a p p e n d i x

Suggested Answers to Stop, Think,

and Respond Boxes
1-1: Florence Nightingale reduced the death rate in the Crimea from
60% to 1% by using trained nurses to care for the sick and wounded.
1-2: (a) Comforting skill; (b) Counseling skill; (c) Assessment skill;
(d) Caring skill.
2-1: Objective data are items B, D, and E because they identify observable or measurable information. Items A and C are examples of subjective data because only the client can validate them.
2-2: One cluster of data includes cough, fever, and nasal congestion,
suggesting a respiratory infection. The second cluster includes dry
skin, infrequent urination, and thirst, suggesting reduced uid volume. Fever also could be clustered in the second group because inadequate body uid can lead to an elevated body temperature.
2-3: Option 2 is the best nursing diagnostic statement because the
client is manifesting signs and symptoms of a problem that currently
exists. Option 1 is inaccurate because the client is beyond being at
risk. Option 3 is incorrect because weight loss is not listed among
the problems within the NANDA taxonomy. Option 4 is incorrect
because the nurse has sufcient evidence to make an actual nursing
diagnosis and related to, not due to, is preferred as the link to
the etiology.
3-1: Obviously the nurses rst responsibility is to keep the client safe.
To do so, the nurse must determine the reason the client is getting
out of bed and implement alternatives to restraint. If the client needs
to eliminate urine, the nursing staff could toilet the client more frequently. If the client is disoriented, a dim night-light may help reorient her. If the nurse restrains the client, he or she could be charged
with false imprisonment. Restraining a client physically or chemically requires justication and collaboration with the clients physician. The nurse must renew a medical order for a physical restraint
frequently, in some cases every 24 hours, to avoid the potential for
abuse.
3-2: The teleologist would believe that the infant is not a candidate for
heroic measures. To do so would prolong the social and nancial burdens on the parents and overall society. A deontologist would believe
that all life is precious and every human has the right to live; consequently, health care workers have a duty to provide whatever treatment measures are available regardless of the outcome.
4-1: The person with frequent indigestion will most likely seek primary care from a nurse practitioner, physicians assistant, or family
physician, who will obtain the clients history, perform a physical
examination, and prescribe symptomatic treatment. If the symptoms
persist, the client may be referred to a health care agency that offers
diagnostic services such as gastrointestinal roentgenography (x-ray)
or endoscopic examination for secondary care. Tertiary care may be
necessary should the client require additional diagnostic procedures
such as a computed tomography (CT) scan or treatment from a specialist such as an oncologist, a physician who is an expert in providing care for clients with cancer.
5-1: Examples include fatigue and sleep deprivation; inadequate exercise; inadequate nutrition; unrealistic goals for academic success;

reduced leisure activities; distance from those who previously provided emotional support; nancial burdens of academic and personal
expenses; guilt about neglecting signicant other, parents, or dependent children; and change in frequency of religious attendance.
5-2: The sequence is H, C, E, F, B, A, D, G.
6-1: The nurse must become educated about the cultural practice to
avoid false accusations of abuse or misinterpreting the assessment
nding as a possible sign of disease. Furthermore, as long as the coining is not signicantly injurious, the nurse permits the practice while
offering suggestions with a scientic basis as accompanying forms of
treatment
7-1: The primary person with whom the nurse collaborates is the
client and his or her family. Others likely to be involved include the
physician, physical therapist, social worker, discharge planner,
home health personnel, dietitian (if the client has nutritional
needs), and personnel in an extended care facility if the client cannot be discharged home immediately.
7-2: The staff nurse would rst collaborate with the student nurses
clinical instructor to determine if the skill has been taught at this
stage in the students curriculum, if the student has had sufcient
practice in performing the skill, or if the student requires supervision
from the clinical instructor. If the student nurse is delegated to assess
the clients vital signs, the staff nurse can determine if vital signs
were taken by reviewing the students documentation of the information. The nurse can compare the students assessment data with
trends in the clients vital signs to determine if they are comparable
or have changed signicantly.
8-1: (1) Psychomotor domain, (2) affective domain, (3) cognitive
domain, (4) psychomotor domain, (5) cognitive domain
8-2: (1) Pedagogic learners because they have short attention spans;
(2) androgogic learners because they respond to collaboration and
seek knowledge based on personal interest; (3) gerogogic learners
because they are motivated by personal needs or goals; (4) pedagogic
learners because they are motivated by potential rewards; (5) androgogic learners because they respond to solving problems and can
think abstractly.
9-1: The writer could improve entry #1 by identifying how much food
the client consumed or by listing the items and amounts the client
ate. This and all separate entries require a signature and title. In
entry #2, many hours have passed since the rst entry. The writer
should make more frequent additions. This entry also lacks necessary details such as whether the client performed hygiene measures
independently or required some assistance. The distance the client
walked is also important, as is his or her tolerance of the activity. In
entry #3, documenting that the client is depressed is a subjective
opinion. The writer could improve the documentation by describing
the clients behavior objectively. The writer should add his or her
title and not leave space between the end of the entry and signature
because someone else could add information, making it appear as if
the signed person wrote it.

825

826

APPENDIX B Suggested Answers to Stop, Think, and Respond Boxes

9-2: (1) 1830, (2) 0000 or 2400, (3) 0845, (4) 2105, (5) 0415
10-1: The registered nurse can delegate those tasks associated with
the admission process that a practical nurse, nursing student, or
nursing assistant has been trained to perform and for which the person has demonstrated competency. Examples may include checking
the clients room prior to arrival and determining if it is ready for
occupancy; greeting the client and those who accompany him or
her; assessing the clients vital signs (temperature, pulse, respirations, blood pressure); checking the clients current level of pain or
discomfort; weighing the client and obtaining height; asking the
client about allergies to medications or food; validating that the
client has an identication bracelet or attaching one if it is absent;
determining if the client has advanced directives (see Chap. 3) or
wishes to complete one; helping the client to change into hospital
attire; orienting the client to the room and the use of the signal
device, telephone, and television; explaining the routines of the unit
such as the times meals are served; and lling a carafe with water.
A practical nurse or nursing student may collect preliminary data
identied on the agencys admission form.
The nurse is responsible for validating the performance of delegated duties and reviews the preliminary assessment data. The
assigned nurse proceeds to interview the client, obtains additional
information about the clients health history that may have been overlooked or requires more details, and performs a physical examination.
10-2: All nursing personnel are obligated to protect the clients privacy and condentiality. It is best to request that anyone accompanying the client leave the room temporarily when the nurse asks the
client health-related questions or performs the physical examination. Doing so ensures that the client can answer questions openly
and truthfully. Privacy avoids potential embarrassment as the nurse
examines the client.
10-3: The nurse evaluates the clients level of function to determine if
he or she can remain independent or requires some level of assistance for a short or long period. The nurse may explore the clients
available support systems such as relatives, neighbors, or close friends
who can assist the client directly or by telephone. The nurse asks
about the clients living environment, especially the locations of the
bedroom and bathroom and whether or not the client may need to
climb stairs. The nurse determines if the client can repeat instructions regarding medication administration and perform other skills to
manage the disease process. The nurse validates that the client has
access to food and can prepare meals. If there are any concerns about
the clients safety or ability to manage self-care, the nurse consults the
discharge planner or case manager who may arrange services that the
client requires.
11-1: Infants and older adults have fewer white adipocytes. Despite
their small size, infants have a proportionately greater surface area
from which they lose body heat and a higher metabolic rate. Both
populations have a reduced ability to shiver and perspire. Because
they may not be able to make their needs clearly known, infants and
adults depend on caretakers to provide measures such as the addition or removal of clothing, food and uids, and cooling or heating
of the environment to assist with temperature regulation. Older
adults generally also have impaired circulation, which compromises
their ability to maintain a stable body temperature under unusually
hot or cold conditions.
11-2: The best choice is an infrared thermometer inserted in the ear
and directed at the tympanic membrane. A measurement from this
type of thermometer is closest to core temperature, which it records
within seconds.
11-3: The nurse could palpate an artery at an alternative peripheral
site such as at the carotid or brachial artery. Another option is to auscultate the heart over the apex and count the rate. A third alternative is to use a Doppler ultrasound device.
11-4: Document and report an abnormal respiratory rate to the nurse
in charge or the physician and collaborate about whether or not
administration of oxygen is indicated. Gather additional data such as
other vital signs, help the client to a sitting position, instruct the client

to modify the depth and rate of respirations to more normal parameters, and stay with the client while offering emotional support.
11-5: The nurse could augment the sounds using one of the following
techniques:
1. Ask the client to elevate the arm before and during cuff ination
then to lower the arm after full ination.
2. Ask the client to open and close the st after cuff ination.
If neither action proves satisfactory, the nurse may use a
Doppler ultrasound stethoscope to amplify the sounds, palpate
the blood pressure, or use an electronic monitor.
12-1: The condition of the client requiring oxygen and intravenous uid
appears more unstable; thus, this client must receive priority attention. This client is best examined in a hospital bed. The nurse may
choose to modify the assessment by obtaining critical data such as
vital signs, level of consciousness, orientation, breathing and lung
assessments, heart sounds, and bowel sounds. If the data indicate that
the client can tolerate additional assessments, the nurse can complete
the examination. If the client is in pain or appears to be worsening, the
nurse may choose to report the abbreviated assessment ndings to the
physician and implement medical orders. He or she can gather subsequent data (e.g., weight and height, condition of the skin and mucous
membranes, status of peripheral circulation) when the clients condition improves but no later than 24 hours from admission.
12-2: A maculopapular skin lesion contains combined characteristics
of macules and papules. In other words, the lesions appear solid,
round, colored, elevated, and palpable.
12-3: Determine if the cough is productive (results in raising sputum)
or nonproductive (dry cough). If the client is producing sputum,
inspect and describe its characteristics. Auscultate the chest anteriorly, laterally, and posteriorly to identify if lung sounds are clear or
if abnormal sounds (e.g., crackles, gurgles, wheezes) are in a particular area. Also auscultate the heart and note if an S3 is evident. S3 in
an adult suggests congestive heart failure with uid backing into the
pulmonary areas. Assess the clients temperature to determine if he
or she has a fever; the cough may be the result of a pulmonary infection. In addition, ask the client about a history of inhalant allergies,
which can cause nasal secretions to drain downward, irritate the
pharynx, and cause a cough.
13-1: A sigmoidoscopy is an important diagnostic screening examination for the early detection of colorectal cancer. According to the
American Cancer Society (2002), colorectal cancer is the third most
common cancer for men and women. The American Cancer Society
and the United States Preventive Services Task Force both recommend that at 50 years of age people begin having a sigmoidoscopy
every 5 years and a fecal occult blood test every year. They predict that
these two examinations can reduce the risk of death from colorectal
cancer from 59% to 75% (http://www.ahcpr.gov/clinic/3rduspstf/
colorectal/colorr.htm).
14-1: Cardiac risk increases when total cholesterol level divided by
HDL level is greater than 5. Client C has the lowest cardiac risk (3.8)
despite having an elevated total cholesterol level. HDL is the type of
cholesterol that reduces cardiac risk. Therefore, Client Cs higher
HDL level offsets the total cholesterol level, which exceeds the recommended amount. Client B has a total cholesterol level within the
recommended amount, but Bs HDL level is low. Client Bs risk factor is calculated at 5.65. Client A has the highest cardiac risk (5.89)
because the total cholesterol level is elevated and the HDL level is
less than desirable.
14-2: She should consume 2 to 3 servings per day.
14-3: This person is considered overweight with a BMI of 29.
14-4: Food can be more visually attractive if there is a variety of color
and texture. Arranging food so that each item is visually separate is
helpful. Other methods for promoting attractiveness are to serve
food on clean dishes with a complementary artistic motif. Fresh
owers and a clean napkin also improve food appeal.
15-1: The total volume may vary slightly with particular agency container measurements. Using the volume equivalents identied in

APPENDIX B Suggested Answers to Stop, Think, and Respond Boxes

Box 15-2, the calculation of intake is as follows: orange juice, 120 mL;
milk, 240 mL; soup, 200 mL; gelatin dessert, 90 mL; coffee, 210 mL;
IV, 100 mL; total volume, 960 mL.
15-2: 0.45% sodium chloride is a hypotonic solution that also is a good
hydrating solution. The water in the solution will move into blood
cells, the intersitial space, and other body cells to replace uid
decits. Ringers solution is an isotonic solution; it will not result in
any appreciable change in uid locations. Isotonic solutions are used
to maintain uid volume. A solution of 50% glucose is an example of
a hypertonic solution. It is administered primarily to raise blood glucose levels. When administered intravenously, hypertonic solutions
pull uid from other more dilute uid compartments, causing an
increase in intravascular volume.
15-3: To administer the rst IV solution, program the electronic infusion device at 83 mL/hr. To administer the second IV solution,
adjust the roller clamp to infuse the solution at 16 gtt/minute.
15-4: A person whose blood type is B positive could receive blood that
is B positive, B negative, O positive, or O negative. A person whose
blood type is O negative can receive only O negative blood.
16-1: Hygiene practices vary widely. Older adults who are less active
and whose skin tends to be dry may not require a complete bath daily.
Nurses can encourage them to have a partial bath; washing the face,
hands, and perineal areas is a means to remove transient microorganisms that may cause illness. Although the nurse should respect a
clients choice of the frequency and extent of personal hygiene, he or
she can explain that carrying out personal hygiene regularly promotes
self-worth, self-condence, and social acceptance.
16-2: Ensuring privacy is the most essential factor in promoting a
clients dignity whenever the client is being examined or given care.
In addition, the nurse always provides the client with an explanation
prior to performing any care and ensures that the client is draped or
covered in such a way that only the area being cleansed is exposed.
16-3: Because the 75-year-old client has arthritis of her hips, she may
have difculty getting in and out of a tub. Therefore if her strength,
endurance, and equilibrium are uncompromised, the client could
bathe independently in a shower with or without a shower chair.
The nurse must consider safety issues for the client with frequent
seizures. It is best to provide supplies for a bed or bag bath that the
client can self-administer except for help with areas he cannot reach
such as his back or feet. The man who becomes dyspneic with exertion may require assistance with bathing at the bedside. The nurse
and client may perform hygiene in stages to avoid compromising
oxygenation status. The client recovering from pneumonia may
bathe independently using a shower or bag bath. The nurse would
provide assistance getting in and out of the shower and provide a
platform on which to sit. The nurse also ensures that this client does
not become chilled or overly fatigued.
16-4: In either case, the nurse ensures that the client receives oral
hygiene. Nursing responsibilities in relation to oral hygiene for an
independent client include assembling the items the client will need,
placing them at the bedside or in the clients bathroom, observing the
client perform self-care, and replacing the items in their original location after the client has nished. When a client depends on the nurse
for oral hygiene, the nurse brushes the clients natural teeth with a
toothbrush, then rinses and suctions the clients mouth if he or she
cannot expectorate. If the client has dentures, the nurse removes
them from the clients mouth, cleans them in the bathroom, and
replaces them in the clients mouth. The nurse offers or provides
opportunities for oral hygiene after each meal and at bedtime. If the
clients nutritional needs are met by means other than oral feedings,
the nurse establishes a schedule for administering oral hygiene several times a day.
17-1: It is appropriate to change some linen when there is evidence of
soiling that does not penetrate all layers. This may be the case, for
example, after drawing a blood specimen or starting an intravenous
infusion and some droplets of blood are evident on the bed linen,
when removing a bedpan or urinal and soiling is observed, when food
is spilled, or when bottom sheets become extremely wrinkled and

827

uncomfortable. It is best to change all the linen when it has been used
for several days, when there is soiling or drainage that penetrates all
layers, or when a client will return following a surgical procedure.
17-2: Examples include having the client bathe or shower before the
massage; tightening or replacing wrinkled or damp bed linen; checking if the client needs bladder or bowel elimination prior to commencing; ensuring that the room temperature is comfortable for the
client; dimming the lights; eliminating noise or providing soft, relaxing music; warming body lotion before applying it to the skin; avoiding unnecessary communication with the client; and reducing the
potential for interruptions.
18-1: To avoid a lawsuit, the nurse follows the agencys restraint protocol; describes the behavior that jeopardizes the clients safety; documents restraint alternatives that were implemented prior to applying
a restraint and the clients response; obtains a physicians order for
the type of restraint used; applies the restraint correctly; assesses the
clients mental status, vital signs, and areas of the body where
restraints are applied on a scheduled basis; and documents the assessment ndings. The nurse includes in the medical record or on a ow
sheet the time at which interventions such as offering nourishment
and uids, toileting the client, skin care, and range of motion exercises
are performed. It is best to inform the clients family about the change
in the clients plan for care and work cooperatively with them to discontinue the use of restraints as soon as possible. The nurse requests
that the physician examines the client and renews the order for the
restraint, if necessary, every 24 hours. Above all, the nurse never uses
restraints punitively or for convenience.
19-1: When a client uses the maximum PCA doses, the nurse should
(1) assess the clients pain level frequently to determine the response
to the medication; (2) check the PCA infuser to determine that the
prescribed dose has been accurately programmed into the infusion
device; (3) consult with the physician about the possibility of administering a repeat of the bolus dose of the analgesia or a higher dose
for intermittent administration, prescribing a different medication
for PCA, or adding an adjuvant drug to the regimen for pain relief;
and (4) implement nonpharmacologic techniques the client may
desire for relieving pain such as applying warmth to the painful area,
changing positions, and using distraction, relaxation techniques, or
imagery.
19-2: Some reasons that a person may object to using a TENS unit
include (1) fear that there may be a risk of injury from the electrical
current, (2) resistance to using a device that requires manual regulation or adjustment of various settings, (3) necessity of wearing or
carrying the operational unit on ones person, (4) doubt that the
device can relieve pain, (5) need to modify clothing to facilitate the
application and use of the device, and (6) need for assistance with
applying the electrodes.
20-1: If a client appears to be hypoxemic despite a normal SpO2, the
nurse may suspect that the equipment is not functioning accurately.
Initially the nurse implements interventions to support and improve
the clients breathing. He or she reports the interventions and the
clients responses to them to the nurse in charge and the physician.
The nurse may re-evaluate the client using a different pulse oximeter. In the reverse scenario, if the client is not in distress, the nurse initially can make sure that the oximeter is attached to the client
correctly; if so, the nurse reassesses the clients SpO2 with a different
oximeter. If the second assessment indicates similar compromised
oxygenation, the nurse can administer 2 to 3 L of oxygen, perform a
comprehensive respiratory assessment, and contact the physician
with the assessment data.
20-2: A owmeter is attached to a source for oxygen such as a wall outlet. It is used to regulate the amount of oxygen delivered to the client.
An oxygen analyzer is used periodically to measure the percentage of
oxygen being delivered to the client. The goal is that the client is
breathing the amount of oxygen prescribed by the physician.
20-3: A well-oxygenated client breathes quietly and effortlessly. The
respiratory rate is generally between 16 to 20 breaths per minute at
rest using the diaphragm and intercostals muscles for breathing. An

828

APPENDIX B Suggested Answers to Stop, Think, and Respond Boxes

adult clients heart rate is between 60 to 100 beats per minute. The
clients blood pressure is within normal range for age. The client can
perform activities of daily living without becoming breathless.
Mucous membranes and nail beds are pink regardless of ethnic or
racial origin. The client is oriented and can think and respond logically. If the clients SpO2 is assessed, it measures 95% to 100%.
20-4: When a lobe or entire lung collapses, it compromises the diffusion of gases through the alveolar and pulmonary capillary membranes. Carbon dioxide is retained and shunted back into arterial
circulation. Oxygen does not diffuse into the blood in normal
amounts. The client becomes hypoxemic and develops hypercarbia
(increased carbon dioxide level in the blood). Aerobic metabolism is
reduced; the clients energy stores are depleted. The brain cannot
function as optimally and the client may become restless, confused,
somnolent (sleepy), and perhaps die. Heart rate increases in an effort
to re-establish adequate oxygenation. The blood pressure increases
in response to anxiety created by a feeling of suffocation.
21-1: A virus (infectious agent) that causes the common cold
reproduces within a persons respiratory passages (reservoir). The
infected person coughs, sneezes, shares food or a beverage, or in
some other manner releases the virus from oral or nasal secretions
(exit route). Droplets (mode of transmission) carry the released
virus to the respiratory passages (port of entry) of a second person.
If the second person cannot resist the infectious agent with mechanical or chemical defense mechanisms, that person (susceptible host)
becomes infected.
21-2: It is best for the nurse to bring individual packets of an alcoholrub product used before and after client care. If that is not an option,
the nurse may choose to bring a supply of paper towels or request a
clean hand towel. The nurse may use the clients bar soap after wetting his or her hands with running water. The nurse rinses the bar
soap afterward. When the nurse has worked the soap lather around
all surfaces of the hands for at least 15 seconds, he or she holds the
hands in a downward position and rinses them with the water that is
still running. The nurse then dries the hands and uses the paper towel
or clean hand towel to turn off the faucet. The nurse might recommend that the client purchase a liquid soap dispenser or use a soap
dish that allows the soap to dry on all sides. Another teaching point
is to suggest that each family member have his or her own personal
face cloths and hand and bath towels.
21-3: Despite even brief contact, when a sterile surface of an item
touches an unsterile area, the sterile item is considered contaminated. The nurse must remove the sterile glove and reglove again
with another pair of sterile gloves to avoid transmitting microscopic
organisms that can cause infection to the client.
21-4: To limit the spread of the virus that causes the common cold, it is
essential that the infected person limit close contact with others and
contain respiratory secretions by covering the mouth with a paper tissue when sneezing or coughing. He or she discards the paper tissue
in a lined receptacle then washes his or her hands or uses a hand sanitizer such as an alcohol rub. It is also helpful that the infected person
not share any items such as a drinking glass, eating utensils, face
cloth, and hand towel with anyone else. Those items should be
washed in hot water and detergent before being reused by others.
22-1: Airborne precautions are correct for a client with pulmonary
tuberculosis. Droplet precautions are necessary for clients with
streptococcal pneumonia and meningococcal meningitis. Contact
precautions are appropriate when caring for clients with infected
wounds and acute diarrhea.
22-2: The nurse cares for the client with a draining wound abscess using
contact precautions. This transmission-based precaution requires that
health care workers and visitors don gloves before entering the clients
room. They also wear a gown if there is a potential that clothing will
touch the client, contaminated surfaces or items in the room, or
wound drainage.
23-1: An advantage of the supine position for newborns and infants is
that it reduces the incidence of sudden infant death syndrome (SIDS);
a disadvantage is that, if prolonged, this position compromises circu-

lation to the posterior areas of the body. It also may contribute to foot
drop. An advantage of the lateral position is that it reduces potential
for foot drop; however, breathing may be compromised if the upper
shoulder and arm are not supported. The lateral oblique position creates less pressure on the hip, reducing the potential for skin breakdown in that area. The prone position keeps the hips extended,
reducing the potential for hip exion contracture but it interferes
with physically assessing the front (anterior) of the client. The Sims
position facilitates performing procedures involving the rectum; like
the prone position, it is difcult to assess the frontal areas of the
client. The Fowlers position helps clients with respiratory problems
to breathe more effectively, but sitting increases pressure on the coccyx, which can lead to skin breakdown.
23-2: To turn and position a client who is weak and cannot fully assist,
the nurse may choose to use a turning sheet and pillows. The nurse
could teach the client to help by using a trapeze and the siderails of
the bed.
23-3: Transfer techniques ranked from safest to greatest potential for
injury for the nurse are (1) having the client use a transfer handle
(2) using a mechanical lift, (3) using a lift sheet, (4) using a transfer
belt, (5) using a transfer board, and (5) performing a passive transfer. The more weight that the nurse must lift either alone or assisted
increases the potential for injury. The risk increases if the nurse does
not use proper body mechanics.
24-1: Nurses would promote active ROM exercises for a client
paralyzed below the waist primarily for the following reasons:
1) to maintain and improve muscle tone, strength, and endurance
because this client will eventually use the upper body to achieve
mobility with a wheel chair and 2) to maintain joint mobility and exibility of the ngers, wrists, elbows, and shoulders. Lack of exercise
may result in muscle atrophy, muscle contractures, and joint ankylosis that can restrict a clients potential for independence.
24-2: Examples include progressively increasing ROM in affected joints,
decreased swelling of the extremity, less need for pain-relieving
medications, warm skin with easily palpated peripheral pulses, negative Homans sign, and an ability to tolerate increased duration of
the exercise.
25-1: Canvas slings have certain advantages. They are more convenient because they are pre-made. They generally have a wide shoulder strap with no knot at the neckline, which avoids pressure on the
cervical spinous process. A disadvantage is that the client is charged
for the canvas sling.
The advantages and its disadvantages of cloth slings are opposite
those of canvas slings. Cloth slings are improvised from materials that
the client has available; therefore, the cost is minimal or nothing.
Because they are fastened with a knot, there is a potential for pressure on the skin over the vertebral bony process unless the knot is
conscientiously applied to the side of the neck.
25-2: The most essential information includes those physical signs that
indicate a complication such as swelling that impairs movement and
sensation, unrelieved pain, and a cold and white appearance in distal areas. The nurse emphasizes to the client that he or she must seek
medical attention for these signs and symptoms. The nurse also
instructs the client to facilitate thorough drying of the cast by leaving it temporarily uncovered yet elevated and supported. He or she
cautions the client to avoid indenting the wet cast with the ngers
by handling or moving it with the palms or a supporting pillow. The
nurse tells the client to avoid getting the cast wet, to reinforce crumbling or sharp edges with petals of tape, and to never insert anything
sharp within the cast.
25-3: When implementing contact transmission-based precautions, the
nurse places the client in a private room. He or she places a sign on
the clients door with instructions for visitors and staff identifying the
necessary actions to avoid spreading the microorganism to oneself or
others. For contact precautions, such actions include donning gloves
as a barrier to avoid contact with drainage that contains the infectious
microorganism and removing the gloves and performing handwashing or an alcohol-based rub before leaving the room. All visitors

APPENDIX B Suggested Answers to Stop, Think, and Respond Boxes

including the nurse wear a gown if there is a possibility that clothing
will touch the client or other surfaces in the clients environment.
They also remove the gown and place it within a laundry container
in the clients room before leaving. They wash the hands or rub them
with an alcohol-based product again after exiting the room.
26-1: One of the greatest problems is falls. Clients also may develop muscle fatigue, musculoskeletal strains, and discomfort if the ambulatory
aid is not tted properly according to the clients height. A dangerous
complication known as crutch palsy can develop from incorrectly tted crutches or poor posture. Manifestations of crutch palsy include
weakened forearm, wrist, and hand muscles from nerve impairment
secondary to pressure on the brachial plexus of nerves in the axilla.
Clients may restrict their activity and social interactions if they fear
they may be injured when using an ambulatory aid.
26-2: An older amputee may nd application and maintenance of a
prosthesis physically difcult. Teaching another person in the household, adult children, or a reliable neighbor who can assist the client
may facilitate the older adults use of the prosthetic limb. A client
who develops skin impairment or other physical discomfort may
avoid wearing a prosthetic limb. The nurse can recommend that the
client consult the prosthetist because the stump size may have
changed or the prosthesis may require some other modication to
ensure a comfortable t. An amputee may lack the stamina and
endurance required for ambulating with a prosthetic limb and may
choose to substitute the use of a wheelchair for mobility. Additional
physical therapy or a regimen of independent exercise may improve
the clients tolerance for activity.
27-1 Surgical clients experience acute incisional pain and are less likely
to move in bed because movement increases pain. A surgical client
is likely to receive analgesic drugs, which cause drowsiness and sedation. Surgical clients need encouragement and assistance to ambulate, especially if surgery involves the extremities or joints in the
lower limbs and the use of crutches, walker, or cane. Surgical clients
are also likely to have an infusing intravenous solution, wound drain
with a drainage collection device, and other tubes such as a urinary
catheter or nasogastric tube that they cannot manage alone.
27-2: Infectious agents have many sources: transient bacteria on the
skin, bacteria within items in the environment such as the bed linen,
and those that may remain on the nurses hands even after handwashing or an alcohol-based handrub. The clients and nurses skin
and the environment represent reservoirs of microorganisms that can
be transmitted by direct contact and within blood and body uids.
The surgical client is more susceptible than usual because of presurgical emotional stress and the pathology for which he or she requires
surgery. The hospital is also a hostile environment because it contains
microbes to which the client is not normally exposed. These microbes
within their respective reservoirs can enter the clients tissue and
blood through microabraded skin. If microorganisms are unchecked
and proliferate, they can exit from the client and be transferred to others whose skin also is impaired.
27-3: Both TED hose and a pneumatic compression device prevent
venous stasis. The TED hose support valves within the veins so that
blood cannot move in a retrograde fashion. The hose propel the
blood forward by the contraction of skeletal muscles in the legs when
a client performs leg exercises or ambulates. A pneumatic compression device is a substitute for the natural contraction of lower
extremity leg muscles. They compress the vein walls and move the
blood toward the heart.
The advantages of TED hose is that they are less expensive and
are easily applied and removed; however, they do not move blood
independently. A pneumatic compression device keeps venous
blood circulating, but device application and regulation require
technical skill.
28-1: An infected wound would likely appear very red and swollen
with white, gray, or greenish drainage. A fever would generally be
present and the white blood cell count would be increased signicantly. The level of localized pain usually would be greater with
infection than with wound trauma and normal healing.

829

28-2: The advantage of sharp debridement is that it is the most time

efcient form of debridement; however, it is painful and may cause
appreciable blood loss. Costs are increased if this form of debridement is performed in the operating room. An advantage of enzymatic
debridement is that it is effective in managing small, uninfected
wounds; it is also an alternative for clients who cannot tolerate sharp
debridement. Enzymatic debridement requires the use of a dressing.
One of the chief advantages of autolytic debridement is that it is painless, but it takes the longest of all debridement methods to achieve
the desired outcome. Mechanical debridement is effective in removing debris from a wound but it is labor intensive, can be painful, and
may disrupt healthy granulating tissue.
28-3: Signs of a therapeutic effect from a sitz bath include that the
wound is clean with no or decreasing drainage, swelling is reduced,
and the client reports no or less pain.
29-1: A nasogastric tube is a solid foreign substance. If placed in the respiratory passages (structures that transport gases), the tube will compromise the volume of gases that can move into and out of the lungs.
Hypoxemia and hypoxia are potential consequences. In most clients,
the tube will cause irritation manifested by violent coughing in an
effort to expel the tube from the airway. If the tube is used to administer liquid formula, medications, or irrigation solution while in the
airway, the client will develop pneumonia or may die of asphyxiation.
29-2: Isotonic saline solution contains 0.9% sodium and chloride
(NaCl), which is the same concentration as in body cells. Using an
isotonic solution will not cause any appreciable change in uids or
electrolytes. Based on osmosis, a hypotonic saline solution (less than
0.9% NaCl) would cause body cells to swell as uid moves through
cellular membranes from a lower concentration of NaCl to one that
is higher within the cell. Diffusion would move electrolytes from the
cells into the stomach. A hypertonic saline solution (greater than
0.9% NaCl) would pull uid from the cells into the irrigating solution. The cells would shrink because of the loss of water, and sodium
and chloride would diffuse into less concentrated areas of body uid.
29-3: After removing a nasogastric tube, the nurse should rst check
the medical orders to validate that the client can resume ingesting
oral uids and food and the type of diet that has been prescribed. It
is always best to resume oral nourishment slowly. The nurse may
initially provide sips of water or ice chips and progress to clear uids such as bouillon, gelatin, apple juice, and tea. If the client tolerates clear uids, the nurse can advance the diet to full liquids, then a
soft diet, and nally a regular (general) diet. If the client develops
nausea or vomits, it is best to temporarily halt the consumption of
food and resume with the type of diet that the client is able to tolerate without becoming symptomatic.
29-4: A client whose nutritional needs are met entirely with tube feedings may feel deprived of the ability to taste food and eat foods that
were personal favorites. He or she may feel unable to participate
fully in celebrations involving food such as birthdays and holidays.
The client may compromise attendance at social events such as going
to gatherings where family and friends eat in a restaurant. In addition, tube feedings may alter bowel elimination patterns, requiring
additional management to ensure normal texture of stool. The client
may want to isolate himself or herself from people other than close
family during administration of tube feedings.
30-1: Demonstrate respect for the clients dignity and facilitate elimination when the client indicates the need. Respond to the clients signal
for assistance with elimination as quickly as possible, ensure the
clients comfort and privacy, and expeditiously dispose of eliminated
urine and stool. Help the client to clean the body areas that have
come in contact with urine or stool, which also includes hand
hygiene, and replace soiled linen or bed clothing if necessary. Store the
bedpan in a bedside cabinet or other unobtrusive location. If any odor
lingers, ventilate the room or use an aerosolized deodorizer.
30-2: Assessment ndings that indicate a problem with an external
condom catheter include changes in the appearance of the penis and
leakage of urine to places other than the drainage system. The penis
may look swollen and discolored. The skin may be irritated or

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APPENDIX B Suggested Answers to Stop, Think, and Respond Boxes

impaired. The clients clothing or bed linen may be wet with urine.
Some measures to address these problems include selecting an appropriate size external catheter and demonstrating how to apply it correctly. Some points to emphasize include washing and drying the
penis well before applying the external condom catheter, using a spiral pattern when applying the adhesive strip and avoiding tight constriction of the penis, leaving a space of 1 to 2 inches below the tip of
the penis, and checking to make sure that the catheter does not twist
and obstruct the ow of urine into a leg bag or gravity drainage bag.
30-3: A female with an indwelling retention (Foley) catheter is at risk
for urinary tract infections because the distance between the urethra
and bladder is quite short and the urinary meatus is anatomically close
to the anus. These factors increase the possibility that microorganisms
in stool can easily colonize these areas. Therefore, it is extremely
important to clean stool from a female client in a direction away from
the urinary meatus and to perform regular catheter care to remove
transient microorganisms and debris from the external surface of the
catheter and urinary meatus with which it comes in contact.
30-4: Unless a urinary catheter has been purposely clamped, accumulation of urine in a drainage receptacle should be continuous. If not,
the distal tip of the catheter may no longer be within the bladder, perhaps because the balloon has lost some of the ination water and the
catheter has migrated. Another possibility is that the catheter may
be obstructed because the client is lying on the tubing or it is compressed between components within the frame of the clients bed.
Mucous or other debris that accumulates within the lumen of the
catheter also can interfere with the drainage of urine. A dependent
loop in the drainage tubing also interferes with the free ow of urine.
Likewise if the drainage device is above bladder level, urine will
backow into the bladder rather than into the urinary collection bag.
30-5: When a catheter is not draining appropriately even after performing an irrigation, rst palpate the clients bladder to determine
if it is distended and question the client about potential discomfort
in the lower abdomen and any sensation of a need to void. To promote patency, encourage a greater intake of oral uids. If there is no
evidence of drainage despite this measure, remove the catheter,
insert a new catheter, and document the outcome in the clients medical record. If upon replacing a catheter, no urine is obtained, notify
the physician.
31-1: Some helpful measures may include (1) eating slowly without
gulping food; (2) chewing food with the mouth closed; (3) avoiding
cruciferous vegetables like cauliflower, brussel sprouts, and cabbage, and other gas-forming foods like radishes, cucumbers, onions,
and beans; (4) regularly eating smaller amounts of fiberous foods
(e.g., bran) rather than sporadically eating an excessive consumption; (5) avoiding foods, beverages, or medications that contain air
(e.g., carbonated soft drinks, whipped toppings, effervescent medications like Alka Seltzer); (6) avoiding chewing gum, sipping
through a straw, or drinking from bottles with a narrow mouth
because they promote swallowing air; (7) walking after eating; and
(8) consulting with a physician to determine if there is a disorder
that causes excessive intestinal gas such as irritable bowel syndrome
or lactose intolerance.
31-2: If stool is felt during insertion of a suppository, the likelihood is
strong that the suppository will have little effect. To work correctly,
a suppository must come in contact with the bowel wall. Therefore,
the nurse attempts to remove the stool digitally or consults with the
physician about administering an oil retention or other type of enema
to eliminate the stool.
31-3: Some measures include responding to the gastrocolic reex as
soon as possible when it is perceived; consuming at least 6 to 8 glasses
of water or other uid daily; being physically active; eating a variety
of foods that contain ber; and avoiding the frequent use of laxatives
or self-administered enemas that reduce natural bowel tone with regular use.
31-4: Although each ostomate is unique, a person with an ostomy
(1) may feel self-conscious that others will detect the odor of stool or
intestinal gas that may collect in an appliance; (2) may be relieved

that the disorder that required the need for an ostomy has been diagnosed and treated; (3) may be reluctant to become sexually intimate;
(4) will be vigilant about dietary and elimination patterns; (5) may
develop skin problems around the stoma; (6) will have the expense
of purchasing supplies to care for the ostomy; and (7) may be selective about style of clothing.
32-1: To ensure the clients safety, never attempt to administer oral
medications to a client at risk for aspiration. Temporarily withhold
the medication and consult the physician. The physician may choose
to cancel the medication order or prescribe a drug with a similar
action by another route.
32-2: A client receives medications through a gastric or intestinal tube
when (1) he or she is unconscious and at risk for aspiration, (2) has
impaired swallowing and may choke or aspirate, or (3) has a nasogastric or nasointestinal tube that occupies space in the pharynx creating a smaller diameter through which medications can move into
and through the esophagus to the stomach.
33-1: If the tip of an ophthalmic medication dropper becomes contaminated, the nurse discards it and requests a replacement for the medication from the pharmacy.
34-1: Assess the clients breathing, heart rate, and blood pressure. If
the data suggest that the client is experiencing dyspnea, tachycardia,
or an irregular heart rhythm, and signicantly low blood pressure,
call for assistance (see Chap. 37). Place the client in a modied Trendelenberg position with the upper body supine and the legs elevated
above heart level. Oxygen may be administered to facilitate breathing. Once assistance arrives with a cart of emergency medications,
prepare to administer prescribed drugs that will combat hypotension
and allergic response. If the clients respirations cease, administer
rescue breathing until the client can be intubated and given supportive ventilation. If the clients heart stops, begin cardiac compressions. Electrical debrillation may be necessary if the heart does
not spontaneously beat with cardiac compressions.
34-2: The nurse can draw a human-like gure with a grid on the arms,
legs, and abdomen. He or she can number the blocks on the grid
(i.e., #1 on the left arm, #2 on the right arm, #3 on the left leg, #4 on
the right leg, #5 on the left abdomen, #6 on the right abdomen). Each
time he or she gives an injection, the nurse crosses through the
number of the site used. The nurse refers to the gure and looks for
the next unmarked number in the sequence to identify the location
for the scheduled injection.
34-3: Intravenous administration of medication intended for the intramuscular route would cause more sudden absorption and circulation
than desired. The intramuscular dose may be in excess of that for the
intravenous route, which could cause a toxic effect. Sometimes intramuscular injections are prepared in a vehicle such as oil that is not
compatible with vascular uid. The oil, which is not immiscible in
blood, may act as an embolus and circulate to a vital organ like the
lungs or brain, injuring that tissue. To prevent such an adverse
effect, the nurse draws back on the plunger and looks to see if blood
appears in the tip or barrel of the syringe. If that occurs, the nurse
withdraws the needle, prepares another syringe with medication,
and attempts to administer the medication in another site.
35-1: (1) The drug is delivered continuously to target sites for action.
(2) A consistent blood level of medication is maintained. (3) The
medication is diluted in a large volume of uid, which may reduce
irritation of the vein. (4) The infusion can be slowed or discontinued if the client has an adverse response to the medication.
35-2: To determine the compatibility of two drugs that will infuse
through the same IV tubing, the nurse can consult with an agencys
pharmacist. Pharmacists are experts in drugs and drug therapy. The
nurse also may refer to an IV drug compatibility chart, which often
lists drugs commonly administered intravenously. Drug compatibility charts frequently are posted in medication rooms where nurses
prepare drugs and IV solutions.
35-3: Using a volume-control set to instill IV medications and uid is
preferable to other administration techniques because the nurse lls
the volume chamber with a small amount of uid and clamps the bag

APPENDIX B Suggested Answers to Stop, Think, and Respond Boxes

above that contains the larger volume. By doing so, the nurse helps
to ensure that an infant or small child will not receive more than the
volume in the lled chamber. This avoids the potential for overloading the circulatory system with excess uid. Children have been
known to manipulate IV roller clamps and change the rate of infusion unless safety measures are taken. The instillation of the small
amount of uid in a volume-control chamber is not as potentially lifethreatening as the accidental infusion of a large volume in a primary
bag of uid.
36-1: A client with hypoxia is likely to exhibit restlessness, an effort
to sit up, tachypnea, tachycardia, nasal aring, use of accessory muscles, and confusion. Blood pressure may rise in response to the stress
of being unable to breathe adequately. Cyanosis of the lips, nailbeds,
and skin may be a late sign of poor oxygenation.
36-2: Clients who cannot speak and, therefore, cannot easily make
needs known may manifest symptoms of a stress response. They are
likely to be tense and hypervigilant; they may startle easily. Heart
rate, blood pressure, and respirations may increase; clients may not
sleep well. They may feel frustrated if caregivers, family, and friends
cannot understand what they are trying to convey. Clients may feel
lonely if others avoid attempts to communicate. They may fear
being unable to obtain help in a life-threatening situation. They may
develop impatience at having to write thoughts when verbal communication is impaired. Illiterate clients may be embarrassed if
others discover their inability to communicate by writing.
37-1. Airway obstruction is very common among infants and young
children, who often place toys and other objects in their mouths.
Some foods contraindicated for young children include peanuts, popcorn, chewing gum, and hard candy. Parents and other caregivers
should not give toys with small components that are loose or could
be removed (e.g., plastic eyes in stuffed animals) to infants and toddlers. Balloons and buttons are also common sources of airway
obstruction in young children.
In adults, airway obstruction may result when they do not chew
large bites of food thoroughly before swallowing. Older adults who
have had a cerebral vascular accident (stroke) are at risk for aspirat-

831

ing food because the muscular ability to swallow has been compromised. Clients in a hospital or extended care facility should sit upright
when eating or being fed in bed.
37-2: Resuscitation of infants (1 year), children (1-8 years), and
adults (8 years) is similar with the following exceptions:

Infants and children receive rescue breaths every 3 seconds;

adults receive rescue breaths every 5 seconds.

After the initial two breaths, infants and children receive at least
20 breaths/minute; adults receive 10 to 12 breaths/minute.

For infants, the location for chest compressions is midline, one nger width below the nipples. For children and adults, the location
for chest compressions is two nger widths above the tip of the
sternum; however, the newest guidelines (2000) also describe this
location as in the center of the chest between the nipples.
When the victim is an infant, the rescuer encircles the chest
with both hands and administers chest compressions with
both thumbs. When the victim is a child, the rescuer uses the
heel of one hand. When the victim is an adult, the rescuer uses
two hands.
The rescuer compresses the infants chest 12 to 1 inch. The rescuer compresses the childs chest 1 to 112 inches. The rescuer
compresses the adults chest 112 to 2 inches or more.
An AED is used only for people older than 8 years. Health care
personnel can adjust the energy on defribrillators for clients
younger than 8 years or who weigh less than 55 lbs.
38-1: Before and during postmortem care, the nurse ensures privacy.
The nurse and any assistant maintain respectful decorum by avoiding joviality or discussing social or trivial information. The nurse
touches and manipulates the body gently. He or she may even talk
directly to the deceased person about experiences prior to death.
The nurse cleans the body thoroughly, grooms the hair, and safeguards personal effects. He or she keeps the room door closed after
giving postmortem care, helps mortuary personnel transfer the
body from the room to the mobile stretcher, or escorts the body to
the morgue in such a way that others do not view it.