Contemporary Medical Surgical Nursing 2nd Edition by Daniels, Rick -Test Bank

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INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

Contemporary Medical Surgical Nursing 2nd Edition by Daniels, Rick -Test Bank

 

Sample  Questions

 

Chapter 5–Legal and Ethical Aspects of Health Care

 

MULTIPLE CHOICE

 

  1. The nurse is providing care for a client who is 18 years old. Which of the following ethical principles should be implemented for this client?
1. Liberty
2. Agency
3. Justice
4. Autonomy

 

 

ANS:  4

A person who is at least 18 years of age and can make reasoned choices has autonomy and is free to make decisions regarding his own health care. Liberty is a characteristic of autonomy. Justice is an ethical principle that supports all people seeking health care receiving the best treatment available with dignity and respect. Agency is another characteristic of autonomy that means the capacity for intentional action.

 

PTS:   1                    DIF:    Apply            REF:   Principles of Clinical Ethics

 

  1. A client, being treated with chemotherapy and radiation for terminal cancer, decides to stop any further treatment and enter the hospice program. The nurse realizes this client’s decision is supported by the ethical principle of:
1. autonomy.
2. nonmaleficence.
3. beneficence.
4. justice.

 

 

ANS:  2

Nonmaleficence is the use of ability, judgment, or skill to help someone else without intent to cause injury or harm. In this case, nonmaleficence can support the option of not providing further aggressive or invasive treatment that could cause injury or harm. Autonomy is a self-rule that is free from interference by others and from limitations that prevent a meaningful choice. Beneficence means to be of benefit to others. Justice is a principle whereby all people who seek health care should receive the best possible treatment available with dignity and respect.

 

PTS:   1                    DIF:    Analyze         REF:   Principles of Clinical Ethics

 

  1. The care a nurse provides to clients is considered as being a benefit to their health and recovery. The principle that supports the nurse’s behavior is considered:
1. autonomy.
2. nonmaleficence.
3. beneficence.
4. justice.

 

 

ANS:  3

Justice requires that all cases are treated in like fashion. Beneficence requires that actions are of benefit to others. Autonomy is self-rule that is free from controlling influence by others and from limitations such as inadequate understanding. Nonmaleficence means “do no harm.”

 

PTS:   1                    DIF:    Analyze         REF:   Principles of Clinical Ethics

 

  1. A client recovering from surgery does not want to move out of bed because of pain. The nurse explains the long-term effects of staying in bed and the benefits of movement. The client agrees and is assisted out of bed. This is an example of:
1. autonomy.
2. nonmaleficence.
3. beneficence.
4. justice.

 

 

ANS:  3

Beneficence requires that actions are of benefit to others even if the nurse must first cause harm (pain). Autonomy is self-rule that is free from controlling influence by others and from limitations such as inadequate understanding. Nonmaleficence means “do no harm.” Justice requires that cases are treated in like fashion.

 

PTS:   1                    DIF:    Analyze         REF:   Principles of Clinical Ethics

 

  1. The nurse who bases client care actions on the principle of “greatest good” is implementing which ethical theory?
1. Teleology
2. Deontology
3. Utilitarian
4. Justice

 

 

ANS:  3

Utilitarian theory (part of teleology theory) means that the action must be of benefit to the greatest number of people affected by the action. Teleology is the evaluation of final causes (outcomes). Deontology is about one’s moral duty and obligation and is most concerned not with the outcomes of an action but rather with the action. Justice is an ethical principle, not a theory.

 

PTS:   1                    DIF:    Apply            REF:   Ethical Theories

 

  1. The nurse is preparing a consent form for a client to sign before a procedure. Which of the following statements explains a characteristic of informed consent?
1. The client does not need autonomy to give consent.
2. Minors are permitted to give consent.
3. The client does not need to give consent if the situation is an emergency.
4. If the client is of legal age, he or she does not need the cognitive ability to understand.

 

 

ANS:  3

In an emergency situation in which life or limb is at risk, the process of informed consent is waived. Minors cannot give consent unless the client is an emancipated minor. The client must have autonomy, be of legal age, and have the cognitive ability to understand to give consent.

 

PTS:   1                    DIF:    Analyze         REF:   Informed Consent

 

  1. When the nurse obtains a client’s signature for informed consent, the nurse’s responsibility is the verification that:
1. the client understands everything about the procedure.
2. a family member witnesses the signature.
3. the client was not coerced into signing the form.
4. the client has asked questions.

 

 

ANS:  3

The nurse verifies that the person named on the consent is the person to receive the procedure. The nurse ensures that the patient has the right to freely consent or refuse to consent based on the information given and her own personal values and wishes. Informed consent is not agreeing that the client understands everything about a procedure, that a family member witnesses the signature, nor the client has asked all questions about the procedure.

 

PTS:   1                    DIF:    Apply            REF:   Informed Consent

 

  1. The health care team is addressing an ethical issue regarding one client’s continuing care. The nurse wants to ensure that the principle of justice is taken into consideration. Which of the following ethical decision-making modules would support this principle?
1. Medical indications
2. Patient preferences
3. Quality of life
4. Contextual features

 

 

ANS:  4

The contextual features ethical decision-making model supports the ethical principle of justice. Medical indications support the ethical principles of beneficence and nonmaleficence. Patient preferences support the ethical principle of autonomy. Quality of life supports the ethical principles of beneficence, nonmaleficence, and autonomy.

 

PTS:   1                    DIF:    Apply            REF:   Ethical Decision Making Models

 

  1. The nurse, caring for an elderly client recovering from a fractured coccyx, wants to discuss palliative care. The client becomes alarmed and asks “is there something you aren’t telling me? Am I dying?” Which of the following should the nurse respond?
1. “We are all dying.”
2. “It’s an approach to care to help relieve pain and provide you with support.”
3. “It’s care provided to all elderly patients.”
4. “Since it is covered by Medicare, you are entitled to it.”

 

 

ANS:  2

Palliative care is a process that focuses on relieving pain, enhancing psychosocial supports, and allowing clients and families to achieve meaningful resolution to their lives together. This is what the nurse should respond to the client. The other responses are either inappropriate for the nurse to make or are incorrect.

 

PTS:   1                    DIF:    Apply            REF:   Hospice and Palliative Care

 

  1. The nurse provides a terminally ill client with dose of a newly prescribed pain medication. Shortly afterwards, the client experiences respiratory arrest and dies. Which of the following describes this client scenario?
1. Euthanasia
2. Assisted suicide
3. Intended effect
4. Double effect

 

 

ANS:  4

Double effect occurs when the intended use of a palliative therapy has the unintended effect of hastening a client’s death. This is what occurred with the client and the pain medication. Euthanasia is the act of administering a lethal injection of medication with the intent to end another person’s life. Assisted suicide is similar to euthanasia in that a health care provider assists another person to end his life. Intended effect is an intervention that has the outcome that was expected to occur.

 

PTS:   1                    DIF:    Analyze         REF:   Concept of Double Effect

 

  1. An elderly client with septic leg wounds develops multi-system organ failure. The physicians discuss treatment options with the family but explain that success to reverse the condition is minimal. The family has decided to stop all further treatment of the client. This scenario is an example of:
1. medical futility.
2. do-not-resuscitate.
3. assisted suicide.
4. active euthanasia.

 

 

ANS:  1

Medical futility means that an identified therapy for a client has no medical benefit. Do-not-resuscitate means if a client stops breathing or the heart stops beating, resuscitation will not be provided. Active euthanasia is performing an action that ends a person’s life. Assisted suicide is an action by a health care provider that assists a client in ending his or her life.

 

PTS:   1                    DIF:    Analyze         REF:   Limitation of Treatment

 

  1. A client is asked to participate in a research study. The client does not want to participate but does not want to seem unwilling to receive treatment for an illness. Which of the following should the nurse explain to this client?
1. Negative effects from research rarely occur.
2. It is an honor to be asked to participate in a research study.
3. Refusing to participate is the client’s right.
4. The physician wants the client to participate.

 

 

ANS:  3

The nurse needs to support the client’s right to autonomy and explain that the client has the right to refuse participation in the research study. There is no guarantee that negative effects from the research study will not occur. The nurse should not persuade the client by stating that it is an honor to be asked to participate or that the physician wants the client to participate.

 

PTS:   1                    DIF:    Apply            REF:   Research Ethics

 

  1. The nurse caring for elderly clients begins to experience anger, guilt, and frustration over the prescribed medical treatments for the clients. The nurse is demonstrating which of the following?
1. Moral distress
2. Burnout
3. Signs of a chronic illness
4. Evidence of an acute illness

 

 

ANS:  1

Moral distress in nursing occurs when the nurse is aware of the right and moral action to take in client situations but is unable to carry out the action because of external constraints. This form of distress can lead to feelings of anger, guilt, and frustration. The nurse is not experiencing burnout though burnout could occur if moral distress continues. The nurse is not experiencing signs of a chronic or acute illness.

 

PTS:   1                    DIF:    Analyze         REF:   Moral Distress

 

MULTIPLE RESPONSE

 

  1. The nurse is analyzing the main principles of clinical ethics prior to planning care for a client. Which of the following are considered the main principles of clinical ethics? (Select all that apply.)
1. Malfeasance
2. Autonomy
3. Liberty
4. Nonmaleficence
5. Beneficence
6. Justice

 

 

ANS:  2, 4, 5, 6

The four main principles of clinical ethics are: 1) autonomy, 2) nonmaleficence, 3) beneficence, and 4) justice. Liberty is a component of autonomy. Malfeasance is wrong or illegal conduct.

 

PTS:   1                    DIF:    Analyze         REF:   Principles of Clinical Ethics

 

  1. A client, hospitalized with an extensive cerebral vascular accident, is unable to make any treatment decisions. Which of the following documents addresses the client’s treatment choices? (Select all that apply.)
1. Living will
2. Durable power of attorney for health care
3. Incident report
4. Verbal advance directive
5. Advance directive
6. Medication administration record

 

 

ANS:  1, 2, 4, 5

Advance directives allow a person to make specific decisions about their future health care treatments in advance. Forms of advance directives are the living will, durable power of attorney for health care, and written or verbal advance directive. The incident report is a document that records errors of omission or commission as well as any unusual occurrence. The medication administration record does not address clients’ treatment choices.

 

PTS:   1                    DIF:    Apply            REF:   Advance Directives

 

  1. The nurse is confronted with an ethical decision regarding a client’s continuing care. Which of the following approaches can be used to reach a decision for this client? (Select all that apply.)
1. Medical indications
2. Client preferences
3. Quality of life
4. Health insurance plan
5. Contextual features
6. Integrated model

 

 

ANS:  1, 2, 3, 5, 6

There are several approaches that can be used to help with ethical decision making. These approaches are medical indications, client preferences, quality of life, contextual features, and the integrated model. The client’s health insurance plan is not used to help with ethical decision making.

 

PTS:   1                    DIF:    Apply            REF:   Ethical Decision Making Models

 

  1. An elderly terminally ill client is experiencing apnea periods and within an hour, dies. No efforts were provided to resuscitate this client. Which of the following would describe this client event?
1. Do-not-resuscitate
2. Coma depasse
3. Brain death
4. Passive euthanasia
5. Assisted suicide
6. Active euthanasia

 

 

ANS:  1, 4

Passive euthanasia means the omission of an action that could prevent death and allowing death to occur. An example of passive euthanasia is following a do-not-resuscitate order. Coma depasse is a term for irreversible coma. Brain death is used when a client is assessed as being dead by neurological criteria. Assisted suicide and active euthanasia are similar in that an action must be carried out by one person to help end the life of another person.

 

PTS:   1                    DIF:    Analyze         REF:   Euthanasia and Assisted Suicide

 

  1. The nurse reviews the American Nurses Association’s Code of Ethics for Nurses. Which of the following is included in this code?
1. Care is provided with compassion and respect.
2. Primary commitment is to the client.
3. Strive to protect the health, safety, and rights of the client.
4. Delegation is not an option.
5. Client needs supercede those of the nurse.
6. Collaboration with other health care professionals is expected.

 

 

ANS:  1, 2, 3, 6

The American Nurses Association’s Code of Ethics for Nurses has nine statements that define and guide the moral sense of nursing. These statements include: 1) care is provided with compassion and respect; 2) primary commitment is to the client; 3) strive to protect the health, safety, and rights of the client; 4) and collaborate with other health care professionals. Delegation is to be conducted to provide optimum client care. The nurse owes the same duties to self as others.

 

PTS:   1                    DIF:    Analyze         REF:   Box 5-1 The ANA Code of Ethics for Nurses

 

Chapter 7–Palliative Care

 

MULTIPLE CHOICE

 

  1. The nurse believes that a client is eligible as a participant for The National Hospice Reimbursement Act of 1986. This act mandated that:
1. clients with terminal illnesses are reimbursed.
2. a physician must order hospice to be reimbursed.
3. to receive reimbursement that client must be eligible for Medicare.
4. to receive benefits, the physician must certify that the client has a limited life expectancy of 6 months or less.

 

 

ANS:  4

The Medicare hospice benefit is a reimbursement benefit for those with a prognosis of 6 months or less to live (certified by a physician). The act does not mandate reimbursement to clients with terminal illnesses, physicians do not have to order hospice for reimbursement, nor does a client have to be eligible for Medicare for hospice eligibility.

 

PTS:   1                    DIF:    Analyze         REF:   History and Overview of Hospice Care

 

  1. After a Native American client has died, the family begins the practice of purifying the body. The nurse realizes that the deceased client may stay with the family for what period of time?
1. 12 hours
2. 24 hours
3. 36 hours
4. 48 hours

 

 

ANS:  3

Native Americans believe that the soul departs from the body 36 hours after death. The family may want the body to remain at the place of death for this period. The other choices are incorrect lengths of time according to Native American culture.

 

PTS:   1                    DIF:    Analyze

REF:   Table 7-1 Cultural Considerations Related to Dying

 

  1. A client is receiving care for symptoms; however, the treatment will not alter the course of the disease. This client is receiving which type of care?
1. Hospital-based
2. Managed
3. Palliative
4. Therapeutic

 

 

ANS:  3

Palliative care, or “comfort” care, is directed at providing relief to a terminally ill client through symptom and pain relief. The goal is not curative. Care for symptoms that will not alter the course of the disease does not need to be provided in the hospital. Managed care is guided through the direction of a primary care physician. Therapeutic is a type of care that focuses on a specific treatment for a health problem.

 

PTS:   1                    DIF:    Analyze         REF:   Overview of Palliative Care

 

  1. A client diagnosed with a terminal illness is receiving an opioid/acetaminophen combination for pain control. The nurse realizes this client is being managed at which step of the World Health Organization approach to pain management?
1. Step 1
2. Step 2
3. Step 3
4. Step 4

 

 

ANS:  2

The World Health Organization approach to pain management involves three steps. Step 1: Clients are treated with around-the-clock doses of nonopioids. Step 2: The use of opioid/acetaminophen combinations are used to treat mild to moderate pain. Step 3: Strong opioids are used. There is no Step 4 in the World Health Organization’s approach to pain management.

 

PTS:   1                    DIF:    Analyze

REF:   Figure 7-2 Conceptual Model of Ladder Approach to Pain Management

 

  1. A dying client is surrounded by family and friends at home. The hospice nurse talks with the spouse of the dying client to ensure that everything the family needs during this time is being done. The nurse is providing support to:
1. the client.
2. the bereaved.
3. ensure compliance with the hospice rules and regulations.
4. determine if the spouse understands that the client is dying.

 

 

ANS:  2

Supporting the family’s rituals and cultural practices gives structure to support the bereaved through this painful process when people are vulnerable and feel off balance. The nurse is not providing support to the client. The nurse is not providing support to ensure compliance with the hospice rules and regulations. The nurse is also not providing support to determine if the spouse understands that the client is dying.

 

PTS:   1                    DIF:    Analyze         REF:   Role of the Hospice and Palliative Care Nurse

 

  1. A client of the Hispanic culture is nearing death and the family requests that the client be prepared for discharge. The nurse realizes that the reason the family and client want to return home is because:
1. individuals within this culture do not trust hospital caregivers.
2. the family wants to have a spiritual healer care for the client.
3. it is bad luck to die in the hospital.
4. the spirit may get lost if the client dies in the hospital, and it will not be able to find its way home.

 

 

ANS:  4

Within the Hispanic culture, the client and family may not want to die in the hospital because the spirit may get lost and will not be able to find its way home. The reason the family and client want to return home is not because of a distrust of hospital caregivers. The family may want to have a spiritual healer conduct a ceremony for the client, but this does not need to be done in the home. Members of the Hispanic culture do not believe that it is bad luck to die in the hospital.

 

PTS:   1                    DIF:    Analyze

REF:   Table 7-1 Cultural Considerations Related to Dying

 

  1. During the period of time when a client diagnosed with a terminal illness became comatose, a health care proxy made decisions about the client’s care. When the client regained consciousness a few days later, the nurse consulted whom regarding the client’s ongoing care decisions?
1. The client
2. The health care proxy
3. The client’s family
4. The client’s physician

 

 

ANS:  1

A health care proxy is in effect whenever the client is unable to communicate and ceases to be in effect as soon as the client regains decision-making capacity. The nurse should consult with the client regarding the client’s ongoing care decisions. The nurse should not consult with the health care proxy, the family, or the physician.

 

PTS:   1                    DIF:    Apply

REF:   Ethics in Practice: Legal and Ethical Considerations Related to Dying

 

  1. The nurse is concerned that the spouse of a terminally ill client is experiencing Anticipatory Grieving when which of the following is assessed?
1. Confidence in the ability to care for the ill client at home
2. Expressing anger about the client’s pending death and crying throughout the day
3. Large social support system
4. Knowledge of equipment function

 

 

ANS:  2

Anticipatory grieving is the intellectual and emotional responses and behaviors by which individuals work through the process of modifying self-concept based on the perception of potential loss. Anger and crying about the client’s pending death are signs of Anticipatory Grieving. The other assessment findings are evidence that the spouse is accepting the caregiver role.

 

PTS:   1                    DIF:    Analyze         REF:   Nursing Diagnoses

 

  1. The nurse administers additional intravenous medication to a hospice client with uncontrollable pain. After receiving the additional medication, the client demonstrates apneic periods and bradycardia. Which of the following does this nurse’s actions suggest?
1. Euthanasia
2. Assisted suicide
3. Double effect
4. Malpractice

 

 

ANS:  3

The principle of double effect means that increasing the dose of medication to achieve pain control, even if death is hastened, is ethically justified. Euthanasia is the administration of medication to purposefully cause another’s death. Assisted suicide is the practice of providing medication to a client with the intent that the client use the medication to voluntarily commit suicide. Malpractice is conducting some aspect of care that causes a client harm.

 

PTS:   1                    DIF:    Analyze         REF:   Managing Pain

 

  1. A client with a terminal illness was ingesting morphine sulfate 10 mg by mouth every 6 hours for pain. To ensure that the client receives the same degree of pain control when delivering the same medication through the intravenous route, which of the following should the nurse do?
1. Provide morphine sulfate 10 mg intravenous every 6 hours.
2. Provide morphine sulfate 20 mg intravenous every 4 hours.
3. Provide a different medication since morphine sulfate cannot be given through the intravenous route.
4. Consult a dose equivalent table to determine the dose of morphine sulfate the client will need through the intravenous route.

 

 

ANS:  4

Dose equivalent tables should be used by the nurse when analgesics or the routes of administration are changed. The nurse should not provide the same dosage of the medication through the intravenous route since this may be too much. Morphine sulfate can be administered through the intravenous route.

 

PTS:   1                    DIF:    Apply            REF:   Managing Pain

 

  1. A terminally ill client is experiencing nausea. Which of the following interventions can be used to help the client at this time?
1. Administer diphenhydramine (Benadryl) as prescribed.
2. Provide three regular meals.
3. Limit mouth care.
4. Restrict iced fluids.

 

 

ANS:  1

Diphenhydramine (Benadryl) acts on the vomiting center in the medulla. This is the intervention that would be the most helpful to the client at this time. The client should be provided with small, frequent meals. Mouth care should be provided when necessary. Iced fluids are helpful for dry mouth.

 

PTS:   1                    DIF:    Apply

REF:   Managing Loss of Appetite, Constipation, Nausea, and Vomiting

 

  1. A terminally ill client is more alert and talkative, and she is requesting specific foods to eat. The nurse should caution the family regarding the client’s behavior because this could indicate:
1. total remission of the disease process.
2. final surprising rally before retreating.
3. the client is cured of the terminal illness.
4. the client was misdiagnosed.

 

 

ANS:  2

Nurses should prepare the family of a terminally ill client for an occasional final surprising rally in which the client becomes temporarily more alert and responsive before retreating. The period of alertness does not indicate total remission of the disease process, the client’s being cured of the terminal illness, or the client’s being misdiagnosed.

 

PTS:   1                    DIF:    Apply            REF:   Providing Care in the Active Phase of Dying

 

  1. The nurse is concerned that a hospice client is approaching death when which of the following is assessed?
1. Respiratory rate 16 and regular
2. Blood pressure 110/60 mmHg
3. Restlessness, irritability, and anxiety
4. Periods of wakefulness are greater than periods of sleep

 

 

ANS:  3

Symptoms of hypoxia include restlessness, irritability, and anxiety. Respirations of 16 and regular is a normal respiratory rate. Blood pressure of 110/60 mmHg is within normal limits. Periods of wakefulness being greater than periods of sleep is also a normal physiological finding.

 

PTS:   1                    DIF:    Analyze         REF:   Table 7-2 Physiology of Dying

 

MULTIPLE RESPONSE

 

  1. The nurse is discussing end-of-life wishes with a client and his family. Since the client is not sure of what type of care he wants, the nurse provides the document “Five Wishes” because this document provides which of the following types of information? (Select all that apply.)
1. What the client wants his loved ones to know
2. The level of comfort that the client wants
3. Comments and ideas for health care providers
4. The person designated by the client to make health care decisions
5. The kinds of medical treatment that the client wants or does not want
6. The way in which the client wants to be treated

 

 

ANS:  1, 2, 4, 5, 6

The “Five Wishes” document helps clients express themselves if they are seriously ill and unable to communicate their wishes for themselves. It looks at all of a client’s needs: medical, personal, emotional, and spiritual. Comments and ideas for health care providers is not a part of the Five Wishes document.

 

PTS:   1                    DIF:    Apply            REF:   Role of the Hospice and Palliative Care Nurse

 

  1. The nurse is making a home visit to a client receiving hospice care. Which of the following symptoms will the nurse assess in the client during the visit? (Select all that apply.)
1. Aggression
2. Anxiety
3. Confusion
4. Depression
5. Increased appetite
6. Urinary continence

 

 

ANS:  2, 3, 4

Common symptoms of the client receiving hospice care include pain, dyspnea, nausea, vomiting, constipation, loss of appetite, urinary urgency and incontinence, insomnia, confusion, delirium, anxiety, and depression. Aggression, increased appetite, and urinary continence are not symptoms typically assessed in a client receiving hospice care.

 

PTS:   1                    DIF:    Apply

REF:   Assessment of the Patient Receiving Hospice and Palliative Care

 

  1. The nurse, assessing pain in a client receiving hospice care, uses the ABCDE model to guide pain management. Which of the following is a part of this pain management approach? (Select all that apply.).
1. Ask about the pain regularly.
2. Believe the patient and family in their reports of pain.
3. Confront the patient if you believe pain control was not achieved.
4. Deliver interventions only when requested.
5. Enable the patient to control her course of pain management to the greatest extent possible.
6. Utilize complementary alternative medicine approaches first.

 

 

ANS:  1, 2, 5

The “ABCDE” model is a guide to pain management. For A, the nurse should regularly ask about pain. For B, the nurse should believe the patient and family in their reports of pain and what relieves it. For C, the nurse should choose pain control options that are appropriate for the patient. The nurse should not confront the patient about pain control since this is not therapeutic. For D, interventions should be delivered in a timely, logical, and coordinated manner and not only when requested. For E, patients and families should be empowered. Complementary alternative medicine approaches should not be used first.

 

PTS:   1                    DIF:    Apply            REF:   Box 7-2 ABCDE Guide to Pain Assessment

 

  1. The nurse is providing a terminally ill client with morphine for pain control. In addition to this medication, which of the following can be provided to enhance analgesic effect? (Select all that apply.)
1. Antihypertensive
2. Antidepressant
3. Antibiotic
4. Antiemetic
5. Anticonvulsant
6. Corticosteroid

 

 

ANS:  2, 5, 6

Adjuvant medications can enhance analgesic effect and include antidepressants, anticonvulsants, and corticosteroids. Antihypertensives, antibiotics, and antiemetics are not considered adjuvant medications for pain control.

 

PTS:   1                    DIF:    Apply            REF:   Managing Pain

 

  1. A client with a terminal illness refuses pain medication. The nurse realizes that the client may decline pain medication for which of the following reasons? (Select all that apply.)
1. Fear that the pain means the disease is worse
2. Insufficient health plan benefits to pay for the medication
3. Cultural background prevents the use of pain medication
4. Fear of becoming addicted to pain medication
5. Fear of side effects
6. Concern about being labeled as a “bad” client

 

 

ANS:  1, 4, 5, 6

Client barriers to sufficient pain management include fear that the disease is worse, fear of becoming addicted to pain medication, fear of side effects, and concern about being labeled as a “bad” client. Insufficient health plan benefits to pay for the medication and cultural background preventing the use of pain medication are not identified client barriers to sufficient pain management.

 

PTS:   1                    DIF:    Analyze         REF:   Box 7-4 Barriers to Pain Management

 

 

Chapter 13–Infusion Therapy

 

MULTIPLE CHOICE

 

  1. A client is scheduled for a peripherally inserted central catheter in a few days. However, the client needs intravenous fluids infused immediately. Which of the following veins should the nurse avoid when starting the intravenous infusion now?
1. Accessory cephalic vein
2. Basilic vein
3. Cephalic vein
4. Median vein

 

 

ANS:  3

The cephalic vein should be reserved for a midline or peripherally inserted central catheter since it is located near the antecubital fossa. The other veins are appropriate for IV starts.

 

PTS:   1                    DIF:    Apply            REF:   Anatomy and Physiology; Percutaneous Catheters

 

  1. The tubing on a client’s intravenous infusion administration set is not long enough to support the client’s ambulation needs. Which of the following can the nurse do to assist this client?
1. Apply a stopcock.
2. Add an extension set.
3. Use a filter.
4. Attach a needleless access device.

 

 

ANS:  2

An extension set is used to add length and additional medication ports to primary tubing. A stopcock is used to direct the flow of fluid in the intravenous line. A filter is used to eliminate air and particles that should not be infused into the client. A needleless access device is used at medication ports to add a layer of safety.

 

PTS:   1                    DIF:    Apply            REF:   Box. 13-1 Add-On Devices for Infusion Therapy

 

  1. An intravenous catheter has been inserted over a client’s antecubital joint. Which of the following should the nurse do to ensure the client’s comfort and the usefulness of the catheter?
1. Use an arm board to keep the arm straight.
2. Wrap gauze around the insertion site.
3. Place a gauze dressing over the insertion site.
4. Apply a wrist restraint to keep the arm straight.

 

 

ANS:  1

If an intravenous catheter has to be placed over a joint, the nurse should use an arm board to immobilize the site, prolong the life of the intravenous line, and decrease mechanical phlebitis.

 

PTS:   1                    DIF:    Apply            REF:   IV Procedure Special Considerations

 

  1. After preparing a client’s skin for insertion of an intravenous catheter, the nurse accidentally touches the skin site with an uncovered finger. Which of the following should the nurse do?
1. Cleanse the skin again.
2. Apply clean gloves and continue.
3. Locate another vein to access.
4. Continue with the insertion of the catheter.

 

 

ANS:  1

Once the site is prepared, the nurse should not touch the site unless sterile gloves are worn. If the site is touched by unprotected skin, the nurse should cleanse the skin again. The nurse should not apply clean gloves and continue. The nurse does not need to locate another vein to access. The nurse should not continue with the insertion of the catheter since this can lead to an infection of the site.

 

PTS:   1                    DIF:    Apply            REF:   IV Complications

 

  1. Which of the following should the nurse assess to determine if a client’s intravenous infusion has infiltrated?
1. A blood return
2. Size of extremity
3. Presence of pain
4. Presence of a temperature

 

 

ANS:  2

If infiltration is suspected, the nurse should compare both arms. The dominant arm should be a bit larger, but a significant difference in size could mean infiltration. A blood return may still be visible with an infiltrated intravenous line. A lack of a blood return does not always mean the cannula is no longer in the vein since some cannulas can collapse when aspirating from them. Presence of pain could be due to the solution type. Hypertonic solutions cause more pain. The presence of a temperature could mean a variety of health conditions and not necessarily an infiltration.

 

PTS:   1                    DIF:    Apply            REF:   Infiltration

 

  1. A client is diagnosed with an extravasation of a intravenous medication. Which of the following should the nurse do to assist this client?
1. Remove the catheter and apply heat.
2. Place the extremity lower than the level of the heart.
3. Keep the catheter intact until an antidote is administered.
4. Apply ice over the site until the swelling subsides.

 

 

ANS:  3

If extravasation occurs, the cannula should not be removed until it is determined if an antidote exists. If an antidote exists, instill it through the cannula into the area of extravasation. Then the cannula can be removed and the extremity elevated. Heat or cold should be applied according to the medication which extravasated.

 

PTS:   1                    DIF:    Apply            REF:   Extravasation

 

  1. A client is complaining of numbness and tingling around the intravenous infusion catheter. Which of the following should the nurse do?
1. Apply heat.
2. Remove the cannula.
3. Elevate the extremity.
4. Slow the intravenous infusion rate.

 

 

ANS:  2

Complaints of numbness and tingling around the intravenous infusion catheter could indicate nerve damage. The nurse should remove the cannula, document the complaint, and notify the physician if the symptoms do not resolve after the cannula is removed. Applying heat will not be helpful. Elevating the extremity is not indicated for suspected nerve damage. Slowing the intravenous infusion rate will not reduce the likelihood of nerve damage and should not be done.

 

PTS:   1                    DIF:    Apply            REF:   Nerve Damage

 

  1. A client is prescribed to receive a medication diluted in 50 mL of 0.9% Normal Saline four times a day. The nurse realizes that this type of administration is considered:
1. continuous.
2. direct injection.
3. patient-controlled.
4. intermittent.

 

 

ANS:  4

Intermittent infusion means that a small volume of fluid is infused in a short amount of time. A continuous infusion means that a large volume of fluid is infused over hours and days. Patient-controlled infusion provides the client with the ability to deliver a pain medication. Direct injection provides the medication directly into the bloodstream for immediate results.

 

PTS:   1                    DIF:    Analyze         REF:   Pharmacology

 

  1. A client has an implanted port for medication administration. Which of the following should the nurse use when administering medications through this port?
1. Use a noncoring needle.
2. Use an 18 gauge needle.
3. Apply heat to the site prior to administering medication.
4. Flush the port after administering medications.

 

 

ANS:  1

An implanted port contains a reservoir that is accessed with a noncoring needle. The nurse should not use an 18 gauge needle. The nurse does not need to apply heat to the site prior to administering medication. The port does not need to be flushed after administering medications.

 

PTS:   1                    DIF:    Apply            REF:   Implanted Ports

 

  1. A client is receiving total parenteral nutrition. Which of the following interventions are appropriate for this client?
1. Provide the infusion at the maximum rate.
2. Do not use a pump for infusing.
3. Measure weights daily.
4. Assess blood glucose levels every week.

 

 

ANS:  3

Interventions for a client receiving total parenteral nutrition include measuring the client’s weight daily. The infusion should be started slowly and gradually increase to the maximum infusion rate. The infusion should be administered with a pump. Blood glucose levels should be assessed every 6 hours during the first week of receiving this infusion.

 

PTS:   1                    DIF:    Apply            REF:   Total Parenteral Nutrition

 

  1. A client has the blood type of O+. Which of the following types of blood can the client receive if a transfusion is needed?
1. A+
2. B+
3. O-
4. AB+

 

 

ANS:  3

A client with the blood type of O+ can receive either O+ or O- blood. A client who has the blood type of O+ cannot receive A+, B+, or AB+ blood.

 

PTS:   1                    DIF:    Understand    REF:   Table 13-4 Blood Types

 

MULTIPLE RESPONSE

 

  1. A client is prescribed to receive an intravenous infusion of a hypertonic solution. The nurse realizes that which of the following solutions are considered hypertonic? (Select all that apply.)
1. 0.45% Normal Saline
2. Dextrose 5% and 0.9% Normal Saline
3. Dextrose 5% and water
4. Dextrose 10% and water
5. Ringer’s lactate
6. Dextran 5% in water

 

 

ANS:  2, 4

Hypertonic solutions cause fluid to move out of the cells, resulting in shrinkage of the cells. Hypertonic solutions include Dextrose 5% and 0.9% Normal Saline and Dextrose 10% and water. Ringer’s lactate is an isotonic solution. The solutions of 0.45% Normal Saline and Dextrose 5% and water are hypotonic. Dextran 5% in water is a plasma extender.

 

PTS:   1                    DIF:    Analyze         REF:   Table 13-1 Common IV Therapy Solutions

 

  1. A client is prescribed to receive an infusion of intralipid 10%. Which of the following should the nurse do when providing this infusion? (Select all that apply.)
1. Use a filter.
2. Infuse with 0.9% Normal Saline.
3. Hang for 24 hours.
4. Administer for up to 16 hours.
5. Measure strict output.
6. Limit oral fluids.

 

 

ANS:  1, 4

When administering an infusion of intralipids 10%, the nurse should administer it with a filter. The nurse should not add medications and should not hang for more than 16 hours. The infusion should not be provided with 0.9% Normal Saline. The infusion should not be delivered for 24 hours. Strict output and oral fluid restriction is not necessary when providing intralipids to a client.

 

PTS:   1                    DIF:    Apply            REF:   Table 13-1 Common IV Therapy Solutions

 

  1. The nurse is having difficulty accessing a client’s vein to insert an intravenous catheter. Which of the following interventions can be used to assist in this process? (Select all that apply.)
1. Use a tourniquet.
2. Dangle the arm off the side of the bed.
3. Apply a warm towel.
4. Have the client pump the fist.
5. Apply a heating pad.
6. Warm the catheter in the microwave.

 

 

ANS:  1, 2, 3, 5

To promote venous distention, the nurse can use a tourniquet, dangle the arm off the side of the bed, apply a warm towel, and apply a heating pad. Having the client pump the fist will increase vasospasm. The catheter should not be warmed in the microwave since this could adversely affect the functioning.

 

PTS:   1                    DIF:    Apply            REF:   Box 13-2 Selecting a Vein

 

  1. The nurse suspects that a client has developed phlebitis from an intravenous catheter when which of the following is assessed? (Select all that apply.)
1. Redness
2. Cool skin over the intravenous site
3. Warmth over the intravenous site
4. Elevated body temperature
5. Hard palpable cord along the vein track
6. Blanching of the skin

 

 

ANS:  1, 3, 4, 5

Evidence of phlebitis from an intravenous catheter includes redness, warmth over the intravenous site, pain, elevated body temperature, and a hard palpable cord along the vein track. Cool skin over the intravenous site and blanching of the skin are assessment findings for an infiltration.

 

PTS:   1                    DIF:    Analyze         REF:   Phlebitis

 

  1. The nurse is making a visit to a client prescribed to receive intravenous therapy in the home. Which of the following should the nurse assess when preparing to administer intravenous medication to this client? (Select all that apply.)
1. Food
2. Telephone
3. Sufficient electrical outlets
4. Location of throw rugs
5. Clean work area
6. Home cleanliness

 

 

ANS:  2, 3, 5, 6

When administering intravenous medications in the home, the nurse needs to evaluate the home for cleanliness, place for supplies, clean work area, refrigeration, pets, sufficient electrical outlets, no insects or parasites, telephone, and batteries and supplies. The nurse does not need to assess for food or the location of throw rugs.

 

PTS:   1                    DIF:    Apply            REF:   Special Considerations

 

SHORT ANSWER

 

  1. How many drops per minute should the nurse regulate a client’s intravenous infusion of Lactated Ringer’s 125 mL per hour with a drop factor of 15 drops per mL?

 

ANS:

31 drops per minute

125 mL/60 minutes ´ 15 gtts/mL = 31 gtts/min

 

PTS:   1                    DIF:    Apply            REF:   Administration of IV Solutions

 

  1. A client is prescribed to receive 1000 mL of 0.9% Normal Saline in an 8-hour time frame. Using a microdrip set, how many drops per minute will the infusion run?

 

ANS:

125 gtts/min

RAT: 1000 mL/8 hours = 125 mL/hr; 125 mL/60 minutes ´ 60 gtts/mL = 125 gtts/min

 

PTS:   1                    DIF:    Apply            REF:   Administration of IV Solutions

 

 

Chapter 21–Intraoperative Nursing Management

 

MULTIPLE CHOICE

 

  1. A nurse is considering additional training to become a perioperative nurse. Which of the following skills are implemented by the perioperative nurse?
1. Conducts telephone interviews with the preoperative client
2. Applies principles of aseptic technique
3. Instructs the preoperative client on exercises to use while recovering from surgery
4. Plans for the postoperative client’s discharge to home

 

 

ANS:  2

Skills of the perioperative nurse include applying principles of aseptic technique and explaining how this knowledge applies to other areas within the operating suite. The perioperative nurse does not conduct telephone interviews with the preoperative client, instruct the preoperative client in postoperative exercises, nor plan for the postoperative client’s discharge to home.

 

PTS:   1                    DIF:    Apply            REF:   The Role of the Perioperative Nurse

 

  1. Even though the nurse realizes that the ideal time period to plan for postoperative pain management for a pediatric client begins in the operating room, the nurse will begin the assessment process:
1. at the time the decision is made that the client needs surgery.
2. in the family’s home.
3. during the admission process.
4. in the operating room after anesthesia wears off.

 

 

ANS:  3

Pain management cannot begin before the patient is admitted, and starting after the surgery is too late. It begins at the admission when the type of surgery indicates which type of medication will be needed, and medication skills will be taught to the client and the family. Planning for pain management cannot begin in the client’s home nor at the time the decision is made that the client needs surgery.

 

PTS:   1                    DIF:    Apply            REF:   Pain Management in Pediatric Patients

 

  1. The perioperative nurse realizes that the surgical environment is designed to ensure which of the following?
1. Calming effect on the client
2. Ease of use by personnel
3. Control surgical asepsis
4. Reduce postoperative pain

 

 

ANS:  3

The design of the intraoperative environment is to maintain surgical asepsis. The design is not to have a calming effect on clients. Intraoperative environments are not designs for ease of use by personnel or to reduce postoperative pain.

 

PTS:   1                    DIF:    Analyze         REF:   The Surgical Environment

 

  1. The scrub nurse is preparing the sterile field by opening an instrument package that was sterilized in an autoclave with direct exposure to steam. This type of sterilization is considered to be:
1. high-pressure/high-temperature steam.
2. cold chemical.
3. dry heat.
4. alcohol.

 

 

ANS:  1

High-pressure/high-temperature steam sterilization is the use of an autoclave to directly expose the instruments to steam for a specified period of time. Cold chemical sterilization is the submersion of instruments in a sterilizing solution for a predetermined period of time. Dry heat utilizes static air or forced air to sterilize items. Alcohol is a commonly used disinfectant. It is not an effective sterilant and, therefore, is not acceptable.

 

PTS:   1                    DIF:    Analyze         REF:   Box 21-5 Sterilization Methods

 

  1. Prior to the surgeon’s making an incision into a client, the client’s skin is bathed with a bacteriostatic solution. The nurse realizes that this solution will:
1. sterilize the client’s skin.
2. disinfect the client’s skin.
3. sanitize the client’s skin.
4. inhibit the number of bacteria on the client’s skin.

 

 

ANS:  4

A bacteriostatic solution is one that will inhibit the increase in the number of bacteria. Sterilization, disinfection, and sanitization are all methods to reduce or destroy microorganisms on objects. These methods cannot be used on skin.

 

PTS:   1                    DIF:    Analyze         REF:   Table 21-2 Sterilization Terms and Definitions

 

  1. The operating room personnel are applying masks and either goggles or face shields prior to beginning a surgical procedure. The purpose of these items is to:
1. facilitate vision.
2. protect against splashes or sprays of blood.
3. facilitate breathing.
4. facilitate communication.

 

 

ANS:  2

These pieces of personal protective equipment (PPEs) are used to protect personnel from splashes and sprays of blood and body fluids. Masks, goggles, and face shields do not facilitate vision, breathing, or communication.

 

PTS:   1                    DIF:    Analyze         REF:   Personal Protective Equipment

 

  1. The nurse is preparing to participate in a surgical procedure and has completed the surgical scrub. Which of the following should the nurse do now in preparation for the surgery?
1. Don a surgical gown.
2. Apply sterile gloves.
3. Adjust the surgical mask.
4. Apply covering over the hair.

 

 

ANS:  1

Gowns should be put on after completing a surgical scrub and before gloving. The surgical mask should be adjusted before applying sterile gloves. Head covering should be applied before conducting the surgical scrub.

 

PTS:   1                    DIF:    Apply            REF:   Personal Protective Equipment

 

  1. A client with a suspected degenerative brain disease is having surgery to place an intracerebral shunt. Which of the following should be done with the instruments after this surgical procedure?
1. Sterilize with high-pressure steam.
2. Sterilize with the special treatment to eliminate prions.
3. Wash with bacteriostatic solution and submerge in an appropriate chemical bath.
4. Rinse with disinfectant and place in a gas sterilizer.

 

 

ANS:  2

Prion diseases are rare, but they can survive some sterilization processes, and chemical disinfectants are not strong enough to eliminate them. These instruments will need to be sterilized with a special treatment to eliminate the prions. High-pressure steam, bacteriostatic solutions, chemicals, disinfectants, and gas sterilizers are not known sterilization methods to eliminate prions.

 

PTS:   1                    DIF:    Apply            REF:   Personal Protective Equipment

 

  1. A client received general anesthesia for a surgical procedure. Which of the following assessments will the nurse complete first for this client?
1. Surgical dressing
2. Intravenous sites
3. Airway
4. Pain

 

 

ANS:  3

Clients often require assistance in maintaining a patent airway after use of general anesthesia. The first assessment the nurse should make is that of the client’s airway. The surgical dressing, intravenous sites, and pain can be assessed after the client’s airway has been established.

 

PTS:   1                    DIF:    Apply            REF:   Box 21-7 Types of Anesthesia

 

  1. The student nurse observing a surgical procedure begins to feel lightheaded and nauseated. Which of the following should the student do at this time?
1. Tell someone she does not feel well.
2. Leave the operating room immediately.
3. Nothing since this feeling will pass.
4. Immediately sit down on the floor.

 

 

ANS:  2

If feelings of lightheadedness or nausea occur during an observation of a surgical procedure, the first thing to do is head for the door or at least to a wall away from the surgical field. The student should not tell someone that she is not feeling well. The student should not ignore these feelings since they are signs of fainting. The student should not immediately sit on the floor since this could be in the area of the sterile field and could compromise the surgical procedure.

 

PTS:   1                    DIF:    Apply

REF:   Box 21-2 Tips for the Student When Observing in Operating Room

 

  1. A nurse is filling the role of circulator during a surgical procedure. Which of the following will this nurse do to provide care to the client during the case?
1. Maintain the sterile field.
2. Assist the surgeon.
3. Serve as the client advocate.
4. Assist with the administration of anesthesia.

 

 

ANS:  3

The circulating nurse serves as the client advocate while the client is least able to care for himself. Maintaining the sterile field is a responsibility of the scrub nurse. Assisting the surgeon is an activity of the registered nurse first assistant. Assisting with the administration of anesthesia is an activity of the nurse anesthetist.

 

PTS:   1                    DIF:    Apply            REF:   Circulator/Circulating Nurse

 

  1. An elderly client is scheduled for a surgical procedure. The nurse realizes that the outcome of the client’s operation will depend upon the client’s:
1. age.
2. severity of illnesses.
3. nutritional status.
4. activity status.

 

 

ANS:  2

Severity of illness is a much better predictor of outcome of surgery when compared to age. Nutritional status and activity status would be characteristics that are associated with severity of illness.

 

PTS:   1                    DIF:    Analyze         REF:   Geriatric Considerations

 

  1. During a surgical procedure, the client’s body temperature spikes to a dangerous level. Which of the following will be done to help this client?
1. Reduce the flow of the anesthetic agent.
2. Provide 50% oxygen.
3. Stop the surgery for cardiac dysrhythmias.
4. Administer a Dantrolene infusion.

 

 

ANS:  4

Malignant hyperthermia is a medical emergency. The anesthetic agent should be stopped immediately and the client should be hyperventilated with 100% oxygen. The surgery should be stopped if it is an elective case. Dantrolene should be provided.

 

PTS:   1                    DIF:    Apply            REF:   Malignant Hyperthermia

 

MULTIPLE RESPONSE

 

  1. A perioperative nurse is identified as being the scrub nurse for a surgical procedure. Which of the following is this nurse’s responsibilities during the surgery? (Select all that apply.)
1. Don surgical attire and personal protective equipment.
2. Maintain the sterile field.
3. Pass instruments and supplies to the surgeon.
4. Prepare medication.
5. Remove used instruments.
6. Organize the sterile field for use.

 

 

ANS:  2, 3, 4

Responsibilities of the scrub nurse during a surgical procedure include maintaining the sterile field, passing instruments and supplies to the surgeon, and preparing medication. Donning surgical attire and organizing the sterile field are responsibilities done before the surgery begins. Removing used instruments are done after the surgery has concluded.

 

PTS:   1                    DIF:    Apply            REF:   Box 21-3 Duties of the Scrub Nurse

 

  1. The perioperative nurse is identifying nursing diagnoses appropriate for a client currently having surgery. Which of the following would be appropriate for the client at this time?
1. Risk for infection
2. Risk for impaired skin integrity
3. Risk for injury
4. Risk for inadequate nutrition
5. Risk for hypothermia
6. Risk for fluid volume overload

 

 

ANS:  1, 2, 3, 5

Nursing diagnoses for the perioperative client include risk for infection, risk for impaired skin integrity, risk of injury, and risk of hypothermia. Risk for inadequate nutrition and risk for fluid volume overload would be more appropriate during the postoperative period of client care.

 

PTS:   1                    DIF:    Analyze         REF:   NANDA and the Nursing Process

 

  1. Which of the strategies can a perioperative nurse use to make a child feel less anxious prior to a surgical procedure? (Select all that apply.)
1. Take the client on a tour of the operating room.
2. Allow the client to bring a toy or stuffed animal.
3. Allow the parents to stay with the child as much as possible.
4. Have the chaplain say a prayer with the child.
5. Use age-appropriate explanations.
6. Respond to questions in a straightforward manner.

 

 

ANS:  1, 2, 3, 5, 6

Strategies to help a preoperative pediatric client feel less anxious prior to a surgical procedure include taking the client on a tour of the operating room, allowing the client to bring a toy or stuffed animal, allowing the parents to stay with the client as much as possible, using age-appropriate explanations, and responding to questions in a straightforward manner. Having a chaplain say a prayer with the child is good, but it may not be age appropriate.

 

PTS:   1                    DIF:    Apply            REF:   Pediatric Considerations

 

  1. The circulating nurse is performing a “time out” prior to the beginning of a surgical procedure. Which of the following will be assessed during this time out? (Select all that apply.)
1. Correct client
2. Correct procedure
3. Correct site and side
4. Correct surgeon
5. Correct day
6. Correct time

 

 

ANS:  1, 2, 3, 4

A correctly performed time out includes verifying the right client; the correct procedure; the correct site and side; the correct surgeon; the correct position; the correct equipment, instruments, and implants if necessary. The correct day and time are not parts of the surgical ‘time out.”

 

PTS:   1                    DIF:    Apply            REF:   Time Out

 

  1. The nurse determines that a client is experiencing a risk associated with the use of anesthesia for a surgical procedure. Which of the following are considered risks of anesthesia? (Select all that apply.)
1. Nausea and vomiting
2. Sore throat
3. Seizure
4. Postoperative myocardial infarction
5. Surgical wound infection
6. Hypothermia

 

 

ANS:  1, 2, 3, 4, 6

Risks of anesthesia include adverse reaction to the anesthetic, nausea and vomiting, sore throat, seizure, myocardial infarction, hypothermia, malignant hyperthermia, numbness or loss of function of a body part, and disseminated intravascular coagulation. Surgical wound infection is not a risk associated with anesthesia.

 

PTS:   1                    DIF:    Analyze         REF:   Red Flag: Risks of Anesthesia