www.mynursingtestprep.comnonproductive cough. Antitussives are useful for adults when coughing is unproductive and frequent, leading to throat irritation or interrupted sleep. Expectorants help make coughing more productive. The goal of an antitussive/expectorant combination is to reduce the frequency of dry, unproductive coughing while making voluntary coughing more productive. PTS:1DIFifficultREF:p. 1310 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 5. The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure. The patient is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take? 1) Review and implement the primary care providers prescriptions for treatments. 2) Perform a quick physical examination of breathing, circulation, and oxygenation. 3) Gather a thorough medical history, including current symptoms, from the family. 4) Administer oxygen to the patient through a nasal cannula. ANS: 2 The first action the nurse should take is to make a quick assessment of the adequacy of breathing, circulation, and oxygenation in order to determine the type of immediate intervention required. The nurses assessment should include simple questions about current symptoms. A more thorough medical history can be gathered once the patients oxygenation needs are addressed. Following a quick assessment, the nurse should then review and implement physicians orders. Administering oxygen is not appropriate without knowing what treatments the primary care provider has prescribed. PTS:1DIF:ModerateREF:dm 1301-1302 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 6. You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patients respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern? 1) Biots breathing 2) Kussmauls respirations 3) Sleep apnea 4) Cheyne-Stokes respirations ANS: 4 This respiratory pattern is known as Cheyne-Stokes respirations. It is often associated with damage to the medullary respiratory center or high intracranial pressure due to brain injury. PTS:1DIF:EasyREF:p. 1303 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 7. You are admitting a 54-year-old patient with chronic obstructive pulmonary disease (COPD). The physician prescribes O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient?
www.mynursingtestprep.com1) Nonrebreather mask 2) Nasal cannula 3) Partial rebreather mask 4) Venturi mask ANS: 4 The Venturi mask is capable of delivering 24% to 50% FIO2. The cone-shaped adapter at the base of the mask allows a precise FIO2 to be delivered. This is very useful for patients with chronic lung disease. Rebreather masks are used when high concentrations of oxygen are required. A nasal cannula administers oxygen in liters per minute and does not allow administration of a precise FIO2. PTS:1DIFifficultREF:p. 1335 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 8. Which of the following provide the most reliable data about the effectiveness of airway suctioning? 1) The amount, color, consistency, and odor of secretions 2) The patients tolerance for the procedure 3) Breath sounds, vital signs, and pulse oximetry before and after suctioning 4) The number of suctioning passes required to clear secretions ANS: 3 Breath sounds, vital signs, and oxygen saturation levels before and after suctioning provide data about the effectiveness of suctioning. Information about the amount and appearance of secretions provides data about the likelihood of airway infection and/or inflammation. Data about the patients tolerance of suctioning provide information about the patients overall condition. The number of suctioning passes required to clear the secretions provides information about the amount of secretions present. PTS: 1 DIF: Moderate REF: p. 1351 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 9. What is the rationale for wrapping petroleum gauze around a chest tube insertion site? 1) Prevents air from leaking around the site 2) Prevents infection at the insertion site 3) Absorbs drainage from the insertion site 4) Protects the tube from becoming dislodged ANS: 1 Petroleum gauze creates a seal around the insertion site. Collapse of the lung can occur if there is a leak around the insertion site that causes loss of negative pressure within the system. Air leaks are one common cause of loss of negative pressure.
www.mynursingtestprep.comPTS:1DIF:EasyREF:p. 1322 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 10. You are caring for an adult patient with a tracheostomy who is being mechanically ventilated. His pulse oximetry reading is 85%, heart rate is 113, and respiratory rate is 30. The patient is very restless. His respirations are labored, and you hear gurgling sounds. You auscultate crackles and rhonchi in both lungs. What is the most appropriate action to take? 1) Call the respiratory therapist to check the ventilator settings. 2) Provide endotracheal suctioning. 3) Provide tracheostomy care. 4) Notify the physician of the patients signs of fluid overload. ANS: 2 Increased pulse and respiratory rates, decreased oxygen saturation, gurgling sounds during respiration, auscultation of adventitious breath sounds, and restlessness are signs that indicate the need for suctioning. Airways are suctioned to remove secretions and maintain patency. The patients symptoms should subside once the airway is cleared. PTS: 1 DIF: Moderate REF: p. 1318, 1342 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 11. Chest percussion and postural drainage would be an appropriate intervention for which of the following conditions? 1) Congestive heart failure 2) Pulmonary edema 3) Pneumonia 4) Pulmonary embolus ANS: 3 Chest physiotherapy moves secretions to the large, central airways for expectoration or suctioning. This treatment is not effective for conditions that do not involve the development of airway secretions, including congestive heart failure, pulmonary edema, and pulmonary embolus. PTS:1DIF:ModerateREF:p. 1313 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 12. Which of the following blood levels normally provides the primary stimulus for breathing? 1) pH 2) Oxygen 3) Bicarbonate
www.mynursingtestprep.com4) Carbon dioxide ANS: 4 Carbon dioxide (CO2) level provides the primary stimulus to breathe. High CO2 levels stimulate breathing to eliminate the excess CO2. A secondary, although important, drive to breathe is hypoxemia. Low blood O2 levels stimulate breathing to bring more oxygen into the lungs. PTS:1DIF:ModerateREF:p. 1296 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 13. A 62-year-old man with emphysema says, My doctor wants me to quit smoking. Its too late now, though; I already have lung problems. Which of the following would be the best response to his statement? 1) You should quit so your family does not get sick from exposure to secondhand smoke. 2) You will need to use oxygen, but remember it is a fire hazard to smoke with oxygen in your home. 3) Once you stop smoking, your body will begin to repair some of the damage to your lungs. 4) You should ask your primary care provider for a prescription for a nicotine patch to help you quit. ANS: 3 The nurses response should focus on correcting the patients misinformation rather than on convincing him to stop smoking. Once a person stops smoking, the body begins to repair the damage. During the first few days, the person will cough more as the cilia begin to clear the airways. Then the coughing subsides, and breathing becomes easier. Even long-time smokers can benefit from smoking cessation. The suggestions that the patients family will become ill and that oxygen is a fire hazard appear to be scare tactics, which can be seen as coercive, and would not be effective in motivating the patient to stop smoking. Although asking the primary care provider for a prescription may help the patient to stop smoking, it does not address his incorrect belief that it is too late for him to do so. PTS:1DIF:ModerateREF:p. 1299 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 14. The nurse administers intravenous morphine sulfate to a patient for pain control. She will need to monitor her patient for which of the following adverse effects? 1) Decreased heart rate 2) Muscle weakness 3) Decreased urine output 4) Respiratory depression ANS: 4 Opioids are potent respiratory depressants. Patients receiving opioids should be monitored for decreased rate and depth of respirations. PTS:1DIF:ModerateREF:dm 1299, 1305; critical-thinking and synthesis required KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension
www.mynursingtestprep.com15. When using sterile technique to perform tracheostomy care of a new tracheostomy, which of the following is correct? 1) You will need a single pair of sterile gloves. 2) Place the patient in semi-Fowlers position, if possible. 3) Clean the stoma under the faceplate with hydrogen peroxide. 4) Cut a slit in sterile 4 4 gauze halfway through to make a dressing. ANS: 2 Semi-Fowlers position promotes lung expansion and prevents back strain for the nurse. You will need two pairs of sterile gloves: one pair for dressing removal, and a clean pair for the rest of the procedure. You should clean the stoma under the faceplate with sterile saline. Never cut a 4 4 gauze for the dressing because lint and fibers from the cut edge could enter the trachea and cause respiratory distress. PTS: 1 DIF: Easy REF: p. 1338 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 16. A patient has just had a chest tube inserted to dry-seal suction drainage. Which of the following is a correct nursing intervention for maintenance? 1) Keep the head of the bed flat for 6 hours. 2) Immobilize the patients arm on the affected side. 3) Keep the drainage system lower than the insertion site. 4) Drain condensation into the humidifier when it collects in the tubing. ANS: 3 The drainage system must be below the insertion site to prevent fluid flowing back into the pleural cavity and compromising the patients respiratory status. Maintain patient in semirecumbent position (head of bed elevated 30 to 45 degrees), not flat. This is extremely important to promote lung expansion, reduce gastric reflux, and prevent ventilator-associated pneumonia (VAP), if the person is being mechanically ventilated. Patients being mechanically ventilated are at high risk for developing VAP, which is associated with high mortality rates. Mouth rinses and mouthwashes are a part of the recommended routine for preventing VAP. They also provide comfort and preserve integrity of the mucous membranes. Encourage the patient to move the arm on the affected side; if he cannot, perform passive range-of-motion. You should check the ventilator tubing frequently for condensation, and drain the fluid into a collection device or waste receptacle because condensation in the ventilator tubing can cause resistance to airflow. Moreover, the patient can aspirate it if it backflows down into the endotracheal tube. The fluid should not be drained into the humidifier because the patients secretions may have contaminated it. PTS: 1 DIF: Difficult REF: p. 1353 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. The nurse is counseling a 17-year-old girl on smoking cessation. The nurse
www.mynursingtestprep.comshould include which of the following helpful tips in her education? Choose all that apply. 1) Keep healthy snacks or gum available to chew instead of smoking a cigarette. 2) Dont tell your friends and family you are trying to quit, until you feel confident that youll be successful. 3) Plan a time to quit when you will not have many other demands or stressors in your life. 4) Reward yourself with an activity you enjoy when you quit smoking. ANS: 1, 3, 4 People who are trying to quit smoking often are more successful when they are accountable to other people who are encouraging and supportive. Having something to chew (e.g., carrot sticks, gum, nuts, or seeds) can distract from the desire to smoke a cigarette. Setting a date to stop smoking and choosing a time of low stress are two strategies that help people be more successful with smoking cessation. Self-reward for meeting goals is a form of positive reinforcement. PTS:1DIF:ModerateREF:p. 1311, ESG Self-Care: Smoking Cessation Tips KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension 2. A patient has a history of COPD. His pulse oximetry reading is 97%. What other findings would indicate adequate tissue and organ oxygenation? Choose all that apply. 1) Normal urine output 2) Strong peripheral pulses 3) Clear breath sounds bilaterally 4) Normal muscle strength ANS: 1, 2, 4 To determine adequacy of tissue oxygenation, assess respiration, circulation, and tissue/ organ function. Good peripheral circulation is characterized by strong peripheral pulses. Impaired tissue oxygenation to the kidneys would result in abnormal kidney function (e.g., poor urine output). Hypoxic limb tissue would result in abnormal muscle functioning (e.g., muscle weakness and pain with exercise). Adequacy of tissue oxygenation cannot be determined by assessing pulmonary ventilation alone; circulation must also be assessed. PTS:1DIFifficult REF: p. 1300; higher-order item, some of answer implied in text KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 3. The nurse is teaching a patient about her chest drainage system. Which of the following should the nurse include in the teaching? Choose all that apply. 1) Perform frequent coughing and deep-breathing exercises. 2) Sit up in a chair but do not walk while the drainage system is in place. 3) Get out of bed without assistance as much as possible.
www.mynursingtestprep.com4) Immediately notify the nurse if she experiences increased shortness of breath. ANS: 1, 4 Patients should regularly perform coughing and deep-breathing exercises to promote lung reexpansion. Also to promote lung reexpansion, the nurse should encourage the patient to be as active as her condition permits, rather than telling her not to walk. Chest drainage systems are bulky, but patients with disposable systems can still get out of bed and ambulate. However, the patient will need assistance from one or two staff members to protect and monitor the system and to monitor her responses to activity; she should not get out of bed on her own. If a patient with a chest drainage system becomes acutely short of breath, the patient should immediately notify the nurse so the nurse can check for occlusion of the system, which can result in a tension pneumothorax. PTS:1DIF:ModerateREF:dm 1313, 1358 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 4. When providing safety education to the mother of a toddler, you would inform the mother that, based on the childs developmental stage, he is at high risk for which of the following factors that influence oxygenation? Choose all that apply. 1) Frequent, serious respiratory infections 2) Airway obstruction from aspiration of small objects 3) Drowning in small amounts of water around the home 4) Development of asthma ANS: 2, 3 As a toddlers respiratory and immune systems mature, the risk for frequent and serious infections is less than in infanthood. Most children recover from upper respiratory infections without difficulty. Toddlers airways are relatively short and small and may be easily obstructed, and they often put objects in their mouth as part of exploring their environment, thus increasing their risk for aspiration and airway obstruction. In addition, toddlers are at high risk for drowning in very small amounts of water around the home (e.g., in a bucket of water or toilet bowl). The risk for developing asthma is not significantly influenced by the childs developmental stage. PTS:1DIF:ModerateREF:p. 1297 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension 5. Obesity is associated with higher risk for which of the following conditions that affect the pulmonary and cardiovascular systems? Choose all that apply. 1) Reduced alveolar-capillary gas exchange 2) Lower respiratory tract infections 3) Sleep apnea 4) Hypertension ANS: 2, 3, 4
www.mynursingtestprep.comObesity causes multiple health problems, many of which affect the lungs, heart, and circulation. Large abdominal fat stores press upward on the diaphragm, preventing full chest expansion and leading to hypoventilation and dyspnea on exertion. The risk for respiratory infection increases because lower lung segments are poorly ventilated, and secretions are not removed effectively. When an obese person lies down, chest expansion is limited even more. Excess neck girth and fat stores in the upper airway often lead to obstructive sleep apnea. Obesity also increases the risk of developing atherosclerosis and hypertension. Obesity does not cause reduced alveolar-capillary gas exchange. PTS: 1 DIF: Easy REF: p. 1299 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension 6. Which of the following is/are accurate about nasotracheal suctioning? Choose all that apply. 1) Apply suction for no longer than 10-15 sec during a single pass. 2) Apply suction while inserting and removing the catheter. 3) Reapply oxygen between suctioning passes for ventilator patients. 4) Gently rotate the suction catheter as you remove it. ANS: 1, 4 Limiting suctioning to 10 seconds or less and reapplying oxygen between suctioning passes prevent hypoxia. Suction should be applied only while withdrawing the catheter, using a continuous rotating motion to prevent trauma to the airway. Endotracheal suctioning is used when the patient is being mechanically ventilated, and most ventilator patients have in-line suctioning, so there is no need to reapply oxygen. PTS: 1 DIF: Moderate REF: p. 1347 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 7. Which of the following factors influence normal lung volumes and capacities? Choose all that apply. 1) Age 2) Race 3) Body size 4) Activity level ANS: 1, 3, 4 Normal lung volumes and capacities vary with body size, age, and exercise level. Volumes and capacities are higher in men, in large people, and in athletes. Race does not influence normal lung volumes and capacities. PTS:1DIF:EasyREF:p. 1305 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 8. Of the following interventions, which is/are likely to reduce the risk of postoperative atelectasis? Choose all that apply. 1) Administer bronchodilators. 2)
Apply low-flow oxygen. 3) Encourage coughing and deep breathing. 4) Administer pain medication. ANS: 3, 4 Pain alters the rate and depth of respirations. Often, patients in pain breathe shallowly, which puts them at risk for atelectasis. Regularly assess all patients for pain. Once you have medicated the patient, reassess breath sounds, and encourage the patient to cough and breathe deeply. This will help to open air sacs and mobilize secretions in the airways. PTS: 1 DIF: Moderate REF: dm 1303, 1313 ; critical-thinking item that requires synthesis of www.mynursingtestprep.com information KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Synthesis Completion Complete each statement. 1. is the movement of air into and out of the lungs through the act of breathing. refers to the exchange of gases (oxygen and carbon dioxide) in the lungs. ANS: Ventilation; Respiration Pulmonary ventilation (breathing) is the movement of air into and out of the lungs. Oxygenation of the blood, and ultimately of organs and tissues, depends on adequate ventilation. Respiration refers to gas exchangethat is, the oxygenation of blood and elimination of carbon dioxide in the lungs. Although the plural form respirations is used to mean breaths when taking vital signs, this is a misnomer: You cannot measure gas exchange by counting breaths per minute. PTS:1DIF:EasyREF:p. 1295 KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension 2.Prolonged use of high oxygen concentrations reduces production, which leads to alveolar collapse and reduced lung elasticity. ANS: surfactant Oxygen toxicity can develop when oxygen concentrations of more than 50% are administered for longer than 48 to 72 hours. PTS:1DIF:ModerateREF:p. 1314 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall 3.The amount of air moved into and out of the lungs with each normal breath is known as the . Normally, this volume is around mL. ANS: tidal volume; 500 PTS:1DIF:EasyREF:p. 1306 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension True or False 1. A positive TB skin test indicates that a patient has active tuberculosis. ANS: F Patients with positive TB skin tests must undergo further testing (chest x-ray and sputum cultures) to determine whether they have merely been exposed to the tuberculosis bacillus or whether they have active disease. Chapter 34 Circulation Identify the choice that best completes the statement or answers the question. 1. A patient diagnosed with hypertension is taking an angiotensin-converting enzyme (ACE) inhibitor. When planning care, which of the following outcomes would be
www.mynursingtestprep.comappropriate for the patient? 1) BP will be lower than 135/85 mm Hg on all occasions. 2) BP will be normal after 2 to 3 weeks on medication. 3) Patient will not experience dizziness on rising. 4) Urine output will increase to at least 50 mL/hr ANS: 1 Goals must be clearly stated so that it is easy to evaluate if they have been met. BP . . . lower than 135/85 mm Hg . . . is clearly stated and easily evaluated. In contrast, BP will be normal . . . does not clearly state the desired endpoint. Freedom from dizziness on rising is probably not achievable because ACE inhibitors are vasodilating agents, which may cause vessel dilation and hypotension, especially when the patient arises from a seated or lying position. Patients should be warned of this effect. The expected/desired effect of the ACE inhibitor is to lower the blood pressure; the urine output is minimally relevant in determining that outcome, if at all. PTS: 1 DIF: Difficult REF: dm 1372-1373 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 2. You are preparing the nursing care plan for a middle-aged patient admitted to the intensive care unit for an acute myocardial infarction (heart attack). His symptoms include tachycardia, palpitations, anxiety, jugular vein distention, and fatigue. Which of the following nursing diagnoses is most appropriate? 1) Decreased Cardiac Output 2) Impaired Tissue Perfusion 3) Impaired Cardiac Contractility 4) Impaired Activity Tolerance ANS: 1 The patients symptoms reflect altered cardiac preload, a component of cardiac output. Acute myocardial infarction is often associated with decreased cardiac output as a result of altered cardiac pumping ability. Although the other nursing diagnoses might be associated with Decreased Cardiac Output, these diagnoses cannot be determined from the symptoms presented. Additionally, Impaired Cardiac Contractility is not a NANDA-I nursing diagnosis. PTS: 1 DIF: Difficult REF: p. 1372 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 3. You are to connect a patient to a cardiac monitor. Which of the following actions should you take to ensure an accurate electrocardiogram tracing? 1) Select electrode placement sites over bony prominences. 2) Apply the electrodes immediately after cleansing the skin, before the alcohol evaporates. 3) Before applying the electrodes, rub the placement sites with gauze until the skin reddens.
www.mynursingtestprep.com4) Ensure that the gel on the back of the electrodes is dry. ANS: 3 Electrodes should be placed over soft tissues or close to bone in order to obtain accurate waveforms. Sites over bony prominences, thick muscles, and skinfolds can produce artifact; therefore, they should not be used. Alcohol removes skin oils that may prevent the electrodes from adhering. However, the alcohol should be allowed to dry before the electrodes are placed. Rubbing the skin with gauze or a washcloth removes dead skin cells and promotes better electrical contact. A dry electrode will not conduct electrical activity; gel should not be dry. PTS: 1 DIF: Moderate REF: p. 1377 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 4. Chronic stress may lead directly to cardiovascular disease because of the repeated release of which of the following? 1) Histamine 2) Catecholamines 3) Cortisol 4) Protease ANS: 2 The stress response stimulates release of catecholamines from the sympathetic nervous system. This results in increased heart rate and contractility, vasoconstriction, and increased tendency of blood to clot. Cortisol is also released in the stress response, but it is more indirectly related to development of cardiovascular disease through altered glucose, fat, and protein metabolism. PTS: 1 DIF: Moderate REF: p. 1365 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall 5. The nurse is teaching a pregnant woman about the increased oxygen demand that develops during pregnancy. The nurse knows the patient comprehends the teaching when she makes the following statement: 1) I may need to drink more fluids in order to make more oxygen. 2) I may need to take an iron supplement so that I am not anemic. 3) I will need a multivitamin supplement for several months. 4) I will need to eat more fruits and vegetables. ANS: 2 During pregnancy, oxygen demand increases dramatically. To compensate, the mothers blood volume increases by 30%. The woman requires additional iron to produce this blood as well as to meet fetal requirements. Failure to meet these iron demands can result in maternal anemia, reducing tissue oxygenation of the mother. PTS: 1 DIF: Moderate REF: p. 1365-1366 KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application 6. Which part of the ECG tracing represents ventricular
www.mynursingtestprep.comrepolarization? 1) P wave 2) QRS complex 3) T wave 4) U wave ANS: 2 The QRS complex represents ventricular depolarization and leads to ventricular contraction. The P wave represents the firing of the SA node and conduction of the impulse through the atria. In the healthy heart, this leads to atrial contraction. The T wave represents the return of the ventricles to an electrical resting state so they can be stimulated again (ventricular repolarization). The atria also repolarize, but they do so during the time of ventricular depolarization; thus, they are obscured by the QRS complex and cannot be seen on the ECG complex. The U wave is not always seen on the ECG but may be detected with electrolyte imbalance, such as hypokalemia or hypercalcemia. U waves sometimes occur in response to certain medication (e.g., digitalis, epinephrine). Inverted U wave may occur with ischemia to the cardiac muscle. 1) PTS: 1 DIF: Moderate REF: dm 1371-1372 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall 7. Three days ago a patient had cardiac surgery to bypass three occlusions of his coronary arteries. Veins for the bypass were harvested from his right leg. He informs the nurse that his leg is warm and tender in his right calf. The nurse notes a 3-cm periwound erythema and swelling at the distal end of the incision. Staples are intact along the incision, and there is no drainage. Vital signs are stable. The nurse would suspect that the patient has what kind of complication? 1) Deep vein thrombosis 2) Dehiscence of the wound 3) Internal bleeding 4) Infection at the incisional site ANS: 1 Deep vein thrombosis (DVT) is a clot in the veins that are deep under the muscles of the leg. DVT can occur after surgery, after lengthy bedrest, or after trauma. Symptoms include pain, warmth, redness, and swelling of the leg. Dorsiflexion of the foot (pulling toes forward) and Pratts sign (squeezing calf to trigger pain) have not been found to be reliable in diagnosing DVT. Dehiscence is the rupture of a suture line, whereas evisceration is the protrusion of internal organs through the rupture. Internal bleeding is a wound-healing complication associated with hematoma formation, pain, hypotension, and tachycardia. Infection is a complication of wound healing that causes warmth, pain, inflammation of the affected area, and changes in vital signs (i.e., elevated pulse and temperature). PTS: 1 DIF: Moderate REF: dm 1367-1368 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Nursing interventions to reduce the risk of clot formation in the legs
www.mynursingtestprep.cominclude which of the following activities? Choose all that apply. 1) Keep the patients hips and knees flexed while the patient is in bed. 2) Apply compression devices (e.g., sequential compression devices). 3) Turn the patient frequently or encourage frequent position changes. 4) Promote adequate hydration by encouraging oral intake. ANS: 2, 3, 4 A Antiembolism stockings and SCDs are frequently used in perioperative patients to promote venous return and prevent clot formation. Turn patients frequently; teach patients to change positions frequently. This prevents vessel injury from prolonged pressure in one position. Promote adequate hydration to keep the blood from becoming viscous (thick). Viscous blood clots more readily. PTS: 1 DIF: Difficult REF: p. 1373 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 2. Which of the following medications would you expect to be included in the treatment of a patient with congestive heart failure? Choose all that apply. 1) Nitrates 2) Beta-adrenergic agents 3) Diuretics 4) Anticoagulants ANS: 2, 3 Beta-adrenergic agents block stimulation of beta receptors in the heart, lungs, and blood vessels and decrease heart rate, slow conduction through the AV node, and decrease myocardial oxygen demand by reducing myocardial contractility. Diuretics increase removal of sodium and water from the body through increased urine output. Diuretics reduce the volume of circulating blood and prevent accumulation of fluid in the pulmonary circulation. PTS: 1 DIF: Moderate REF: dm 1373-1374 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 3. As the nurse caring for a patient who has suffered a myocardial infarction that has damaged the sinoatrial (SA) node, you should plan to monitor for which of the following potential complications? Choose all that apply. 1) Decreased heart rate 2) Increased heart rate 3) Decreased cardiac output 4) Decreased strength of ventricular contractions ANS: 1, 3 Normally, the SA node is the primary pacemaker for the heart and initiates a rate of 60 to
www.mynursingtestprep.com100 beats per minute. If the SA node fails, the atrioventricular node can take over as the pacemaker, but it generally triggers a slower heart rate. Cardiac output will decrease as a result of the decrease in heart rate. Damage to the SA node interferes with the electrical activity of the heart but does not directly affect the pumping action of the heart. PTS: 1 DIF: Difficult REF: dm 1362-1363 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 4. Which outcome statement is related to Decreased Cardiac Output? Choose all that apply. 1) No dyspnea or shortness of breath with exertion 2) Normal skin color 3) Respiratory rate less than 16 breaths/min 4) Brisk capillary refill ANS: 1, 2, 4 Individualized goals/outcome statements depend on nursing diagnoses you identify for the patient. However, for a patient with compromised cardiac output, you might plan goals, such as no shortness of breath with exertion, brisk capillary refill in nailbeds, and normal skin color with no pallor. Respiratory rate of less than 16 breaths/min is hypoventilation and can lead to poor oxygenation and tissue acidosis. PTS: 1 DIF: Moderate REF: p. 1367 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 5. Your client is a healthy, older adult who has come to the health clinic because she reports not feeling like herself. When you are gathering data in your clients health history, she tells you that she is feeling more fatigue when walking up stairs and doing her normal household activities. What normal physiologic changes in the cardiovascular system occur with aging? Choose all that apply. 1) Cardiac contractile strength is reduced. 2) Heart valves become more rigid. 3) Peripheral vessels lose elasticity. 4) Heart responds to increased oxygen demands. ANS: 1, 2, 3 Cardiac efficiency gradually declines as the heart muscle loses contractile strength and heart valves become thicker and more rigid. The peripheral vessels become less elastic, which creates more resistance to ejection of blood from the heart. As a result of these changes, the heart becomes less able to respond to increased oxygen demands, and it needs longer recovery times after responding. PTS: 1 DIF: Moderate REF: p. 1365 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension True or False Complete each statement. 1.Nicotine increases the risk for thrombus (blood clot) formation. ANS: T
www.mynursingtestprep.comNicotine increases the risk for thrombus formation because of its constricting effects on blood vessel walls. PTS: 1 DIF: Easy REF: p. 1373 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension 2.A troponin level is a laboratory test performed to determine how well the cells, tissues, and organs are supplied with oxygen. ANS: F Troponin is a serum evaluation used to detect myocardial infarction (MI). Levels of these contractile proteins remain elevated for up to 7 days after MI. Organ function indirectly evaluates the extent to which oxygen demands have been met in the cells, organs, and tissues. Chapter 35 Hydration & Homeostasis Identify the choice that best completes the statement or answers the question. 1. Which body fluid lies in the spaces between the body cells? 1) Interstitial 2) Intracellular 3) Intravascular 4) Transcellular ANS: 1 Extracellular fluid lies outside the cells. It is composed of three types of fluid: interstitial, intravascular, and transcellular. Interstitial fluid lies in the spaces between the body cells. Intracellular fluid is contained within the cells. Intravascular fluid is the plasma within the blood. Transcellular fluid includes specialized fluids, such as cerebrospinal, pleural, peritoneal, and synovial; and digestive juices. PTS:1DIF:EasyREF:p. 1383 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 2. Chloride, bicarbonate, phosphate, and sulfate are examples of what type of charged particles and why? 1) Cations, because they carry a positive charge 2) Cations, because they carry a negative charge 3) Anions, because they carry a positive charge 4) Anions, because they carry a negative charge ANS: 4
www.mynursingtestprep.comAnions are electrolytes that carry a negative charge; they include chloride, bicarbonate, phosphate, and sulfate. Electrolytes that carry a positive charge are called cations. Cations include sodium, potassium, calcium, and magnesium. PTS:1DIF:ModerateREF:p. 1383 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension 3. A patient is brought to the emergency department (ED) by paramedics after a person standing on the sidewalk saw him fall on a crowded street. He has a history of alcoholism and is frequently brought to the ED. The nurse finds the patient to be disoriented; he has periods of being calm mixed with episodes of being disruptive and loud. His vital signs are the following: BP 138/84 mm Hg; pulse 135 beats/min, regular and strong; respiratory rate 22 breaths/min; temperature 37.1C (98.1F). What electrolyte imbalance might the nurse suspect? 1) Hypomagnesemia 2) Hypocalcemia 3) Hyperkalemia 4) Hypernatremia ANS: 1 Hypomagnesemia is a frequent consequence of alcoholism. Signs and symptoms include disorientation, mood changes, and tachycardia. Hypocalcemia, a low calcium level, is associated with muscle spasms and tetany. Hyperkalemia, a high potassium level, manifests as weakness, fatigue, and cardiac dysrhythmias. Hypernatremia, a high sodium level, produces extreme thirst and agitation. PTS:1DIFifficultREF:p. 1392 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 4. The passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration is called which of the following? 1) Osmosis 2) Filtration 3) Hydrostatic pressure 4) Diffusion ANS: 4 Diffusion is a passive process by which molecules move from an area of higher
www.mynursingtestprep.comconcentration to an area of lower concentration. Osmosis is the movement of water across a membrane from an area of a less-concentrated solution to an area of more-concentrated solution. Filtration is the movement of water and smaller particles from an area of high pressure to low pressure. Hydrostatic pressure is the force created by fluid within a closed system. PTS: 1 DIF: Moderate REF: p. 1384 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall 5. A client is admitted to the emergency department (ED) in respiratory distress. The results of his arterial blood gases are the following: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. The nurse interprets the findings as which of the following? 1) Respiratory acidosis with normal oxygen levels 2) Respiratory alkalosis with hypoxia 3) Metabolic acidosis with normal oxygen levels 4) Metabolic alkalosis with hypoxia ANS: 3 The pH is acidotic. The HCO3 of 19 mEq/L is low and has moved in the same direction as the pH, indicating a metabolic disorder. The PCO2 is within normal range with no signs of compensation. The PO2 level is normal. PTS: 1 DIF: Difficult REF: dm 1393-1395 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 6. A patient is admitted to the emergency department (ED) in respiratory distress. The results of his first arterial blood gases were: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. The nurse evaluates the patients treatment plan by examining repeat arterial blood gases (ABGs). The results are: pH = 7.38; PCO2 = 32; HCO3 = 19 mEq/L. The nurse concludes which of the following? 1) Respiratory acidosis; the treatment plan is ineffective. 2) Metabolic alkalosis; the treatment plan is effective. 3) Partial compensation; the treatment plan is ineffective. 4) Full compensation; the treatment plan is effective. ANS: 4 Full compensation has occurred as the PCO2 has returned the pH to the normal range. This change indicates that the treatment plan is effective. Partial compensation would be indicated by changes in the PCO2, but the pH would still be outside the normal range.
www.mynursingtestprep.comThe ABG is now complete compensation metabolic acidosis. PTS: 1 DIF: Difficult REF: dm 1393-1395 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis 7. When a patient has metabolic acidosis, which body system influences the acidbase imbalance to produce the compensatory changes in the arterial blood gases? 1) Respiratory system 2) Renal system 3) Vascular system 4) Neurological system ANS: 1 In a metabolic problem, the respiratory system compensates. In a respiratory problem, the renal system must compensate. The respiratory system compensates early in the disorder, but it may take up to 3 days for the renal system to compensate fully. PTS:1DIF:ModerateREF:p. 1394 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis 8. A patients arterial blood gas results are as follows: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. An appropriate nursing diagnosis for the patient is which of the following? 1) Impaired Gas Exchange 2) Metabolic Acidosis 3) Risk for Impaired Gas Exchange 4) Risk for Acid-Base Imbalance ANS: 1 An appropriate diagnosis is Impaired Gas Exchange. The arterial blood gas (ABG) results provide the defining characteristics for Impaired Gas Exchange. The ABG results demonstrate metabolic acidosis; however, this is not a nursing diagnosis. The patient has an actual problem; therefore, the risk for nursing diagnoses are incorrect. Additionally, there is no nursing diagnosis of AcidBase Imbalance or Risk for AcidBase Imbalance. PTS:1DIF:ModerateREF:p. 1401 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 9. The nurse is caring for a patient with a medical diagnosis of hypernatremia.
www.mynursingtestprep.comThe following prescriptions are written in the clients electronic health record. Which one should the nurse question? 1) Administer an IV of D5W at 125 mL/hr. 2) Strict I&O monitoring. 3) Restrict oral intake to 900 mL every 24 hr. 4) Monitor serum electrolytes every 4 hr. ANS: 3 Restricting the oral intake of a patient with hypernatremia (Na+ greater than 145 mEq/L) would lead to further elevation in the serum sodium level. Infusing D5W IV fluid is appropriate, as this solution does not contain sodium. Hydrating the patient with D5W would reduce the serum sodium level. Strict I&O monitoring and laboratory evaluation of electrolytes every 4 hr would ensure that the patient is safely rehydrated. PTS:1DIFifficultREF:p. 1391 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 10. Which process requires energy to maintain the unique composition of extracellular and intracellular compartments? 1) Diffusion 2) Osmosis 3) Filtration 4) Active transport ANS: 4 Active transport occurs when molecules move across cell membranes from an area of low concentration to an area of high concentration. Active transport requires energy expenditure for the movement to occur against a concentration gradient. In the presence of ATP, the sodiumpotassium pump actively moves sodium from the cell into the extracellular fluid. Active transport is vital for maintaining the unique composition of both the extracellular and intracellular compartments. Diffusion, osmosis, and filtration are passive processes. PTS: 1 DIF: Difficult REF: p. 1385 KEY:Nursing process: N/A | Client need: PHSI| Cognitive level: Comprehension 11. The nurse records a patients hourly urine output from an indwelling catheter as follows: 0700: 36 mL 0800: 45 mL
www.mynursingtestprep.com0900: 85 mL 1000: 62 mL 1100: 50 mL 1200: 48 mL 1300: 94 mL 1400: 78 mL 1500: 60 mL The nurse can conclude that the patients urine output should be described as which of the following? 1) Low 2) Within normal limits 3) High 4) Inconclusive ANS: 2 Urine accounts for the greatest amount of fluid loss. Normal urine output for an average- sized adult is approximately 1,500 mL in 24 hr. Urine output varies according to intake and activity but should remain at least 30 to 50 mL per hour. The patients urine output is within the normal range. This patient has an indwelling catheter, which will result in continual flow of urine. PTS:1DIF:ModerateREF:p. 1385 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis 12. Which of the following is the principal site for regulation of fluid and electrolyte balance? 1) Cardiac system 2) Vascular system 3) Pulmonary system 4) Renal system ANS: 4 A balance of fluid and electrolytes is essential to maintain homeostasis. Excesses or deficits can lead to severe disorders. The kidneys are the principal regulator of fluid and electrolyte balance and are the primary source of fluid output. Specific hormones (e.g., ADH, aldosterone) cause the kidneys to regulate the bodys fluid and electrolyte balance. The heart and vascular system are involved in fluid balance but not in electrolyte balance and not as dramatically in fluid balance as are the kidneysthat is, they do not actually
www.mynursingtestprep.comregulate electrolytes. The pulmonary system plays a major role in regulation of acidbase balance. PTS:1DIF:EasyREF:p. 1386 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension 13. Which electrolyte is the primary regulator of fluid volume? 1) Potassium 2) Calcium 3) Sodium 4) Magnesium ANS: 3 Sodium is the major cation in the extracellular fluid (ECF). Its primary function is to regulate fluid volume. When sodium is reabsorbed in the kidney, water and potassium are also reabsorbed, thereby maintaining ECF volume. Potassium is a key electrolyte in cellular metabolism. Calcium is responsible for bone health and neuromuscular and cardiac functions. It is also an essential factor in blood clotting. Magnesium is a mineral used in more than 300 biochemical reactions in the body. PTS:1DIF:EasyREF:p. 1386 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 14. An 82-year-old woman was brought to the emergency department by her granddaughter. She is a widow and lives alone, although her granddaughter checks on her daily. She has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6F (37.6C) orally; P = 110 beats/min weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L BUN 29 mg/dL
www.mynursingtestprep.comThe nurse recognizes that the patient is displaying symptoms associated with which of the following? 1) Hypovolemia 2) Hypervolemia 3) Hypernatremia 4) Hyponatremia ANS: 1 Hypovolemia may occur as a result of insufficient intake of fluid; bleeding; excessive loss through urine, skin, or the gastrointestinal tract; insensible losses; or loss of fluid into a third space. The first symptom of hypovolemia is thirst. Other symptoms are a rapid weak pulse, a low blood pressure (although initially the blood pressure may rise), dry skin and mucous membranes, decreased skin turgor, and decreased urine output. Temperature increases because the body is less able to cool itself through perspiration. The person with fluid volume deficit usually has elevated BUN (blood urea nitrogen) and hematocrit levels. Hypervolemia involves excessive retention of sodium and water in the extracellular fluid, and the vital sign changes are opposite those of a patient with hypovolemia. Hypernatremia and hyponatremia are not applicable because the patients sodium level is within normal range. PTS:1DIFifficultREF:p. 1390 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 15. A patient has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6F (37.6C) orally; P = 110 beats/min weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L BUN 29 mg/dL Which of the following is an appropriate nursing diagnosis for this patient? 1) Impaired Gas Exchange related to ineffective breathing
www.mynursingtestprep.com2) Excess Fluid Volume related to limited fluid output 3) Deficient Fluid Volume related to abnormal fluid loss 4) Electrolyte Imbalance related to decreased oral intake ANS: 3 Vomiting has made this patient hypovolemic; therefore, she has deficient fluid volume. There is no information to indicate that she has respiratory problems or Impaired Gas Exchange. Her symptoms are not consistent with Excess Fluid Volume. Electrolyte Imbalance is not a nursing diagnosis. PTS:1DIFifficultREF:p. 1400 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 16. Which of the following is the most appropriate goal for a patient with the nursing diagnosis of Deficient Fluid Volume? 1) Electrolyte balance restored, as evidenced by improved levels of alertness and cognitive orientation 2) Electrolyte balance restored, as evidenced by sodium returning to normal range 3) Patient demonstrates effective coughing and deep breathing techniques. 4) Maintains fluid balance, as evidenced by moist mucous membranes and urinating every 4 hours ANS: 4 Moist mucous membranes and urinating every 4 hours would demonstrate restoration of fluid balance. Electrolyte imbalance does not necessarily occur with Deficient Fluid Volume; if electrolyte imbalance were present, the nursing diagnosis would be different. There is no evidence that this patient has a respiratory problem, so coughing and deep breathing are irrelevant. PTS:1DIF:ModerateREF:p. 1401 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 17. Which laboratory results on a clients health record should alert the nurse to a potential problem? 1) Na+ = 137 mEq/L
www.mynursingtestprep.com2) K+ = 5.2 mEq/L 3) Ca2+ = 9.2 mg/dL 4) Mg2+ = 1.8 mg/dL ANS: 2 A potassium level of 5.2 mEq/L indicates hyperkalemia. The other results are all within normal ranges. PTS:1DIF:ModerateREF:p. 1386 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Comprehension 18. A patients vital signs prior to a blood transfusion were: T = 97.6F (36.4C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg. Twenty minutes after the transfusion was begun, the patient began complaining of feeling itchy and hot. The nurse discovered a rash on the patients trunk. Vital signs were: T = 100.8F (38.2C); P = 82 beats/ min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the priority intervention? 1) Administer an antihistamine (anti-allergenic) medication. 2) Flush the blood tubing with D5W immediately. 3) Prepare for emergency resuscitation. 4) Stop the blood transfusion immediately. ANS: 4 The nurse should suspect a transfusion reaction. When a transfusion reaction is suspected, the infusion should be stopped immediately. The blood bag and tubing must be sent to the laboratory for analysis. A new IV line of normal saline should be hung. Diphenhydramine (an antihistamine) may be ordered once the physician has been notified of the patients condition. There is no information indicating that the patient is in danger of cardiovascular collapse or requires resuscitation. PTS: 1 DIF: Moderate REF: p. 1417 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 19. A patient is receiving an IV infusion of lactated Ringers solution and 40 mEq of KCl at 100 mL/hr. When assessing the IV site, the nurse notes swelling, erythema, and warmth. There is a palpable cord along the vein, and the infusion is sluggish. The patient is complaining of pain at the site. The nurse would recognize these findings to be consistent with which of the following? 1) Infiltration 2) Extravasation
www.mynursingtestprep.com3) Hematoma 4) Phlebitis ANS: 4 Phlebitis is an inflammation of the vein. It may be caused by the infusion of solutions that are irritating to the vein. Patients receiving IV solutions with potassium chloride are at a higher risk for phlebitis, as it is irritating to the vein. The symptom of a palpable cord along the vein distinguishes this as phlebitis. Infiltration presents as erythema, pain, and swelling. However, there is no palpable cord with inflammation. Extravasation is infiltration of a vesicant substance into the tissues. Differentiating symptoms include blanching and coolness of the surrounding skin; the formation of blisters and subsequent tissue sloughing and necrosis are later signs. A hematoma is a localized mass of blood outside the blood vessel. This is generally seen when a vein is nicked during an unsuccessful insertion of an IV line or when an IV line is discontinued without pressure applied over the site. PTS:1DIFifficultREF:p. 1412 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 20. The nurse assesses that her patients intravenous solution has infiltrated into the tissues. What action should she take first? 1) Aspirate, then inject 0.5 mL normal saline. 2) Restart the IV line in a different vein. 3) Stop the infusion immediately. 4) Notify the primary care provider. ANS: 3 The nurse should first stop the infusion to avoid further tissue trauma. Because the IV has infiltrated, you must assume that the nurse has already checked the patency of the line by aspirating. There is no point in injecting saline because doing so puts even more fluid in the tissues. Injecting fluid to try to clear a clot from the catheter is not recommended because of the possibility of causing an embolism. Once the infusion is stopped, the nurse must assess whether the patient needs additional IV therapy. If so, a new IV line must be restarted above the site of infiltration or in the opposite arm. The nurse may need to inform the primary care provider if she is unable to find a new IV site or if she believes the patient no longer needs an IV. PTS:1DIF:ModerateREF:p. 1411 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 21. The physician has ordered a complete blood count for a 6-year-old child. When the nurse enters the room, she finds the child sobbing uncontrollably. His mother tells him to shut up and act your age. How should the nurse proceed?
www.mynursingtestprep.com1) Request that the mother leave the room immediately. 2) Request the help of a coworker to hold the child down. 3) Inform the child that this wont hurt a bit. 4) Calmly approach the child and tell him what is going to happen. ANS: 4 Having blood drawn may be uncomfortable and frightening for a 6-year-old child. A calm approach can alleviate some of the fear. Explain to the childs mother that the boys behavior is normal. Informing the child that the blood draw will not hurt is wrong and will make him distrustful of future interventions. The nurse may need the help of a coworker, but she should first try a calm approach. PTS: 1 DIF: Moderate REF: p. 1399; not found in text; critical thinking required KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 22. A healthcare provider prescribes 250 mL of 0.9% sodium chloride to be infused over 2 hours. A microdrip infusion set is being used. What is the drip rate (drops/ min) that the nurse should monitor? 1) 60 2) 75 3) 125 4) 250 ANS: 3 Calculate the drip rate by multiplying the number of milliliters to be infused per hour (hourly rate) by the drop factor in drops/mL, divided by 60 minutes. An infusion of 250 mL in 2 hours results in an hourly rate of 125 mL/hr. 125 (mL/hr) 60 (drops/mL) = 125 drops/min 60 min PTS:1DIF:ModerateREF:p. 1410 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 23. The nurse examines the electrocardiogram (ECG) tracing of a client and notes tall T waves. What electrolyte imbalance should the nurse suspect? 1)
www.mynursingtestprep.comHypokalemia 2) Hypophosphatemia 3) Hyperkalemia 4) Hypercalcemia ANS: 3 Potassium levels affect the heart. A tall, peaked T wave on an ECG is associated with hyperkalemia. A flat T wave is associated with hypokalemia. Phosphorous levels do not trigger ECG changes. PTS:1DIF:ModerateREF:p. 1391 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension 24. The nurse gathers the following data: BP = 150/94 mm Hg; neck veins distended; P = 104 beats/min; pulse bounding; respiratory rate = 20 breaths/min; T = 37C (98.6F). What disorder should the nurse suspect? 1) Hypovolemia 2) Hypercalcemia 3) Hyperkalemia 4) Hypervolemia ANS: 4 Hypervolemia results from retention of sodium and water. Blood pressure rises, the pulse is bounding, and neck veins become distended due to increased intravascular volume. PTS:1DIF:ModerateREF:p. 1390 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application 25. A patient has a continuous IV infusion at 60 mL/hr. The right hand IV has infiltrated and the nurse has started a new IV on the left forearm. Which of the following interventions should the nurse also perform? 1) Elevate the patients left forearm. 2) Schedule daily dressing changes to the new IV site. 3)
www.mynursingtestprep.comChange the administration set. 4) Place the patient in Fowlers position. ANS: 3 Reusing an IV set from a previous site increases the risk of contamination. IV dressings are usually changed every 72 to 96 hours when the IV site is rotated. There is no reason to elevate the patients left forearm or to place him in Fowlers position. PTS:1DIF:EasyREF:p. 1414 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 26. When performing a central venous catheter dressing change, which of the following steps is/are correct? 1) Wear sterile gloves while removing and discarding the soiled dressing. 2) Apply pressure on the catheter-hub junction when removing the soiled dressing. 3) Place a sterile transparent dressing over the site and the catheter-hub junction. 4) Have the patient wear a mask or turn his head away from the site. ANS: 4 Aseptic technique should be used with approaching the insertion site. Therefore, both nurse and patient should wear a mask. If the patient cannot wear a mask, have him turn his head away from the insertion site during the procedure. Sterile gloves should be worn when placing the new sterile dressing; however, procedure gloves are used to remove the soiled dressing. The nurse should stabilize the catheter while removing the soiled dressing but not apply pressure to the catheter-hub junction. The transparent dressing should cover the hub of the catheter, but not the catheter-hub junction; this makes it too difficult to remove without disturbing the integrity of the IV line or the site. PTS: 1 DIF: Difficult REF: p. 1432 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. In a healthy adult, which of the following regulate(s) body fluids? Choose all that apply. 1) Hormone levels 2) Fluid intake 3) Oxygen saturation 4) Kidney function
www.mynursingtestprep.comANS: 1, 2, 4 A balance between fluid intake and output is essential to maintain homeostasis. Excesses or deficits of intake can lead to severe disorders. The kidneys are the principal regulator of fluid and electrolyte balance and are the primary source of fluid output. Specific hormones (e.g., ADH, aldosterone) cause the kidneys to regulate the bodys fluid and electrolyte balance. Oxygen saturation does not regulate fluids. It measures the saturation of oxygen on hemoglobin and is influenced by the partial pressure of oxygen, alveolararterial gradient lung disease, and the amount and type of hemoglobin (such as sickle cell anemia). PTS:1DIF:ModerateREF:dm 1385-1386 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension 2. A patient has been admitted to the nursing unit with a diagnosis of chronic renal failure. She will be dialyzed for the first time the following morning. Which of the following are appropriate nursing interventions for the patient? Choose all that apply. 1) Encourage oral fluid intake as desired. 2) Place the patient on strict I&O. 3) Weigh the patient before and after dialysis. 4) Maintain a total fluid restriction of 1,000 mL as prescribed. ANS: 2, 3, 4 Fluids are restricted in patients with chronic renal failure because of decreased renal function. Therefore, encouraging oral fluids would not be appropriate. Appropriate nursing interventions for this patient include monitoring the intake and output, weighing the patient before and after dialysis, following a strict renal diet, and monitoring laboratory values. PTS:1DIF:ModerateREF:p. 1391-1393, 1402; critical thinking required KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 3. Identify the mechanism(s) involved in acidbase balance. Choose all that apply. 1) Respiratory mechanisms 2) Active transport mechanisms 3) Renal mechanisms 4) Buffer systems ANS: 1, 3, 4 Acidbase balance is regulated by respiratory mechanisms, renal mechanisms, and buffer systems. Acidbase regulation can be monitored by examining arterial blood gases, especially blood pH. Buffer systems prevent wide swings in pH by absorbing or releasing free hydrogen ions. The lungs (respiratory mechanisms) control the carbonic acid supply via carbon dioxide. Conditions that cause retention of carbon dioxide, such as chronic
www.mynursingtestprep.comobstruction pulmonary disease, lower the pH, whereas tachypneic conditions, such as hyperventilation syndrome, blow off carbon dioxide and increase the pH. The kidneys (renal mechanisms) regulate the concentration of plasma bicarbonate. By reabsorbing or excreting bicarbonate, the kidneys affect acidbase balance. Active transport involves the movement of fluids and electrolytes in the body. PTS:1DIF:ModerateREF:p. 1389 KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension 4. Identify the appropriate intervention(s) for a patient with hypovolemia. Choose all that apply. 1) Teach deep-breathing techniques. 2) Monitor I&O daily. 3) Encourage fluid intake. 4) Monitor electrolyte balance. ANS: 2, 3, 4 Hypovolemia occurs when more fluid is lost than is taken into the body. Monitoring I&O provides information to evaluate the status of the problem. Encouraging fluid intake helps to correct the problem. It is good to monitor electrolytes because electrolyte imbalance can occur with hypovolemia (although it may not occur at first). Deep-breathing techniques do not address fluid balance; there is no evidence that the patient has a respiratory disorder. PTS:1DIF:EasyREF:p. 1390 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application 5. A patients blood group is B. The nurse knows the patient can receive blood only from donors with what group(s) of blood? Choose all that apply. 1) A 2) B 3) O 4) AB ANS: 2, 3 Persons with blood group B can receive blood only from the blood groups B and O. Those with blood group AB may receive AB, A, B, and O blood. Blood group A persons may receive blood from A and O donors. Persons with blood group O may receive blood only from O donors. Blood group AB persons are considered universal recipients, and blood group O persons are considered universal donors. PTS:1DIF:ModerateREF:p. 1416
www.mynursingtestprep.comKEY: Nursing process: Analysis/Diagnosis | Client need: SECE | Cognitive level: Analysis 6. A nurse is caring for a patient with a peripheral IV line located in the right forearm. The patient informs the nurse that the IV site is burning. Upon assessment the nurse determines that the IV solution has infiltrated. What site(s) is/are appropriate to consider when restarting the IV line? Choose all that apply. 1) Left hand 2) Right wrist 3) Right antecubital area 4) Right saphenous vein ANS: 1, 3 When restarting an IV line after an infiltration, you must restart above the site of infiltration. As a result, the right antecubital area is correct. The opposite extremity (e.g., left hand) may also be used. The right saphenous vein is incorrect because that vein is located in the leg. The leg should be used as a last resort for an IV site. The primary care provider should be notified if a leg is being considered as an IV site. PTS:1DIFifficultREF:p. 1414 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 7. A patient has been diagnosed with hypovolemia. Which order(s) for hydration should the nurse question? Choose all prescriptions that should be questioned. 1) 0.9% (normal) saline at 100 mL/hr 2) Lactated Ringers solution at 100 mL/hr 3) Total parenteral nutrition solution at 100 mL/hr 4) D5W solution at 100 mL/hr ANS: 3, 4 Hypovolemia occurs when there is a proportional loss of water and electrolytes from the ECF. Lactated Ringers and 0.9% (normal) saline are isotonic fluids that remain inside the intravascular space, thus increasing volume. The D5W is a hypotonic solution that would pull body water from the intravascular compartment into the interstitial fluid compartment. Total parenteral nutrition is a hypertonic fluid used to provide nutrition for the patient who
www.mynursingtestprep.comcannot meet caloric needs by eating or enteral nutrition. Chapter 36 Caring for the Surgical Patient Identify the choice that best completes the statement or answers the question. 1. The preoperative phase encompasses which period of time? 1) Entry to the operating suite until admission to postanesthesia care 2) Entry into the operating suite until discharge from the hospital 3) The decision to have surgery until admission to postanesthesia care 4) The decision to have surgery until entry to the operating suite ANS: 4 The preoperative phase begins with the decision to have surgery and ends when the patient enters the operating room. The intraoperative phase begins when the patient enters the operating suite and ends when the patient is admitted to the postanesthesia care unit. PTS:1DIF:EasyREF:p 1448 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 2. A 2-year-old child is scheduled for a tonsillectomy. When determining the plan of care, the nurse should: 1) Include the parents or caregivers in the plan of care. 2) Explain to the child that she will have a sore throat after surgery. 3) Tell the child that she can have her favorite foods for the first 24 hours after surgery. 4) Prepare the child for discharge from the hospital as soon as she is alert. ANS: 1 It is developmentally normal for toddlers to experience anxiety with separation from parents or caregivers. Be sure to include these people in the plan of care. Developmentally, a 2-year-old lives in the here and now and wouldnt grasp an intangible concept, such as pain in the future. The toddler would take liquids and soft foods within the first 24 hours when her throat is sore during swallowing. She should not eat foods that are rough and crunchy because they may scratch her throat and cause bleeding. After a tonsillectomy, the child will need to be monitored for bleeding and stable vital signs; therefore, she will not be discharged as soon as she is alert. PTS: 1 DIF: Moderate REF: dm 1449, 1455 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Synthesis 3. Which of the following is the most appropriate nursing goal for a 2-year-old who is to have a tonsillectomy? 1) Separation anxiety will be minimal. 2) The child will verbalize understanding of expected pain. 3) The child will tolerate a normal diet 24 hours after surgery. 4)
www.mynursingtestprep.comThe parent will indicate readiness to assume the childs care. ANS: 1 The only concrete information in this question is that the child is 2 years old. Therefore, the only problem the nurse can reasonably predict from this would be developmental in nature. It is developmentally normal for toddlers to experience anxiety with separation from parents or caregivers. Minimizing anxiety by involving the parents or caregivers would be the appropriate goal for separation anxiety. A 2-year-old child would not be expected to verbalize understanding of expected pain. The toddler would take liquids and soft foods within the first 24 hours when her throat is sore during swallowing. She should not eat foods that are rough and crunchy because they may scratch her throat and cause bleeding. Nurses should encourage parental involvement, but parents should not be expected to assume the childs care. PTS:1DIFifficult REF: p. 1449; critical-thinking question requiring synthesis of previously learned knowledge KEY: Nursing process: Planning | Client need: PSI | Cognitive level: Application 4. The focus of nursing activities in the preoperative phase is to: 1) Admit the patient to the surgical suite. 2) Prepare the patient mentally and physically for surgery. 3) Set up the sterile field in the operating room. 4) Perform the primary surgical scrub to the surgical site. ANS: 2 The nursing focus in the preoperative phase is to prepare the patient mentally and physically for surgery. The patient is in the intraoperative phase when admitted to the surgical suite. The sterile field and the surgical scrub would be performed in the surgery suite during the intraoperative phase. PTS:1DIF:EasyREF:p. 1451 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application 5. A patient is scheduled for abdominal surgery tomorrow. While gathering preoperative data, the nurse learns that the patient takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E 1,500 IU. The patient reports that he stopped taking the anticoagulant 4 days ago as instructed by the surgeon. He has continued to take the multivitamin and vitamin E. Based on the information given, the nurse notifies the surgeon because she: 1) Needs an order to restart the anticoagulant. 2) Is concerned about continued use of the multivitamin. 3) Is concerned about the vitamin E dosage. 4) Has canceled the surgery so more lab tests can be done. ANS: 3 Both prescribed and over-the-counter medications may increase surgical risk. Many herbs can cause potassium loss and increase the risk for cardiac arrhythmias. High doses of vitamin E may increase the risk for bleeding. This patients use of 1,500 IU of vitamin E daily exceeds the recommended dosage, so the nurse should inform the surgeon of the
www.mynursingtestprep.comvitamin E intake. Generally, the surgeon or anesthesiologist instructs patients to continue or discontinue taking their prescribed medicines. However, it is important to assess use of supplements and over-the-counter medicines. The nurse cannot cancel surgery without an order from the surgeon, who determines whether the surgery should be delayed or whether it is so urgent that it needs to continue as scheduled, even with the additional risk factor of the vitamin E dosage. PTS:1DIFifficultREF:p. 1450 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis 6. A patient is admitted for hip surgery. The patient usually takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E 1,500 IU. He stopped taking his anticoagulant 4 days ago as instructed by his surgeon, but has continued to take the multivitamin and vitamin E. An important problem for this patient is which of the following? 1) Potential complication: anemia 2) Risk for infection related to inadequate anticoagulant dosage 3) Risk for noncompliance related to inability to follow instructions 4) Risk for bleeding ANS: 4 The patient is at an increased risk for bleeding due to his intake of vitamin E. He may be at risk for anemia if he experiences a large blood loss in surgery; however, this problem is not appropriate before he experiences the blood loss. This patient does not have a higher-than-average risk for infection because he is not having surgery involving a contaminated system (e.g., the gastrointestinal system). There is no evidence to suggest that this patient is noncompliant simply because he stopped taking his anticoagulant as ordered. PTS:1DIFifficultREF:p. 1450 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 7. A patient is admitted from a local skilled nursing facility to the outpatient surgery center for surgical dbridement of a stage IV sacral pressure ulcer. The perioperative nurse discovers that the patient does not have a signed consent form for the surgery on the chart or in the surgery center. The patient says that she has not talked to the surgeon and that she has many questions regarding her surgery. When informed of this, the surgeon tells the nurse to have the patient sign the informed consent form, and he will review it prior to the surgery. What should the nurse do? 1) Follow the surgeons orders, and ask the patient to sign the surgical consent form. 2) Inform the surgeon that she will have the patient sign after he discusses the surgery with the patient. 3) Ensure that the signed surgical consent is witnessed by two nurses, because the surgeon is not available. 4) Cancel the surgery and transfer the patient back to the long-term care facility. ANS: 2 Informed surgical consent requires that the surgeon present information about the surgery
www.mynursingtestprep.comto the patient, that the patient understands the information and agrees to the surgery, and that the patient has not been coerced to give consent. As a patient advocate, the nurse should verify with the patient that the surgeon has explained the procedure and answered all her questions. The surgeon is responsible for giving the patient the necessary information and determining the patients competence to make an informed decision about the surgery. If the patient has further questions, the nurse should notify the surgeon and delay sending the patient to surgery until an informed consent is obtained. PTS:1DIFifficultREF:p. 1455, 1458 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 8. Identify the type of surgery a terminally ill patient will undergo if the purpose is removal of tissue to relieve pain. 1) Procurement 2) Ablative 3) Palliative 4) Diagnostic ANS: 3 Palliative surgery alleviates discomfort or other disease symptoms without producing a cure. Procurement surgery occurs when an organ or tissue is harvested for transplantation into another. Ablative surgery involves removal of a body part. Diagnostic surgery confirms or negates a diagnosis. PTS:1DIF:EasyREF:p. 1449 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 9. A patient had a hiatal hernia repair earlier today and is now in the postanesthesia care unit (PACU). The family asks the nurse why the patient is in the PACU rather than back in his room on the postsurgical unit. The nurse should inform the family that: 1) Patients who have had surgical complications are observed in the PACU until they are stable enough to return to the floor. 2) Patients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care. 3) The PACU is a holding area for patients awaiting a surgical unit bed or awaiting adequate staff to provide care on the postsurgical unit. 4) The nurse will ask the surgeon explain to them why the patient is not on the postsurgical unit, as is the usual procedure. ANS: 2 A client remains in the PACU until he has recovered from the effects of anesthesia. In the PACU, the client is assessed every 5 to 15 minutes in order to quickly identify surgical or anesthesia-related problems. Most surgical units routinely admit patients to the PACU for a period of observation. Admission to the PACU does not indicate surgical complications or imply that a holding area is required. There is no reason the surgeon would need to explain this to the family, as the nurse could communicate the procedure. It is not usual procedure for a patient to be transferred directly from surgery to the postsurgical unit.
www.mynursingtestprep.comPTS:1DIF:ModerateREF:p. 1471 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application 10. The focus of nursing care in the intraoperative phase is to: 1) Prepare the patient for surgery. 2) Maintain the sterile field. 3) Ensure patient safety during the surgery. 4) Obtain a signed informed consent. ANS: 3 The intraoperative phase begins when the patient enters the operating suite and ends when the patient is admitted to the postanesthesia care unit. The nursing focus is to ensure patient safety during the surgical procedure by functioning as an advocate when clients cannot advocate for themselves and by monitoring the client and surgical environment throughout the procedure. Although the sterile field must be maintained in this phase and sterility contributes to patient safety, the focus of care is broader than the maintenance of sterility. Obtaining informed consent and preparing the patient for surgery are activities associated with the preoperative phase. PTS:1DIF:EasyREF:p. 1463 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension 11. The nurse has a prescription to give a series of medications on an on call basis. The nurse realizes that these medications will be given: 1) In the postanesthesia recovery unit. 2) At the time specified in the order. 3) On the patients arrival in the surgery suite. 4) When the OR staff notify the nurse to do so. ANS: 4 The anesthesia team may order medications to be given on call if the surgery time is likely to vary. The nurse will give on call medications when he is notified to do so by the OR staff. PTS:1DIF:EasyREF:p. 1460 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 12. A patient has chronic confusion secondary to dementia. As a result, he is unable to sign an informed consent for surgery. In this situation: 1) An informed consent is not needed. 2) Two nurses may sign the informed consent for the patient. 3) The surgeon must sign the informed consent. 4) A family member will be asked to sign the informed consent. ANS: 4
www.mynursingtestprep.comIn most states, a family member, conservator, or legal guardian may give consent for a procedure if a patient is not capable of giving an informed consent or if the patient is a minor. PTS:1DIF:ModerateREF:p. 1458 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 13. The patient tells the nurse, Im so nervous. I want to be knocked out for the surgery so that I dont know what is going on. When the nurse communicates with the surgeon and anesthetist, she tells them that the patient desires which type of anesthesia? 1) Conscious sedation 2) General anesthesia 3) Local anesthesia 4) Regional anesthesia ANS: 2 General anesthesia produces rapid unconsciousness and loss of sensation. During conscious sedation, the client feels sleepy but is easily aroused by touch or speech. Regional anesthesia interrupts nerve impulses to and from the affected area, but the patient remains alert. Local anesthesia produces loss of pain sensation at the desired site and is typically used for minor procedures. The client remains alert during local anesthesia. PTS:1DIF:EasyREF:p. 1464 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 14. A patient is to have a sequential compression device (SCD) applied on the postoperative unit. The patient is wearing knee-high elastic (antiembolism) stockings. When applying the SCD, what should the nurse do? 1) Remove the antiembolism stockings and not replace them. 2) Replace the knee-high stockings with thigh-high stockings. 3) Notify the surgeon that the patient is wearing antiembolism stockings. 4) Apply the SCD over the knee-high antiembolism stockings. ANS: 4 If elastic stockings have been ordered with the sequential compression device, leave them in place; if the patient is not yet wearing them, obtain them and put them on the patient. Knee-high stockings do not need to be replaced with thigh-high stockings. Some research has shown knee-high stockings to be equally effective. There is no need to notify the surgeon, as patients commonly return from surgery wearing antiembolism stockings, as prescribed. PTS: 1 DIF: Moderate REF: p. 1490 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Surgeries are commonly classified by which of the following? Choose all that apply.
www.mynursingtestprep.com1) Acuity 2) Level of urgency 3) Length of surgery 4) Organ involved ANS: 1, 2 Surgeries can be classified by body systems, purpose, level of urgency, and degree of seriousness (acuity). The length of surgery and organ involved are not used for classifying surgeries. PTS:1DIF:ModerateREF:p. 1449 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis 2. Which of the following describes the Perioperative Nursing Data Set? Choose all that apply. 1) A standardized tool for assessing high-risk surgical patients 2) A standardized vocabulary encompassing all surgical patient outcomes 3) The first specialized nursing language recognized by the ANA 4) A standardized language designed to describe the care of perioperative patients ANS: 3, 4 The Perioperative Nursing Data Set (PNDS) is a standardized vocabulary specifically designed to describe the care of perioperative clients. It consists of 74 nursing diagnoses, 133 nursing interventions, and 28 nurse-sensitive patient outcomes appropriate for use in any surgical setting. It was the first specialty language recognized by the ANA. PTS:1DIFifficultREF:p. 1451 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 3. The nurse is caring for a patient who had abdominal surgery 3 days ago and will be discharged home later today. The nurse will know that teaching is effective if the patient does which of the following? Choose all that apply. 1) Describes clinical findings associated with infection 2) Performs the dressing change as prescribed 3) Demonstrates absence of surgical incision pain 4) Completes the regimen of prescribed antibiotics ANS: 1, 2, 4 The nurse would know that patient teaching was effective if the patient verbalizes signs and symptoms of infection, can perform the ordered dressing change, and completes the regimen of ordered antibiotics. Nurses cannot teach a patient to be free of pain. Pain is subjective. The nurse can teach the patient strategies to assist with pain, but they may not remove the pain completely. PTS:1DIF:ModerateREF:p. 1481
www.mynursingtestprep.comKEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application 4. Which of the following members of the operative team use sterile technique during the surgical procedure? Choose all that apply. 1) Surgeon 2) Anesthetist 3) Scrub nurse 4) Registered nurse first assistant ANS: 1, 3, 4 The anesthetist is a member of the clean team and remains outside the sterile field. Members of the sterile team include the surgeon, the scrub nurse, and the registered first nurse assistant. PTS:1DIF:ModerateREF:p. 1463 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall 5. A young adult woman is scheduled for a bilateral breast reduction under general anesthesia. She is normally healthy and takes no daily medications. Identify the preoperative screening tests appropriate for this patient. Choose all that apply. 1) Urinalysis 2) EKG 3) Creatinine clearance 4) CBC ANS:1, 4 Preoperative screening tests are ordered to determine if the client has undetected underlying health concerns. Most institutions require a complete blood count (CBC) and urinalysis prior to all surgical procedures. Generally, an electrocardiograph (ECG) is ordered for clients over the age of 50 years or with known cardiac disease. A creatinine clearance is not a routine presurgical screening test. PTS: 1 DIF: Moderate REF: dm 1451, 1454 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application 6. Identify the desired effects of general anesthesia. Choose all that apply. 1) Reduction of risk 2) Analgesia 3) Amnesia 4) Muscle relaxation ANS: 2, 3, 4 General anesthesia is used to control pain (analgesia), relax muscles, and promote amnesia. Anesthesia is not used for the purpose of obtaining a reduction in risk potential; however, surgical risk is influenced by the type of anesthesia used. PTS: 1 DIF: Moderate REF: p. 1464
www.mynursingtestprep.comKEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension 7. The preoperative nurse is preparing a patient for surgery. Identify the interventions the nurse will perform. Choose all that apply. 1) Inform the family to wait in the surgical waiting room. 2) Prepare the surgical suite for the operation. 3) Remove the patients dentures and contact lenses. 4) Assist the patient to complete a living will. ANS: 1, 3 Before being transported to the operating suite, the patient must remove all artificial body parts, such as dentures, artificial limbs, or contact lenses. Wigs, eyeglasses, makeup, and jewelry must also be removed. The nurse will also inform the patients relatives where they may wait during the surgery. The surgical suite will be prepared by the surgical team. It is not necessary to have a living will prior to surgery. However, the nurse will ask the patient if there is one when obtaining the nursing history. PTS:1DIF:ModerateREF:p. 1459 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 8. A patient had a colon resection for removal of a cancerous tumor. Postoperatively, on the surgical floor which of the following activities would the nurse perform for the purpose of decreasing the risk of postoperative complications? Choose all that apply. 1) Assist the patient to turn, breathe deeply, and cough every 2 hours. 2) Teach the patient about the type of tumor removed. 3) Assess the drainage from the surgical site. 4) Monitor vital signs on a regular basis. ANS: 1, 3, 4 The nurse assists the patient to turn, breathe deeply, and cough every 2 hours in order to decrease the risk of postoperative atelectasis or pneumonia. The nurse assesses the wound drainage to monitor for signs of bleeding, infection, or wound complications. Vital signs are monitored to detect the potential for infection or hemorrhage, not to prevent them. The nurse may teach the patient about cancerous tumors; however, this intervention will not decrease the risk of postoperative complications. PTS:1DIF:ModerateREF:p. 1472 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension 9. A patient returns from surgery with a nasogastric tube and intermittent gastric suction to provide abdominal decompression. Which of the following are correct nursing activities for managing the equipment and drainage? Choose all that apply. 1) Wear nonsterile procedure gloves when emptying the drainage container. 2) When irrigating the nasogastric tube, use sterile water. 3) Wear sterile gloves when irrigating the nasogastric tube.
www.mynursingtestprep.com4) Apply water-soluble lubricant if the patients lips are dry. ANS: 1, 4 Nonsterile procedure gloves are to protect the nurse and other patients against microorganisms that might be present in body fluids; wearing them is in observance of standard precautions. For patients with an NG tube, frequent oral care, including water- soluble lubricant for dry lips, is important. Sterile gloves are not needed for irrigating the NG tube because the nasal passages, esophagus, and stomach are not sterile. Sterile normal saline and a sterile syringe are used for irrigation, however. Sterile water is not used; saline compensates for electrolytes lost through NG drainage. Chapter 39 Leading & Managing Identify the choice that best completes the statement or answers the question. 1. Theories that focus on what the leader does are called: 1) Trait theories. 2) Behavioral theories. 3) Situational theories. 4) Transformational theories. ANS: 2 Behavioral theories are concerned with what a leader does, whereas trait theories are concerned with what a leader is. Situational theories recognize that each situation is different and that leaders must consider a number of factors when deciding how to take action. Transformational theories focus on the ability of the leader to communicate her vision in such a way that it inspires commitment among workers. PTS:1DIF:ModerateREF:p. 3 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 2. At a recent nurse staff meeting, the chief nursing officer (CNO) announced that all nursing staff would work 12-hour shifts on a daynight rotation schedule that would alternate every 6 weeks. The CNO announced that she made this decision as a means to solve discord between the day- and night-shift nurses. She explained that this plan will allow the staff to experience the work on each shift and to appreciate the various job responsibilities on each shift. What type of leadership is the CNO displaying? 1) Management 2) Laissez-faire 3) Democratic 4) Authoritarian ANS: 4 The authoritarian leader makes decisions for the group as a whole, gives orders, and bears most of the responsibility for the outcomes. A laissez-faire leader postpones making decisions or may never make a decision at all. Thus, laissez-faire leadership is really a lack
www.mynursingtestprep.comof leadership. A democratic leader shares the planning, decision making, and responsibility for outcomes with other members of the group. This type of leader tends to provide guidance rather than control. There is no leadership style called management. PTS:1DIF:ModerateREF:p. 3 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application 3. A graduate nurse completed her nursing education 3 weeks ago and has just begun work at the local hospital. She is orienting to her new position with an experienced nurse, one who has been an RN for 15 years and an employee at the hospital for 7 years. She will provide guidance and practical teaching to the new graduate as she assumes a new position in the nursing unit. What role is the experienced RN assuming? 1) Mentor 2) Manager 3) Preceptor 4) Leader ANS: 3 A preceptor is someone with more experience who provides practical teaching and guidance for a student or new employee. In contrast, a mentor is someone more experienced who provides career development information and serves as a role model. A manager is an employee of an organization who has the power, authority, and responsibility for planning, organizing, coordinating, and directing the work of others. A leader is someone who has the ability to influence others and commit them to action. PTS:1DIF:ModerateREF:p. 7 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application 4. What is the first stage of the complex process of change? 1) Recognizing resistance 2) Unfreezing 3) Forming a comfort zone 4) Actively resisting ANS: 2 The first stage in the change process is unfreezing. In this stage, the person leaves the stable comfort zone that has existed and begins to make changes. Recognizing resistance and actively resisting are activities associated with change, but they are not the first stage of the process. PTS:1DIF:ModerateREF:p. 13 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 5. Within the past month, there has been a change in the nursing documentation requirements at the hospital. The nurses have been trained in the new requirements and are documenting as requested, with the exception of one nurse. This nurse has been unable to attend any of the documentation in-service meetings and has been too busy to attend a private training session with the nurse manager. Meanwhile, she continues to use the old
www.mynursingtestprep.comdocumentation process. What do the nurses actions illustrate? 1) Unfreezing 2) Active resistance 3) Passive resistance 4) Comfort zone ANS: 3 Passive resistance behaviors include avoidance; canceling appointments to discuss implementing change; being too busy to make the change; agreeing to the change but doing nothing to change; and simply ignoring the entire process as much as possible. In the above situation, the nurse is not actively refusing to comply with the new documentation requirements; however, her actions are a passive approach to resisting change. When a person knows what to expect and how to deal with whatever problems arise in the course of a day, that person is operating within her comfort zone. The first stage in the change process is when the person begins moving out of the comfort zone, unfreezing. This nurse is resisting, not unfreezing. PTS:1DIF:ModerateREF:p. 13 KEY: Nursing process: N/A | Client need: SECE | Cognitive level:Application 6. The surgical unit is experiencing difficulty recruiting new RNs, although the hospital has an excellent reputation in the community and has no difficulty recruiting nurses for other units. A task force has been formed, consisting of one nurse from each shift on the unit, the unit manager, and the hospital nurse recruiter. The group has gathered data and identified the problem. What is the next step in this process? 1) Generate possible solutions. 2) Evaluate whether the problem has been resolved. 3) Implement the solution changes. 4) Evaluate suggested solutions. ANS: 1 The next step in the process is to generate possible solutions. Once several possibilities have been identified, each of the suggested solutions should be evaluated. From among that list, the best solution is chosen and then implemented. Finally, the task force critiques the process by evaluating whether the problem has been resolved. PTS:1DIFifficultREF:dm 15-16 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application 7. A nurse with 2 years experience frequently appears stressed and has difficulty completing his work. He is clocking out 30 to 45 minutes late every day, even when his assignment load is light. The charge nurse describes his problem as running from one duty to the next and having no organization or daily routine. Which situation most likely describes this nurse? 1) Has time management problems 2) Has a heavy patient load
www.mynursingtestprep.com3) Works at a hospital that is understaffed 4) Is in a management position ANS: 1 This nurse most likely has trouble managing his time. Time management entails setting your own goals and organizing your work. Although there will be difficult days, the nurse who consistently finishes late and has no organization to his daily schedule has a problem managing time. Time management includes efficiently meeting clients care needs during a nursing shift and organizing ones workload. PTS:1DIF:EasyREF:dm 16-17 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis 8. An expert nurse feels confident in her role as a clinician on the unit. The nurse enjoys her work and feels in charge of her career. Which leadership state is she experiencing? 1) Power-based authority 2) Effective management skills 3) Empowerment in her role 4) Followership skills ANS: 3 Empowerment is a psychological state, a feeling of competence, control, and entitlement that a person experiences. Empowerment refers to feelings, whereas power refers to action. The person who feels empowered has feelings of self-determination, meaning, competence, and impact. This nurse may have power on the unit because of her expertise, but there is no evidence that she is an authority figure. Empowerment is not always associated with management. Managers have authority by virtue of their position but do not always thrive in that role. There is not enough information in the scenario to judge the nurses followership skills. PTS:1DIFifficultREF:p. 10 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 9. The physical therapy department and the nursing department at a local rehabilitation hospital are in conflict over which department is responsible for transporting patients to and from therapy appointments. The members of the therapy department state they do not have sufficient time to come to the nursing unit to pick up the patients and that patients often are not ready to be transported. Nursing staff members state that they do not have the time to transport the patients from the unit and this leaves a shortage of nursing personnel on the floor. Managers from both departments have attempted to resolve the conflict with input from nursing and therapy staff members. All attempts at conflict resolution have failed. What is the next step the managers should take? 1) Inform the nurses that they must take the patients to and from therapy. 2) Inform the therapists that they must take the patients to and from therapy. 3) Ask the hospital administrator to make an unbiased decision.
www.mynursingtestprep.com4) Begin informal negotiation between the two departments. ANS: 4 One of a managers responsibilities is to function as an informal negotiator when a resolution to conflict cannot be reached. PTS:1DIF:ModerateREF:dm 15-16 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 10. The manager is conducting an informal negotiation between two staff members who have had ongoing difficulty working together peacefully. Most recently there was an argument about who would be scheduled for first lunch each day. At this stage of the informal negotiation, the manager is focusing on managing the emotions and setting the ground rules. Which stage does this demonstrate? 1) Setting the stage 2) Conducting the negotiation 3) Making offers and counteroffers 4) Agreeing on resolution of the conflict ANS: 2 The manager has begun conducting informal negotiation. This includes managing the emotions, setting ground rules, and clarifying the problem. The first step of conflict resolution is introspective and is similar to data gathering. The negotiator thinks, What am I trying to achieve? What problems am I likely to encounter? The next step, setting the stage, may involve confronting the two parties with their behavior toward one another and making direct statements designed to open communication and challenge them to seek resolution of the situation. After conducting the negotiation, the parties move to making offers and counteroffers, and then to agreeing on the resolution of the conflict. PTS:1DIF:ModerateREF:p. 16 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application 11. A nurse observes a nursing assistant (NAP) fail to wash her hands before and after placing a patient on a bedpan. When giving negative feedback to the NAP, the nurse should: 1) Be certain to offer constructive criticism about the task and do so in private. 2) Ask the unit manager to be present to document responses of both parties. 3) Call a meeting of all NAPs and stress hand washing to the entire group. 4) Keep a record of the NAPs actions and save them for her annual formal review. ANS: 1 It is important to provide negative feedback in private. It is not necessary for the nurse manager to be present because staff nurses are responsible for delegating to and supervision of NAPs. The nurse should not call a meeting. It would be a waste of time for those who are already washing their hands properly, and it dilutes the effect of the feedback to the NAP who is not washing her hands. She might think, Oh, everybody does it; no big deal. It is important to allow some time every day for timely feedback. This allows the worker to know what she is doing right and wrong, and allows her to make
www.mynursingtestprep.comcorrective actions. The nurse should not allow this NAP to continue with her hand washing errors until her annual formal review because this can pose a threat to patient safety and increase the risk of transmitting infectious microbes. PTS: 1 DIF: Moderate REF: dm 7-8 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Which of the following are characteristics of an effective nurse manager? Choose all that apply. 1) Clinical expertise 2) Business sense 3) Masters degree 4) Leadership skills ANS: 1, 2, 4 An effective nurse manager possesses a combination of qualities: leadership skills, clinical expertise, and business sense. It is the combination of all these that prepares a person for the complex task of managing a group or team of healthcare providers. The extent of education that a person has does not determine her effectiveness as a manager. PTS:1DIF:ModerateREF:p. 5 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension 2. Which of the following activities is/are involved when delegating tasks to other members of the nursing team? Choose all that apply. 1) Supervising patient care that is given 2) Determining the skill mix of unit personnel 3) Assessing the needs of the clients involved 4) Deciding which tasks to assign to a team member ANS: 1, 2, 3, 4 Delegation of patient care tasks to other healthcare workers is one of the most important responsibilities of the registered nurse. When delegating tasks, the nurse must take into consideration the skills and competency of the team members as well as the condition and needs of the clients receiving care. The nurse is also responsible for supervising patient care to ensure that it is competently delivered. PTS:1DIFifficultREF:dm 12-13 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension 3. An experienced nurse serves as a mentor to a new graduate. Which of the following are responsibilities of the person being mentored? Choose all that apply. 1) Demonstrates an ability to move toward independence 2) Has the ability to encourage excellence in others
3) Seeks feedback and uses it to modify behaviors 4) Demonstrates flexibility and an ability to change ANS: 1, 3, 4 The ability to encourage excellence in others is a responsibility of the mentor. Responsibilities of the person being mentored are the following: demonstrates an ability to move toward independence; seeks feedback and uses it to modify behaviors; and demonstrates flexibility and an ability to change. PTS:1DIF:ModerateREF:p. 8; Box 45-2 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension www.mynursingtestprep.com Completion Complete each statement. • Compared with management, is the ability to influence other people with or without an official appointment to a position in the organization. ANS: leadership PTS: 1 DIF: Easy REF: p. 2 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension • is the ability to influence other people despite resistance from them. Said another way, it is the ability of one person or group to impose his, or their, will on another person or group. ANS: Power PTS:1DIF:ModerateREF:p. 10 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall • A(n) is someone with more experience who provides career development behaviors. ANS: mentor PTS:1DIF:EasyREF:dm 6-7 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall • A(n) is an employee of an organization who has the power, authority, and responsibility for planning, organizing, coordinating, and directing the work of others. ANS: manager Chapter 37 Community & Home Health Nursing Identify the choice that best completes the statement or answers the question. 1. The inhabitants of Yulupa, California, form which of the following? 1) Aggregate 2) Community 3) Population 4) Vulnerable population ANS: 3 A population is all of the people inhabiting a specified area. In contrast, a community is a group of like-minded individuals or one whose members have a common purpose, and an
www.mynursingtestprep.comaggregate has shared characteristics. A vulnerable population is an aggregate with increased risk for poor health outcomes. PTS: 1 DIF: Moderate REF: p. 1499 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 2. A community health nurse prepares for a new assignment. She has been assigned census tracts 131 and 132. This large area crosses the border of two towns and includes 4,000 people. What components of the community must the community health nurse assess prior to beginning her new assignment? 1) Income levels, health status, and relationships among groups 2) Structure of the tracts, effectiveness of the community, and current status 3) Number of clients with health problems compared to the number of healthcare providers 4) Community organizations and beliefs about their role in the community ANS: 2 To understand a community and its needs, the nurse must assess the communitys structure, status (the biological, social, and emotional outcome components of the community), and process (overall effectiveness of the community). Income level and demographic data, such as community organizations and healthcare providers, are included in the assessment of the community structure. The number of clients with health problems is only a part of the assessment of the community status. PTS:1DIFifficultREF:p. 1500 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Analysis 3. A community health nurse is evaluating the current health programs in the community. Which of these outcomes would indicate a healthy community? 1) Ninety percent of members report adequate access to primary care services. 2) Immunization services are available at hospitals and clinics. 3) Affordable housing in the community is under construction. 4) Mortality rates have been stable over the past 5 years. ANS: 1 Evidence of health in a community can be judged by examining progress in the focus areas delineated in Healthy People 2020. Access to primary care services is a measurable outcome that provides evidence of effectiveness of health programs. The availability of immunization services at the hospital or at many offices does not provide evidence that these services are being utilized. Similarly, the fact that affordable housing is under construction does not mean that it is being accepted and used or that enough is being built. Mortality rates may be stable but could be quite high and within unacceptable parameters. PTS:1DIFifficultREF:p. 1500 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis 4. What is the type of nursing with a focus on the community as a whole and the health status of individuals as an aggregate? 1) School nursing 2)
www.mynursingtestprep.comCommunity health nursing 3) Community-oriented nursing 4) Public health nursing ANS: 4 Public health nursing focuses on the community at large and the eventual effect of the communitys health status on the health of individuals, families, and groups. Community health nursing focuses on the health of individuals, families, and groups and on how their health affects the health of the community. Community-oriented care combines elements of community health nursing and public health. School nursing focuses on optimizing health for a community of students in a school setting. PTS: 1 DIF: Moderate REF: p. 1501 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 5. The community health nurse is working with the residents of government- subsidized senior housing. She meets with them regularly to discuss concerns and evaluate whether they receive healthcare that meets their needs. Which of the following nursing roles best describes these actions? 1) Case manager 2) Client advocate 3) Collaborator 4) Counselor 5) Educator ANS: 3 As a collaborator, the nurse forges partnerships and coalitions that can effectively address common concerns among different communities. In this role, the nurse facilitates discussion to work toward problem resolution. As a case manager, the nurse makes referrals to or collaborates with other health and social agencies. In the client advocate role, the nurse supports the identified or voiced concerns of the client or community. As an educator, the nurse focuses on wellness and disease prevention through patient teaching. A counselor offers practical solutions to resolve problems. PTS:1DIF:ModerateREF:p. 1502 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 6. A community health nurse gathers information about how individuals in a low- income neighborhood perceive the community and its state of health. Which of the following assessment strategies would be appropriate? 1) Conducting a windshield survey while driving 2) Reviewing a multitude of community databases 3) Interviewing residents living on every fifth block 4) Analyzing demographic data on the community ANS: 3 To assess community perceptions, the nurse will need to interact with a cross-section of the community. Interviewing residents is one way to find out about community concerns
www.mynursingtestprep.comand opinions. The other methods are assessment strategies that will provide data about the community but do not offer information on how community members view the community. PTS:1DIF:ModerateREF:dm 1506-1507 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 7. The community health nurse has gathered data about the community. She identifies many weaknesses in the community health system that contribute to poor health outcomes. What should be her next step? 1) Prioritize the list of problems. 2) Validate the data. 3) Evaluate the effectiveness of the interventions. 4) Plan the care. ANS: 1 After a thorough assessment, the nurse compiles a list of community strengths and weaknesses. Once this list is in place, the nurse must prioritize the list considering the client needs, funding, and political feasibility. PTS:1DIF:ModerateREF:p. 1507 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis 8. The similarities between the Omaha System and the NANDA-I taxonomy are that both contain which of the following? 1) Evaluation tools expressed in standardized language 2) Nursing diagnoses expressed in standardized language 3) Diagnoses, outcomes, and interventions 4) Labels that are intended for use in any healthcare setting ANS: 2 NANDA-I and the Omaha System both contain nursing diagnoses expressed in standardized language. The Omaha System also contains outcomes and interventions. The Omaha System was developed for use in community settings, whereas NANDA-I may be used in all settings. PTS:1DIF:ModerateREF:p. 1507 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis 9. A nurse serving the community in a public health role would likely perform which of the following functions within a particular community? 1) Tracking the prevalence of gonorrhea between January and June 2) Screening for scoliosis among 12- to 14-year-old girls in middle school 3) Weighing premature infants receiving phototherapy at home 4) Giving the H1N1 vaccine to fire and police personnel
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