, and re e ◯ Shivering (with cold applications)
vasodilation (with cold therapy). ◯ Blisters
● Do not use cold applications for clients who have cold ◯ Decreased sensation
intolerance, ascular insufficiency, open ounds, and ◯ Mottling of the skin
disorders aggravated by cold (Raynaud’s phenomenon). ◯ Cyanosis (with cold applications)

● Discontinue the application if any of the above occur, ● Perform hand hygiene.
or remove the application at the predetermined time ● Assess circulation and skin prior to application.
usually to min . ● Measure around the largest part of the thigh to
● Document the following. determine the stocking size.
◯ Location, type, and length of the application ● Apply the sleeves to each leg. Position the opening at
◯ Condition of the skin before and after the application the client’s knees.
◯ Client’s tolerance of the application ● Attach the slee es to the in ator.
● Turn on the device.
● Monitor circulation and skin after application.
Promoting venous return ●
●
Remove every 8 hr for assessment of calves.
Document the application and removal of the stockings.
● Elastic (antiembolic) stockings cause external pressure
on the muscles of the lower extremities to promote Positioning techniques
blood return to the heart.
To reduce compression of leg veins
● SCDs and IPC have plastic or fabric sleeves that wrap
around the leg and secure with hook-and-loop closures. CLIENT EDUCATION: Avoid the following.
The sleeves are then attached to an electric pump that ● Crossing legs
alternately in ates and de ates the slee e around the leg. ● Sitting for long periods
These machines are set to cycle, typically a 10- to ● Wearing restrictive clothing on the lower extremities
second in ation and a to second de ation. ● Putting pillows behind the knees
● Positioning techniques reduce compression of leg veins. ● Massaging legs
● ROM exercises cause skeletal muscle contractions,
hich promote blood return. peci c e ercises that help ROM exercises
prevent thrombophlebitis include ankle pumps, foot
Hourly while awake.
circles, and nee e ion.
● Antiembolic stockings and SCDs require a prescription. CLIENT EDUCATION: Perform the following.
● Clients who are immobile should perform leg exercises, ● Ankle pumps: Point the toes toward the head and then
increase their uid inta e, and change positions fre uently. away from the head.
● When suspecting poor venous return or possible thrombus, ● Foot circles: Rotate the feet in circles at the ankles.
notify the provider, elevate the leg, and do not apply ● Knee flexion: Flex and extend the legs at the knees.
pressure or massage the thrombus to avoid dislodging it.
COMPLICATIONS
Thrombophlebitis, deep-vein thrombosis
Antiembolic stockings
Thrombophlebitis and deep-vein thrombosis are
EQUIPMENT: Tape measure in ammation of a ein usually in the lo er e tremities
that result in clot formation.
PROCEDURE
● Perform hand hygiene. MANIFESTATIONS: Pain, edema, warmth, and erythema
● Assess skin, circulation, and presence of edema in the legs. at the site
● Measure the calf and/or thigh circumference and the
ASSESSMENT: Another assessment method for clients
length of the leg to select the correct size stocking.
prone to thrombosis is to measure bilateral calf and thigh
● Turn the stockings inside to the heel.
circumference daily. Unilateral increase is early indication
● Put the stocking on the foot.
of thrombosis.
● Pull the remainder of the stocking over the heel and
up the leg. NURSING ACTIONS
● Smooth any creases or wrinkles. ● Notify the provider immediately.
● Remove the stockings every 8 hr to assess for redness, ● Position the client in bed with the leg elevated.
warmth, or tenderness. ● A oid any pressure at the site of the in ammation.
● Make sure the stockings are not too tight over the toes. ● Anticipate giving anticoagulants.
● Keep the stockings clean and dry. Clients who are
postoperati e or ha e speci c needs can need a second Pulmonary embolism
pair of hose.
A pulmonary embolism is a potentially life-threatening
● Document the application and removal of the stockings.
occlusion of blood o to one or more of the pulmonary
arteries by a clot. The clot or embolus often originates in
SCDs
the venous system of the lower extremities.
EQUIPMENT
MANIFESTATIONS: Shortness of breath, chest pain,
● Tape measure
hemoptysis (coughing up blood), decreased blood pressure,
● Sequential stockings
and rapid pulse
PROCEDURE
NURSING ACTIONS

NURSING ACTIONS Active Learning Scenario
● Prepare to give thrombolytics or anticoagulants.
● Position client in a high-Fowler’s position. A nurse is reviewing the effects of immobility
● Obtain pulse oximetry. on various body systems with a group of newly
● Administer oxygen. licensed nurses. Use the ATI Active Learning
● Prepare to obtain blood gas analysis. Template: Basic Concept to complete this item.
● Monitor vital signs frequently.
RELATED CONTENT: List at least two effects
of immobility on the cardiovascular system and
at least two on the respiratory system.
1. A nurse is caring for a client who has been 4. A nurse is evaluating a client’s understanding
sitting in a chair for 1 hr. Which of the following of the use of a sequential compression device.
complications is the greatest risk to the client? Which of the following client statements
A. Decreased subcutaneous fat indicates client understanding?
B. Muscle atrophy A. “This device will keep me from
C. Pressure injury getting sores on my skin.”
D. Fecal impaction B. “This device will keep the blood
pumping through my leg.”
C. “With this device on, my leg
2. A nurse is caring for a client who is postoperative. muscles won’t get weak.”
D. “This device is going to keep my
the nurse take to reduce the risk of thrombus
joints in good shape.”
development? (Select all that apply.)
A. Instruct the client not to perform
the Valsalva maneuver. 5. A nurse is instructing a client, who has an injury
B. Apply elastic stockings. of the left lower extremity, about the use of a
cane. Which of the following instructions should
C. Review laboratory values for total protein level. the nurse include? (Select all that apply.)
D. Place pillows under the client’s A. Hold the cane on the right side.
knees and lower extremities.
B. Keep two points of support on the floor.
E. Assist the client to change positions often.
C. Place the cane 38 cm (15 in) in front
of the feet before advancing.
3. A nurse is planning care for a client who is on D. After advancing the cane, move
bed rest. Which of the following interventions the weaker leg forward.
should the nurse plan to implement? E. Advance the stronger leg so that it
A. Encourage the client to perform aligns evenly with the cane.
antiembolic exercises every 2 hr.
B. Instruct the client to cough and
deep breathe every 4 hr.
C. Restrict the client’s fluid intake.
D. Reposition the client every 4 hr.

1. A. The client is at risk for decreased subcutaneous Using the ATI Active Learning Template: Basic Concept
fat due to altered mobility. However, there is RELATED CONTENT
another risk that is the priority.
B. The client is at risk for muscle atrophy due to altered mobility. Cardiovascular system
However, there is another risk that is the priority. ●
Orthostatic hypotension
C. CORRECT: The greatest risk to this client is injury ●
Less fluid volume in the circulatory system
from skin breakdown due to unrelieved pressure ●
Stasis of blood in the legs
over a bony prominence from prolonged sitting in ●
Diminished autonomic response
a chair. Instruct the client to shift his weight every ●
Decreased cardiac output leading to poor cardiac
15 min and reposition the client after 1 hr.
effectiveness, which results in increased cardiac workload
D. The client is at risk for fecal impaction due to altered
mobility. However, there is another risk that is the priority.
●
Increased oxygenation requirement
●
Increased risk of thrombus development
NCLEX® Connection: Basic Care and Comfort, Mobility/
Immobility Respiratory system
●
Decreased respiratory movement resulting in decreased
oxygenation and carbon dioxide exchange
2. A. The Valsalva maneuver increases the workload of the ●
Stasis of secretions and decreased and weakened respiratory
heart, but it does not affect peripheral circulation. muscles, resulting in atelectasis and hypostatic pneumonia
B. CORRECT: Elastic stockings promote venous ●
Decreased cough response
return and prevent thrombus formation.
C. A review of the client’s total protein level is important for NCLEX® Connection: Basic Care and Comfort, Mobility/Immobility
evaluating his ability to heal and prevent skin breakdown.
D. Placing pillows under the knees and lower extremities
can impair circulation of the lower extremities.
E. CORRECT: Frequent position changes
prevents venous stasis.
Immobility
3. A. CORRECT: Encourage the client to perform antiembolic

exercises every 1 to 2 hr to promote venous return
and reduce the risk of thrombus formation.
B. Instruct the client to cough and deep breathe every
1 to 2 hr to reduce the risk of atelectasis.
C. Increase the client’s intake of fluids, unless
contraindicated, to reduce the risk of thrombus
formation, constipation, and urinary dysfunction.
D. Reposition the client every 1 to 2 hr to
reduce the risk for pressure injuries.
Immobility
4. A. Assess the skin under the sequential pressure

device every 8 hr to check for manifestations
of a thrombus and skin breakdown.
B. CORRECT: Sequential pressure devices promote
venous return in the deep veins of the legs and
thus help prevent thrombus formation.
C. Continuous passive motion machines, not sequential
pressure devices, provide some muscle movement that
can assist in preserving some muscle strength.
D. Continuous passive motion machines, not sequential pressure
devices, exercise the knee joint after arthroplasty.
Immobility
5. A. CORRECT: The client should hold the cane on the uninjured

side to provide support for the injured left leg.
B. CORRECT: The client should keep two points of
support on the ground at all times for stability.
C. The client should place the cane 15 to 25 cm (6 to
10 in) in front of their feet before advancing.
D. CORRECT: The client should advance the weaker
leg first, followed by the stronger leg.
E. The client should advance the stronger leg past the cane.
Immobility

CHAPTER 41
UNIT 4 PHYSIOLOGICAL INTEGRITY PAIN CATEGORIES
Pain is categorized by duration (acute or chronic) or by
Pain Management origin (nociceptive or neuropathic).

CHAPTER 41
Acute pain
Acute pain is protective, temporary, usually self-limiting,
Effective pain management includes the use
●
has a direct cause, and resolves with tissue healing.

of pharmacological and nonpharmacological ● Physiological responses (sympathetic nervous system)
are ght or ight responses tachycardia, hypertension,
pain management therapies. Invasive therapies anxiety, diaphoresis, muscle tension).
(nerve ablation) can be appropriate for ● Behavioral responses include grimacing, moaning,
inching, and guarding.
intractable cancer-related pain. ● Interventions include treatment of the
underlying problem.
Clients have a right to adequate assessment and ● Can lead to chronic pain if unrelieved.
management of pain. Nurses are accountable
Chronic pain
for the assessment of pain. The nurse’s role is
Chronic pain is not protective. It is ongoing or recurs
that of an advocate and educator for effective
●
frequently, lasting longer than 6 months and persisting

pain management. beyond tissue healing.
● Physiological responses do not usually alter vital signs,
Nurses have a priority responsibility to measure but clients can have depression, fatigue, and a decreased
level of functioning. It is not usually life-threatening.
the client’s pain level on a continual basis and to ● Psychosocial implications can lead to disability.
provide individualized interventions. Depending on ● Management aims at symptomatic relief. Pain does not
always respond to interventions.
the setting and route of analgesia administration, ● Chronic pain can be categorized as either cancer pain or
the nurse might be required to reassess pain 10 to noncancer pain.
Idiopathic pain is a form of chronic pain without a
60 min after administering medication.
●
known cause, or pain that exceeds typical pain levels

associated with the client’s condition.
Assessment challenges can occur with clients
trategies speci c for relie ing chronic pain include the
who have cognitive impairment, who speak
following.
a different language than the nurse, or who ● Administering long-acting or controlled-release opioid
analgesics (including the transdermal route).

receive prescribed mechanical ventilation. ● Administering analgesics around the clock
rather than PRN.

Undertreatment of pain is a serious health care
problem. Consequences of undertreatment of
pain include physiological and psychological 41.1 Comparative pain scale
components. Acute/chronic pain can cause
anxiety, fear, and depression. Poorly managed
acute pain can lead to chronic pain syndrome.
FUNDAMENTALS FOR NURSING CHAPTER 41 PAIN MANAGEMENT 235

Nociceptive pain PHYSIOLOGY OF NOCICEPTIVE PAIN
● Nocicepti e pain arises from damage to or in ammation Transduction is the conversion of painful stimuli to
of tissue, which is a noxious stimulus that triggers the an electrical impulse through peripheral ner e bers
pain receptors called nociceptors and causes pain. (nociceptors).
● It is usually throbbing, aching, and localized.
Transmission occurs as the electrical impulse travels
● This pain typically responds to opioids and
along the ner e bers, here neurotransmitters
non-opioid medications.
regulate it.
TYPES OF NOCICEPTIVE PAIN
Pain threshold is the point at which a person feels pain.
● Somatic: In bones, joints, muscles, skin, or
connective tissues. Pain tolerance is the amount of pain a person is
● Visceral: In internal organs (the stomach or intestines). willing to bear.
It can cause referred pain in other body locations
Perception or awareness of pain occurs in various
separate from the stimulus.
areas of the brain, ith in uences from thought and
● Cutaneous: In the skin or subcutaneous tissue.
emotional processes.
Neuropathic pain Modulation occurs in the spinal cord, causing muscles

to contract re e i ely, mo ing the body a ay from
● Neuropathic pain arises from abnormal or damaged
painful stimuli.
pain nerves.
● It includes phantom limb pain, pain below the level of a SUBSTANCES THAT INCREASE PAIN TRANSMISSION AND
spinal cord injury, and diabetic neuropathy. CAUSE AN INFLAMMATORY RESPONSE
● Neuropathic pain is usually intense, shooting, burning, ● Substance P
or described as “pins and needles.” ● Prostaglandins
● This pain typically responds to adjuvant medications ● Bradykinin
(antidepressants, antispasmodic agents, skeletal ● Histamine
muscle relaxants). Topical medications can provide
SUBSTANCES THAT DECREASE PAIN TRANSMISSION AND
relief for peripheral neuropathic pain.
PRODUCE ANALGESIA
● Serotonin
● Endorphins
41.2 Focused pain assessment

Use anatomical terminology and Intensity, strength, and severity are Setting: how the pain affects
landmarks to describe location “measures” of the pain. Use a pain daily life or how activities of daily
(superficial deep, referred, or radiating). intensity scale (visual analog, description, living (ADLs) affect the pain
or number rating scales) to measure
QUESTIONS pain, monitor pain, and evaluate the QUESTIONS
“Where is your pain? Does it effectiveness of interventions. “Where are you when the
radiate anywhere else?” symptoms occur?”
QUESTIONS
Ask clients to point to the location. “What are you doing when
“How much pain do you have now?” the symptoms occur?”
“What is the worst/best “How does the pain affect your sleep?”
Quality refers to how the pain feels: the pain has been?”
sharp, dull, aching, burning, stabbing, “How does the pain affect your ability
“Rate your pain on a scale of 0 to 10.” to work or interact with others?”
pounding, throbbing, shooting, gnawing,
tender, heavy, tight, tiring, exhausting,
sickening, terrifying, torturing, nagging, Timing: onset, duration, frequency
annoying, intense, or unbearable. Associated findings: fatigue,
QUESTIONS depression, nausea, anxiety.
QUESTIONS
“When did it start?” QUESTIONS
“What does the pain feel like?”
“How long does it last?” “What other symptoms do you have
Give more than two choices: “Is the pain when you are feeling pain?”
throbbing, burning, or stabbing?” “How often does it occur?”
“Is it constant or intermittent?”
Aggravating/relieving factors
QUESTIONS
“What makes the pain better?”
“What makes the pain worse?”
“Are you currently taking any prescription,
herbal, or over-the-counter medications?”
236 CHAPTER 41 PAIN MANAGEMENT CONTENT MASTERY SERIES

Online Video: Pain Assessment
ASSESSMENT/DATA COLLECTION EXPECTED FINDINGS

● Noted pain experts agree that pain is whatever the ● Behaviors complement self-report and assist in pain
person experiencing it says it is, and it exists whenever assessment of nonverbal clients.
the person says it does. The client’s report of pain is the ◯ Facial expressions (grimacing, wrinkled forehead),
most reliable diagnostic measure of pain. body movements (restlessness, pacing, guarding)
● Self-report using standardized pain scales is useful for ◯ Moaning, crying
clients over the age of 7 years. Pain scales can include ◯ Decreased attention span
images, numbers, words, or other intensity markers that ● Blood pressure, pulse, and respiratory rate increase
allow the client to select a pain level. temporarily with acute pain. Eventually, increases
● Specialized pain scales are available for use with in vital signs will stabilize despite the persistence of
younger children or indi iduals ho ha e difficulty pain. Therefore, physiologic indicators might not be an
communicating verbally. accurate measure of pain over time.
● Assess and document pain the fth ital sign fre uently. ● Clients might experience hyperalgesia (a heightened
● Use a symptom analysis to obtain subjective data. (41.2) sense of pain).
● Allodynia is a condition in which the client experiences
pain following experiences that are not usually painful
RISK FACTORS (when wearing clothes or feeling the wind blow).
UNDERTREATMENT OF PAIN
● Cultural and societal attitudes
● Lack of knowledge PATIENT-CENTERED CARE
● Fear of addiction
Exaggerated fear of respiratory depression
NURSING CARE
●
POPULATIONS AT RISK FOR UNDERTREATMENT OF PAIN ● When pain is persistent, schedule pain interventions
● Infants
around the clock to keep pain at a more tolerable
● Children
level. Including PRN dosing is helpful for managing
● Older adults
pain exacerbations.
● Clients who have substance use disorder ● Review provider prescriptions for analgesia, noting
CAUSES OF ACUTE AND CHRONIC PAIN that some might be for mild, moderate, or severe pain.
● Trauma Use nursing judgment to determine the prescription to
● Surgery administer based on client data.
● Cancer (tumor invasion, nerve compression, bone ● Older adults are at an increased risk for undertreatment
metastases, associated infections, immobility) of pain, as well as increased risk for adverse events
● Arthritis following analgesia administration.
● Fibromyalgia ● Take a proactive approach by giving analgesics before
● Neuropathy pain becomes too severe. It takes less medication
● Diagnostic or treatment procedures (injection, to prevent pain than to treat pain. Medicating the
intubation, radiation) client prior to painful procedures can prevent or
minimize pain.
FACTORS THAT AFFECT THE PAIN EXPERIENCE ● Instruct clients to report developing or recurrent
● Age
pain and not wait until pain is severe (for PRN
◯ Infants cannot verbalize or understand their pain.
pain medication).
◯ Older adult clients can have multiple pathologies that ● Explain misconceptions about pain (medication
cause pain and limit function.
dependence, pain measurement and perception).
● Fatigue: Can increase sensitivity to pain. ● Help clients reduce fear and anxiety.
● Genetic sensitivity: Can increase or decrease ● Create a treatment plan that includes both
pain tolerance.
nonpharmacological and pharmacological
● Cognitive function: Clients who have cognitive
pain-relief measures.
impairment might not be able to report pain or report
it accurately.
● Prior experiences: Can increase or decrease sensitivity
depending on whether clients obtained adequate relief.
● Anxiety and fear: Can increase sensitivity to pain.
● Support systems and coping styles: Presence of these
can decrease sensitivity to pain.
● Culture: Can in uence ho clients e press pain or the
meaning they give to pain.

NONPHARMACOLOGICAL PAIN Non-opioid analgesics
MANAGEMENT STRATEGIES Non-opioid analgesics (acetaminophen, nonsteroidal
The nurse should not require the client to use anti in ammatory drugs N AIDs , including salicylates
nonpharmacological strategies in place of pharmacological are appropriate for treating mild to moderate pain.
pain measures, although the client has the right to choose ● e a are of the hepatoto ic effects of acetaminophen.
whether to use both types. Clients who have a healthy liver should take no more
● Ensure bed linens are clean and smooth, and that the than 4 g/day. Make sure clients are aware of opioids that
client is not lying on tubing or other equipment that contain acetaminophen (hydrocodone bitartrate 5 mg/
could cause discomfort. acetaminophen 500 mg).
● Position the client in anatomic position, using gentle ● Monitor for salicylism (tinnitus, vertigo, decreased
positioning techniques, and reposition frequently to hearing acuity).
minimize discomfort. ● Prevent gastric upset by administering the medication
● Instruct clients on the use of strategies to reduce pain. with food or antacids.
● Monitor for bleeding with long-term NSAID use.
Cognitive-behavioral measures: changing the way
a client perceives pain, and physical approaches to
Opioid analgesics
improve comfort
Opioid analgesics (morphine sulfate, fentanyl, and
Cutaneous (skin) stimulation: transcutaneous electrical
codeine) are appropriate for treating moderate to severe
nerve stimulation (TENS), heat, cold, therapeutic touch,
pain (postoperative pain, myocardial infarction pain,
and massage
cancer pain).
● Interruption of pain pathways ● It is essential to monitor and intervene for adverse
● Cold for in ammation
effects of opioid use.
● Heat to increase blood o and to reduce stiffness ◯ Sedation: Monitor level of consciousness and take
Distraction safety precautions. Sedation usually precedes
● Includes ambulation, deep breathing, visitors, television, respiratory depression.
games, prayer, and music ◯ Respiratory depression: Monitor respiratory rate prior
● Decreased attention to the presence of pain can decrease to and following administration of opioids (especially
perceived pain level. for clients who have little previous exposure to
opioid medications). Initial treatment of respiratory
Relaxation: Includes meditation, yoga, and progressive
depression and sedation is generally a reduction in
muscle relaxation
opioid dose. If necessary, slowly administer diluted
Imagery nalo one to re erse opioid effects until the client can
● Focusing on a pleasant thought to divert focus deep breathe with a respiratory rate of at least 8/min.
● Requires an ability to concentrate ◯ Orthostatic hypotension: Advise clients to sit or lie
down if lightheadedness or dizziness occur. Instruct
Acupuncture and acupressure: Stimulating subcutaneous
clients to avoid sudden changes in position by slowly
tissues at speci c points using needles acupuncture or
moving from a lying to a sitting or standing position.
the digits (acupressure)
Provide assistance with ambulation.
Reduction of pain stimuli in the environment ◯ Urinary retention: Monitor I&O, assess for distention,
administer bethanechol, and catheterize.
Elevation of edematous extremities to promote venous ◯ Nausea/vomiting: Administer antiemetics,
return and decrease swelling
advise clients to lie still and move slowly, and
eliminate odors.
PHARMACOLOGICAL INTERVENTIONS ◯ Constipation: Use a preventative approach
monitoring of bo el mo ements, uids, ber inta e,
Analgesics are the mainstay for relieving pain. The
exercise, stool softeners, stimulant laxatives, enemas).
three classes of analgesics are non-opioids, opioids,
and adjuvants.
Adjuvant analgesics
● The parenteral route is best for immediate, short-term
relief of acute pain. The oral route is better for chronic, Ad u ant analgesics, or coanalgesics, enhance the effects
non uctuating pain. of non-opioids, help alleviate other manifestations that
aggra ate pain depression, sei ures, in ammation , and
are useful for treating neuropathic pain.
Anticonvulsants: carbamazepine, gabapentin

Antianxiety agents: diazepam, lorazepam
Tricyclic antidepressants: amitriptyline, nortriptyline
Anesthetics: infusional lidocaine
Antihistamine: hydroxyzine
Glucocorticoids: dexamethasone
Antiemetics: ondansetron
Bisphosphonates and calcitonin: for bone pain

Patient-controlled analgesia Application Exercises
Patient-controlled analgesia (PCA) is a medication delivery
system that allows clients to self-administer safe doses 1. A nurse at a clinic is collecting data about pain from of
of opioids. a client who reports severe abdominal pain. The nurse
● Small, frequent dosing ensures consistent plasma levels. asks the client if there has been any accompanying
● Clients ha e less lag time bet een identi ed need and nausea and vomiting. Which of the following pain
delivery of medication, which increases their sense characteristics is the nurse attempting to determine?
of control and can decrease the amount of medication A. Presence of associated manifestations
they need. B. Location of the pain
● Morphine, hydromorphone, and fentanyl are typical C. Pain quality
opioids for PCA delivery.
D. Aggravating and relieving factors
● Clients should let the nurse know if using the pump
does not control the pain.
2. A nurse is collecting data from a client who is
To prevent inadvertent overdosing, the client is the reporting pain despite taking analgesia. Which
only person who should push the PCA button. of the following actions should the nurse take to
determine the intensity of the client’s pain?
Other interventions A. Ask the client what precipitates the pain.
ADDITIONAL PHARMACOLOGICAL PAIN INTERVENTIONS: B. Question the client about the location of the pain.
Local and regional anesthesia and topical analgesia C. Offer the client a pain scale to measure their pain.
D. Use open-ended questions to identify
the client’s pain sensations.
COMPLICATIONS AND
NURSING IMPLICATIONS
3. A nurse is discussing the care of a group of
Undertreatment of pain is a serious complication and can clients with a newly licensed nurse. Which of
lead to increased anxiety with acute pain and depression the following clients should the newly licensed
with chronic pain. Assess clients for pain frequently, and nurse identify as experiencing chronic pain?
intervene as appropriate. A. A client who has a broken femur
Sedation, respiratory depression, and coma can occur as and reports hip pain.
a result of overdosing. Sedation always precedes B. A client who has incisional pain 72 hr
respiratory depression. following pacemaker insertion.
● Identify high-risk clients (older adult clients, clients C. A client who has food poisoning and
who are opioid-naïve). reports abdominal cramping.
● Carefully titrate client dose while closely monitoring D. A client who has episodic back pain
respiratory status. following a fall 2 years ago.
● Stop the opioid and give the antagonist naloxone if
respiratory rate is below 8/min and shallow, or the
client is difficult to arouse.
4. A nurse is monitoring a client for adverse effects
following the administration of an opioid. Which of
● Identify the cause of sedation. the following effects should the nurse identify as an
adverse effect of opioids? (Select all that apply.)
A. Urinary incontinence
B. Diarrhea
A nurse on a medical-surgical unit is reviewing with a C. Bradypnea
group of newly licensed nurses the various types of pain D. Orthostatic hypotension
the clients on the unit have. Use the ATI Active Learning
E. Nausea
UNDERLYING PRINCIPLES: List the four different 5. A nurse is caring for a client who is receiving
types of pain, their definitions, and characteristics. morphine via a patient-controlled analgesia
(PCA) infusion device after abdominal surgery.
Which of the following statements indicates
that the client knows how to use the device?
A. “I’ll wait to use the device until
it’s absolutely necessary.”
B. “I’ll be careful about pushing the button
too much so I don’t get an overdose.”
C. “I should tell the nurse if the pain doesn’t
stop while I am using this device.”
D. “I will ask my adult child to push the
dose button when I am sleeping.”

1. A. CORRECT: Attempt to identify manifestations that occur Using the ATI Active Learning Template: Basic Concept
along with the client’s pain (nausea, fatigue, or anxiety).
B. Ask the client to point out where they feel
pain to determine the location. Acute pain
C. Ask the client if the pain is throbbing, dull, or ●
Definition: Protective, temporary, usually
aching to determine the pain quality. self-limiting, resolves with tissue healing
D. Ask the client what makes the pain better or worse to ●
Physiological responses: Tachycardia, hypertension,
determine aggravating and relieving factors. anxiety, diaphoresis, muscle tension
NCLEX® Connection: Pharmacological and Parenteral Therapies, ●
Behavioral responses: Grimacing, moaning, flinching, guarding
Pharmacological Pain Management
Chronic pain
●
Definition: Not protective; ongoing or recurs frequently,
2. A. Ask what precipitates the client’s pain when collecting lasts longer than 6 months, persists beyond tissue
data to determine the cause of the pain. healing, can be malignant or nonmalignant
B. Ask the location of the client’s pain to help ●
Physiological responses: No change in vital signs; depression;
determine the cause or classify the pain as fatigue; decreased level of functioning; disability
deep, subcutaneous, or radiating. Nociceptive pain
C. CORRECT: Use a pain rating scale to help the ●
Definition: Arises from damage to or inflammation of tissue,
client report the intensity of the pain. The nurse
which is a noxious stimulus that triggers the pain receptors called
should use a numeric, verbal, or visual analog scale
nociceptors and causes pain, is usually throbbing, aching, localized;
appropriate to the client’s individual needs.
pain typically responds to opioids and non-opioid medications
D. Ask open-ended questions about the client’s
pain sensation to help determine the quality of
●
Types of nociceptive pain:
the pain (exhausting, tight, or burning). Somatic: In bones, joints, muscles, skin, or connective tissues
◯
Visceral: In internal organs (the stomach or

◯
NCLEX® Connection: Pharmacological and Parenteral Therapies,

intestines) can cause referred pain
Cutaneous: In skin or subcutaneous tissue
◯
Neuropathic pain
3. A. Pain from a recent, nonhealed bone ●
Definition: Arises from abnormal or damaged pain
fracture is acute pain. nerves (phantom limb pain, pain below the level of
B. Postoperative pain is acute pain. a spinal cord injury, diabetic neuropathy), usually
C. Pain associated with a current illness intense, shooting, burning, or “pins and needles”
(food poisoning, is acute pain). ●
Physiological responses to adjuvant medications (antidepressants,
D. CORRECT: A client who reports pain that lasts more than
antispasmodic agents, skeletal muscle relaxants).
6 months and continues beyond the time of tissue healing is
experiencing chronic pain. Assist with planning interventions NCLEX® Connection: Pharmacological and Parenteral Therapies,
to relieve manifestations associated with the pain. Pharmacological Pain Management
4. A. Urinary retention is a possible adverse

effect of opioid analgesia.
B. Constipation is a possible adverse effect of opioid analgesia.
C. CORRECT: Opioid analgesia can cause respiratory
depression, which causes respiratory rates to drop to
dangerously low levels. Monitor the client’s respiratory
rate, and administer naloxone if indicated.
D. CORRECT: Opioid analgesia can cause
orthostatic hypotension. Monitor for dizziness or
lightheadedness when changing positions.
E. CORRECT: Opioid analgesia can cause nausea and vomiting.
Monitor for and treat these complications as needed.
5. A. Remind the client to use the PCA at the first indications

of pain to achieve better pain control.
B. Remind the client the PCA has a timing control or
lockout mechanism, which enforces a preset minimum
interval between medication doses. The client cannot
self-administer another dose of medication until that time
interval has passed, even if the button is pressed.
C. CORRECT: PCA allows the client to self-administer
pain medication on an as-needed basis. The provider
can modify the PCA settings if needed to ensure
the client achieves adequate pain relief.
D. Warn the client not to allow others to use the PCA pump. In
situations where a client is not able to do so, a provider may
authorize a nurse or a family member to operate the pump.

CHAPTER 42
UNIT 4 PHYSIOLOGICAL INTEGRITY CATEGORIES OF CAM
Whole medical systems: Complete medical systems
Complementary outside of allopathic medicinal beliefs (traditional Chinese

CHAPTER 42 medicine, ayurveda, homeopathy)
and Alternative Biological and botanical therapies: Involve the use
Therapies of natural products to affect health diets, itamins,

minerals, herbal preparations, probiotics)
Body-based and manipulative methods: Involve external

touch to affect body systems massage, touch, chiropractic
In combination with allopathic or biomedicine
therapy, acupressure)
therapies (conventional Western medicine),
Mind-body therapies: Connect the physiological function
complementary and alternative therapies to the mind and emotions (acupuncture, breath work,
biofeedback, art therapy, meditation, guided imagery,
comprise integrative health care, which
yoga, psychotherapy, tai chi)
focuses on optimal health of the whole person.
Energy therapies: In ol e use of the body s energy elds
Complementary and alternative therapies are (reiki, therapeutic touch, magnet therapy)
based on Eastern medical systems. Another Movement therapies: Use exercise or activity to promote
physical and emotional well-being (Pilates, dance therapy)
term for these therapies is complementary and
alternative medicine (CAM).
CAM PRACTITIONERS
Alternative therapies are treatment approaches peciali ed licensed or certi ed practitioners can pro ide
that become the primary treatment and replace complementary or alternative therapies.
allopathic medical care. Complementary therapies Acupuncture/acupressure: Needles or digital pressure

along meridians to alter body function or produce analgesia
are treatment approaches used in addition to or
Homeopathic medicine: Administering doses of substances
to enhance conventional medical care.
(remedies) that would produce manifestations of the disease
state in a well person to ill clients to bring about healing
Many health care entities are developing
Naturopathic medicine: Diet, exercise, environment, and
programs of integrative medicine or integrative
herbal remedies to promote natural healing
therapies to provide clients more options for
Chiropractic medicine: Spinal manipulation for healing
health care interventions, particularly for chronic
Massage therapy: Stretching and loosening muscles and
health problems. connective tissue for relaxation and circulation
Biofeedback: Using technology to increase awareness of

The number of clients using CAM is rising
various neurologic body responses to minimize extremes
considerably. This interest is related to a desire
Therapeutic touch: Using hands to help bring energy
for more natural treatments to add to or replace elds into balance
ineffective allopathic or biomedical treatment,

increased awareness of alternative medicine, NATURAL PRODUCTS AND
HERBAL REMEDIES
and from clients who desire to take a more ● Natural products include herbal medicines, minerals
active role in the treatment process. and vitamins, essential oils, and dietary supplements.
● Clients use nonvitamin, nonmineral natural products to
An important prerequisite for implementing prevent disease and illness, and to promote health.
Herbal remedies are derived from plant sources and are
complementary or alternative therapies is the
●
the oldest form of medicine.

client’s acceptance of and involvement in the ● The FDA does not regulate many of these products.
ome herbal agents ha e been deemed safe or effecti e
therapeutic intervention.
●
by nongovernment agencies. However, even safe or

commonly used substances can ha e ad erse effects and
interfere ith prescription medication efficacy. urther
information about these substances is available in the
PHARMACOLOGY REVIEW MODULE: COMPLEMENTARY,
ALTERNATIVE, AND INTEGRATIVE SUBSTANCES.
FUNDAMENTALS FOR NURSING CHAPTER 42 COMPLEMENTARY AND ALTERNATIVE THERAPIES 241

Aloe: Wound healing THERAPIES
Chamomile: Anti in ammatory, calming Nursing interventions can provide some aspects of
complementary alternative therapies, including the following:
Echinacea: Enhances immunity
Guided imagery/visualization therapy: Encourages
Garlic: Inhibits platelet aggregation
healing and relaxation of the body by having the mind
Ginger: Antiemetic focus on images
Ginkgo biloba: Improves memory Healing intention: Uses caring, compassion, and empathy
in the context of prayer to facilitate healing
Ginseng: Increases physical endurance
Breath work: Reduces stress and increases relaxation
Valerian: Promotes sleep, reduces anxiety
through various breathing patterns
Humor: Reduces tension and improves mood to foster coping

NURSING AND CAM Meditation: Focuses attention to a single or unchanging
Nurses should do the following. stimulus to become more mindful or aware of self
● Understand the varieties of therapies available and any
Simple touch: Communicates presence, appreciation,
safety precautions associated with their use.
and acceptance
● Be receptive to learning about clients’ alternative health
beliefs and practices (home remedies, cultural practices, Music or art therapy: Provides distraction from pain
itamin use, modi cation of prescriptions . and allows the client to express emotions; earphones
● Identify clients’ needs for complementary or alternative improve concentration
therapies, along with the client’s values and treatment
Therapeutic communication: Allows clients to verbalize
preferences.
and become aware of emotions and fears in a safe,
● Incorporate complementary or alternative therapies into
nonjudgmental environment
clients’ care plans.
● Evaluate client’s responses to CAM interventions. Relaxation techniques: Promotes relaxation using
● Assist with evaluating the safety of herbal and natural breathing techniques while thinking peaceful thoughts
products the client can be using. Provide the client (passive relaxation) or while tensing and relaxing
with reliable information, and determine possible speci c muscle groups progressi e rela ation
interactions with prescription medicines and therapies.
242 CHAPTER 42 COMPLEMENTARY AND ALTERNATIVE THERAPIES CONTENT MASTERY SERIES

A nurse is reviewing the various categories of
1. A nurse is caring for a client scheduled for abdominal
complementary and alternative therapies with a group
surgery. The client reports being worried. Which
of newly licensed nurses. Use the ATI Active Learning
of the following actions should the nurse take?
A. Offer information on a relaxation technique and
ask the client if they are interested in trying it. RELATED CONTENT: List at least four different
types of therapies with examples of each.
B. Request a social worker see the
client to discuss meditation.
C. Attempt to use biofeedback
techniques with the client.
D. Tell the client many people feel the same way
before surgery and to think of something else.
2. A nurse is assessing a client as part of an admission

history. The client reports drinking an herbal tea
every afternoon at work to relieve stress. Tea
includes which of the following ingredients?
A. Chamomile
B. Ginseng
C. Ginger
D. Echinacea
3. A nurse is reviewing complementary and

alternative therapies with a group of newly licensed
nurses. Which of the following interventions are
mind-body therapies? (Select all that apply.)
A. Art therapy
B. Acupressure
C. Yoga
D. Therapeutic touch
E. Biofeedback
4. A nurse is teaching a group of newly licensed

nurses on complementary and alternative
therapies they can incorporate into their practice
without the need for specialized licensing or
certification. Which of the following should the nurse
encourage them to use? (Select all that apply.)
A. Guided imagery
B. Massage therapy
C. Meditation
D. Music therapy
E. Therapeutic touch
5. A nurse is planning to use healing intention with a

client who is recovering from a lengthy illness. Which
of the following is the priority action to take before
attempting this particular mind-body intervention?
A. Tell the client the goal of the therapy
is to promote healing.
B. Ask whether the client is comfortable
with using prayer.
C. Encourage the client participate
actively for best results.
D. Instruct the client to relax during the therapy.
FUNDAMENTALS FOR NURSING CHAPTER 42 COMPLEMENTARY AND ALTERNATIVE THERAPIES 243

1. A. CORRECT: It is appropriate for the nurse to recommend a Using the ATI Active Learning Template: Basic Concept
noninvasive technique to facilitate coping, and to allow the RELATED CONTENT
client to make an informed decision about participating. ●
Alternative medical philosophy: traditional Chinese
B. Meditation does not require specialized training.
medicine, Ayurvedic medicine, homeopathy
The nurse can use this therapy and does not
need to request a social worker consult.
●
Biological and botanical therapies: diets,
C. Recognize that biofeedback requires specialized training vitamins, minerals, herbal preparations
and licensing or certification. It is not appropriate for
●
Body manipulation: massage, touch, chiropractic therapy
the nurse to attempt to use these techniques. ●
Mind-body therapies: biofeedback, art therapy,
D. This response by the nurse is nontherapeutic because meditation, yoga, psychotherapy, tai chi
it uses stereotyping and dismisses the client’s ●
Energy therapies: Reiki, therapeutic touch
feelings. Use therapeutic communication techniques
to allow the client to further verbalize fears.
NCLEX Connection: Basic Care and Comfort,
®
2. A. CORRECT: Tea can contain chamomile, which produces a

calming effect, or valerian, which reduces anxiety. Attempt
to gain further information to confirm the ingredients of
any herbal or natural products the client can use.
B. Expect a client to use ginseng tea to
improve physical endurance.
C. Expect a client to use ginger tea to
prevent or relieve nausea.
D. Expect a client to use echinacea tea to
boost the immune system.
Concepts of Management
3. A. CORRECT: Art therapy is a mind-body therapy

because it allows the client to express unconscious
emotions or concerns about their health.
B. Acupressure is a body-based therapy because it focuses
specifically on body structures and systems.
C. CORRECT: Yoga is a mind-body therapy because it
focuses on achieving well-being through exercise,
posture, breathing, and meditation.
D. Therapeutic touch is an energy therapy because it
involves using the hands to balance energy fields.
E. CORRECT: Biofeedback is a mind-body therapy because it
increases mental awareness of the body responses to stress.
4. A. CORRECT: Nurses can use guided imagery with clients once

they understand the general principles of this therapy.
B. Massage therapists undergo training as well
as certification and/or licensure.
C. CORRECT: Nurses can use meditation with clients once
they understand the general principles of this therapy.
D. CORRECT: Nurses can use music therapy with clients
once they understand the general principles.
E. Therapeutic touch practitioners undergo specific training.
5. A. Tell the client the goals of therapy to provide information to

the client. However, there is another action to take first.
B. CORRECT: The first action to take using the nursing process is
to assess or collect data from the client. Because people can
have personal, cultural, or religious sensitivities or aversions to
religious practices (prayer), the nurse must first determine that
the client is comfortable with a therapy that involves prayer.
C. Encourage the client to participate to improve
the effectiveness of the therapy. However,
there is another action to take first.
D. Instruct the client to relax to promote the client’s
ability to focus during the therapy. However,
there is another action to take first.
244 CHAPTER 42 COMPLEMENTARY AND ALTERNATIVE THERAPIES CONTENT MASTERY SERIES

CHAPTER 43
UNIT 4 PHYSIOLOGICAL INTEGRITY Physical activity
Stimulates intestinal activity and increases skeletal
Bowel Elimination muscle tone needed for defecation

CHAPTER 43
Psychosocial factors
Emotional distress increases peristalsis and exacerbates
Many factors can alter bowel function. chronic conditions (colitis, Crohn’s disease, ulcers,
Interventions (surgery, immobility, medications, irritable bowel syndrome)
therapeutic diets) can affect bowel elimination. Depression can lead to decreased peristaltic activity and
constipation
Various disease processes necessitate the
creation of bowel diversions to allow fecal Personal habits
elimination to continue. Reluctance to use public toilets, false perception of the
need for “one-a-day” bowel movements, lack of privacy
Stool specimens are collected both for when hospitalized
screening and for diagnostic tests (detection of Positioning

occult blood, bacteria, or parasites). NORMAL: Squatting
Alterations in bowel pattern include infrequent IMMOBILITY: Can result in difficulty contracting gluteal
muscles and defecating
stools (constipation) or an increased number of
loose, liquid stools (diarrhea). Pain
● Normal defecation is painless; discomfort due to
conditions hemorrhoids, ssures, perianal surgery can
BOWEL ELIMINATION PATTERNS lead to suppression of the urge to defecate
There are objective ways to assess a client’s bowel pattern, ● Opioid use contributes to constipation
but individual bowel patterns vary greatly.
Pregnancy
FACTORS AFFECTING ● Growing fetus compromising intestinal space
BOWEL ELIMINATION ● Slower peristalsis
● Straining increasing the risk of hemorrhoids
Age
Surgery and anesthesia
INFANTS
● Breast milk stools: watery and yellow brown Temporary slowing of intestinal activity (rationale for
● Formula stools: pasty and brown auscultating bowel sounds before advancing diet)
TODDLERS: Bowel control at 2 to 3 years old

Medications
ADOLESCENTS
Laxatives: Soften stool
● Increased secretion of gastric acids
● Accelerated growth of the large intestine Cathartics: Promote peristalsis
OLDER ADULTS: Decreased peristalsis, relaxation Laxative overuse: Chronic use of laxatives causes a
of sphincters weakening of the bowel’s expected response to distention
from feces, resulting in the development of chronic
Diet constipation
Fiber requirement: 25 to 38 g/day

● Difficulty digesting foods lactose intolerance can cause INCONTINENCE
watery stools.
Fecal incontinence is the inability to control defecation,
● Certain foods can increase gas cabbage, cauli o er,
often caused by diarrhea.
apples , ha e a la ati e effect gs, chocolate , or increase ● Determine causes (medications, infections, or
the risk for constipation (pasta,cheese, eggs).
impaction).
Provide perineal care after each stool, and apply a
Fluid intake
●
moisture barrier.
Fluid requirement: 2 L/day for females and 3 L/day for ● Provider can prescribe fecal incontinence pouch or other
males from uid and food sources bowel management system to collect stool and prevent
it from coming into contact with the skin.
FUNDAMENTALS FOR NURSING CHAPTER 43 BOWEL ELIMINATION 245

FLATULENCE CAUSES OF CONSTIPATION
● Frequent use of laxatives
Flatulence results from distention of the bowel from gas ● Advanced age
accumulation (can cause cramping or a feeling of fullness). ● Inade uate uid inta e
● Check for abdominal distention and the ability to pass ● Inade uate ber inta e
gas through the anus. ● Immobilization due to injury
● ncourage ambulation to promote the passage of atus. ● Sedentary lifestyle
● Pregnancy
HEMORRHOIDS ● edication effects
Hemorrhoids are engorged, dilated blood vessels in the

Diarrhea
rectal all from difficult defecation, pregnancy, li er
disease, and heart failure. Diarrhea is a bowel pattern of frequent loose or liquid stools.
● Hemorrhoids can be itchy, painful, and bloody
CAUSES OF DIARRHEA
after defecation. ● Viral gastroenteritis
● Use moist wipes for cleansing the perianal area, and ● Bacterial gastroenteritis
apply ointments or creams as prescribed. ● Antibiotic therapy
● Use a sitz bath or ice pack to promote relief from ● In ammatory bo el disease
hemorrhoid discomfort. ● Irritable bowel syndrome
OSTOMIES
● Some bowel disorders prevent the expected elimination
of stool from the body. Bowel diversions through ● Perform a routine physical examination of the abdomen
ostomies are temporary or permanent openings (bowel sounds, tenderness)
(stomas) surgically created in the abdominal wall to ● Chec for uid de cit
allow fecal matter to pass. ● Inspect skin integrity around the anal area
● Ostomies are created in either the large intestine or ● Collect a detailed history of diet, exercise, and
the small intestine. Colostomies end in the colon, and bowel habits
ileostomies end in the ileum. ● Monitor for constipation
◯ End stomas are a result of colorectal cancer or some ◯ Abdominal bloating
types of bowel disease. ◯ Abdominal cramping
◯ Loop colostomies help resolve a medical emergency ◯ Straining at defecation
and are temporary. In a loop colostomy, a loop ◯ Presence of dry, hard feces at defecation
of bowel is supported on the abdomen with a ◯ Irregular bowel movements, or reduced frequency
proximal stoma draining stool and a distal stoma from client’s normal pattern
draining mucus. It is usually constructed in the ● Monitor for diarrhea
transverse colon. ◯ Frequent loose stools
◯ Double-barrel colostomies consist of two abdominal ◯ Abdominal cramping
stomas: one proximal and one distal. The proximal ◯ Stool of watery consistency
stoma drains stool and the distal stoma leads to ● Perform specimen collection for diagnostic testing
inactive intestine. After the injured area of the as indicated.
intestine heals, the colostomy is often reversed by ● Perform a digital rectal examination for impaction.
reattaching the two ends. ◯ Position client on the left side ith the nees e ed.
◯ Monitor for stimulation of the vagus nerve, which can
result in bradycardia.
Constipation and diarrhea

For healthy clients, constipation and diarrhea are not
DIAGNOSTIC PROCEDURES
serious. For older adult clients and clients who have Stool samples should come from fresh stools. Avoid
pre-existing medical problems, constipation and diarrhea contaminating with water or urine.
can ha e a signi cant impact on the client s health.
Fecal occult blood (guaiac) test: Obtain a fecal sample
using medical asepsis while wearing gloves. Collect stool
Constipation
specimens for serial guaiac testing three times from three
Constipation is a bo el pattern of difficult and infre uent different defecations. ome foods red meat, citrus fruit,
evacuation of hard, dry feces. raw vegetables) and medications can cause false positive
results. Bleeding can be an indication of cancer.
Paralytic ileus is an intestinal obstruction caused by
reduced motility following bowel manipulation during Specimens for stool cultures: Obtain using medical
surgery, electrolyte imbalance, wound infection, or by the asepsis while wearing gloves. Label the specimen, and
effects of medication. promptly send it to the laboratory.
246 CHAPTER 43 BOWEL ELIMINATION CONTENT MASTERY SERIES

Online Video: Bowel Elimination
Specimen collection PATIENT-CENTERED CARE

EQUIPMENT
● Specimen container NURSING CARE
● Soap/cleansing solution or wipe ● Closely monitor uid status and elimination pattern.
● Clean gloves ● ecord food and uid inta e and output. or diarrhea,
● Specimen label
measure the volume of the stools.
● Fecal occult blood test cards ● Observe and document the character of bowel
● Wooden applicator or tongue depressor
movements. Carefully check for blood or pus.
● Developer solution ● Promote regular bowel elimination through several
● Stool collection container (bedside commode, bedpan,
measures.
receptacle in toilet) ◯ Ade uate ber in the diet
PROCEDURE ◯ Ade uate uid inta e
● Fecal occult blood testing (guaiac test) ◯ Adequate activity: Walking 15 to 20 min/day if mobile
◯ Explain the procedure to the client. and exercises in bed or chair (pelvic tilt, single leg
◯ Ask the client to collect a specimen in the toilet lifts, lower trunk rotation)
receptacle, bedpan, or bedside commode.
◯ Don gloves. Constipation
◯ With a wooden applicator, place small amounts of
● Increase ber and ater consumption unless
stool on the windows of the test card or as directed.
contraindicated) before more invasive interventions.
◯ Follow the facility’s procedures for handling.
● Give bulk-forming products before stool softeners,
■ Apply a label to the cards and send them to the
stimulants, or suppositories.
laboratory for processing. ● Enemas are a last resort for stimulating defecation.
■ Alternatively, place a couple of drops of developer
● Encourage regular exercise.
on the opposite side of the card. A blue color
indicates the stool is positive for blood.
◯ Remove the gloves and perform hand hygiene.
Diarrhea
● Stool for culture, parasites, and ova ● Help determine and treat the cause.
◯ Explain the procedure to the client. ● Administer medications to slow peristalsis.
◯ Ask the client to collect the specimen in the toilet ● Provide perineal care after each stool, and apply a
receptacle, bedside commode, or bedpan. moisture barrier.
◯ Don gloves. ● After diarrhea stops, suggest eating yogurt to help
◯ Use a wooden tongue depressor to transfer the stool re establish an intestinal balance of bene cial bacteria.
to a specimen container.
◯ Label the container with the client’s Meeting needs of older adults
identifying information. ● Older adult clients are more susceptible to developing
◯ Remove the gloves.
constipation as bowel tone decreases with age.

◯ Perform hand hygiene.
Therefore, they are more at risk for developing fecal

◯ Transport the specimen to the laboratory.
impaction. Ade uate uid, ber inta e, and e ercise

decrease the likelihood of developing constipation or
Colonoscopy
fecal impaction.
Use of a lighted instrument by the provider to visualize ● Older adult clients are less able to compensate for
and collect tissue samples for biopsy or remove polyps uid lost due to diarrhea. onitor older adults ho
from the colon or lower small bowel. have diarrhea for diarrhea-associated complications
(electrolyte imbalances, dehydration, skin breakdown).
Sigmoidoscopy
Promoting healthy bowel elimination
Use of a lighted instrument by the provider to visualize
and collect tissue for biopsy or remove polyps from the EQUIPMENT
sigmoid colon and rectum. ● Bedpans
◯ Fracture pan for supine clients and clients in body
CLIENT PREPARATION
casts or leg casts
● Protocols vary with the provider and the facility, but ◯ Regular pan for seated clients
generally include clear liquids only and a bowel cleanser. ● Bedside commode
● Clients receive moderate (conscious) sedation and can ● Toilet
not drive home afterwards.
PROCEDURE
● Encourage the client to set aside time to defecate.
Sometimes, after a meal works best.
● If not contraindicated or restricted, encourage the client
to drin plenty of uids and to consume a diet high in
ber to pre ent constipation.
● Wear gloves when addressing toileting needs.

● Provide privacy. ● With the bag level with the client’s hip, open the clamp.
● Assist the client to a sitting position whether using a ● Raise the bag 30 to 45 cm (12 to 18 in) above the anus,
regular bedpan, commode, or toilet. depending on the level of cleansing desired.
● For clients using a fracture pan, raise the head of the ● lo the o of solution by lo ering the container if
bed to 30°. the client reports cramping, or if uid lea s around the
● If the client cannot lift their hips, roll the client onto tube at the anus.
one side, position the bedpan over the buttocks, and roll ● If using a prepackaged solution, insert the lubricated tip
the client back onto the bedpan. into the rectum, and squeeze the container to instill all
● Encourage the client to decrease stress when sitting or of the solution.
rising by using an elevated toilet seat or a footstool. ● Ask the client to retain the solution for the prescribed
● Ne er lea e a client lying at on a regular bedpan. amount of time, or until the client is no longer able to
● After the client defecates, provide skin care to the retain it.
perianal area. ● Discard the enema bag and tubing.
● Assist the client to the appropriate position to defecate.
Cleansing enema ● Remove the gloves.
● Perform hand hygiene.
The height of the bag above the rectum determines the ● For clients who have little or no sphincter control,
depth of cleansing.
administer the enema on a bedpan.
EQUIPMENT ● Document the results and the client’s tolerance of
● Gloves the procedure.
● Lubricant
● Absorbent, waterproof pads Ostomy care
● Bedpan, beside commode, or toilet
EQUIPMENT
● IV pole ● Pouch system (skin barrier and pouch)
● Enema bag with tubing or prepackaged enema ● Pouch closure clamp
● Solutions and additives: vary with the type of enema ● Barrier pastes (optional)
◯ Tap water or hypotonic solution
● Gloves
■ Stimulates evacuation ● Washcloths
■ Never repeated due to potential water toxicity
● Towel
◯ Soapsuds
● Warm water
■ Pure castile soap in tap water or normal saline
● Scissors
■ Acts as an irritant to promote bowel peristalsis
● Pen
■ Used cautiously in older adults and clients who are
pregnant due to an increased risk of electrolyte PROCEDURE

imbalance and intestinal mucosa damage ● If a wound ostomy continence nurse is not available,
◯ Normal saline educate the client about stoma care.
■ Safest due to equal osmotic pressure ● Perform hand hygiene.
■ Volume stimulates peristalsis ● Put on gloves.
◯ Low-volume hypertonic ● Remove the pouch from the stoma.
■ Used by clients who cannot tolerate ● Inspect the stoma. It should appear moist, shiny, and
high-volume enemas pink. The peristomal area should be intact, and the skin
■ Commercially prepared should appear healthy.
■ Not used on infants or clients who are dehydrated ● Use mild soap and water to cleanse the skin, then dry it
◯ Oil retention: Lubricates the rectum and colon for gently and completely. Moisturizing soaps can interfere
easier passage of stool with adherence of the pouch.
◯ Medicated enema: Contains medications (antibiotics or ● Apply paste if necessary.
anthelmintics) to retain for a period of time (1 to 3 hr). ● Measure and mark the desired size for the skin barrier.
● Cut the opening 0.15 to 0.3 cm (1 18 to 1 8 in) larger,
PROCEDURE
allowing only the stoma to appear through the opening.
● Perform hand hygiene. ● If necessary, apply barrier pastes to creases.
● Prepare and warm the enema solution. ● Apply the skin barrier and pouch.
● Pour the solution into the enema bag, allo ing it to ll ● Fold the bottom of the pouch and place the closure
the tubing, and then close the clamp.
clamp on the pouch.
● Provide privacy. ● Dispose of the used pouch. Remove the gloves and
● Provide quick access to a commode or bedpan.
perform hand hygiene.
● Place absorbent pads under the client to protect the
bed linens.
● Position the client on the left side with the right leg
e ed for ard.
● Put on gloves.
● Lubricate the rectal tube or nozzle.
● Slowly insert the rectal tube 7.5 to 10 cm (3 to 4 in). For
a child, insert the tube 5 to 7.5 cm (2 to 3 in).

COMPLICATIONS Complications of diarrhea
Dehydration
Complications of constipation
Fluid and electrolyte disturbances: Metabolic acidosis
Fecal impaction: Stool becomes wedged in the rectum,
from excessive loss of bicarbonate
and can in ol e diarrhea uid lea ing around the ● Monitor for manifestations of dehydration (weak, rapid
impacted stool.
pulse; hypotension; poor skin turgor; elevated body
● Administer enemas and suppositories or stool softeners
temperature).
as prescribed to promote relief of fecal impaction. If ◯ Hypernatremia: Muscle weakness, lethargy, swollen
necessary, manually remove fecal impactions that do

red tongue
not respond to other interventions. ◯ Hypokalemia: Leg cramps, muscle weakness, nausea,
● se a glo ed, lubricated nger for digital
vomiting, cardiac dysrhythmias.
removal of stool. ● Monitor for manifestations of electrolyte imbalance.
● Loosen the stool around the edges and then remove it in ● eplace uid and electrolytes as prescribed.
small pieces, allowing the client to rest as necessary.
● When evacuating the rectum, be careful to avoid Skin breakdown around the anal area: Provide treatment
stimulating the vagus nerve. for skin breakdown as prescribed.
● top the procedure if the heart rate drops signi cantly
or the heart rhythm changes.
Hemorrhoids and rectal fissures
Bradycardia, hypotension, syncope A nurse is explaining to a group of newly licensed

● Associated with the Valsalva maneuver (occurs with
nurses the various factors that alter bowel elimination
patterns. Use the ATI Active Learning Template:
straining/bearing down).
● Instruct clients not to strain to have bowel movements.
● Encourage measures to treat and prevent constipation. UNDERLYING PRINCIPLES: List at least eight
factors that affect bowel elimination, along with
a brief example or description of each.
1. A nurse is caring for a client who will perform 4. While a nurse is administering a cleansing enema,
fecal occult blood testing at home. Which of the client reports abdominal cramping. Which of
the following information should be included the following actions should the nurse take?
when explaining the procedure to the client? A. Have the client hold their breath
A. Eating more protein is optimal prior to testing. briefly and bear down.
B. One stool specimen is sufficient for testing. B. Clamp the enema tubing.
C. A red color change indicates a positive test. C. Remind the client that cramping
D. The specimen cannot be contaminated with urine. is common at this time.
D. Raise the level of the enema fluid container.
2. A nurse is providing dietary teaching for a

client who reports constipation. Which of the 5. A nurse is preparing to administer a cleansing
following foods should the nurse recommend? enema to an adult client in preparation for a
A. Macaroni and cheese diagnostic procedure. Which of the following steps
should the nurse take? (Select all that apply.)
B. One medium apple with skin
A. Warm the enema solution prior to instillation.
C. One cup of plain yogurt
B. Position the client on the left side with
D. Roast chicken and white rice the right leg flexed forward.
C. Lubricate the rectal tube or nozzle.
3. A nurse is assessing a client who has had diarrhea D. Slowly insert the rectal tube about 5 cm (2 in).
for 4 days. Which of the following findings should
E. Hang the enema container 61 cm
the nurse expect? (Select all that apply.)
(24 in) above the client’s anus.
A. Bradycardia
B. Hypotension
C. Elevated temperature
D. Poor skin turgor
E. Peripheral edema

1. A. Some proteins can alter the test results. Instruct the client not Using the ATI Active Learning Template: Basic Concept
to consume red meat, fish, and poultry prior to testing. UNDERLYING PRINCIPLES
B. Instruct the client to obtain three specimens ●
Age
from three different bowel movements.
Infants
◯
C. Inform the client to look for a blue color on the

card to indicate positive blood in the stool. Breast milk stools: Watery and yellow brown
■
D. CORRECT: For fecal occult blood testing, instruct the client Formula stools: Pasty and brown
■
not to contaminate the stool specimens with water or urine. Toddlers: Bowel control at 2 to 3 years old
◯
NCLEX® Connection: Reduction of Risk Potential, Older adults: Decreased peristalsis, relaxation of sphincters
◯
Therapeutic Procedures ●
Diet
Fiber requirement: 25 to 30 g/day
◯
Lactose intolerance: Difficulty digesting milk products

◯
2. A. Recommend a different food choice, because Fluid requirement: 2 L per day for females, and
◯
another option contains more fiber. 3 L/day from fluid and food sources
B. CORRECT: One medium apple with the skin is the best food ●
Physical activity: Stimulates intestinal activity
source to recommend because it contains 4.4 g of fiber. ●
C. Recommend a different food choice, because
another option contains more fiber. Emotional distress increasing peristalsis and
◯
D. Recommend a different food choice, because exacerbating chronic conditions (colitis, Crohn’s
another option contains more fiber. disease, ulcers, irritable bowel syndrome)
Depression decreasing peristalsis
◯
NCLEX® Connection: Basic Care and Comfort, Elimination ●

Personal habits: Use of public toilets, false perception of the need for
“one-a-day” bowel movements, lack of privacy when hospitalized
3. A. Expect the client who has prolonged diarrhea to ●
Positioning
have tachycardia due to dehydration. Normal: Squatting
◯
B. CORRECT: Prolonged diarrhea leads to dehydration. Immobilized client: Difficulty defecating

◯
Expect the client to have a decrease in blood pressure. ●

Pain
C. CORRECT: Prolonged diarrhea leads to dehydration. Discomfort leading to suppression of the urge to defecate
◯
Expect the client to have an increased temperature. Opioid use contributing to constipation
◯
D. CORRECT: Prolonged diarrhea leads to dehydration. ●

Pregnancy
Expect the client to have poor skin turgor.
E. Expect the client who has prolonged diarrhea to possibly Growing fetus compromising intestinal space
◯
have weakened peripheral pulses due to dehydration. Slower peristalsis

◯
Peripheral edema results from a fluid overload. Straining increasing the risk of hemorrhoids
◯

●
Surgery and anesthesia
Illness Management Temporary slowing of intestinal activity
◯
Paralytic ileus
◯
●
Medications
4. A. Have the client take slow, deep breaths to Laxatives: To soften stool; overuse leads to chronic constipation
◯
relax and ease discomfort. Cathartics: To promote peristalsis

◯
B. CORRECT: Clamp the enema tubing for

30 seconds to reduce intestinal spasms. NCLEX® Connection: Physiological Adaptation, Pathophysiology
C. This action by the nurse is nontherapeutic because it
implies that the client must tolerate the discomfort and
that the nurse cannot or will not do anything to ease it.
D. Do not raise the enema fluid container because this action
can increase intestinal spasms and abdominal cramping.
Complications of Diagnostic Tests/Treatments/Procedures
5. A. CORRECT: Warm the enema solution because

cold fluid can cause abdominal cramping, and hot
fluid can injure the intestinal mucosa.
B. CORRECT: Place the client in this position to promote
a downward flow of solution by gravity along the
natural anatomical curve of the sigmoid colon.
C. CORRECT: Lubricate the tubing to prevent
trauma or irritation to the rectal mucosa.
D. The correct length of insertion for a child is 5 cm (2 in). For
an adult client, insert the tube 7.6 to 10.2 cm (3 to 4 in).
E. The maximum recommended height is 46 cm
(18 in). The height of the fluid container affects the
speed of instillation. Hang the container within the
recommended height range to prevent rapid instillation
and possibly painful distention of the colon.
Diagnostic Tests

CHAPTER 44
UNIT 4 PHYSIOLOGICAL INTEGRITY Kock pouch (continent ileal bladder conduit): A continent
SECTION: BASIC CARE AND COMFORT urinary diversion in which the surgeon forms a reservoir
from the ileum. The pouch is emptied by clean straight
CHAPTER 44 Urinary Elimination catheterization every 2 to 3 hr initially, and every 5 to 6 hr

once the pouch expands to capacity.
Neobladder: A new bladder created by the surgeon using

Urinary elimination is a precise system of filtration, the ileum that attaches to the ureters and urethra. It
allows the client to maintain continence; the client learns
reabsorption, and excretion. These processes
to void by straining the abdominal muscles.
help maintain fluid and electrolyte balance while
filtering and excreting water-soluble wastes. NURSING INTERVENTIONS
Consult a wound ostomy continence nurse to assist
The primary organs of urinary elimination are the
●
clients who have an incontinent diversion.

kidneys, with the nephrons performing most of ● Monitor stoma and peristomal skin for indications
of breakdown.
the functions of filtration and elimination. Most
adults produce 1,000 to 2,000 mL/day of urine.
FACTORS AFFECTING
After filtration, the urine passes through the URINARY ELIMINATION
ureters into the bladder, the storage reservoir for ● Poor abdominal and pelvic muscle tone
Acute and chronic disorders
urine. Once an adequate amount of urine (250 to
●
● Spinal cord injury

450 mL in adults) collects in the bladder, stretch
Age
receptors in the bladder wall send a signal to the
Children achieve full bladder control by 4 to 5 years of age.
brain to indicate the need to urinate. The person
●
● The prostate can enlarge in older adult males. An enlarged

then relaxes the internal and external sphincters prostate can obstruct the bladder outlet and cause urinary
retention and urgency, which can lead to incontinence and
at the bottom of the bladder and the urethra. urinary tract infections (UTIs).
Urine passes from the bladder through the ● Childbirth and gra ity ea en the pel ic oor, putting
clients at risk for prolapse of the bladder, leading to
urethra, from which it exits the body. stress incontinence, which clients can help manage with
pel ic oor egel e ercises.
Interventions (surgery, immobility, medications, and ● Clients who are post-menopausal can have decreased
therapeutic diets) can affect urinary elimination. perineal tone due to reduced estrogen levels, which can
cause urgency, stress incontinence, and UTIs
OLDER ADULT CLIENTS

URINARY DIVERSIONS ● Fewer nephrons
● Urinary diversions are created to reroute urine, and can ● Loss of muscle tone of the bladder leading to frequency
be temporary or permanent. Surgeons create urinary ● Inefficient emptying of the bladder residual urine
diversions for clients who have bladder cancer increasing the risk for UTIs
or injury. ● Increase in nocturia due to a decrease in bladder capacity
● Urinary diversions have many similarities to bowel ● Presence of chronic illnesses
diversions. Clients who have urinary diversions often ● Factors that interfere with mobility and dexterity
share similar body image concerns as those who have
bowel diversions. Pregnancy
● Diversions are either continent (with controlled ● A growing fetus compromises bladder space and
elimination of urine from the body) or incontinent (with
compresses the bladder.
urine draining continuously without control). ● There is a 30% to 50% increase in circulatory volume,
● Continent diversions have a reservoir in the abdomen
which increases renal workload and output.
that allows clients to control the elimination of urine. ● The hormone relaxin causes relaxation of the sphincter.
Ureterostomy (ileal conduit): An incontinent urinary
diversion in which the surgeon attaches one or both Diet
ureters via a stoma to the surface of the abdominal wall ● An increase in sodium leads to decreased urination.
Nephrostomy: An incontinent urinary diversion in which ● Caffeine and alcohol inta e lead to increased urination.
the surgeon attaches a tube from the renal pelvis via a
stoma to the surface of the abdominal wall
FUNDAMENTALS FOR NURSING CHAPTER 44 URINARY ELIMINATION 251

Immobility Renal ultrasound: View of gross renal structures and
structural abnormalities using high-frequency sound waves
Incontinence can occur as a result of impaired mobility
due to difficulty transferring to the bathroom. Cystoscopy: Use of a lighted instrument to visualize, treat,
and obtain specimens from the bladder and urethra
Urodynamic testing: Test for bladder muscle function by
● Emotional stress and anxiety lling the bladder ith C 2 or 0.9% sodium chloride and
● Having to use public toilets comparing pressure readings with reported sensations
● Lack of privacy during hospital stays
● Not having enough time to urinate (predetermined
bathroom breaks in elementary schools) CONSIDERATIONS
Pain Promoting healthy urinary elimination
● Suppression of the urge to urinate when there is pain in EQUIPMENT
the urinary tract ● Urinal for males
● Obstruction in the ureter leading to renal colic ● Toilet, bedpan, or commode
● Arthritis or painful joints causing immobility and ◯ Fracture pan: For clients who must remain supine and
leading to delayed urination clients in body or leg casts

◯ Regular pan: For clients who can sit up
Surgical procedures
PROCEDURE NURSING ACTIONS
● Alterations in glomerular ltration rate from anesthesia ● Have clients sit when possible.
and opioid analgesics, resulting in decreased urine output ● Provide for privacy needs with adequate time
● Lower abdominal surgery creating obstructive edema for urinating.
and in ammation
I&O
Medications
EQUIPMENT
● Diuretics preventing reabsorption of water ● Hard plastic urometer on an indwelling catheter
● Antihistamines and anticholinergics causing drainage bag
urinary retention ● Graduated cylinders, urinal, or toilet receptacle
● Chemotherapy creating a toxic environment for
the kidneys ● Measure output from a bedpan, commode, or collection
MEDICATIONS THAT CHANGE URINE COLOR bag into a graduated container.
● Phenazopyridine: orange, red ● Use a receptacle to measure urine clients void into
● Amitriptyline: green-blue the toilet.
● Levodopa: dark ● Use markings on the side of the urinal to measure urine.
ibo a in bright yello
! Less than 30 mL/hr for more than
●
2 hr is a cause for concern.

DIAGNOSTIC TESTS Bladder retraining for treating urge incontinence
Bedside sonography with a bladder scanner: Noninvasive
EQUIPMENT: Clock
portable ultrasound scanner for measuring bladder volume
and residual volume after urination PROCEDURE NURSING ACTIONS
● Use timed voiding to increase intervals
Kidneys, ureters, bladder: X-ray to determine size, shape,
between urination.
and position of these structures ● Assist clients to perform relaxation techniques.
Intravenous pyelogram: Injection of contrast media ● ffer incontinence undergarments hile clients
(iodine) for viewing of ducts, renal pelvis, ureters, bladder, are retraining.
and urethra ● Provide positive reinforcement as clients remain continent.
! Allergy to shellfish contraindicates PROCEDURE CLIENT EDUCATION

the use of this contrast medium. ● Perform pel ic oor egel e ercises.
● Do not to ignore the urge to urinate.
Renal scan: ie of renal blood o and anatomy of the ● liminate or decrease caffeine drin s.
kidneys without contrast ● Take diuretics in the morning.
252 CHAPTER 44 URINARY ELIMINATION CONTENT MASTERY SERIES

Specimen collection Routine catheter care
EQUIPMENT EQUIPMENT
● Specimen container ● Soap and water
◯ Non-sterile for urinalysis ● Washcloth
◯ Sterile for clean-catch midstream and specimens ● Gloves
from a catheter
● Soap or cleansing solution and towel ● Use soap and water at the insertion site.
● lo es for contact ith any body uids ● Cleanse the catheter at least three times a day and
● Specimen label
after defecation.
● Urine collection container (catheter, urinal, receptacle in ● Monitor the patency of the catheter.
toilet, commode) ◯ For reports of fullness in the bladder area, check
Urinalysis: random non-sterile specimen for kinks in the tubing, and check for sediment in
NURSING ACTIONS the tubing.
● Explain the procedure. ◯ Make sure the collection bag is at a level below the
● Label the container with clients’ identifying bladder to a oid re u .

information, and follow the facility’s policy for
transporting the specimen to the laboratory. Condom catheter application
Clean-catch midstream for culture and sensitivity (C&S) EQUIPMENT
NURSING ACTIONS ● Gloves
● Teach the technique for obtaining the specimen. ● Condom catheter
● After thorough cleansing of the urethral meatus, clients ● Elastic tape
catch the urine sample midstream. ● Leg or standard collection bag
Catheter urine specimen for C&S PROCEDURE NURSING ACTIONS

NURSING ACTIONS: Obtain a sterile specimen from a ● Explain the procedure.
straight or indwelling catheter using surgical asepsis ● Use the correct technique for application of a
(sterile technique). condom catheter.
Timed urine specimens

NURSING ACTIONS
● Collect for 24 hr or other duration.
COMPLICATIONS
Discard the rst oiding.
Catheter-associated urinary tract infection (CAUTI)
●
● Collect all other urine. Refrigerate, label, and transport

the specimen. Occurs while an indwelling catheter is in place or up to 48
hr after discontinuing.
Straight or indwelling catheter insertion
RISK FACTORS
EQUIPMENT ● Use of indwelling catheters
● Usual size and type of catheter ● Increased dwell time of indwelling urinary catheter
◯ 8 to 10 Fr for children ● Opening the closed urinary drainage system
◯ 14 to 16 Fr for females ● Routine changes of indwelling urinary catheter
◯ 16 to 18 Fr for males ● Irrigation of the indwelling catheter
◯ se silicon or Te on products for clients ho ha e
MANIFESTATIONS
latex allergies. ● rinary fre uency, urgency, nocturia, an pain,
● Catheterization kit with a sterile drainage bag for
hematuria, cloudy, foul-smelling urine, and fever.
indwelling catheter insertion ● In older adults, new onset of increased confusion, recent
● Soap and water
falls, new onset incontinence, anorexia, fever,
● Collection container for straight catheterization
tachycardia, hypotension.
NURSING ACTIONS
● Explain the procedure, and provide for privacy. ● Use aseptic technique when inserting catheters.
● Use the correct technique for inserting an indwelling ● Pre ent obstruction and bac o of urine through
catheter or for straight catheterization.
catheter, drainage tubing, and drainage bag.
Provide perineal hygiene routinely and after soiling.
Closed intermittent irrigation
●
● Assess ongoing need for indwelling urinary

Use the correct technique to perform closed intermittent catheter daily.
irrigation.

Urinary incontinence EXPECTED FINDINGS
● Loss of urine when laughing, coughing, sneezing
rinary incontinence is a signi cant contributing factor to ● Enuresis (bed-wetting)
skin breakdown and falls, especially in older adults. ● Bladder spasms
● Urinary retention
MAJOR TYPES ● Frequency, urgency, nocturia
Stress: Loss of small amounts of urine from increased

abdominal pressure without bladder muscle contraction LABORATORY TESTS
with laughing, sneezing, or lifting. Can occur in females
Urinalysis and urine culture and sensitivity: To identify
due to ea pel ic oor muscles follo ing childbirth or
UTI (presence of RBCs, WBCs, micro-organisms)
menopause, and in males due to alterations in the urethra
following a prostatectomy Blood creatinine and BUN: To assess renal function
(elevated with renal dysfunction)
Urge: Inability to stop urine o long enough to reach
the bathroom due to an overactive detrusor muscle with
increased bladder pressure. Can occur due to bladder DIAGNOSTIC PROCEDURES
irritation from a UTI or an overactive bladder
Ultrasound: Detects bladder abnormalities and/or
Overflow: Urinary retention from bladder overdistention residual urine
and frequent loss of small amounts of urine due
Voiding cystourethrography: Identi es the si e, shape,
to obstruction of the urinary outlet or an impaired
support, and function of the urinary bladder, obstruction
detrusor muscle. Can occur as a result of a neurologic
(prostate), residual urine
disorder (spinal cord injury, or multiple sclerosis), and can
lead to a neurogenic accid bladder. Can also occur ith Urodynamic testing
an enlarged prostate ● Cystourethroscopy: Visualizes the inside of the bladder
● Uroflowmetry: Measures the rate and degree of
Reflex: Involuntary loss of a moderate amount of urine
bladder emptying
usually ithout arning due to hyperre e ia of the
detrusor muscle, usually from spinal cord dysfunction. Electromyography: Measures the strength of pelvic
Can occur due to impaired central nervous system (stroke, muscle contractions
multiple sclerosis, or spinal cord lesions)
Functional: Loss of urine due to factors that interfere with

responding to the need to urinate (cognitive, mobility, and
environmental barriers)
Transient: e ersible incontinence due to in ammation

NURSING CARE
or irritation (UTI), temporary cognitive impairment, ● Establish a toileting schedule.
disease process (hyperglycemia), medications (diuretics, ● onitor and increase uid inta e during the daytime,
anticholinergics, sedatives) and decrease uid inta e prior to bedtime.
● Remove or control barriers to toileting.
● Provide incontinence garments.
ASSESSMENT/DATA COLLECTION ● Apply an external or condom catheter for males.
● Avoid the use of indwelling urinary catheters.
Provide incontinence care.
RISK FACTORS
●
Female sex
CLIENT EDUCATION
●
● History of multiple pregnancies and vaginal births,

aging, chronic urinary retention, urinary bladder spasm, ● Maintain regular bowel movements.
renal disease, chronic bladder infection (cystitis) ● Try to empty bladder completely with each void.
● Neurologic disorders: Parkinson’s disease, cerebrovascular ● Keep an incontinence diary.
accident, spinal cord injury, multiple sclerosis ● Perform Kegel exercises: Tighten pelvic muscles for a count
● Medication therapy: Diuretics, opioids, anticholinergics, of 10, relax slowly for a count of 10, and repeat in sequences
calcium channel blockers, sedative/hypnotics, of 15 in the lying-down, sitting, and standing positions.
adrenergic antagonists ● Perform bladder compression techniques (Credé,
● Obesity Valsalva, double voiding, splinting) to help manage
● Confusion, dementia, immobility, depression re e incontinence.
● Physiological changes of aging ● A oid caffeine and alcohol consumption because these
● Decreased estrogen levels and decreased can irritate the bladder and increase diuresis and the
pelvic-muscle tone urge to urinate.
● Immobility, chronic degenerative diseases, dementia, ● Ad erse effects of medications can affect urination.
diabetes mellitus, cerebrovascular accident ● Conduct vaginal cone therapy to strengthen pelvic
● Urinary incontinence increasing the risk for falls, muscles (for stress incontinence).
fractures, pressure injuries, and depression

MEDICATIONS THERAPEUTIC PROCEDURES
Antibiotics Bladder-retraining program
Gentamicin, cephalexin, trimethoprim/sulfamethoxazole, Urinary bladder retraining increases the bladder’s ability
cipro o acin for infection to hold urine and clients’ ability to suppress urination.
NURSING ACTIONS: Administer medication with food to CLIENT EDUCATION

decrease gastrointestinal distress. ● Urinate at scheduled intervals.
● Gradually increase urination intervals after no
CLIENT EDUCATION
incontinence episodes for 3 days, working toward the
● Antibiotics might change the urine’s odor.
optimal 4-hr intervals.
● Complete the full course of therapy even if ● Hold urine until the scheduled toileting time.
manifestations resolve. ● Keep track of urination times.
● Take trimethoprim/sulfamethoxazole with 8 oz of water.
Trimethoprim sulfametho a ole and cipro o acin can
Urinary habit training
●
increase sensitivity to the sun. Avoid sun exposure.

● Monitor for loose stools and a rash. Report these to Urinary habit training helps clients who have limited
the provider. cognitive ability to establish a predictable pattern of
bladder emptying.
Tricyclic antidepressants
CLIENT EDUCATION
Nortriptyline has anticholinergic effects that help relie e ● Urinate at scheduled intervals.
urinary incontinence. ● Urination patterns determine the toileting schedule.
● Follow a toileting schedule according to the pattern with
NURSING ACTIONS
which they have no incontinence.
● Monitor for dizziness.
Evaluate blood pressure for orthostatic hypotension.
Intermittent urinary catheterization
●
● Do not administer to clients taking an MAOI.

Intermittent urinary catheterization is periodic
CLIENT EDUCATION: Change positions slowly.
catheterization to empty the bladder. It reduces the
risk of infection from indwelling catheterization, which
Urinary antispasmodics or anticholinergic agents
is a temporary intervention for clients at risk for skin
Oxybutynin and dicyclomine decrease urgency and help breakdown, or when other options have failed.
alleviate pain from a neurogenic or overactive bladder.
NURSING ACTIONS
NURSING ACTIONS ● Adjust the frequency of catheterization to keep output at
● Ask clients about a history of glaucoma. These 300 mL or less.
medications increase intraocular pressure. ● Explain the procedure.
● Monitor for dizziness, tachycardia, and urinary retention.
CLIENT EDUCATION: Follow a toileting schedule according
CLIENT EDUCATION to the pattern with which they have no incontinence.
● Report dysuria, palpitations, and constipation.
● Dizziness and dry mouth are common with Anterior vaginal repair, retropubic suspension,
these medications. pubovaginal sling, insertion of an artificial sphincter
Surgeons insert suprapubic catheters into the abdomen
Phenazopyridine
●
above the pubic bone and in the bladder and suture the
This bladder analgesic treats the manifestations of UTIs. catheter in place. The care for the catheter tubing and
drainage bag is the same as for an indwelling catheter.
NURSING ACTIONS ● Catheters (suprapubic or urinary) remain until clients
● This medication will not treat infection but will help
have a post-void residual of less than 50 mL. Traction
relieve bladder discomfort.
(with tape) helps prevent movement of the bladder.
● Monitor for decreases in Hgb and Hct.
● Hepatic disorders and renal insufficiency NURSING ACTIONS
are contraindications. ● Monitor output and for any manifestations of infection
(color of urine, sediment, level of output).
CLIENT EDUCATION ● Keep the catheter patent at all times.
● Take the medication with food. ● Determine clients’ ability to detect the urge to urinate.
● The medication turns urine orange.
● Notify the provider immediately if jaundice occurs CLIENT EDUCATION
(yellowing of skin, palms and soles of feet, mucous ● Perform skin care around the insertion site.
membranes). ● Perform care and emptying of the catheter bag.
Hormone replacement therapy

This is controversial, but it increases the blood supply to
the pelvis.

Periurethral collagen injections to the bladder neck COMPLICATIONS
Injection of collagen or silicone implants into the urethral
Skin breakdown (from chronic exposure to urine)
all to impede urine o .
NURSING ACTIONS
CARE AFTER DISCHARGE: Consult home care services to ● Keep the skin clean and dry.
provide intermittent catheters, portable commodes, or ● Assess for manifestations of breakdown.
stool risers. Suggest installing handrails to assist clients ● Apply protective barrier creams.
who have bathroom needs. ● Implement a bladder-retraining program.
CLIENT EDUCATION Social isolation

● Drin to L of uid daily. NURSING ACTIONS
● Try to hold urine, and stay on schedule with ● Assist with measures to conceal urinary
bladder retraining. leaking (perineal pads, external catheters, adult
● Drink cranberry juice to decrease the risk of infection. incontinence garments).
● If obese, participate in a weight-reduction program to ● ffer emotional support.
help resolve stress incontinence.
● Intake medications to help resolve incontinence.
● Perform intermittent catheterization if necessary. Active Learning Scenario
● Express any feelings about incontinence.
the various types of urinary incontinence. Use the ATI Active
Learning Template: System Disorder to complete this item.
ALTERATION IN HEALTH (DIAGNOSIS): List at least

four of the six types of urinary incontinence, along
with a brief example or description of each.
RISK FACTORS: List at least 10 common
risk factors for urinary incontinence.
1. A nurse is teaching a client who reports stress urinary 4. A nurse is reviewing factors that increase the risk
incontinence. Which of the following instructions of urinary tract infections (UTIs) with a client who
should the nurse include? (Select all that apply.) has recurrent UTIs. Which of the following factors
A. Limit total daily fluid intake. should the nurse include? (Select all that apply.)
B. Decrease or avoid caffeine. A. Frequent sexual intercourse
C. Take calcium supplements. B. Lowering of testosterone levels
D. Avoid drinking alcohol. C. Wiping from front to back to clean the perineum
E. Use the Credé maneuver. D. Location of the urethra closer to the anus
E. Frequent catheterization
2. A client who has an indwelling catheter

reports a need to urinate. Which of the 5. A nurse is preparing to initiate a bladder-retraining
following actions should the nurse take? program for a client who has incontinence.
A. Check to see whether the catheter is patent. Which of the following actions should the
nurse take? (Select all that apply.)
B. Reassure the client that it is not
possible for them to urinate. A. Restrict the client’s intake of
fluids during the daytime.
C. Recatheterize the bladder with
a larger-gauge catheter. B. Have the client record urination times.
D. Collect a urine specimen for analysis. C. Gradually increase the urination intervals.
D. Remind the client to hold urine until the
next scheduled urination time.
3. A nurse is caring for a client who has a prescription E. Provide a sterile container for urine.
for a 24-hr urine collection. Which of the
following actions should the nurse take?
A. Discard the first voiding.
B. Keep the urine in a single container
at room temperature.
C. Dispose of the last voiding.
D. Ask the client to urinate into the toilet,
stop midstream, and finish urinating
into the specimen container.

1. A. Because stress incontinence results from weak Using the ATI Active Learning Template: System Disorder
pelvic muscles and other structures, limiting ALTERATION IN HEALTH (DIAGNOSIS)
fluids will not resolve the problem. ●
Stress: The loss of small amounts of urine from
B. CORRECT: Caffeine is a bladder irritant and
increased abdominal pressure without bladder muscle
can worsen stress incontinence.
contraction with laughing, sneezing, or lifting
C. Calcium has no effect on stress incontinence.
D. CORRECT: Alcohol is a bladder irritant and
●
Urge: The inability to stop urine flow long enough to
can worsen stress incontinence. reach the bathroom due to an overactive detrusor
E. The Credé maneuver helps manage reflex muscle with increased bladder pressure
incontinence, not stress incontinence.
●
Overflow: Urinary retention from bladder overdistention and
frequent loss of small amounts of urine due to obstruction
NCLEX Connection: Basic Care and Comfort, Elimination
®
of the urinary outlet or an impaired detrusor muscle
●
Reflex: The involuntary loss of a moderate amount of
2. A. CORRECT: A clogged or kinked catheter causes the urine usually without warning due to hyperreflexia of the
bladder to fill and stimulates the need to urinate. detrusor muscle, usually from spinal cord dysfunction
B. Reassuring the client that it is not possible to
●
Functional: The loss of urine due to factors that
urinate is a nontherapeutic response because interfere with responding to the need to urinate
it dismisses the client’s concern. (cognitive, mobility, and environmental barriers)
C. There are less invasive approaches the nurse ●
Transient: Reversible incontinence due to inflammation or
can try before replacing the catheter. irritation (UTI), temporary cognitive impairment, disease process
D. Although it might become necessary to collect a (hyperglycemia), medications (diuretics, anticholinergics, sedatives)
urine specimen, there is a simpler approach to take to RISK FACTORS
assess and possibly resolve the client’s problem. ●
Female sex
NCLEX® Connection: Reduction of Risk Potential, Potential for ●
History of multiple pregnancies and vaginal births,
Complications of Diagnostic Tests/Treatments/Procedures chronic urinary retention, urinary bladder spasm,
renal disease, chronic bladder infection
●
Neurologic disorders: Parkinson’s disease, cerebrovascular
3. A. CORRECT: Discard the first voiding of the 24-hr
accident, spinal cord injury, multiple sclerosis
urine specimen, and note the time.
B. Keep the urine in a refrigerated container.
●
Medications: diuretics, opioids, anticholinergics, calcium channel
C. Instruct the client to completely empty the bladder, and blockers, sedative/hypnotics, adrenergic antagonists
save the last voiding at the end of the collection period.
●
Obesity
D. For a culture specimen, ask the client to urinate ●
Confusion, dementia, immobility, depression
first into the toilet and insert the specimen cup ●
Physiological changes of aging
during midstream to collect specimen. ●
Decreased estrogen levels, decreased pelvic-muscle tone
Immobility, chronic degenerative diseases, dementia,
Diagnostic Tests diabetes mellitus, cerebrovascular accident
●
Urinary incontinence increasing the risk for falls,
fractures, pressure injuries, and depression
4. A. CORRECT: Having frequent sexual intercourse
increases the risk of UTIs in all clients. NCLEX® Connection: Physiological Adaptation, Pathophysiology
B. The decrease in estrogen levels during menopause
increases a client’s susceptibility to UTIs.
C. Wiping from front to back when cleaning the
perineum decreases a client’s risk of UTIs.
D. CORRECT: The close proximity of the urethra to the
anus is a factor that increases the risk of UTIs.
E. CORRECT: Frequent catheterization and the use of
indwelling catheters are risk factors for UTIs.
5. A. Encourage the client’s fluid intake during the

daytime to promote urine production and
establish bladder retraining.
B. CORRECT: Ask the client to keep track of urination
times as a record of progress toward the goal
of 4-hr intervals between urination.
C. CORRECT: Gradually increasing the urination
intervals helps the client progress toward the
goal of 4-hr intervals between urination.
D. CORRECT: Remind the client to hold urine until the
next scheduled urination time as part of progressing
toward the goal of 4-hr intervals between urination.
E. A bladder-retraining program does not involve
collecting sterile urine specimens.

CHAPTER 45
UNIT 4 PHYSIOLOGICAL INTEGRITY PATIENT-CENTERED CARE
CHAPTER 45 Sensory Perception NURSING CARE

● Chec for communication de cits, and ad ust
care accordingly.
Sensory perception is the ability to receive and ● Collect equipment necessary to care for any assistive
devices clients have (corrective lenses, hearing aids).
interpret sensory impressions through sight (visual), Make sure these devices are available for use.
hearing (auditory), touch (tactile), smell (olfactory), ● a e e ery effort to communicate ith clients ho
have sensoriperceptual losses because they tend to
taste (gustatory), and movement or position withdraw from interactions with others.
(kinesthetic). Sensory input affects consciousness, EQUIPMENT
arousal, awareness, memory, affect, judgment, ● Assistive devices (hearing aid, glasses)
Orientation tools (clocks, calendars)
awareness of reality, and language.
●
● Radio, television, CD/DVD player, digital audio player

Large-print materials
A sensory deficit is a change in reception and/or
●
NURSING ACTIONS
perception. Deficits can affect any of the senses. ● Keep clients safe and free from injury.
When a sensory deficit develops gradually, the ◯ Make sure the call light is easily accessible.
Orient clients to the room.

body often compensates for the deficit.
◯
◯ Keep furniture clear from the path to the bathroom.
◯ Keep personal items within reach.
Sensory deprivation is reduced sensory input ◯ Place the bed in its lowest position.
from the internal or external environment. It ◯ Make sure IV poles, drainage tubes, and bags are easy
to maneuver.
can result from illness, trauma, or isolation. ● Learn clients’ preferred method of communication, and
Manifestations of sensory deprivation can make accommodations.
FOR CLIENTS WHO HAVE HEARING LOSS
be cognitive (decreased ability to learn,
●
◯ Sit and face the clients.

disorientation), affective (restlessness, ◯ Avoid covering your mouth while speaking.
Encourage the use of hearing devices.
anxiousness), or perceptual (decreased
◯
◯ Speak slowly and clearly.

coordination, decreased color perception). ◯ Try lowering vocal pitch before increasing volume.
◯ Use brief sentences with simple words.
Sensory overload is excessive, sustained, and ◯ Write down what clients do not understand.
Minimize background noise.
unmanageable multisensory stimulation.
◯
◯ Ask for a sign-language interpreter if necessary.

Manifestations are similar to those of sensory ◯ Do not shout.
FOR CLIENTS WHO HAVE VISION LOSS
deprivation and include racing thoughts,
●
◯ Call clients by name before approaching to avoid

anxiousness, and restlessness. startling them.
◯ Identify yourself.
◯ tay ithin clients isual eld if they ha e a
CONTRIBUTING FACTORS partial loss.
◯ i e speci c information about the location of items
Vision loss: Presbyopia, cataracts, glaucoma, diabetic
or areas of the building.
retinopathy, macular degeneration, infection, ◯ Explain interventions before touching clients.
in ammation, in ury, brain tumor ◯ Before leaving, inform clients of your departure.
Conductive hearing loss: Obstruction, wax accumulation, ◯ Carefully appraise clients’ clothing, and suggest
tympanic membrane perforation, ear infections,
changes if soiled or torn.
otosclerosis ◯ Make a radio, television, CD player, or digital audio
Sensorineural hearing loss: Exposure to loud noises,
player available.
ototoxic medications, aging, acoustic neuroma ◯ Describe the arrangement of the food on the tray
Taste deficit: Xerostomia or reduced salivation; alters
before leaving the room.
appetite
Neurologic deficits: Peripheral neuropathy; peripheral
numbness
Stroke: Can result in loss of sensation, difficulty
spea ing, and isual de cits
FUNDAMENTALS FOR NURSING CHAPTER 45 SENSORY PERCEPTION 259

● FOR CLIENTS WHO HAVE APHASIA COMPLICATIONS
◯ Greet clients, and call them by name.
◯ Make sure only one person speaks at a time. Risk for injury in the home environment
◯ Speak clearly and slowly using short sentences and
Teach ways to reduce hazards at home.
simple words.
◯ Do not shout. VISUAL
◯ Pause between statements to allow time for clients ● Remove throw rugs to prevent tripping hazards.
to understand. ● Keep walking pathways clear.
◯ Check for comprehension. ● Ensure that stairways are well lit with secure handrails.
◯ Tell clients when you do not understand them. ● Instruct client to use a magnifying glass when reading.
◯ Ask questions that require simple answers. ● Paint the edge of steps or replace steps with ramps.
◯ Reinforce verbal with nonverbal communication
AUDITORY: se ashing lights s. a arning sound for
(gestures, body language).
alarms and doorbells.
◯ Allow plenty of time for clients to respond.
◯ Use methods speech therapists implement (a picture OLFACTORY: Make sure smoke and carbon monoxide
chart) to improve communication. detectors are functioning to sense odors and odorless
◯ Acknowledge any frustration in communicating. gases (burning food, natural gas, carbon monoxide).
● FOR CLIENTS WHO ARE DISORIENTED Remove sources of unpleasant odors (bedpans, soiled
◯ Call clients by name, and identify yourself. dressings).
◯ Maintain eye contact at eye level.
◯ Use brief, simple sentences.
GUSTATORY: Read expiration dates on food packages to
avoid consuming contaminated or spoiled food products.
◯ Ask only one question at a time.
Promote good oral hygiene.

◯ Allow plenty of time for clients to respond.
◯ Give directions one step at a time. TACTILE: Protect and inspect body parts that lack
◯ Avoid lengthy conversations. sensation from injury (burns, pressure injuries, frostbite).
◯ Provide for adequate sleep and pain management. Avoid the use of hot water bottles; label faucets “hot” and
● Encourage clients to verbalize feelings about “cold” with words or colors; and set hot water heaters to
sensoriperceptual loss. avoid excessively hot water. Sources vary, but an upper
● Orient clients to time, person, place, and situation. limit of 48.8° C (120° F) is generally acceptable. Encourage
◯ Keep a clock in the room. use of prescribed assistive devices.
◯ Post a calendar, or write the date where it is visible.
● Provide and use assistive devices. Sensory deprivation

● Provide care clients cannot perform (reading menus,
Provide meaningful stimulation.
opening containers). Assess client’s level of satisfaction ● Provide large-print materials or electronic players for
with family and friends’ support.
audio books.
● Amplify phones.
INTERPROFESSIONAL CARE ● Provide pleasant aromas.

● Increase touch (if acceptable) with back rubs, hand
● Determine which assistive devices clients need, and
holding, range-of-motion exercises, and hair care.
plan for their procurement. ● Ensure client has vision and hearing assistive devices.
● Consult with rehabilitation therapists for ● Communicate frequently with the client.
restorative potential. ● ncourage family to bring o ers, sculptures, and
● Refer clients to community-based support groups and
pictures, or pets, when allowed.
organizations for additional resources. ● Provide objects with various textures. Encourage
the client to engage in activities that require mental
engagement (crossword puzzles, whistling, reciting).
Sensory overload
Minimize overall stimuli.
● Provide a private room
● educe lights and noises. ffer the client earplugs and
dark glasses if needed.
● Provide orientation cues (calendars, clocks).
● Limit visitors.
● Reduce unpleasant odors.
● Assist the client with stress reduction.
● Ensure pain is adequately managed.

● Schedule sleep to minimize interruptions.
260 CHAPTER 45 SENSORY PERCEPTION CONTENT MASTERY SERIES

Vision loss EXPECTED FINDINGS
● Frequent headaches
● Visual acuity is the degree of detail clients can perceive ● Frequent eye strain
in an image. ● Blurred vision
● Reduced visual acuity can be unilateral (one eye) or ● Poor judgment of depth
bilateral (both eyes). ● Diplopia: double vision
● Tendency to close or favor one eye
Poor hand-eye coordination
HEALTH PROMOTION AND
●
DISEASE PREVENTION
● Advise clients to wear sunglasses while outside and
DIAGNOSTIC PROCEDURES
protective eyewear while working in areas and at tasks Ophthalmoscopy: Allows visualization of the back part
with a risk for eye injury. of the eyeball (fundus), including the retina, optic disc,
● Instruct clients to avoid rubbing eyes. macula, and blood vessels
● Tell clients to get an eye examination regularly,
Visual acuity tests: Snellen and Rosenbaum eye charts
especially after age 40.
Tonometry: Measures intraocular pressure (expected
range 10 to 21 mm Hg), which is elevated with glaucoma,
ASSESSMENT/DATA COLLECTION especially angle-closure glaucoma
Gonioscopy: Allows visualization of the iridocorneal angle

RISK FACTORS or anterior chamber of the eyes to distinguish open-angle
or closed-angle glaucoma.
● Age is a signi cant ris factor for isual sensory
alterations Slit lamp examination: Allows visualization of the
● ye infection, in ammation, or in ury anterior portion of the eye (the cornea, anterior chamber,
● Brain tumor and lens)
Presbyopia: Age-related loss of the eye’s ability to focus

on close objects due to decreased elasticity of the lens
Cataracts: Opacity of the lens,

which blocks the entry of light rays
into the eye
45.1 Intraocular pressure
Glaucoma: Structural eye disorder
which causes an increase in
intraocular pressure; can lead to
blindness
Diabetic retinopathy: Leakage and

blockage of retinal blood vessels;
can lead to retinal hypoxia, retinal
hemorrhages, blindness
Macular degeneration: Loss of

central vision from deterioration of
the center of the retina

PATIENT-CENTERED CARE COMPLICATIONS
Risk for injury
NURSING CARE
Reduced vision increases injury risk, especially for
● Monitor the following.
older adults.
◯ Visual acuity using Snellen and Rosenbaum eye charts
■ Both measure distance vision. NURSING ACTIONS: Monitor for safety risks (the ability to
■ The Snellen method has clients stand 6 m (20 ft) away. drive safely), and intervene to reduce risks.
A larger denominator indicates poorer visual acuity.
■ The Rosenbaum method has clients hold the chart
36 cm (14 in) away from their eyes.

◯ External and internal eye structures (ophthalmoscope)
Hearing loss
◯ Functional ability Hearing loss is difficulty in hearing or interpreting speech
● Assess how clients adapt to the environment to and other sounds due to a problem in the middle or
maintain safety. inner ear.
◯ Increase the amount of light in a room.
◯ Arrange the home to remove hazards (eliminating

Conductive hearing loss is an alteration in the middle ear
that blocks sound waves before they reach the cochlea of
throw rugs).
◯ Use phones with large numbers and auto dial.
the inner ear.
● Suggest adaptive devices that accommodate for Sensorineural hearing loss is an alteration in the inner
reduced vision. ear, auditory nerve, or hearing center of the brain.
◯ Magnifying lens and large-print books and newspapers
◯ Talking devices (clocks and watches)

Mixed hearing loss is a combination of conductive and
sensorineural hearing loss.
CLIENT EDUCATION
Contact lens care
DISEASE PREVENTION
●
◯ Periodically remove contact lenses to prevent corneal
abrasions and ocular infection. ● Advise clients not to place any objects in the ear,
◯ Monitor for corneal abrasion or eye infection (pain, including cotton-tipped swabs.
redness, visual disturbance) ● Tell clients to have an otologist remove any object
◯ Use fresh solution to store contacts and wash and dry lodged in the ear. Use a commercial ceruminolytic (ear
lens case daily drops that soften cerumen) for impactions, and follow
● Eyeglasses care with warm-water irrigation.
◯ Use soft cloth for drying to prevent scratching when ● Instruct clients to wear ear protection during exposure
cleaning eyeglasses. to high-intensity noise and risk for ear trauma.
◯ Store eyeglasses in a labeled container inside a drawer ● Tell clients to blow the nose gently and with both
in the client’s bedside table. nostrils unobstructed.
● Advise clients to keep the volume as low as possible
when wearing headphones.
MEDICATIONS
Anticholinergics
Anticholinergics (atropine ophthalmic solution) provide
mydriasis (dilation of the pupil) and cycloplegia (ciliary
paralysis) for examinations and surgery.
RISK FACTORS
● Advancing age
CLIENT EDUCATION: Ad erse effects include reduced ● Use of ototoxic medications (aminoglycosides,
accommodation, blurred vision, and photophobia. With
monobactams, diuretics, NSAIDs)
systemic absorption, there could be anticholinergic effects
(tachycardia, decreased secretions).
Conductive hearing loss
History of middle ear infections
CLIENT EDUCATION
●
● Older age (otosclerosis)

● Wash hands before and after instilling eye medication.
● Quit smoking. Sensorineural hearing loss
● Limit alcohol intake. ● Prolonged exposure to loud noises
● Keep blood pressure, blood glucose, and cholesterol ● Ototoxic medications
under control. ● Infectious processes
● Eat foods rich in antioxidants (green leafy vegetables). ● Older age (presbycusis: decreased ability to hear
CARE AFTER DISCHARGE: Initiate referrals to social high-pitched sounds)
services, support groups, and reduced-vision resources.

Online Videos: Rinne and Weber Tests; Otoscopic Examination
EXPECTED FINDINGS Tympanogram

A tympanogram measures the mobility of the tympanic
Conductive hearing loss
membrane and middle ear structures relative to sound to
● Hears better in a noisy environment diagnose disorders of the middle ear.
● Speaks softly
● Obstruction in external canal (packed cerumen) Otoscopy
● Tympanic membrane ndings holes, scarring
An otoscope allows visualization of the external auditory
● Rinne test that demonstrates air conduction of sound
canal, the tympanic membrane (TM), and malleus bone
less than or e ual to bone conduction AC C
visible through the TM.
● eber test that laterali es to the affected ear
NURSING ACTIONS
Sensorineural hearing loss ● Perform an otoscopic examination when audiometry
results indicate a possible impairment or for ear pain.
● Tinnitus (ringing, roaring, humming in ears) ● Select a speculum according to the size of the ear, then
● Dizziness
attach it and insert the otoscope into the external ear.
● Hears poorly in a noisy environment ● Pull up and back on the auricle of adults and down and
● Speaks loudly
back on the auricle of children younger than 3 years to
● No otoscopic ndings
straighten out the canal and enhance visualization.
● Rinne test that demonstrates expected response of air ● The tympanic membrane should be pearly gray and
conduction being greater than bone conduction (AC > BC),
intact. It should provide complete structural separation
but with length of time decreased for both
of the outer and middle ear structures.
● eber test laterali ing to unaffected ear ● The light re e should be isible from the center of the
● Diagnosis of acoustic neuroma (benign tumor cranial
TM anteriorly (5 o’clock right ear; 7 o’clock left ear).
nerve VIII) ● ith uid or infection in the middle ear, the tympanic
membrane ill become in amed and can bulge from
DIAGNOSTIC PROCEDURES the pressure of the exudate. This also will displace the
light re e , a signi cant nding.
Audiometry ● Avoid touching the lining of the ear canal, which causes
pain due to sensitivity.
An audiogram identi es hether hearing loss is
sensorineural and/or conductive.
NURSING ACTIONS
● Use audiometry when screening for hearing loss in a
school or older adult setting (after
speci c training to perform this
procedure). Results are more
accurate in a quiet room.
● Assess clients’ ability to hear 45.2 External, middle, and internal ear
various frequencies (high vs. low
pitch) at various decibels (soft vs.
loud tones).
● Have clients wear audiometer
headphones and face away from
the examiner.
● Have clients indicate when they
hear a tone and in which ear
by raising their hand on the
corresponding side. Comparing
the responses on a graph with
expected age and other norms
yields information about the type
and degree of hearing loss.

PATIENT-CENTERED CARE THERAPEUTIC PROCEDURES
Hearing aids
NURSING CARE
● Hearing aids amplify sounds, but do not help clients
● Monitor functional ability.
interpret what they hear.
● Check the hearing of clients receiving ototoxic ● Ampli cation of sound in a loud en ironment can be
medications for more than 5 days. Reduced renal function
distracting and disturbing.
that occurs with aging increases the risk for ototoxicity.
● Provide visual teaching aids and written CLIENT EDUCATION
instructional materials. ● Use the lowest setting that allows hearing without feedback.
● Hospitals are required to give the deaf client access to a ● To clean the ear mold, use mild soap and water while
professional interpreter to read sign language. keeping the hearing aid dry.
● When the hearing aid is not in use for an extended
Ototoxic medications period of time, turn it off and remo e the battery to
conserve battery power and avoid corrosion of the
● Antibiotics: gentamicin, metronidazole
hearing aid. Keep replacement batteries on hand.
● Diuretics: furosemide
NSAIDs: aspirin, ibuprofen
Tympanoplasty and myringoplasty
●
● Chemotherapeutic agents: cisplatin

For conductive hearing loss
Communication ● Tympanoplasty is a surgical reconstruction of the
middle ear structures.
● Get clients’ attention before speaking. ● Myringoplasty is an eardrum repair.
● Stand or sit facing clients in a well-lit, quiet room
without distractions. NURSING ACTIONS
● Speak clearly and slowly without shouting and without ● Place sterile ear packing postoperatively.
hands or other objects covering the mouth. ● Position clients at ith the operati e ear facing
● Arrange for communication assistance (sign-language up for 12 hr.
interpreter, closed captions, phone ampli ers,
CLIENT EDUCATION
teletypewriter [TTY] capabilities). ● Tell clients to avoid air travel and forceful straining,
coughing, or sneezing with the mouth closed.
INTERPROFESSIONAL CARE ● Teach clients to cover the ear with a dressing before
washing hair and not to allow water to enter the ear.
efer clients ho ha e une pected audiometry ndings to ● Remind clients that they will hear less while packing is
an audiologist for more sensitive testing.
in the ear.
45.3 Light reflex

1. A nurse is caring for a client who had a stroke and A nurse is teaching a group of newly licensed nurses
has aphasia. Which of the following interventions how to intervene for clients who have sensory
should the nurse use to promote communication impairment. Use the ATI Active Learning Template:
with this client? (Select all that apply.) System Disorder to complete this item.
A. Speak at a higher volume to the client. NURSING CARE

B. Make sure only one person speaks at a time. ●
List at least six interventions for clients
C. Avoid discouraging the client by indicating who have hearing loss.
that they cannot be understood. ●
List at least six interventions for clients who have vision loss.
D. Allow plenty of time for the client to respond.
E. Use brief sentences with simple words.
2. A nurse is caring for a client who had an amphetamine

toxicity and has sensory overload. Which of the
following interventions should the nurse implement?
A. Immediately complete a thorough assessment.
B. Encourage visitors to distract the client.
C. Provide a private room, and limit stimulation.
D. Speak at a higher volume to the client.
3. A nurse is caring for a client who reports difficulty

hearing. Which of the following assessment
findings indicate a sensorineural hearing loss
in the left ear? (Select all that apply.)
A. Weber test showing lateralization to the right ear
B. Light reflex at 10 o’clock in the left ear
C. Indications of obstruction in the left ear canal
D. Rinne test showing less time for
air and bone conduction
E. Rinne test showing air conduction less
than bone conduction in the left ear
4. A nurse is caring for a client who has several risk factors

for hearing loss. Which of the following medications
the client currently takes should alert the nurse to a
further risk for ototoxicity? (Select all that apply.)
A. Furosemide
B. Ibuprofen
C. Cimetidine
D. Simvastatin
E. Amiodarone
5. A nurse is reviewing instructions with a client who

has a hearing loss and has just started wearing
hearing aids. Which of the following statements
should the nurse identify as an indication that
the client understands the instructions?
A. “I use a damp cloth to clean the
outside part of my hearing aids.”
B. “I clean the ear molds of my hearing
aids with rubbing alcohol.”
C. “I keep the volume of my hearing aids
turned up so I can hear better.”
D. “I take the batteries out of my hearing
aids when I take them off at night.”

1. A. Speak in a normal tone of voice to a client who had a Using the ATI Active Learning Template: System Disorder
stroke and has aphasia to promote communication.
NURSING CARE
B. CORRECT: Make sure only one person speaks
at a time because trying to understand more Hearing loss
than one voice at a time is challenging. ●
Sit and face the client.
C. Tell the client if they cannot be understood, because ●
Avoid covering your mouth while speaking.
pretending to understand shows a lack of respect for the ●
Encourage the use of hearing devices.
client’s needs and blocks further communication. ●
Speak slowly and clearly.
D. CORRECT: Allowing ample time for the client to respond
helps enhance communication. Rushing ahead to the next
●
Do not shout.
question would be demeaning and could cause frustration.
●
Try lowering vocal pitch before increasing volume.
E. CORRECT: Use brief sentences with simple words ●
Use brief sentences with simple words.
because these are easier for the client to understand. ●
Write down what clients do not understand.
Minimize background noises.
Ask for a sign-language interpreter if necessary.
Vision loss
2. A. Immediately completing a thorough assessment
●
Call clients by name before approaching to avoid startling them.
might overwhelm the client at this time. Brief
●
Identify yourself.
assessments throughout the shift are better. ●
Stay within the clients’ visual field if they have a partial loss.
B. Limit visitors to decrease stimulation. ●
Give specific information about the location
C. CORRECT: Provide the client with a private of items or areas of the building.
room to decrease stimulation. ●
Explain interventions before touching clients.
D. Talking at a higher volume would increase ●
Before leaving, inform clients of your departure.
environmental stimuli. ●
Carefully appraise clothing and suggest changes if soiled or torn.
NCLEX® Connection: Basic Care and Comfort, Assistive Devices ●
Make a radio, television, CD player, or digital audio player available.
●
Describe the arrangement of the food on
the tray before leaving the room.
3. A. CORRECT: With sensorineural hearing loss, the Weber test
demonstrates lateralization to the unaffected ear. NCLEX® Connection: Psychosocial Integrity, Sensory/Perceptual
B. A light reflex at 10 o’clock in the left ear indicates that Alterations
air or fluid has displaced the tympanic membrane, but
it does not indicate sensorineural hearing loss.
C. Indications of obstruction in the ear canal would
indicate conductive hearing loss.
D. CORRECT: With sensorineural hearing loss
in the left ear, length of time is decreased
for both air and bone conduction.
E. With sensorineural hearing loss in the left ear, air conduction
is greater than bone conduction in the left ear.
4. A. CORRECT: Furosemide, a loop diuretic, can cause

hearing loss as well as blurred vision.
B. CORRECT: Ibuprofen, a nonsteroidal anti-inflammatory
agent, can cause hearing loss as well as vision loss.
C. Hearing loss is not an adverse effect of cimetidine, a
medication that decreases gastric acid secretion.
D. Hearing loss is not an adverse effect of simvastatin,
a medication that lowers cholesterol.
E. Hearing loss is not an adverse effect of amiodarone,
an antidysrhythmic medication.
5. A. The client should keep the hearing aids

completely dry at all times.
B. The client should clean the ear molds
with mild soap and water.
C. To avoid feedback, the client should keep the volume
on the lowest setting that allows them to hear.
D. CORRECT: To conserve battery power, the
client should turn off the hearing aids and
remove the batteries when not in use.
Sensory/Perceptual Alterations

NCLEX® Connections
Management of Care
CLIENT RIGHTS: Recognize the client’s right
to refuse treatment/procedures.
CONTINUITY OF CARE: Use approved abbreviations

and standard terminology when documenting care.
INFORMATION TECHNOLOGY: Receive and

transcribe health care provider orders.

ACCIDENT/ERROR/INJURY PREVENTION: Ensure
proper identi cation of client hen pro iding care.
Pharmacological and Parenteral Therapies

DOSAGE CALCULATION: Perform calculations
needed for medication administration.
EXPECTED ACTIONS/OUTCOMES: Obtain

information on a client’s prescribed medications.
MEDICATION ADMINISTRATION
Prepare and administer medications, using
rights of medication administration.
Administer and document medications given by common routes.
Administer and document medications given by parenteral routes.
Educate client on medication self-administration procedures.

PARENTERAL/INTRAVENOUS THERAPIES: Monitor
intravenous infusion and maintain site.
POTENTIAL FOR COMPLICATIONS OF DIAGNOSTIC

TESTS/TREATMENTS/PROCEDURES: Insert, maintain,
or remove a peripheral intravenous line.

CHAPTER 46
UNIT 4 PHYSIOLOGICAL INTEGRITY Distribution
SECTION: PHARMACOLOGICAL AND PARENTERAL THERAPIES
The transportation of medications to sites of action by
Pharmacokinetics bodily uids.

CHAPTER 46
and Routes of
FACTORS INFLUENCING DISTRIBUTION
● Circulation: Conditions that inhibit blood o or
Administration perfusion (peripheral vascular or cardiac disease) can

delay medication distribution.
● Permeability of the cell membrane: The medication
must be able to pass through tissues and membranes to
Pharmacokinetics refers to how medications travel reach its target area. Medications that are lipid-soluble
or have a transport system can cross the blood-brain
through the body. Medications undergo a variety barrier and the placenta.
of biochemical processes that result in absorption, ● Plasma protein binding: Medications compete for
protein binding sites within the bloodstream, primarily
distribution, metabolism, and excretion. albumin. The ability of a medication to bind to a protein
can affect ho much of the medication ill lea e and
PHASES OF PHARMACOKINETICS travel to target tissues. Two medications can compete
for the same binding sites, resulting in toxicity.
Absorption
The transmission of medications from the location of Metabolism (biotransformation)
administration (gastrointestinal [GI] tract, muscle, skin,
Changes medications into less active forms or inactive
or subcutaneous tissue) to the bloodstream. The most
forms by the action of enzymes. This occurs primarily
common routes of administration are enteral (through the
in the liver, but also takes place in the kidneys, lungs,
GI tract) and parenteral (by injection). Each of these routes
intestines, and blood.
has a unique pattern of absorption.
● The rate of medication absorption determines how soon FACTORS INFLUENCING MEDICATION METABOLISM RATE
the medication ta es effect. ● Age: Infants have a limited medication-metabolizing
● The amount of medication the body absorbs determines capacity. The aging process also can in uence
its intensity. medication metabolism, but varies with the individual.
● The route of administration affects the rate and amount In general, hepatic medication metabolism tends to
of absorption. decline with age. Older adults require smaller doses of
medications due to the possibility of accumulation in
Route: Oral
the body.
● BARRIERS TO ABSORPTION: Medications must pass ● An increase in some medication-metabolizing
through the layer of epithelial cells that line the GI tract.
enzymes: This can metabolize a particular medication
● ABSORPTION PATTERN varies greatly due to
sooner, requiring an increase in dosage of that
◯ Stability and solubility of the medication
medication to maintain a therapeutic level. It can

◯ Gastrointestinal pH and emptying time
also cause an increase in the metabolism of other

◯ Presence of food in the stomach or intestines
concurrent-use medications.
◯ Concurrent medications ● First‑pass effect: The liver inactivates some
◯ Forms of medications (enteric-coated pills, liquids)
medications on their rst pass through the li er. Thus,

Route: Subcutaneous and intramuscular they require a nonenteral route (sublingual, IV) because
● BARRIERS TO ABSORPTION: The capillary walls have of their high rst pass effect.
large spaces between cells. Therefore, there is no ● Similar metabolic pathways: When the same
signi cant barrier. pathway metabolizes two medications, it can alter the
● ABSORPTION PATTERN: factors determining the rate metabolism of one or both of them. In this way, the
of absorption rate of metabolism can decrease for one or both of the
◯ Solubility of the medication in water medications, leading to medication accumulation.
■ Highly soluble medications have rapid absorption ● Nutritional status: Clients who are malnourished can
(10 to 30 min). be de cient in the factors that are necessary to produce
■ Poorly soluble medications have slow absorption. speci c medication metaboli ing en ymes, thus
◯ Blood perfusion at the site of injection impairing medication metabolism.
■ Sites with high blood perfusion have rapid absorption.
■ Sites with low blood perfusion have slow absorption. Excretion
Route: Intravenous The elimination of medications from the body, primarily
● BARRIERS TO ABSORPTION: No barriers through the kidneys. Elimination also takes place through
● ABSORPTION PATTERN the liver, lungs, intestines, and exocrine glands (in breast
◯ Immediate: enters directly into the blood milk). Kidney dysfunction can lead to an increase in the
◯ Complete: reaches the blood in its entirety duration and intensity of a medication’s response.
FUNDAMENTALS FOR NURSING CHAPTER 46 PHARMACOKINETICS AND ROUTES OF ADMINISTRATION 269

View Video: Routes of Administration
MEDICATION RESPONSES Agonist: Medication that can mimic the receptor activity
that endogenous compounds regulate. For example,
● Medication dosing attempts to regulate medication
morphine is an agonist because it activates the receptors
responses to maintain plasma levels between the
that produce analgesia, sedation, constipation, and other
minimum effecti e concentration C and the
effects. eceptors are the medication s target sites on or
toxic concentration.
within the cells.)
● A plasma medication level is in the therapeutic
range hen it is effecti e and not to ic. Nurses use Antagonist: Medication that can block the usual receptor
therapeutic levels of many medications to monitor activity that endogenous compounds regulate or the
clients’ responses. receptor activity of other medications. For example,
losartan, an angiotensin II receptor blocker, is an
antagonist. It works by blocking angiotensin II receptors
THERAPEUTIC INDEX (TI) on blood vessels, which prevents vasoconstriction.
Medications with a high TI have a wide safety Partial agonists: Medication that acts as an agonist and
margin; therefore, there is no need for routine blood an antagonist, ith limited affinity to receptor sites. or
medication-level monitoring. Medications with a low TI example, nalbuphine acts as an antagonist at mu receptors
require close monitoring of medication levels. Nurses and an agonist at kappa receptors, causing analgesia at
should consider the route of administration when low doses with minimal respiratory depression.
monitoring for peak levels (highest plasma level when
elimination = absorption).
● For example, an oral medication can peak from 1 to 3 hr
after administration.
Routes of administration
● If the route is IV, the peak time might occur
within 10 min.
● Refer to a medication reference or a pharmacist for
ORAL OR ENTERAL
speci c medication pea times. Tablets, capsules, liquids, suspensions, elixirs, lozenges
● For trough levels, obtain a blood sample immediately ● Most common route
before the next medication dose, regardless of the route ● Least expensive
of administration. ● Convenient
● A plateau is a medication concentration in plasma
NURSING ACTIONS
during a series of doses. ● For liquids, suspension, and elixirs, follow directions for
dilution and shaking. To prepare the medication, place
a medicine cup on a at surface before pouring, and
HALF-LIFE (t1/2) ensure the base of the meniscus lo est uid line is at
The time for the medication in the body to drop by 50%. the level of the dose.
Li er and idney function affect half life. It usually ta es ● Contraindications for oral medication administration
four half-lives to achieve a steady blood concentration include vomiting, decreased GI motility, absence of a
(medication intake = medication metabolism and gag re e , difficulty s allo ing, and a decreased le el
excretion). of consciousness.
● Have clients sit upright at a 90° angle to facilitate
Short half-life Long half-life swallowing.
Medications Medications leave the body more slowly: ● Administer irritating medications (analgesics) with
leave the body over more than 24 hr, with a greater risk small amounts of food.
quickly: 4 to 8 hr. for medication accumulation and toxicity. ● Do not mix with large amounts of food or beverages in
Short-dosing Can give medications at longer intervals case clients cannot consume the entire quantity.
interval or without a loss of therapeutic effects.
MEC drops
● Avoid administration with interacting foods or
Medications take a longer time
between doses. to reach a steady state. beverages (grapefruit juice).
● Administer oral medications as prescribed, and follow
directions for whether medication is to be taken on an
empty stomach (30 min to 1 hr before meals, 2 hr after
PHARMACODYNAMICS meals) or with food.
(MECHANISM OF ACTION) ● Follow the manufacturer’s directions for crushing, cutting,
The interactions between medications and target cells, and diluting medications. Break or cut scored tablets only.
body systems, and organs to produce effects. These ● Make sure clients swallow enteric-coated or
interactions result in functional changes that are the time-release medications whole.
mechanism of action of the medication. ● Use a liquid form of the medication to facilitate
swallowing whenever possible.
270 CHAPTER 46 PHARMACOKINETICS AND ROUTES OF ADMINISTRATION CONTENT MASTERY SERIES

Sublingual and buccal Ear
NURSING ACTIONS
Directly enters the bloodstream and bypasses the liver ● Use medical aseptic technique when administering
● Sublingual: under the tongue
medications into the ears.
● Buccal: between the cheek and the gum ● Have clients sit upright or lie on their side.
CLIENT EDUCATION ● Straighten the ear canal by pulling the auricle upward
● Keep the medication in place until complete and outward for adults or down and back for children
absorption occurs. less than 3 years of age. Hold the dropper 1 cm above the
● Do not eat or drink while the tablet is in place or until it ear canal, instill the medication, and then gently apply
has completely dissolved. pressure ith your nger to the tragus of the ear unless
it is too painful.
● Do not press a cotton ball deep into the ear canal. If
TOPICAL necessary, gently place it into the outermost part of the
ear canal.
Medications directly applied to the mucous membranes or ● Have clients remain in the side-lying position if
skin. Includes powders, sprays, creams, ointments, pastes,
possible for 2 to 3 min after installation of ear drops.
oil-and suspension-based lotions.
● Painless Nasal
● Limited ad erse effects NURSING ACTIONS
● Use medical aseptic technique when administering
NURSING ACTIONS
medications into the nose.
● Apply with a glove, tongue blade, or ● Have clients lie supine with their head positioned to allow
cotton-tipped applicator.
the medication to enter the appropriate nasal passage.
● Do not apply with a bare hand. ● Use your dominant hand to instill the drops, supporting
● For skin applications, wash the skin with soap and
the head with your nondominant hand.
water. Pat dry before application. ● Instruct clients to breathe through the mouth, stay in a
● Use surgical asepsis to apply topical medications to
supine position, and not to blow the nose for 5 min after
open wounds.
drop instillation.
For nasal spray, prime the spray if indicated, insert
Transdermal
●
tip into nare, and point nozzle away from the center
Medication in a skin patch for absorption through the of the nose.
s in, producing systemic effects ● Spray into nose while the client inhales, and instruct the
client not to blow their nose for several minutes.
CLIENT EDUCATION
● Apply patches as prescribed to ensure proper dosing. Rectal suppositories
● Wash the skin with soap and water, and dry it NURSING ACTIONS
thoroughly before applying a new patch. ● Position clients in the left lateral or Sims’ position.
● Place the patch on a hairless area and rotate sites to ● Insert the suppository just beyond the internal sphincter.
prevent skin irritation. ● Instruct clients to remain at or in the left lateral
position for at least 5 min after insertion to retain the
Instillation (drops, ointments, sprays) suppository. Absorption times vary with the medication.
Generally used for eyes, ears, and nose Vaginal

NURSING ACTIONS
Eye ● Position clients supine with their knees bent and their
NURSING ACTIONS
feet at on the bed and close to their hips modi ed
● Use medical aseptic technique when instilling
lithotomy or dorsal recumbent position).
medications in eyes. ● Provide perineal care, if needed.
● Have clients sit upright or lie supine, tilt their head ● Lubricate the suppository or ll the applicator,
slightly, and look up at the ceiling.
depending on the formulation.
● Rest your dominant hand on the clients’ forehead, hold the ● Insert the medication along the posterior wall of the
dropper above the conjunctival sac about 1 to 2 cm, drop
vagina (7.5 to 10 cm [3 to 4 in] for suppositories; 5 to
the medication into the sac, avoid placing it directly on the
7.6 cm [2 to 3 in] for creams, jellies or foams) or instill
cornea, and have them close the eye gently. If they blink
irrigation as indicated.
during installation, repeat the procedure. ● Instruct clients to remain supine for at least 5 min after
● Apply gentle pressure ith your nger and a clean facial
insertion to retain the suppository.
tissue on the nasolacrimal duct for 30 to 60 seconds to ● If using a reusable applicator, wash it with soap and
prevent systemic absorption of the medication.
water. (If it is disposable, discard it.)
● If instilling more than one medication in the same eye,
wait at least 5 min between them.
● For eye ointment, apply a thin ribbon to the edge of the
lower eyelid from the inner to the outer canthus.

INHALATION NASOGASTRIC AND
Administered through metered-dose inhalers (MDI) or
GASTROSTOMY TUBES
dry-powder inhalers (DPI) NURSING ACTIONS
● Verify proper tube placement.
MDI ● se a syringe and allo the medication to o in by
gravity or push it in with the plunger of the syringe.
CLIENT EDUCATION
● Remove the cap from the inhaler’s mouthpiece. GENERAL GUIDELINES
● ha e the inhaler igorously e or si times. ● Use liquid forms of medications; if not available,
● Hold the inhaler with the mouthpiece at the bottom. consider crushing medications if appropriate
● Hold the inhaler with your thumb near the mouthpiece guidelines allow.
and your inde and middle ngers at the top. ● Do not administer sublingual medications.
● Hold the inhaler about 2 to 4 cm (1 to 2 in) away from ● Do not crush specially prepared oral medications
the front of your mouth or close your mouth around the e tended time release, uid lled, enteric coated .
mouthpiece of the inhaler with the opening pointing ● Administer each medication separately.
toward the back of your throat. ● Do not mi medications ith enteral feedings.
● Ta e a deep breath, and then e hale. ● Completely dissolve crushed tablets and capsule
● Tilt your head back slightly, press the inhaler, and, at contents in 15 to 30 mL of tepid water prior
the same time, begin a slow, deep inhalation breath. to administration.
Continue to breathe slowly and deeply for 3 to 5 seconds ● To pre ent clogging, ush the tubing before and after
to facilitate delivery to the air passages. each medication with 15 to 30 mL water.
● Hold your breath for 10 seconds to allow the medication ● Flush with another 30 to 60 mL of water after instilling
to deposit in your airways. all the medications.
● Ta e the inhaler out of your mouth and slo ly e hale ● Use sterile water for immunocompromised or critically
through pursed lips. ill clients.
● Resume normal breathing.
● A spacer keeps the medication in the device longer,
thereby increasing the amount of medication the device PARENTERAL
delivers to the lungs and decreasing the amount of
NURSING ACTIONS
medication in the oropharyn . ● The vastus lateralis is best for infants 1 year
● For clients who use a spacer
and younger.
◯ Remove the covers from the mouthpieces of the
● The ventrogluteal site is preferable for IM injections and
inhaler and of the spacer.
for in ecting olumes e ceeding mL.
◯ Insert the MDI into the end of the spacer.
● The deltoid site has a smaller muscle mass and can only
◯ ha e the inhaler e or si times.
accommodate up to mL of uid.
◯ hale completely, and then close your mouth around ● Use a needle size and length appropriate for the type
the spacer’s mouthpiece. Continue as with an MDI.
of injection and the client’s size. Syringe size should
appro imate the olume of medication.
DPI ● Use a tuberculin syringe for solution volumes less
CLIENT EDUCATION than 0.5 mL.
● Do not shake the device. ● Rotate injection sites to enhance medication absorption,
● Ta e the co er off the mouthpiece. and document each site.
● Follow the manufacturer’s directions for preparing the ● Do not use in ection sites that are edematous, in amed,
medication (turning the wheel of the inhaler or loading or have moles, birthmarks, or scars.
a medication pellet). ● For IV administration, immediately monitor clients for
● hale completely. therapeutic and ad erse effects.
● Place the mouthpiece between your lips and take a deep ● Discard all sharps (broken ampule bottles, needles) in
inhalation breath through your mouth. leak- and puncture-proof containers.
● Hold your breath for 5 to 10 seconds.
● Ta e the inhaler out of your mouth and slo ly e hale Intradermal
through pursed lips.
NURSING ACTIONS
● Resume normal breathing. ● Use for tuberculin testing or checking for medication or
● Clients ho need more than one puff should ait
allergy sensitivities.
the length of time the pro ider speci es before ● Use small amounts of solution (0.01 to 0.1 mL) in a
self administering the second puff.
tuberculin syringe ith a ne gauge needle to
● Rinse your mouth out with water or brush your teeth if
27-gauge) in lightly pigmented, thin-skinned, hairless
using a corticosteroid inhaler to reduce the risk of
sites (the inner surface of the mid-forearm or scapular
fungal infections of the mouth.
area of the back) at a 10° to 15° angle.
● Remove the canister and rinse the inhaler, cap, and ● Insert the needle with the bevel up. A small bleb
spacer once a day with warm running water and dry
should appear.
them completely before using the inhaler again. ● Do not massage the site after injection.

Subcutaneous Intravenous
NURSING ACTIONS NURSING ACTIONS
● Use for small doses of nonirritating, water-soluble ● se for administering medications, uid, and
medications (insulin and heparin). blood products.
● Use a 3 8- to 5 8-inch, 25- to 27-gauge needle or a 28- to ● Vascular access devices can be for short-term use
31-gauge insulin syringe. Inject no more than 1.5 mL (catheters) or long-term use (infusion ports).
of solution. ◯ Use 16-gauge devices for clients who have trauma.
● Select sites that have an adequate fat-pad size (abdomen, ◯ Use 18-gauge during surgery and
upper hips, lateral upper arms, thighs). blood administration.

● For average-size clients, pinch up the skin and inject at ◯ Use 22- to 24-gauge for children, older adults,
a 45° to 90° angle. For clients who are obese, use a and clients who have medical issues or are
90° angle. stable postoperatively.
● Peripheral veins in the arm or hand are preferable. Ask
Intramuscular clients which site they prefer. For newborns, use veins
in the head, lower legs, and feet. After administration,
NURSING ACTIONS
immediately monitor for therapeutic and ad erse effects.
● Use for irritating medications, solutions in oils, and
aqueous suspensions.
● The most common sites are ventrogluteal, deltoid, and
vastus lateralis (pediatric). The dorsogluteal is no longer
recommended as a common injection site due to its
close proximity to the sciatic nerve.
● Use a needle size 18- to 27-gauge (usually 22- to
25-gauge), 1- to 1.5-inch long, and inject at a 90° angle.
Solution volume is usually 1 to 3 mL. Divide larger
olumes into t o syringes and use t o different sites.
● Use the Z-track technique for IM injections of
irritating uids or uids that can stain the s in iron
preparations). This method prevents medication from
leaking back into subcutaneous tissue. Reference
guidelines to determine whether this technique is
recommended for a given medication.
46.1 Advantages and disadvantages of different routes

ADVANTAGES DISADVANTAGES
Oral medications have highly variable absorption.
Safe Inactivation can occur by the GI
Oral Inexpensive tract or first-pass effect.
Easy and convenient Clients must be cooperative and conscious.
Contraindications include nausea and vomiting.
Injections are more costly.
Use for poorly soluble medications.
Injections are inconvenient.
Subcutaneous and Use for administering medications that
There can be pain with the risk for local
intramuscular (IM) have slow absorption for an extended
tissue damage and nerve damage.
period of time (depot preparations).
There is a risk for infection at the injection site.
Onset is rapid, and absorption IV injections are even more costly.
into the blood is immediate, which IV injections are inconvenient.
provides an immediate response.
Absorption of the medication into the blood is
This route allows control over the precise immediate. This is potentially dangerous if giving
Intravenous (IV) amount of medication to administer. the wrong dosage or the wrong medication.
It allows for administration of There is an increased risk for infection
large volumes of fluid. or embolism with IV injections.
It dilutes irritating medications Poor circulation can inhibit the
in free-flowing IV fluid. medication’s distribution.

1. A nurse is caring for a client who is 1 day postoperative A nurse educator is teaching a module on biotransformation
and reports a pain level of 10 on a scale of 0 as a phase of pharmacokinetics during nursing orientation
to 10. After reviewing the client’s medication to a group of newly licensed nurses. Use the ATI Active
administration record, which of the following Learning Template: Basic Concept to complete this item.
medications should the nurse administer?
RELATED CONTENT: List four areas of the body
A. Meperidine 75 mg IM where biotransformation takes place.
B. Fentanyl 50 mcg/hr transdermal patch
UNDERLYING PRINCIPLES: List at least three factors
C. Morphine 2 mg IV that influence the rate of biotransformation.
D. Oxycodone 10 mg PO
2. A nurse is teaching a client about medications

at discharge. Which of the following statements
should the nurse identify as an indication that
the client understands the instructions?
A. “I can open the time-release capsule with the
beads in it and sprinkle them on my oatmeal.”
B. “If I am having difficulty swallowing,
I will add the liquid medication to a
prepared package of pudding.”
C. “I can crush the enteric coated pill, if needed.”
D. “I will eat two crackers with the pain pills.”
3. A nurse is teaching a client how to administer

medication through a jejunostomy tube. Which of
the following instructions should the nurse include?
A. “Flush the tube before and after each medication.”
B. “Mix your medications with your enteral feeding.”
C. “Push tablets through the tube slowly.”
D. “Mix all the crushed medications prior
to dissolving them in water.”
4. A nurse is preparing to inject heparin subcutaneously

for a client who is postoperative. Which of the
following actions should the nurse take?
A. Use a 22-gauge needle.
B. Select a site on the client’s abdomen.
C. Use the Z-track technique to displace
the skin on the injection site.
D. Observe for bleb formation to
confirm proper placement.
5. A nurse is teaching an adult client how to

administer ear drops. Which of the following
statements should the nurse identify as an
indication that the client understands?
A. “I will straighten my ear canal by
pulling my ear down and back.”
B. “I will gently apply pressure with my finger to the
front part of my ear after putting in the drops.”
C. “I will insert the nozzle of the ear drop bottle snug
into my ear before squeezing the drops in.”
D. “After the drops are in, I will place a cotton
ball all the way into my ear canal.”

1. A. Although meperidine is a strong analgesic, the IM Using the ATI Active Learning Template: Basic Concept
route of administration can allow for slow absorption, RELATED CONTENT: Biotransformation (metabolism) changes
delaying the onset of pain relief. The IM route also medications into less active forms or inactive forms by the
can cause additional pain from the injection. action of enzymes. This occurs primarily in the liver, but also
B. Although fentanyl is a strong analgesic, the takes place in the kidneys, lungs, intestines, and blood.
transdermal route of administration can allow for slow
absorption, delaying the onset of pain relief. UNDERLYING PRINCIPLES
C. CORRECT: Administer IV morphine because the onset is ●
Age: Infants have a limited medication-metabolizing capacity. The
rapid, and absorption of the medication into the blood aging process also can influence medication metabolism, but varies
is immediate, which provides the optimal response with the individual. In general, hepatic medication metabolism
for a client who is reporting pain at a level of 10. tends to decline with age. Older adults require smaller doses of
D. Although oxycodone is a strong analgesic, the oral route medications due to the possibility of accumulation in the body.
of administration of this medication can allow for onset ●
An increase in some medication-metabolizing enzymes: This
of pain relief in 10 to 15 min, which can be a long time can metabolize a particular medication sooner, requiring
for a client who is reporting pain at a level of 10. an increase in dosage of that medication to maintain a
NCLEX® Connection: Pharmacological and Parenteral Therapies, therapeutic level. It can also cause an increase in the
Pharmacological Pain Management metabolism of other concurrent-use medications.
●
First-pass effect: The liver inactivates some medications on
their first pass through the liver. Thus, they require a nonenteral
2. A. Although this might help a client who has swallowing route (sublingual, IV) because of their high first-pass effect.
issues, it is essential for the client to swallow enteric-coated ●
Similar metabolic pathways: When the same pathway metabolizes
or time-release medications whole. two medications, it can alter the metabolism of one or both of
B. Although adding a liquid medication to food is helpful if the them. In this way, the rate of metabolism can decrease for one or
client is having difficulty swallowing, they should not mix both of the medications, leading to medication accumulation.
the medication with large amounts of food or beverages ●
Nutritional status: Clients who are malnourished
in case they cannot consume the entire quantity. can be deficient in the factors that are necessary to
C. The client must not crush enteric-coated or time-release produce specific medication-metabolizing enzymes,
preparations. He must swallow them whole. thus impairing medication metabolism.
D. CORRECT: The client should take irritating
medications (analgesics) with small amounts of food. NCLEX® Connection: Physiological Adaptation, Pathophysiology
It can help prevent nausea and vomiting.
3. A. CORRECT: The client should flush the tubing

before and after each medication with 15 to 30 mL
water to prevent clogging of the tube.
B. To maximize the therapeutic effect of a medication, the
client should not mix medications with enteral formula.
In addition, if the client does not receive the entire
feeding, they do not receive the entire medication. This
can also delay the client receiving the medication.
C. The client should not administer tablets or
undissolved medications through a jejunostomy
tube because they can clog the tube.
D. The client should self-administer each
medication separately.
Medication Administration
4. A. For a subcutaneous injection, use a

25- to 27-gauge needle.
B. CORRECT: For a subcutaneous injection, select a
site that has an adequate fat-pad size (abdomen,
upper hips, lateral upper arms, thighs).
C. The Z-track technique is for IM injections. For a
subcutaneous injection, pinch a section of skin or pull
the skin taut using the thumb and index finger.
D. Bleb formation confirms injection into the
dermis, not into subcutaneous tissue.
5. A. The client should straighten their ear canal by pulling the

auricle upward and outward to open up the ear canal
and allow the medication to reach the eardrum.
B. CORRECT: The client should gently apply pressure with
the finger to the tragus of the ear after administering
the drops to help the drops go into the ear canal.
C. The client should never occlude the ear canal with the
dropper when instilling ear drops because this can
cause pressure that could injure the eardrum.
D. The client should not place a cotton ball past the
outermost part of the ear canal because it could
introduce bacteria to the inner or middle ear.

CHAPTER 47
UNIT 4 PHYSIOLOGICAL INTEGRITY PRESCRIPTION MEDICATIONS
Nurses administer prescription medications under the
Safe Medication supervision of providers. These medications can be

CHAPTER 47 habit forming, ha e potential harmful effects, and
Administration and require monitoring.
Error Reduction Uncontrolled substances

These medications require monitoring by a provider,
but do not generally pose a risk of misuse or
The providers who can legally write prescriptions addiction. Antibiotics are an example of uncontrolled
prescription medications.
in the United States include physicians, advanced
practice nurses, dentists, and physician assistants. Controlled substances
Medications that have a potential for misuse and dependence
PROVIDER RESPONSIBILITIES and ha e a schedule classi cation. Heroin is in chedule
I and has no medical use in the United States. Medications
● Obtaining clients’ medical history and performing
in Schedules II through V have legitimate applications.
a physical examination
Each subsequent level has a decreasing risk of misuse
● Diagnosing
and dependence. For example, morphine is a Schedule II
● Prescribing medications
medication that has a greater risk for misuse and dependence
● Monitoring the response to therapy
than phenobarbital, which is a Schedule IV medication.
● Modifying medication prescriptions as necessary
NURSE RESPONSIBILITIES KNOWLEDGE REQUIRED PRIOR TO

● Having knowledge of federal, state (nurse practice acts),
and local laws, and facilities’ policies that govern the Medication category
prescribing, dispensing, and administration of medications
Medications have a pharmacological action, therapeutic use,
● Preparing and administering medications, and
body system target, chemical ma eup, and classi cation
evaluating clients’ responses to medications
for use during pregnancy. For example, lisinopril is an
● Developing and maintaining an up-to-date knowledge
angiotensin-converting enzyme inhibitor (pharmacological
base of medications they administer, including uses,
action) and an antihypertensive (therapeutic use).
mechanisms of action, routes of administration,
safe dosage range, ad erse effects, precautions,
Mechanism of action
contraindications, and interactions
● Maintaining knowledge of acceptable practice and This is ho the medication produces its therapeutic effect.
skills competency For example, glipizide is an oral hypoglycemic agent
● Determining the accuracy of medication prescriptions that lowers blood glucose levels primarily by stimulating
● Reporting all medication errors pancreatic islet cells to release insulin.
● Safeguarding and storing medications
Therapeutic effect
This is the e pected effect physiological response for
MEDICATION CATEGORY hich the nurse administers the medication to a speci c
AND CLASSIFICATION client. One medication can have more than one therapeutic
effect. or e ample, one client might ta e diphenhydramine
NOMENCLATURE to relieve allergies while another takes it to induce sleep.
Chemical name: A medication’s chemical composition

Adverse effects
(N-acetyl-para-aminophenol).
These are undesirable and potentially dangerous responses
Generic name: fficial or nonproprietary name the nited
to a medication. Ad erse effects can be inad ertent or
States Adopted Names Council gives a medication. Each
predictable. Some are immediate; others take weeks or
medication has only one generic name (acetaminophen).
months to develop. For example, the antibiotic gentamicin
Trade name: Brand or proprietary name the company that can cause hearing loss.
manufacturers the medication gives it. One medication
can have multiple trade names (Tylenol, Tempra). Toxic effects
edications can ha e speci c ris s and manifestations
of toxicity. For example, nurses monitor clients taking
digoxin for dysrhythmias, a manifestation of cardiotoxicity.
Hypokalemia places these clients at greater risk for
digoxin toxicity.
FUNDAMENTALS FOR NURSING CHAPTER 47 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION 277
Interactions Stat prescriptions
Medications can interact with each other, resulting in A stat prescription is only for administration once and
bene cial or harmful effects. or e ample, gi ing the immediately. For example, a stat prescription instructs the
beta-blocker atenolol concurrently with the calcium nurse to administer digoxin 0.125 mg IV bolus stat.
channel bloc er nifedipine helps pre ent re e tachycardia.
Medications can also increase or decrease the actions of Now prescriptions
other medications, and food can interact bene cially or
A now prescription is only for administration once, but up
harmfully with medications.
to 90 min from when the nurse received the prescription.
For example, a now prescription instructs the nurse to
Precautions, contraindications
administer vancomycin 1 g intermittent IV bolus now.
These are conditions (diseases, age, pregnancy, lactation)
that make it risky or completely unsafe for clients to take PRN prescriptions
speci c medications. or e ample, tetracyclines can stain
A PRN (pro re nata prescription speci es at hat dosage, hat
developing teeth; therefore, children younger than 8 years
frequency, and under what conditions a nurse can administer
should not take these medications. Another example is
the medication. The nurse uses clinical judgment to
that heart failure is a contraindication for labetalol, an
determine the client’s need for the medication. For example,
antihypertensive medication.
a PRN prescription instructs the nurse to administer
morphine 2 mg IV bolus every hour PRN for chest pain.
Preparation, dosage, administration
It is important to no any speci c considerations for Other prescriptions
preparation, safe dosages, and how to administer the
Pro iders might rite prescriptions for speci c
medication. For example, morphine is available in many
circumstances or for speci c units. or e ample, a critical
different formulations. ral doses of morphine are
care unit has standing prescriptions for treating clients
generally higher than parenteral doses due to extensive
who have asystole.
rst pass effect. Clients ho ha e chronic se ere pain
(with cancer) generally take oral doses of morphine.
COMPONENTS OF A
MEDICATION PRESCRIPTION
MEDICATION PRESCRIPTIONS ● The client’s full name
Each facility has written policies for medication prescriptions, ● The date and time of the prescription
including which providers can write, receive, and transcribe ● The name of the medication (generic or brand)
medication prescriptions. ● The strength and dosage of the medication
● The route of administration
The time and frequency of administration: exact times
TYPES OF MEDICATION PRESCRIPTIONS
●
or number of times per day (according to the facility’s

policy or the speci c ualities of the medication
Routine or standing prescriptions ● The uantity to dispense and the number of re lls
● A routine or standing prescription identi es medications ● The signature of the prescribing provider
nurses give on a regular schedule with or without a
termination date. Without a termination date, the
prescription ill be in effect until the pro ider
COMMUNICATING
discontinues it or discharges the client.
MEDICATION PRESCRIPTIONS
Providers must re-prescribe some medications (opioids
Origin of medication prescriptions
●
and antibiotics ithin a speci c amount of time or they

will automatically discontinue. Providers or nurses who take verbal or telephone
prescriptions from a provider write medication
Single or one-time prescriptions prescriptions on the client’s medical record. If the
nurse writes a medication prescription on the client’s
A single or one-time prescription is for administration once
medical record, the facility s policy speci es ho much
at a speci c time or as soon as possible. These prescriptions
time the provider has to sign the prescription. Nurses
are common for preoperative or preprocedural medications.
transcribe medication prescriptions onto the medication
For example, a one-time prescription instructs the nurse to
administration record (MAR).
administer warfarin 5 mg PO at 1700.
278 CHAPTER 47 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION CONTENT MASTERY SERIES
View Video: Safe Administration of Medications
Taking a telephone prescription RIGHTS OF SAFE

Only when absolutely necessary
Ensure that the prescription is complete and correct by
Right client
●
reading it back to the provider: the client’s name, the

name of the medication, the dosage, the time to give it, erify clients identi cation before each medication
the frequency, and the route. administration. The Joint Commission requires two client
● To ensure correct spelling, use aids (“b as in boy”). State identi ers. Acceptable identi ers include the client s
numbers separately (“one, seven” for 17). name, an assigned identi cation number, telephone
● Remind the provider to verify the prescription and sign it number, birth date, or other person speci c identi er
ithin the amount of time the facility s policy speci es. a photo identi cation card . Nurses also use bar code
● Write or enter the prescription in the client’s scanners to identify clients. Check for allergies by asking
medical record. clients, checking for an allergy bracelet or medal, and
● If possible, have a second nurse listen on an checking the MAR.
extension or on a speaker in a private area (to ensure
con dentiality . Right medication
Correctly interpret medication prescriptions, verifying
MEDICATION RECONCILIATION completeness and clarity. Read medication labels and
compare them with the MAR three times: before removing
The Joint Commission requires policies and procedures for
the container, when removing the amount of medication
medication reconciliation. Nurses compile a list of each
from the container, and in the presence of the client
client’s current medications, including all medications
before administering the medication. Leave unit-dose
with correct dosages and frequency. They compare the
medication in its package until administration.
list with new medication prescriptions and reconcile it
to resolve any discrepancies. This process takes place at
Right dose
admission, when transferring clients between units or
facilities, and at discharge. Use a unit-dose system to decrease errors. If not available,
calculate the correct medication dose; check a drug reference
to make sure the dose is within the usual range. Ask another
PRE-ASSESSMENT FOR nurse to verify the dose if uncertain of the calculation.
MEDICATION THERAPY Prepare medication dosages using standard measurement
devices (graduated cups or syringes). Some medication
Nurses obtain the following information before initiating
dosages re uire a second eri er or itness some cytoto ic
medication therapy and update it as necessary.
medications). Automated medication dispensing systems use
a machine to control the dispensing of medications.
Health history
● Age Right time
● Health problems and the current reason for seeking care
Administer medication on time to maintain a
● All medications clients currently take (prescription
consistent therapeutic blood level. Refer to the drug
and nonprescription): the name, dose, route, and
reference or the facility’s policy for exceptions; general
frequency of each
recommendations follow.
● Any une pected ndings possibly from ● Administer time-critical medications within 30 min of
medication therapy
the prescribed time. acilities de ne hich medications
● Use of herbal or “natural” products for
are time-critical; usually this includes medications that
medicinal purposes
require a consistent blood level (antibiotics).
● se of caffeine, tobacco, alcohol, or illicit drugs ● Administer non-time-critical medications prescribed
● Clients’ understanding of the purpose of
once daily, weekly, or monthly within 2 hr of the
the medications
prescribed time.
● All medication and food allergies ● Administer non-time-critical medications prescribed
more than once daily (but not more than every 4 hr)
Physical examination
within 1 hr of the prescribed time.
A systematic physical examination provides a baseline for
e aluating the therapeutic effects of medication therapy Right route
and for detecting possible ad erse effects.
The most common routes of administration are oral, topical,
subcutaneous, intramuscular (IM), and intravenous (IV).
Additional administration routes include sublingual, buccal,
intradermal, transdermal, epidural, inhalation, nasal,
ophthalmic, otic, rectal, vaginal, intraosseous, and via enteral
tubes. Select the correct preparation for the route the provider
prescribed (otic vs. ophthalmic topical ointment or drops).
Online Video: Look-Alike, Sound-Alike Medications
Right documentation RESOURCES FOR

Immediately record pertinent information, including
MEDICATION INFORMATION
the client’s response to the medication. Document the ● Nursing drug handbooks
medication after administration, not before. ● Pharmacology textbooks
● Professional journals
Right client education ● Physicians’ Desk Reference (PDR)
● Professional websites
Inform clients about the medication: its purpose, ● Pharmacists
what to expect, how to take it, and what to report. To
individualize the teaching, determine what the clients
already know about the medication, need to know about
the medication, and want to know about the medication.
MEDICATION ERROR PREVENTION
Right to refuse COMMON MEDICATION ERRORS

Respect clients’ right to refuse any medication. Explain ● rong medication or I uid
the consequences, inform the provider, and document ● Incorrect dose or IV infusion rate
the refusal. ● Wrong client, route, or time
● Administration of a medication to which the client
Right assessment is allergic
● Omission of a dose or extra doses
Collect any essential data before and after administering ● Incorrect discontinuation of medication or I uid
any medication. For example, measure apical heart rate ● Inaccurate prescribing
before giving digoxin.
The Institute for Safe Medication Practices (ISMP) is a
Right evaluation nonprofit organization working to educate health
care providers and consumers about safe
ollo up ith clients to erify therapeutic effects as ell
medication practices. The ISMP and the FDA
as ad erse effects.
identify the most common medical abbreviations
that result in misinterpretation, mistakes, and injury.
For a complete list, go to the ISMP website.
47.1 Error-prone abbreviation list

Some abbreviations cause a high number of medication errors. DO NOT USE USE
DO NOT USE USE q.o.d., QOD every other day
MS, MSO4 morphine 6 p.m. daily or
Q6PM, etc.
daily at 6 p.m.
MgSO4 magnesium sulfate
TIW, tiw 3 times weekly
abbreviated medication
names (AZT, KCl, full name of medication mg., mL. mg, mL (no period)
HCT, PTU, HCTZ) half-strength, bedtime
HS
nitro nitroglycerin (hour of sleep)
decimal points without smaller units (500 mcg) or BT, hs, HS, qhs, qn bedtime or hour of sleep
a leading zero (.5 mg) a leading zero (0.5 mg) SC, SQ, sub q subcutaneously
trailing zero (1.0 mg, without a trailing IN intranasal
100.0 g) zero (1 mg, 100 g)
IJ injection
u, U, IU units
OJ orange juice
μ, μg mcg or microgram
> or < greater than or less than
x3d times 3 days
@ at
cc mL
&, + and
apothecary units metric units
/ per
daily or intended time
od, O.D., OD AD, AS, AU right ear, left ear, both ears
of administration
q.d, qd, Q.D, QD, q1d, i/d daily OD, OS, OU right eye, left eye, both eyes
D/C, dc, d/c discharge or discontinue
NURSING PROCESS ● Use verbal prescriptions only for emergencies, and follow
the facility’s protocol for telephone prescriptions. Nursing
Use the nursing process to prevent medication errors.
students cannot accept verbal or telephone orders.
Follow all laws and regulations for preparing and
Assessment/data collection
●
administering controlled substances. Keep them in a

● Ensure knowledge of medication to administer and why. secure area. Have another nurse witness the discarding
● Obtain information about the clients’ medical diagnoses of controlled substances.
and conditions that relate to medication administration ● Do not leave medications at the bedside. Some facilities’
(the ability to swallow, diet, allergies, and heart, liver, policies allow exceptions (for topical medications).
and kidney disorders).
◯ Identify allergies. Evaluation
◯ Obtain necessary preadministration data (heart rate, ● Evaluate clients’ responses to medications, and
blood pressure) to assess the appropriateness of the
document and report them.
medication and to obtain baseline data for evaluating ● ecogni e ad erse effects, and document and
the effecti eness of medications.
report them.
◯ mit or delay doses according to ndings, and notify ● Notify the provider of all errors, and implement
the provider.
corrective measures immediately.
● Determine if the medication prescription is complete: ◯ Complete an incident report ithin the speci ed
with the client’s name, date and time, name of
time frame, usually 24 hr. Include the client’s
medication, dosage, route of administration, time and
identi cation, the time and place of the incident,
frequency, and signature of the prescribing provider.
an accurate account of the e ent, ho you noti ed,
● Interpret the medication prescription accurately. Refer
what actions you took, and your signature. Do not
to the ISMP lists for error-prone abbreviations, confused
reference or include the incident report in the client’s
medication names, and high-alert medications.
medical record.
● Question the provider if the prescription is unclear or ◯ Medication errors relate to systems, procedures,
seems inappropriate for the client’s condition. Refuse to

product design, or practice patterns. Report all errors
administer a medication if it seems unsafe, and notify
to assist the facility’s risk managers to learn how
the charge nurse or supervisor.
errors occur and what changes to make to avoid
● Providers usually make dosage changes gradually.
similar errors in the future.
Question the provider about abrupt and excessive changes.
● Determine clients’ learning needs.
Planning
● Identify clients’ outcomes for medication administration.
● Prioritize medication administration to administer
critical medications rst, or to no hich medications
need to be given prior to treatment, procedures, or meals.
Implementation
● Avoid distractions during medication preparation (poor
lighting, phones). Interruptions increase the risk of error.
● Prepare medications for one client at a time.
● Check the labels for the medication’s name and
concentration. Read labels carefully. Measure doses
accurately, and double-check dosages of high-alert
medications (insulin and heparin) with a colleague.
Check the medication’s expiration date.
● Doses are usually one to two tablets or one single-dose
vial. Question multiple tablets or vials for a single dose.
● Follow the rights of medication administration
consistently. Take the MAR to the bedside.
● Only give medications that you have prepared.
● Encourage clients to become part of the safety net,
teaching them about medications and the importance of
proper identi cation before medication administration.
Omit or delay a dose when clients question the size of
the dose or the appearance of the medication.
● Follow correct procedures for all routes of administration.
● Communicate clearly both in writing and speaking.
1. A nurse prepares an injection of morphine to A nurse educator is teaching a group of newly

administer to a client who reports pain, then asks a licensed nurses. Use the ATI Active Learning
second nurse to give the injection because another Template: Basic Concept to complete this item.
assigned client needs to use a bedpan. Which of the
following actions should the second nurse take? RELATED CONTENT: List the rights of
safe medication administration.
A. Offer to assist the client who needs the bedpan.
B. Administer the injection the other nurse prepared. UNDERLYING PRINCIPLES: List at least three acceptable
identifiers to use to verify the client’s identity.
C. Prepare another syringe and
administer the injection.
D. Tell the client who needs the bedpan to wait
while the nurse gives someone else medication.
2. A nurse is reviewing a client’s prescribed medications

at the beginning of the day shift. Which of the
following 0900 medications can be given anytime
between 0700 and 1100? (Select all that apply.)
A. A once-daily multivitamin
B. Eye drops prescribed every 3 hr
C. An antibiotic prescribed every 8 hr
D. A blood pressure pill prescribed twice daily
E. A subcutaneous injection prescribed once weekly
3. A nurse orienting a newly licensed nurse is

reviewing the procedure for taking a telephone
prescription. Which of the following statements
should the nurse identify as an indication that the
newly licensed nurse understands the process?
A. “A second nurse enters the prescription
into the client’s medical record.”
B. “Another nurse should listen to the phone call.”
C. “The provider can clarify the prescription
when they sign the health record.”
D. “I should omit the ‘read back’ if this
is a one-time prescription.”
4. A nurse educator is teaching newly licensed

nurses about safe medication administration.
Which of the following statements indicates
understanding? (Select all that apply.)
A. “I will observe for adverse effects.”
B. “I will monitor for therapeutic effects.”
C. “I will prescribe the appropriate dose.”
D. “I will change the dose if adverse effects occur.”
E. “I will refuse to give a medication
if I believe it is unsafe.”
5. A nurse reviewing a client’s health record notes

a new prescription for lisinopril 10 mg PO once
every day. The nurse should identify this as
which of the following types of prescription?
A. Single
B. Stat
C. Routine
D. Now
1. A. CORRECT: The second nurse should offer to assist the Using the ATI Active Learning Template: Basic Concept
client who needs the bedpan. This will allow the nurse RELATED CONTENT: Rights of Safe Medication Administration
who prepared the injection to administer it. ●
Right client: Verify clients’ identification before each
B. Only administer medications that were personally prepared.
medication administration. The Joint Commission requires
C. Preparing another syringe will delay the administration of
two client identifiers. Acceptable identifiers include the
the pain medication and adds extra cost for the client.
client’s name, an assigned identification number, telephone
D. Telling the client to wait is not an acceptable option for a
number, birth date, or other person-specific identifier (a photo
client who needs a bedpan if other assistance is available.
identification card). Nurses also use bar-code scanners to
NCLEX® Connection: Management of Care, identify clients. Check for allergies by asking clients, checking
Legal Rights and Responsibilities for an allergy bracelet or medal, and checking the MAR.
●
Right medication: Correctly interpret medication prescriptions,
verifying completeness and clarity. Read medication labels
2. A. CORRECT: Administer a once-daily non-time-critical and compare them with the MAR three times: before
medication within 1 to 2 hr of the prescribed time. removing the container, when removing the amount of
B. Administer medications prescribed more frequently than medication from the container, and in the presence of
every 4 hr within 30 min of the prescribed time. the client before administering the medication. Leave
C. Administer time-critical medications (antibiotics) unit-dose medication in its package until administration.
within 30 min of the prescribed time. ●
Right dose: Use a unit-dose system to decrease errors. If not
D. Administer medications prescribed more frequently
available, calculate the correct medication dose; check a drug
than once daily within 1 hr of the prescribed time.
reference to make sure the dose is within the usual range. Ask
E. CORRECT: Administer medications prescribed once
another nurse to verify the dose if uncertain of the calculation.
weekly within 1 to 2 hr of the prescribed time.
Prepare medication dosages using standard measurement
NCLEX® Connection: Pharmacological and Parenteral Therapies, devices (graduated cups or syringes). Some medication
Medication Administration dosages (some cytotoxic medications) require a second
verifier or witness. Automated medication dispensing systems
use a machine to control the dispensing of medications.
3. A. The nurse who accepts the telephone prescription ●
Right time: Administer medication on time to maintain a consistent
should enter it into the client’s medical record therapeutic blood level. It is generally acceptable to administer
to prevent errors in translation. the medication 30 min before or after the scheduled time. Refer
B. CORRECT: A second nurse should listen to a telephone to the drug reference or the facility’s policy for exceptions.
prescription to prevent errors in communication. ●
Right route: The most common routes of administration are
C. Verify that the prescription is complete and
oral, topical, subcutaneous, intramuscular, and intravenous.
accurate at the time they take it by reading
Additional administration routes include sublingual, buccal,
it back to the prescribing provider.
intradermal, transdermal, epidural, inhalation, nasal, ophthalmic,
D. A telephone prescription includes reading back
otic, rectal, vaginal, intraosseous, and via enteral tubes.
all types of medication prescriptions.
Select the correct preparation for the route the provider
NCLEX® Connection: Pharmacological and Parenteral Therapies, prescribed (otic vs. ophthalmic topical ointment or drops).
Medication Administration ●
Right documentation: Immediately record pertinent information,
including the client’s response to the medication. Document
the medication after administration, not before.
4. A. CORRECT: The nurse is responsible for ●
Right client education: Inform clients about the medication: its
observing for adverse effects.
purpose, what to expect, how to take it, and what to report. To
B. CORRECT: The nurse is responsible for
individualize the teaching, determine what the clients already
monitoring therapeutic effects.
know, need to know, and want to know about the medication.
C. The provider is responsible for prescribing the appropriate
dose. This is outside of the nurse’s scope of practice.
●
Right to refuse: Respect clients’ right to refuse any
D. The provider is responsible for changing the dose if adverse medication. Explain the consequences, inform
effects occur. This is outside of the nurse’s scope of practice. the provider, and document the refusal.
E. CORRECT: The nurse is responsible for identifying
●
Right assessment: Collect any essential data before
when a medication could harm a client. It is the and after administering any medication. For example,
nurse’s responsibility to refuse to administer the measure apical heart rate before giving digoxin.
medication and contact the provider. UNDERLYING PRINCIPLES
Acceptable identifiers include the client’s name, an
Expected Actions/Outcomes assigned identification number, telephone number,
birth date, or other person-specific identifier.
●
The nurse can use bar-code scanners to identify clients.
5. A. A single or one-time prescription is for administration
once at a specific time (prior to a procedure). NCLEX® Connection: Pharmacological and Parenteral Therapies,
B. A stat prescription is only for administration Medication Administration
once and immediately.
C. CORRECT: A routine or standing prescription identifies
medications to give on a regular schedule with or without a
termination date or a specific number of doses. Administer
this medication every day until the provider discontinues it.
D. A now prescription is used when a client
needs medication soon, but can wait a short
time, and can be given within 90 min.
NCLEX® Connection: Management of Care, Client Rights
CHAPTER 48
UNIT 4 PHYSIOLOGICAL INTEGRITY For dosages greater than 1.0: Round to the nearest tenth.
SECTION: PHARMACOLOGICAL AND PARENTERAL THERAPIES ● For example (rounding up): 1.38 = 1.4. The calculated
dose is 1.38 mg. Look at the number in the hundredths
CHAPTER 48 Dosage Calculation place (8). Eight is greater than 5. To round to the tenth,
add 1 to the 3 in the tenth place and drop the 8. The
rounded dose is 1.4 mg.
Or (rounding down): 1.34 mL = 1.3 mL. The calculated
Basic medication dose conversion and
●
dose is 1.34 mL. Look at the number in the hundredths

calculation skills are essential for providing safe place (4). Four is less than 5. To round to the tenth, drop
the 4 and leave the 3 as is. The rounded dose is 1.3 mL.
nursing care.
Nurses are responsible for administering the

correct amount of medication by calculating the Solid dosage
Example: A nurse is preparing to administer
precise amount of medication to give. Nurses phenytoin 0.2 g PO every 8 hr. The amount available
can use three different methods for dosage is phenytoin 100 mg/capsule. How many capsules
should the nurse administer per dose? (Round the
calculation: ratio and proportion, formula answer to the nearest whole number. Use a leading
(desired over have), and dimensional analysis. zero if it applies. Do not use a trailing zero.)
TYPES OF CALCULATIONS USING RATIO AND PROPORTION

● Solid oral medication STEP 1: What is the unit of measurement the nurse
● Liquid oral medication should calculate?
● Injectable medication
capsules
● Correct doses by weight
● IV infusion rates STEP 2: What is the dose the nurse should administer?
Dose to administer = Desired
STANDARD CONVERSION FACTORS 0.2 g

● 1 mg = 1,000 mcg STEP 3: What is the dose available? Dose available = Have
● 1 g = 1,000 mg
100 mg
● 1 kg = 1,000 g
● 1 oz = 30 mL STEP 4: Should the nurse convert the units of measurement?
● 1 L = 1,000 mL es g mg
● 1 tsp = 5 mL Set up an equation.
● 1 tbsp = 15 mL
1g 0.2 g
● 1 tbsp = 3 tsp =
● 1 kg = 2.2 lb 1,000 mg X mg
● 1 gr = 60 mg
Solve for X.
X mg = 200 mg
GENERAL ROUNDING GUIDELINES
Or you can use your knowledge of equivalents.
ROUNDING UP: If the number to the right is equal to
or greater than 5, round up by adding 1 to the number 1 g = 1,000 mg (1 × 1,000)
on the left.
0.2 g = 200 mg (0.2 × 1,000)
ROUNDING DOWN: If the number to the right is less
than 5, round down by dropping the number, leaving the STEP 5: What is the quantity of the dose available? = Quantity
number to the left as is.
1 capsule
For dosages less than 1.0: Round to the nearest hundredth.
STEP 6: Set up the equation and solve for X.
● For example (rounding up): 0.746 mL = 0.75 mL. The
calculated dose is 0.746 mL. Look at the number in the Have Desired
=
thousandths place (6). Six is greater than 5. To round to Quantity X
hundredths, add 1 to the 4 in the hundredths place and
drop the 6. The rounded dose is 0.75 mL. 100 mg 200 mg
1 capsule =
● Or (rounding down): 0.743 mL = 0.74 mL. The X capsule(s)
calculated dose is 0.743 mL. Look at the number in the
X capsule(s) = 2 capsules
thousandths place (3). Three is less than 5. To round
to the hundredth, drop the 3 and leave the 4 as is. The STEP 7: Round, if necessary.
rounded dose is 0.74 mL.
FUNDAMENTALS FOR NURSING CHAPTER 48 DOSAGE CALCULATION 285

STEP 8: Determine whether the amount to administer makes USING DIMENSIONAL ANALYSIS
sense. If there are 100 mg/capsule and the prescription reads
STEP 1: What is the unit of measurement the nurse
0.2 g (200 mg), it makes sense to administer 2 capsules. The
should calculate? (Place the unit of measure being
nurse should administer phenytoin 2 capsules PO.
calculated on the left side of the equation.)
X capsule(s) =
USING DESIRED OVER HAVE
STEP 2: Determine the ratio that contains the same unit as
the unit being calculated. (Place the ratio on the right side
should calculate?
of the equation ensuring that the unit in the numerator
capsules matches the unit being calculated.)
STEP 2: What is the dose the nurse should administer? = 1 capsule

X capsule(s)
Dose to administer = Desired 100 mg
STEP 3: Place any remaining ratios that are relevant to
0.2 g
the item on the right side of the equation along with any
STEP 3: What is the dose available? Dose available = Have needed conversion factors to cancel out unwanted units
of measure.
100 mg
STEP 4: Should the nurse convert the units of 1 capsule 1,000 mg 0.2 g
X capsule(s) = x x
measurement es g mg
100 mg 1g 1
Set up an equation.
STEP 4: Solve for X.
= 0.2 g × 1,000 mg
X mg
1g X capsule(s) = 2 capsules
X mg = 200 mg
STEP 5: Round, if necessary.
STEP 6: Determine whether the amount to administer
1 g = 1,000 mg (1 × 1,000) makes sense. If there are 100 mg/capsule and the
prescription reads 0.2 g, it makes sense to administer
0.2 g = 200 mg (0.2 × 1,000) 2 capsules. The nurse should administer phenytoin
2 capsules PO.
STEP 5: What is the quantity of the dose available? = Quantity
1 capsule
= Desired × Quantity
X
Have
200 mg × 1 cap
X capsule(s) =
100 mg
X capsule(s) = 2 capsules

makes sense. If there are 100 mg/capsule and the
prescription reads 0.2 g (200 mg), it makes sense to
administer 2 capsules. The nurse should administer
phenytoin 2 capsules PO.
286 CHAPTER 48 DOSAGE CALCULATION CONTENT MASTERY SERIES

Liquid dosage USING DESIRED OVER HAVE
should calculate?
amoxicillin 0.25 g PO every 8 hr. The amount
available is amoxicillin oral suspension 250 mg/5 mL. mL
How many mL should the nurse administer per
STEP 2: What is the dose the nurse should administer?
dose? (Round the answer to the nearest tenth. Use a
leading zero if it applies. Do not use a trailing zero.)
0.25 g
USING RATIO AND PROPORTION STEP 3: What is the dose available? Dose available = Have
STEP 1: What is the unit of measurement the nurse 250 mg
should calculate?
STEP 4: Should the nurse convert the units of
mL measurement es g mg
Set up an equation:
Dose to administer = Desired 0.25 g × 1,000 mg
X mg = 1g
0.25 g
X mg = 250 mg
STEP 3: What is the dose available? Dose available = Have
250 mg
1 g = 1,000 mg (1 × 1,000)
measurement es g mg Place the unit of measure
0.25 g = 250 mg (0.25 × 1,000)
being calculated on the left side of the equation.)
Set up an equation. STEP 5: What is the quantity of the dose available? = Quantity
1 mg 0.25 g 5 mL
=
1,000 mg X mg STEP 6: Set up the equation and solve for X.
X mg = 200 mg Desired × Quantity
X mL =
Have
250 mg × 5 mL
1 g = 1,000 mg (1 × 1,000) X mL =
250 mg
0.25 g = 250 mg (0.25 × 1,000) X mL = 5 mL
STEP 5: What is the quantity of the dose available? = Quantity STEP 7: Round, if necessary.
5 mL STEP 8: Determine whether the amount to administer
makes sense. If there are 250 mg/5 mL and the
prescription reads 0.25 g (250 mg), it makes sense to
Have Desired administer 5 mL. The nurse should administer amoxicillin
=
Quantity X 5 mL PO every 8 hr.
250 mg 250 mg
= USING DIMENSIONAL ANALYSIS
5 mL X mL
X mL = 5 mL
STEP 7: Round, if necessary. calculated on the left side of the equation.)
STEP 8: Determine whether the amount to administer makes X mL =

sense. If there are 250 mg/5 mL and the prescription reads
0.25 g (250 mg), it makes sense to administer 5 mL. The
nurse should administer amoxicillin 5 mL PO every 8 hr.
matches the unit being calculated.)
5 mL
X mL = 250 mg

STEP 3: Place any remaining ratios that are relevant to USING DESIRED OVER HAVE
needed conversion factors to cancel out unwanted units of
should calculate?
measurement.
5 mL 1,000 mg 0.25 g mL
X mL = 250 mg x 1g x 1 STEP 2: What is the dose the nurse should administer?
8,000 units
X mL = 5 mL
10,000 units
makes sense. If there are 250 mg/5 mL and the
measurement? No
prescription reads 0.25 g, it makes sense to administer
5 mL. The nurse should administer amoxicillin 5 mL PO STEP 5: What is the quantity of the dose available? = Quantity
every 8 hr.
1 mL
STEP 6: Set up an equation and solve for X.
Injectable dosage X mL = Desired × Quantity
Have
Example: A nurse is preparing to administer heparin
8,000 units subcutaneously every 12 hr. Available
is heparin injection 10,000 units/mL. How many = 8,000 units × 1 mL
X mL
mL should the nurse administer per dose? (Round
10,000 units
the answer to the nearest tenth. Use a leading
zero if it applies. Do not use a trailing zero.) X mL = 0.8 mL

USING RATIO AND PROPORTION STEP 8: Determine whether the amount to administer
STEP 1: What is the unit of measurement the nurse makes sense. If there are 10,000 units/mL and the
should calculate? prescription reads 8,000 units, it makes sense to
administer 0.8 mL. The nurse should administer heparin
mL
injection 0.8 mL subcutaneously every 12 hr.
USING DIMENSIONAL ANALYSIS
8,000 units
STEP 3: What is the dose available? Dose available = Have should calculate? (Place the unit of measure being
10,000 units
X mL =
measurement? No STEP 2: Determine the ratio that contains the same unit as
1 mL matches the unit being calculated.)
STEP 6: Set up the equation and solve for X. = 1 mL

X mL
10,000 units
Have = Desired
Quantity X STEP 3: Place any remaining ratios that are relevant to
10,000 units 8,000 units needed conversion factors to cancel out unwanted units of
=
1 mL X mL measurements.
8,000 units 1 mL
X mL = 0.8 mL X mL = x
10,000 units 1 dose
X mL = 0.8 mL
makes sense. If there are 10,000 units/mL and the
prescription reads 8,000 units, it makes sense to STEP 5: Round, if necessary.
administer 0.8 mL. The nurse should administer heparin
injection 0.8 mL subcutaneously every 12 hr.

STEP 6: Determine whether the amount to administer STEP 8: What is the dose available? Dose available = Have
makes sense. If there are 10,000 units/mL and the
100 mg
prescription reads 8,000 units, it makes sense to
administer 0.8 mL. The nurse should administer heparin STEP 9: Should the nurse convert the units of
injection 0.8 mL subcutaneously every 12 hr. measurement? No
Dosages by weight 5 mL
cefixime 8 mg/kg/day PO to divide equally every Have Desired
=
12 hr to a toddler who weighs 22 lb. Available is Quantity X
cefixime suspension 100 mg/5 mL. How many mL
should the nurse administer per dose? (Round the 100 mg 40 mg
=
answer to the nearest whole number. Use a leading 5 mL X mL
zero if it applies. Do not use a trailing zero.)
X mL = 2 mL

USING RATIO AND PROPORTION
STEP 13: Determine whether the amount to give makes
should calculate?
40 mg, it makes sense to give 2 mL. The nurse should
kg administer ce ime suspension mL P e ery hr.

2.2 lb Client’s desired weight in lb
=
1 kg X kg STEP 1: What is the unit of measurement the nurse should
calculate?
2.2 lb 22 lb
= kg
1 kg X kg
X kg = 10 kg
Client's weight in lb × 1 kg
What is the dose the nurse should calculate? Dose to X kg =
2.2 lb
administer = Desired
What is the dose available? Dose available = Have 22 lb × 1 kg
X kg = 2.2 lb
100 mg
X kg = 10 kg
should calculate? STEP 3: What is the unit of measurement the nurse should
calculate?
mg
mg
X mg × kg/day =
X = Dose per kg × Client’s weight in kg
X mg/day = mg/kg/day × Client’s weight in kg
X mg = 8 mg × 10 kg
X mg/day = 8 mg/kg/day × 10 kg
X mg = 80 mg
X mg/day = 10 kg/day
STEP 5: The dose is divided equally every 12 hours. The dose is divided equally every 12 hours; therefore,
Divide X by 2. divide X by 2.
80 mg = 40 mg 80 mg = 40 mg
2 2
STEP 6: What is the unit of measurement the nurse STEP 5: What is the unit of measurement the nurse
should calculate? should calculate?
mL mL
STEP 7: What is the dose the nurse should administer? STEP 6: What is the dose the nurse should administer?
Dose to administer = Desired Dose to administer = Desired
40 mg 40 mg

IV flow rates
100 mg
Nurses calculate I o rates for large olume continuous
IV infusions and intermittent IV bolus infusions
measurement? No
using electronic infusion pumps (mL/hr) and manual
STEP 9: What is the quantity of the dose available? = Quantity IV tubing (gtt/min).
5 mL
STEP 10: Set up an equation and solve for X. IV INFUSIONS WITH ELECTRONIC
Desired × Quantity
INFUSION PUMPS
X mL =
Have Infusion pumps control an accurate rate of uid infusion.
Infusion pumps deli er a speci c amount of uid during
= 40 mg × 5 mL
X mL 100 mg a speci c amount of time. or e ample, an infusion pump
can deliver 150 mL in 1 hr or 50 mL in 20 min.
X mL = 2 mL
STEP 11: Round, if necessary. dextrose 5% in water (D5W) 500 mL IV to infuse
over 4 hr. The nurse should set the IV infusion
STEP 12: Determine whether the amount to give makes
pump to deliver how many mL/hr? (Round the
answer to the nearest whole number. Use a leading
administer ce ime suspension mL P e ery hr.
USING DIMENSIONAL ANALYSIS USING RATIO AND PROPORTION

AND DESIRED OVER HAVE
should calculate?
mL/hr
X mL/dose =
STEP 2: What is the volume the nurse should infuse?
the unit being calculated. (Place the ratio on the right side 500 mL
STEP 3: What is the total infusion time?
4 hr
X mL = 5 mL
dose 100 mg STEP 4: Should the nurse convert the units of
measurement? No
STEP 3: Place any remaining ratios that are relevant to
the item on the right side of the equation along with any STEP 5: Set up the equation and solve for X.
Volume (mL)
measurements. X mL/hr =
Time (hr)
X mL/dose =
= 500 mL
X mL/hr 4 hr
X mL = 5 mL × 8 mg × 1 kg × 22 lb × 1 day
dose 100 mg × 1 kg × 2.2 lb × 1 day × 2 dose X mL/hr = 125 mL/hr
STEP 4: Solve for X. STEP 6: Round, if necessary.

X mL = 2 mL STEP 7: Determine hether the I o rate ma es sense.
If the prescription reads 500 mL to infuse over 4 hr, it
makes sense to administer 125 mL/hr. The nurse should
STEP 6: Determine whether the amount to give makes set the IV pump to deliver D5W 500 mL IV at 125 mL/hr.
administer ce ime suspension mL P e ery hr.
STEP 1: What is the unit of measurement the nurse should
calculate? (Place the unit of measure being calculated on
the left side of the equation.)
X mL/hr =

STEP 2: Determine the ratio that contains the same unit as STEP 7: Determine hether the I o rate ma es sense.
the unit being calculated. (Place the ratio on the right side If the prescription reads 100 mL to infuse over 45 min (0.75
of the equation ensuring that the unit in the numerator hr), it makes sense to administer 133 mL/hr. The nurse
matches the unit being calculated.) should set the IV pump to deliver cefotaxime 1 g in 100 mL
500 mL of 0.9% NaCl IV at 133 mL/hr.
X mL/hr = 4 hr
STEP 3: Place any remaining ratios that are relevant to USING DESIRED OVER HAVE
STEP 1: What is the unit of measure the nurse should
calculate?
measurements.
500 mL mL/hr
X mL/hr = 4 hr STEP 2: What is the volume the nurse should infuse?
100 mL
X mL/hr = 125 mL/hr
45 min
STEP 6: Determine hether the I o rate ma es sense.
If the prescription reads 500 mL to infuse over 4 hr, it
measurement?
makes sense to administer 125 mL/hr. The nurse should
Yes (min does not equal hr)
set the IV pump to deliver D5W 500 mL IV at 125 mL/hr.
45 min x 1 hr
X hr = 60 min
X hr = 0.75 hr
cefotaxime 1 g intermittent IV bolus over 45 min. STEP 5: Set up the equation and solve for X.
Available is cefotaxime 1 g in 100 mL 0.9% sodium
Volume (mL)
chloride (0.9% NaCl). The nurse should set the X mL/hr =
Time
IV infusion pump to deliver how many mL/hr?
(Round the answer to the nearest whole number.) 100 mL
X mL/hr = 0.75 hr
USING RATIO AND PROPORTION X mL/hr = 133.333333 mL/hr
should calculate?
133.333333 rounds to 133
mL/hr
makes sense. If the prescription reads 100 mL to infuse
100 mL over 45 min (0.75hr), it makes sense to administer
133 mL/hr. The nurse should set the IV pump to deliver
cefotaxime 1 g in 100 mL of 0.9% NaCl IV at 133 mL/hr.
45 min
STEP 4: Should the nurse convert the units of USING DIMENSIONAL ANALYSIS
measurement?
STEP 1: What is the unit of measurement the nurse should
Yes (min does not equal hr)
calculate? (Place the unit of measure being calculated on
60 min 45 min the left side of the equation.)
1 hour = X hr
X mL/hr =
X hr = 0.75 hr
X mL Volume (mL) of the equation ensuring that the unit in the numerator
= matches the unit being calculated.)
hr Time (hr)
100 mL
X mL/hr = 30 min
X mL 100 mL
=
hr 0.75 hr
X mL/hr = 133.333333 mL/hr

133.3333 rounds to 133

STEP 3 : Place any remaining ratios that are relevant to STEP 5: Set up the equation and solve for X.
Volume (mL) x drop factor (gtt/mL)
needed conversion factors to cancel out unwanted units of X =
Time (min)
measurements.
100 mL x 60 min 1,500 mL x 15 gtt
X mL/hr = X gtt/min =
45 min x 1 hr 600 min x 1 mL
STEP 4: Solve for X. X gtt/min = 37.5 gtt/min
X mL/hr = 133.333333 mL/hr STEP 6: Round, if necessary.

STEP 5: Round, if necessary. 37.5 rounds to 38
133.333333 rounds to 133 STEP 7: Determine hether the I o rate ma es sense.
If the prescription reads 1,500 mL to infuse over 10 hr
(600 min), it makes sense to administer 38 gtt/min. The
If the prescription reads 100 mL to infuse over 45 min
nurse should adjust the manual IV infusion to deliver LR
(0.75 hr), it makes sense to administer 133 mL/hr. The
1,500 mL IV at 38 gtt/min.
nurse should set the IV pump to deliver cefotaxime 1 g in
100 mL of 0.9% NaCl IV at 133 mL/hr.
MANUAL IV INFUSIONS should calculate?
If an electronic infusion pump is not available, regulate
gtt/min
the I o rate using the roller clamp on the I tubing.
hen setting the o rate, count the number of drops STEP 2: What is the volume the nurse should infuse?
that fall into the drip chamber over 1 min. Then calculate
1,500 mL
the o rate using the drop factor on the manufacturer s
package containing the administration set. The drop STEP 3: What is the total infusion time?
factor is the number of drops per milliliter of solution.
10 hr
lactated Ringer’s (LR) 1,500 mL IV to infuse over
measurement?
10 hr. The drop factor of the manual IV tubing is
Yes (hr does not equal min)
15 gtt/mL. The nurse should adjust the manual IV
infusion to deliver how many gtt/min? (Round the 60 min x 10 hr
X hr =
answer to the nearest whole number. Use a leading 1 hr
X min = 600 min

USING RATIO AND PROPORTION
STEP 1: What is the unit of measurement the nurse X =
Time (min)
should calculate?
gtt/min 1,500 mL x 15 gtt

X gtt/min =
600 min x 1 mL
X gtt/min = 37.5 gtt/min
1,500 mL
37.5 rounds to 38
10 hr
If the prescription reads 1,500 mL to infuse over 10 hr
measurement No mL mL es hr min
1 hr 10 hr nurse should adjust the manual IV infusion to deliver LR
60 min =
X min 1,500 mL IV at 38 gtt/min.
X min = 600 min

X gtt/min =

STEP 2: Determine the ratio that contains the same unit as STEP 6: Round if necessary.
33.333333 rounds to 33
matches the unit being calculated.) STEP 8: Determine hether the I o rate ma es sense.
If the amount prescribed is 100 mL to infuse over 30
10 gtt
X gtt/min = min, it makes sense to administer 33 gtt/min. The nurse
1 mL
should adjust the manual IV infusion to deliver famotidine
STEP 3: Place any remaining ratios that are relevant to 120 mg in 100 mL of 0.9% NaCl IV at 33 gtt/min.
measurements.
STEP 1: What is the unit of measure to calculate? (Place
10 gtt x 1,500 mL x 1 hr
X gtt/min = the unit of measure being calculated on the left side of the
1 mL x 10 hr x 60 min
equation.)
X gtt/min =
STEP 5: Round, if necessary. the unit being calculated. (Place the ratio on he right side
37.5 rounds to 38
10 gtt
If the prescription reads 1,500 mL to infuse over 10 hr X gtt/min =
1 mL
nurse should adjust the manual IV infusion to deliver LR STEP 3: Place any remaining ratios that are relevant to
1,500 mL IV at 38 gtt/min. the item on the right side of the equation along with any
measurements.
10 gtt x 100 mL
Example: A nurse is preparing to administer X gtt/min =
1 mL x 30 min
famotidine 120 mg by intermittent IV bolus.
Available is famotidine 120 mg in 100 mL of 0.9% STEP 4: Solve for X.
sodium chloride (0.9% NaCl) to infuse over 30
min. The drop factor of the manual IV tubing is
10 gtt/mL. The nurse should adjust the manual IV STEP 5: Round if necessary.
infusion to deliver how many gtt/min? (Round the
33.333333 rounds to 33
answer to the nearest whole number. Use a leading
zero if it applies. Do not use a trailing zero.) STEP 6: Determine hether the I o rate ma es sense.
If the amount prescribed is 100 mL to infuse over 30
min, it makes sense to administer 33 gtt/min. The nurse
USING RATIO AND PROPORTION should adjust the manual IV infusion to deliver famotidine
AND DESIRED OVER HAVE 120 mg in 100 mL of 0.9% NaCl IV at 33 gtt/min.
should calculate?
gtt/min
100 mL
30 min
measurement? No

X =
Time (min)
100 mL x 10gtt
X gtt/min =
30 min x 1 mL

1. A nurse is preparing to administer methylprednisolone 5. A nurse is preparing to administer ketorolac 0.5 mg/kg
10 mg by IV bolus. The amount available is IV bolus every 6 hr to a school-age child who weighs
methylprednisolone injection 40 mg/mL. How many 66 lb. The amount available is ketorolac injection
mL should the nurse administer? (Round the answer 30 mg/mL. How many mL should the nurse administer
to the nearest tenth. Do not use a trailing zero.) per dose? (Round the answer to the nearest tenth. Use
a leading zero if it applies. Do not use a trailing zero.)
2. A nurse is preparing to administer lactated

Ringer’s (LR) IV 100 mL over 15 min. The nurse 6. A nurse is preparing to administer dextrose 5% in
should set the IV infusion pump to deliver how water (D5W) 1,000 mL IV to infuse over 10 hr. The
many mL/hr? (Round the answer to the nearest nurse should set the IV infusion pump to deliver
whole number. Do not use a trailing zero.) how many mL/hr? (Round the answer to the nearest
whole number. Do not use a trailing zero.)
3. A nurse is preparing to administer 0.9% sodium

chloride (0.9% NaCl) 250 mL IV to infuse over 30 min. 7. A nurse is preparing to administer acetaminophen
The drop factor of the manual IV tubing is 10 gtt/mL. 320 mg PO every 4 hr PRN for pain. The amount
The nurse should adjust the manual IV infusion to available is acetaminophen liquid 160 mg/5 mL.
deliver how many gtt/min? (Round the answer to the How many mL should the nurse administer per
nearest whole number. Do not use a trailing zero.) dose? (Round the answer to the nearest tenth. Use a
leading zero if it applies. Do not use a trailing zero.)
4. A nurse is preparing to administer metoprolol

200 mg PO daily. The amount available is metoprolol 8. A nurse is preparing to administer dextrose 5% in
100 mg/tablet. How many tablets should the nurse lactated Ringer’s (D5LR) 1,000 mL to infuse over 6 hr.
administer? (Round the answer to the nearest The drop factor of the manual IV tubing is 15 gtt/
whole number. Do not use a trailing zero.) mL. The nurse should adjust the manual IV infusion to
deliver how many gtt/min? (Round the answer to the
nearest whole number. Do not use a trailing zero.)

1. 0.3 mL
Using Ratio and Proportion Using Desired Over Have Using Dimensional Analysis
STEP 1: What is the unit of measurement STEP 1: What is the unit of measurement STEP 1: What is the unit of measurement
the nurse should calculate? mL the nurse should calculate? mL the nurse should calculate? (Place the
unit of measurement being calculated
STEP 2: What is the dose the STEP 2: What is the dose the
on the left side of the equation.)
nurse should administer? Dose to nurse should administer? Dose to
administer = Desired = 10 mg administer = Desired = 10 mg X mL =
STEP 3: What is the dose available? STEP 3: What is the dose available? STEP 2: Determine the ratio that
Dose available = Have = 40 mg Dose available = Have = 40 mg contains the same units as the unit
being calculate. (Place the ratio
STEP 4: Should the nurse convert STEP 4: Should the nurse convert
on the right side of the equation
the units of measurement? No the units of measurement? No
ensuring that the unit in the numerator
STEP 5: What is the quantity of the STEP 5: What is the quantity of the matches the unit being calculated.)
dose available? = Quantity = 1 mL dose available? = Quantity = 1 mL
1 mL
STEP 6: Set up the equation and solve for X. STEP 6: Set up an equation and solve for X. X mL =
40 mg
Have Desired Desired × Quantity STEP 3: Place any remaining ratios that
= X = are relevant to the item on the right
Quantity X Have
side of the equation along with any
40 mg 10 mg 10 mg × 1 mL needed conversion factors to cancel
× X mL = out unwanted units of measurements.
1 mL X mL 40 mg
X mL = 0.25 mL 1 mL 10 mg
X mL = 0.25 mL X
= ×
STEP 7: Round, if necessary. 0.25 mL 40 mg 1
rounds to 0.3 STEP 7: Round, if necessary. 0.25
rounds to 0.3 X mL = 0.25 mL
STEP 8: Determine whether the amount
to administer makes sense. If there are STEP 8: Determine whether the amount STEP 4: Round, if necessary. 0.25
40 mg/mL and the prescription reads to administer makes sense. If there are rounds to 0.3
10 mg, it makes sense to administer 40 mg/mL and the prescription reads
10 mg, it makes sense to administer STEP 5: Determine whether the amount
0.3 mL. Administer methylprednisolone to administer makes sense. If there are
injection 0.3 mL by IV bolus. 0.3 mL. Administer methylprednisolone
injection 0.3 mL by IV bolus. 40 mg/mL and the prescription reads
10 mg, it makes sense to administer
0.3 mL. Administer methylprednisolone
injection 0.3 mL by IV bolus.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Dosage Calculation
2. 400 mL/hr
STEP 1: What is the unit STEP 4: Should the nurse STEP 5: Set up an equation STEP 6: Round, if necessary.
of measurement the nurse convert the units of and solve for X.
STEP 7: Reassess to determine
should calculate? mL/hr measurement?
whether the IV flow rate makes
No (mL = mL) Volume (mL)
STEP 2: What is the volume the = X mL/hr sense. If the prescription reads
nurse should infuse? 100 mL
Yes (min ≠ hr) Time (hr) 100 mL to infuse over 15 min
(0.25 hr), it makes sense to
STEP 3: What is the total 60 min 1 hr 100 mL
= = X mL/hr administer 400 mL/hr. Set
infusion time? 15 min 15 min X hr 0.25 hr the IV pump to deliver LR
X hr = 0.25 hr 100 mL IV at 400 mL/hr.
X mL/hr = 400 mL/hr

3. 83 gtt/min
Using Ratio and Proportion and Desired Over Have Using Dimensional Analysis
STEP 1: What is the unit of measurement the STEP 1: What is the unit of measurement to calculate? (Place the
nurse should calculate? gtt/min ratio on he right side of the equation ensuring that the unit in
the numerator matches the unit being calculated.) gtt/min =
STEP 2: What is the quantity of the drop
factor that is available? 10 gtt/mL STEP 2: Determine the ratio that contains the same
units as the unit being calculate. (Place the ratio on the
STEP 3: What is the volume the nurse should infuse? 250 mL
right side of the equation ensuring that the unit in the
STEP 4: What is the total infusion time? 30 min numerator matches the unit being calculated.)
STEP 5: Should the nurse convert the units of measurement? No
10 gtt
X gtt/min =
STEP 6: Set up an equation and solve for X. 1 mL
STEP 3: Place any remaining ratios that are relevant to the item on
Volume (mL) the right side of the equation along with any needed conversion
X gtt/mL = × Drop factor (gtt/mL)
Time (min) factors to cancel out unwanted units of measurements.
250 mL 10 gtt 250 mL
X gtt/mL = × 10 gtt/mL X gtt/min = ×
30 min 1 mL 30 min
X gtt/mL = 83.3333 gtt/mL X gtt/mL = 83.3333 gtt/mL
STEP 7: Round, if necessary. 83.3333 rounds to 83 STEP 4: Round, if necessary. 83.3333 rounds to 83
STEP 8: Determine whether the IV flow rate makes sense. STEP 5: Determine whether the IV flow rate makes sense.
If the amount prescribed is 250 mL to infuse over 30 min, it If the amount prescribed is 250 mL to infuse over 30 min, it
makes sense to administer 83 gtt/min. Adjust the manual makes sense to administer 83 gtt/min. Adjust the manual
IV infusion to deliver 0.9% NaCl 250 mL at 83 gtt/min. IV infusion to deliver 0.9% NaCl 250 mL at 83 gtt/min.
4. 2 tablets
the nurse should calculate? tablets the nurse should calculate? tablets to calculate? (Place the ratio on he
right side of the equation ensuring that
STEP 2: What is the dose the STEP 2: What is the dose the
the unit in the numerator matches the
nurse should administer? Dose to nurse should administer? Dose to
unit being calculated.) tablets =
administer = Desired = 200 mg administer = Desired = 200 mg
STEP 2: Determine the ratio that
STEP 3: What is the dose available? STEP 3: What is the dose available?
contains the same units as the unit
Dose available = Have = 100 mg Dose available = Have = 100 mg
being calculate. (Place the ratio
STEP 4: Should the nurse convert STEP 4: Should the nurse convert on the right side of the equation
the units of measurement? No the units of measurement? No ensuring that the unit in the numerator
STEP 5: What is the quantity of the STEP 5: What is the quantity of the
dose available? = Quantity = 1 tablet dose available? = Quantity = 1 tablet
X 1 tablet
=
STEP 6: Set up the equation and solve for X. STEP 6: Set up the equation and solve for X. tablets 100 mg
STEP 3: Place any remaining ratios that
Have Desired Desired × Quantity are relevant to the item on the right
= X tablets =
Quantity X Have side of the equation along with any
needed conversion factors to cancel
100 mg 200 mg 200 mg × 1 tablet out unwanted units of measurements.
× X tablets =
1 tablet X tablets 100 mg
1 tablet 200 mg
X tablet(s) = 2 tablets X tablets = ×
X tablet(s) = 2 tablets 100 mg 1
STEP 7: Round, if necessary. X tablet(s) = 2 tablets
STEP 8: Determine whether the
STEP 8: Determine whether the STEP 7: Round, if necessary.
amount to administer makes sense.
amount to administer makes sense. If there are 100 mg/tablet and the STEP 8: Determine whether the
If there are 100 mg/tablet and the prescription reads 200 mg, it makes amount to administer makes sense.
prescription reads 200 mg, it makes sense to administer 2 tablets. Administer If there are 100 mg/tablet and the
sense to administer 2 tablets. Administer metoprolol 2 tablets daily. prescription reads 200 mg, it makes
metoprolol 2 tablets daily. sense to administer 2 tablets. Administer
metoprolol 2 tablets daily.

5. 0.5 mL
STEP 1: What is the unit of measurement Using Desired Over Have
the nurse should calculate? kg
STEP 9: What is the unit of measurement
STEP 2: Set up an equation and solve for X. the nurse should calculate? mL
2.2 lb client’s weight in lb STEP 10: What is the dose the nurse should administer?
= Dose to administer = Desired = 15 mg
1 kg X kg
STEP 11: What is the dose available? Dose available = Have = 30 mg
2.2 lb 66 lb STEP 12: Should the nurse convert the units of measurement? No
×
1 kg X kg STEP 13: What is the quantity of the dose
X kg = 30 kg available? = Quantity = 1 mL
STEP 3: Round, if necessary. STEP 14: Set up an equation and solve for X.
STEP 4: Determine whether the equivalent makes sense.
If 1 kg = 2.2 lb, it makes sense that 66 lb = 30 kg. Desired × Quantity
X =
Have
the nurse should calculate? mg 15 mg × 1 mL
X mL =
30 mg
X mL = 0.5 mL
X = mg × kg
0.5 mg × 30 kg = 15 mg
STEP 16: Determine whether the amount makes sense.
X mg = 15 mg If the prescription reads 0.5 mg/kg every 6 hr and the
STEP 7: Round, if necessary. school-age child weighs 30 kg, it makes sense to give
15 mg. If there are 30 mg in 1 mL, it makes sense to give
STEP 8: Determine whether the amount makes sense. If the 0.5 mL. Give ketorolac 0.5 mL IV bolus every 6 hr.
prescription reads 0.5 mg/kg every 6 hr and the school-age
child weighs 30 kg, it makes sense to give 15 mg. Using Dimensional Analysis
Using Ratio and Proportion
the nurse should calculate? mL
the nurse should calculate? mL STEP 10: What is the quantity of the dose
available? = Quantity = 1 mL
Dose to administer = Desired = 15 mg STEP 11: What is the dose available? Dose available = Have = 30 mg
STEP 11: What is the dose available? Dose available = Have = 30 mg STEP 12: What is the dose the nurse should administer?
Dose to administer = Desired = 15 mg
STEP 13: What is the quantity of the dose
available? = Quantity = 1 mL STEP 14: Set up an equation and solve for X.
STEP 14: Set up the equation and solve for X. Quantity Conversion (Have)
X = × × Desired
Have Conversion (Desired)
Have Desired 30 mg 15 mg
= ×
Quantity X 1 mL X mL 1 mL
X mL = 30 mg × 15 mg
X mL = 0.5 mL
STEP 15: Round, if necessary. X mL = 0.5 mL
STEP 16: Determine whether the amount makes sense. If the STEP 15: Round, if necessary.
prescription reads 0.5 mg/kg every 6 hr and the school-age child STEP 16: Determine whether the amount makes sense. If the
weighs 30 kg, it makes sense to give 15 mg. If there are 30 mg in 1 mL, prescription reads 0.5 mg/kg every 6 hr and the school-age child
it makes sense to give 0.5 mL. Give ketorolac 0.5 mL IV bolus every 6 hr. weighs 30 kg, it makes sense to give 15 mg. If there are 30 mg in 1 mL,
it makes sense to give 0.5 mL. Give ketorolac 0.5 mL IV bolus every 6 hr.
6. 100 mL/hr
STEP 1: What is the unit of measurement STEP 5: Set up an equation and solve for X. STEP 6: Round, if necessary.
the nurse should calculate? mL/hr
STEP 7: Determine whether the IV flow
Volume (mL)
STEP 2: What is the volume the X mL/hr = rate makes sense. If the prescription
nurse should infuse? 1,000 mL Time (hr) reads 1,000 mL to infuse over 10 hr,
it makes sense to administer 100
STEP 3: What is the total 1,000 mL
X mL/hr = mL/hr. Set the IV pump to deliver
infusion time? 10 hr 10 hr D 5W 1,000 mL IV at 100 mL/hr.
STEP 4: Should the nurse convert
X mL/hr = 100 mL/hr
the units of measurement? No

7. 10 mL
the nurse should calculate? mL the nurse should calculate? mL the nurse should calculate? mL
STEP 2: What is the dose the STEP 2: What is the dose the STEP 2: What is the quantity of the
nurse should administer? Dose to nurse should administer? Dose to dose available? = Quantity = 5 mL
administer = Desired = 320 mg administer = Desired = 320 mg
STEP 3: What is the dose available?
STEP 3: What is the dose available? STEP 3: What is the dose available? Dose available = Have = 160 mg
Dose available = Have = 160 mg Dose available = Have = 160 mg
STEP 4: What is the dose the
STEP 4: Should the nurse convert STEP 4: Should the nurse convert nurse should administer? Dose to
the units of measurement? No the units of measurement? No administer = Desired = 320 mg
STEP 5: What is the quantity of the STEP 5: What is the quantity of the STEP 5: Should the nurse convert
dose available? = Quantity = 5 mL dose available? = Quantity = 5 mL the units of measurement? No
STEP 6: Set up the equation and solve for X. STEP 6: Set up the equation and solve for X. STEP 6: Set up the equation and solve for X.
Have Desired Desired × Quantity Quantity Conversion (Have)

= X =
Quantity X Have X= × Conversion × Desired
Have
(Desired)
160 mg 320 mg 320 mg × 5 mL
× X mL = 5 mL
5 mL X mL 160 mg
X mL = × 320 mg
160 mg
X mL = 10 mL X mL = 10 mL
X mL = 10 mL
STEP 7: Round, if necessary. STEP 7: Round, if necessary.
STEP 8: Determine whether the amount STEP 8: Determine whether the amount
to administer makes sense. If there are to administer makes sense. If there are STEP 8: Determine whether the amount
160 mg/5 mL and the prescription reads 160 mg/5 mL and the prescription reads to administer makes sense. If there are
320 mg, it makes sense to administer 320 mg, it makes sense to administer 160 mg/5 mL and the prescription reads
10 mL. Administer acetaminophen liquid 10 mL. Administer acetaminophen liquid 320 mg, it makes sense to administer
10 mL PO every 4 hr PRN for pain. 10 mL PO every 4 hr PRN for pain. 10 mL. Administer acetaminophen liquid
10 mL PO every 4 hr PRN for pain.
8. 42 gtt/min
Using Ratio and Proportion and Desired Over Have Using Dimensional Analysis
STEP 1: What is the unit of measurement the STEP 1: What is the unit of measurement to calculate? gtt/min
nurse should calculate? gtt/min
STEP 2: What is the quantity of the drop
STEP 2: What is the quantity of the drop factor that is available? 15 gtt/mL
factor that is available? 15 gtt/mL
STEP 3: What is the total infusion time? 6 hr
STEP 3: What is the volume the nurse should infuse? 1,000 mL
STEP 4: What is the volume the nurse should infuse? 1,000 mL
STEP 4: What is the total infusion time? 6 hr
STEP 5: Should the nurse convert the units of measurement? No (mL = mL) Yes (hr ≠ min)
measurement? No (mL = mL) Yes (hr ≠ min)
1 hr 6 hr
1 hr 6 hr =
= 60 min X hr
60 min X hr
X min = 360 min
X min = 360 min STEP 6: Set up an equation and solve for X.
Quantity Conversion (Have) Volume
Volume (mL) X = × ×
X = × Drop factor (gtt/mL)
1 mL Conversion (Desired) Time
Time (min)
15 gtt 1 hr 1,000 mL
1,000 mL X gtt/min = × ×
X gtt/mL = × 15 gtt/mL 1 mL 60 min 6 hr
360 min
X gtt/mL = 41.6666 gtt/mL STEP 7: Round, if necessary. 41.6666 gtt/min = 42 gtt/min
STEP 7: Round, if necessary. 41.6666 gtt/mL = 42 gtt/mL STEP 8: Determine whether the IV flow rate makes sense.
STEP 8: Determine whether the IV flow rate makes sense. If the amount prescribed is 1,000 mL to infuse over 6 hr
If the amount prescribed is 1,000 mL to infuse over 6 hr (360 min), it makes sense to administer 42 gtt/min. Adjust the
(360 min), it makes sense to administer 42 gtt/min. Adjust the manual IV infusion to deliver D 5LR 1,000 mL at 42 gtt/min.
manual IV infusion to deliver D 5LR 1,000 mL at 42 gtt/min.

CHAPTER 49
UNIT 4 PHYSIOLOGICAL INTEGRITY CONSIDERATIONS
CHAPTER 49 Intravenous Therapy NURSING ACTIONS

Nurses administer IV medication infusions in the
following ways.
Give the medication the pharmacist mixed in a large
Intravenous (IV) therapy involves infusing fluids
●
olume of uid to , mL as a continuous I

via an IV catheter to administer medications, infusion (potassium chloride and vitamins)
Deliver the medication in premixed solution bags from
supplement fluid intake, or provide fluid
●
the medication’s manufacturer

replacement, electrolytes, or nutrients.
Administering volume-controlled infusions
Give some medications (antibiotics) intermittently in
Nurses administer large-volume IV infusions, as
●
a small amount of solution (25 to 250 mL) through a

well as IV boluses, usually in a small amount of continuous I uid system or ith saline or heparin
lock systems
fluid. Nurses or pharmacists mix IV medication in ● Infuse the medications for short periods of time and on
a large volume of fluid to give as a continuous IV a schedule
Use a secondary IV bag or bottle or tandem
infusion or intermittently in a small amount of fluid.
●
setup, a volume-control administration set, or a

mini-infusion pump
PROCEDURE Giving an IV bolus dose
● The pro ider prescribes the type of I uid, the olume ● Inject the medications in small amounts of solution,
to infuse, and either the rate at which to infuse the IV concentrated or diluted, over a short time (1 to 2 min)
uid or the total amount of time it should ta e to infuse ● Administer medications directly into the peripheral IV
the uid. The nurse regulates the I infusion, either or access port to achieve an immediate medication level
with an IV pump or manually, to be sure to deliver the in the bloodstream (with pain medication)
right amount. ● Prepare medications in the correct concentration and at
● Nurses administer large-volume IV infusions on a a safe rate (amount of medication per minute)
continuous basis, (0.9% sodium chloride IV to infuse at ● Use extreme caution and observing for adverse reactions
100 mL/hr) or intermittently (0.9% sodium chloride 500 or complications (redness, burning, or increasing pain)
mL to give IV over 3 hr).
● A uid bolus is a large amount of I uid to gi e in a Older adult clients, clients taking anticoagulants,
short time, usually less than hr. A uid bolus rapidly or clients who have fragile veins
replaces uid loss from dehydration, shoc , hemorrhage, ● Avoid tourniquets.
burns, or trauma. A large-gauge catheter (18-gauge ● se a blood pressure cuff instead.
or larger) is essential for maintaining the rapid rate ● Do not slap the extremity to visualize veins.
necessary to gi e a uid bolus to an adult. ● Avoid rigorous friction while cleaning the site.
● Nurses administer medications as an IV bolus,
giving the medication in a small amount of solution,
Edema in extremities
concentrated or diluted, and injecting it over a short
time (1 to 2 min). ● Apply digital pressure over the selected vein to
displace edema.
ADVANTAGES ● Apply pressure with a swab of cleaning solution.
● Rapid absorption and onset of action ● Cannulate the vein quickly.
● Constant therapeutic blood levels
Less irritation to subcutaneous and muscle tissue
Clients who are obese
●
DISADVANTAGES
se anatomical landmar s to nd eins.
● Circulatory uid o erload is possible if the olume of the
solution is large or the infusion rate is rapid.
● Immediate absorption leaves little time to correct errors.
● Solutions and IV catheters can irritate the lining
of the vein.
● Failure to maintain surgical asepsis can lead to local
and systemic infection.
FUNDAMENTALS FOR NURSING CHAPTER 49 INTRAVENOUS THERAPY 299

PREPROCEDURE ● ntie the tourni uet or de ate the blood pressure cuff.
● Cleanse the area at the site using friction in a
EQUIPMENT
circular motion from the middle and outwardly with
● IV start kit if available: Tourniquet, sterile drape, antiseptic
chlorhexidine or the cleaning agent the facility’s
swabs, transparent dressing, small roll of sterile tape, 2x2
protocol speci es. Allo it to air dry for to min.
or 4x4 gauze sponges, and safety positioning device. ● Remove the cover from the catheter, grasp the plastic
● Correct size catheter
hub, and examine the device for smooth edges.
◯ gauge for clients ho ha e trauma, rapid uid olume ● etie the tourni uet or rein ate the blood pressure cuff.
◯ 18- to 20-gauge for clients who are having surgery,
● Anchor the vein below the site of insertion.
rapid blood administration ● Pull the skin taut and hold it.
◯ 22- to 24-gauge for other clients (children, adults)
● Warn the client of a sharp, quick stick.
● Tubing ● Use a steady, smooth motion to insert the catheter into
● Pre lled syringe containing to mL of . sodium
the skin at an angle of 10° to 30° with the bevel up.
chloride solution ● Advance the catheter through the skin and into the vein,
● Infusion pump
maintaining a to angle. A ashbac of blood ill
● Clean gloves
con rm placement in the ein.
● Scissors or clippers for hair removal ● Lower the hub of the catheter close to the skin to
NURSING ACTIONS prepare for threading it into the vein approximately
● Check the prescription (solution, rate). 0.6 cm (0.24 in).
● Identify allergies to latex or tape. ● Loosen the needle from the catheter and pull back
● Follow the rights of medication administration. slightly on the needle so that it no longer extends past
● Check compatibilities of IV solutions and medications. the tip of the catheter.
● Perform hand hygiene. ● se the thumb and inde nger to ad ance the
● Examine the IV solution for clarity, leaks, and catheter into the vein until the hub rests against the
expiration date. insertion site.
● Don clean gloves. ● Stabilize the IV catheter with one hand and release the
● Evaluate extremities and veins. Clip hair at and around the tourni uet or blood pressure cuff ith the other.
insertion site with scissors. Do not shave the area because ● Apply pressure approximately 3 cm (1.2 in) above the
an abrasion can occur, increasing the risk of infection. insertion site ith the middle nger and stabili e the
catheter ith the inde nger.
CLIENT EDUCATION ● Remove the needle and activate the safety device.
● Understand the procedure. ● Maintain pressure above the IV site and connect the
● Lie in a comfortable position.
appropriate equipment to the hub of the IV catheter.
Apply a dressing and leave it in place until catheter
INTRAPROCEDURE
●
removal, unless it becomes damp, loose, or soiled.

NURSING ACTIONS ● Avoid encircling the entire extremity with tape and
● Apply a clean tourni uet or blood pressure cuff taping under the sterile dressing.
(especially for older adults) 10 to 15 cm (4 to 6 in) above ● For a continuous IV infusion, regulate the infusion rate
the insertion site to compress only enous blood o . according to the prescription.
● elect the ein by using isuali ation, gra ity, st ● Dispose of used equipment and supplies.
clenching, friction with the cleaning solution, or heat ● Document the following in the medical record.
and choose: ◯ The date and time of insertion
◯ Distal eins rst on the nondominant hand ◯ The insertion site and appearance
◯ A site that is not painful or bruised and will not ◯ The catheter’s size
interfere with activity ◯ The type of dressing
◯ A vein that is resilient with a soft, bouncy sensation ◯ The I uid and rate
on palpation ◯ The number, locations, and conditions of previously
◯ Avoid the following. attempted catheterizations

■ Varicose veins that are permanently dilated ◯ The client’s response
and tortuous
Sample documentation: 6/1/20XX, 1635,
■ eins in the inner rist ith bifurcations, in e ion
Inserted #22-gauge IV catheter into left wrist
areas, near valves (appearing as bumps), in lower
cephalic vein (one attempt); applied sterile
extremities, and in the antecubital fossa (except for
occlusive dressing. IV dextrose 5% in lactated
emergency access)
■ Veins in the back of the hand
Ringer’s infusing at 100 mL/hr per infusion
■ Veins that are sclerosed or hard
pump without redness or edema at the site.
■ Veins in an extremity with impaired sensitivity
Tolerated without complications. S. Velez, RN
(scar tissue, paralysis), lymph nodes removed,
recent in ltration, a PICC line, or an arterio enous
stula or graft
■ Veins that had previous venipunctures
300 CHAPTER 49 INTRAVENOUS THERAPY CONTENT MASTERY SERIES

POSTPROCEDURE
49.1 Needleless injection system
NURSING ACTIONS
● Maintaining the patency
of IV access
◯ Do not stop a continuous
infusion or allow blood to

back up into the catheter for
any length of time. Clots can
form at the tip of the needle
or catheter and lodge against
the vein’s wall, blocking the
o of uid.
◯ Instruct clients not to
manipulate the o rate de ice,

change the settings on the IV
pump, or lie on the tubing.
◯ Make sure the IV insertion
site’s dressing is not too tight.

◯ Flush intermittent IV catheters
with the appropriate solution

after every medication
administration or every 8 to
12 hr when not in use, according
to the facility’s policy.
◯ Monitor the site and infusion
rate at least every hour.

Discontinuing IV therapy
GUIDELINES FOR SAFE
●
Check the prescription.

IV MEDICATION ADMINISTRATION
◯
◯ Prepare the equipment.
◯ Perform hand hygiene. ● Use an infusion pump to administer medications that

◯ Don clean gloves. can cause serious adverse reactions (potassium chloride).
◯ Clamp the IV tubing. Never administer them by IV bolus.
◯ Remove the tape and dressing, stabilizing the ● Never administer IV medications through tubing
IV catheter. that is infusing blood, blood products, or parenteral
◯ Apply a sterile gauze pad over the site without putting nutrition solutions.
pressure on the vein. Do not use alcohol. ● Verify the compatibility of medications with IV solutions
◯ Using the other hand, withdraw the catheter by before infusing a medication through tubing that is
pulling it straight back from the site, keeping the hub infusing another medication or I uid.
parallel to the skin.
◯ Elevate the extremity and apply pressure for 2 to
3 min and until bleeding stops.

NEEDLESTICK PREVENTION
◯ Examine the site. ● Be familiar with IV insertion equipment.
◯ Apply tape over the gauze. ● Do not use needles when needleless systems
◯ Use a pressure dressing, if necessary. are available.
◯ Check the catheter for intactness. ● Use protective safety devices when available. (49.1)
◯ Dispose of the catheter in the designated ● Dispose of needles immediately in designated
puncture-resistant receptacle, and the IV solution and puncture-resistant receptacles.
equipment in the appropriate location. ● Do not break, bend, or recap needles.
◯ Document.
TYPES OF IV ACCESS
● Peripheral vein via a catheter
● Jugular or subclavian vein via a central venous
access device

PREVENTING IV INFECTIONS TREATMENT
● Stop the infusion and remove the catheter.
● Perform hand hygiene before and after handling ● Elevate the extremity.
IV systems. ● Encourage active range of motion.
● Use standard precautions. ● Apply a warm or cold compress depending on the
● Change IV sites according to the facility’s policy (usually
solution infusing.
every 72 hr). ● Restart the infusion proximal to the site or in
● Replacement of the administration set is dependent
another extremity.
upon the type of infusion. Administration sets with a
continuous infusion of uids ith or ithout secondary PREVENTION
uids should be changed e ery hr. Intermittent ● Carefully select the site and catheter.
infusions should be changed every 24 hr. Some products ● Secure the catheter.
(blood) or medications (propofol) should be changed
more frequently, according to facility policy. Phlebitis or thrombophlebitis
● Remove catheters as soon as there is no clinical
Edema; throbbing, burning, or pain at the site; increased
need for them.
skin temperature; erythema; a red line up the arm with a
● Replace catheters when suspecting any break in surgical
palpable band at the vein site; slowed rate of infusion
aseptic technique (during emergency insertions).
● Use a sterile needle or catheter for each TREATMENT
insertion attempt. ● Promptly discontinue the infusion and remove
● Avoid writing on IV bags with pens or markers, because the catheter.
ink can contaminate the solution. ● Elevate the extremity.
● Change tubing immediately for potential contamination. ● Apply warm compresses 3 to 4 times/day.
● Do not allo uids to hang for more than hr unless ● estart the infusion in a different ein pro imal to the
it is a closed system (pressure bags for hemodynamic site or in another extremity.
monitoring). ● Obtain a specimen for culture at the site and prepare the
● Wipe all ports with alcohol or an antiseptic swab before catheter for culture if drainage is present.
connecting IV lines or inserting a syringe to prevent the
PREVENTION
introduction of micro-organisms into the system. ● Change the IV site at least every 72 hr or sooner
● Never disconnect tubing for convenience or to reposition
according to the facility’s policy.
the client. ● Avoid the lower extremities.
● Use hand hygiene.
Use surgical aseptic technique.
COMPLICATIONS
●
Complications re uire noti cation of the pro ider

and documentation. Use new tubing and catheters for
restarting IV infusions after detecting complications.
Infiltration or extravasation
IV solution or medication leaks into the subcutaneous
tissue. In ltration is the lea of a non esicant
extravasation is the leak of a vesicant solution which can
damage the tissues. With extravasation, prior to regular
treatment, the nurse must withdraw the solution from
the client’s IV access, and might need to administer an
antidote prior to discontinuing the IV access. Findings
include pallor, local swelling at the site, decreased skin
temperature around the site, damp dressing, or slowed 49.2 Needle Safety Cap
rate of infusion.

Fluid overload Catheter embolus
Distended neck veins, increased blood pressure, Missing catheter tip on removal, severe pain at the site
tachycardia, shortness of breath, crackles in the lungs, ith migration, absence of ndings if no migration
edema, additional ndings arying ith the I solution
TREATMENT
TREATMENT ● Place a tourniquet high on the extremity to limit
● Stop the infusion. enous o .
● Raise the head of the bed. ● Prepare for removal under x-ray or via surgery.
● Measure vital signs and oxygen saturation. ● Save the catheter after removal to determine the cause.
● Ad ust the rate after correcting uid o erload.
PREVENTION: Do not reinsert the stylet into the catheter.
● Administer diuretics.
PREVENTION
● Use an infusion pump.
● Monitor I&O.
Cellulitis
Pain, warmth, edema, induration, red streaking, fever,
chills, malaise
TREATMENT
● Discontinue the infusion and remove the catheter.
● Elevate the extremity.
● Apply warm compresses 3 to 4 times/day.
● Obtain a specimen for culture at the site and prepare the
catheter for culture if drainage is present.
● Administer the following.
◯ Antibiotics
◯ Analgesics
◯ Antipyretics
PREVENTION
● Rotate sites at least every 72 hr.
● Avoid the lower extremities.
● Use hand hygiene.
● Use surgical aseptic technique.

1. A nurse is demonstrating how to insert an IV 3. During new employee orientation, a nurse is

catheter. Which of the following statements by explaining how to prevent IV infections. Which of
a nurse viewing the demonstration indicates the following statements by an orientee indicates
understanding of the procedure? understanding of the preventive strategies?
A. “I will thread the needle all the way into the A. “I will leave the IV catheter in place after the
vein until the hub rests against the insertion client completes the course of IV antibiotics.”
site after I see a flashback of blood.” B. “As long as I am working with the same
B. “I will insert the needle into the client’s skin at an client, I can use the same IV catheter
angle of 10 to 30 degrees with the bevel up.” for my second insertion attempt.”
C. “I will apply pressure approximately C. “If my client needs to use the rest room,
1.2 inches below the insertion site it would be safer to disconnect their IV
prior to removing the needle.” infusion as long as I clean the injection port
D. “I will choose a vein in the antecubital thoroughly with an antiseptic swab.”
fossa for IV insertion due to its size D. “I will replace any IV catheter when I suspect
and easily accessible location.” contamination during insertion.”
2. A nurse is collecting data from a client who is receiving 4. A nurse on the IV team is conducting an in-service
IV therapy and reports pain in the arm, chills, and education program about the complications of
“not feeling well.” The nurse notes warmth, edema, IV therapy. Which of the following statements by
induration, and red streaking on the client’s arm an attendee indicates an understanding of the
close to the IV insertion site. Which of the following manifestations of infiltration? (Select all that apply.)
actions should the nurse plan to take first? A. “The temperature around the IV site is cooler.”
A. Obtain a specimen for culture. B. “The rate of the infusion increases.”
B. Apply a warm compress. C. “The skin at the IV site is red.”
C. Administer analgesics. D. “The IV dressing is damp.”
D. Discontinue the infusion. E. “The tissue around the venipuncture
site is swollen.”
5. A nurse is caring for a client receiving dextrose 5% in

0.9% sodium chloride IV at 120 mL/hr. Which of the
following statements by the client should alert the
nurse to suspect fluid overload? (Select all that apply.)
A. “I feel lightheaded.”
B. “I feel as though my heart is racing.”
C. “I feel a little short of breath.”
D. “The nurse technician told me that my
blood pressure was 150 over 90.”
E. “I think my ankles are less swollen.”

A nurse has inserted an IV catheter for a client who
requires IV rehydration. What information should the nurse
document in the client’s medical record? Use the ATI Active
RELATED CONTENT: List the seven components of

documentation following insertion of an IV catheter.

1. A. After seeing a flashback of blood, lower the hub close 4. A. CORRECT: A decrease in skin temperature around the site is
to the skin to prepare for threading the needle into the a manifestation of infiltration due to the IV solution entering
vein, then loosen the needle from the catheter and pull the subcutaneous tissue around the venipuncture site.
back slightly on the needle so that it no longer extends B. When infiltration occurs, the rate of infusion can slow
past the tip of the catheter. Use the thumb and index or stop, not increase, as the solution is no longer
finger to advance the catheter into the vein until the hub infusing directly into the vein. This occurs due to
rests against the insertion site. Inserting the needle all dislodgement of the catheter or rupture of the vein.
the way into the vein could puncture the vein. C. When infiltration occurs, the skin around the IV
B. CORRECT: Use a smooth, steady motion to insert the site is pale, not red, because the solution is no
catheter through the skin at an angle of 10° to 30° with longer infusing directly into the vein and enters the
the bevel up. This is the optimal angle for preventing subcutaneous tissue around the venipuncture site.
the puncture of the posterior wall of the vein. D. CORRECT: A damp IV dressing is a common finding with
C. Apply pressure approximately 3 cm (1.2 in) above infiltration due to the IV solution entering the subcutaneous
the insertion site to reduce the backflow of blood tissue and leaking out through the venipuncture site.
into the vein prior to removing the needle. E. CORRECT: Swollen tissue around the venipuncture site
D. Do not use a vein in the antecubital fossa for IV is a manifestation of infiltration due to the IV solution
insertion, except for emergency access, because entering the subcutaneous tissue and causing swelling,
it will limit the mobility of the client’s arm. as the fluid is no longer infusing into the vein.
NCLEX® Connection: Pharmacological and Parenteral Therapies, NCLEX® Connection: Pharmacological and Parenteral Therapies,
Parenteral/Intravenous Therapies Medication Administration
2. A. Obtain a specimen for culture to identify pathogens causing 5. A. A manifestation of fluid overload is hypertension.
infection. However, another action is the priority. Lightheadedness is a manifestation of hypotension.
B. Apply a warm compress to promote healing and B. CORRECT: A manifestation of fluid overload is
comfort. However, another action is the priority. tachycardia due to the increased blood volume,
C. Administer analgesics to promote comfort. which causes the heart rate to increase.
However, another action is the priority. C. CORRECT: A manifestation of fluid overload is
D. CORRECT: The greatest risk to this client is further injury shortness of breath or dyspnea due to the increased
to the irritated vein. The first action is to stop the infusion amount of fluid entering the air spaces in the lungs,
and remove the catheter to prevent further harm. which reduces the amount of circulating oxygen.
NCLEX® Connection: Pharmacological and Parenteral Therapies, D. CORRECT: A manifestation of fluid overload is
Medication Administration hypertension due to the increased blood volume,
which causes the blood pressure to increase.
E. A manifestation of fluid overload is edema. If the
3. A. Remove catheters as soon as they are no longer clinically client’s ankles are less swollen, this is an indication that
necessary to eliminate a portal of entry for pathogens. the edema and the fluid overload are resolving.
B. Use a sterile needle or catheter for each insertion NCLEX® Connection: Physiological Adaptation,
attempt for safety and prevention of infection. Fluid and Electrolyte Imbalances
C. Do not disconnect tubing for convenience, because this
increases the risk of bacteria entering the system.
D. CORRECT: Replace IV catheters when suspecting any break
in surgical aseptic technique (in emergency insertions).

RELATED CONTENT
●
Date and time of insertion ●
IV fluid and rate
●
Insertion site and appearance ●
The number, locations, and conditions of
●
Catheter’s size previously attempted catheterizations
●
Type of dressing ●
Client’s response
NCLEX® Connection: Pharmacological and Parenteral Therapies, Parenteral/Intravenous Therapies

CHAPTER 50
UNIT 4 PHYSIOLOGICAL INTEGRITY ADVERSE EFFECTS
Central nervous system effects
CHAPTER 50 Adverse Effects, From either central nervous system (CNS) stimulation
Interactions, and (excitement) or CNS depression
Contraindications NURSING ACTIONS: Implement seizure precautions for

CNS stimulation.
CLIENT EDUCATION: If CNS depression is likely, do not

drive, operate heavy machinery, or participate in other
To ensure safe medication administration activities that can be dangerous.
and prevent errors, nurses must know the
Extrapyramidal symptoms
therapeutic effect, potential adverse effects,
Abnormal body movements: tremors, rigidity,
interactions, contraindications, and precautions
●
restlessness, acute dystonia (spastic movements of

for each medication they administer. the back, neck, tongue, face), drooling, agitation,
shu ing gait
Every medication has the potential to cause ● These can take a few hours or months to develop.
adverse effects. These are undesired, NURSING ACTIONS

ore common ith medications affecting the CN
inadvertent, and harmful effects of the
●
(those that treat mental health disorders).

medication. Adverse effects can range from mild ● Keep clients safe when movements and balance
are uncontrollable.
to severe, and some can be life-threatening.
Anticholinergic effects
Medications are chemicals that affect the body.
esult from muscarinic receptor bloc ade and affect the
With concurrent use of medications, there is a eyes, smooth muscle tone, exocrine glands, and heart
potential for an interaction. Medications can also NURSING ACTIONS
interact with foods and dietary supplements. ● Ha e clients sip uids to relie e dry mouth.
● Tell clients to wear sunglasses outdoors to
Contraindications and precautions for specific prevent photophobia.
Suggest that clients urinate before taking the
medications are conditions (diseases, age,
●
medication to lessen urinary retention.

pregnancy, lactation) that make it risky or ● To prevent constipation, instruct clients to increase
dietary ber and uids and to increase e ercise.
completely unsafe for clients to take them. ● Remind clients to avoid activities that could lead to
overheating, because there is a decreased ability to
Anticipation of adverse effects, interactions, produce sweat to cool the body.
contraindications, and precautions is an
Cardiovascular effects
important component of client education. Both
Involve blood vessels and the heart
the nurse and the client should know the major
●
● Antihypertensives can cause orthostatic hypotension.

adverse effects a medication can cause. Early NURSING ACTIONS: To relieve and prevent postural
identification of adverse effects allows for timely hypotension (lightheadedness, dizziness), instruct
clients to sit or lie down and to get up and change
intervention to minimize harm. positions slowly.
FUNDAMENTALS FOR NURSING CHAPTER 50 ADVERSE EFFECTS, INTERACTIONS, AND CONTRAINDICATIONS 307
Gastrointestinal effects Toxicity
From local irritation of the gastrointestinal (GI) tract, e ere and potentially life threatening effects from
stimulation of the vomiting center, or stimulation or excessive dosing, but can also occur at therapeutic
slowing of bowel motility dose levels
NURSING ACTIONS NURSING ACTIONS

● Many medications (NSAIDs) cause GI distress. ● An excess of acetaminophen can result in hepatotoxicity,
● Tell clients to try taking the medication with food and which can lead to liver damage.
to notify the pro ider about consistent I effects. ● The antidote acetylcysteine minimizes liver damage due
to acetaminophen toxicity.
Hematologic effects ● There is a greater risk of toxicity and liver damage with
chronic alcohol use.
Relatively common and potentially life-threatening ● Liver damage from disease states can delay or prevent
NURSING ACTIONS medication metabolism.
● Bone marrow depression can result from anticancer
medications and hemorrhagic disorders from Hypersensitivity/allergies
anticoagulants and thrombolytics. ● An overactive immune response to the presence of a
● Instruct clients taking an anticoagulant to report
foreign protein or allergen
bruising, discolored urine or stool, petechiae, and ● Four types: rapid hypersensitivity reactions, cytotoxic
bleeding gums to the provider immediately.
reactions, immune complex reactions, delayed
hypersensitivity reactions
Hepatotoxicity
Rapid hypersensitivity
Because metabolism of most medications takes place ● Rapid or immediate hypersensitivity (atopic allergy)
in the liver, the liver is particularly vulnerable to
occurs following inhalation, ingestion, injection, or
medication-induced injury. Damage to liver cells can
direct contact with an allergen. It includes allergies
impair medication metabolism and cause accumulation
to substances (iodine, latex, venom, nuts, and
in the body or alter results of liver function tests with no
medications).
obvious manifestations of liver dysfunction. ● apid hypersensiti ity results in acute in ammation,
NURSING ACTIONS histamine release, and vasoactive amines release
● When combining two or more medications that are (basophils, eosinophils, and mast cells).
hepatotoxic, the risk for liver damage increases. ● apid hypersensiti ity reactions can include super cial
● Liver function tests are essential when a client responses (hay fever, rhinosinusitis), and allergic
starts taking a hepatotoxic medication and asthma, anaphylaxis, and angioedema.
periodically thereafter.
Allergic asthma is the production of an asthma response
following exposure to an allergen.
Nephrotoxicity
Angioedema causes swelling of the deep tissues—usually
● Primarily the result of antimicrobial agents and NSAIDs
of the lips, face, and nec but can affect other parts
● Impaired kidney function can interfere with medication
of the body (the gastrointestinal system). Onset can be
e cretion, leading to accumulation and ad erse effects.
ithin the rst hr follo ing dosing, or can de elop
NURSING ACTIONS after long-term exposure. NSAIDs and ACE inhibitors are
● Aminoglycosides can cause kidney damage. the most common medication that can cause angioedema.
● Monitor blood creatinine and BUN levels of clients
taking nephrotoxic medications.
50.1 Over-the-counter medication interactions
Interactions Interactions
Ingredients in OTC medications NURSING INTERVENTIONS Interactions of some NURSING INTERVENTIONS
can interact with other OTC or Obtain a complete prescription and Advise clients to use caution
prescription medications. medication history. Include OTC medications and to check with their provider
Inactive ingredients (dyes, any prescription medications, can interfere with before using any OTC preparations
alcohol, and preservatives) can OTC medications, recreational therapeutic effects. (antacids, laxatives, decongestants,
cause adverse reactions. drugs, and herbal and other and cough syrups). For example,
The potential for toxicity exists with dietary supplements. antacids can interfere with the
the use of several preparations Instruct clients to follow absorption of cimetidine and
(including prescription medications) the manufacturer’s other medications. Tell clients to
that have similar ingredients. recommendations for take antacids 1 hr or more apart
dosage and to avoid taking from other medications, following
multiple OTC products with the timing recommendation
the same ingredients. for the specific medications.
308 CHAPTER 50 ADVERSE EFFECTS, INTERACTIONS, AND CONTRAINDICATIONS CONTENT MASTERY SERIES
Anaphylaxis is a rapid systemic reaction following an MEDICATION-MEDICATION
allergic response to an allergen. Common sources are INTERACTIONS
medications, dyes, foods, and insect bites and stings.
● Initial manifestations of anaphylaxis include GI Increased therapeutic effects
cramping and apprehension, with generalized itching
NURSING ACTIONS: Taking some medications together
and hives following, progressing to angioedema and
can increase their therapeutic effect. or e ample,
intensely large, itchy hives.
clients who have asthma inhale albuterol, a beta2
● espiratory manifestations follo ing in ammation and
adrenergic agonist, min prior to inhaling uticasone, a
mucous production include lung crackles, wheezing,
glucocorticoid, to increase the absorption of uticasone.
decreased breath sounds, a feeling of a lump in the
throat, hoarseness, and stridor. The client can develop
Increased adverse effects
respiratory failure and death.
● Cardiovascular manifestations include weak, thready NURSING ACTIONS: Taking two medications that have
pulse, tachycardia, and hypotension. the same ad erse effects together increases the ris of or
● Allergic asthma can have a similar progression orsens these ad erse effects. Dia epam and hydrocodone
following exposure to an allergen, and can become ith acetaminophen both ha e CN depressant effects.
life-threatening. The risk increases when clients take both concurrently.
NURSING ACTIONS
Decreased therapeutic effects
● Before administering any medications, obtain a
complete medication and allergy history. NURSING ACTIONS: One medication can increase the
● Administer diphenhydramine to treat mild rashes and metabolism of another medication and therefore decrease
hives, and to decrease angioedema and urticaria. the blood le el and effecti eness of that medication.
● Monitor closely if a client is receiving a medication Phenytoin increases hepatic medication-metabolizing
known to be highly allergenic. en ymes that affect arfarin and thereby decreases the
● Provide rapid intervention including epinephrine blood le el and the therapeutic effect of arfarin.
administration for severe allergic reaction to prevent
death. Notify the Rapid Response team if anaphylaxis Decreased adverse effects
is suspected.
NURSING ACTIONS: One medication can counteract the
● Remove or prevent further exposure to the allergen.
ad erse effects of another medication. ndansetron, an
● Treat anaphylaxis with epinephrine, bronchodilators,
antiemetic, counteracts the ad erse effects of nausea and
and antihistamines. Provide respiratory support and
vomiting that result from chemotherapy.
notify the provider.
Monitor ABGs and administer inhaled beta-adrenergic
Increased blood levels, leading to toxicity
●
agonists (albuterol). The client can require intubation or

a tracheostomy for severe manifestations. NURSING ACTIONS: One medication can decrease the
● Monitor hemodynamic status. The client usually metabolism of a second medication and therefore increase
experiences extensive vasodilation and capillary leak the serum level of the second medication and lead to
(tachycardia, weak pulse) toxicity. Fluconazole, an antifungal, inhibits hepatic
● Monitor the client frequently, as manifestations can medication metaboli ing en ymes that affect aripipra ole,
recur as treatment ears off. an antipsychotic, and thereby increases blood levels
of aripiprazole.
CLIENT EDUCATION
● Wear a medical alert bracelet or other device to make
others aware of the allergy.
● Keep injectable epinephrine available at all times.
Ensure you and someone close to you understand how to
use it properly.
Immunosuppression
A decreased or absent immune response
NURSING ACTIONS
● Glucocorticoids depress the immune response and
increase the risk for infection.
● Monitor for indications of infection.
MEDICATION-FOOD INTERACTIONS CONTRAINDICATIONS
Food can alter medication absorption and can contain
AND PRECAUTIONS
substances that react with some medications. ● Take extra precautions for clients who are at greater
risk for developing an adverse reaction to a medication.
Tyramine For example, morphine depresses respiratory function,
so clients who have asthma and respiratory dysfunction
Consuming foods that contain tyramine a ocados, gs,
require precautions with the use of morphine.
aged cheese, yeast extracts, beer, smoked meats) while ● Contraindications for speci c medications relate
taking monoamine oxidase inhibitors (MAOIs) can lead to
to clients’ physical status, health, and allergy
hypertensive crisis.
history. For example, an allergy to any medication
CLIENT EDUCATION: If taking an MAOI, avoid foods high is a contraindication for taking that medication.
in tyramine. Pregnancy or health conditions (kidney disease) are also
contraindications for many medications.
Vitamin K
itamin can decrease the therapeutic effects of arfarin PREGNANCY RISK CATEGORIES
and put clients at risk for developing blood clots.
The U.S. Food and Drug Administration (FDA) has assigned
CLIENT EDUCATION: If taking warfarin, maintain an categories to medications according to the risks they
inta e of dietary itamin to a oid sudden uctuations pose to a fetus. Although this classi cation system is
that could affect the action of arfarin. still in widespread use, a new labeling system is required
for medications that have received FDA approval since
Dairy mid-2015. New labeling requirements include outlining
the risks in three sections: pregnancy, lactation, and
Tetracycline can interact with a chelating agent (milk) to
females and males of reproductive potential. Medications
form an insoluble, unabsorbable compound.
approved prior to mid-2015 will be updated accordingly,
CLIENT EDUCATION: Take tetracycline at least 1 hr before and should be in compliance by 2020. The following are
or 2 hr after consuming any dairy products. Follow the previous pregnancy risk categories.
provider instructions for other medications that should
Category A: There is no evidence of risk to a fetus from
not be taken with dairy.
taking the medication during pregnancy, according to
adequate and well-controlled studies. Ferrous sulfate, an
Grapefruit
iron supplement, is a Category A medication.
Grapefruit juice seems to act by inhibiting presystemic
Category B: There is no evidence of risk to an animal
medication metabolism in the small bowel, thus
fetus according to studies, but there are no adequate and
increasing the absorption of some oral medications
well-controlled studies of pregnant women. Or, there is
(nifedipine) a calcium channel blocker. This combination
evidence of risk to an animal fetus, but controlled studies
can result in increased effects or intensi ed ad erse
of pregnant women show no evidence of risk to the fetus.
reactions.
Esomeprazole, an antiulcer medication, is in Category B.
CLIENT EDUCATION: Do not drink grapefruit juice or
Category C: tudies ha e demonstrated ad erse effects
consume grapefruit if ta ing a medication it affects.
on animal fetuses, but there are no adequate and
well-controlled studies of pregnant women. Or, there
Caffeine
have not been any studies of animals or pregnant women.
Theophylline, a methylxanthine for asthma control, and Glipizide, an antidiabetic medication, is in Category C.
caffeine can result in e cessi e CN e citation.
Category D: tudies ha e demonstrated ad erse effects on
CLIENT EDUCATION: Avoid consuming beverages human fetuses according to data from investigational or
containing caffeine if ta ing theophylline, or for other mar eting e perience, but potential bene ts from the use
medications as instructed by the provider. of the medication during pregnancy might warrant its use.
Sorafenib, an antineoplastic medication, is in Category D.
Antacids, vitamin C
Category X: tudies ha e demonstrated ad erse effects on
Taking aluminum-containing antacids with citrus animal and human fetuses, according to studies and data
beverages can result in excessive absorption of aluminum. from investigational or marketing experience. Pregnancy
is a contraindication for the use of the medication because
CLIENT EDUCATION: Avoid taking vitamin C supplements
the ris s out eigh the potential bene ts. stradiol, an
or drinking citrus juices at the same time as medications
estrogen replacement, is a Category X medication.
that contain aluminum.
1. A nurse is collecting data from a client who takes A nurse is reviewing the FDA’s pregnancy risk categories
haloperidol to treat schizophrenia. Which of the in an in-service presentation. Use the ATI Active Learning
following findings should the nurse document as Template: Basic Concept to complete this item.
extrapyramidal symptoms (EPSs)? (Select all that apply.)
RELATED CONTENT: Include the definition and an
A. Orthostatic hypotension example of each of the five pregnancy risk categories.
B. Tremors
C. Acute dystonia
D. Decreased level of consciousness
E. Restlessness
2. A nurse is teaching a client who has a new

prescription for oxybutynin about managing
the medication’s anticholinergic effects.
Which of the following instructions should
A. Take sips of water frequently.
B. Wear sunglasses when outdoors in sunlight.
C. Use a soft toothbrush when brushing teeth.
D. Take the medication with an antacid.
E. Urinate prior to taking the medication.
3. A nurse is reviewing a client’s medications. They

include cimetidine and imipramine. Knowing that
cimetidine decreases the metabolism of imipramine,
the nurse should identify that this combination is
likely to result in which of the following effects?
A. Decreased therapeutic effects of cimetidine
B. Increased risk of imipramine toxicity
C. Decreased risk of adverse effects of cimetidine
D. Increased therapeutic effects of imipramine
4. A nurse in an outpatient clinic is caring for

a client who has a new prescription for an
antihypertensive medication. Which of the following
instructions should the nurse give the client?
A. “Get up and change positions slowly.”
B. “Avoid eating aged cheese and smoked meat.”
C. “Report any usual bruising or bleeding
to the doctor immediately.”
D. “Eat the same amount of foods that
contain vitamin K every day.”
5. A nurse in an outpatient surgical center is admitting

a client for a laparoscopic procedure. The client
has a prescription for preoperative diazepam.
Prior to administering the medication, which of
the following actions is the nurse’s priority?
A. Teaching the client about the
purpose of the medication
B. Giving the medication at the administration
time the provider prescribed
C. Identifying the client’s medication allergies
D. Documenting the client’s anxiety level
1. A. Orthostatic hypotension is an adverse Using the ATI Active Learning Template: Basic Concept
effect, but it is not an EPS.
RELATED CONTENT
B. CORRECT: Tremors are an EPS. Others are rigidity,
drooling, agitation, and a shuffling gait.
●
Category A: There is no evidence of risk to a fetus from
C. CORRECT: Acute dystonia is an EPS. It includes spastic taking the medication during pregnancy, according to
movements of the back, neck, tongue, and face. adequate and well-controlled studies. Ferrous sulfate,
D. Decreased level of consciousness is an an iron supplement, is a Category A medication.
adverse effect, but it is not an EPS. ●
Category B: There is no evidence of risk to an animal fetus according
E. CORRECT: Restlessness is an EPS. Others are rigidity, to studies, but there are no adequate and well-controlled studies of
drooling, agitation, and a shuffling gait. pregnant women. Or, there is evidence of risk to an animal fetus, but
controlled studies of pregnant women show no evidence of risk to
the fetus. Esomeprazole, an antiulcer medication, is in Category B.
Adverse Effects/Contraindications/Side Effects/Interactions ●
Category C: Studies have demonstrated adverse effects
on animal fetuses, but there are no adequate and
2. A. CORRECT: Taking sips of water frequently will help well-controlled studies of pregnant women. Or, there
relieve the anticholinergic effect of dry mouth. have not been any studies of animals or pregnant women.
B. CORRECT: Wearing sunglasses will help relieve Glipizide, an antidiabetes medication, is in Category C.
the anticholinergic effect of photophobia. ●
Category D: Studies have demonstrated adverse effects
C. Anticholinergic effects do not increase the on human fetuses according to data from investigational or
client’s risk for bleeding. Constipation is an marketing experience, but potential benefits from the use
example of an anticholinergic effect. of the medication during pregnancy might warrant its use.
D. Taking the medication with an antacid will not Sorafenib, an antineoplastic medication, is in Category D.
decrease anticholinergic effects. Constipation is ●
Category X: Studies have demonstrated adverse effects on
an example of an anticholinergic effect. animal and human fetuses, according to studies and data
E. CORRECT: Urinating prior to taking the medication will help from investigational or marketing experience. Pregnancy
relieve the anticholinergic effect of urinary retention. is a contraindication for the use of the medication because
NCLEX® Connection: Pharmacological and Parenteral Therapies, the risks outweigh the potential benefits. Estradiol, an
Medication Administration estrogen replacement, is a Category X medication.
3. A. A medication that increases the metabolism
of another medication can decrease the
effectiveness of that medication.
B. CORRECT: A medication that decreases the metabolism
of another medication increases the blood level of
that medication, increasing the risk for toxicity.
C. A medication that decreases the metabolism of another
medication does not decrease the risk for adverse effects.
D. A medication that decreases the metabolism
of another medication does not increase that
medication’s therapeutic effects.
4. A. CORRECT: Antihypertensive medications can cause

orthostatic hypotension. Instruct the client to change
positions slowly and to sit or lie down when feeling
dizzy or lightheaded to prevent injury.
B. Consuming foods that contain tyramine (avocados,
figs, aged cheese, yeast extracts, beer, smoked
meats) while taking monoamine oxidase inhibitors, not
antihypertensives, can lead to hypertensive crisis.
C. Clients taking an anticoagulant, not an antihypertensive,
should report bruising, discolored urine or stool,
petechiae, bleeding gums, and any other manifestations
of bleeding to the provider immediately.
D. Clients taking anticoagulants, not antihypertensives,
should maintain a consistent intake of dietary
vitamin K to avoid sudden fluctuations that could
affect the action of the anticoagulant.
5. A. Teach the client about the purpose of the medication

to make sure the client understands why the provider
prescribed it. However, another action is the priority.
B. Administer the medication at the time the provider prescribed
that the client receive it to help prepare the client for the
surgical procedure. However, another action is the priority.
C. CORRECT: The greatest risk to this client is injury from
an allergic reaction. The priority action is to identify the
client’s allergies prior to medication administration.
D. Document the client’s anxiety level to have a baseline
against which to measure the effectiveness of the
medication. However, another action is the priority.
CHAPTER 51
UNIT 4 PHYSIOLOGICAL INTEGRITY Psychological factors: Emotional state and expectations
SECTION: PHARMACOLOGICAL AND PARENTERAL THERAPIES can in uence the effects of a medication. The placebo
effect describes positi e medication effects that
CHAPTER 51 Individual psychological factors, not biochemical properties of the
Considerations
medication, in uence.
Diet: Inade uate nutrition star ation can affect the
of Medication protein-binding response of medications. It increases
Administration
their response and thus increases the risk for
medication toxicity.
Medical problems
Inadequate gastric acid inhibits the absorption of
Various factors affect how clients respond to
●
medications that require an acid medium to dissolve.

medications. It is important for nurses to identify ● Diarrhea causes oral medications to pass through the
gastrointestinal tract too quickly for adequate absorption.
these factors to help them individualize nursing ● ascular insufficiency pre ents the distribution of a
care when administering medications. medication to affected tissue.
● Liver disease or failure impairs medication metabolism,
which can cause toxicity.
FACTORS AFFECTING MEDICATION ● Kidney disease or failure prevents or delays medication
DOSAGES AND RESPONSES excretion, which can cause toxicity.
● Prolonged gastric emptying time delays the absorption
Body weight: Because body tissues absorb medications,
of medications in the intestines.
individuals with a greater body mass require larger doses.
Because the percentage of body fat an individual has can
alter the distribution of a medication, basing dosages on
body surface area (BSA) can be a more precise method of
PHARMACOLOGY AND CHILDREN
regulating an individual’s response to a medication. Although most medications adults take are useful for
children, the dosages are different. Pro iders base
Age: Liver and kidney function are immature in young
pediatric dosages on body weight or BSA.
children and often decreased in older adults, which can ● Newborns and infants (2 days to 1 year old) have
cause heightened sensitivities to medications and thus
immature liver and kidney function, alkaline gastric
necessitate proportionately smaller medication doses.
juices, and an immature blood-brain barrier, making
Sex: Males and females can have varied responses to them especially sensiti e to medications that affect the
medications, including an increased therapeutic response CNS. Providers base some medication dosages on age
in some cases, or increased risk of harm in others. due to a greater risk for decreased skeletal bone growth,
acute cardiopulmonary failure, and hepatic toxicity.
Genetics: Genetic factors (missing enzymes) can alter the ● Be particularly alert when administering medications to
metabolism of certain medications, thus enhancing or
children due to the increased risk for
reducing a medication s action. The usual effect is either
medication errors.
fe er bene ts from the medication or greater medication ◯ Check that dosages are accurate for weight or BSA.
toxicity. ◯ Initial pediatric dosages are an approximation.
Biorhythmic cycles: Responses to some medications ◯ Be aware that most medications do not undergo
vary with the biologic rhythms of the body. For example, testing on children.
hypnotic medications work better when clients take them ◯ Some adult medication forms and concentrations
at their usual sleep time than at other times. require dilution, calculation, preparation, and
administration of very small doses for children.
Tolerance: Reduced responsiveness to a medication clients ◯ Limited sites exist for IV medication administration.
take over time (morphine) is pharmacodynamic tolerance. ◯ Give written and verbal instructions to parents to
Other medications (barbiturates) cause metabolic

promote adherence to medication regimens.
tolerance as metabolism of the medication increases over
time and the effecti eness of the medication declines. Additional pharmacokinetic factors specific to children
Cross-tolerance can occur with other chemically similar ● Decreased gastric acid production and slower gastric
medications. emptying time
● Decreased rst pass medication absorption due to
Accumulation: Medication concentration in the body
immaturity of the liver
increases due to the inability to metabolize or excrete a ● Increased absorption of topical medications (greater
medication rapidly enough, resulting in a toxic medication
blood o to the s in and thinner s in
effect. or older adults, decreased idney and li er ● Higher body water content (dilutes
function are the major causes of medication accumulation
water-soluble medications)
leading to toxicity. ● Decreased protein-binding sites in the blood (until age
1 year). This can result in an increase in the blood level
of protein-binding medications.
FUNDAMENTALS FOR NURSING CHAPTER 51 INDIVIDUAL CONSIDERATIONS OF MEDICATION ADMINISTRATION 313

PHARMACOLOGY AND PHARMACOLOGY:
OLDER ADULTS (65+ YEARS) PREGNANCY, LACTATION, AND
REPRODUCTIVE POTENTIAL
PHYSIOLOGIC CHANGES WITH AGING The U.S. Food and Drug Administration (FDA) has
THAT AFFECT PHARMACOKINETICS pre iously classi ed medications in e categories that
range from remote risk to proven risk of fetal harm. The
● Increased gastric pH (alkaline)
agency now requires labeling that details three risk
● Decreased gastrointestinal motility and gastric
sections: pregnancy, lactation, and females and males of
emptying time, resulting in a slower rate of absorption
reproductive potential.
● Decreased blood o through the cardio ascular system,
liver, kidneys
● Decreased hepatic enzyme function PREGNANCY
● Decreased idney function and glomerular ltration rate ● Most medications are potentially harmful to the
● Decreased protein-binding sites, resulting in lower
fetus. Prescribers must eigh the bene ts of maternal
blood albumin levels
medication administration against possible fetal risk.
● Decreased body water, increased body fat, decreased ● Medications taken during pregnancy include nutritional
lean body mass
supplements (iron, vitamins, minerals) and medications
the provider prescribes to treat nausea, vomiting,
OTHER FACTORS AFFECTING gastric acidity, and mild discomforts.
MEDICATION THERAPY ● Providers manage chronic medical disorders (diabetes
mellitus and hypertension) in conjunction with careful
● Impaired memory or altered mental state
maternal-fetal monitoring.
● Multiple or severe illnesses ● Pregnancy is a contraindication for live-virus vaccines
● Changes in vision and hearing
(measles, mumps, rubella, varicella, yellow fever).
● Decreased mobility and dexterity
● Poor adherence
● Inadequate supervision of long-term therapy LACTATION
● Limited nancial resources ● Most medications taken during lactation enter
● Polypharmacy: The practice of taking several
breast milk. Clients who are lactating should avoid
medications simultaneously (prescription,
medications that have an extended half-life, are
over-the-counter [OTC], herbal, and recreational) with
sustained-release, or are harmful to infants.
diminished bodily functions and some medical problems ● For medications that are safe, administer them
can contribute to the potential for medication toxicity.
immediately after breastfeeding to minimize the
medication’s concentration in the next feeding. Use the
NURSING INTERVENTIONS lo est effecti e dosage for the shortest possible time.
Decreasing the risk of adverse medication effects

● Obtain a complete medication history and include any REPRODUCTIVE POTENTIAL
prescription medications, OTC medications, recreational ● Some medications include special considerations for clients
drugs, and herbal supplements.
of reproductive potential to reduce the risk of fetal harm
● Make sure medication therapy starts at the lowest
and to preserve reproductive ability, if desired.
possible dose. ● ther medications can affect hormone le els that
● Assess and monitor for therapeutic and ad erse effects.
affect reproduction and lead to infertility. This can be a

● Monitor plasma medication levels to provide a rational
desired or undesired effect for the client.
basis for dosage adjustment. ● peci c inter entions can include pregnancy testing
● Assess and monitor for medication-medication and
before and during medication therapy, and beginning or

medication-food interactions.
altering contraceptive use.
● Document ndings. ● nsure the client understands the effect of prescribed
● Notify the pro ider of ad erse effects.
medications on reproductive potential, and understands
Promoting adherence any speci c actions to ta e during medication use.
● Give clear and concise instructions, verbally and in writing.
● Ensure that the dosage form is appropriate.
Administer liquid forms to clients who have
difficulty s allo ing.
● Provide clearly-marked containers that are easy to open.
● Assist the client with setting up a daily calendar and
using pill containers.

● Discuss the availability of and access to local resources
for obtaining and paying for medications.
● Suggest that the client obtain assistance from a friend,
neighbor, or relative.
314 CHAPTER 51 INDIVIDUAL CONSIDERATIONS OF MEDICATION ADMINISTRATION CONTENT MASTERY SERIES

1. To promote adherence with medication A nurse is preparing to administer medications to a

self-administration, a nurse is making client who has vascular insufficiency and impaired
recommendations for an older adult client. kidney function. Use the ATI Active Learning
Which of the following instructions should Template: Basic Concept to complete this item.
A. Adjust dosages according to daily weight.
●
Discuss medication considerations with vascular insufficiency.
B. Place pills in daily pill holders.
●
Discuss medication considerations with
C. Ask for liquid forms if the client has impaired kidney function.
difficulty swallowing pills.
●
Identify at least four physiologic changes with
D. Ask a relative to assist periodically. aging that affect pharmacokinetics.
E. Request child-resistant caps on
NURSING INTERVENTIONS: Identify at least three
medication containers.
interventions for reducing the risk for adverse effects.
2. A client in a provider’s office tells the nurse that “I fast

for several days each week to help control my weight.”
The client takes several medications for various
chronic issues. The nurse should explain to the client
that which of the following mechanisms that results
from fasting puts her at risk for medication toxicity?
A. Increasing the metabolism of the
medications over time
B. Increasing the protein-binding response
C. Increasing medications’ transit
time through the intestines
D. Decreasing the excretion of medications
3. A nurse is preparing medications for a preschooler.

Which of the following factors should the
nurse identify as altering how a medication
affects children? (Select all that apply.)
A. Increased gastric acid production
B. Immature liver
C. Higher body water content
D. Increased absorption of topical medications
E. Increased gastric emptying time
4. A nurse is teaching a client who is lactating

about taking medications. Which of the following
actions should the nurse recommend to minimize
in the entry of medication into breast milk?
A. Drink 8 oz of milk with each dose of medication.
B. Use medications that have an extended half-life.
C. Take each dose right after breastfeeding.
D. Pump breast milk and freeze it prior
to feeding to the newborn.
5. A nurse in an outpatient clinic is teaching a client

who is in the first trimester of pregnancy. Which of
the following statements should the nurse make?
A. “You will need to get a rubella immunization
if you haven’t had one prior to pregnancy.”
B. “You can safely take over-the-counter medications.”
C. “You should avoid any vitamin
preparations containing iron.”
D. “Your provider can prescribe medication
for nausea if you need it.”
FUNDAMENTALS FOR NURSING CHAPTER 51 INDIVIDUAL CONSIDERATIONS OF MEDICATION ADMINISTRATION 315

1. A. The provider adjusts the client’s dosages. Instructing Using the ATI Active Learning Template: Basic Concept
the client to base dosages on daily weight increases the UNDERLYING PRINCIPLES
risk for error in medication self-administration. ●
Vascular insufficiency prevents distribution of a medication to
B. CORRECT: Organizing medications in daily pill
affected tissue. The nurse should document and monitor for the
holders promotes medication adherence.
medication’s effectiveness and report concerns to the provider.
C. CORRECT: Providing a form of medication that is easier for
the client to swallow promotes medication adherence.
●
Impaired kidney function prevents or delays medication excretion,
D. CORRECT: Including the client’s support system which increases the risk for toxicity. Decreased kidney function is
promotes medication adherence. a major cause of medication accumulation leading to toxicity.
E. Some older adult clients have difficulty opening child-resistant
●
Physiologic changes
caps. Request easy-open containers from the pharmacy. Increased gastric pH (alkaline)
◯
NCLEX® Connection: Pharmacological and Parenteral Therapies, Decreased gastrointestinal motility and gastric emptying
◯
Medication Administration time, resulting in a slower rate of absorption

Decreased blood flow through the
◯
cardiovascular system, liver, kidneys

2. A. Some medications, not fasting, cause metabolic tolerance Decreased hepatic enzyme function
◯
as metabolism of the medication increases over time and Decreased kidney function and glomerular filtration rate
◯
the effectiveness of the medication declines. Decreased protein-binding sites, resulting in lower albumin levels
◯
B. CORRECT: Inadequate nutrition (starvation) can affect the Decreased body water, increased body
◯
protein-binding response of medications. It increases their fat, decreased lean body mass
response and thus increases the risk for medication toxicity.
Impaired memory or altered mental state
◯
C. Disorders that cause diarrhea, not fasting, cause oral

medications to pass through the gastrointestinal Multiple or severe illnesses
◯
tract too quickly for adequate absorption. This Changes in vision and hearing
◯
mechanism does not cause toxicity. Decreased mobility and dexterity

◯
D. Kidney disease or failure, not fasting, prevents or delays NURSING INTERVENTIONS

medication excretion, which can cause toxicity. ●
Obtain a complete medication history and include
NCLEX® Connection: Physiological Adaptation, Pathophysiology any prescription medications, OTC medications,
recreational drugs, and herbal supplements.
●
Make sure medication therapy starts at the lowest possible dose.
3. A. Children have decreased gastric acid production. ●
Assess and monitor for therapeutic and adverse effects.
B. CORRECT: Children have an immature liver,
which means a reduction in first-pass elimination
●
Monitor plasma medication levels to provide a
during medication absorption. rational basis for dosage adjustment.
C. CORRECT: Children have a higher body water content,
●
Assess and monitor for medication-medication
which helps dilute water-soluble medications. and medication-food interactions.
D. CORRECT: Children have increased absorption ●
Document findings.
of topical medications, due to greater blood ●
Notify the provider of adverse effects.
flow to the skin and thinner skin.
NCLEX® Connection: Physiological Adaptation, Illness
E. Children have a slower gastric emptying time.
Management
®
4. A. The intake of food or fluid with medication does not

affect the entry of medications into breast milk.
B. The client should avoid medications that have an extended
half-life due to their increased entry into breast milk.
C. CORRECT: Taking medication immediately
after breastfeeding helps minimize medication
concentration in the next feeding.
D. Pumping and freezing breast milk does not affect
the entry of medications into breast milk.
5. A. Pregnancy is a contraindication for live-virus vaccines,

including rubella, due to possible teratogenic effects.
B. Most medications, including over-the-counter, are
potentially harmful to the fetus. The client should avoid
any medications unless her provider prescribes them.
C. Nutritional supplements that include iron are
common recommendations during pregnancy to
support the health of the mother and fetus.
D. CORRECT: Providers can prescribe medications to
treat nausea and other discomforts of pregnancy.
316 CHAPTER 51 INDIVIDUAL CONSIDERATIONS OF MEDICATION ADMINISTRATION CONTENT MASTERY SERIES

NCLEX® Connections
Client Needs: Basic Care and Comfort

NUTRITION AND ORAL HYDRATION: Provide
client nutrition through tube feedings.
Client Needs: Reduction of Risk Potential

DIAGNOSTIC TESTS: Perform diagnostic testing.

TREATMENTS/PROCEDURES: Position the client to prevent
complications following tests/treatments/procedures.
THERAPEUTIC PROCEDURES: Educate client

about home management of care.
Client Needs: Physiological Adaptation

ALTERATIONS IN BODY SYSTEMS: Provide pulmonary hygiene.
FLUID AND ELECTROLYTE IMBALANCES: Identify signs

and symptoms of client uid and or electrolyte imbalance.
ILLNESS MANAGEMENT: Manage the care of a

client with impaired ventilation/oxygenation.

CHAPTER 52
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: REDUCTION OF RISK POTENTIAL
Blood glucose testing
For blood glucose testing, clients who have diabetes
CHAPTER 52 Specimen Collection mellitus use a glucometer or a blood glucose meter with
for Glucose
small test strips to “read” the blood sample. These
systems require proper calibration, storage of supplies,
Monitoring and matching of lot numbers.
INDICATIONS
Monitoring blood glucose levels is an essential Regular testing is necessary for clients who have diabetes
component in the care of clients who have mellitus to manage the disease by maintaining safe blood
glucose levels.
diabetes mellitus. Blood glucose testing is the
preferred method of monitoring blood
glucose levels. Other conditions that require CONSIDERATIONS
monitoring of blood glucose levels include
PREPROCEDURE
pancreatitis, Cushing syndrome, hypothyroidism, NURSING ACTIONS
liver disease, receiving enteral or parenteral ● Check the client’s record and prescription.
◯ Frequency and type of test: Testing times vary based
nutrition, or taking corticosteroids. on the goals of management and the complexity of

the client’s hypoglycemic medication schedule.
Urine testing is not an effective measure of ◯ Results from previous tests: norms and ranges
glucose level because glucose levels must be ◯ Actions according to results
e ie the client s medication pro le.

greater than 220 mg/dL before glucose appears
●
◯ Note anticoagulant usage, history of bleeding
in the urine. disorders, and low platelet count.

◯ Note the times and dose of hypoglycemic agents.
Clients who are able and willing to monitor ◯ Note the use of corticosteroids, oral contraceptives,
beta blockers, antipsychotics, and other medications

independently can learn how to self-monitor that can elevate blood glucose levels.
blood glucose levels. Required abilities include ● Gather materials, and prepare the equipment.
◯ Blood glucose meter
alertness, the ability to comprehend and give a ◯ Reagent strip compatible with the meter
return demonstration of the process, adequate ◯ Washcloth and soap or antiseptic swab
Clean gloves
finger dexterity, and adequate visual acuity.
◯
◯ Sterile lancet
◯ Cotton ball
● Review the meter and the manufacturer’s instructions.
● Check the strip solution’s expiration date.
● Some meters require calibration; others require zeroing
of the timer. No-code models require no calibration
because the calibration is integrated into the test strips.
Follow the manufacturer’s directions.
● Explain the procedure to the client.
● Evaluate the selected puncture site.
◯ Integrity of the skin (to avoid areas of bruising,
open lesions)
◯ Compromised circulation
● Perform hand hygiene and put on gloves.
FUNDAMENTALS FOR NURSING CHAPTER 52 SPECIMEN COLLECTION FOR GLUCOSE MONITORING 319
INTRAPROCEDURE Urine glucose testing
NURSING ACTIONS
● Select a site from which to collect the blood sample. INDICATIONS
◯ uter edge of a ngertip most common site ● Routine urinalysis includes testing for glucose, which
◯ Alternate site (earlobe, heel, palm, arm, thigh)
is useful in monitoring treatment of diabetes mellitus.

● Rotate sites to avoid ongoing tenderness.
Checks for glucose in the urine (glucosuria) are often
● Wrap the site in a warm, moist towel to enhance
scheduled before meals and at bedtime.
circulation, especially hen it has been difficult to ● For clients who do not have diabetes mellitus,
obtain an adequate sample.
glucosuria can indicate conditions (gestational diabetes,
● Cleanse the site with warm water and soap or an
impaired kidney absorption of glucose, and increased
antiseptic swab (not alcohol), and allow it to dry.
intracranial pressure).
Alcohol can interfere with results.
● Hold the nger in a dependent position before
puncturing to impro e blood o . CONSIDERATIONS
● Pierce the skin using a sterile lancet (or a lancet injector
device) and holding it perpendicular to the skin. PREPROCEDURE
● ipe a ay the rst drop of blood ith a cotton ball.
NURSING ACTIONS
● Place a drop of blood on the test strip. ● Assess the client’s ability to urinate.
◯ Follow the manufacturer’s procedure for applying
● Verify the prescription for frequency and actions to take
blood to the strip.
based on the results.
◯ If necessary, gently mil the nger to obtain a ● Gather materials, and prepare the equipment.
drop. (Forceful milking or squeezing can cause pain, ◯ Clean urine specimen cup
bruising, and scarring.) Do not touch the site directly ◯ Chemical reagent strips, container with glucose
to stimulate bleeding.
reading scale
◯ Hold the test strip ne t to the blood on the ngertip. ◯ Clean gloves
◯ Do not smear blood onto the strip because this can
◯ Towelette or soap and washcloth
cause an inaccurate reading. ● Check the strip’s expiration date.

◯ Allow the meter to process the reading. (Time varies
● Explain the procedure.
with the meter.) ● Perform hand hygiene, and put on clean gloves.
◯ Apply a cotton ball over the puncture site.
● Use fresh urine for the test. (Urine that has been in the
◯ Note the reading turn off the meter and dispose
bladder several hours will not provide accurate results.)
of the cotton ball, test strip, lancet, and gloves in
Have the client void and discard urine 30 to 40 min prior
proper receptacles.
to testing.
POSTPROCEDURE INTRAPROCEDURE
NURSING ACTIONS
NURSING ACTIONS
● Perform hand hygiene. ● Assist the client with urine sample collection at the time
● Document the meter’s reading.
of testing.
● Check the prescription for medication or treatment ● Dip the reagent strip into the urine sample and gently
actions, and implement them.
sha e off e cess urine.
● Compare the strip’s color change with the ranges on
the container within the instructed time (usually 1 to
INTERPRETATION OF FINDINGS 5 seconds).
● Usually, a casual (random) blood glucose level greater
than 200 mg/dL indicates hyperglycemia. A casual POSTPROCEDURE
blood glucose level is obtained at any time, regardless of
NURSING ACTIONS
caloric intake. ● Dispose of the remaining urine sample, test strip,
● Usually, a blood glucose level less than 70 mg/dL
and gloves.
indicates hypoglycemia. ● Perform hand hygiene.
● Poor storage of glucose test strips can lead to falsely ● Check the prescription for medication or treatment
high or low readings. Typically, these test strips
actions, and implement.
come in a vial to store at room temperature or as the
manufacturer directs.
INTERPRETATION OF FINDINGS
● The e pected nding is no glucose in the
urine. Glycosuria can occur after eating a
high-carbohydrate meal.
● Record or report the presence of glucose in the urine.
Determine whether further testing is needed (checking
urine for ketones).
320 CHAPTER 52 SPECIMEN COLLECTION FOR GLUCOSE MONITORING CONTENT MASTERY SERIES
1. A nurse is reviewing the medical record of a client who A nurse is teaching a group of newly licensed nurses how to
has a blood glucose of 260 mg/dL and no documented perform urine glucose testing. Use the ATI Active Learning
history of diabetes mellitus. Which of the following Template: Diagnostic Procedure to complete this item.
types of medications can cause hyperglycemia
NURSING INTERVENTIONS: List the steps of the procedure
as an adverse effect? (Select all that apply.)
in the three phases (pre-, intra-, post-procedure).
A. Diuretics
B. Corticosteroids
C. Oral anticoagulants
D. Opioid analgesics
E. Antipsychotics
2. A nurse teaching a client how to check blood

glucose levels. The nurse should include which
of the following instructions about transferring
blood onto the reagent portion of the test strip?
A. Smear the blood onto the strip.
B. Squeeze the blood onto the strip.
C. Touch the puncture to stimulate bleeding.
D. Hold the test strip next to the
blood on the fingertip.
3. A nurse attempting to collect a capillary blood

specimen via finger stick for blood glucose
monitoring is unable to obtain an adequate
drop of blood for the reagent strip. Which of the
A. Puncture another finger to obtain
a capillary specimen.
B. Test the urine with a urine reagent strip.
C. Wrap the hand in a warm, moist cloth.
D. Perform a venipuncture to obtain a venous sample.
4. A nurse is teaching self-monitoring of blood

glucose (SMBG) to a client who has diabetes
mellitus. Which of the following instructions
A. Perform SMBG once daily at bedtime.
B. Wipe the hand with an alcohol swab.
C. Hold the hand in a dependent
position prior to the puncture.
D. Place the puncturing device
perpendicular to the site.
E. Prick the outer edge of the fingertip
for the blood sample.
FUNDAMENTALS FOR NURSING CHAPTER 52 SPECIMEN COLLECTION FOR GLUCOSE MONITORING 321
1. A. CORRECT: Diuretics can cause hyperglycemia, Using the ATI Active Learning Template: Diagnostic Procedure
especially in clients who have diabetes mellitus, and
also can cause many electrolyte imbalances.
B. CORRECT: Corticosteroids can cause Preprocedure
hyperglycemia and glycosuria. ●
Evaluate the client’s ability to urinate. Have the client urinate
C. Anticoagulants can cause excessive bleeding 30 to 40 min prior to testing, and discard that urine.
during blood sampling for glucose testing. ●
Verify the prescription for frequency and
D. Opioid analgesics cause many adverse effects, actions to take based on the results.
including respiratory depression, but they are ●
Gather materials and prepare equipment: urine specimen cup,
unlikely to raise blood glucose levels. chemical reagent strips, container with the glucose reading
E. CORRECT: Antipsychotics, particularly atypical scale, clean gloves, towelette or soap, and washcloth.
antipsychotics, can cause new-onset diabetes mellitus. ●
Check the strip’s expiration date.
Explain the procedure.
Adverse Effects/Contraindications/Side Effects/Interactions ●
Perform hand hygiene, and put on clean gloves.
Intraprocedure
2. A. Smearing the blood on the test strip can ●
Assist the client to provide a fresh urine sample.
cause inaccurate results. ●
Dip the reagent strip into the urine sample.
B. The client should milk the finger gently to obtain ●
Compare the strip’s color change with the ranges on the
a drop of blood. Forceful milking or squeezing container within the instructed time (usually 1 to 5 seconds).
can cause pain, bruising, and scarring.
C. Touching the puncture site can cause transfer Postprocedure
of micro-organisms to the site. ●
Dispose of the remaining urine sample, test strip, and gloves.
D. CORRECT: Holding the pad of the strip next to the puncture ●
Perform hand hygiene.
allows the blood to flow until the amount on the strip is ●
Check the prescription for medication or
adequate. Too little blood can result in falsely low readings. treatment actions, and implement.
NCLEX® Connection: Reduction of Risk Potential, NCLEX® Connection: Reduction of Risk Potential, Therapeutic
Therapeutic Procedures Procedures
3. A. Another finger can be punctured to obtain a capillary

specimen. However, use a less invasive intervention first.
B. A urine glucose can be obtained. However, the
client’s blood glucose level should be significantly
elevated in order to detect glucose in the urine.
Use a less invasive intervention first.
C. CORRECT: When providing client care, first use
the least invasive intervention. Warm the client’s
finger with a warm, moist cloth to promote blood
flow in preparation for the next finger stick.
D. A venipuncture might need to be requested
for checking the blood glucose level. However,
use a less invasive intervention first.
4. A. Clients usually perform SMBG as often as before each meal

and at bedtime. Generally, the timing and frequency of SMBG
testing correlates with the client’s medication schedule.
Monitoring once a day at bedtime does not provide enough
information to monitor blood glucose control effectively.
B. The client should wash the hand with warm water and
soap. Alcohol can alter the blood glucose reading.
C. CORRECT: The client should hold the hand in a dependent
position to increase blood flow to the fingers.
D. CORRECT: The client should hold the lancet perpendicular
to the skin to ensure the correct piercing depth.
E. CORRECT: The client should use the outer edge
of the fingertip for blood sampling. The client
can also use a heel, palm, arm, or thigh.
322 CHAPTER 52 SPECIMEN COLLECTION FOR GLUCOSE MONITORING CONTENT MASTERY SERIES
CHAPTER 53
SECTION: REDUCTION OF RISK POTENTIAL
Pulse oximetry
Noninvasive measurement of the oxygen saturation of the
CHAPTER 53 Airway Management blood for monitoring respiratory status when assessment
ndings include any of the follo ing.
● Increased work of breathing
Wheezing
Managing airway compromise includes
●
● Coughing
respiratory assessment and measuring vital ● Cyanosis
Changes in respiratory rate or rhythm
signs, including oxygen saturation via pulse
●
● Adventitious breath sounds
oximetry and administration of oxygen. ● Restlessness, irritability, confusion

● Dyspnea
Oxygen helps maintain adequate cellular ● Orthopnea
oxygenation for clients who have many

acute and chronic respiratory problems CONSIDERATIONS
(bronchitis, cystic fibrosis, asthma) or are at INTERVENTIONS FOR READINGS LESS THAN 90%
(INDICATING HYPOXEMIA)
risk for developing hypoxia (respiratory illness, ● Con rm probe placement.
circulatory impairment). ● Con rm that the o ygen deli ery system is functioning
and that the client is receiving the prescribed
Maintaining a patent airway is a nursing priority. oxygen levels.
Place the client in semi-Fowler’s or Fowler’s position to
It involves mobilizing secretions, suctioning
●
promote chest expansion and to maximize

the airway, and managing artificial airways ventilation.
Encourage deep breathing.
(endotracheal tubes, tracheostomy tubes)
●
● Remain with the client and provide emotional support

to promote adequate gas exchange and to decrease anxiety.
lung expansion.
INTERPRETATION OF FINDINGS
The expected reference range is 95% to 100%.
Pulse oximetry and

●
Acceptable levels range from 91% to 100%. Some illness
oxygen therapy
states can allow for 85% to 89%. Readings less than
re ect hypo emia.
● Values can be slightly lower for older adult clients and
clients who have dark skin.
● A pulse oximeter is a device with a sensor probe that ● Additional reasons for low readings include
attaches securely to the ngertip, toe, bridge of nose,
hypothermia, poor peripheral blood o , too much light
earlobe, or forehead with a clip or band.
(sun, infrared lamps), low hemoglobin levels, jaundice,
● A pulse oximeter measures pulse saturation (SpO2) via
movement, edema, metal studs in nails, and nail polish.
a wave of infrared light that measures light absorption
by oxygenated and deoxygenated hemoglobin in arterial
blood. SpO2 reliably re ects the percent of saturation of
hemoglobin (SaO2) when the SaO2 is greater than 70%.
● Oxygen is a tasteless and colorless gas that accounts for
21% of atmospheric air.
● ygen o rates ary to maintain an p 2 of 95% to
100% using the lowest amount of oxygen to achieve the
goal without risking complications.
● The fraction of inspired oxygen (FiO2) is the percentage
of oxygen the client receives.
FUNDAMENTALS FOR NURSING CHAPTER 53 AIRWAY MANAGEMENT 323

Oxygen therapy LOW-FLOW OXYGEN DELIVERY SYSTEMS
Oxygen is a therapeutic gas that treats hypoxemia (low Nasal cannula
levels of arterial oxygen). Administering and adjusting it
Tubing with two small prongs for insertion into the nares
requires a prescription.
FRACTION OF INSPIRED OXYGEN: Delivers an FiO2 of 24%
to at a o rate of to L min.
INDICATIONS
ADVANTAGES
MANIFESTATIONS OF HYPOXIA ● A cannula is a safe, simple, and easy-to-apply method.
● A cannula is comfortable and well-tolerated.
EARLY ● The client is able to eat, talk, and ambulate.
● Tachypnea
● Tachycardia DISADVANTAGES
● Restlessness, anxiety, confusion ● The FiO2 aries ith the o rate, and the rate and
● Pale skin, mucous membranes depth of the client’s breathing.
● Elevated blood pressure ● Extended use can lead to skin breakdown and dry
● se of accessory muscles, nasal aring, ad entitious mucous membranes.
lung sounds ● Tubing is easily dislodged.
LATE NURSING ACTIONS

● Stupor ● Assess the patency of the nares.
● Cyanotic skin, mucous membranes ● nsure that the prongs t in the nares properly.
● Bradypnea ● Use water-soluble gel to prevent dry nares.
● Bradycardia ● Pro ide humidi cation for o rates of L min
● Hypotension and greater.
● Cardiac dysrhythmias
Simple face mask
CONSIDERATIONS Covers the client’s nose and mouth
NURSING ACTIONS FRACTION OF INSPIRED OXYGEN

● Monitor respiratory rate and pattern, level of ● It delivers an FiO2 of to at o rates of
consciousness, SpO2, and arterial blood gases (ABGs). to 12 L/min.
● Pro ide o ygen therapy at the lo est liter o that ill ● The minimum o rate is L min to ensure ushing of
correct hypoxia. CO2 from the mask.
● Make sure the mask creates a secure seal over the nose
ADVANTAGES
and mouth. ● A face mask is easy to apply and can be more
● Assess/monitor hypoxia and hypercarbia (elevated levels
comfortable than a nasal cannula.
of CO2): restlessness, hypertension, and headache. ● It is a simple delivery method.
● Auscultate the lungs for breath sounds and adventitious ● It is more comfortable than a nasal cannula.
sounds (crackles and wheezes). ● It pro ides humidi ed o ygen.
● Assess/monitor oxygenation status with pulse
oximetry and ABGs. DISADVANTAGES
● Promote oral hygiene. ● Flow rates less than 6 L/min can result in
● Encourage turning, coughing, deep breathing, and the rebreathing of CO2.
use of incentive spirometry and suctioning. ● Clients who have anxiety or claustrophobia do not
● Promote rest and decrease environmental stimuli. tolerate it well.
● Provide emotional support. ● Eating, drinking, and talking are impaired.
● Assess nutritional status. Provide supplements. ● Moisture and pressure can collect under the mask and
● Assess skin integrity. Provide moisture and cause skin breakdown.
pressure-relief devices. ● Face masks pose a greater risk of aspiration.
● Assess and document the response to oxygen therapy.
NURSING ACTIONS
● Titrate oxygen to maintain the recommended ● Assess proper t to ensure a secure seal o er the nose
oxygen saturation.
and mouth.
● Discontinue supplemental oxygen gradually. ● Make sure the client wears a nasal cannula during meals.
● Monitor for respiratory depression (decreased respiratory ● Use with caution for clients who have a high risk of
rate and level of consciousness).
aspiration or airway obstruction.
● Lo o o ygen deli ery systems deli er arying ● Monitor for skin breakdown.
amounts of oxygen based on the delivery method and the
client’s breathing pattern.
324 CHAPTER 53 AIRWAY MANAGEMENT CONTENT MASTERY SERIES

Partial rebreather mask
53.1 Nasal cannula 53.2 Simple face mask
Covers the client’s nose and mouth
FRACTION OF INSPIRED OXYGEN:

Delivers an FiO2 of to at o
rates of 6 to 11 L/min.
ADVANTAGES: The mask has a reservoir

bag attached with no valve, which allows
the client to rebreathe up to of e haled
air together with room air. It also allows
easier humidi cation of o ygen.
DISADVANTAGES
● Complete de ation of the reser oir bag
during inspiration causes CO2 buildup.
● The FiO2 varies with the client’s
breathing pattern.
● Clients who have anxiety or
claustrophobia do not tolerate it well.
● Eating, drinking, and talking
are impaired.
● The bag can twist or kink easily.
NURSING ACTIONS
● eep the reser oir bag from de ating by ad usting the HIGH-FLOW OXYGEN DELIVERY SYSTEMS
o ygen o rate to eep the reser oir bag to full
on inspiration. Venturi mask
● Assess proper t to ensure a secure seal o er nose and
Covers the client’s nose and mouth
mouth. Assess for skin breakdown beneath the edges of
the mask and bridge of the nose. FRACTION OF INSPIRED OXYGEN: Delivers an FiO2 of 24% to
● Make sure the client uses a nasal cannula during meals. at o rates of to L min ia different si e adapters,
● Use with caution for clients who have a high risk of hich allo s speci c amounts of air to mi ith o ygen.
ADVANTAGES
It delivers the most precise oxygen concentration with
Non-rebreather mask
●
humidity added.
Covers the client’s nose and mouth ● Best for clients who have chronic lung disease.
FRACTION OF INSPIRED OXYGEN: Delivers an FiO2 of 80% DISADVANTAGES

to at o rates of to L min to eep the reser oir ● Use is expensive.
bag full during inspiration and e piration. ● Eating, drinking, and talking are impaired.
● The mask and added humidity can lead to
ADVANTAGES
skin breakdown.
● It delivers the highest O2 concentration possible (except
for intubation). NURSING ACTIONS
● A one-way valve situated between the mask and reservoir ● Assess fre uently to ensure an accurate o rate.
allows the client to inhale maximum O2 from the reservoir ● Assess proper t to ensure a secure seal o er the nose
bag. The t o e halation ports ha e aps co ering them and mouth. Assess for skin breakdown beneath the
that prevent room air from entering the mask. edges of the mask, particularly on the nares.
● Make sure the tubing is free of kinks.
DISADVANTAGES ● Ensure that the client wears a nasal cannula during meals.
● The al e and ap on the mas must be intact and
functional during each breath.
Aerosol mask
● It is poorly tolerated by clients who have anxiety
or claustrophobia. Face tent: ts loosely around the face and nec
● Eating, drinking, and talking are impaired.
Tracheostomy collar: a small mask that covers the
● Use with caution for clients who have a high risk of
surgically created opening of the trachea
FRACTION OF INSPIRED OXYGEN
NURSING ACTIONS ● Delivers an FiO2 of to at o rates of at
● Perform an hourly assessment of the al e and ap.
least 10 L/min.
● Assess proper t to ensure a secure seal o er the nose ● Pro ides high humidi cation ith o ygen deli ery.
and mouth. Assess for skin breakdown beneath the
edges of the mask and bridge of nose.
● Make sure the client uses a nasal cannula during meals.

ADVANTAGES Oxygen-induced hypoventilation
● Use with clients who do not tolerate masks well.
Clients who have conditions that cause alveolar
● Useful for clients who have facial trauma, burns, and
hypoventilation can be sensitive to the administration
thick secretions.
of oxygen.
DISADVANTAGES: High humidi cation re uires
NURSING ACTIONS
frequent monitoring. ● Monitor respiratory rate and pattern, level of
NURSING ACTIONS consciousness, behavior, and SpO2.
● Empty condensation from the tubing often. ● Pro ide o ygen therapy at the lo est liter o rate that
● nsure ade uate ater in the humidi cation canister. manages hypoxemia.
● Ensure that the aerosol mist leaves from the vents ● If the client tolerates it, use a Venturi mask to deliver
during inspiration and expiration precise oxygen levels.
● Make sure the tubing does not pull on the tracheostomy. ● Notify the provider of impending respiratory depression
(a decreased respiratory rate and a decreased level of
consciousness).
COMPLICATIONS
Combustion
Oxygen toxicity
Oxygen is combustible.
Oxygen toxicity can result from high concentrations of
NURSING ACTIONS
oxygen (typically greater than 50%), long durations of ● Post “No Smoking” or “Oxygen in Use” signs to alert
oxygen therapy (typically more than 24 to 48 hr), and the
others of the re ha ard.
severity of lung disease. ● no here to nd the closest re e tinguisher.
MANIFESTATIONS: Nonproductive cough, substernal ● ducate about the re ha ard of smo ing ith
pain, nausea, vomiting, fatigue, dyspnea, restlessness, oxygen use.
paresthesias ● Have clients wear a cotton gown because synthetic or
wool fabrics can generate static electricity.
NURSING ACTIONS ● Ensure that all electric devices (razors, hearing aids,
● Use the lowest level of oxygen necessary to maintain an
radios) are working well.
adequate SpO2. ● Make sure all electric machinery (monitors, suction
● Monitor ABGs and notify the provider if SpO2 levels are
machines) is grounded.
outside the expected reference range. ● Do not use olatile, ammable materials alcohol,
● Decrease the FiO2 as the client’s SpO2 improves.
acetone) near clients receiving oxygen.
53.3 Non-rebreather mask 53.4 Venturi mask 53.5 Face tent

Specimen collection Sputum specimen collection
and airway clearance Collection of sputum for analysis
Mucosal secretion buildup or aspiration of emesis can INDICATIONS

obstruct a client’s airway. ● For cytology to identify aberrant cells or cancer
● Adequate hydration and coughing help the client
● For culture and sensitivity to grow and identify
maintain airway patency.
micro organisms and the antibiotics effecti e
● Nursing interventions that mobilize secretions and
against them
maintain airway patency include assistance with ● To identify acid-fast bacilli (AFB) to diagnose
coughing, hydration, positioning, humidi cation,
tuberculosis (requires three consecutive
nebulizer therapy, chest physiotherapy, and suctioning.
morning samples)
● These interventions promote adequate gas exchange and
lung expansion.
CONSIDERATIONS
NURSING ACTIONS
INDICATIONS ● Obtain specimens early in the morning.
CLIENTS AT RISK FOR DEVELOPING AIRWAY ● Wait 1 to 2 hr after the client eats to obtain a specimen
COMPROMISE: infants, clients who have neuromuscular to decrease the likelihood of emesis or aspiration.
disorders, clients who are quadriplegic, clients who have ● Perform chest physiotherapy to help mobilize secretions.
cystic brosis ● Use a sterile specimen container, a label, a laboratory
requisition slip, a biohazard bag for delivery of the
INDICATIONS THAT CLIENTS NEED HELP MAINTAINING
specimen to the laboratory, clean gloves, and a mask
AIRWAY CLEARANCE: hypoxia (restlessness, irritability,
and goggles if necessary.
tachypnea, tachycardia, cyanosis, decreased level of ● Use a container with a preservative to obtain a specimen
consciousness, decreased SpO2 levels), adventitious breath
for cytology.
sounds, visible secretions, absence of spontaneous cough ● Use a sterile container for routine cultures and AFB testing.
● If a client cannot cough effecti ely and e pectorate
sputum into the container, collect the specimen by
CONSIDERATIONS endotracheal suctioning.
● Humidi cation of o ygen moistens the air ays, hich ● lder adult clients ha e a ea cough re e and
loosens and mobilizes pulmonary secretions. decreased muscle strength, ma ing it difficult for them
● Nebulization breaks up medications (bronchodilators, to expectorate. They can require suctioning for sputum
mucolytic agents) into minute particles that disperse specimen collection.
throughout the respiratory tract and improves clearance
of pulmonary secretions.
● Chest physiotherapy involves the use of chest INTERPRETATION OF FINDINGS
percussion, vibration, and postural drainage to help ● Presence of micro-organisms indicating infection
mobilize secretions. Chest percussion and vibration ● Presence of cancer cells
facilitate movement of secretions into the central
airways. For postural drainage, one or more positions
Chest physiotherapy
allow gravity to assist with the removal of secretions
from speci c areas of the lung.
● Early-morning postural drainage mobilizes secretions ● The use of a set of techniques that loosen respiratory
that have accumulated through the night.
secretions and move them into the central airways
NURSING ACTIONS where coughing or suctioning can remove them
● Collect sputum specimens by suctioning ● For clients who have thick secretions and are unable to
during coughing. clear their airways
● Whenever possible, encourage coughing. Coughing is ● Contraindicated for clients who are pregnant; have a rib,
more effecti e than arti cial suctioning at mo ing chest, head, or neck injury; have increased intracranial
secretions into the upper trachea and laryngopharynx. pressure; have had recent abdominal surgery; have
● Suction orally, nasally, or endotracheally, not routinely a pulmonary embolism; or have bleeding disorders
but only when clients need it. or osteoporosis
● Maintain surgical asepsis when performing any form of
Percussion: the use of cupped hands to clap rhythmically
tracheal suctioning to avoid bacterial contamination of
on the chest to break up secretions
the airway.
Vibration: the use of a shaking movement during
exhalation to help remove secretions
Postural drainage: the use of various positions to allow

secretions to drain by gravity

CONSIDERATIONS Suctioning
Suction orally, nasally, or endotracheally when clients
NURSING ACTIONS have early signs of hypoxemia (restlessness, confusion,
● Schedule treatments 1 hr before or 2 hr after meals, tachypnea, tachycardia, decreased SpO2 levels,
and at bedtime to decrease the likelihood of vomiting adventitious breath sounds, audible or visible secretions,
or aspirating. cyanosis, and absence of spontaneous cough).
● Administer a bronchodilator medication or nebulizer
treatment 30 min to 1 hr prior to postural drainage. CONSIDERATIONS
● ffer the client an emesis basin and facial tissues.
Apply manual percussion to the chest wall using cupped
NURSING ACTIONS
●
hands or a speci c de ice.

● Place hands on the affected area, tense hand and arm ● Don the required personal protective equipment.
muscles, and move the heel of the hands to create ● Assist the client to high-Fowler’s or Fowler’s position for
vibrations as the client exhales. Have the client cough suctioning if possible.
after each set of vibrations. ● Encourage the client to breathe deeply and cough in an
● Have the client remain in each position for 10 to attempt to clear the secretions ithout arti cial suction.
15 min to allow time for percussion, vibration, and ● Obtain baseline breath sounds and vital signs, including
postural drainage. SaO2 by pulse oximeter. Can monitor SaO2 continually
● Discontinue the procedure if the client reports faintness during the procedure.
or dizziness. ● For oropharyngeal suctioning, use a Yankauer or
● Note that older adult clients have decreased respiratory tonsil-tipped rigid suction catheter and move the
muscle strength and chest wall compliance, which puts catheter around the mouth, gum line, and pharynx.
them at risk for aspiration. They require more frequent ● For nasopharyngeal and nasotracheal suctioning, use
position changes and other interventions to promote a e ible catheter and lubricate the distal to cm
mobility of secretions. (2 to 3 in) with water-soluble lubricant.
● For endotracheal suctioning, use a suction catheter.
Positioning: Ensure proper positioning to promote
The catheter should not exceed one half of the internal
drainage of speci c areas of the lungs.
diameter of the endotracheal tube to prevent hypoxia.
● Both lobes in general: high Fowler’s
The nurse should use no larger than a 16 French suction
● Apical segments of both lobes: sitting on the side
catheter when suctioning an 8 mm endotracheal tube

of the bed
or tracheostomy tube. Hyperoxygenate the client using
● Right upper lobe, anterior segment: supine with
a bag-valve-mask (BVM) or specialized ventilator
head elevation
function with an FiO2 of 100%.
● Right upper lobe, posterior segment: on the left side ● Use medical asepsis for suctioning the mouth.
with a pillow under the right side of the chest ● Use surgical asepsis for all other types of suctioning.
● Right middle lobe, anterior segment: three-quarters ● Use suction pressure no higher than 120 to 150 mm Hg.
supine with dependent lung in Trendelenburg ● Limit each suction attempt to no longer than 10 to
● Right middle lobe, posterior segment: prone with thorax
15 seconds to avoid hypoxemia and the vagal response.
and abdomen elevation
Repeat suctioning if needed. Limit total suctioning time
● Right lower lobe, lateral segment: on the left side
to 5 min.
in Trendelenburg
● Left upper lobe, anterior segment: supine with
head elevation
● Left upper lobe, posterior segment: on the right side with
a pillow under the left side of the chest
● Left lower lobe, lateral segment: on the right side
in Trendelenburg
● Both lower lobes, anterior segments: supine 53.6 Tracheal suctioning
in Trendelenburg
● Both lower lobes, posterior segments: prone
in Trendelenburg

Additional guidelines for nasopharyngeal and ● Air o in and out of a tracheostomy ithout air lea age
nasotracheal suctioning a cuffed tracheostomy tube bypasses the ocal cords,
● Insert the catheter into the naris during inhalation. resulting in an inability to produce sound or speech.
● Do not apply suction while inserting the catheter. ● ncuffed tubes and fenestrated tubes, in place or capped,
● Follow the natural course of the naris and slightly slant allo speech. Clients ho ha e a cuffed tube can be off
the catheter downward while advancing it. mechanical ventilation, can breathe around the tube,
● Advance the catheter 15 to 20 cm (6 to 8 in). and can use a speci c al e to allo for speech. The cuff
● Apply suction intermittently by covering and releasing is de ated and the al e occludes the opening.
the suction port with the thumb for 10 to 15 seconds. ● Indications for a tracheostomy include acute or
● Apply suction only while withdrawing the catheter and chronic upper airway obstruction, edema, anaphylaxis,
rotating it ith the thumb and fore nger. burns, trauma, head/neck surgery, copious secretions,
● Do not perform more than two passes with the catheter. obstructive sleep apnea refractory to conventional
Allow at least 1 min between passes for ventilation therapy, and the need for long-term mechanical
and oxygenation. ventilation or reconstruction after laryngeal trauma or
laryngeal cancer surgery.
Additional guidelines for endotracheal suctioning
● Remove the bag or ventilator from the tracheostomy
or endotracheal tube and insert the catheter into ARTIFICIAL AIRWAY TUBE TYPES
the lumen of the airway. Advance the catheter until
resistance is met. The catheter should reach the Single-lumen (cannula)
level of the carina (location of bifurcation into the ● Long, single-cannula tube
mainstem bronchi). ● For clients who have long or thick necks
● Pull the catheter back 1 cm (0.4 in) prior to applying
suction to prevent mucosal damage. NURSING ACTIONS: Do not use with clients who have
● Apply suction intermittently by covering and releasing excessive secretions.
the suction port with the thumb for 10 to 15 seconds.
● Apply suction only while withdrawing the catheter and Double-lumen (cannula)
rotating it ith the thumb and fore nger. ● An outer cannula ts into the stoma and eeps the
● Reattach the BVM or ventilator and administer
airway open.
100% oxygen. ● An inner cannula ts snugly into the outer cannula and
● Rinse catheter and suction tubing with sterile saline
locks into place.
until clear. ● An obturator is a thin, solid tube the provider places
● Do not reuse the suction catheter for subsequent
inside the tracheostomy and uses as a guide for
suctioning sessions.
inserting the outer cannula, and removes immediately
after outer cannula insertion.
● This device allows removing, cleaning, reusing,
Artificial airways and

discarding, and replacing the inner cannula with a
disposable inner cannula.
tracheostomy care ● It is useful for clients who have excessive secretions.
Cuffed tube
A tracheotomy is a sterile surgical incision into the
It has a balloon that in ates around the outside of the
trachea through the skin and muscles for the purpose of
distal segment of the tube to protect the lower airway by
establishing an airway.
producing a seal between the upper and lower airway.
● A tracheotomy can be an emergency or a scheduled
surgical procedure; it can be temporary or permanent. NURSING ACTIONS

● A tracheostomy is the stoma/opening that results from a ● A cuffed tube permits mechanical entilation.
tracheotomy to provide and secure a patent airway. ● A cuffed tube pre ents aspiration of
● Arti cial air ays can be placed orotracheally, oropharyngeal secretions.
nasotracheally, or through a tracheostomy to assist ● Cuffs do not hold the tube in place.
with respiration. ● Cuff pressures must be monitored to pre ent tracheal
● Tracheostomy tubes vary in their composition (plastic, tissue necrosis.
steel, silicone), number of parts, size (long vs. short), ● The client is unable to speak.
and shape (50° to 90° angles). ● Children do not re uire a cuffed tube.
● There is no standard tracheostomy sizing system.
However, the diameter of the tracheostomy tube must
be smaller than the trachea.
● The outside cannula has a ange or nec plate that
sits against the skin of the neck and has holes on each
side for attaching ties around the neck to stabilize the
tracheostomy tube.

Cuffless tube ● Provide tracheostomy care every 8 hr to reduce the risk
of infection and skin breakdown.
It has no balloon and is for clients who have long-term ◯ Suction the tracheostomy tube, if necessary, using
airway-management needs.
sterile suctioning supplies.
NURSING ACTIONS ◯ Apply the oxygen source loosely if the client’s SpO
2
● The client must be at low risk for aspiration. decreases during the procedure.
● Cu ess tubes are not for clients recei ing ◯ Use surgical asepsis to remove and clean the inner
mechanical ventilation. cannula (with the facility-approved solution). Use a

● This device allows the client to speak. new inner cannula if it is disposable.
◯ Remove soiled dressings and excess secretions.
Fenestrated tube with a cuff ◯ Clean the stoma site and then the tracheostomy plate.
◯ Place a fresh split-gauze tracheostomy dressing
● It has one large or multiple openings (fenestrations) in
of nonraveling material under and around the
the posterior wall of the outer cannula with a balloon
tracheostomy holder and plate.
around the outside of the distal segment of the tube. ◯ Replace tracheostomy ties if they are wet or soiled.
● It also has an inner cannula.
Secure the new ties before removing the soiled ones
NURSING ACTIONS to prevent accidental decannulation.
● This device allows for mechanical ventilation. ◯ If a knot is needed, tie a square knot that is visible on
● Removing the inner cannula allows the fenestrations to the side of the nec . Chec that one or t o ngers t
permit air to o through the openings. between the tie and the neck.
● This device allows the client to speak. ● Change nondisposable tracheostomy tubes every 6 to
8 weeks or per protocol.
Fenestrated tube without a cuff ● Reposition the client every 2 hr to prevent atelectasis
and pneumonia.
● It has one larger or multiple openings (fenestrations) in ● Minimize dust in the room. Do not shake bedding.
the posterior wall of the outer cannula with no balloon. ● If the client is permitted to eat, position them upright
● It also has an inner cannula.
and tip the chin to the chest to enable swallowing.
NURSING ACTIONS Assess for aspiration.
● The holes in the tube help wean the client from
the tracheostomy.
● Removing the inner cannula allows the fenestrations to COMPLICATIONS
permit air to o through the openings.
● This device allows the client to speak. Accidental decannulation
Accidental decannulation ithin the rst hr after
surgery is an emergency because the tracheostomy tract
CONSIDERATIONS has not matured, and replacement can be difficult.
NURSING ACTIONS
● Keep the following at the bedside: two extra
! Ventilate the client with a BVM. Call for assistance.
tracheostomy tubes (one the client’s size and one NURSING ACTIONS
size smaller, in case of accidental decannulation), the ● Always keep the tracheostomy obturator and two spare
obturator for the existing tube, an oxygen source, tracheostomy tubes at the bedside.
suction catheters and a suction source, and a BVM. ● If unable to replace the tracheostomy tube, administer
● Pro ide methods to communicate ith staff paper and oxygen through the stoma. If unable to administer
pen, dry-erase board). oxygen through the stoma, occlude the stoma and
● Provide an emergency call system and a call light. administer oxygen through the nose and mouth, except
● Pro ide ade uate humidi cation and hydration to thin for clients who have had a laryngectomy.
secretions and reduce the risk of mucous plugs.
If accidental decannulation occurs after the first 72 hr
● Give oral care every 2 hr. ● Immediately hyperextend the neck and with the obturator
inserted into the tracheostomy tube, quickly and gently
replace the tube, and remove the obturator.
● Secure the tube.
● Assess tube placement by auscultating for bilateral
breath sounds.

Damage to the trachea Application Exercises
Tracheal stenosis: Narrowing of the tracheal lumen due
to scar formation resulting from irritation of the tracheal 1. A nurse is assessing a client who has an acute
mucosa from the tracheal tube cuff. respiratory infection, increasing the risk for
hypoxemia. Which of the following findings are early
NURSING ACTIONS indications that should alert the nurse that the client
● eep the cuff pressure bet een and mm Hg. is developing hypoxia? (Select all that apply.)
● Chec the cuff pressure at least once e ery hr.
A. Restlessness
● Keep the tube in the midline position and prevent
B. Tachypnea
pulling or traction on the tracheostomy tube.
C. Bradycardia
Tracheal wall necrosis: Tissue damage that results when
D. Confusion
the pressure of the in ated cuff impairs blood o to the
E. Hypertension
tracheal wall.
2. A provider is discharging a client who has a prescription

Active Learning Scenario for home oxygen therapy via nasal cannula. Client and
family teaching by the nurse should include which of
A nurse is reviewing with a group of newly licensed nurses the following instructions? (Select all that apply.)
how to perform postural drainage. Use the ATI Active
A. Apply petroleum jelly around and inside the nares.
Learning Template: Nursing Skill to complete this item.
B. Remove the nasal cannula during mealtimes.
DESCRIPTION OF SKILL: List the specific C. Check the position of the cannula frequently.
positions that facilitate secretion drainage
D. Report any nausea or difficulty breathing.
from at least eight specific lung areas.
E. Post “No Smoking” signs in prominent locations.
3. A nurse is caring for a client who is having difficulty

breathing. The client is lying in bed and is already
receiving oxygen therapy via nasal cannula. Which of
the following interventions is the nurse’s priority?
A. Increase the oxygen flow.
B. Assist the client to Fowler’s position.
C. Promote removal of pulmonary secretions.
D. Obtain a specimen for arterial blood gases.
4. A nurse is preparing to perform endotracheal

suctioning for a client. The nurse should follow which
of the following guidelines? (Select all that apply.)
A. Apply suction while withdrawing the catheter.
B. Perform suctioning on a routine
basis every 2 to 3 hr.
C. Maintain medical asepsis during suctioning.
D. Use a new catheter for each suctioning attempt.
E. Apply suction for 10 to 15 seconds.
5. A nurse is caring for a client who has a

tracheostomy. Which of the following actions
should the nurse take when providing
tracheostomy care? (Select all that apply.)
A. Apply the oxygen source loosely if the
SpO2 decreases during the procedure.
B. Use surgical asepsis to remove and
clean the inner cannula.
C. Clean the outer cannula surfaces in a circular
motion from the stoma site outward.
D. Replace the tracheostomy ties with new ties.
E. Cut a slit in gauze squares to place
beneath the tube holder.

1. A. CORRECT: Monitor for restlessness, which is an early 4. A. CORRECT: Apply suction pressure only while withdrawing
manifestation of hypoxia, along with tachycardia, elevated the catheter to prevent damaging the tracheal tissue.
blood pressure, use of accessory muscles, nasal flaring, B. Suction the client’s airway only as needed, because
tracheal tugging, and adventitious lung sounds. suctioning is not without risk. It can cause mucosal
B. CORRECT: Monitor for tachypnea, which is damage, bleeding, and bronchospasm.
an early manifestation of hypoxia. C. Use surgical asepsis when performing endotracheal
C. Bradycardia is a late manifestation of hypoxia, along suctioning to prevent contamination with micro-
with stupor, cyanotic skin and mucous membranes, organisms that can cause an infection.
bradypnea, hypotension, and cardiac dysrhythmias. D. CORRECT: Use a new suction catheter, unless an in-line
D. CORRECT: Monitor for confusion, which is suctioning system is in place, to prevent contamination
an early manifestation of hypoxia. with micro-organisms that can cause an infection.
E. CORRECT: Monitor for hypertension, which E. CORRECT: To prevent hypoxemia, apply suction for
is an early manifestation of hypoxia. only 10 to 15 seconds and allow 2 to 3 min between
NCLEX® Connection: Physiological Adaptation, passes for ventilation and oxygenation.
Illness Management NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems
2. A. Teach the client to apply a water-based lubricant to protect

the nares from drying during oxygen therapy. 5. A. CORRECT: Provide supplemental oxygen in
B. Teach the client to leave the nasal cannula on while response to any decline in oxygen saturation
eating, because it does not interfere with eating. while performing tracheostomy care.
C. CORRECT: Teach the client that a disadvantage B. CORRECT: Use a sterile disposable tracheostomy
of the nasal cannula is that it dislodges easily. The cleaning kit or sterile supplies and maintain surgical
client should form the habit of checking its position asepsis throughout this part of the procedure.
periodically and readjusting it as necessary. C. CORRECT: Cleanse the exposed surfaces of the outer
D. CORRECT: Teach the client about oxygen toxicity, which cannula and the area around and under the faceplate in
is a complication of oxygen therapy, usually from high a circular motion from the stoma site outward. Cleansing
concentrations or long durations. Manifestations include in this manner helps move mucus and contaminated
a nonproductive cough, substernal pain, nausea, and material away from the stoma for easy removal.
vomiting. The client should report any of these promptly. D. Replace the tracheostomy ties if they are wet or
E. CORRECT: Teach the client that oxygen is combustible soiled. There is a risk of tube dislodgement with
and thus increases the risk of fire injuries. No one in replacing the ties, do not replace them routinely.
the house should smoke or use any device that might E. Use a commercially-prepared tracheostomy dressing
generate sparks in the area where the oxygen is in use. with a slit in it. Cutting gauze squares can loosen
NCLEX® Connection: Reduction of Risk Potential, lint or gauze fibers the client could aspirate.
Therapeutic Procedures NCLEX Connection: Reduction of Risk Potential, Potential for
3. A. There might be a need to increase the client’s oxygen

flow, as hypoxia can be the cause of a client’s difficulty
breathing. However, another action is the priority.
B. CORRECT: The priority action to be taken when using the
airway, breathing, circulation (ABC) approach to care delivery
is to relieve dyspnea (difficulty breathing). Fowler’s position
facilitates maximal lung expansion and thus optimizes
breathing. With the client in this position, the cause of the
client’s dyspnea can better assessed and determined.
C. There might be a need to suction the client’s airway
or encourage expectoration of pulmonary secretions.
However, another action is the priority,
D. Check the client’s oxygenation status. However,
another action is the priority.
Illness Management

Using the ATI Active Learning Template: Nursing Skill
DESCRIPTION OF SKILL
●
Both lobes in general: high-Fowler’s ●
Right middle lobe, anterior segment: ●
Left upper lobe, posterior segment:
●
Apical segments of both lobes: three-quarters supine with dependent on the right side with a pillow under
sitting on the side of the bed lung in Trendelenburg the left side of the chest
●
Right upper lobe, anterior segment: ●
Right middle lobe, posterior segment: ●
Left lower lobe, lateral segment: on
supine with head elevation prone with thorax and abdomen elevation the right side in Trendelenburg
●
Right upper lobe, posterior segment: ●
Right lower lobe, lateral segment: on ●
Both lower lobes, anterior segments:
on the left side with a pillow under the left side in Trendelenburg supine in Trendelenburg
the right side of the chest ●
Left upper lobe, anterior segment: ●
Both lower lobes, posterior segments:
supine with head elevation prone in Trendelenburg
NCLEX® Connection: Physiological Adaptation, Alterations in Body Systems

CHAPTER 54
SECTION: REDUCTION OF RISK POTENTIAL 54.1 Enteral feeding tube
CHAPTER 54 Nasogastric
Intubation and
Enteral Feedings
Nasogastric intubation is the insertion
of a nasogastric (NG) tube to manage
gastrointestinal (GI) dysfunction and provide
enteral nutrition via the NG tube. Nurses also
give enteral feedings through jejunal and
gastric tubes.
Nasogastric intubation
An N tube is a hollo , e ible, cylindrical de ice the
nurse inserts through the nasopharynx into the stomach.
54.2 Sengstaken-Blakemore tube

INDICATIONS
Decompression
● Removal of gas or stomach contents to prevent or
relieve distention, nausea, and vomiting
● Tube types: Salem sump, Miller-Abbott, Levin
Feeding
● Alternative to the oral route for administering
nutritional supplements
● Tube types Duo, Le in, Dobhoff
Lavage
● Washing out the stomach to treat active bleeding,
ingestion of poison, or for gastric dilation
● Tube types: Ewald, Levin, Salem sump
Compression
● Using an internal balloon to apply pressure for
preventing GI or esophageal hemorrhage
● Tube type: Sengstaken-Blakemore
FUNDAMENTALS FOR NURSING CHAPTER 54 NASOGASTRIC INTUBATION AND ENTERAL FEEDINGS 333
CONSIDERATIONS ● If the tube is not in the stomach, advance it 2.5 to 5 cm
(1 to 2 in).
Clamp the NG tube, or connect it to the suction device.
PREPROCEDURE
●
● Salem sump tubing has a blue pigtail for negative air

NURSING ACTIONS release, preventing vacuum pressure if the tube adheres
● Review the prescription and purpose, plan for drainage to the stomach lining and allowing secretions to drain
or suction, and understand the need for placement for continuously. Do not clamp it when the tube is attached
diagnostic purposes. to suction.
● Identify the client, and explain the procedure.
Review the client’s history (nasal problems, anticoagulants,
POSTPROCEDURE
●
previous trauma, past history of aspiration).

● Evaluate the client’s ability to assist and cooperate. NURSING ACTIONS
● Establish a means of communication to signal distress ● The insertion and maintenance of an NG tube is a nursing
(the client raising a hand). responsibility, but nurses may delegate measuring output,
● Perform hand hygiene. providing comfort, and giving oral care.
● Set up the equipment. ● For removal, wear clean gloves.
◯ NG tube: selected according to the indication ◯ Inform the client of the prescription and process,
◯ Tape or use a commercial ation de ice to secure emphasizing that removal is less stressful
the dressing than placement.
◯ Clean gloves ◯ Measure and record any drainage, assessing it for
◯ Water-soluble lubricant color, consistency, and odor.

◯ Topical anesthetic ◯ Ensure comfort.
◯ Cup of water and straw ◯ Document all relevant information.
◯ Catheter-tipped syringe, usually 30 to 60 mL ■ Tubing removal and condition of the tube
◯ Basin to prepare for gag-induced nausea ■ Volume and description of the drainage
◯ pH test strip or meter to measure gastric secretions ■ Abdominal assessment, including inspection,
for acidity auscultation, percussion, and palpation

◯ Stethoscope ■ Last and next bowel movement and urine output
◯ Disposable towel to maintain a clean environment
◯ Clamp or plug to close the tubing after insertion

◯ Suction apparatus if attaching the tube to continuous COMPLICATIONS
or intermittent suction
◯ Gauze square to cleanse the outside of the tubing Excoriation of nares and stomach
after insertion ● Apply water-soluble lubricant to the nares as necessary.
◯ Safety pin and elastic band or commercial device to
● Assess the color of the drainage. Report dark,
secure the tubing and prevent accidental removal
coffee ground, or blood strea ed drainage immediately.
● Position a disposable towel and basin. ● Consider switching the tube to the other naris.
Discomfort
INTRAPROCEDURE ● Rinse the mouth with water for dryness.
NURSING ACTIONS ● Throat lozenges and swabs moistened with
● Auscultate for bowel sounds, and palpate the abdomen water can help.
for distention, pain, and rigidity. ● Obtain a prescription for a local anesthetic solution for
● Raise the bed to a level comfortable for the nurse. gargling to help relieve irritation.
● Assist the client to high-Fowler’s position (if possible). ● Provide oral hygiene frequently.
● Assess the nares for the best route to determine how to ● eplace soiled tape or loose ation de ices.
avoid a septal deviation or other obstruction during the
insertion process. Occlusion of the NG tube leading to distention
● Use the correct procedure for tube insertion, wearing ● Irrigate the tube per the facility’s protocol to unclog
clean gloves, and evaluate the outcome.
blockages. Use water with enteral feedings. Have the
● If the client vomits, clear the airway, and provide
client change position in case the tip of the tube is
comfort prior to continuing.
against the stomach wall.
● Check placement. Aspirate gently to collect gastric ● Verify that suction equipment functions properly.
contents, testing pH (4 or less is expected), and assess
odor, color, and consistency.
● After placement eri cation, secure the N tube on the
nose, avoiding pressure on the nares.
◯ Con rm placement ith an ray.
◯ Injecting air into the tube and then listening over the
abdomen is not an acceptable practice.
334 CHAPTER 54 NASOGASTRIC INTUBATION AND ENTERAL FEEDINGS CONTENT MASTERY SERIES
Enteral feedings CONSIDERATIONS
Enteral feeding is a method of providing nutrients to
clients who cannot consume foods orally but whose GI
PREPARATION OF THE CLIENT
tract is functioning. NURSING ACTIONS
● Review the prescription. Generally, the provider and
dietary staff consult to determine the type of tube
ENTERAL FORMULAS feeding formula.
Standard (polymeric): 1 to 2 kcal/mL ● Set up the equipment.
● Milk-based, blenderized foods ◯ Feeding bag
● Whole-nutrient formulas, either commercial or from the ◯ Tubing
dietary department ◯ 30- to 60-mL syringe (compatible with the tubing)
● Only for clients whose GI tract can absorb ◯ Stethoscope
whole nutrients ◯ pH indicator strip

◯ Infusion pump (if not a gravity drip)
Modular formulas: 3.8 to 4 kcal/mL ◯ Appropriate enteral formula

● Single-macronutrient preparation ◯ Irrigant solution: sterile or tap water, according to the
● Not nutritionally complete
facility’s policy
● Supplement to other foods ◯ Clean gloves
Elemental formulas: 1 to 3 kcal/mL ◯ Supplies for blood glucose (if protocol or
● Predigested nutrients prescription indicates)

● Not nutritionally complete ◯ Suction equipment to use in case of aspiration
● Easier for a partially dysfunctional GI tract to absorb
Specialty formulas: 1 to 2 kcal/mL ONGOING CARE

● or meeting speci c nutritional needs
NURSING ACTIONS
● Not nutritionally complete ● Prepare the formula, tubing, and infusion device.
● Primarily for clients who have hepatic failure, ◯ Check expiration dates, and note the content of
respiratory disease, or HIV infection
the formula.
◯ Ensure that the formula is at room temperature.
ENTERAL ACCESS TUBES ◯ Set up the feeding system via gravity or pump.
◯ i or sha e the formula, ll the container, prime the

astroparesis, esophageal re u , or a history of aspiration
tubing, and clamp it.
pneumonia generally requires intestinal placement. ● Assist the client to semi-Fowler’s position, or elevate
Nasogastric or nasointestinal the head of the bed to a minimum of 30°.
● For short-term therapy ● Auscultate for bowel sounds.
● Inserted via the nose ● Monitor tube placement.
◯ Check gastric contents for pH. A good indication of
Gastrostomy or jejunostomy
appropriate placement is obtaining gastric contents
● Therapy duration longer than 6 weeks
with a pH between 0 and 4.
● Inserted surgically ◯ Aspirate for residual volume.
Percutaneous endoscopic gastrostomy or jejunostomy ◯ Note the appearance of the aspirate.
● Therapy duration longer than 6 weeks ◯ Return aspirated contents, or follow the
● Inserted endoscopically facility’s protocol.

● Flush the tubing with at least 30 mL water.
● Administer the formula.
INDICATIONS ◯ Intermittent feeding
■ Prepare the formula and a 60-mL syringe.

● Critical illness/trauma ■ Remove the plunger from the syringe.
● Neurologic and muscular disorders: brain neoplasm, ■ Hold the tubing above the instillation site.
stroke, dementia, myopathy, Parkinson’s disease ■ Open the stopcock on the tubing, and insert the
● Cancer that affects the head and nec , upper I tract
barrel of the syringe with the end up.
● I disorders enterocutaneous stula, in ammatory ■ Fill the syringe with 40 to 50 mL formula.
bowel disease, mild pancreatitis ■ If using a feeding bag, ll the bag ith the total
● Respiratory failure with prolonged intubation
amount of formula for one feeding, and hang it to
● Inadequate oral intake
drain via gravity until empty (about 30 to 45 min).
■ If using a syringe, hold it high enough for the
formula to empty gradually via gravity.

■ Continue to re ll the syringe until the amount for
the feeding is instilled. Follow with at least 30 mL
ater to ush the tube and pre ent clogging.
◯ Continuous-drip feeding Nausea or vomiting
■ Connect the feeding bag system to the feeding tube.
■ If using a pump, program the instillation
NURSING ACTIONS
● Slow the instillation rate.
rate, and set the total volume to instill. ● Keep the head of the bed at 30°.
■ Start the pump. ● Make sure the formula is at room temperature.
■ Flush the enteral tubing with at least 30 mL water
● Turn the client to the side.
every 4 to 6 hr, and check tube placement again. ● Notify the provider.
■ Monitor intake and output, and include 24-hr totals. ● Check the tube’s patency.
■ Monitor capillary blood glucose every 6 ● Aspirate gastric residual volume.
hr until the client tolerates the maximum ● Auscultate for bowel sounds.
administration rate for 24 hr. ● Obtain a chest x-ray.
■ Use an infusion pump for intestinal tube feedings.
■ Follow the manufacturer’s recommendations
Aspiration of formula
for formula hang time. Refrigerate unused
formula, and discard after 24 hr. NURSING ACTIONS
■ Some facilities require gastric residual volume checks, ● Withhold the feeding.
typically every 4 to 6 hr. Check facility protocol for ● Turn the client to the side.
speci c actions to ta e for the amount of residual. ● Suction the airway.
■ Do not delegate this skill to assistive personnel. ● Provide oxygen if indicated.
● Monitor vital signs for elevated temperature.
● Monitor for decreased oxygen saturation
COMPLICATIONS or increased respiratory rate.
● Auscultate breath sounds for increased congestion.
Diarrhea three times or more in a 24-hr period ● Notify the provider.
● Obtain a chest x-ray.
NURSING ACTIONS
Slow the instillation rate.
Skin irritation around the tubing site
●
● Notify the provider.

● Confer with the dietitian. NURSING ACTIONS
● Provide skin care and protection. ● Provide a skin barrier for any drainage at the site.
● Consult with the provider if the client is receiving ● Monitor the tube’s placement.
antibiotics, possibly for a prescription for a
different antibiotic.
A nurse is teaching a group of newly licensed nurses
1. A nurse is delivering an enteral feeding to a client who about administering enteral feedings. Use the ATI Active
has an NG tube in place for intermittent feedings. Learning Template: Nursing Skill to complete this item.
When the nurse pours water into the syringe after
the formula drains from the syringe, the client asks INDICATIONS: List at least four
the nurse why the water is necessary. Which of the indications for enteral feedings.
following responses should the nurse make?
NURSING INTERVENTIONS (INTRAPROCEDURE):
A. “Water helps clear the tube so List the steps of administering an enteral feeding.
it doesn’t get clogged.”
B. “Flushing helps make sure the tube stays in place.”
C. “This will help you get enough fluids.”
D. “Adding water makes the formula
less concentrated.”
2. A nurse is caring for a client who is receiving

continuous enteral feedings. Which of the following
nursing interventions is the highest priority when
the nurse suspects aspiration of the feeding?
A. Auscultate breath sounds.
B. Stop the feeding.
C. Obtain a chest x-ray.
D. Initiate oxygen therapy.
3. A nurse is preparing to instill an enteral feeding for

a client who has an NG tube in place. Which of the
following actions is the nurse’s highest assessment
priority before performing this procedure?
A. Check how long the feeding
container has been open.
B. Verify the placement of the NG tube.
C. Confirm that the client does not have diarrhea.
D. Make sure the client is alert and oriented.
4. A nurse is caring for a client in a long-term care

facility who is receiving enteral feedings via an
NG tube. Which of the following actions should
the nurse complete prior to administering
the tube feeding? (Select all that apply.)
A. Auscultate bowel sounds.
B. Assist the client to an upright position.
C. Test the pH of gastric aspirate.
D. Warm the formula to body temperature.
E. Discard any residual gastric contents.
5. A nurse is preparing to insert an NG tube for a client

who requires gastric decompression. Which of the
following actions should the nurse perform before
beginning the procedure? (Select all that apply.)
A. Review a signal the client can use
if feeling any distress.
B. Lay a towel across the client’s chest.
C. Administer oral pain medication.
D. Obtain a Dobhoff tube for insertion.
E. Have a petroleum-based lubricant available.
1. A. CORRECT: Flush the tube after instilling the feeding to help Using the ATI Active Learning Template: Nursing Skill
keep the NG tube patent by clearing any excess formula from
INDICATIONS
the tube so that it doesn’t clump and clog the tube.
B. Tape a securing device, not flush the tube with water,
●
Critical illness, trauma
to help maintain the position of the NG tube.
●
Neurologic and muscular disorders: brain neoplasm, cerebrovascular
C. Administer additional fluids. The small amount used accident, dementia, myopathy, Parkinson’s disease
for flushing the NG tube will not be adequate. ●
GI disorders: enterocutaneous fistula, inflammatory
D. Contact the dietary staff to prepare formula according bowel disease, mild pancreatitis
to the prescription before the nurse instills it. ●
Respiratory failure with prolonged intubation
Inadequate oral intake
Potential for Alterations in Body Systems NURSING INTERVENTIONS (INTRAPROCEDURE)
●
Prepare the formula and a 60 mL syringe.
2. A. Listen to breath sounds whenever there is
●
Remove the plunger from the syringe.
suspicion of the client aspirating. However,
●
Hold the tubing above the instillation site.
another assessment is the priority. ●
Open the stopcock on or pinch the tubing, and insert
B. CORRECT: The greatest risk to the client is aspiration the barrel of the syringe with the end up.
pneumonia. The first action to take is to stop the feeding ●
Fill the syringe with 40 to 50 mL formula.
so that no more formula can enter the lungs. ●
If using a feeding bag, fill the bag with the total amount
C. Obtain a chest x-ray whenever there is suspicion of the client of formula for one feeding, and hang it to drain via
aspirating. However, another assessment is the priority. gravity until empty (about 30 to 45 min).
D. Initiate oxygen therapy whenever there is ●
If using a syringe, hold it high enough for the
suspicion of the client aspirating. However, formula to empty gradually via gravity.
another assessment is the priority. ●
Continue to refill the syringe until the
NCLEX® Connection: Reduction of Risk Potential, Potential for amount for the feeding is instilled.
Complications of Diagnostic Tests/Treatments/Procedures ●
Follow with at least 30 mL water to flush
the tube and prevent clogging.
3. A. Checking that the container has not exceeded its NCLEX® Connection: Reduction of Risk Potential, Potential for
expiration date, either for having it open or for Complications of Diagnostic Tests/Treatments/Procedures
opening it, is important. However, there is a higher
assessment priority among these options.
B. CORRECT: The greatest risk to the client receiving
enteral feedings is injury from aspiration. The priority
nursing assessment before initiating an enteral feeding
is to verify proper placement of the NG tube.
C. Assess the client for any possible complications
of enteral feedings (diarrhea). However, there is
another assessment that is the priority.
D. Determine the client’s level of consciousness as an
assessment parameter that is ongoing and should precede
any procedure. However, another assessment is the priority.
4. A. CORRECT: Auscultate for bowel sounds, because the client’s

gastrointestinal tract might not be able to absorb nutrients.
Then withhold feedings and notify the provider.
B. CORRECT: Place the client in an upright position,
with at least a 30° elevation of the head of the bed.
Upright positioning helps prevent aspiration.
C. CORRECT: Before administering enteral feedings,
verify the placement of the NG tube. The only reliable
method is x-ray confirmation, which is impractical prior
to every feeding. Testing the pH of gastric aspirate is an
acceptable method between x-ray confirmations.
D. Have the enteral formula at room temperature
before administering the enteral feeding.
E. Return the residual to the client’s stomach, unless
the volume of gastric contents is more than 250 mL
or the facility has other guidelines in place.
5. A. CORRECT: Establish a means for the client to

communicate that they want to stop the procedure
before inserting an NG tube.
B. CORRECT: Place a disposable towel across the
client’s chest to provide for a clean environment and
protect the client’s gown from becoming soiled.
C. Because the purpose of the procedure is to
remove stomach contents, the procedure would
also remove the oral pain medication.
D. Plan to use the prescribed type of tube for gastric
decompression, which is a Salem sump, Miller-Abbott,
or Levin. A Dobhoff tube is for feeding.
E. Plan to use a water-based lubricant to reduce
complications from aspiration.
NCLEX® Connections

CHANGES/ABNORMALITIES IN VITAL SIGNS: Assess
and respond to changes in client vital signs.

TREATMENTS/PROCEDURES: Apply knowledge of
nursing procedures and psychomotor skills when caring
for a client with potential for complications.
SYSTEM SPECIFIC ASSESSMENTS

Assess the client for peripheral edema.
Identify factors that result in delayed wound healing.
Perform a risk assessment.
Physiological Adaptation
ALTERATIONS IN BODY SYSTEMS
Monitor wounds for signs and symptoms of infection.
Perform wound care or dressing change.
FLUID AND ELECTROLYTE IMBALANCES: Identify signs

and symptoms of client uid and or electrolyte imbalance.
MEDICAL EMERGENCIES: Perform emergency care procedures.
PATHOPHYSIOLOGY: Understand general principles of pathophysiology.

MOBILITY/IMMOBILITY: Perform skin assessment and implement
measures to maintain skin integrity and prevent skin breakdown.

CHAPTER 55
UNIT 4 PHYSIOLOGICAL INTEGRITY HEALING PROCESSES
SECTION: PHYSIOLOGICAL ADAPTATION
Primary intention
CHAPTER 55 Pressure Injury, Little or no tissue loss
Wounds, and Wound

●
● Edges approximated, as with a surgical incision

Heals rapidly
Management
●
● Low risk of infection

● No or minimal scarring
Example: Closed surgical incision with staples,

Wounds are a result of injury to the skin. sutures, or liquid glue to seal laceration
Although there are many different methods and Secondary intention
degrees of injury, the basic phases of healing ● Loss of tissue
are essentially the same for most wounds. ● Wound edges widely separated, unapproximated
(pressure injury, open burn areas)
A pressure injury is a specific type of tissue ● Longer healing time
Increase for risk of infection
injury from unrelieved pressure, usually over
●
● Scarring
bony prominences, that results in ischemia and ● Heals by granulation
damage to the underlying tissue. Example: Pressure injury left open to heal
Tertiary intention
WOUND HEALING AND MANAGEMENT ● Widely separated
● Deep
STAGES OF WOUND HEALING ● Spontaneous opening of a previously closed wound
● Closure of wounds occurs when they are free of
Inflammatory stage infection and edema
● Risk of infection
Begins with the injury and lasts 3 to 6 days. ● Extensive drainage and tissue debris
EFFECTS TO THE WOUND ● Closed later
● Controlling bleeding with vasoconstriction, retraction ● Long healing time
of blood essels, brin accumulation, and clot formation.
Example: Abdominal wound initially left open
● Delivering oxygen, white blood cells, and nutrients
until infection is resolved and then closed
to the area via the blood supply. Macrophages engulf
microorganisms and cellular debris (phagocytosis). This
phase is prolonged hen there is too little in ammation FACTORS AFFECTING WOUND HEALING
(with debilitating disease), or when there is too
Age: Increased age delays healing.
much in ammation. ● Loss of skin turgor
Skin fragility
Proliferative stage
●
● Decrease in peripheral circulation and oxygenation

Lasts the next 3 to 24 days. ● Slower tissue regeneration
● Decrease in absorption of nutrients
EFFECTS TO THE WOUND ● Decrease in collagen
● Replacing lost tissue with connective or granulated ● Impaired immune system function
tissue and collagen. ● Dehydration due to decreased thirst sensation
● Contracting the wound’s edges to reduce the area that
requires healing. Overall wellness: A wound in a young, healthy client that
● Resurfacing of new epithelial cells. heals faster than a wound in an older adult who has a
chronic illness
Maturation or remodeling stage
Decreased leukocyte count: Delays wound healing because
Occurs on or about day 21 and involves the strengthening the immune system s function is to ght infection by
of the collagen scar and the restoration of a more normal destroying invading pathogens
appearance. It can take more than 1 year to complete,
Infection: Prolongs healing and can result in further
depending on the extent of the original wound.
tissue destruction
Some medications (anti‑inflammatory and

antineoplastic): Interferes with the body’s ability to
respond to and prevent infection
FUNDAMENTALS FOR NURSING CHAPTER 55 PRESSURE INJURY, WOUNDS, AND WOUND MANAGEMENT 341
Malnourished clients: Nutrition that provides energy and ● Note and document the number of dressings and
elements for wound healing frequency of dressing changes.
◯ Serous drainage: The portion of the blood (serum) that
Tissue perfusion: Provides circulation that delivers
is watery and clear or slightly yellow in appearance
nutrients for tissue repair and infection control
uid in blisters .
Low Hgb levels: Hgb that is essential for oxygen delivery ◯ Sanguineous drainage: Contains serum and red blood
to healing tissues cells. It is thick and appears reddish. Brighter drainage
indicates active bleeding; darker drainage indicates older
Obesity: Fatty tissue that lacks blood supply
bleeding/drainage.
Chronic diseases: Place additional stress on the body’s ◯ Serosanguineous drainage: Contains both serum and
healing mechanisms. Examples include diabetes mellitus blood. It is watery and looks pale and pink due to a
and cardiovascular disorders. mi ture of red and clear uid.
◯ Purulent drainage: The result of infection. It is thick and
Smoking: Impairs oxygenation and clotting
contains white blood cells, tissue debris, and bacteria. It
Wound stress: Puts pressure on the suture line and may have a foul odor, and its color (yellow, tan, green,
disrupts the wound’s healing process. Examples include bro n re ects the type of organism present green for a
vomiting or coughing. Pseudomonas aeruginosa infection).
◯ Purosanguineous: A mixed drainage of pus and blood
(newly infected wound).
General principles of WOUND CLOSURE: Staples, sutures, tissue adhesives

wound management (surgical glue)
STATUS: Of any drains or tubes

● Wounds impair skin integrity.
● In ammation is a locali ed protecti e response to in ury PAIN: Note the location, quality, intensity, timing, setting,
or destruction of tissue. associated manifestations, and aggravating/relieving factors.
● Wounds heal by various processes and in stages.
Wound infections result from the invasion of pathogenic
●
micro-organisms.
● Principles of wound care include assessment, cleansing, ● Provide adequate hydration and meet protein and
and protection. calorie needs.
◯ ncourage an inta e of at least , mL day of uid from
food and beverage sources if no contraindications (heart and
ASSESSMENT/DATA COLLECTION chronic kidney disease).
◯ Pro ide education about good sources of protein meat, sh,
APPEARANCE
poultry, eggs, dairy products, beans, nuts, whole grains).
● Note the color of open wounds. ◯ Note if blood albumin levels are low (below 3.5 g/dL), because
◯ Red: Healthy regeneration of tissue
a lack of protein increases the risk for a delay in wound
◯ Yellow: Presence of purulent drainage and slough
healing and infection.
◯ Black: Presence of eschar that hinders healing and ◯ Provide nutritional support (vitamin and mineral supplements,
requires removal
nutritional supplements, and enteral and parenteral
● Assess the length, width, and depth, and any
nutrition). Most adult clients need at least 1,500 kcal/day for
undermining, sinus tracts or tunnels, and redness or
nutritional support.
swelling. Use a clock face with 12:00 toward the client’s ● Perform wound cleansing and irrigation.
head to document the location of sinus tracts. ◯ For clean wounds (a surgical incision), cleanse from the
● Use the RYB color code guide for wound care:
least contaminated (the incision) toward the most
red (cover), yellow (clean), black (debride, remove
contaminated (the surrounding skin).
necrotic tissue). ◯ Use gentle friction when cleansing or applying solutions to
● Closed wounds: Skin edges should be
the skin to avoid bleeding or further injury to the wound.
well-approximated. ◯ Although the provider might prescribe other mild
DRAINAGE (EXUDATE): A result of the healing process and cleansing agents, isotonic solutions remain the preferred
accumulates during the in ammatory and proliferati e cleansing agents.
phases of healing ◯ Never use the same gauze to cleanse across an incision or
● Note the amount, odor, consistency, and color of wound more than once.
drainage from a drain or on a dressing. ◯ Do not use cotton balls and other products that shed bers.
● Note the integrity of the surrounding skin. ◯ If irrigating, use a piston syringe or a sterile straight
● With each cleansing, observe the skin around a drain for catheter for deep wounds with small openings. Apply 5 to
irritation and breakdown. 8 psi of pressure. A 30 to 60 mL syringe with a 19-gauge
● For accurate measurement of drainage, weigh the dressing. needle provides approximately 8 psi. Use normal saline,
lactated Ringer’s, or an antibiotic/antimicrobial solution.
1 g = 1 mL drainage
Hold the tip 2.5 cm (1 in) above the wound. Use continuous
pressure to ush the ound, repeating the procedure until
the irrigant o ing out of the ound is clear.
342 CHAPTER 55 PRESSURE INJURY, WOUNDS, AND WOUND MANAGEMENT CONTENT MASTERY SERIES
● Remove sutures and staples. COMPLICATIONS AND
● Administer analgesics and monitor for effecti e NURSING IMPLICATIONS
pain management.
● Administer antimicrobials (topical, systemic) and Dehiscence and evisceration
monitor for effecti eness reduced fe er, increase in
Dehiscence: A partial or total rupture (separation) of a
comfort, decreasing WBC count).
sutured wound, usually with separation of underlying
● Document the location and type of wound and incision,
skin layers
the status of the wound and type of drainage, the type
of dressing and materials, client teaching, and how the Evisceration: A dehiscence that involves the protrusion of
client tolerated the procedure. visceral organs through a wound opening
MANIFESTATIONS
WOUND DRESSINGS ● A signi cant increase in the o of serosanguineous
uid on the ound dressings
Protects the wound from microbes ● Immediate history of sudden straining (coughing,
Woven gauze (sponges): Absorbs exudate from the wound sneezing, vomiting)
● Client report of a change or “popping” or “giving way”
Nonadherent material: Does not stick to the wound bed
in the wound area
Damp to damp 4-inch by 4-inch dressings: Used to ● Visualization of viscera
mechanically debride a wound until granulation tissue
PREVENTION: Thin, folded blanket or small pillow over
starts to form in the wound bed. Must keep moist at all
surgical wounds when client coughs in order to support
times to prevent pain and disruption of wound healing.
the wound
Self‑adhesive, transparent film: A temporary “second
RISK FACTORS
s in ideal for small, super cial ounds ● Chronic disease
Hydrocolloid: An occlusive dressing that swells in the ● Advanced age
presence of exudate; composed of gelatin and pectin, it ● Obesity
forms a seal at the wound’s surface to prevent evaporation ● Invasive abdominal cancer
of moisture from the skin. ● Vomiting
● Maintains a granulating wound bed ● Excessive straining, coughing, sneezing
● Can stay in place for 3 to 5 days ● Dehydration, malnutrition
● Ineffecti e suturing
Hydrogel: Composition is mostly water. Gels after contact ● Abdominal surgery
with exudate, promoting autolytic debridement and ● Infection
cooling. ehydrates and lls dead space. ight re uire a
secondary occlusive dressing. NURSING INTERVENTIONS
● For infected, deep wounds or necrotic tissue
Evisceration and dehiscence require
● Not for moderately to heavily draining wounds
emergency treatment.
● Provides a moist wound bed
● Soothing and can reduce wound pain ● Call for help. Notify the provider immediately due to the
● Prevents skin breakdown in high-pressure areas need for surgical intervention.
(the sacrum) ● Stay with the client.
● Cover the wound and any protruding organs with sterile
Alginates: Nonadherent dressings that conform to the
towels or dressings soaked with sterile normal saline
wound’s shape and absorb exudate
solution to decrease the chance of bacteria invasion and
● Provides a moist wound bed
drying of the tissues. Do not attempt to reinsert
● Packs wounds
the organs.
● Supports debridement ● Position the client supine with the hips and knees bent.
Collagen: Powders, pastes, granules, sheets, gels, and ● Observe for indications of shock.
pastes ● Maintain a calm environment.
● Helps stop bleeding ● Keep the client NPO in preparation for returning
● Promotes healing to surgery.
VACUUM-ASSISTED CLOSURE SYSTEM

● Use of foam strips laid into the wound bed with an
occlusive sealed drape applied and suction tubing placed
for negative pressure (suction) to occur once the tubing
is connected to the systems therapy unit
◯ Speeds tissue generation
◯ Decreases swelling
◯ Enhances healing in a moist, protected environment
Hemorrhage
Pressure injury
● The risk is greatest 24 to 48 hr after injury or surgery.
Pressure injury involves local damage to the skin and
● Can be caused by clot dislodgement, slipped suture, or
tissues following prolonged or intense pressure. Pressure
blood vessel damage.
injury occurs over bony prominences or on areas where an
● Internal bleeding will present with swelling or
object or device comes in contact with the skin.
distention in the area and sanguineous drainage.
● Hematoma is a local area of blood collection that The National Pressure Ulcer Advisory Panel (NPUAP)
appears as a red or blue bruise. classi es pressure in uries in si stages categories isit
● Wound hemorrhage is an emergency. Pressure dressing the NPUAP website for additional information). (55.1)
should be applied, ith noti cation of the pro ider and
Deep tissue pressure injury, persistent nonblanchable deep
monitoring of vital signs.
red, maroon, or purple discoloration: Discoloration of non-
intact or intact skin from damage following prolonged or
Infection
intense pressure or shear. Intact skin is nonblanchable with
RISK FACTORS deep red, maroon, or purple discoloration; open wounds
● Extremes in age (immature immune system, decrease in have a dark wound bed or blood blister (color changes vary
immune function) depending on skin tone). Pain and temperature changes
● Impaired circulation and oxygenation (COPD, peripheral can be detected earlier than color changes. If subcutaneous
vascular disease) or granulation tissue, or other structure (bone, fascia) are
● Wound condition and nature (gunshot wound vs. present, the wound should be restaged.
surgical incision)
Stage 1, nonblanchable erythema of intact skin: Intact skin
● Impaired or suppressed immune system
with an area of persistent, nonblanchable redness that can
● Malnutrition (with alcohol use disorder)
feel warmer or cooler than the adjacent tissue. The tissue is
● Chronic disease (diabetes mellitus or hypertension)
s ollen and can ha e a different te ture than surrounding
● Poor wound care (breaches in aseptic technique)
skin, with possible discomfort or altered sensation at the
MANIFESTATIONS: 2 to 11 days after injury or surgery site. ith dar er s in tones, the ound s coloring differs
● Purulent drainage from that of the surrounding area.
● Pain
Stage 2, partial thickness skin loss with exposed dermis:
● Redness, edema (in and around the wound)
Involves the epidermis and the dermis. The wound bed is
● Fever
viable with reddish-pinkish bed without slough, eschar,
● Chills
granulation tissue, or adipose tissue. It can appear as an
● Odor
intact or ruptured blister.
● Increased pulse, respiratory rate
● Increase in WBC count Stage 3, full-thickness skin loss: Visible adipose tissue with
possible granulation tissue and epibole (wound edges appear
rolled under); some slough, eschar present. No exposed
● Prevent infection by using aseptic technique when
muscle, tendons, ligaments, cartilage, or bones. Possible
performing dressing changes.
undermining or tunneling.
● Provide optimal nutrition to promote the
immune response. Stage 4, full-thickness skin and tissue loss: Skin and tissue
● Provide for adequate rest to promote healing. loss with cartilage, bone, fascia, muscle, ligaments, or tendon
● Administer antibiotic therapy after collecting specimens exposed in the wound or easily palpable. Epibole, tunneling,
for culture and sensitivity testing. and undermining are common.
Unstageable, obscured, full-thickness skin and tissue loss:

No determination of stage because eschar or slough obscures
the wound bed. The actual depth of injury is unknown
unless slough and eschar removed, at which time the wound
is restaged.
The primary focus of prevention and treatment of pressure
injury is to relieve the pressure and provide optimal
nutrition and hydration.
● Monitor all clients regularly for skin-integrity status and
for risk factors that contribute to impaired skin integrity.
● Use a risk assessment tool (Braden, Norton scales) for
periodic systemic monitoring for skin breakdown risk.
● Pressure in ury is a signi cant source of morbidity and
mortality among older adults and those who have limited
mobility.
55.1 Stages of pressure ulcers
aise heels off of the bed to pre ent pressure.

RISK FACTORS
●
● Ambulate clients as soon and as often as possible.

● Aging skin (older adult clients) ● Instruct clients who are mobile to shift their weight
● Immobility every 15 min when sitting.
● Incontinence, excessive moisture ● Keep clients from sliding down in bed, as this increases
● Skin friction, shearing shearing forces that pull tissue layers apart and cause
● Vascular disorders damage. Lift, rather than pull, clients up in bed or in a
● Obesity chair, because pulling creates friction that can damage
● Inadequate nutrition, hydration the outer layer of skin (epidermis).
● Anemia
Provide supportive devices.
● Fever, dehydration ● Use pressure-reducing surfaces and devices (overlays;
● Impaired circulation
replacement mattresses; specialty beds; kinetic therapy;
● Edema
foam, gel, or air cushions).
● ensory de cits
● Impaired cognitive functioning, neurologic disorders Maintain skin hygiene.
● Chronic diseases (diabetes mellitus, chronic kidney ● Inspect the skin frequently and document the client’s
disease, heart failure, chronic lung disease) risk using a tool (the Braden scale).
● Sedation that impairs spontaneous repositioning ● Clean the skin with gentle, nonionic surfactants,
and pat it dry immediately following urine or
stool incontinence.
NURSING INTERVENTIONS ● Bathe with tepid (not hot) water and avoid scrubbing.
● Apply dimethicone-based moisture barrier creams or
alcohol free barrier lms to the s in of clients ho

PREVENTION have incontinence.
Avoid skin trauma. ● Do not use powder or cornstarch to prevent friction
● eep s in clean, dry, and intact. Pro ide a rm, or repel moisture, due to their abrasive grit and
wrinkle-free foundation with wrinkle-free linens. aspiration potential.
● Reposition the client in bed at least every 2 hr and every ● Implement active and passive exercises for clients who
1 hr in a chair. Document position changes. are immobile.
● eep the head of the bed at or belo a angle or at , ● Do not massage bony prominences.
unless contraindicated, to relieve pressure on the
sacrum, buttocks, and heels.
Encourage proper nutrition. STAGE IV
● Provide adequate hydration (at least 2,500 mL/day) and ● Clean and/or debride with the following.
meet protein and calorie needs. ◯ Prescribed dressing
● Note if blood albumin levels are low (less than 3.5 g/dL), ◯ Surgical intervention
because a lack of protein puts the client at greater risk ◯ Proteolytic enzymes
for skin breakdown, slowed healing, and infection. ● Perform nonadherent dressing changes every 12 hr.
● Provide nutritional support as indicated (vitamin and ● Treatment can include skin grafts or specialized therapy
mineral supplements [especially A, C, zinc, copper], (hyperbaric oxygen).
nutritional supplements, and enteral and parenteral ● Provide nutritional supplements.
nutrition). ● Administer analgesics.
● Monitor lymphocyte count. ● Administer antimicrobials (topical and/or systemic).
● Lift, rather than pull, clients up in bed or in a chair,
UNSTAGEABLE: Debride until staging is possible.
because pulling creates friction that can damage the
outer layer of skin (epidermis). Note: Do not use alcohol, Dakin’s solution, acetic
acid, povidone-iodine, hydrogen peroxide, or any
other cytotoxic cleansers on a pressure injury wound.
TREATMENT
SUSPECTED DEEP TISSUE INJURY AND STAGE I
● Relieve pressure. COMPLICATIONS AND
● Encourage frequent turning and repositioning. NURSING IMPLICATIONS
● se pressure relie ing de ices an air uidi ed bed .
● Implement pressure-reduction surfaces (air mattress, Deterioration to higher-stage ulceration or infection
foam mattress). (55.2) ● Check the injury frequently and report an increase in
● Keep the client dry, clean, well-nourished, and hydrated.
the size or depth of the lesion, changes in granulation
STAGE II tissue (color, texture), and changes in exudate (color,
● Maintain a moist healing environment (saline or quantity, odor).
occlusive dressing). Apply hydrocolloid dressing. ● Follow the facility’s protocol for injury treatment.
● Promote natural healing while preventing the formation ● Might need to confer with wound care specialist.
of scar tissue.
● Provide nutritional supplements. Systemic infection
● Administer analgesics. ● Monitor for indications of sepsis (changes in level of
STAGE III consciousness, persistent recurrent fever, tachycardia,
● Clean and/or debride with the following. tachypnea, hypotension, oliguria, increase in
◯ Prescribed dressing WBC count).
◯ Surgical intervention ● Prevent infection by using aseptic technique when
◯ Proteolytic enzymes performing injury treatment and dressing changes.
● Provide nutritional supplements. ● Provide optimal nutrition to promote the
● Administer analgesics. immune response.
● Administer antimicrobials (topical and/or systemic). ● Provide for adequate rest to promote healing.
● Administer antibiotic therapy after collecting specimens
for culture and sensitivity testing.
55.2 Pressure-relieving device
1. A nurse is caring for a client who is 2 days 3. A nurse educator is reviewing the wound healing
postoperative following an appendectomy and process with a group of nurses. The nurse
has type I diabetes mellitus. Their Hgb is 12 g/dL educator should include in the information which
and BMI is 17.1. The incision is approximated and of the following alterations for wound healing by
free of redness, with scant serous drainage on secondary intention? (Select all that apply.)
the dressing. The nurse should recognize that the A. Stage 3 pressure injury
client has which of the following risk factors for
B. Sutured surgical incision
impaired wound healing? (Select all that apply.)
C. Casted bone fracture
A. Extremes in age
D. Laceration sealed with adhesive
B. Chronic illness
E. Open burn area
C. Low hemoglobin
D. Malnutrition
E. Poor wound care 4. A client who had abdominal surgery 24 hr ago
suddenly reports a pulling sensation and pain
in their surgical incision. The nurse checks the
2. A nurse is collecting data from a client who is 5 days surgical wound and finds it separated with
postoperative following abdominal surgery. The viscera protruding. Which of the following actions
surgeon suspects an incisional wound infection and should the nurse take? (Select all that apply.)
has prescribed antibiotic therapy for the nurse to A. Cover the area with saline-soaked sterile dressings.
initiate after collecting wound and blood specimens for
B. Apply an abdominal binder snugly
culture and sensitivity. Which of the following findings
around the abdomen.
C. Use sterile gauze to apply gentle
A. Increase in incisional pain
pressure to the exposed tissues.
B. Fever and chills
D. Position the client supine with
C. Reddened wound edges the hips and knees bent.
D. Increase in serosanguineous drainage E. Offer the client a warm beverage (herbal tea).
E. Decrease in thirst
5. A nurse is caring for a client who is at risk for

developing pressure injury. Which of the following
interventions should the nurse use to help maintain
the integrity of the client’s skin? (Select all that apply.)
A. Keep the head of the bed elevated 30°.
B. Massage the client’s bony prominences frequently.
C. Apply cornstarch liberally to the skin after bathing.
D. Have the client sit on a gel cushion when in a chair.
E. Reposition the client at least
every 3 hr while in bed.

the National Pressure Ulcer Advisory Panel’s classification
system for pressure injuries. Use the ATI Active Learning
RELATED CONTENT: List the six pressure injury

stages along with a brief description of the assessment
findings typical for ulcers at each stage.
1. A. The client is not at either extreme of the age spectrum. Using the ATI Active Learning Template: Basic Concept
B. CORRECT: Diabetes mellitus is a chronic illness that places RELATED CONTENT
additional stress on the body’s healing mechanisms. ●
Suspected deep tissue injury, depth unknown: Discoloration
C. CORRECT: Hgb is essential for oxygen delivery to
but intact skin from damage to underlying tissue.
healing tissues, and this client’s Hgb level is low.
D. CORRECT: A BMI of 17.1 indicates that the client is
●
Stage I, nonblanchable erythema: Intact skin with an area
underweight and, therefore, malnourished. Deficiencies of persistent, nonblanchable redness, typically over a bony
in essential nutrients delay wound healing. prominence, that can feel warmer or cooler than the adjacent
E. There is no indication that there have been any tissue. The tissue is swollen and has congestion, with possible
breaches in aseptic technique during wound care. discomfort at the site. With darker skin tones, the ulcer’s
coloring differs from that of the surrounding area.
NCLEX® Connection: Reduction of Risk Potential, System Specific ●
Stage II, partial thickness: Involves the epidermis and the
Assessments dermis. The ulcer is visible with reddish-pinkish bed without
slough or bruising, superficial, and can appear as an abrasion,
blister, or shallow crater. Edema persists. The ulcer can
2. A. CORRECT: Expect the client to have pain and tenderness
become infected, possibly with pain and scant drainage.
at the wound site with an incisional infection.
B. CORRECT: Expect the client to have fever
●
Stage III, full-thickness skin loss: Damage to or necrosis of
and chills with an incisional infection. subcutaneous tissue. The ulcer can extend down to, but not
C. CORRECT: Expect the client to have reddened or through, underlying fascia. The ulcer appears as a deep crater with
inflamed wound edges with an incisional infection. or without undermining or tunneling of adjacent tissue and without
D. Expect the client to have purulent drainage exposed muscle or bone. Drainage and infection are common.
with an incisional infection.
●
Stage IV, full-thickness tissue loss: Destruction, tissue necrosis,
E. Do not expect changes in thirst as an or damage to muscle, bone, or supporting structures.
indication of an incisional infection. There can be sinus tracts, deep pockets of infection,
tunneling, undermining, eschar (black scab-like material),
NCLEX® Connection: Physiological Adaptation, or slough (tan, yellow, or green scab-like material).
Alterations in Body Systems ●
Unstageable/unclassified, full-thickness skin or tissue loss, depth
unknown: No determination of stage because eschar or slough
3. A. CORRECT: Open pressure ulcers heal by secondary obscures the wound bed. The actual depth of injury is unknown.
intention, which is the process for wounds that have NCLEX® Connection: Physiological Adaptation, Pathophysiology
tissue loss and widely separated edges.
B. Sutured surgical incisions heal by primary intention,
which is the process for wounds that have little or
no tissue loss and well-approximated edges.
C. Unless the bone edges have pierced the skin, a casted
bone fracture is an injury to underlying structures
and does not require healing of the skin.
D. Lacerations sealed with tissue adhesive heal by primary
intention, which is the process for wounds that have little
or no tissue loss and well-approximated edges.
E. CORRECT: Open burn areas heal by secondary
intention, which is the process for wounds that have
tissue loss and widely separated edges.
4. A. CORRECT: Cover the wound with a sterile dressing

soaked with sterile normal saline solution to keep
the exposed organs and tissues moist until the
surgeon can assess and intervene.
B. An abdominal binder can help prevent,
not treat, a wound evisceration.
C. Do not handle or apply pressure to any exposed
organs or tissues, because these actions increase
the risks of trauma and perforation.
D. CORRECT: This position minimizes
pressure on the abdominal area.
E. Keep the client NPO in anticipation of the surgical team taking
them back to the surgical suite for repair of the evisceration.
NCLEX® Connection: Physiologic Adaptation, Medical
Emergencies
5. A. CORRECT: Slightly elevate the head of the client’s

bed to reduce shearing forces that could tear sensitive
skin on the sacrum, buttocks, and heels.
B. Deep tissues can be traumatized when massaging
the skin over bony prominences.
C. Cornstarch and powder can abrade the client’s
sensitive skin and increase the risk for aspiration.
D. CORRECT: Have the client sit on a gel, air, or foam cushion
to redistribute weight away from ischial areas.
E. Reposition the client at least every 2 hr. Frequent
position changes are important for preventing skin
breakdown, but every 3 hr is not frequent enough.
Immobility
CHAPTER 56
UNIT 4 PHYSIOLOGICAL INTEGRITY INFECTION PROCESS
The infection process (chain of infection) includes
Bacterial, Viral, the following.

CHAPTER 56
Fungal, and Causative agent
Parasitic Infections Bacterium, virus, fungus, prion, parasite
Reservoir
Human, animal, food, water, soil, insects, fomites
Pathogens are the microorganisms or microbes
that cause infections. Virulence is the ability of a Portal of exit from (means for leaving) the host
pathogen to invade the host and cause disease. Respiratory tract (droplet, airborne): Mycobacterium
tuberculosis and Parain uen a irus
Herpes zoster is a common viral infection that
Gastrointestinal tract: Shigella, Salmonella enteritidis,
erupts years after exposure to chickenpox and
Salmonella typhi, hepatitis A, Clostridium difficile
invades a specific nerve tract.
Genitourinary tract: Escherichia coli, herpes simplex virus
(type 1), HIV
PATHOGENS Skin/mucous membranes: Herpes simplex virus, varicella
Bacteria: Most common type of pathogen (Staphylococcus Blood/body fluids: HIV, hepatitis B and C
aureus, Escherichia coli, Mycobacterium tuberculosis)
Transplacental: Mycobacterium tuberculosis, cytomegalovirus
Viruses: Organisms that use the host’s genetic machinery
Reproductive tract: Neisseria gonorrhoeae, Treponema pallidum
to reproduce (rhinovirus, HIV, hepatitis, herpes zoster,
herpes simplex)
Mode of transmission
Fungi: Molds and yeasts (Candida albicans, Aspergillus)
CONTACT
Prions: Protein particles that have the ability to cause ● Direct physical contact: Person to person
infections (Creutzfeldt-Jakob disease) ● Indirect contact with a vehicle of transmission:
Inanimate object, water, food, blood
Parasites: Organisms that live on and often cause harm to
a host organism DROPLET: Large droplets travel through the air within
● Protozoa (malaria, toxoplasmosis) 0.9 m (3 feet) (sneezing, coughing, talking)
● Helminths orms at orms, round orms
AIRBORNE: Small droplets remain in the air and
● Flukes (schistosomes)
can tra el e tended distances depending on air o
● Arthropods (lice, mites, ticks)
(sneezing, coughing)
VECTOR-BORNE: Animals or insects as intermediaries

56.1 Chain of infection (ticks transmit Lyme disease; mosquitoes transmit
West Nile virus, malaria)
VEHICLE-BORNE: Material that transmits a causative agent

to a host (food contaminated by someone who had sneezed
close to it)
Portal of entry to the host

Often the same as the portal of exit
Susceptible host
Compromised defense mechanisms (immunosuppression,
breaks in skin) leave the host more susceptible
to infections.
FUNDAMENTALS FOR NURSING CHAPTER 56 BACTERIAL, VIRAL, FUNGAL, AND PARASITIC INFECTIONS 349
IMMUNE DEFENSES AGE
Older adults are at increased risk for infections due to
Nonspecific innate‑native immunity the following.
● Slowed response to antibiotic therapy
Allows the body to restrict entry or immediately respond ● Slowed immune response: indicators of infection more
to a foreign organism (antigen) through the activation of
difficult to identify, resulting in possible delays in
phagocytic cells, complement, and in ammation
diagnosis and treatment
● Nonspeci c innate nati e immunity pro ides temporary ● Loss of subcutaneous tissue and thinning of the skin
immunity but does not have memory of past exposures. ● Decreased vascularity and slowed wound healing
● Intact s in is the body s rst line of defense against ● Decreased cough and gag re e es
microbial invasion. ● Chronic illnesses (diabetes mellitus, COPD, neurologic or
● The skin, mucous membranes, secretions, enzymes,
musculoskeletal impairments)
phagocytic cells, and protective proteins work in concert ● Decreased gastric acid production
to prevent infections. ● Decreased mobility
Inflammatory response ● Bowel/bladder incontinence
● Phagocytic cells (neutrophils, eosinophils, macrophages), ● Dementia
the complement system, and interferons are involved. ● Greater incidence of invasive devices (urinary catheters,
● An in ammatory response locali es the area of feeding tubes, tracheostomies, intravenous catheters)
microbial invasion and prevents its spread.
Common indications of infection are not always
present in older adult clients. Altered mental status,
Specific adaptive immunity
agitation, or incontinence can be present instead.
Allows the body to make antibodies in response to a
foreign organism (antigen)
● Requires time to react to antigens
EXPECTED FINDINGS
● Provides permanent immunity due to memory of ● Chills
past exposures ● Sore throat
● Involves B and T lymphocytes ● Fatigue, malaise
● Produces speci c antibodies against speci c antigens ● Change in level of consciousness, nuchal rigidity,
(immunoglobulins: IgA, IgD, IgE, IgG, IgM) photophobia, headache
● Nausea, vomiting, anorexia, abdominal
cramping, diarrhea
ASSESSMENT/DATA COLLECTION ● Localized pain or discomfort
PHYSICAL ASSESSMENT FINDINGS

RISK FACTORS ● Fever
● Increased pulse and respiratory rate,
ENVIRONMENTAL FACTORS
decreased blood pressure
● Excessive alcohol consumption ● Localized redness and edema
● Nicotine use: smoking, smokeless tobacco ● Enlarged lymph nodes
● Malnutrition ● Dyspnea, cough, purulent sputum, crackles in
MEDICATION THERAPY (IMMUNOSUPPRESSIVE AGENTS) lung elds
● Glucocorticosteroids ● Dysuria, foul-smelling urine, urinary frequency,
● Antineoplastics hematuria, pyuria
● Rash, skin lesions, purulent wound drainage, erythema
CHRONIC DISEASES ● Dysphagia, hyperemia, enlarged tonsils
● Diabetes mellitus
● Multiple sclerosis
● Cancer LABORATORY TESTS
● HIV, AIDS
White blood cell (WBC) count with differential
● Peripheral vascular disease ● An elevated WBC count is an indicator of infection
● Chronic pulmonary disease
(expected reference range is 5,000 to 10,000/mm3).
● Heart failure ● The differential identi es speci c types of Cs that
INTERNAL FACTORS can assist in determining the severity of infection or the
● Stress speci c type of pathogen.
● Poor nutrition and uid inta e
Erythrocyte sedimentation rate (ESR)
● Lack of immunizations ● The rate at which red blood cells settle out of plasma
● Inadequate rest ● An elevated ESR is an indicator of an active
● Poor hygiene
in ammatory process or infection e pected reference
range is 15 to 20 mm/hr).
● An increase indicates an acti e in ammatory process
or infection.
350 CHAPTER 56 BACTERIAL, VIRAL, FUNGAL, AND PARASITIC INFECTIONS CONTENT MASTERY SERIES
Immunoglobulin electrophoresis PATIENT-CENTERED CARE
● Determines the presence and uantity of speci c
immunoglobulins (IgG, IgA, IgM) NURSING CARE
● Used to detect hypersensitivity disorders, autoimmune ● Assess the following.
disorders, chronic iral infections, immunode ciency, ◯ Presence of risk factors for infection
multiple myeloma, intrauterine infections ◯ Recent travel or exposure to an infectious disease
Antibody screening tests ◯ Behaviors that can put the client at increased risk
● Detects the presence of antibodies against speci c ◯ Increased temperature, heart, and respiratory rate;
causative agents (bacteria, fungi, viruses, parasites) thirst; anorexia

● A positive antibody test indicates that the client ◯ Presence of chills, which occur when temperature
has been exposed to and developed antibodies to a is rising, and diaphoresis, which occurs when
speci c pathogen, but it does not pro ide information temperature is decreasing
about whether or not the client is currently infected ◯ Presence of hyperpyrexia (greater than 41º C
(HIV antibodies). [105.8° F]), which can cause brain and organ damage
● Implement infection control measures.
Auto-antibody screening tests ◯ Perform frequent hand hygiene to prevent
● Detects the presence of antibodies against a person’s
transmission of infection to other clients.
own DNA (self-cells) ◯ Maintain a clean environment.
● The presence of antibodies against self cells is ◯ Perform wound care measures (sterile
associated with autoimmune conditions (systemic lupus

dressing changes).
erythematosus, rheumatoid arthritis). ◯ Use personal protective equipment/barriers
Antigen tests (gloves, masks, gowns, goggles).

● Detects the presence of a speci c pathogen HI ◯ Encourage recommended immunizations.
● Used to identify certain infections or disorders ◯ Implement protective precautions as needed.
■ Standard: Implemented for all clients

Stool for ova and parasites ■ Contact: Clostridium difficile, herpes simplex virus,
● Detects the presence of ova and parasites (hookworm
impetigo, methicillin-resistant Staphylococcus
ova in stool)
aureus (MRSA), vancomycin-resistant
● Three separate stool specimens usually collected
Staphylococcus aureus (VRSA)
● Each specimen must be transported to the laboratory ■ Droplet: Haemophilus influenzae type B (Hib),
while it is still warm.
pertussis, mumps, rubella, plague, streptococcal
Culture and sensitivity pneumonia, meningococcal pneumonia
● A culture is a microscopic examination to identify an ■ Airborne: Measles, varicella, tuberculosis
infecting organism. ● Encourage adequate rest and nutrition.

● Cultures can be obtained from blood, sputum, urine, ● Provide diversional activities.
wound, and soft tissue. ● ncourage increased uid inta e or maintain
● Cultures should be obtained before any antibiotic intra enous uid replacement to pre ent dehydration.
therapy is initiated. ● Protect and maintain the client’s protective barriers
● The sensitivity report indicates which antibiotics are (skin, mucous membranes).
effecti e against the identi ed organism.
MEDICATIONS
DIAGNOSTIC PROCEDURES Antipyretics
X-rays, computed tomography (CT) scans, magnetic Acetaminophen and aspirin help reduce fever
resonance imaging (MRI), and biopsies are used and discomfort.
to determine the presence of infection, abscesses,
NURSING ACTIONS
and lesions. ● onitor fe er to determine the effecti eness of
Gallium scan the medication.
● A nuclear scan that uses a radioactive substance to ● Document temperature uctuations on the medical
identify hot spots of WBCs within the client’s body record for trending.
Radioactive gallium citrate injected intravenously and
Antimicrobial therapy
●
accumulates in areas here in ammation is present

Antimicrobial medications kill pathogens or prevent their
growth. Anthelmintics are given for worm infestations.
There are currently no treatments for prions.
NURSING ACTIONS
● Administer antimicrobial therapy.
● onitor for medication effecti eness reduced fe er,
increased level of comfort, decreasing WBC count).
● Maintain a medication schedule to assure consistent
therapeutic blood levels of the antibiotic.
CLIENT EDUCATION Herpes zoster (shingles)
● Understand the following.
Herpes zoster is a viral infection. It initially produces
◯ Any infection control measures needed at home
chickenpox, after which the virus lies dormant in the

◯ Self-administration of medication therapy
dorsal root ganglia of the sensory cranial and spinal

◯ Complications to report immediately
nerves. It is then reactivated as shingles later in life.
● Infants should recei e the H. in uen ae type b ● Shingles is usually preceded by a prodromal period of
(Hib) vaccine.
several days, during which pain, itching, tingling, or
● Adults and older adults at risk should receive the
burning can occur along the involved dermatome.
pneumococcal polysaccharide vaccine (PPSV). ● Shingles can be very painful and debilitating.
● Adolescents should receive the meningococcal vaccine
on schedule and prior to living in a residential or
communal setting.
DISEASE PREVENTION
COMPLICATIONS Immunization with the two-dose recombinant
zoster vaccine to prevent herpes zoster infection and
Medication-resistant infections postherpetic neuralgia
Antimicrobials are becoming less effecti e for some

strains of pathogens, due to the pathogens’ ability to
adapt and become resistant to antibiotics to which they
ere pre iously sensiti e. This signi cantly limits the
number of antibiotics that are effecti e against the RISK FACTORS
pathogen. Use of antibiotics, especially broad-spectrum ● Concurrent illness
antibiotics, has signi cantly decreased to pre ent ne ● Stress
strains from evolving. Taking the measures below can ● Compromise of the immune system
ensure an antimicrobial is warranted and increase the ● Fatigue
effecti eness of treatment. ● Poor nutritional status
● MRSA is a strain of Staphylococcus aureus that is resistant
to most antibiotics, except vancomycin. Possible immunocompromise makes older adult
● VRSA is a strain of Staphylococcus aureus that is resistant clients more susceptible to herpes zoster infection.
to vancomycin but so far is sensitive to other antibiotics Assess these clients carefully for typical and atypical
speci c to the strain. indications of infection.
NURSING ACTIONS
● Obtain specimens for culture and sensitivity prior to EXPECTED FINDINGS
initiation of antimicrobial therapy. ● Paresthesia
● Monitor antimicrobial levels and ensure that therapeutic ● Pain that is unilateral and extends horizontally along
levels are maintained.
a dermatome
● Implement precautions to prevent the spread of the
infection, including protecting others whenever PHYSICAL ASSESSMENT FINDINGS
transporting the client outside the isolation room. ● Vesicular, unilateral rash (the rash and lesions occur on
the skin area innervated by the infected nerve)
CLIENT EDUCATION ● Changes in or loss of ision if the eye is affected
● Complete the full course of antimicrobial therapy. ● Rash that is erythematous, vesicular, pustular, or
● Avoid overuse of antimicrobials.
crusting (depending on the stage)
Rash that usually lasts several weeks
Sepsis
●
● Low-grade fever
A systemic in ammatory response syndrome resulting ● Chills
from the body’s response to a serious infection, usually ● Upset stomach
bacterial (peritonitis, meningitis, pneumonia, wound
infections, urinary tract infections)
● Sepsis is a potentially life-threatening complication that
LABORATORY TESTS
can lead to idespread in ammation, blood clotting, ● Cultures pro ide a de niti e diagnosis but the irus
organ failure, and shock. grows so slowly that cultures are often of minimal
● lood cultures de niti ely diagnose sepsis. ystemic diagnostic use).
antimicrobials are prescribed accordingly. Vasopressors ● ccasionally, an immuno uorescence assay is done.
and anticoagulants treat shock and blood clotting
manifestations. Mechanical ventilation, dialysis, and
other inter entions treat speci c organ failure.
RISK FACTORS: Very young age, very old age, weakened

immune system, severe injuries (trauma)
PATIENT-CENTERED CARE Application Exercises
NURSING CARE
1. A nurse is discussing direct and indirect contact
● Assess/monitor the following. modes of transmission of infection at a staff
◯ Pain education session. Which of the following incidents
◯ Condition of lesions should the nurse include as examples of the direct
◯ Presence of fever mode of transmission? (Select all that apply.)
◯ Neurologic complications A. Blood spurting from an arterial wound
◯ Indications of infection splashes into a nurse’s eye.
● Use an air mattress or bed cradle for pain prevention B. A nurse has a needlestick injury.
and control of affected areas. C. A mosquito bites a hiker in the woods.
● Isolate the client until the vesicles have crusted over.
D. A nurse finds a hole in their glove
● Maintain strict wound care precautions. while handling a soiled dressing.
● The virus can be transmitted through direct contact,
E. A person fails to wash their hands after
causing chickenpox. Avoid exposing infants, pregnant
using the bathroom and touches a client.
women who have not had chickenpox, and clients who
are immunocompromised.
● Moisten dressings with cool water or 5% aluminum 2. A nurse in a residential care facility is assessing an
acetate uro s solution and apply to the affected s in older adult client. Which of the following findings
for 30 to 60 min, four to six times per day. should the nurse identify as atypical indications
● Use lotions (calamine lotion) or recommend colloidal of infection in this client? (Select all that apply.)
oatmeal bath per CDC to help relieve itching A. Urinary incontinence
and discomfort. B. Malaise
MEDICATIONS C. Acute confusion

D. Fever
● Analgesics (NSAIDs, opioids) enhance client comfort.
E. Agitation
● If started soon after the rash appears, antiviral agents
(acyclovir) can decrease the severity of the infection and
shorten the clinical course. 3. A nurse is preparing to admit a client who is suspected
● Recommend recombinant zoster vaccine for clients to have pulmonary tuberculosis. Which of the following
60 years and older to prevent shingles. This vaccine actions should the nurse plan to perform first?
does not treat active shingles infections. A. Implement airborne precautions.
B. Obtain a sputum culture.
COMPLICATIONS C. Administer antituberculosis medications.
Postherpetic neuralgia D. Recommend a screening test for family members.
Characterized by pain that persists for longer than

4.
●
1 month following resolution of the vesicular rash. A nurse in a primary care clinic is assessing
a client who has a history of herpes zoster.
● Tricyclic antidepressants might help.
Which of the following findings suggests that
● Postherpetic neuralgia is common in adults older than
the client has postherpetic neuralgia?
60 years of age.
A. Linear clusters of vesicles on the right shoulder
B. Purulent drainage from both eyes
Active Learning Scenario C. Decreased white blood cell count
D. Report of continued pain following
A nurse is admitting a client who has a new diagnosis resolution of the rash
of herpes zoster. Use the ATI Active Learning
Template: System Disorder and the Medical-Surgical
Nursing Review Module to complete this item. 5. A charge nurse is teaching a newly licensed
nurse about the care of a client who has
PATHOPHYSIOLOGY RELATED TO CLIENT methicillin-resistant Staphylococcus aureus (MRSA).
PROBLEM: Identify the mode of transmission. Which of the following statements should the
RISK FACTORS: Identify at least three risk charge nurse identify as an indication that the
factors for acquiring herpes zoster. newly licensed nurse understands the teaching?
A. “I should obtain a specimen for culture and
EXPECTED FINDINGS: Identify at least three sensitivity after the first dose of an antimicrobial.”
indications of infection with herpes zoster.
B. “MRSA is usually resistant to vancomycin, so
NURSING CARE: Identify information the nurse another antimicrobial will be prescribed.”
should provide the client and family about C. “I will protect others from exposure when I
acquiring adaptive immunity for herpes zoster. transport the client outside the room.”
CLIENT EDUCATION: Identify one preventative measure D. “To decrease resistance, antimicrobial therapy is
to prevent the transmission of herpes zoster. discontinued when the client is no longer febrile.”
1. A. CORRECT: Transmission from blood to the nurse’s eyes, nose, Using the ATI Active Learning Template: System Disorder
or mouth is person-to-person or direct transmission. PATHOPHYSIOLOGY RELATED TO CLIENT
B. Transmission from a needle or other inanimate PROBLEM: Contact transmission
object is indirect transmission.
C. Transmission from an insect is vector-borne RISK FACTORS
(indirect) transmission. ●
Concurrent illness
D. Transmission from a soiled dressing or other inanimate ●
Stress
object is vehicle-borne (indirect) transmission. ●
Compromise of the immune system
E. CORRECT: Transmission from contaminated hands to a ●
Fatigue
client is person-to-person or direct transmission. ●
Poor nutritional status
NCLEX Connection: Safety and Infection Control, Standard
®
Precautions/Transmission-Based Precautions/Surgical Asepsis EXPECTED FINDINGS

●
Paresthesia
●
Pain that is unilateral and extends horizontally along a dermatome
2. A. CORRECT: Urinary incontinence is an atypical ●
Vesicular, unilateral rash (the rash and lesions occur on
indication of infection in an older adult client. the skin area innervated by the infected nerve)
B. Malaise is a typical indication of infection. ●
Changes in or loss of vision if the eye is affected
C. CORRECT: Acute confusion is an atypical indication ●
Rash that is erythematous, vesicular, pustular,
of infection in an older adult client. or crusting (depending on the stage)
D. Fever is a typical indication of infection. ●
Rash that usually lasts several weeks
E. CORRECT: Agitation is an atypical indication
of infection in an older adult client.
●
Low-grade fever
●
Chills
NCLEX® Connection: Safety and Infection Control, Standard ●
Upset stomach
NURSING CARE
●
Assess/monitor the following.
3. A. CORRECT: The greatest safety risk to the nurse and Pain
◯
others is transmission of the infection from airborne

Condition of lesions
◯
exposure to tuberculosis. The priority action to take

is to implement airborne precautions. Presence of fever
◯
B. Obtain a sputum culture to help confirm the Neurologic complications

◯
diagnosis, but another action is the priority. Indications of infection

◯
C. Administer medications to treat tuberculosis, ●

Use an air mattress or bed cradle for pain
but another action is the priority. prevention and control of affected areas.
D. Recommend screening tests for those in close contact ●
Isolate the client until the vesicles have crusted over.
with the client to determine whether they need antibiotic ●
Maintain strict wound care precautions.
therapy, but another action is the priority. ●
Moisten dressings with cool water or 5% aluminum
NCLEX® Connection: Safety and Infection Control, Standard acetate (Burow’s solution) and apply to the affected
Precautions/Transmission-Based Precautions/Surgical Asepsis skin for 30 to 60 min, four to six times per day.
●
Use lotions (calamine lotion) or recommend oatmeal
baths to help relieve itching and discomfort.
4. A. Localized linear clusters of vesicles are an expected finding
with herpes zoster rather than postherpetic neuralgia. CLIENT EDUCATION
B. Eye infection is a potential complication of herpes zoster ●
The virus can be transmitted through direct contact, causing
but does not suggest postherpetic neuralgia. chickenpox. Avoid exposing infants, pregnant women who have
C. Immunosuppression increases the risk for herpes zoster not had chickenpox, and clients who are immunocompromised.
but does not suggest postherpetic neuralgia. ●
Recommend zoster vaccine live for clients 60
D. CORRECT: Pain that persists following resolution of the years and over to prevent shingles. This vaccine
vesicular rash is an indication of postherpetic neuralgia. does not treat active shingles infections.
NCLEX® Connection: Physiological Adaptation, NCLEX® Connection: Safety and Infection Control, Standard
Illness Management Precautions/Transmission-Based Precautions/Surgical Asepsis
5. A. Obtain a specimen for culture and sensitivity prior

to the initiation of antimicrobial therapy.
B. MRSA is resistant to most antibiotics except vancomycin.
C. CORRECT: Particularly with infections due to
antibiotic-resistant bacteria, protect everyone the
client comes in contact with from transmission,
especially when outside the isolation room.
D. Discontinuing antimicrobial therapy prior to
completing a full course of treatment increases
the risk of producing resistant pathogens.
CHAPTER 57
UNIT 4 PHYSIOLOGICAL INTEGRITY ASSESSMENT/DATA COLLECTION
CHAPTER 57 Fluid Imbalances RISK FACTORS

CAUSES OF ISOTONIC FVD (HYPOVOLEMIA)
● Excessive gastrointestinal (GI) loss:
vomiting, nasogastric suctioning, diarrhea
Body fluids are distributed between intracellular ● Excessive skin loss: diaphoresis without water and
fluid (ICF) and extracellular fluid (ECF) sodium replacement
Excessive renal system losses: diuretic therapy, kidney
compartments. ICF lies within body cells and
●
disease, adrenal insufficiency

constitutes two-thirds of the total body fluids in ● Third spacing: burns
Hemorrhage or plasma loss
adults. ECF is comprised of intravascular (plasma),
●
● Altered intake: anorexia, nausea, impaired swallowing,

interstitial (fluid that surrounds the cells), lymph, confusion, nothing by mouth (NPO) (decreased intake of
water and sodium)
and transcellular fluids (cerebrospinal, pericardial,
CAUSES OF DEHYDRATION
pancreatic, pleural, intraocular, biliary, peritoneal, ● Hyperventilation or excessive perspiration without
and synovial fluids). water replacement
● Prolonged fever
Fluid can move between compartments ● Diabetic ketoacidosis
Insufficient ater inta e enteral feeding ithout ater
(through selectively permeable membranes)
●
administration, decreased thirst sensation, aphasia)

by a variety of methods (diffusion, active ● Diabetes insipidus
Osmotic diuresis
transport, filtration, osmosis) in order to maintain
●
● cessi e inta e of salt, salt tablets, or hypertonic I uids

homeostasis. Fluid imbalances that the nurse
should be familiar with are fluid volume deficit EXPECTED FINDINGS
and fluid volume excess. VITAL SIGNS: Hypothermia (hypovolemia) or hyperthermia
(dehydration), tachycardia, thready pulse, hypotension,
orthostatic hypotension, decreased central venous
Dehydration
pressure, tachypnea (increased respirations), hypoxia
NEUROMUSCULOSKELETAL: Dizziness, syncope, confusion,

● Dehydration is a lac of uid in the body, from weakness, fatigue; seizures (rapid/severe dehydration)
insufficient inta e or e cessi e loss.
◯ Actual dehydration is a lac
GI: Thirst, dry mucous membranes, dry furrowed tongue,
of uid in the body
nausea, vomiting, anorexia, acute weight loss
relative dehydration involves a shift of water from the
plasma (blood) to the interstitial space. RENAL: Oliguria (decreased production of urine)
◯ Hypovolemia, or isotonic dehydration, is a lack of
OTHER FINDINGS: Diminished capillary re ll, cool

both water and electrolytes, causing a decrease in
clammy s in, diaphoresis, sun en eyeballs, attened nec
circulating blood olume. This is also called uid
veins, absence of tears, decreased skin turgor
olume de cit.
● Compensatory mechanisms include sympathetic Assessment of skin turgor in the older adult might
nervous system responses of increased thirst, not provide reliable findings due to a natural loss of
antidiuretic hormone (ADH) release, and skin elasticity.
aldosterone release.
Rapid or severe dehydration can induce seizures.
LABORATORY TESTS
●
● FVD can lead to hypovolemic shock.

● Older adults have an increased risk for dehydration due Hct: Increased in both hypovolemia and dehydration
to multiple physiological factors including a decrease in unless the uid olume de cit is due to hemorrhage
total body mass, which includes total body water
Blood osmolarity
content and a decrease in the ability to detect thirst.
Dehydration: Increased hemoconcentration osmolarity
(greater than 295 mOsm/kg)
Urine specific gravity

Dehydration Increased concentration urine speci c
gravity greater than 1.030)
FUNDAMENTALS FOR NURSING CHAPTER 57 FLUID IMBALANCES 355

Blood sodium ASSESSMENT/DATA COLLECTION
Dehydration: Increased hemoconcentration (greater than
145 mEq/L)
RISK FACTORS
BUN: Increased (greater 25 mg/dL) due to
CAUSES OF HYPERVOLEMIA
hemoconcentration ● Chronic stimulus to the kidney to conserve
Dehydration: Increased protein, electrolytes, glucose sodium and water (heart failure, cirrhosis,
increased glucocorticosteroids)
● Altered kidney function with reduced excretion of
PATIENT-CENTERED CARE sodium and water (kidney failure)
● Interstitial to plasma uid shifts hypertonic uids, burns
Age-related changes in cardiovascular and
NURSING CARE
●
kidney function
● onitor respiratory rate, effort, and o ygen ● cessi e sodium inta e from I uids, diet, or
saturation (SaO2). medications (sodium bicarbonate antacids, hypertonic
● Check urinalysis, CBC, and electrolytes. enema solutions)
● Administer supplemental oxygen as prescribed.
CAUSES OF OVERHYDRATION
● Measure the client’s weight daily at same time of day ● Water replacement without electrolyte replacement,
using the same scale.
excessive water intake (forced or psychogenic polydipsia)
● Observe for nausea and vomiting. ● Syndrome of inappropriate antidiuretic hormone
● Assess postural blood pressure and pulse. (Check for
(SIADH), which is the excess secretion of ADH
hypotension and orthostatic hypotension.) ● Excessive administration of IV D5W; use of hypotonic
● Check neurologic status to determine level of
solutions for irrigations, enemas
consciousness.
● Assess heart rhythm.
● Initiate and maintain IV access. EXPECTED FINDINGS
● Provide oral and IV rehydration therapy as prescribed.
VITAL SIGNS: Tachycardia, bounding pulse, hypertension,
● onitor I . ncourage uids as tolerated. Alert the
tachypnea, increased central venous pressure
provider to a urine output less than 30 mL/hr.
● Monitor level of consciousness and ensure client safety. NEUROMUSCULOSKELETAL: Confusion, muscle weakness,
● Observe level of gait stability. altered level of consciousness, paresthesias, visual changes;
● Encourage the client to use the call light and ask seizures (if severe, sudden hyponatremia/water excess).
for assistance.
GI: Increased motility, ascites
● Encourage the client to change positions slowly (rolling
from side to side or standing up). RESPIRATORY: Dyspnea, orthopnea, crackles
OTHER FINDINGS: Pitting edema, distended neck veins,
Overhydration
weight gain, skin pallor and cool to touch
● erhydration is too much uid in the body, from LABORATORY TESTS

e cessi e inta e, or ineffecti e remo al from the body.
Hct
◯ luid o erload is an e cess of uid or ater ith ● Hypervolemia: Decreased Hct
water intoxication). This includes hemodilution, ● Overhydration: Decreased Hct = hemodilution
which makes the amount of blood components (blood
cells, electrolytes) seem lower. Blood osmolarity
◯ Hyper olemia, or uid olume e cess, in ol es and Overhydration: Osmolarity less than 280 mOsm/kg
excess of water and electrolytes, so that the two are
Blood sodium
still in the right proportions. For example, excessive
Overhydration: Sodium decreased
sodium intake causes the body to retain water, so that
there is too much of both. BUN
● Severe FVE can lead to pulmonary edema and Hypervolemia: Decreased
heart failure.
Arterial blood gases
● Compensatory mechanisms include an increased release
Respiratory alkalosis: Decreased PaCO2 (less than
of natriuretic peptides, causing increased excretion of
35 mm Hg), increased pH (greater than 7.45)
sodium and water by the kidneys, usually accompanied
by a decreased release of aldosterone. Urine specific gravity
Less than 1.010 (if not due to SIADH)
Other electrolytes
Overhydration: decreased
356 CHAPTER 57 FLUID IMBALANCES CONTENT MASTERY SERIES

DIAGNOSTIC PROCEDURES Application Exercises
Chest x-rays can indicate pulmonary congestion.
1. A nurse is performing an admission assessment
on a client who has hypovolemia due to vomiting
PATIENT-CENTERED CARE and diarrhea. The nurse should expect which of
the following findings? (Select all that apply.)
A client ho has e cess uid and ater uid olume
A. Distended neck veins
excess) will require sodium restriction. FVE and
o erhydration usually re uire uid restriction. B. Hyperthermia
C. Tachycardia
D. Syncope
NURSING CARE
E. Decreased skin turgor
● bser e respiratory rate, symmetry, and effort.
● Auscultate breath sounds in all lung elds. Lung sounds
can be diminished with crackles. 2. A nurse on a medical-surgical unit is caring for a
● Monitor for shortness of breath and dyspnea. group of clients. The nurse should identify that which
of the following clients is at risk for hypovolemia?
● Check ABGs, SaO2, CBC, and chest x-ray results.
● Position the client in semi-Fowler’s position. A. A client who has nasogastric suctioning
● Measure the client’s weight daily at same time of day B. A client who has chronic constipation
using the same scale. C. A client who has syndrome of
● Monitor and document edema (pretibial, inappropriate antidiuretic hormone
sacral, periorbital). D. A client who took an toxic dose of
● Monitor I&O. sodium bicarbonate antacids
● Implement prescribed restrictions for uid and
sodium intake.
◯ Pro ide uids in small glass to promote the 3. A nurse is reviewing the laboratory test results for a
client who has an elevated temperature. The nurse
perception of a full glass of uid.
should identify which of the following findings is a
◯ et to hr short term goals for the uid restriction
manifestation of dehydration? (Select all that apply.)
to promote client control and understanding.
A. Hct 55%
● Administer supplemental oxygen as needed. Reduce
I o rates. B. Blood osmolarity 260 mOsm/kg
● Administer diuretics (osmotic, loop) as prescribed. C. Blood sodium 150 mEq/L
● Monitor and document circulation to the extremities. D. Urine specific gravity 1.035
● Reposition the client at least every 2 hr. E. Blood creatinine 0.6 mg/dL
● Support arms and legs to decrease dependent edema.
4. A nurse on a medical-surgical unit is caring for a group

of clients. For which of the following clients should
the nurse expect a prescription for fluid restriction?
A. A client who has a new diagnosis
of adrenal insufficiency
B. A client who has heart failure
Active Learning Scenario C. A client who is receiving treatment
for diabetic ketoacidosis
A nurse is caring for a client who has fluid volume D. A client who has abdominal ascites
excess due to cirrhosis of the liver. Use the ATI Active
Learning Template: System Disorder to complete
this item to include the following sections. 5. A nurse is planning care for a client who
has dehydration. Which of the following
ALTERATION IN HEALTH (DIAGNOSIS): Describe actions should the nurse include?
the diagnosis of fluid volume excess.
A. Administer antihypertensive on schedule.
COMPLICATIONS: Identify two complications B. Check the client’s weight each morning.
that can result from this disorder.
C. Notify the provider of a urine output
EXPECTED FINDINGS: Identify at least five expected greater than 30 mL/hr.
assessment findings and three expected laboratory findings. D. Encourage independent ambulation
NURSING CARE: Identify at least five interventions four times a day.
the nurse should include in the plan of care.
FUNDAMENTALS FOR NURSING CHAPTER 57 FLUID IMBALANCES 357

1. A. Distended neck veins is an expected Using the ATI Active Learning Template: System Disorder
finding of hypervolemia.
DESCRIPTION OF DISORDER/DISEASE PROCESS: Fluid volume excess
B. Hypothermia is an expected finding of hypovolemia.
(FVE) is the isotonic retention of water and sodium in high proportions.
C. CORRECT: Tachycardia is an expected
finding of hypovolemia. COMPLICATIONS
D. CORRECT: Syncope is an expected finding of hypovolemia. ●
FVE is often referred to as hypervolemia because
E. CORRECT: Decreased skin turgor is an of the resulting increased blood volume.
expected finding of hypovolemia. ●
Severe FVE can lead to pulmonary edema and heart failure.
NCLEX® Connection: Physiological Adaptation, EXPECTED FINDINGS
Fluid and Electrolyte Imbalances
Assessment findings
●
Vital signs: Tachycardia, bounding pulse, hypertension,
2. A. CORRECT: Identify that a client who has nasogastric tachypnea, increased central venous pressure
suctioning is at risk for hypovolemia due to ●
Neuromusculoskeletal: Confusion, muscle weakness
excessive gastrointestinal losses. ●
GI: Weight gain, ascites
B. Diarrhea, rather than constipation, places the client at risk ●
Respiratory: Dyspnea, orthopnea, crackles
for hypovolemia due to excessive gastrointestinal losses.
C. Syndrome of inappropriate antidiuretic hormone places
●
Other findings: Edema, distended neck veins
the client at risk for hypervolemia due to overhydration. Laboratory findings
D. A toxic dose of sodium bicarbonate antacids places the client ●
Decreased Hct
at risk for hypervolemia due to excessive sodium intake. ●
Blood sodium within the expected reference range
NCLEX® Connection: Physiological Adaptation, ●
Decreased BUN
Fluid and Electrolyte Imbalances ●
Respiratory alkalosis: decreased PaCO2 (less than
35 mm Hg), increased pH (greater than 7.45)
●
Urine specific gravity less than 1.010
3. A. CORRECT: This Hct is greater than the expected reference
range of 42-52% for males and 37-47% for females and is an PATIENT-CENTERED CARE
indication of dehydration due to hemoconcentration. ●
Observe respiratory rate, symmetry, and effort.
B. This blood osmolarity is within the expected reference ●
Auscultate breath sounds in all lung fields. Lung
range of 285-295 mOsm/kg. A blood osmolarity greater sounds can be diminished with crackles.
than 295 mOsm/kg is an indication of dehydration. ●
Monitor for shortness of breath and dyspnea.
C. CORRECT: This blood sodium level is greater than the ●
Check ABGs, SaO2, CBC, and chest x-ray results.
expected reference range of 136-145 mEq/L and is an
indication of dehydration due to hemoconcentration.
●
Position the client in semi-Fowler’s position.
D. CORRECT: This urine specific gravity is greater than the
●
Measure the client’s weight daily at same
expected reference range of 1.005-1.030. An increased time of day using the same scale.
urine specific gravity is an indication of dehydration. ●
Monitor and document edema (pretibial, sacral, periorbital).
E. This blood creatinine is within the expected reference ●
Monitor I&O.
range of 0.6 to 1.3 mg/dL. An elevated blood ●
Implement prescribed restrictions for fluid and sodium intake.
creatinine level is an indication of dehydration. ●
Provide fluids in a small glass to promote the
NCLEX® Connection: Basic Care and Comfort, perception of a full glass of fluid.
Nutrition and Oral Hydration ●
Set 1- to 2-hr short-term goals for the fluid restriction
to promote client control and understanding.
●
Administer supplemental oxygen as needed. Reduce IV flow rates.
4. A. A client who has adrenal insufficiency is at risk for ●
Administer diuretics (osmotic, loop) as prescribed.
isotonic fluid volume deficit (hypovolemia) because ●
Monitor and document circulation to the extremities.
of a decrease in aldosterone secretion and an
increase in sodium and water excretion .
●
Reposition the client at least every 2 hr.
B. CORRECT: Anticipate a client who has heart
●
Support arms and legs to decrease dependent edema.
failure to require fluid and sodium restriction NCLEX® Connection: Physiological Adaptation,
to reduce the workload on the heart. Fluid and Electrolyte Imbalances
C. A client who has diabetic ketoacidosis is at risk for
dehydration because hyperglycemia can cause osmotic
dieresis which leads to dehydration and electrolyte loss.
D. A client who has ascites is at risk for hypovolemia because of
a fluid shift from the intravascular space to the abdomen.
Illness Management
5. A. Hypotension is a manifestation of dehydration

therefore the administration of antihypertensive
medication would further lower the client’s blood
pressure and increase the risk for injury.
B. CORRECT: Include obtaining the client’s weight each day in
the plan of care. To ensure accuracy the client’s weight should
be obtained at the same time each day using the same scale.
By determining the client’s weight gain or loss each day the
nurse can evaluate the client’s response to treatment.
C. A urine output greater than 30 mL/hr is an expected
finding and is an indicator of adequate fluid balance.
Plan to monitor the client’s urine output and notify
the provider if it is less than 30 mL/hr.
D. The client who has dehydration is at risk for falls due
to orthostatic hypotension, possible decrease in
level of consciousness, and possible gait instability.
Encourage the client to use the call light and ask for
assistance when getting out of bed or ambulating.
358 CHAPTER 57 FLUID IMBALANCES CONTENT MASTERY SERIES

CHAPTER 58
Sodium imbalances
Electrolyte
● Sodium (Na+) is the major electrolyte found in ECF and
CHAPTER 58 is present in most body uids or secretions.
Imbalances ● Sodium is essential for maintenance of acid-base

and uid balance, acti e and passi e transport
mechanisms, and irritability and conduction of nerve
and muscle tissue.
Electrolytes are minerals (sometimes called
salts) that have an electric charge and are
present in all body fluids. They regulate fluid Hyponatremia
Hyponatremia is a blood sodium level less than
balance and hormone production, strengthen
●
136 mEq/L.
skeletal structures, and act as catalysts in ● Hyponatremia results from an excess of water in the
plasma or loss of sodium rich uids.
nerve response, muscle contraction, and the ● Hyponatremia delays and slows the depolarization
metabolism of nutrients. of membranes.
● Water moves from the ECF into the ICF, which causes
Major electrolytes in the body include sodium, cells in the brain and nervous system to swell.
potassium, chloride, magnesium, phosphorus,

and calcium. Electrolytes are either positive ASSESSMENT/DATA COLLECTION
(cations: magnesium, potassium, sodium,
calcium) or negative (anions: phosphate, sulfate, RISK FACTORS
De cient C olume
chloride, bicarbonate).
●
● Excessive GI losses: vomiting, nasogastric suctioning,

diarrhea, tap water enemas
Monitoring laboratory values can help in ● Renal losses: diuretics, kidney disease, adrenal
identifying any electrolyte imbalances. While insufficiency, e cessi e s eating
Skin losses: burns, wound drainage, gastrointestinal
laboratory tests can accurately reflect the
●
obstruction, peripheral edema, ascites

electrolyte concentrations in plasma, it is ● Increased or normal ECF volume: excessive oral water
intake, syndrome of inappropriate antidiuretic hormone
not possible to directly measure electrolyte secretion (SIADH)
concentrations within cells. ● Edematous states: heart failure, cirrhosis,
nephrotic syndrome
It is important to recognize the manifestations of ● Excessive IV administration of dextrose 5% in water
Inadequate sodium intake (NPO status)
electrolyte imbalance. Clients at greatest risk for
●
● Use of hypotonic irrigating solutions

electrolyte imbalance are infants, children, older ● Hyperglycemia
Older adult clients are at greater risk due to an increased
adults, clients who have cognitive disorders, and
●
incidence of chronic illnesses, use of diuretic

clients who have chronic illnesses. medications, and ris for insufficient sodium inta e.
EXPECTED REFERENCE RANGES EXPECTED FINDINGS

Sodium: 136 to 145 mEq/L PHYSICAL ASSESSMENT FINDINGS: Vary with a normal,
decreased, or increased ECF volume
Calcium: 9 to 10.5 mg/dL
VITAL SIGNS: Hypothermia, tachycardia, rapid thready
Potassium: 3.5 to 5 mEq/L
pulse, hypotension, orthostatic hypotension
Magnesium: 1.3 to 2.1 mEq/L
NEUROMUSCULOSKELETAL: Headache, confusion,
Chloride: 98 to 106 mEq/L lethargy, muscle weakness with possible respiratory
compromise, fatigue, decreased deep tendon re e es
Phosphorus: 3 to 4.5 mg/dL
(DTRs), seizures, coma
GI: Increased motility, hyperactive bowel sounds,

abdominal cramping, anorexia, nausea, vomiting
FUNDAMENTALS FOR NURSING CHAPTER 58 ELECTROLYTE IMBALANCES 359

PATIENT-CENTERED CARE EXPECTED FINDINGS
VITAL SIGNS: Hyperthermia, tachycardia,
NURSING CARE orthostatic hypotension
● Monitor I&O, and weigh the client daily at same time of NEUROMUSCULOSKELETAL: Restlessness, fatigue,
day using the same scale. disorientation, irritability, muscle twitching, muscle
● Monitor vital signs and level of consciousness, reporting weakness, seizures, decreased level of consciousness,
irregular ndings. reduced to absent DTRs
● Encourage the client to change positions slowly.
GI: Thirst, dry and sticky mucous membranes, dry and
● ollo any prescribed uid restrictions.
swollen tongue that is red in color, increased motility,
● Monitor respiratory status if muscle weakness
hyperactive bowel sounds, abdominal cramping, nausea
is present.
● ncourage foods and uids high in sodium cheese, OTHER FINDINGS: dema, arm ushed s in, oliguria
milk, condiments).
FLUID OVERLOAD
● Restrict water intake as prescribed.
● This treatment is typically effecti e hen uid olume
is normal to high. NURSING CARE
SEVERE HYPONATREMIA: Administer hypertonic oral and ● Monitor level of consciousness and ensure safety.
I uids as prescribed. ● Provide oral hygiene and other comfort measures to
decrease thirst.
● Monitor I&O, and alert the provider if urinary output
Hypernatremia ●
is inadequate.
Maintain prescribed diet (low sodium, no added salt).
● Hypernatremia is a blood sodium level greater than ● ncourage oral uids as prescribed.
145 mEq/L.
FLUID LOSS: Based on blood osmolarity
● Hypernatremia is a serious electrolyte imbalance.
Administer hypotonic or isotonic non sodium I uids.
It can cause signi cant neurologic, endocrine, and
cardiac disturbances. EXCESS SODIUM
● Increased sodium causes hypertonicity of the blood. ● Encourage water intake and discourage sodium intake.
This causes a shift of water out of the cells, making the ● Administer diuretics (loop diuretics) if impaired kidney
cells dehydrated. excretion is the cause of hypernatremia.
Potassium imbalances
RISK FACTORS
● Potassium (K+) is the major cation in ICF.
● Water deprivation (NPO) ● Potassium plays a vital role in cell metabolism;
● Heat stroke
transmission of nerve impulses; functioning of cardiac,
● Excessive sodium intake: dietary sodium intake,
lung, and muscle tissues; and acid-base balance.
hypertonic I uids, hypertonic tube feedings, ● Potassium has reciprocal action with sodium.
bicarbonate intake
● Excessive sodium retention: kidney failure, Cushing’s
Hypokalemia
syndrome, aldosteronism, some medications
(glucocorticosteroids)
● Fluid losses: fever, diaphoresis, burns, respiratory ● Hypokalemia is a blood potassium level less than
infection, diabetes insipidus, hyperglycemia,
3.5 mEq/L.
watery diarrhea ● Hypokalemia is the result of an increased loss of
potassium from the body, decreased intake and
absorption of potassium, or movement of potassium
into the cells.
360 CHAPTER 58 ELECTROLYTE IMBALANCES CONTENT MASTERY SERIES

ASSESSMENT/DATA COLLECTION Hyperkalemia
Hyperkalemia is a blood potassium level greater than
RISK FACTORS
●
5.0 mEq/L.
● Hyperaldosteronism ● Hyperkalemia is the result of an increased intake of
● Inadequate dietary intake (rare) potassium, movement of potassium out of the cells, or
● Prolonged administration of non-electrolyte-containing inadequate renal excretion.
IV solutions (5% dextrose in water) ● Hyperkalemia uncommon in clients who have adequate
● Receiving total parenteral nutrition kidney function.
● Metabolic alkalosis ● Hyperkalemia is potentially life-threatening due to the
risk of cardiac arrhythmias and cardiac arrest.
EXCESSIVE GI LOSSES: Vomiting, nasogastric suctioning,
diarrhea, excessive laxative use
RENAL LOSSES: Excessive use of potassium-excreting ASSESSMENT/DATA COLLECTION

diuretics (furosemide, corticosteroids)
SKIN LOSSES: Diaphoresis, wound losses RISK FACTORS

INCREASED TOTAL BODY POTASSIUM: IV potassium
EXPECTED FINDINGS administration, salt substitutes, blood transfusion
VITAL SIGNS: Weak, irregular pulse, hypotension, ECF SHIFT: Insufficient insulin, acidosis
orthostatic hypotension, respiratory distress (diabetic ketoacidosis), tissue catabolism (sepsis, burns,
trauma, surgery, fever, myocardial infarction)
NEUROMUSCULOSKELETAL: Ascending bilateral muscle
weakness with respiratory collapse and paralysis, muscle HYPERTONIC STATES: Uncontrolled diabetes mellitus
cramping, decreased muscle tone and hypoacti e re e es,
DECREASED EXCRETION OF POTASSIUM: Kidney
paresthesias, mental confusion
failure, severe dehydration, potassium-sparing diuretics,
ELECTROCARDIOGRAM (ECG): Premature ventricular AC inhibitors, adrenal insufficiency
contractions (PVCs), bradycardia, blocks, ventricular
AGE: Older adult clients at greater risk due to decreased
tachycardia, attening, attened, or in erted T a es,
kidney function and medical conditions resulting in the
increased U waves, and ST depression
use of salt substitutes, angiotensin-converting enzyme
GI: Decreased motility, hypoactive bowel sounds, abdominal inhibitors, and potassium-sparing diuretics
distention, constipation, ileus, nausea, vomiting, anorexia
OTHER CLINICAL FINDINGS: Anxiety, which can progress EXPECTED FINDINGS

to lethargy
VITAL SIGNS: Slow, irregular pulse; hypotension
NEUROMUSCULOSKELETAL: Irritability, confusion,
PATIENT-CENTERED CARE ea ness ith ascending accid paralysis, paresthesias,
lac of re e es
NURSING CARE GI: Increased motility, diarrhea, abdominal cramps,

hyperactive bowel sounds
● Treat the underlying cause.
● Replace potassium.
◯ Provide dietary education and encourage foods high DIAGNOSTIC PROCEDURES
in potassium (avocados, dried fruit, cantaloupe,
ECG will show peaked T waves, widened PR and QRS.
bananas, potatoes, spinach).
Dysrhythmias and asystole are possible.
◯ Provide oral potassium supplementation.
◯ IV potassium administration can be required; it
should always be diluted and administered slowly by

intermittent infusion.
! Never IV bolus (high risk of cardiac arrest). NURSING CARE
● Monitor for and maintain an adequate urine output. ● Implement continuous ECG monitoring.
● onitor for shallo , ineffecti e respirations and ● Decrease potassium intake.
diminished breath sounds. ◯ Stop infusion of IV potassium.
● Monitor cardiac rhythm, and intervene promptly as needed. ◯ Withhold oral potassium.
● Monitor clients receiving digoxin. Hypokalemia ◯ Provide a potassium-restricted diet.
increases the risk for digoxin toxicity.

● Monitor level of consciousness and ensure safety.
● Monitor bowel sounds and abdominal distention and
intervene as needed.

● If potassium levels are extremely high, dialysis might EXPECTED FINDINGS
be required.
MUSCLE TWITCHES/TETANY
● Administer I uids ith de trose and regular insulin ● Numbness and tingling ngers and around mouth
as prescribed to promote the movement of potassium ● Frequent, painful muscle spasms at rest that can
from the ECF to the ICF. Follow agency protocol.
progress to tetany
● Monitor cardiac rhythm, and intervene promptly as needed. ● Hyperactive DTRs
● Maintain IV access. ● Positive Chvostek’s sign (tapping on the facial nerve
● Prepare the client for dialysis if prescribed.
triggering facial twitching)
● Administer sodium polystyrene sulfonate as prescribed. ● Positi e Trousseau s sign hand nger spasms ith
sustained blood pressure cuff in ation
MEDICATIONS ● Laryngospasms
TO INCREASE POTASSIUM EXCRETION CARDIOVASCULAR

● Administer loop diuretics (furosemide) if kidney ● Weak, thready pulse, tachycardia or bradycardia
function is adequate. Loop diuretics increase the ● Cardiac dysrhythmias: prolonged QT interval and
excretion of potassium from the renal system. ST segments
● Sodium polystyrene sulfonate is given orally or as an
GI: Hyperactive bowel sounds, diarrhea,
enema. Sodium polystyrene sulfonate increases the
abdominal cramping
excretion of potassium from the gastrointestinal system.
● Other medications can include calcium gluconate, CENTRAL NERVOUS SYSTEM: Seizures due to
albuterol, and patiromer. overstimulation of the CNS
Calcium imbalances
NURSING CARE
● Calcium is found in the body’s cells, bones, and teeth. ● Administer oral or IV calcium supplements and vitamin
● Calcium balance is essential for proper functioning
D supplements.
of the cardiovascular, neuromuscular, and endocrine ● Initiate seizure and fall precautions.
systems, as well as blood clotting and bone and ● Keep emergency equipment on standby.
teeth formation. ● Encourage foods high in calcium, including dairy
products and dark green vegetables.
Hypocalcemia
Hypocalcemia is a total blood calcium level less Hypercalcemia
than 9 mg/dL.
Hypercalcemia is a total blood calcium level greater
than 10.5 mg/dL. Hypercalcemia is not as common as
hypocalcemia. Causes include thiazide diuretic or long-
ASSESSMENT/DATA COLLECTION term glucocorticoid use, Paget’s disease, hyperthyroidism
and hyperparathyroidism, and bone cancer.
RISK FACTORS
Increased calcium output EXPECTED FINDINGS
● Chronic diarrhea
NEUROMUSCULAR
● Laxative misuse ● Decreased re e es
● Steatorrhea as with pancreatitis (binding of calcium to ● Bone pain
undigested fat)
CARDIOVASCULAR
Inadequate calcium intake or absorption ● Dysrhythmias (shortened QT and ST intervals)
● Malabsorption syndromes (Crohn’s disease) ● Increased risk for blood clot
● itamin D de ciency alcohol use disorder, chronic
kidney disease) GI: Anorexia, nausea, vomiting, constipation
Calcium shift from ECF into bone or to an inactive form CENTRAL NERVOUS SYSTEM
● Rapid infusion of citrated blood transfusion ● Weakness, lethargy
● Post-thyroidectomy ● Confusion, decreased level of consciousness
● Hypoparathyroidism ● Personality change
● Hypoalbuminemia
● Alkalosis
GU: Hypercalciuria
● Pancreatitis
● Hyperphosphatemia

PATIENT-CENTERED CARE PATIENT-CENTERED CARE
NURSING CARE NURSING CARE

● Treatment includes restricting calcium and increasing ● Discontinue magnesium-losing medications.
uid inta e. ● Magnesium replacement can be required orally (if the
● Monitor the client for pathological fractures. client is experiencing mild manifestations) or IV (if
manifestations are severe). Oral magnesium can cause
diarrhea and increase magnesium depletion.
Encourage foods high in magnesium, including whole
Magnesium imbalances
●
grains and dark green vegetables.
Hypermagnesemia
Most of the body’s magnesium is found in the bones.
Magnesium in smaller amounts is found within the body
cells. A very small amount is found in ECF.
Hypermagnesemia is a blood magnesium level greater
than 2.1 mEq/L. Hypercalcemia is not as common
Hypomagnesemia
as hypocalcemia. Causes include kidney or adrenal
impairment and increased intake of medications
containing magnesium (laxatives, antacids).
Hypomagnesemia is a blood magnesium level less than
1.3 mEq/L.
EXPECTED FINDINGS
NEUROMUSCULAR
ASSESSMENT/DATA COLLECTION ● Diminished DTRs
● Muscle paralysis
RISK FACTORS ● Shallow respirations, decreased respiratory rate
INCREASED MAGNESIUM OUTPUT CARDIOVASCULAR

● GI losses (diarrhea, nasogastric suction) ● Bradycardia, hypotension
● Thiazide or loop diuretics ● Cardiac arrest
● Often associated with hypocalcemia ● Dysrhythmias, ECG changes (prolonged PR interval)
SHIFT INTO INACTIVE FORM: Rapid infusion of CENTRAL NERVOUS SYSTEM: Lethargy
citrated blood
INADEQUATE MAGNESIUM INTAKE OR ABSORPTION DIAGNOSTIC PROCEDURES

● Malnutrition
ECG: Prolonged PR interval, widened QRS
● Alcohol use disorder
● Laxative misuse
EXPECTED FINDINGS
NEUROMUSCULAR: Increased nerve impulse transmission NURSING CARE
(hyperactive DTRs, paresthesias, muscle tetany), ● Perform frequent focused assessments (vital signs,
positive Chvostek’s and Trousseau’s signs, tetany,
le el of consciousness, re e es . Notify the pro ider of
seizures, insomnia
changes or absent re e es.
GI: Hypoactive bowel sounds, constipation, ● Administer loop diuretics and magnesium free I uids
abdominal distention, paralytic ileus if kidney function is adequate.
● Administer calcium gluconate for severe cardiac changes.
CARDIOVASCULAR: Dysrhythmias, tachycardia,
hypertension, ECG waveform changes or PVCs

1. A nurse is planning care for a client who has A nurse is caring for a client who has hypokalemia as
hypernatremia. Which of the following actions an adverse effect of furosemide. Use the ATI Active
should the nurse include in the plan of care? Learning Template: System Disorder to complete
this item to include the following sections.
A. Infuse hypotonic IV fluids.
B. Implement a fluid restriction. ALTERATION IN HEALTH (DIAGNOSIS)
C. Increase sodium intake. EXPECTED FINDINGS: Identify at
D. Administer sodium polystyrene sulfonate. least five expected findings.
NURSING CARE: Identify two nursing

2. A nurse is reviewing the medical record of a client interventions for hypokalemia.
who has hypocalcemia. The nurse should identify
which of the following findings as a risk factor for
the development of this electrolyte imbalance?
A. Crohn’s disease
B. Postoperative following appendectomy
C. History of bone cancer
D. Hyperthyroidism
3. A nurse receives a laboratory report for a client

indicating a potassium level of 5.2 mEq/L.
When notifying the provider, the nurse should
expect which of the following actions?
A. Starting an IV infusion of 0.9% sodium chloride
B. Consulting with dietitian to increase
intake of potassium
C. Initiating continuous cardiac monitoring
D. Preparing the client for gastric lavage
4. A nurse is collecting data from a client who has

hypercalcemia as a result of long-term use of
glucocorticoids. Which of the following findings
A. Hyperreflexia
B. Confusion
C. Positive Chvostek’s sign
D. Bone pain
E. Nausea and vomiting
5. A nurse is providing education for a client who

has severe hypomagnesemia and is prescribed
oral magnesium sulfate. Which of the following
information should the nurse include in the teaching?
A. “Avoid green, leafy vegetables
while taking this medication.”
B. “You should receive a prescription for a thiazide
diuretic to take with the magnesium.”
C. “You should eliminate whole grains from your
diet until your magnesium level increases.”
D. “Report diarrhea while taking this medication.”

1. A. CORRECT: Hypotonic IV fluids are indicated for the Using the ATI Active Learning Template: System Disorder
treatment of hypernatremia related to fluid loss to ALTERATION IN HEALTH (DIAGNOSIS): Hypokalemia is a
expand the ECF volume and rehydrate the cells. blood potassium level less than 3.5 mEq/L that can result
B. Increased fluid intake is indicated for the from the increased loss of potassium from the body due to
treatment of hypernatremia. the use of potassium-excreting diuretics (furosemide).
C. Decreased sodium intake is indicated for
the treatment of hypernatremia. EXPECTED FINDINGS
D. Administration of sodium polystyrene sulfonate is ●
Vital signs: Weak irregular pulse, hypotension, respiratory distress
indicated for the treatment of hyperkalemia. ●
Neuromusculoskeletal: Ascending bilateral muscle
NCLEX® Connection: Physiological Adaptation, weakness, muscle cramping, decreased muscle tone,
Unexpected Response to Therapies hypoactive reflexes, paresthesias, mental confusion
●
GI: Decreased motility, hypoactive bowel sounds, abdominal
distention, constipation, nausea, vomiting, anorexia
2. A. CORRECT: Crohn’s disease is a risk factor for hypocalcemia. ●
Dysrhythmias: PVCs, bradycardia, blocks, ventricular
This malabsorption disorder places the client at risk for tachycardia, flattening T waves, ST depression
hypocalcemia due to inadequate calcium absorption.
B. A thyroidectomy places the client at risk for NURSING CARE
hypocalcemia due to the possible removal of
●
Monitor for cardiac dysrhythmia.
or injury to the parathyroid glands. ●
Monitor for shallow or ineffective respirations.
C. A history of bone cancer increases the client’s risk of ●
Teach and encourage consumption of potassium
hypercalcemia due to the shift of calcium from bone to ECF. rich foods (bananas, avocados, cantaloupe).
D. Hyperthyroidism places the client at risk for hypercalcemia ●
Ensure the underlying cause of hypokalemia is corrected.
due to the shift of calcium from bone to ECF.
NCLEX® Connection: Physiological Adaptation, Expected Actions/Outcomes
3. A. Initiate an IV infusion of a fluid containing dextrose to

promote the movement of potassium from ECF to ICF.
B. Withhold oral potassium and provide the client
with a potassium-restricted diet.
C. CORRECT: A potassium level of 5.2 mEq/L
indicates hyperkalemia. Anticipate the initiation of
continuous cardiac monitoring due to the client’s
risk for dysrhythmias (ventricular fibrillation).
D. Gastric lavage is not indicated for the treatment
of hyperkalemia. However, prepare the client for
dialysis if hyperkalemia becomes severe.
Illness Management
4. A. Expect the client who has hypercalcemia

to have decreased reflexes.
B. CORRECT: Expect the client who has hypercalcemia to have
confusion and a possible decreased level of consciousness.
C. Expect the client who has hypocalcemia to
have a positive Chvostek’s sign.
D. CORRECT: Expect the client who has
hypercalcemia to have bone pain.
E. CORRECT: Expect the client who has hypercalcemia
to have nausea and vomiting along with anorexia.
Adverse Effects/Contraindications/Side Effects/Interactions
5. A. Green, leafy vegetables are rich in magnesium and

do not hinder oral magnesium therapy.
B. Thiazide diuretics increase magnesium output, thereby
worsening the client’s hypomagnesemia.
C. Encourage the client’s intake of foods that are high
in magnesium (whole grains, nuts, cocoa).
D. CORRECT: Instruct the client to report diarrhea while
taking oral magnesium replacement. This is a potential
adverse effect of taking oral magnesium, which
could worsen the client’s hypomagnesemia.

References
Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier &
Erb’s fundamentals of nursing: Concepts, process, and practice
(10th ed.). Upper Saddle River, NJ: Prentice-Hall.
Burchum, J. R., & Rosenthal L. D. (2019) Lehne's
pharmacology for nursing care (10th ed.). St. Louis, MO.
Dahlkemper, T. R. (2018). Nursing leadership, management, and
professional practice for the LP/LVN (6th ed.). Philadelphia: F. A. Davis.
Dudek, S. G. (2018). Nutrition essentials for nursing
practice (8th ed.). Philadelphia: Wolters Kluwer.
Halter, M. J. (2018). Varcarolis’ foundations of psychiatric mental health
nursing: A clinical approach (8th ed.). St. Louis, MO: Elsevier.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook
of medical-surgical nursing (14th ed.). Philadelphia: Wolters Kluwer.
Hockenberry, M. J., & Wilson, D. (2015). Wong’s nursing care
of infants and children (10th ed). St. Louis, MO: Mosby.
Hockenberry, M. J., Wilson, D., & Rodgers, C. (2019). Wong’s nursing
care of infants and children (11th ed). St. Louis, MO: Mosby.
Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018).
Medical-Surgical nursing: Concepts for Interprofessional
collaborative care (9th ed.). St. Louis, MO.
Lilley, L. L., Rainforth-Collins, S., & Snyder, J. S. (2017). Pharmacology
and the nursing process (8th ed.). St. Louis, MO: Elsevier.
Lowdermilk, D. L., Perry, S. E., Cashion, M. C., & Aldean, K. R. (2016).
Maternity & women’s health care (11th ed.). St. Louis, MO: Elsevier.
ffice of Disease Pre ention and Health Promotion.
2015 - 2020 Dietary guidelines: Appendix 7. Nutritional
goals for age-sex groups based on dietary reference intakes
and dietary guidelines recommendations. Retrieved from
https://health.gov/dietaryguidelines/2015/guidelines/appendix-7/
Pagana, K. D., & Pagana, T. J. (2018). Mosby’s manual of
diagnostic and laboratory tests (6th ed.). St. Louis: Elsevier.
Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2017).
Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier.
Touhy, T. A., & Jett, K. F. (2016) Ebersole & Hess’ toward healthy aging:
Human needs and nursing response (9th ed.). St. Louis, MO: Elsevier.
Vallerand, A. H., Sanoski, C. A. & Deglin, J. H. (2017).
Davis's drug guide for nurses (15 ed.) Philadelphia.
United States Department of Agriculture (USDA). (2018).
All about the protein foods group. Retrieved from
https://www.choosemyplate.gov/protein-foods
United States Department of Agriculture (USDA). Food composition
databases. Retrieved from https://ndb.nal.usda.gov/ndb/nutrients
FUNDAMENTALS FOR NURSING REFERENCES 367

ACTIVE LEARNING TEMPLATE: Basic Concept
STUDENT NAME _____________________________________
CONCEPT ______________________________________________________________________________ REVIEW MODULE CHAPTER ___________
Related Content Underlying Principles Nursing Interventions

(E.G., DELEGATION, WHO? WHEN? WHY? HOW?
LEVELS OF PREVENTION,
ADVANCE DIRECTIVES)
ACTIVE LEARNING TEMPLATES BASIC CONCEPT A1

A2 BASIC CONCEPT CONTENT MASTERY SERIES
ACTIVE LEARNING TEMPLATE: Diagnostic Procedure
STUDENT NAME _____________________________________
PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________
Description of Procedure
Indications CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Interpretation of Findings
Client Education
Potential Complications Nursing Interventions
ACTIVE LEARNING TEMPLATES DIAGNOSTIC PROCEDURE A3

A4 DIAGNOSTIC PROCEDURE CONTENT MASTERY SERIES
ACTIVE LEARNING TEMPLATE: Growth and Development
STUDENT NAME _____________________________________
DEVELOPMENTAL STAGE _______________________________________________________________ REVIEW MODULE CHAPTER ___________
EXPECTED GROWTH AND DEVELOPMENT
Physical Cognitive Psychosocial Age-Appropriate

Development Development Development Activities
Health Promotion
Immunizations Health Screening Nutrition Injury Prevention
ACTIVE LEARNING TEMPLATES GROWTH AND DEVELOPMENT A5

A6 GROWTH AND DEVELOPMENT CONTENT MASTERY SERIES
ACTIVE LEARNING TEMPLATE: Medication
STUDENT NAME _____________________________________
MEDICATION __________________________________________________________________________ REVIEW MODULE CHAPTER ___________
CATEGORY CLASS ______________________________________________________________________
PURPOSE OF MEDICATION
Expected Pharmacological Action Therapeutic Use
Complications Medication Administration
Contraindications/Precautions
Nursing Interventions
Interactions
Client Education
Evaluation of Medication Effectiveness
ACTIVE LEARNING TEMPLATES MEDICATION A7

A8 MEDICATION CONTENT MASTERY SERIES
ACTIVE LEARNING TEMPLATE: Nursing Skill
STUDENT NAME _____________________________________
SKILL NAME____________________________________________________________________________ REVIEW MODULE CHAPTER ___________
Description of Skill
Outcomes/Evaluation
Client Education
ACTIVE LEARNING TEMPLATES NURSING SKILL A9

A10 NURSING SKILL CONTENT MASTERY SERIES
ACTIVE LEARNING TEMPLATE: System Disorder
STUDENT NAME _____________________________________
DISORDER/DISEASE PROCESS __________________________________________________________ REVIEW MODULE CHAPTER ___________
Alterations in Pathophysiology Related Health Promotion and

Health (Diagnosis) to Client Problem Disease Prevention
ASSESSMENT SAFETY
CONSIDERATIONS
Risk Factors Expected Findings
Laboratory Tests Diagnostic Procedures
PATIENT-CENTERED CARE Complications
Nursing Care Medications Client Education
Therapeutic Procedures Interprofessional Care
ACTIVE LEARNING TEMPLATES SYSTEM DISORDER A11

A12 SYSTEM DISORDER CONTENT MASTERY SERIES
ACTIVE LEARNING TEMPLATE: Therapeutic Procedure
STUDENT NAME _____________________________________
PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________
Description of Procedure
Outcomes/Evaluation
Client Education
ACTIVE LEARNING TEMPLATES THERAPEUTIC PROCEDURE A13

A14 THERAPEUTIC PROCEDURE CONTENT MASTERY SERIES
ACTIVE LEARNING TEMPLATE: Concept Analysis
STUDENT NAME _____________________________________
CONCEPT ANALYSIS ____________________________________________________________________
Defining Characteristics
Antecedents Negative Consequences

(WHAT MUST OCCUR/BE IN PLACE FOR (RESULTS FROM IMPAIRED ANTECEDENT —
CONCEPT TO EXIST/FUNCTION PROPERLY) COMPLETE WITH FACULTY ASSISTANCE)
Related Concepts Exemplars

(REVIEW LIST OF CONCEPTS AND IDENTIFY, WHICH
CAN BE AFFECTED BY THE STATUS OF THIS CONCEPT
— COMPLETE WITH FACULTY ASSISTANCE)
ACTIVE LEARNING TEMPLATES CONCEPT ANALYSIS A15

A16 CONCEPT ANALYSIS CONTENT MASTERY SERIES

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Fundamentals for Nursing

REVIEW MODULE EDITION 10.0

Mary Jane Janowski, RN, MA

INTELLECTUAL PROPERTY NOTICE

Copyright © 2019 Assessment Technologies Institute, LLC. All rights reserved.

REPRINTED APRIL 2021

FUNDAMENTALS FOR NURSING I

Director of development: Derek Prater

Project management: Tiffany Pavlik, Shannon Tierney

Coordination of content review: Honey C. Holman, Debborah Williams

Copy editing: Kelly Von Lunen, Bethany Phillips, Kya Rodgers

Layout: Spring Lenox, Maureen Bradshaw, Bethany Phillips

Illustrations: Randi Hardy

Cover design: Jason Buck

Interior book design: Spring Lenox

IMPORTANT NOTICE TO THE READER

II CONTENT MASTERY SERIES

(included at the back of this book) to record the important

◯ Pharmacological and Parenteral Therapies

◯ Reduction of Risk Potential

An NCLEX Connection might, for example, alert you that

■ Assess client use of assistive devices.

FUNDAMENTALS FOR NURSING USER’S GUIDE III

As needed updates to the e ie odules are identi ed,

IV USER’S GUIDE CONTENT MASTERY SERIES

UNIT 1 Safe, Effective Care Environment 3

CHAPTER 1 Health Care Delivery Systems 3

CHAPTER 2 The Interprofessional Team 7

CHAPTER 3 Ethical Responsibilities 11

CHAPTER 4 Legal Responsibilities 15

CHAPTER 5 Information Technology 21

CHAPTER 6 Delegation and Supervision 27

CHAPTER 7 Nursing Process 31

CHAPTER 8 Critical Thinking and Clinical Judgment 37

CHAPTER 9 Admissions, Transfers, and Discharge 41

SECTION: Safety and Infection Control 49

CHAPTER 10 Medical and Surgical Asepsis 49

CHAPTER 11 Infection Control 53

CHAPTER 12 Client Safety 59

CHAPTER 13 Home Safety 65

CHAPTER 14 Ergonomic Principles 73

CHAPTER 15 Security and Disaster Plans 77

FUNDAMENTALS FOR NURSING TABLE OF CONTENTS V

UNIT 2 Health Promotion 85

CHAPTER 16 Health Promotion and Disease Prevention 85

CHAPTER 17 Client Education 89

CHAPTER 18 Infants (2 Days to 1 Year) 93

CHAPTER 19 Toddlers (1 to 3 Years) 99

CHAPTER 20 Preschoolers (3 to 6 Years) 103

CHAPTER 21 School-Age Children (6 to 12 Years) 107

CHAPTER 22 Adolescents (12 to 20 Years) 111

CHAPTER 23 Young Adults (20 to 35 Years) 115

CHAPTER 24 Middle Adults (35 to 65 Years) 119

CHAPTER 25 Older Adults (65 Years and Older) 123

NCLEX® Connections 127

SECTION: Health Assessment/Data Collection 129

CHAPTER 26 Data Collection and General Survey 129

CHAPTER 27 Vital Signs 135

CHAPTER 28 Head and Neck 145

CHAPTER 29 Thorax, Heart, and Abdomen 153