Understanding Medical Surgical Nursing 5th Edition by Linda S. Williams , Paula D. Hopper – Test Bank

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INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

Understanding Medical Surgical Nursing 5th Edition by Linda S. Williams , Paula D. Hopper – Test Bank

 

Sample  Questions

 

 

Chapter 3. Issues in Nursing Practice

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   After working a 12-hour shift, the nurse is asked to work part of the next shift due to short staffing. Which obligation to work should the nurse use to guide the response to this request?

a. Justice
b. Welfare
c. Moral
d. Legal

 

 

____    2.   The family of a patient who has been diagnosed with cancer does not want the patient to be told about the diagnosis. The patient asks the nurse, “Do I have cancer?” Which ethical principles should the nurse consider when resolving this situation?

a. Autonomy and veracity
b. Beneficence and justice
c. Welfare rights and moral obligations
d. Nonmaleficence and legal obligations

 

 

____    3.   A patient tells the nurse that the Patient’s Bill of Rights gives patients the legal right to read their medical information. Which of these responses would be appropriate for the nurse to make?

a. “I’ll ask your physician if you can read the record.”
b. ”Are you concerned about the care you are receiving?”
c. ”I’ll stay here with you while you read it in case you have any questions.”
d. ”Let me check with the charge nurse first.”

 

 

____    4.   The nurse assigned to care for a patient who has HIV accepts the patient assignment despite believing that the patient’s condition is a punishment from God. With which ethical principle is this nurse’s behavior associated?

a. Justice
b. Veracity
c. Beneficence
d. Nonmaleficence

 

 

____    5.   While planning patient care, the nurse considers what needs to be done to limit any liability. Which action should the nurse take to minimize liability when providing patient care?

a. Ensure patients’ rights.
b. Follow verbal orders.
c. Follow directions exactly as given.
d. Verify employer’s liability insurance.

 

 

____    6.   A patient is identified to participate in a new drug study, but does not understand the drug or the study. Which ethical principle should the nurse use to prevent the patient from participating in the study?

a. Veracity
b. Autonomy
c. Nonmaleficence
d. Standard of Best Interest

 

 

____    7.   The nurse educator is preparing a seminar that focuses on the impact of technology on patient care. Which effect of technology on ethical decision making should the educator include in this seminar?

a. Ethical situations remain similar to what they have always been in health care.
b. Nurses have fewer ethical decisions, because computers now make many decisions.
c. Ethical dilemmas have become more complex owing to technologies that prolong life.
d. Nurses can postpone ethical decisions, because technology allows patients to live longer.

 

 

____    8.   The nurse is concerned about a patient’s ability to make decisions about a proposed treatment plan. Which patient characteristic is causing the nurse to have this concern?

a. Lower socioeconomic status
b. Authoritarian family relationship
c. Past experience with hospitalization
d. Lack of information about treatment

 

 

____    9.   A patient has a living will and gives it to the nurse to follow. The patient says, “Do not tell my family about the living will.” Which action should the nurse take?

a. Send a copy of the living will to medical records.
b. Assure the patient that the nurse will not tell anyone.
c. Encourage the patient to discuss the living will with the family.
d. Return the living will to the patient until the family is informed.

 

 

____  10.   The nurse is caring for an 80-year-old patient. Which statement made by the nurse conveys dignity and respect to the patient?

a. “Honey, I have your medications.”
b. “I have your medications for you, dear.”
c. “I have your medications for you.”
d. “It’s time for us to take our medications.”

 

 

____  11.   The charge nurse is concerned that an HCP is breaching a patient’s confidentiality. What did the charge nurse observe to come to this conclusion?

a. A physician asking a nurse if a friend has cancer
b. Use of patient initials on nurse’s assignment worksheet
c. A nurse asking an unknown physician for identification
d. A nurse reviewing charts of assigned patients for orders

 

 

____  12.   The nurse is reviewing information on the state board of nursing website prior to renewing a state license. Which type of law is guiding this nurse’s actions?

a. Tort
b. Civil
c. Moral
d. Administrative

 

 

____  13.   While providing wound care, the nurse skips a step and does not cleanse the wound before applying a new sterile dressing. What action did this nurse make?

a. Crime
b. Summons
c. Malpractice
d. Respondeat superior

 

 

____  14.   The nurse is served with a summons relating to the care of a patient. Which action should the nurse take first?

a. Notify employer immediately.
b. Answer summons after 30 days.
c. Acknowledge liability promptly.
d. Seek legal counsel after 30 days.

 

 

____  15.   The nurse is concerned that a nursing assistant is violating a patient’s rights. What action did the nursing assistant make to cause the nurse to come to this conclusion?

a. Telling the patient to bathe right now
b. Identifying name and title to the patient
c. Knocking before entering the patient’s room
d. Asking the patient which beverage is preferred

 

 

____  16.   The nurse is deciding whether or not to obtain personal liability insurance, even though the organization has insurance for each employee. What must the nurse do to ensure the organization’s liability insurance provides adequate coverage against liability?

a. Follow institutional policies.
b. Have premiums payroll-deducted.
c. Understand the state’s tort laws.
d. Provide professional nursing care.

 

 

____  17.   The nurse is concerned about a patient filing a civil liability suit. What should the nurse expect to occur if a civil liability suit is planned?

a. Receive a summons
b. Receive a copy of the complaint
c. Respondeat superior determination
d. Receive a notice that a complaint was filed with a court

 

 

____  18.   A patient decides to not to have a hysterectomy, even though it is recommended by the physician. The nurse disagrees and says that it should be done, because the patient has already had children; the nurse leaves to get the consent form for the surgery. Which ethical principle is the nurse demonstrating with this patient?

a. Autonomy
b. Paternalism
c. Beneficence
d. Nonmaleficence

 

 

____  19.   During a patient care conference, the HCPs are reviewing potential outcomes based on individual interventions. Which bioethical theory is being demonstrated during this care conference?

a. Religion
b. Deontology
c. Theological
d. Utilitarianism

 

 

____  20.   The ethical decision-making process is being used for a patient regarding the use of life support measures. What action should the nurse take as the final step in this decision-making process?

a. Evaluate the outcomes.
b. Implement the decision.
c. Clarify the values of all the participants.
d. Determine which action has the strongest ethical support.

 

 

____  21.   The nurse educator is preparing an in-service program to review laws applicable for patient care. Which law should the educator include that was established to protect a patient’s medical and personal information?

a. Medicare
b. Patients’ Bill of Rights
c. Department of Health and Human Services regulations
d. Health Insurance Portability and Accountability Act (HIPAA)

 

 

____  22.   While standing in the lunchroom, the nurse recognizes friends of a patient who was recently transferred to critical care. The nurse approaches them and offers to take them to the patient’s care area. What action is this nurse demonstrating?

a. Defamation
b. Compassion
c. False Imprisonment
d. Disclosure of Confidential Information

 

 

____  23.   Before leaving a patient’s room, the nurse says that pain medication will be provided within 15 minutes. The nurse returns in 10 minutes with the pain medication. Which ethical principle did the nurse demonstrate?

a. Justice
b. Fidelity
c. Veracity
d. Beneficence

 

 

____  24.   The nurse manager actively listens to the nursing staff and encourages the staff to be accountable for all patient care. Which leadership style is this manager demonstrating?

a. Coaching
b. Utilitarian
c. Autonomy
d. Democratic

 

 

____  25.   The nursing staff is meeting to discuss a patient’s desire for all life support measures, even though the patient has end-stage renal disease. Once a list of all possible actions is generated, what should the staff do next?

a. List the stakeholders.
b. Determine the best action.
c. Gather important information.
d. Identify positive and negative consequences.

 

 

____  26.   A patient with malnutrition refuses to ingest animal protein products, because it is against religious teachings. What should the nurse do to support this patient’s beliefs while ensuring the patient’s health status?

a. Explain the animal protein is the best source of nutrition for the patient’s needs at this time.
b. Talk with a dietitian about sources of non-animal–based protein to include in the patient’s diet.
c. Suggest to the physician that the patient is going against medical advice and should be discharged.
d. Schedule the organization’s clergy to meet with the patient to discuss interpretation of religious teachings.

 

 

____  27.   The nurse is informed of several victims of gang violence being brought by ambulance to the emergency department. Which injury should the nurse prepare to report to the authorities?

a. Fractures
b. Abrasions
c. Lacerations
d. Gunshot wounds

 

 

____  28.   A health care administrator is reviewing material submitted to the legislature on tort reform. What should the administrator explain to nurse leaders about this legislation?

a. Limits organizational liability for damages
b. Requires continuing education for all caregivers
c. Expects all staff to have read organizational policies before completing procedures
d. Expects all staff to have malpractice or liability insurance

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  29.   The nurse is performing a procedure while caring for a patient and unintentionally eliminates a step in the procedure. What may result from the nurse’s action? (Select all that apply.)

a. Negligence
b. Breach of duty
c. Unintentional tort
d. Assault and battery
e. Civil liability for employer

 

 

____  30.   The nurse is preparing to delegate a task to unlicensed assistive personnel (UAP). Which actions should the nurse take in compliance with The National Council of State Boards of Nursing’s (NCSBN) rights of delegation? (Select all that apply.)

a. Right day
b. Right place
c. Right person
d. Right supervision
e. Right circumstances
f. Right communication

 

 

____  31.   A nurse is working on a medical unit in a hospital undergoing a Joint Commission review. The investigator asks the nurse to explain “never events.” What examples should the nurse use to explain these kinds of events? (Select all that apply.)

a. Surgery on the wrong body part
b. Paralyzed leg after falling from a bed
c. Death from falling out of bed
d. Having to restart an intravenous (IV) infusion
e. Canceling surgery because blood work is not safe

 

 

____  32.   The LPN is working in a senior center and is approached by a participant who asks the nurse, “Can you help me understand my Medicare benefits?” What should the nurse include in a response to this patient? (Select all that apply.)

a. Medicare is a payment system for the working poor.
b. Medicare Part B covers outpatient services and has a monthly cost.
c. Medicare is a federally funded program for individuals 65 and over.
d. Prescription drug coverage for those with Medicare is available.
e. Medicare Part A covers inpatient hospital care and is free to those who qualify for Social Security.

 

 

____  33.   The nurse is planning to prepare medications for assigned patients. Which actions should the nurse take to ensure a safe environment while preparing the medications? (Select all that apply.)

a. Find a laboratory value for a physician as requested.
b. Place a “no interruption sign” on the door of the medication room.
c. Answer a patient’s call-light after checking the medication administration record.
d. Listen to information provided by the charge nurse about a newly admitted patient.
e. Ask coworkers to provide you with time to concentrate while preparing medication.

Chapter 5. Complementary and Alternative Modalities

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   A patient is receiving acupuncture therapy in addition to analgesics for chronic pain. How should the nurse document the use of acupuncture for pain control?

a. Alternative therapy
b. Mainstream therapy
c. Complementary therapy
d. Unconventional therapy

 

 

____    2.   The nurse is using a mind-body approach to help a patient reduce the pain during labor and delivery. Which type of therapy is the nurse using?

a. Massage
b. Muscle relaxant
c. Guided imagery
d. Non-narcotic pain reliever

 

 

____    3.   During an assessment, the nurse learns that a patient only uses traditional medicine approaches to treat illnesses or diseases. How should the nurse document the health care approach that the patient uses?

a. Ayurveda
b. Allopathy
c. Osteopathy
d. Chiropractic

 

 

____    4.   A patient tells the nurse that a chiropractor has been used to help with chronic neck and lower back pain. Which principle of chiropractic medicine should the nurse use to supplement this patient’s plan of care?

a. Maintain health by keeping the body and mind in balance with nature
b. Remove interference with nerve function, so the body can heal itself
c. Promote healing and prevent illness through the use of nutrition, botanical medicine, and hydrotherapy
d. Relieve symptoms by administering tiny doses of substances that create symptoms of disease in a healthy person

 

 

____    5.   A patient scheduled for spinal surgery the following day lists ginkgo and ginger on a home medication assessment. How should the nurse respond to this information?

a. “What dose of each herb do you take?”
b. “For what effects do you take the herbs?”
c. “How many times per day do you take each herb?”
d. “Have you told your surgeon that you take these herbs?”

 

 

____    6.   The nurse learns that a patient plans to try St. John’s wort for depression. How should the nurse respond to the patient about this herbal remedy?

a. “Some people believe it can be helpful for depression. Because it is an herb, it would be safe to try it.”
b. “Herbs are medicines. You should not try anything without first consulting your primary care provider.”
c. “Herbs can be dangerous. You should avoid taking them while you are on other medications, because interactions could occur.”
d. “St. John’s wort has been shown in research to be safe and effective for treating depression. Be sure to follow the package instructions.”

 

 

____    7.   A patient wants to try acupressure techniques in addition to conventional treatment for headaches and asks, “What is so good about Western medicine anyway?” Which response by the nurse is best?

a. “Western medicine uses natural remedies that are less likely to cause long-term side effects.”
b. “Western medicine is based on research, which means treatments are more likely to have consistent results.”
c. “Western medicine has fewer regulations and restrictions, so practitioners are able to choose the best treatments for you.”
d. “Western medicine is based primarily on nutrition and exercise therapies that are safer than potentially toxic medications.”

 

 

____    8.   A patient with advanced cancer decides to discontinue chemotherapy treatment and try an alternative therapy that has not been proven effective. The nurse, whose mother recently died of the same type of cancer, strongly disagrees with the patient’s choice. How should the nurse respond when the patient asks for an opinion about the alternative therapy?

a. “I’m sorry, but I don’t feel prepared to answer your question. I would prefer you ask your physician that question.”
b. “My mother died recently of the same type of cancer you have. I would be very careful before stopping the therapy.”
c. “Because your disease is so advanced and traditional treatments have failed, I think trying the alternative treatment can do no harm.”
d. “As a nurse, I am obligated to encourage you to seek the best treatment possible. I cannot in good conscience advise you to have the alternative treatment.”

 

 

____    9.   During an assessment, the nurse learns that a patient sees a practitioner who is balancing the patient’s qi and vital energy. Which type of medicine should the nurse document that the patient is using?

a. Ayurvedic medicine
b. Naturopathic medicine
c. American Indian medicine
d. Traditional Chinese medicine

 

 

____  10.   The staff development instructor is preparing a presentation on the different types of medicine being used by the patients cared for in the organization. Which definition should the instructor use to describe the allopathic system or philosophy of health care?

a. A system that holds that disease is a result of nerve dysfunction
b. A system that maintains that illness is the result of falling out of balance with nature
c. A method of treating disease with remedies that produce effects different from those caused by the disease
d. A system that uses tiny doses of a substance that create the symptoms of disease in a healthy person to relieve those symptoms in a sick person

 

 

____  11.   The nurse is assisting a patient to use guided imagery. Which health problem is the patient most likely experiencing?

a. Gallstones
b. Hypertension
c. Hyperthyroidism
d. Diabetes mellitus

 

 

____  12.   The nurse is identifying research-based interventions when planning a patient’s care. Which type of health care is the nurse planning to provide to the patient?

a. Allopathy
b. Osteopathy
c. Naturopathy
d. Homeopathy

 

 

____  13.   A patient is prescribed antiplatelet therapy to treat a health problem. Which herbal preparation should the nurse instruct the patient to avoid while taking the prescribed antiplatelet medication?

a. Garlic
b. Gingko
c. Ginseng
d. Vitamin C

 

 

____  14.   During a health history, the nurse learns that a patient follows a specific diet, detoxification program, exercise, and breathing patterns recommended by a natural health practitioner. In which type of medical therapy should the nurse realize the patient is participating?

a. Chinese
b. Ayurveda
c. Chiropractic
d. Homeopathy

 

 

____  15.   The nurse educator is preparing a seminar on alternative and complementary therapies for the nursing staff. Which therapy should the nurse explain as having principles that support wellness and health promotion applicable to all patients?

a. Chinese
b. Osteopathic
c. Chiropractic
d. American Indian

 

 

____  16.   The nurse is reviewing a patient’s medication history and becomes concerned about the use of an herbal preparation. Which medication-herb interaction should the nurse discuss with the primary care provider?

a. Garlic and CO Q 10
b. St. John’s wort and digoxin (Lanoxin)
c. Vitamin C and ampicillin (Amoxicillin)
d. Chamomile and hydrochlorothiazide (HCTZ)

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   The nurse is caring for a patient experiencing poor appetite, nausea, and vomiting from chemotherapy. Which herbs should the nurse suggest the patient use to help with these symptoms? (Select all that apply.)

a. Kava
b. Ginger
c. Ginkgo
d. Feverfew
e. Echinacea

 

 

____  18.   The nurse is caring for a patient who is of American Indian descent. Which rituals and practices should the nurse assess as being used by this patient? (Select all that apply.)

a. Acupuncture
b. The sweat lodge
c. Herbal remedies
d. Spinal manipulation
e. The medicine wheel

 

 

____  19.   A patient with arthritis asks the nurse what can be used to reduce pain and inflammation without having to take prescribed medication. What should the nurse recommend to the patient? (Select all that apply.)

a. Aloe vera
b. Capsaicin
c. Chamomile
d. Aquatherapy
e. Biofeedback

 

 

____  20.   The health care provider suggests a patient with fibromyalgia engage in mind-body therapy. Which therapies should the nurse review with the patient? (Select all that apply.)

a. Reiki
b. Art therapy
c. Music therapy
d. Guided imagery
e. Meditation and relaxation

 

 

____  21.   A patient is concerned about the frequency of colds during the past winter season. What herbs should the nurse discuss as having the potential to lessen the symptoms of colds and other viral infections? (Select all that apply.)

a. Feverfew
b. Echinacea
c. Bee pollen
d. Chamomile
e. St. John’s wort

 

 

____  22.   The nurse is considering instructing a patient with chronic pain on an energetic therapy approach. Which therapies should the nurse include in this teaching? (Select all that apply.)

a. Reiki
b. Biofeedback
c. Magnet therapy
d. Guided imagery
e. Therapeutic touch

 

 

____  23.   A patient is considering the use of alternative therapy to treat lumbar stenosis. What should the nurse recommend that the patient complete before beginning this type of therapy? (Select all that apply.)

a. Find out the costs of the therapy.
b. Talk about the therapy with the primary care practitioner.
c. Look at the conditions of the alternative practitioner’s practice setting.
d. Check the background and qualifications of the alternative practitioner.
e. Call the Centers for Disease Control and Prevention (CDC) for additional information.

 

 

____  24.   The nurse reviews a list of patients scheduled for appointments in a cancer clinic and notes the types of treatments each patient is using. Which patients are using complementary therapy? (Select all that apply.)

a. A 74-year-old with leukemia uses self-hypnosis prior to a bone marrow biopsy.
b. A 17-year-old with sarcoma practices relaxation and imagery during radiation therapy.
c. A 66-year-old with lymphoma uses headphones to listen to music during chemotherapy.
d. A 41-year-old with breast cancer chooses to have radiation therapy instead of a mastectomy.
e. A 52-year-old with colon cancer stops chemotherapy and goes to Mexico for shark cartilage therapy.

 

 

____  25.   The nurse is identifying ways to help a patient with chronic pain release the natural production of endorphins. On which strategies should the nurse focus to help the patient achieve this physiological response? (Select all that apply.)

a. Use of electrical nerve stimulation devices
b. Health food stores that sell quality probiotics
c. Types of physical exercise the patient likes to perform
d. Suggestions to use when engaging in guided imagery
e. Locations of qualified acupuncturists in the patient’s neighborhood

 

 

____  26.   A patient is scheduled to see an acupuncturist as complementary treatment for back pain. What should the nurse instruct the patient to expect when seeing the acupuncturist for the first time? (Select all that apply.)

a. The patient’s tongue will be examined.
b. The patient’s pallor will be assessed.
c. The patient’s voice and scent will be assessed.
d. The patient’s blood pressure will be measured.
e. The patient’s peripheral pulse will be checked.

 

 

____  27.   The community health nurse learns that a naturopathic doctor is opening a practice in the neighborhood strip mall. What should the nurse do to ensure the safety of the community members? (Select all that apply.)

a. Find out the state in which the doctor is licensed.
b. Make an appointment to be evaluated for health problems.
c. Petition city hall to prevent the doctor from opening the practice.
d. Ask what types of needles are being used for acupuncture treatments.
e. Find out the school of naturopathic medicine that the person attended.

Chapter 7. Nursing Care of Patients Receiving Intravenous Therapy

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The health care provider is planning to discontinue total parenteral nutrition for a patient who has been receiving it for 3 weeks after an episode of severe gastrointestinal (GI) bleeding. What patient care order should the nurse anticipate?

a. Place the patient on clear liquids for 1 week.
b. Start tube feedings tid via nasogastric tube.
c. Sodium-restricted diet with high-protein snacks bid.
d. Taper PN rate and introduce regular feedings slowly.

 

 

____    2.   The nurse is preparing to insert an intravenous (IV) catheter in a newly admitted patient. Which area should the nurse use first for this catheter?

a. Hand
b. Forearm
c. Upper arm
d. Antecubital space

 

 

____    3.   The IV infusion pump for a patient receiving an IV therapy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first?

a. Notify the physician.
b. Check for kinking of the tubing or a closed clamp.
c. Decrease the rate to 10 mL/hr, and flush the line with 1 mL of heparin solution.
d. Turn off the IV solution, and gently flush the line with 3 mL of saline flush solution.

 

 

____    4.   Assessment of blood glucose levels is prescribed every 6 hours for a patient who is receiving parenteral nutrition (PN). The patient asks why this is necessary. Which response by the nurse is most appropriate?

a. “We have to monitor your glucose because the physician prescribed it.”
b. “When people receive PN, they develop mild diabetes, which needs to be well regulated.”
c. “PN contains a lot of sugar. We monitor blood glucose to be sure it doesn’t get too high.”
d. “There is a lot of sugar in the solution, which can increase the risk for rebound hypoglycemia.”

 

 

____    5.   The nurse notes that a patient’s central venous access device (CVAD) infusion site gauze dressing is saturated with blood. What should the nurse do?

a. Change the dressing.
b. Reinforce the dressing with a gauze pad.
c. Notify the physician to change the dressing.
d. Apply a transparent dressing over the gauze.

 

 

____    6.   An angiocatheter site in a patient’s left forearm has become red and tender. What should the nurse do first?

a. Check for a blood return.
b. Remove the angiocatheter.
c. Apply a warm compress over the insertion site.
d. Run the IV solution at a slightly faster rate to encourage sluggish circulation.

 

 

____    7.   As soon as the nurse begins to insert an IV catheter in the patient’s antecubital space, a hematoma forms at the site. What should the nurse do first?

a. Remove the catheter and call for help.
b. Remove the catheter and apply pressure to the site.
c. Remove the catheter and insert a new one in the same site.
d. Finish threading the catheter quickly and apply a pressure dressing and tape.

 

 

____    8.   The nurse is preparing heparin to use as a flush for a patient’s IV infusion site. For which type of site is the nurse providing care?

a. Peripheral access device
b. Intermittent access device
c. CVAD
d. Intermittent piggyback device

 

 

____    9.   A patient in an outpatient oncology clinic is going to have a peripherally inserted central catheter (PICC) line placed and wants to know what that means. What is the best response by the nurse?

a. “A PICC line is a percutaneous IV core catheter.”
b. “A PICC line is just a regular IV, but an extra-small catheter is used to prevent vein irritation.”
c. “A PICC line is a catheter that is inserted into your jugular vein and ends in the central circulation.”
d. “A PICC line is an IV device that is inserted into your arm and ends in the circulation near your heart.”

 

 

____  10.   An IV infusion is not running. The insertion site looks normal. Which action should the nurse take to try to get it to run again?

a. Reposition the extremity.
b. Place gentle pressure on the bag of solution.
c. Flush the catheter with 1 to 2 mL of heparin flush solution.
d. Flush the catheter with 1 to 2 mL of normal saline solution.

 

 

____  11.   A patient is in the intensive care unit with acute renal failure secondary to septic shock and is receiving IV fluids of 0.9% NaCl at 125 mL/hr. The patient develops crackles in the lungs, distended neck veins, 1+ pitting edema in the feet, and a 4-pound weight gain from the previous day. What nursing diagnosis is most appropriate for this situation?

a. Excess fluid volume
b. Decreased cardiac output
c. Ineffective tissue perfusion: peripheral
d. Imbalanced nutrition: greater than body requirements

 

 

____  12.   An IV insertion site begins to leak, and the tape over the site is wet. What should the nurse do first?

a. Reduce the IV flow rate.
b. Call the physician to report the problem.
c. Remove the dressing from the IV site, and observe the insertion site.
d. Slowly increase the speed of the IV drip, and watch the site carefully for increased leaking of IV solution.

 

 

____  13.   The nurse needs to dilate a patient’s vein prior to inserting an IV catheter. Which technique should the nurse use to dilate the patient’s vein?

a. Elevate the extremity for 5 minutes.
b. Apply an alcohol swab for 60 seconds.
c. Apply a cool compress for 15 minutes.
d. Apply a tourniquet for up to 3 minutes.

 

 

____  14.   Upon entering a patient’s room, the licensed practical nurse (LPN) notes a white precipitate forming in the IV tubing at the site of a piggybacked antibiotic. What should the nurse do first?

a. Stop the infusion.
b. Notify the physician.
c. Call the pharmacy to see whether this is an expected reaction.
d. When the infusion is complete, remove the tubing, and send it to the laboratory for analysis.

 

 

____  15.   A patient’s IV fluids are infusing too quickly despite adjustments made to the flow rate. Which approach should the nurse consider to slow the flow rate of a gravity solution?

a. Opening the roller clamp
b. Flushing the cannula with saline solution
c. Raising the level of the solution container
d. Flexing the extremity above the insertion site

 

 

____  16.   A patient is prescribed an IV infusion of a hypertonic solution. Which fluid shift should the nurse expect to occur with this type of infusion?

a. Fluid moves from the plasma into the cells.
b. Fluid moves from the venous circulation into the interstitial space.
c. Fluid moves from the interstitial space into the venous circulation.
d. Fluid moves from the arterial circulation into the venous circulation.

 

 

____  17.   The nurse suspects a patient receiving IV therapy is experiencing fluid overload. Which assessment should the nurse perform first?

a. Check the patient’s weight.
b. Assess lung sounds for crackles.
c. Observe the patient’s feet for edema.
d. Inspect the insertion site for infiltration.

 

 

____  18.   A patient is prescribed IV fluid to replace electrolytes and expand plasma volume. Which type of fluid will the nurse provide to the patient?

a. Isotonic solution
b. Dextrose solution
c. Hypotonic solution
d. Hypertonic solution

 

 

____  19.   When assessing a patient with an IV line in the right arm, the LPN notices that the skin near the infusion site is taut and cool, and when the arm is lowered, it appears to swell. What should the nurse consider is occurring with this patient’s IV access site?

a. Infection
b. Embolism
c. Infiltration
d. Venous spasm

 

 

____  20.   At a monthly staff meeting, the nurse manager announces that all central line insertion and dressing kits will now come bundled with 2% chlorhexidine gluconate for site preparation and cleansing. Which evidence best supports this decision?

a. The use of 2% chlorhexidine gluconate reduces hospital costs by 7%.
b. Chlorhexidine gluconate (CHG) is the preferred prep solution of choice based on scientific evidence.
c. The company that supplies IV and central line catheter equipment has recently changed the product bundling to include 2% chlorhexidine gluconate.
d. The chief of surgery is interested in performing a direct comparison study examining infection rates associated with long-term access devices as they are related to length of time the catheters are in place.

 

 

____  21.   The nurse is preparing to flush a patient’s intermittent IV catheter. Why is the nurse flushing this catheter?

a. To open an occluded catheter
b. To provide electrolyte replacement
c. To prevent the formation of emboli
d. To ensure the patency of the catheter

 

 

____  22.   The nurse is preparing to administer a bolus IV medication through a patient’s saline lock. Which action should the nurse take immediately before providing the patient with this medication?

a. Calculate the drip rate.
b. Prepare the saline flush.
c. Cleanse the hub for 15 seconds.
d. Check the order for the medication.

 

 

____  23.   A patient is prescribed to receive two units of packed red blood cells. When preparing for this patient’s infusion of blood, which type of IV solution should the licensed practical nurse/licensed vocational nurse LPN/LVN select?

a. 0.9% Normal Saline
b. 0.45% Normal Saline
c. Dextrose 5% and water
d. Dextrose 5% and 0.9% Normal Saline

 

 

____  24.   A patient is prescribed to receive a continuous infusion of IV fluids. When preparing to place the catheter, the nurse notes that the client has a dialysis fistula in the right arm and had a left breast mastectomy three years prior. What should the nurse do?

a. Place the catheter in the left hand.
b. Place the catheter in the right foot.
c. Place the catheter in the right hand.
d. Ask the physician where to place the catheter.

 

 

____  25.   After preparing the skin for IV catheter placement, the nurse decides that the vein needs to be palpated before introducing the catheter. How should the nurse perform this action?

a. Palpate the vein with the clean gloved hand.
b. Palpate the vein and then cleanse the skin again.
c. Apply sterile gloves before palpating the cleansed skin site.
d. Apply skin cleanser to the gloved fingertip before palpating the vein.

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  26.   The nurse analyzes the fluid volume status of assigned patients. Which patients are most likely to need continuous IV therapy? (Select all that apply.)

a. A 45-year-old woman with a broken humerus
b. A patient with pitting edema and lung crackles
c. A 16-year-old girl with anorexia who has been repeatedly purging
d. A 3-year-old who has had frequent diarrhea and vomiting for 3 days
e. An 85-year-old man with Alzheimer’s disease who refuses to eat or drink

 

 

____  27.   The nurse is concerned that a patient is developing complications from peripheral IV therapy. For which systemic complication should the nurse assess the patient? (Select all that apply.)

a. Phlebitis
b. Infiltration
c. Septicemia
d. Air embolism
e. Extravasation
f. Fluid overload

 

 

____  28.   The nurse is preparing to start a peripheral IV infusion. Which technique should the nurse use to help ensure success with the venipuncture? (Select all that apply.)

a. Use a tourniquet to dilate the vein.
b. Elevate the extremity to promote venous return.
c. Apply a warm compress prior to site preparation.
d. Lower the head of the bed to reduce cardiac output.
e. Encourage the patient to open the hand and lay it flat on the bed.
f. Push the skin toward the intended puncture site to prevent rolling.

 

 

____  29.   The nurse is planning to insert an IV catheter into a patient with severe upper extremity edema. Which actions should the nurse take to ensure the catheter is placed appropriately? (Select all that apply.)

a. Select a catheter that is 2 inches in length.
b. Use alcohol to cleanse the site before insertion.
c. Bring three tourniquets to the patient’s bedside.
d. Displace edema to visualize the patient’s veins.
e. Apply sterile gloves before beginning the procedure.

 

 

Completion

Complete each statement.

 

  1. A patient is prescribed an IV antibiotic medication that is 100 mg in 50 mL D5W to be infused over 20 minutes. The infusion set delivers 15 gtt per mL. How many drops of medication per minute should the infusion set deliver to the patient?

 

31.       A patient is to receive an IV liter of normal saline over 6 hours. To deliver the fluid, how many mL per hour should the nurse set the pump

Chapter 9. Nursing Care of Patients in Shock

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   A patient with gastrointestinal bleeding is awake, alert, and oriented and has vital sign measurements of: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature 98.6°F (37°C). Which finding should the nurse consider as a possible sign of early shock?

a. Respirations 18/min
b. Heart rate 118 beats/min
c. Temperature 98.6°F (37°C)
d. Blood pressure 130/90 mm Hg

 

 

____    2.   A patient with gastrointestinal bleeding has hemoglobin of 8.5 g/dL. While receiving care the patient becomes anxious and irritable and bright red drainage appears through the nasogastric tube. The patient’s vital sign measurements are pulse 130 beats/minute, blood pressure 105/55 mm Hg, and respirations 28/minute. What should the nurse recognize as causing the changes in the patient’s vital signs?

a. Early shock
b. Patient anxiety
c. Progressive shock
d. Parasympathetic response

 

 

____    3.   A patient involved in a motor vehicle accident has pale mucous membranes, diaphoresis, confusion, blood pressure 88/48 mm Hg, irregular heart rhythm, and metabolic acidosis. Which finding should the nurse recognize as the likely cause of acidosis?

a. Hyperventilation
b. Aerobic metabolism
c. Inadequate ventilation
d. Anaerobic metabolism

 

 

____    4.   A patient with progressive shock is diaphoretic and confused. The most recent blood pressure measurement was 82/40 mm Hg and a urinary catheter output was 10 mL for 1 hour. Intravenous (IV) fluids are infusing at 150 mL/hr. Which action should the nurse take related to the urine output?

a. Encourage oral fluids.
b. Irrigate urinary catheter.
c. Increase IV fluid infusion rate.
d. Check urinary catheter for kinking.

 

 

____    5.   A patient with hypovolemic shock is experiencing oliguria due to hemorrhage. Which should the nurse recognize as the most likely cause of the patient’s oliguria?

a. End-stage renal failure
b. Secretion of aldosterone
c. Inadequate oral fluid intake
d. Obstructed urinary catheter

 

 

____    6.   On arrival in the emergency department, a patient who was in a motor vehicle accident is apprehensive, confused, and hypotensive. The patient has tachycardia, oliguria, and cool clammy skin. What should the nurse do first?

a. Cover patient with warm blankets.
b. Perform a rapid head-to-toe assessment.
c. Obtain patient’s medical history from family.
d. Reorient the patient to person, place, and time.

 

 

____    7.   A patient who is hemorrhaging has pale mucous membranes, blood pressure 92/52 mm Hg, pulse 160 beats/minute, and respirations 30/minute. The patient is receiving IV fluids at 150 mL/hour, has a blood transfusion infusing, and is being provided oxygen via a mask. What should the nurse recognize as the most likely cause of the patient’s respiratory rate?

a. Electrolyte imbalances
b. Inadequate tissue perfusion
c. Rapid rate of fluid replacement
d. Reaction to the blood transfusion

 

 

____    8.   Despite aggressive treatment, the condition of a patient in shock continues to worsen. Surgical intervention stops the bleeding, and the shock stabilizes. Which finding should the nurse act upon immediately?

a. The blood pH is 7.36.
b. Bowel sounds are hypoactive.
c. Urinary output is 15 mL/hour.
d. Pupils are equally reactive to light.

 

 

____    9.   After an episode of shock, a patient’s laboratory results reveal elevated serum levels of ammonia and bilirubin and decreased plasma proteins and clotting factors. Which organ should the nurse recognize as being damaged from the shock?

a. Heart
b. Liver
c. Kidneys
d. Intestines

 

 

____  10.   After an episode of shock, a patient’s laboratory results reveal decreased clotting factors. Based on these laboratory results, the nurse should monitor for which complication of shock?

a. Brain attack
b. Multisystem organ failure
c. Adult respiratory distress syndrome
d. Disseminated intravascular coagulation

 

 

____  11.   The family of a patient in shock asks the nurse to explain the condition. How should the nurse respond to this family?

a. “It is caused by massive blood loss.”
b. “It is a profound circulatory collapse.”
c. “It is the result of overwhelming emotion.”
d. “There is inadequate oxygen delivered to the tissues.”

 

 

____  12.   A patient is demonstrating signs of anaphylactic shock. What action should the nurse take first?

a. Provide pain relief.
b. Ensure a patent airway.
c. Provide patient teaching.
d. Obtain a detailed patient history.

 

 

____  13.   The nurse provides comfort measures to maintain normal body temperature and reduce pain and anxiety for a patient who is experiencing shock. What is the purpose of the nurse performing these actions?

a. Increases fluid volume
b. Decreases fluid volume
c. Increases oxygen demand
d. Decreases oxygen demand

 

 

____  14.   The nurse is caring for a patient in mild shock. Which medication should the nurse question before providing if ordered for a patient experiencing shock?

a. Benadryl
b. Morphine
c. Dopamine
d. Solu-Medrol

 

 

____  15.   A patient is receiving a dopamine infusion for shock. What should the nurse expect to assess in the patient because of this medication?

a. Pain relief
b. Decreased heart rate
c. Increased blood pressure
d. Increased respiratory rate

 

 

____  16.   A patient is admitted with suspected septic shock. Which action should the nurse take first?

a. Obtain patient temperature.
b. Insert an IV access device.
c. Determine if the patient has any medication allergies.
d. Reassure the patient that everything possible will be done.

 

 

____  17.   A patient recovering from vascular leg surgery is found standing in a large pool of blood flowing from the surgical site. After assisted into bed, the patient is pale with a palpable pulse. What action should the nurse take?

a. Notify the charge nurse.
b. Start an infusion of 0.9% NaCl.
c. Apply oxygen at 2 L/min via nasal cannula.
d. Elevate legs and apply pressure over the bleeding site.

 

 

____  18.   A patient hemorrhaging from an incision has a blood pressure of 70/0 mm Hg. What type of fluid replacement should the nurse anticipate will be ordered initially?

a. 0.9 % normal saline
b. Fresh frozen plasma
c. Packed red blood cells
d. Lactated Ringer’s with 50 mL albumin

 

 

____  19.   A patient is experiencing respiratory distress and mild shock. In which position should the nurse place the patient?

a. Prone
b. Head elevated
c. Trendelenburg position
d. Flat with elevated foot of bed

 

 

____  20.   Data collection findings for a patient include shortness of breath with crackles in the lung bases, jugular vein distention, daily weight increased by 3 pounds from yesterday, report of chest pain, blood pressure 86/40 mm Hg, pulse 132 beats/minute, and respirations 30/minute. Which order should the nurse question?

a. Electrocardiogram (ECG) STAT
b. 500 mL 0.9% NS over 30 minutes
c. Oxygen 2 L/min via nasal cannula
d. Arterial blood gases (ABGs) STAT and repeat in 1 hour

 

 

____  21.   A patient with a history of a myocardial infarction has chest pain. The patient’s skin color is grayish, blood pressure is 88/70 mm Hg, pulse is 116 beats/minute and irregular, and respirations are 30/minute. Which action should the nurse take?

a. Place the patient supine.
b. Notify the charge nurse.
c. Check the urine specific gravity.
d. Infuse 0.9% normal saline wide open.

 

 

____  22.   The nurse discovers that a patient recovering from surgery is hemorrhaging from the incisional site. What action should the nurse take?

a. Offer oral fluids.
b. Warm the patient.
c. Relieve the patient’s apprehension.
d. Apply pressure to the bleeding site.

 

 

____  23.   A patient who had surgery 3 days ago has a temperature of 98°F (36.6°C), blood pressure 82/72 mm Hg, pulse 120 beats/minute, and respirations 30/minute. Which type of shock should the nurse suspect is occurring in this patient?

a. Septic
b. Neurogenic
c. Cardiogenic
d. Hypovolemic

 

 

____  24.   The nurse obtains vital signs on a patient with gastrointestinal bleeding who has a large, dark red, foul-smelling stool. Which vital sign changes should the nurse report as indicative of early shock?

a. Normal blood pressure, tachycardia, and rapid respirations
b. Rise in diastolic blood pressure, bradycardia, and slow respirations
c. Decreasing systolic blood pressure, bradycardia, and slow respirations
d. Drop in diastolic blood pressure, bradycardia, and shallow respirations

 

 

____  25.   The spouse of a patient in neurogenic shock asks what is happening to the patient. How should the nurse response to the spouse?

a. “This is because of an allergic reaction.”
b. “There is a drop in circulating blood volume.”
c. “The heart has failed to pump blood throughout the body.”
d. “The blood vessels have dilated and lowered the blood pressure.”

 

 

____  26.   Patients are being treated in the intensive care unit for anaphylactic, septic, and neurogenic shock. For which type of shock should the nurse plan to provide care?

a. Obstructive
b. Distributive
c. Cardiogenic
d. Hypovolemic

 

 

____  27.   A patient in shock is diagnosed with metabolic acidosis. What should the nurse realize as being the mechanism behind the development of this acid-base imbalance?

a. Excessive aerobic metabolism
b. Excessive anaerobic metabolism
c. Decreased anaerobic metabolism
d. Release of cortisol and glucagon

 

 

____  28.   The nurse is contributing to a staff education program about complications associated with urinary catheters. Which type of shock should the nurse recommend be included in the presentation?

a. Septic
b. Cardiogenic
c. Anaphylactic
d. Hypovolemic

 

 

____  29.   As part of ongoing data collection and care of a patient in shock, the nurse notes a slowing heart rate, systolic blood pressure less than 60 mm Hg, a decreasing temperature, decreasing respiration rate, and scant urine output. These signs and symptoms should indicate to the nurse that the patient is in which stage of shock?

a. Mild
b. Severe
c. Moderate
d. Compensated

 

 

____  30.   After collecting data, the nurse suspects that a patient is experiencing cardiogenic shock. Which finding supports this nurse’s suspicion?

a. Oliguria
b. Tachypnea
c. Bronchospasm
d. Pulmonary edema

 

 

____  31.   The nurse is assisting in the planning of care for a patient in shock. Which nursing diagnoses should the nurse recommend be included in the patient’s plan of care?

a. Hopelessness
b. Risk for aspiration
c. Excess fluid volume
d. Inadequate tissue perfusion

 

 

____  32.   The nurse is receiving report on patients assigned for the next shift. Which patient should the nurse observe first?

a. A patient who has a pressure ulcer who is due for a dressing change
b. A patient with diabetes who has a blood sugar of 85 and is eating lunch
c. A patient with cellulitis who is receiving the first dose of IV antibiotics and who is reporting a feeling of tightness in the throat
d. A patient with sickle cell anemia who is receiving a monthly transfusion of a unit of packed red blood cells who is reporting left knee pain

 

 

____  33.   A patient is admitted for care because of heat stroke. Why should the nurse include interventions to prevent the onset of shock?

a. The heat causes excessive dilation of veins and arteries.
b. Inability to tolerate oral fluids could lead to more water lost.
c. Parasympathetic stimulation causes blood to pool in the extremities.
d. Excessive water lost through sweating can lead to hypovolemic shock.

 

 

____  34.   The nurse is caring for an 85-year-old patient with septic shock. What should the nurse keep in mind when repositioning this patient?

a. Change positions slowly.
b. Reduce flow rate of oxygen.
c. Increase flow rate of IV fluids.
d. Place in Trendelenburg position.

 

 

____  35.   The nurse is monitoring hourly urine output from an indwelling catheter for a patient experiencing hypovolemic shock. What should the nurse do if the patient’s urine output drops to 15 mL for one hour of monitoring?

a. Document the finding.
b. Flush the urinary catheter
c. Clamp the catheter for 30 minutes.
d. Immediately report the drop in urine output.

 

 

____  36.   A patient in shock is found unresponsive. The nurse knows that immediate cardiopulmonary resuscitation is required because brain cells begin to die if deprived of oxygen for how many minutes?

a. 1
b. 2
c. 4
d. 8

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  37.   The nurse is monitoring a patient being for septic shock. Which findings indicate that the patient is improving? (Select all that apply.)

a. SpO2 94%
b. pH is 7.33
c. Pulse 75 beats/minute
d. Temperature 101°F (38.3°C)
e. Blood pressure 110/90 mm Hg
f. Urine output less than 25 mL/hr

 

 

____  38.   The nurse is assisting in the care of a patient with early signs and symptoms of shock. Which diagnostic tests should the nurse expect to be prescribed for this patient? (Select all that apply.)

a. Urinalysis
b. Chest x-ray
c. Arterial blood gas
d. Complete blood count
e. Electroencephalogram (EEG)
f. Blood type and crossmatch

 

 

____  39.   A patient who is taking atenolol (Tenormin) is experiencing shock. Which symptom of shock should the nurse expected to be absent in this patient?

a. Pulse 115 beats per minute
b. Respirations 28 per minute
c. Blood pressure 88/48 mm Hg
d. Capillary refill greater than 3 seconds

 

 

____  40.   A patient in shock has a falling blood pressure. What should the nurse realize occurs as the sympathetic nervous system responds to falling blood pressure? (Select all that apply.)

a. Blood glucose levels increase.
b. Sodium and water are retained.
c. Less oxygen is delivered to tissues.
d. Vasodilation leads to increased fluid loss.
e. Epinephrine is released from the adrenal medulla.
f. Blood is shunted away from the skin, kidneys, and intestines.

 

 

____  41.   The nurse explains procedures and treatments while caring for a patient in shock. Why should the nurse provide these explanations to the patient? (Select all that apply.)

a. Provide support
b. Decrease anxiety
c. Enhance learning
d. Reduce the signs of shock
e. Prevent future shock episodes

 

 

____  42.   A patient is developing anaphylactic shock. What should the nurse expect to observe in this patient? (Select all that apply.)

a. Polyuria
b. Urticaria
c. Bronchospasm
d. Muscle cramps
e. Laryngeal edema

 

 

____  43.   The nurse is monitoring a patient who has been in a shock state for several days. For which serious complications should the nurse observe in the patient and then report? (Select all that apply.)

a. Sepsis
b. Malnutrition
c. Diabetes mellitus
d. Cerebrovascular accident
e. Adult respiratory distress syndrome
f. Multiple organ dysfunction syndrome

 

 

____  44.   A patient in shock is being transported to the nearest emergency department. Upon arrival in which order should the nurse provide care? Place the actions in the order that they should be performed.

a. Ensure breathing.
b. Secure an airway.
c. Assess level of consciousness.
d. Prepare for x-rays and other tests.
e. Apply pressure to bleeding wounds.
f. Monitor heart rate and blood pressure.

 

 

____  45.   The nurse determines that a patient with severely bleeding wounds does not have an adequate airway. What should the nurse do to help this patient? (Select all that apply.)

a. Insert an oral airway.
b. Insert a nasal airway.
c. Apply 100% oxygen via face mask.
d. Prepare for endotracheal intubation.
e. Attempt the head tilt/chin lift method.

 

 

____  46.   The nurse determines that a patient with hypovolemic shock is improving. What did the nurse observe to come to this conclusion? (Select all that apply.)

a. Heart rate increasing
b. Respiratory rate increasing
c. Present of peripheral pulses
d. Systolic blood pressure increasing
e. Urine output 20 mL over the last hour

Chapter 11. Nursing Care of Patients With Cancer

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse is reviewing the function of DNA and RNA with a group of students. Which structure should the nurse explain as providing the genetic code for a gene?

a. Cell
b. Protein
c. Piece of DNA
d. Piece of RNA

 

 

____    2.   A patient with lung cancer is receiving chemotherapy. Why should the nurse closely monitor the patient’s white blood cell (WBC) count?

a. Chemotherapy drugs cause polycythemia and can precipitate thrombosis.
b. Chemotherapy drugs attack WBCs and shorten their life span, which increases risk for infection.
c. Chemotherapy drugs cause proliferation of blood cells, which can lead to sluggish circulation.
d. Chemotherapy drugs depress the bone marrow, which can lead to infection and an increase in WBC count.

 

 

____    3.   A patient asks what dietary changes can be made to help protect against cancer. The nurse should base his or her response to the patient’s question on which of the following?

a. Reduced dietary fat intake can lower cancer risk.
b. Reduced dietary salt intake reduces malignancy development.
c. Increased intake of beef and poultry decrease the risk of malignancy.
d. Increased intake of milk products will lower risk of cancer development.

 

 

____    4.   A patient is diagnosed with a malignant tumor of the bone. Which term should the nurse consider when documenting this patient’s health problem?

a. Sarcoma
b. Osteoma
c. Adenoma
d. Carcinoma

 

 

____    5.   A patient who has been treated for breast cancer is undergoing routine laboratory work. Which laboratory finding would cause the nurse to be most concerned about metastasis?

a. Elevated serum calcium
b. Decreased serum calcium
c. Elevated serum potassium
d. Decreased serum potassium

 

 

____    6.   A patient is scheduled for a needle biopsy of the breast. Which statement indicates that teaching has been effective?

a. “A small needle will be used to inject chemotherapy into my tumor.”
b. “The doctor will use a needle to go into the tumor for a sample of cells.”
c. “A needle will be implanted into the tumor so medication can be injected.”
d. “The doctor is going to make a small incision in my breast to get some tumor cells.”

 

 

____    7.   A patient is scheduled for radiation treatments before having surgery to remove a tumor. What should the nurse cite as the reason for the radiation treatments?

a. Reduces the need for chemotherapy
b. Reduces the size of the tumor before surgery
c. Reduces the need for radiation after the surgery
d. Reduces the spread of cancer cells during the surgery

 

 

____    8.   A patient with prostate cancer asks the nurse the meaning of his high prostate-specific antigen (PSA) level. Which response by the nurse is correct?

a. “PSA is a tumor marker that is elevated in patients with prostate cancer.”
b. “PSA levels are done routinely to determine whether your prostate cancer has spread to a new site.”
c. “The doctor orders PSA measurements to monitor the level of chemotherapy medication in your blood.”
d. “A PSA test allows the pathologist to view the cancer cells under the microscope to monitor the progression of cancer.”

 

 

____    9.   A patient is diagnosed with a stage I tumor in situ (TIS). Which explanation of TIS by the nurse is the best?

a. “The tumor has spread and is generalized throughout the body.”
b. “The tumor has not invaded any tissues beyond the original site.”
c. “The tumor has spread to the lymph nodes in the immediate area.”
d. “The tumor is situated between two tissues, so there is risk for metastasis to both tissues.”

 

 

____  10.   A patient with cancer is scheduled for palliative surgery. Which explanation should the nurse use to describe the purpose of this surgery?

a. Palliative surgery is done to reconstruct tissues damaged by the cancer.
b. Palliative surgery is done to increase the patient’s comfort when cure is not possible.
c. Palliative surgery is done to remove a cancer completely and increase the chances for cure.
d. Palliative surgery is done to remove surrounding lymph nodes, reducing the risk for spread of the primary tumor.

 

 

____  11.   A patient receiving radiation therapy for a tumor in the salivary gland is complaining of a very dry mouth. How should the nurse document this finding?

a. “Halitosis noted.”
b. “Patient reports xerostomia.”
c. “Grade II stomatitis present.”
d. “Patient experiencing dysphagia with liquids.”

 

 

____  12.   The nurse is planning care for a patient with a radioactive implant. Which intervention should the nurse select to help prevent social isolation in this patient?

a. Visit the patient frequently, but do not touch the patient.
b. Help provide diversional activities that the patient enjoys.
c. Have only one nurse provide care to increase consistency.
d. Encourage family to stay with the patient, but have them wear masks and gloves at all times.

 

 

____  13.   The nurse is assessing a patient and notes drainage on the sheets from the site of a radioactive colloid injection. What should the nurse do first?

a. Change the patient’s sheets.
b. Assist the patient with skin care.
c. Stay with the patient while calling for help.
d. Follow hospital policy for radioactive waste cleanup.

 

 

____  14.   The nurse is preparing to teach a patient about the effects of chemotherapy on other body tissues. What should the nurse explain as the reason why hair, blood, skin, and gastrointestinal (GI) tract cells are more likely to be adversely affected by chemotherapy than other cells?

a. Because they are fast growing
b. Because they are exposed to air
c. Because they are all porous tissues
d. Because they are less able to excrete waste products

 

 

____  15.   A patient receiving doxorubicin (Adriamycin) voids urine that is bright red. Which action by the nurse is appropriate?

a. Notify the physician STAT.
b. Withhold all red dye from the patient’s diet.
c. Draw a hemoglobin sample and prepare for possible blood transfusion.
d. Check the patient’s urine, and tell the patient that this is a common side effect of Adriamycin.

 

 

____  16.   The intravenous line of a patient receiving a vesicant chemotherapy agent has disconnected and is lying on the floor. The medication is dripping all over the floor. Which action should the nurse take first?

a. Reconnect the IV tubing immediately.
b. Wipe it up as quickly as possible with disposable cloths.
c. No special precautions are needed for vesicant drug cleanups.
d. Use gloves and a protective gown to clean the spill according to agency policy.

 

 

____  17.   A patient develops alopecia related to doxorubicin (Adriamycin) therapy. Which statement should the nurse use to explain this side effect?

a. Uric acid collects in hair cells.
b. Antibiotics stop all hair growth.
c. Bone marrow suppression prevents nourishment of hair follicles.
d. Anti-neoplastics, such as Adriamycin, attack all rapidly dividing cells.

 

 

____  18.   When inspecting the IV site of a patient receiving a vesicant chemotherapy agent, the licensed practical nurse (LPN) notes a small area of swelling. What should the LPN do first?

a. Check the site every hour.
b. Document the finding in the chart.
c. Discontinue the infusion and notify the RN.
d. No action is needed; this is an expected finding.

 

 

____  19.   The nurse is caring for a patient with leukopenia. Which item creates the greatest risk for this patient?

a. A fresh apple brought in by a friend
b. A can of soda from a vending machine
c. A get-well card from a family member
d. A paperback book purchased at the hospital gift shop

 

 

____  20.   A patient on chemotherapy after surgery develops thrombocytopenia. Which manifestation should the nurse report immediately to the physician?

a. Headache
b. Tarry stools
c. Pain at the surgical site
d. Blood pressure 136/88 mm Hg

 

 

____  21.   Based on the diagnosis “Imbalanced Nutrition related to nausea and vomiting,” the goal of maintaining a stable weight during chemotherapy was identified for a patient receiving care. Which statement provides the best evidence that the goal has been met?

a. Patient’s weight is unchanged during treatment.
b. Patient states nausea and vomiting are controlled.
c. Patient is able to eat 90% of meals without nausea.
d. Patient’s nausea and vomiting are controlled with antiemetic medication.

 

 

____  22.   The nurse educator is preparing a seminar on cancer for a group of nursing students. Which definition should the nurse educator use to accurately describe cancer?

a. Cancer is a name for cells that produce toxins that destroy body organs.
b. Cancer is a term used to describe all new abnormal growths in the body.
c. Cancer is a name given to a disease caused primarily from toxins in the environment.
d. Cancer is a name for a large group of diseases characterized by cells that multiply rapidly and invade normal tissue.

 

 

____  23.   The nurse is planning care for a patient with leukopenia caused by chemotherapy. Which nursing intervention is most important for the nurse to include in this patient’s plan of care?

a. Protect the patient from injury.
b. Observe for bruising or bleeding.
c. Ensure that staff members practice good hand washing.
d. Assist the patient with activities of daily living (ADLs).

 

 

____  24.   A patient undergoing chemotherapy telephones the clinic to complain of a nosebleed 2 days after a treatment. Which nursing diagnosis should the nurse consider while further assessing the patient?

a. Ineffective Protection related to thrombocytopenia
b. Imbalanced Nutrition: less than body requirements
c. Risk for Infection related to low WBC count
d. Disturbed Body Image related to effects of chemotherapy

 

 

____  25.   A patient develops fatigue related to radiation therapy. Which intervention is the most appropriate for this patient?

a. Discuss the patient’s views concerning blood transfusion.
b. Encourage moderate exercise between radiation treatments.
c. Encourage larger portions of foods rich with calories and protein.
d. Encourage the patient to prioritize activities around frequent rest periods.

 

 

____  26.   The nurse is caring for a patient with lung cancer who is receiving chemotherapy. Which assessment finding suggests that the patient is experiencing pericardial effusion?

a. Bruising and tarry stools
b. Edema and shortness of breath
c. Nausea and decreased bowel sounds
d. Peripheral numbness and tingling

 

 

____  27.   A patient being treated with chemotherapy for breast cancer also is being given epoetin alfa for anemia. During the assessment, of what finding should the nurse be most observant?

a. Dyspnea
b. Bone pain
c. Fluid retention
d. Elevated blood pressure

 

 

____  28.   The nurse is checking the laboratory reports of a patient being treated with paclitaxel. Which platelet count might indicate spontaneous bleeding?

a. 15,000/mm3
b. 60,000/mm3
c. 175,000/mm3
d. 300,000/mm3

 

 

____  29.   A nurse is teaching a patient about risk factors for cancer. Which statement by the patient indicates a need for further teaching?

a. “I should eat plenty of fruits and vegetables.”
b. “I should eat a low-fat diet that is high in fiber.”
c. “I understand that eating a high-fat diet increases my risk of breast cancer.”
d. “I know that eating pickled and smoked foods can help prevent GI cancers.”

 

 

____  30.   The nurse is assessing a 58-year-old patient. For what yearly screening test for colorectal cancer should the nurse assess the patient?

a. Colonoscopy
b. Barium enema
c. Stool test for blood
d. Flexible sigmoidoscopy

 

 

____  31.   A nurse is conducting a community education class on cancer risk. The nurse knows that teaching has been effective when women recognize that they are most at risk of dying of which type of cancer?

a. Lung cancer
b. Breast cancer
c. Uterine cancer
d. Ovarian cancer

 

 

____  32.   The nurse is reviewing a patient’s diagnostic test report. For which tumor diameter should the nurse evaluate the report to determine if cancer is present?

a. 0.5 cm
b. 1 cm
c. 2 cm
d. 5 cm

 

 

____  33.   The nurse is reviewing laboratory results and becomes concerned about one patient being treated for cancer. Which patient does the nurse suspect is in need of nutritional support?

a. An 18-year-old with an albumin of 2.5
b. A 60-year-old with a calcium level of 8 mg/dL
c. A 43-year-old with a platelet level of 180,000/mm3
d. A 56-year-old with a white cell count of 6000/mm3

 

 

____  34.   The nurse is preparing an oral chemotherapeutic medication for a patient’s cancer treatment. What should the nurse do to ensure personal safety when preparing this medication?

a. Wear gloves while preparing.
b. Wash hands before administering.
c. Apply a lead apron when providing.
d. Crush the medication before providing.

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  35.   The nurse is reviewing the process of cellular mutation with a patient newly diagnosed with cancer. What should the nurse explain about cellular mutation? (Select all that apply.)

a. The cell becomes malignant.
b. The cell can no longer divide.
c. DNA mistakes have been made.
d. The cell membrane is punctured.
e. Proteins are no longer synthesized.
f. There has been a genetic change in the cell.

 

 

____  36.   The nurse is explaining mitosis to a group of nursing students. What should the nurse explain as the characteristics of a cell that has undergone mitosis? (Select all that apply.)

a. 23 chromosomes
b. 46 chromosomes
c. A nuclear membrane
d. Two sets of amino acids
e. A strengthened cell wall
f. Fewer organelles than the parent cell

 

 

____  37.   The nurse is explaining the characteristics of a malignant tumor to a patient who is newly diagnosed with cancer. What should the nurse include in this explanation? (Select all that apply.)

a. The growth rate is rapid.
b. Tissue damage is minimal.
c. The cells resemble the tissue of origin.
d. The cells may invade surrounding tissues.
e. The cells can travel to distant organs and initiate new tumors.

 

 

____  38.   A patient is experiencing mucositis as a result of radiation therapy. Which interventions should the nurse include in the plan of care? (Select all that apply.)

a. Provide oral care once daily.
b. Discourage use of alcohol and tobacco.
c. Encourage citrus juice for vitamin C supplementation.
d. Advise the patient to avoid very cold foods and drinks.
e. Heat all liquids before drinking to promote oral blood flow.
f. Advise the patient to use a neutral mouthwash, such as diphenhydramine (Benadryl), and water.

 

 

____  39.   A patient is diagnosed with a blood disorder after receiving chemotherapy. Which colony-stimulating drugs should the nurse expect might be prescribed to help treat this disorder? (Select all that apply.)

a. Filgrastim (Neupogen)
b. Pegfilgrastim (Neulasta)
c. Hydroxyurea (Hydrea)
d. Epoetin alfa (Epogen)
e. Exemestane (Casodex)
f. Irinotecan (Camptosar)

 

 

____  40.   The nurse is explaining cancer cells to a patient newly diagnosed with cancer. Which of the following should the nurse tell the patient are characteristic of cancer cells? (Select all that apply).

a. They have division limits.
b. They usually grow slowly.
c. They are considered immortal.
d. They result from mutations of cellular genes.
e. They destroy the gluelike substance found between normal cells.
f. They take on the characteristics of the cells in the tissue to which they migrate.

 

 

____  41.   The nurse is providing dietary teaching to help a patient reduce the risk of cancer. Which foods should the nurse instruct the patient to avoid? (Select all that apply.)

a. Alcohol
b. Whole grains
c. Smoked meats
d. Root vegetables
e. Charbroiled meat
f. Cruciferous vegetables

 

 

____  42.   The nurse is preparing a seminar on cancer incidence for a group of community members. Which types of cancer are common for both men and women? (Select all that apply.)

a. Skin
b. Lung
c. Breast
d. Kidney
e. Prostate
f. Colorectal

 

 

____  43.   The nurse is planning a teaching seminar for members of a Native American tribal community on ways to prevent the development of cancer. What should the nurse include in this teaching? (Select all that apply.)

a. Encourage traditional customs of physical fitness and exercise.
b. Provide teaching materials in the participants’ native language.
c. Identify healing practices that can be incorporated into tribal customs.
d. Emphasize the use of same-sex caregivers when seeking preventive care.
e. Discuss the importance of dietary portion control and healthy food preparation.

 

 

____  44.   A patient with cancer is receiving a dose of an oral radioactive isotope. What should the nurse keep in mind to ensure personal safety when caring for this patient? (Select all that apply.)

a. The best skin care approaches for the patient
b. The time needed to provide quality patient care
c. The distance between the patient and caregivers
d. The use of a barrier to protect from radiation exposure
e. The types of foods the patient should abstain from ingesting

 

 

____  45.   The nurse identifies the diagnosis Imbalanced nutrition: Less than body requirements for a patient experiencing nausea from chemotherapy. Which interventions should the nurse include in this patient’s plan of care? (Select all that apply.)

a. Add nutmeg to foods.
b. Provide oral care before meals.
c. Provide large meals with hot foods.
d. Offer sour foods containing lemon.
e. Spray the room with disinfectant before meals.

 

 

____  46.   A patient with lung cancer is experiencing neck edema and shortness of breath. What actions can the nurse take to help relieve this patient’s symptoms? (Select all that apply.)

a. Restrict fluids.
b. Elevate the head of the bed.
c. Remove restrictive clothing.
d. Insert an indwelling urinary catheter.
e. Avoid using the arms for venipuncture.

Chapter 13. Nursing Care of Patients With Emergent Conditions and Disaster/Bioterrorism Response

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse in the emergency department is caring for a patient with a partial-thickness thermal burn. Which treatment should the nurse expect to be prescribed for this patient?

a. Application of wet dressings
b. Use of clean dressing technique
c. Application of moisturizing lotion
d. Application of silver sulfadiazine cream

 

 

____    2.   The physician orders haloperidol (Haldol) 2 mg intramuscularly (IM) for a patient who is experiencing a psychiatric crisis. Haldol 5 mg/mL is available. How many milliliters should the nurse give?

a. 0.3 mL
b. 0.4 mL
c. 1 mL
d. 1.5 mL

 

 

____    3.   The nurse is preparing teaching for the home treatment of ingested poisons. Which medication is no longer recommended for use at home to induce vomiting for certain ingested poisons?

a. Syrup of ipecac
b. Cimetidine (Tagamet)
c. Thiethylperazine (Torecan)
d. Prochlorperazine (Compazine)

 

 

____    4.   A patient with a head injury is diagnosed with increased intracranial pressure. In which position should the nurse maintain the patient’s head to assist in reducing intracranial pressure?

a. Flexed
b. Midline
c. Turned to left side
d. Turned to right side

 

 

____    5.   A patient who has ingested a corrosive product is vomiting. For which potential complication should the nurse prepare to provide care to this client?

a. Coma
b. Esophageal burns
c. Chemical pneumonia
d. Aspiration pneumonia

 

 

____    6.   When using the Glasgow Coma Scale for a patient involved in a motor vehicle crash, the patient opens the eyes when spoken to and points to the location of pain but is confused in conversation. What score should the nurse assign to this patient?

a. 8
b. 10
c. 12
d. 14

 

 

____    7.   The nurse is caring for a patient who was bitten by a snake. Which action should the nurse take to decrease the effects of the venom?

a. Keep the patient calm.
b. Elevate the patient’s limb.
c. Encourage the patient to ambulate.
d. Perform passive range of motion on the affected limb.

 

 

____    8.   The nurse is preparing to care for a client with a poisonous snake wound. Which method should the nurse use to cleanse the site?

a. Wash with soap and water.
b. Scrub with hydrogen peroxide.
c. Rinse with normal saline, and apply Betadine.
d. Soak in povidone-iodine (Betadine) for 10 minutes.

 

 

____    9.   The nurse assists with the provision of an educational program on the symptoms of smallpox. Which response indicates that the participants understand the location that the rash first appears?

a. Legs and feet
b. Neck and back
c. Tongue and face
d. Abdomen and perineum

 

 

____  10.   The results of a primary survey reveal that a victim of a motor vehicle crash has an open airway, is breathing, and is conscious but bleeding heavily from severe leg injuries. For which complication should the nurse plan care for this client?

a. Anaphylaxis
b. Hemothorax
c. Cardiogenic shock
d. Hypovolemic shock

 

 

____  11.   The nurse is planning care for a patient with a mental health disorder. Which nursing diagnosis should the nurse select if the patient is demonstrating manic behavior?

a. Grieving
b. Confusion
c. Risk for Injury
d. Defensive Coping

 

 

____  12.   The nurse is evaluating care provided to a patient recovering from a psychotic episode. Which patient statement should the nurse recognize as an indication of reduced anxiety?

a. “I feel calm.”
b. “I like the nurses.”
c. “The restraints can be removed.”
d. “I do not need any tranquilizers.”

 

 

____  13.   The nurse is caring for a patient experiencing acute psychosis. What should the nurse realize as being the purpose of medication for this patient?

a. Encourage sleep
b. Reduce psychosis
c. Improve cognition
d. Enhance oxygenation

 

 

____  14.   The nurse is planning care for a patient who experienced a near-drowning. What should the nurse identify as the goal of care for this patient?

a. Maintain ventilation
b. Decompress the stomach
c. Drain fluid from the lungs
d. Drain fluid from the stomach

 

 

____  15.   The nurse ensures that a trauma patient has an effective airway. On what should the nurse focus after the airway has been established for this patient?

a. Exposure
b. Disability
c. Breathing
d. Circulation

 

 

____  16.   A patient who sustained multiple injuries in a motor vehicle crash is brought to the emergency department. After the primary survey, what should be the nurse’s next action?

a. Explain to the patient what happened.
b. Prepare patient for surgery immediately.
c. Complete out a rapid head-to-toe assessment.
d. Obtain a medical history from a family member.

 

 

____  17.   A patient is brought to the emergency department after a motor vehicle crash. Which symptom assessed during data collection should the nurse report promptly?

a. Oliguria
b. Wheezing
c. Ecchymosis
d. Tachycardia

 

 

____  18.   A patient who has fallen has superficial abrasions and an abdomen that is distended, firm, and tender when touched. Which complication should the nurse consider that this patient is experiencing?

a. Anaphylaxis
b. Emotional stress
c. Cardiac arrhythmia
d. Internal abdominal bleeding

 

 

____  19.   A patient seeking treatment after being in a house fire has thermal burns to the neck and shoulders and singed nasal hairs. Which action should the nurse take first?

a. Monitor respirations.
b. Monitor urine output.
c. Obtain blood pressure.
d. Place the patient in a private room.

 

 

____  20.   The nurse in the emergency department is triaging victims of a building collapse. Which victim should the nurse determine is a priority for care?

a. A severely injured patient with full potential for recovery
b. A severely injured patient with slight potential for survival
c. A severely injured patient with moderate potential for survival
d. A severely injured patient with less than 1% chance of survival

 

 

____  21.   A patient who works in a non-air conditioned manufacturing plant is experiencing weakness and a headache. The patient’s skin is cool and clammy, temperature is slightly elevated, and pulse rate is rapid. For which health problem should the nurse plan care for this patient?

a. Heatstroke
b. Heat cramps
c. Heat exhaustion
d. Initial signs of infection

 

 

____  22.   A homeless person is brought to the hospital for weakness, feeling faint, and having a headache. The patient’s skin is cool and clammy and vital signs are temperature 99.9°F, pulse 100 bpm, respirations 18/minute, blood pressure 108/60 mm Hg. What action should the nurse take?

a. Provide oral fluids.
b. Provide Ciprofloxin 400 mg intravenously (IV).
c. Prepare the patient for a chest x-ray.
d. Provide acetaminophen (Tylenol) 500 mg orally.

 

 

____  23.   The nurse is caring for a patient who has sustained an abdominal injury in a motor vehicle crash. Which symptom should be the most concerning to the nurse?

a. pH 7.35
b. Blood pressure 104/52 mm Hg
c. A red macular rash on the patient’s back
d. Weak distal pulses in the lower extremities

 

 

____  24.   The nurse is providing care to a college student having a psychiatric emergency and related suicide attempt. Which action should the nurse take first?

a. Obtain a list of drug allergies from the student.
b. Determine if alcohol or illicit drugs have been used recently.
c. Instruct the student how to place an order with dietary services.
d. Encourage the patient to verbalize his or her feelings about the event.

 

 

____  25.   The nurse determines that a patient has a normal capillary refill time. What was this patient’s refill time?

a. 3 seconds
b. 4 seconds
c. 5 seconds
d. 6 seconds

 

 

____  26.   A patient with severe hypothermia is comatose with fixed dilated pupils, flaccid muscles, and ventricular fibrillation. Which body temperature should the nurse expect to assess in this patient?

a. 95.0
b. 90.0
c. 82.1
d. 80.6

 

 

____  27.   The nurse is reviewing a 40-year-old patient’s immunization schedule. At which age should the patient have received the most recent tetanus booster vaccination?

a. 2 months
b. 6 years
c. 20 years
d. 35 years

 

 

____  28.   While assessing a victim of a motor vehicle crash, the nurse notes that the patient’s trachea is shifted towards the left. What does this finding indicate to the nurse?

a. Cardiac tamponade
b. Right lung hemothorax
c. Left lung pneumothorax
d. Right lung tension pneumothorax

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  29.   A patient is admitted for mild hypothermia. Which manifestations should the nurse expect when assessing this patient? (Select all that apply.)

a. Pinpoint pupils
b. Depleted glucose stores
c. Increased respiratory rate
d. Decreased respiratory rate
e. Decreased muscular activity
f. Decreased heart rate and cardiac output

 

 

____  30.   The nurse is caring for a patient with a traumatic brain injury. What should the nurse recognize as manifestations of early increased intracranial pressure (ICP)? (Select all that apply.)

a. Amnesia
b. Headache
c. Drowsiness
d. Decreased pulse rate
e. Nausea and vomiting
f. Dilated nonreactive pupils

 

 

____  31.   The nurse is caring for a patient who reports being bitten by a coral snake less than an hour ago. Which symptoms should the nurse expect to assess in this patient? (Select all that apply.)

a. Two small puncture wounds
b. Cramping of large muscle groups
c. Localized swelling at the site of the bite
d. Reports of burning pain at the site of injury
e. Discoloration surrounding the site of the bite
f. A pale mottled cyanotic center at the site of injury

 

 

____  32.   A patient brought into the emergency department is diagnosed with shock. Which interventions should the nurse prepare to provide to this patient? (Select all that apply.)

a. Raise the head of the bed.
b. Encourage sips of warm fluid.
c. Provide oxygen as prescribed.
d. Measure and record vital signs.
e. Provide IV fluids as prescribed.

 

 

____  33.   A patient is experiencing an anaphylactic reaction to peanuts. Which medication should the nurse prepare to administer to this patient? (Select all that apply.)

a. Steroids
b. Antibiotics
c. Epinephrine
d. Anticoagulants
e. Antihistamines

 

 

____  34.   The nurse is receiving a victim of a traumatic amputation in the emergency department. What should the nurse do with the amputated limb? (Select all that apply.)

a. Place on ice
b. Rinse with saline
c. Place in ice water
d. Wrap in sterile gauze
e. Place in a sealed plastic bag

 

 

Other

 

  1. The nurse is helping triage in the emergency department as victims of an explosion are being brought in. Rank (1–5) the following patients according to their need for priority treatment according to disaster response protocols and best chance of survival.
  2. _____ A 15-year-old with a laceration to the foot that is bleeding slightly
  3. _____ A 36-year-old who has no pulse or respirations and has an open head injury
  4. _____ A 70-year-old with shortness of breath but no detectable cardiac arrhythmias
  5. _____ A 5-year-old with a suspected fracture of the humerus
  6. _____ A 58-year-old woman with a distended abdomen who reports severe abdominal painChapter 15. Nursing Care of Older Adult Patients 

    Multiple Choice

    Identify the choice that best completes the statement or answers the question.

     

    ____    1.   The nurse is monitoring a patient’s skin status. What should the nurse recognize as the first sign of prolonged pressure on the skin?

    a. Coolness
    b. Cyanosis
    c. Paleness
    d. Redness

     

     

    ____    2.   The nurse has been providing interventions to address an older patient’s nutritional status. Which observation should the nurse use to determine if nursing care has been effective?

    a. Appetite
    b. Skin turgor
    c. Body weight
    d. Urine output

     

     

    ____    3.   The nurse is concerned about medication safety for a patient with confusion. Which action should the nurse recommend be included in the patient’s plan of care to address this issue?

    a. Instruct the patient to take all of the medications together.
    b. Have the patient set up the medications for an entire week.
    c. Have a family member set up and administer the medications.
    d. Have the patient turn medication bottles upside down after taking medication.

     

     

    ____    4.   The nurse is caring for a patient with Alzheimer’s disease. Which environment should the nurse provide to decrease the patient’s symptoms?

    a. A variety of sensory experiences
    b. An environment that varies weekly
    c. A physically challenging environment
    d. A familiar, non-stimulating environment

     

     

    ____    5.   The nurse is collecting data for an older patient. Which characteristic should the nurse identify in a patient with an age-related loss of water in the vertebral discs?

    a. Spinal flexion
    b. Decreased height
    c. Increased spinal flexibility
    d. Protruding bony prominences

     

     

    ____    6.   The nurse has reinforced teaching about age-related mouth changes. Which client statement indicates a correct understanding of the cause of tooth loss in an older adult?

    a. “Jawbone loss.”
    b. “Receding gums.”
    c. “Poor dental care.”
    d. “The aging process.”

     

     

    ____    7.   The nurse is making recommendations to an older patient’s plan of care for safety measures. Which musculoskeletal change should the nurse consider as contributing to a reduction in the older adult’s ability to safely perform routine tasks?

    a. Increased reflexes
    b. Increased joint flexibility
    c. Rapid nerve transmissions
    d. Slower muscle response time

     

     

    ____    8.   The nurse is reinforcing teaching provided to an older patient on how to safely rise from a seated to a standing position. Which age-related change does the nurse use to emphasize the need to change positions gradually for safety?

    a. Joint stiffness
    b. Leg muscle weakness
    c. Decreased circulatory efficiency
    d. Decreased neurological reflex times

     

     

    ____    9.   The nurse is providing care to a person who has difficulty hearing high-pitched tones. Which action should the nurse take when caring for this patient?

    a. Speak loudly from across the room.
    b. Speak softly, using a near-whisper tone.
    c. Speak slowly, emphasizing lip movements.
    d. Speak rapidly, using multiple hand gestures.

     

     

    ____  10.   A 70-year-old patient asks what can be done to protect his hearing. What should the nurse recommend to the patient?

    a. Clean the ears of ear wax every day.
    b. Cover the ears if loud noises are expected.
    c. Have a hearing test performed twice a year.
    d. Raise the volume on televisions and radios in the home.

     

     

    ____  11.   The nurse is making a home health visit to a frail but basically healthy 86-year-old patient. The nurse assesses a heart rate of 104 beats/minute. What action should the nurse take?

    a. Inform the physician of the heart rate immediately.
    b. Teach the patient deep breathing exercises to reduce heart rate.
    c. Ask about liquids the patient is drinking and urination frequency.
    d. Have the patient request a tranquilizer from the physician at the next visit.

     

     

    ____  12.   The nurse is contributing to a patient’s plan of care for comfort needs. What age-related change would explain why an 84-year-old patient is chronically cold even with the thermostat set at 80°F (26.6°C)?

    a. Decreased subcutaneous fat layer
    b. Increased layer of subcutaneous fat
    c. Increased muscular retention of heat
    d. Decreased muscular retention of heat

     

     

    ____  13.   The nurse is making recommendations to the plan of care for a patient who has limited mobility. On which skin condition should the nurse focus as the greatest risk for this patient?

    a. Rashes
    b. Melanoma
    c. Pressure ulcer
    d. Venous stasis ulcer

     

     

    ____  14.   The nurse is collecting patient data. Which findings should the nurse expect because of a decrease in melanin?

    a. Graying of hair
    b. Thinning of hair
    c. Thinning of bone
    d. Thickening of bone

     

     

    ____  15.   The home health nurse is visiting an older patient who fears becoming incontinent and reports restricting personal fluid intake to prevent urinary leakage. Which action should the nurse take?

    a. Instruct the patient to drink more fluids.
    b. Praise the patient for this creative action.
    c. Refer the patient to a continence program.
    d. Provide the patient with literature on oral fluids.

     

     

    ____  16.   The home health nurse is visiting an older adult who reports nocturia. Which night-light bulb color should the nurse suggest to increase safety and enable the patient to see better at night?

    a. Red
    b. White
    c. Yellow
    d. Orange

     

     

    ____  17.   The nurse is reinforcing teaching with an older patient. When interacting with the patient the nurse should recognize which effect of aging on short- and long-term memory?

    a. Both types of memory are retrieved more easily with aging.
    b. Short-term memory is slightly more difficult to retrieve with aging.
    c. Short-term memory is retrieved more easily than long-term memory.
    d. Long-term memory is retrieved more easily than short-term memory.

     

     

    ____  18.   The nurse is caring for a patient who is prone to developing constipation. Which action should the nurse take to help this patient?

    a. Give the patient a Fleet enema.
    b. Help the patient develop an exercise routine.
    c. Instruct the patient to use suppositories once a week.
    d. Instruct the patient to take an oral laxative every night.

     

     

    ____  19.   Which measure should the nurse recommend for inclusion in the plan of care for an older adult who has a nursing diagnosis of ineffective sexual patterns?

    a. Play favorite music.
    b. Schedule private time.
    c. Provide a soft mattress.
    d. Provide pain medication.

     

     

    ____  20.   While assisting with the admission of a new resident to the long-term care facility, the nurse notes the patient’s feet are moist with dry skin on the heels. The toenails are long and brittle. Which action should the nurse take first?

    a. File the nails.
    b. Dry feet well.
    c. Apply lotion to the feet.
    d. Soak feet in warm water.

     

     

    ____  21.   The nurse is administering medications to a group of older residents and monitors them for adverse reactions. In which way should the nurse recognize that a reduction in liver enzyme production effects medication metabolism in the older patient?

    a. The elimination of substances is increased.
    b. The metabolism of substances is decreased.
    c. There is increased detoxification of substances.
    d. There is a need for an increase in the medication dosage.

     

     

    ____  22.   The nurse is identifying recommendations to help an older patient with sleeping needs. What should the nurse recognize as a sleeping pattern in the older adult?

    a. Sleep needs decrease.
    b. Rest time is decreased.
    c. Rest patterns are unchanged.
    d. Sleep needs remain unchanged.

     

     

    ____  23.   The nurse is reviewing the ages of assigned patients in a skilled nursing facility. Which patient age represents the fastest–growing segment of individuals in the United States?

    a. 64
    b. 70
    c. 81
    d. 87

     

     

    ____  24.   The nurse is evaluating the skin of an older patient who has been lying in bed for most of the day. How long would it take a pressure ulcer to begin to form in this patient?

    a. 5 minutes
    b. 10 minutes
    c. 15 minutes
    d. 20 minutes

     

     

    ____  25.   The nurse has finished drawing blood from an older patient. How long should the nurse apply pressure to the puncture site?

    a. 2 minutes
    b. 3 minutes
    c. 4 minutes
    d. 5 minutes

     

     

    Multiple Response

    Identify one or more choices that best complete the statement or answer the question.

     

    ____  26.   The nurse is contributing to the care plan of an immobile patient. What should the nurse recognize as increasing the patient’s risk of developing a pressure ulcer on the heels? (Select all that apply.)

    a. Being obese
    b. Turning every hour
    c. Lying on wet linens
    d. Impaired circulation
    e. Elevating legs on pillows
    f. Wearing oxygen at 2 L per nasal cannula

     

     

    ____  27.   The nurse is contributing to a staff education program about the physical changes of aging. What should the nurse include as a common change in the skeletal system of an older adult? (Select all that apply.)

    a. Osteoporosis
    b. Eroded cartilage
    c. Thickening of bone
    d. Increased flexibility
    e. Shortening in height
    f. Increasing bone density

     

     

    ____  28.   The nurse is collecting data for a patient who has a developing pressure ulcer. What should the nurse expect to assess as early manifestations of a pressure ulcer? (Select all that apply.)

    a. Coolness of site to touch
    b. Cyanosis of site observed
    c. Report of redness at the site
    d. Report of burning at the site
    e. Tenderness at site when touched
    f. Report of decreased sensation at site

     

     

    ____  29.   The nurse is contributing to a staff education program on grooming techniques for older adults. Which methods should the nurse recommend to reduce the potential for nail infections? (Select all that apply.)

    a. Cut nails with scissors.
    b. Clip nails with nail clippers.
    c. File nails with an emery board.
    d. Use resident’s own grooming equipment.

     

     

    ____  30.   An older patient with diabetes mellitus reports difficulty sleeping. Which manifestations should the nurse recognize as being related to sleep deprivation? (Select all that apply.)

    a. Fatigue
    b. Anxiety
    c. Irritability
    d. Hyperactivity
    e. Persistent hunger
    f. Decreased pain sensitivity

     

     

    ____  31.   The nurse is contributing to the plan of care for an older adult. Which should the nurse recognize as being age-related changes of the integumentary system? (Select all that apply.)

    a. Thinning of the scalp hair
    b. Increase in nail growth rate
    c. Decreased sweat production
    d. Increased dryness of the skin
    e. Increased subcutaneous fat layer of skin
    f. Increased growth of nose, ear, and facial hair

     

     

    ____  32.   The nurse is contributing to the plan of care for an older adult. What should the nurse recognize as being age-related changes in the cardiovascular system? (Select all that apply.)

    a. Less efficient leg veins
    b. An increase in heart rate
    c. Decreased cardiac output
    d. Decreased blood pressure
    e. An increase in irregular heartbeats
    f. Thinning of the heart valves and aorta

     

     

    ____  33.   The nurse is contributing to a staff education program to prevent falls in the older population. What should the nurse include as areas to assess for fall prevention? (Select all that apply.)

    a. Use of alcohol
    b. History of falls
    c. Medication side effects
    d. Pressure sore development
    e. Gait and balance screening

     

     

    ____  34.   The nurse is identifying ways to ensure environmental safety for an older patient. Which actions should the nurse recommend for this patient’s plan of care? (Select all that apply.)

    a. Place call light within reach.
    b. Demonstrate confidence during care.
    c. Ask for permission before moving items.
    d. Return items to patient preferred location.
    e. Plan ahead and communicate plans to patient.

     

     

    ____  35.   During a visit to the wellness clinic, an older patient with arthritis asks what can be done to improve joint motion. What should the nurse suggest to this patient? (Select all that apply.)

    a. Walk with an assistive device as needed.
    b. Wear non-skid sturdy shoes when walking.
    c. Perform range-of-motion exercises in warm water.
    d. Consume a balanced diet rich in vitamin D and calcium.
    e. Take prescribed anti-inflammatory medications before exercising.

     

     

    ____  36.   The nurse is assisting in the preparation of a teaching session for older patients on respiratory health. What information should the nurse suggest be included in this program? (Select all that apply.)

    a. Instruct regarding the importance of frequent position changes to stimulate all lung lobes
    b. Recommend deep breathing and coughing as part of a daily exercise program
    c. Encourage receiving pneumonia vaccination and annual influenza vaccination
    d. Suggest taking an over-the-counter expectorant every day to help remove lung secretions
    e. Remind that life-long habits and exposure to respiratory irritants may influence breathing

     

     

    ____  37.   The nurse is concerned that an older patient is demonstrating signs of depression. What did the nurse observe to come to this conclusion? (Select all that apply.)

    a. Difficulty sleeping
    b. Change in behavior
    c. Reminiscing about past events
    d. Increase in physical complaints
    e. Inability to recall events from a week ago

     

     

    ____  38.   During a home visit, the nurse suspects that an older patient recovering from an acute illness is not taking medications as prescribed. What should the nurse assess to determine the patient’s adherence to prescribed medications? (Select all that apply.)

    a. Use of over-the-counter or herbal remedies
    b. Pharmacy that filled the patient’s prescriptions
    c. Location of the medications in the patient’s home
    d. Frequency with which medication doses are being skipped
    e. Frequency with which medications are being taken as prescribed

Chapter 17. Nursing Care of Patients at the End of Life

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse observes a terminal patient making a gurgling sound when breathing. Which nursing diagnosis should the nurse use to guide interventions for this patient?

a. Impaired Gas Exchange
b. Ineffective Breathing Pattern
c. Ineffective Airway Clearance
d. Impaired Oral Mucous Membranes

 

 

____    2.   The nurse is preparing to provide cardiopulmonary resuscitation (CPR) to a patient found unresponsive and not breathing. What should the nurse keep in mind regarding the survival rate of patients who receive CPR in the hospital?

a. Most patients survive after receiving CPR in the hospital.
b. About 5% of patients survive who receive CPR in the hospital.
c. Less than 1% of patients survive who receive CPR in the hospital.
d. Between 10% to 15% of patients survive who receive CPR in the hospital.

 

 

____    3.   A family member is concerned that a patient near the end of life is not eating or drinking and asks the nurse how the family can help the patient increase oral intake. Which response by the nurse is most appropriate?

a. “The best way to feed the patient is with a syringe and small amounts of water or liquid feeding.”
b. “The less the patient drinks, the less urination will be necessary and urination can be uncomfortable at this point in the dying process.”
c. “The starvation process at the end of life is quite natural; a side benefit is that lower doses of medications are needed to keep the patient comfortable.”
d. “As your family member becomes dehydrated from not eating or drinking, natural endorphins will be released, which increase comfort near the end of life.”

 

 

____    4.   A patient is very restless and agitated near the end of life, and the physician orders haloperidol (Haldol) by mouth. However, the patient coughs and chokes every time foods or fluids are offered. Which action should the nurse take?

a. Crush the medication, and mix it with applesauce.
b. Hold the medication until the patient is more alert and able to swallow.
c. Ask the physician for an order to administer the Haldol intramuscularly.
d. Dissolve the medication in a small amount of water, and administer it with an oral syringe.

 

 

____    5.   A patient with lung cancer who expected to die within a few days is being given a blood transfusion. Family members, who realize death is imminent, ask, “Why are you giving a blood transfusion when we all know death is just around the corner?” What should the nurse respond to the family?

a. “That question is best answered by the physician during rounds.”
b. “It is my duty as a nurse to continue to administer life-prolonging treatments until the patient dies.”
c. “The blood will raise the hemoglobin level, which will increase energy level and sense of well-being.”
d. “The transfusion will help increase the patient’s oxygen levels. It will not prolong life but will increase comfort.”

 

 

____    6.   The nurse is reviewing a terminally ill patient’s advance directive. In which part of this directive should the nurse find the patient’s instructions to the physician concerning the care wanted as death nears?

a. HIPAA
b. Living will
c. Durable power of attorney
d. Patient Self-Determination Act

 

 

____    7.   A patient asks what a do not resuscitate order means. What should the nurse explain to the patient?

a. “A DNR order means that you will not be placed on a ventilator if your heart stops and you require CPR.”
b. “A DNR order means you will not be resuscitated if your heart stops, and that all therapeutic support will be withdrawn.”
c. “A DNR order means that you will receive everything you need to remain comfortable, but you will not receive treatment that will prolong life.”
d. “A DNR order means you will not be resuscitated if your heart stops; you can specify whether you still want treatment to prolong your life, or only care that keeps you comfortable.”

 

 

____    8.   The nurse finds a patient unresponsive and not breathing. While beginning CPR, the nurse realizes that the best outcome for this patient would be if CPR was started at which time?

a. Within 1 to 2 minutes of asystole
b. Within 3 to 5 minutes of collapse
c. Within 1 to 2 minutes of patient discovery
d. Within 8 to 10 minutes of patient symptoms

 

 

____    9.   The spouse of a patient with end-stage renal disease sits quietly at the patient’s bedside, staring at the patient as the patient slips into a coma. What should the nurse do at this time?

a. Ask the spouse what plans have been made for the patient once death occurs.
b. Remind the spouse to use the call light if the patient wakes up wanting something.
c. Sit down with the spouse and engage in conversation about the patient’s care needs.
d. Suggest the spouse return home, as the patient is unaware of the spouse being there.

 

 

____  10.   During the last vital signs assessment, a patient with end-stage heart failure has a body temperature of 102°F. Which action should the nurse take at this time?

a. Provide additional blankets
b. Assist to a side-lying position
c. Encourage increased oral fluid intake
d. Administer acetaminophen as prescribed

 

 

____  11.   The spouse of a patient who died from a terminal illness expresses guilt for not encouraging the patient to seek medical attention sooner. The nurse realizes that the spouse is experiencing which stage of the grief process?

a. Reintegration
b. Shock and disbelief
c. Experiencing the loss
d. Denial and resistance

 

 

____  12.   The family of a dying patient is sitting at the bedside, silently watching the patient slip into a coma. What should the nurse suggest to the family at this time?

a. Count the patient’s respirations to know when death is near.
b. Talk to the patient because hearing is the last sense to leave the patient.
c. Stimulate the patient so that the patient is able to engage in conversation.
d. Return home to get some rest because it will be awhile before the patient dies.

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  13.   The nurse is providing care to a patient with a terminal illness. What should be the nurse’s priorities when providing care to this patient? (Select all that apply.)

a. Helping the patient define goals of care
b. Preparing the family for life after the patient has died
c. Encouraging the patient to have hope for a full recovery
d. Supporting the patient through losses leading to a good death
e. Helping the patient communicate care wishes to health care providers (HCPs)

 

 

____  14.   The nurse is identifying approaches so that a terminally ill patient experiences a “good death.” Which strategies should the nurse select to meet this goal? (Select all that apply.)

a. Dying that is not prolonged
b. Adequate pain and symptom management
c. A conclusion to relationships with loved ones
d. Allowing loved ones to make end-of-life decisions
e. Minimal financial and emotional burdens on family members
f. Using remaining time to strengthen relationships with loved ones

 

 

____  15.   The nurse is reviewing the nutritional status for a group of patients. In which patients would a feeding tube most likely be beneficial? (Select all that apply.)

a. An 80-year-old patent with dementia
b. A 76-year-old patient with terminal cancer
c. A 65-year-old patient recovering from pneumonia
d. A 90-year-old patient with diabetes and heart failure
e. A 55-year-old with esophageal cancer who is receiving radiation therapy
f. A 55-year-old patient receiving chemotherapy and experiencing loss of appetite

 

 

____  16.   A patient with terminal cancer has just died. Which actions should the nurse take during the immediate postmortem period? (Select all that apply.)

a. Bathe and dress the patient.
b. Ask the family if they want the patient’s face covered or uncovered.
c. Remove all tubes, medical supplies, and equipment from the bedside.
d. Provide the family a place away from the patient’s room to talk and grieve.
e. Notify the physician with the patient’s time of death per institutional policy.
f. Recommend that the family donate the patient’s organs as a way to find meaning from the death.

 

 

____  17.   A dying patient is experiencing copious secretions, difficulty in swallowing, and labored breathing. Which interventions should the nurse carry out? (Select all that apply.)

a. Suction secretions.
b. Encourage oral fluids.
c. Place a dehumidifier in the room.
d. Administer scopolamine as ordered.
e. Increase oxygen to 3 L per nasal cannula.
f. Place the patient in Fowler’s or semi-Fowler’s position.

 

 

____  18.   The nurse is concerned that a patient has a short time left to live. Which criterion is the nurse using that indicates a prognosis of 6 months or less to live? (Select all that apply.)

a. Incontinence
b. Functional decline
c. Increased agitation
d. Recurrent infections
e. Frequent hospitalizations
f. Weight loss of 10% or more

 

 

____  19.   The nurse is scheduling a hospice team to meet with the family of a dying patient. Which individuals will most likely participate in this meeting? (Select all that apply.)

a. Nurse to manage symptoms of pain and nausea
b. Social worker to assist with community resources
c. Chaplain to provide spiritual and emotional support
d. Physical therapist working to regain patient ability to walk
e. Bereavement counselor to provide assistance to family and loved ones
f. Hospitalist to direct an emergency response team and provide CPR

 

 

____  20.   The nurse is providing hospice care for a patient in the terminal phase of lung cancer. Which nursing actions would be appropriate? (Select all that apply.)

a. Provide low-dose morphine.
b. Place a fan at the patient’s bedside.
c. Encourage the patient to bathe daily.
d. Administer diuretic therapy as ordered.
e. Position the patient upright in a recliner with pillows.
f. Teach family members how to perform deep tracheal suctioning.

 

 

____  21.   A terminally ill patient is experiencing mouth discomfort. Which actions should the nurse take to help this patient? (Select all that apply.)

a. Offer ice chips.
b. Offer sips of water.
c. Apply lanolin to the lips.
d. Provide an alcohol-based mouthwash.
e. Use sponge-tipped Toothettes for mouth care.

 

 

____  22.   A terminally ill patient who is not able to talk is demonstrating restlessness. What actions can the nurse take to help this patient achieve comfort? (Select all that apply.)

a. Medicate for pain.
b. Elevate the head of the bed.
c. Measure oxygen saturation.
d. Reposition the patient in bed.
e. Ensure incontinence pad is clean and dry.

 

 

____  23.   The adult daughter of a terminally ill patient is upset because the patient is confused and is talking to people who are not in the room. What should the nurse do to help the patient and daughter? (Select all that apply.)

a. Encourage the patient to continue to talk.
b. Make sure that a dim light is on in the patient’s room.
c. Suggest the daughter provide the patient with sips of fluids.
d. Explain to the daughter that confusion is common and expected.
e. Encourage the daughter to provide tactile stimulation to the patient.