Medical-Surgical Nursing- Concepts and Practice 3th Edition deWit TESTBANK ( COMPLETE, ALL ANSWERS ARE 100% CORRECT, GUARANTEED GRADES ) COVERS ALL CHAPTERS

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Chapter 01: Caring for Medical-Surgical Patients deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition MULTIPLE CHOICE 1. Which statement accurately describes the primary purpose of the... state nurse practice act (NPA)? a. To test and license LPN/LVNs. b. To define the scope of LPN/LVN practice. c. To improve the quality of care provided by the LPN/LVN. d. To limit the LPN/LVN employment placement. ANS: B While improving quality of care provided by the LPN/LVN may be a result of the NPA, the primary purpose of the NPA of each state defines the scope of nursing practice in that state. PTS: 1 DIF: Cognitive Level: Comprehension REF: 2 OBJ: 3 TOP: NPA KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 2. The charge nurse asks the new vocational nurse to start an intravenous infusion, a skill that the vocational nurse has not been taught during her educational program. How should the vocational nurse respond? a. Ask a more experienced nurse to demonstrate the procedure. b. Look up the procedure in the procedure manual. c. Attempt to perform the procedure with supervision. d. Inform the charge nurse of her lack of training in this procedure. ANS: D The charge nurse should be informed of the lack of training to perform the procedure, and the vocational nurse should seek further training to gain proficiency. Although the other options might be helpful, they are not safe. PTS: 1 DIF: Cognitive Level: Application REF: 3 OBJ: 1 TOP: Providing Safe Care KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 3. Which patient statement indicates a need for further discharge teaching that the vocational nurse should address? a. “I have no idea of how this drug will affect me.” b. “Do you know if my physician is coming back today?” c. “Will my insurance pay for my stay?” d. “Am I going to have to go to a nursing home?” ANS: A Lack of knowledge at discharge about medication effects and side effects is a concern that should be addressed by the vocational nurse. The other concerns in the options are the responsibility of other departments to which the nurse might refer the patient. PTS: 1 DIF: Cognitive Level: Application REF: 2 OBJ: 1 TOP: Teaching KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 4. According to most state NPAs, the vocational nurse acting as charge nurse in a long-term care facility acts in which capacity? a. Working under direct supervision of an RN on the unit b. Working with the RN in the building c. Working under general supervision by the RN available on site or by phone d. Working as an independent vocational nurse ANS: C The vocational nurse in the capacity of the charge nurse in a long-term care facility acts with the general supervision of an RN available on site or by phone. PTS: 1 DIF: Cognitive Level: Comprehension REF: 2 OBJ: 1 TOP: Charge Nurse/Manager KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care5. The nurse is educating a patient that is a member of a health maintenance organization (HMO). Which information should the nurse include? a. Seek the opinion of an alternate health care provider. b. Obtain insurance approval for medical services prior to treatment. c. Provide detailed documentation of all care received for his condition. d. Wait at least 6 months to see a specialist. ANS: B Most HMOs require preprocedure authorization for treatment. Patients are not required to seek a second opinion, provide documentation of care, or wait a specific time period before visiting a specialist. PTS: 1 DIF: Cognitive Level: Application REF: 9 OBJ: 9 TOP: Charge Nurse/Manager KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 6. The patient complains to the nurse that he is confused about his “deductible” that he owes the hospital. Which statement accurately explains a deductible? a. An amount of money put aside for the payment of future medical bills b. A one-time fee for service c. An amount of money deducted from the bill by the insurance company d. An annual amount of money the patient must pay out-of-pocket for medical care ANS: D The deductible is the annual amount the insured must pay out-of-pocket prior to the insurance company assuming the cost. This practice improves the profit of the insurance company. PTS: 1 DIF: Cognitive Level: Comprehension REF: 7 OBJ: 9 TOP: Health Care Financing KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 7. The nurse compares the characteristics of a health maintenance organization (HMO) and a preferred provider organization (PPO). Which information should the nurse include about HMOs? a. HMOs require a set fee of each member monthly. b. HMOs allow the member to select his health care provider. c. HMOs permit admission to any facility the member prefers. d. HMOs offer unlimited diagnostic tests and treatments. ANS: A HMOs require a set fee from each member monthly (capitation). The patient will be treated by the HMO staff in HMO-approved facilities. Excessive use of diagnostic tests and treatments is discouraged by the HMO. PTS: 1 DIF: Cognitive Level: Application REF: 9 OBJ: 9 TOP: Managed Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 8. A patient asks the nurse what Medicare Part A covers. Which response is correct? a. Medicare Part A covers inpatient hospital costs. b. Medicare Part A covers reimbursement to the physician. c. Medicare Part A covers outpatient hospital services. d. Medicare Part A covers ambulance transportation. ANS: A Medicare Part A covers inpatient hospital expenses, drugs, x-rays, laboratory work, and intensive care. Medicare Part B pays the physician, ambulance transport, and outpatient services. PTS: 1 DIF: Cognitive Level: Comprehension REF: 7, Box 1-4 OBJ: 9 TOP: Government-Sponsored Health Insurance KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 9. Which is the main cost-containment component of diagnosis-related groups (DRGs)?a. Hospitals focus only on the specific diagnosis. b. Hospitals treat and discharge patients quickly. c. Reduced cost drugs are ordered for specific diagnoses. d. Diagnostic group classification streamlines care. ANS: B DRGs are a prospective payment plan in which hospitals receive a flat fee for each patient’s diagnostic category regardless of the length of time in the hospital. If hospitals can treat and discharge patients before the allotted time, hospitals get to keep the excess payment; cost is contained, and the patient is discharged sooner. PTS: 1 DIF: Cognitive Level: Comprehension REF: 8 OBJ: 9 TOP: Government-Sponsored Health Insurance KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 10. The nurse is assessing a group of patients. Which patient would most likely qualify for Medicaid? a. A 35-year-old unemployed single mother with diabetes b. A 70-year-old Medicare recipient with retirement income who needs to be in a long-term care facility c. An 80-year-old blind woman living in her own home who has inadequate private insurance d. A 67-year-old stroke victim with Medicare Part A and an income from investments ANS: A Medicaid is a joint effort of federal and state governments geared primarily for low-income people with no insurance. PTS: 1 DIF: Cognitive Level: Application REF: 8, Box 1-5 OBJ: 9 TOP: Government-Sponsored Health Insurance–Medicaid KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 11. Which area is the major focus of Healthy People 2020 and the primary mechanism through which to improve the health of Americans in the second decade of the century? a. Research funding b. Health information distribution c. Healthy lifestyle encouragement d. Health improvement program designs ANS: C Healthy People 2020 focuses on expanding ongoing programs to include support and information to reduce infant mortality, cancer, cardiovascular disease, and HIV/AIDS, and to increase effective immunizations, healthy eating habits, and healthy weight. PTS: 1 DIF: Cognitive Level: Comprehension REF: 6 OBJ: 7 TOP: Healthy People 2020 KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 12. Which term explains the type of care that addresses interventions for all dimensions of a patient’s life? a. Focused care b. General care c. Directed care d. Holistic care ANS: D Holistic care addresses the physiologic, psychological, social, cultural, and spiritual needs of the patient. PTS: 1 DIF: Cognitive Level: Comprehension REF: 6 OBJ: 8 TOP: Holistic Care KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 13. A patient furiously says, “My doctor was so busy giving me instructions that he didn’t hear what I was trying to ask him!” Which response is most empathetic? a. “When people ignore me, I really get mad.”b. “I’m sure that the doctor was rushed and unaware of your needs.” c. “I’ll bet that made you feel very frustrated.” d. “Take a deep breath and plan what you will say to him tomorrow.” ANS: C Empathy demonstrates that the nurse perceives the patient’s feelings but does not share the emotion. Belittling the patient’s feelings, showing sympathy, or defending the doctor makes the patient feel devalued. PTS: 1 DIF: Cognitive Level: Analysis REF: 10 OBJ: 10 TOP: Nurse–Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 14. The nurse is explaining differences in a therapeutic relationship and a social relationship to a patient. Which information about therapeutic relationships is most important for the nurse to include in the explanation? a. Therapeutic relationships lack formal boundaries. b. Therapeutic relationships are goal directed. c. Therapeutic relationships meet the needs of each person in the relationship. d. Therapeutic relationships extend past the hospitalization period. ANS: B The therapeutic relationship is focused on the patient and is goal directed and designed to meet only the needs of the patient and does not extend past the period of hospitalization. PTS: 1 DIF: Cognitive Level: Comprehension REF: 9 OBJ: 10 TOP: Therapeutic Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 15. The long-term care facility nurse is caring for a newly admitted 80-year-old patient who is depressed. Which approach is best for the nurse to employ? a. Encourage the resident to engage in an activity. b. Remind the resident of reasons to be positive. c. Point out episodes of negative behavior. d. Present a bright and cheerful behavior. ANS: A Activity and social interaction are helpful to depressed patients. Presenting a cheery approach and pointing out negative behavior and reasons to be positive are not therapeutic at this stage of the relationship. PTS: 1 DIF: Cognitive Level: Analysis REF: 10 OBJ: 10 TOP: Depressed Behavior KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 16. The nurse is caring for a patient who has been on antidepressants for 3 days. The patient tearfully says, “I still feel terrible. I don’t think anything can help how I feel.” Which response is best? a. “I will tell the charge nurse how you are feeling.” b. “You just need to be patient and give your medicine some time to work.” c. “Look how much you have improved since you were admitted to the facility.” d. “It must be frustrating to be going through this difficult time.” ANS: D This response is an empathetic response that allows for further exploration of the patient’s feelings. The other responses will block communication with this patient. PTS: 1 DIF: Cognitive Level: Application REF: 9 OBJ: 10 TOP: Therapeutic Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 17. An overweight male patient rips off his hospital gown, throws it out the door, and shouts, “I’m not wearing this stupid gown! It is too small, too short, and exposes my backside to the world!” Which response is most appropriate? a. Remind patient of the need to wear the gown for convenience in care.b. Confer with the patient for methods to acquire a larger gown. c. Replace the torn gown with another. d. Inform the charge nurse of the hostile behavior. ANS: B Allowing hostile patients to make reasonable requests defuses the anger and allows patients to vent their feelings. PTS: 1 DIF: Cognitive Level: Application REF: 9 OBJ: 10 TOP: Hostile Behavior KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 18. The nurse is caring for a patient who states, “You are the only nurse who understands about my pain. Can’t you give me an extra dose of pain medication?” How should the nurse respond to the patient’s request? a. Explain that dosage schedules are by physician’s orders. b. Ignore the request. c. Tell the patient that his behavior is manipulative. d. Agree to give an extra dose of pain medication. ANS: A A matter-of-fact response to a manipulative request limits the effect of the manipulation, thereby helping the nurse to avoid becoming defensive or being swayed by flattery. PTS: 1 DIF: Cognitive Level: Application REF: 9 OBJ: 10 TOP: Manipulative Behavior KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 19. A female patient who has recently been diagnosed with an inoperable brain tumor asks the nurse, “Do you think God punishes us?” Which response demonstrates therapeutic communication? a. “What do you think?” b. “God loves you.” c. “Would like to speak with the chaplain?” d. “God will not give you more than you can bear.” ANS: A Sitting with the patient and offering oneself to listen to the patient’s concerns and encouraging reflection is the best approach rather than responding with a cliché or suggesting speaking with the chaplain. PTS: 1 DIF: Cognitive Level: Application REF: 10 OBJ: 10 TOP: Spiritual Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 20. The nurse is communicating with a patient who voices concern about an upcoming high-risk procedure. Which statement best demonstrates empathy? a. “Would you like to talk about your feelings regarding the procedure?” b. “My mother had the same procedure and did very well.” c. “I can’t imagine how you feel.” d. “It must be difficult preparing for the procedure; how are you feeling?” ANS: D This statement by the nurse displays empathy by trying to place oneself in the patient’s circumstance and validating the patient’s feelings. Simply asking patients if they would like to talk about their feelings does not show empathy and may elicit a “yes” or “no” response. Telling the patient one’s mother had the procedure or stating “I can’t imagine how you feel” does not show empathy toward the patient. PTS: 1 DIF: Cognitive Level: Application REF: 10 OBJ: 10 TOP: Nurse–Patient Relationship KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE21. Which of the following are sources of clear guidelines for upholding clinical standards for safe and competent care? (Select all that apply.) a. The state’s nurse practice act (NPA) b. The State Board of Nurse Examiners (BNE) c. The National Association for Practical Nurse Education and Service (NAPNES) d. Institutional policies e. The National Federation of Licensed Practical Nurses, Inc. (NFLPN) ANS: C, E NAPNES and the NFLPN give clear guidelines for clinical standards that can be used as a basis for court decisions. The NPA has broad guidelines, and institutional policies may not be complete. The BNE enforces the NPA. PTS: 1 DIF: Cognitive Level: Comprehension REF: 5 OBJ: 3 TOP: Upholding Clinical Standards KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 22. Which statement(s) accurately describes the role of the LPN/LVN regardless of employment placement? (Select all that apply.) a. Uphold clinical standards b. Educate patients c. Communicate effectively d. Collaborate with the health care team e. Initiate a care plan immediately after admission ANS: A, B, C, D The LPN/LVN has the accountability to uphold clinical standards, educate patients, communicate effectively, and collaborate with the health care team. Depending on the type of facility, initiation of a care plan is often the role of the registered nurse. PTS: 1 DIF: Cognitive Level: Comprehension REF: 2 OBJ: 3 TOP: Roles of LPN/LVNs KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 23. The newly licensed LPN/LVN demonstrates an understanding of employment opportunities when applying to a position in which area(s)? (Select all that apply.) a. An outpatient clinic b. A home health care agency c. An intravenous (IV) therapy team d. A long-term care facility e. An ambulatory care unit ANS: A, B, D, E With the exception of an IV therapy team, which requires postgraduate education and/or certification, the other options are open to newly graduated vocational nurses. PTS: 1 DIF: Cognitive Level: Application REF: 2 OBJ: 2 TOP: Employment Opportunities for LPN/LVNs KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 24. What factor(s) should the LPN/LVN consider when delegating a task to unlicensed assistive personnel (UAP)? (Select all that apply.) a. A need for the UAP to voluntarily accept the task delegated b. Continued accountability for the task by the LPN/LVN c. Assurance that the task requires no further need for supervision of the UAP d. An understanding that the task is in the job description of the UAP e. A transfer of authority to the UAP ANS: A, B, D, E Delegation is a considered act involving the condition of the patient and the competency of the UAP. Delegation requires that the UAP voluntarily accept the task, which is in the job description of the UAP. The vocational nurse has transferred authority for the completion of the task but is still accountable and should supervise.PTS: 1 DIF: Cognitive Level: Application REF: 3 OBJ: 1 TOP: Delegation KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 25. The LPN/LVN participates in an in-service about cost containment within the health care facility. Which action(s) demonstrate understanding of cost-containment principles? (Select all that apply.) a. Telling patients to limit their usage of supplies. b. Asking the UAP to ensure correct charges for patient care items. c. Only using necessary items for patient care. d. Charging for extra patient care items that the patient may take home upon discharge. e. Documenting supplies used for patients in their patient care record. ANS: B, C, E The UAP must correctly charge patients utilizing the facility’s charging system, only necessary supplies should be used for patient care, and documenting supplies used assists in reimbursement. It is inappropriate and not the patient’s responsibility to monitor their supply use, and excess charges would be incurred if items were given to the patient upon discharge. PTS: 1 DIF: Cognitive Level: Application REF: 6 OBJ: 8 TOP: Cost Containment KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Management of Care COMPLETION 26. When an insurance company directly reimburses a licensed health care provider for services, the form of financing is called ______________. ANS: fee for service Fee for service is the direct reimbursement by an insurance company to a health care provider. PTS: 1 DIF: Cognitive Level: Comprehension REF: 7 OBJ: 9 TOP: Health Care Financing KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 27. The nurse explains that the term _____________ refers to the severity of illness. ANS: acuity Acuity is the term referring to the severity of illness or condition of a patient. PTS: 1 DIF: Cognitive Level: Knowledge REF: 4 OBJ: 6 TOP: Acuity KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care Chapter 02: Critical Thinking and the Nursing Process deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition MULTIPLE CHOICE 1. Which foundational behavior is necessary for effective critical thinking? a. Unshakable beliefs and values b. An open attitude c. An ability to disregard evidence inconsistent with set goals d. An ability to recognize the perfect solution ANS: B An open attitude not clouded by unshakable beliefs and values or preset goals allows the application of critical thinking. Acceptance that there may not be a perfect solution leaves the field open to new ideas.PTS: 1 DIF: Cognitive Level: Comprehension REF: 16, Box 2-1 OBJ: 2 (theory) TOP: Factors Influencing Critical Thinking KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 2. Which fundamental belief underscores the basis of the nursing process? a. Recognition that basic needs must be met by the individual without assistance. b. Acknowledgment that patients and families appreciate an efficient health care system that functions without their input. c. A focus on disease control as the most important aspect of patient care. d. Recognition that all people have worth and dignity. ANS: D The nursing process is based on the belief that all people have worth and dignity. Patient-centered care that is applied to all aspects of the patient’s health, and is not just disease oriented, is appreciated by the family and patient. Holistic care approach can support the patient to meet basic needs. PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 5 (theory) TOP: Basic Beliefs Pertinent to the Nursing Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 3. The nurse is assessing a new patient who complains of his chest feeling tight. The patient displays a temperature of 100° F and an oxygen saturation of 89%, and expectorates frothy mucus. Which finding is an example of subjective data? a. Temperature b. Oxygen saturation c. Frothy mucus d. Chest tightness ANS: D Subjective data is information given by the patient that cannot be measured otherwise. The other data are considered objective data. Objective data are pieces of information that can be measured by the examiner. The nurse should avoid making judgments or conclusions when obtaining data. PTS: 1 DIF: Cognitive Level: Application REF: 18 OBJ: 8 (clinical) TOP: Assessment Data KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 4. The nurse is caring for a newly admitted patient who is describing his recent symptoms to the nurse. This scenario is an example of which type of source? a. Primary b. Objective c. Secondary d. Complete ANS: A The patient is the primary source of information. Objective refers to a type of data obtained by the nurse that is measured or can be verified through assessment techniques, secondary information is obtained from relatives or significant others, and information is not necessarily complete when the patient is the source. PTS: 1 DIF: Cognitive Level: Application REF: 19 OBJ: 8 (clinical) TOP: Sources of Information KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 5. The nurse is performing an intake interview on a new resident to the long-term care facility. The nurse detects the odor of acetone from the patient’s breath. Which term accurately describes this assessment? a. Inspection b. Observation c. Auscultation d. Olfaction ANS: DOlfaction is an assessment method of smells. Inspection and observation use the sense of vision. Auscultation refers to use of the sense of hearing. PTS: 1 DIF: Cognitive Level: Comprehension REF: 20 OBJ: 9 (clinical) TOP: Olfaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 6. During a morning assessment, the nurse observes that the patient displays significant edema of both feet and ankles. Which statement best documents these findings? a. Pitting edema present in both feet and ankles b. Edema in both feet and ankles approximately 4 mm deep c. 4 mm pitting edema quickly resolving d. Bilateral pitting edema in feet and ankles, 4 mm deep, resolving in 3 seconds ANS: D Edema should be recorded as to location, depth of pitting, and time for resolution. PTS: 1 DIF: Cognitive Level: Application REF: 20 OBJ: 9 (theory) TOP: Palpation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 7. Which technique should the nurse employ to best assess skin turgor? a. Examine mucous membranes of the mouth. b. Compare limbs for similar color. c. Pinch a skinfold on chest to assess for tenting. d. Palpate the ankles for evidence of pitting edema. ANS: C Skin turgor can be assessed by tenting the skin on the chest and recording the speed at which the “tent” subsides. PTS: 1 DIF: Cognitive Level: Comprehension REF: 22 OBJ: 9 (clinical) TOP: Practical Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. Which example shows that the nursing student demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPAA)? a. The student uses the patient’s full name only on clinical assignments submitted to the instructor. b. The student uses the facility printer to copy laboratory reports on an assigned patient. c. The student shreds any documents that contain identifying patient information before leaving the clinical facility. d. The student asks the patient for permission to copy laboratory and diagnostic reports for educational purposes. ANS: C HIPAA forbids any information used for educational purposes to have any identifying information; therefore, shredding documents would be appropriate. Full names on documents, printing copies of chart forms, and asking the patient for permission to copy forms would be violations of HIPAA regulations. PTS: 1 DIF: Cognitive Level: Comprehension REF: 26 OBJ: 4 (theory) TOP: HIPAA KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 9. The diabetic patient who had blood drawn for an HbA1c level says, “I don’t know why they want to look at my hemoglobin.” Which response is most appropriate for the nurse to make? a. “Diabetes increases your risk of bleeding.” b. “The HbA1c provides information relative to blood sugar levels for the last 2 to 3 months.” c. “Hemoglobin levels and blood sugar levels are closely related.” d. “The HbA1c tells if you have type 1 or type 2 diabetes.” ANS: B HbA1c evaluates the average blood glucose level for the last 2 to 3 months. By explaining the purpose of the common laboratory test (HgbA1c) and its relationship to diabetes, the nurse answers the patient’s question and clearly communicates relevant data. PTS: 1 DIF: Cognitive Level: Comprehension REF: 25, 27 OBJ: 8 (clinical) TOP: Diagnostic StudiesKEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 10. The nurse is caring for a patient with the problem statement/nursing diagnosis of Risk for Impaired Skin Integrity Related to Immobility. Which goal/outcome statement best correlates with this diagnosis? a. The patient will sit in chair at bedside for 15 minutes after each meal. b. The nurse will assist the patient to chair every shift. c. The nurse will assess skin and record condition every shift. d. The patient will change positions frequently. ANS: A The goal/outcome statement is directed at the etiology and should be patient oriented. The statement should be realistic and measurable and reflect what the patient will do. PTS: 1 DIF: Cognitive Level: Comprehension REF: 24 OBJ: 11 (clinical) TOP: Goals KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 11. The nurse who has recently moved from Louisiana to Texas is uncertain about the LPN/LVN’s role in applying the nursing process. Which source is most appropriate source for the nurse to consult? a. Hospital policies b. The Texas State Board of Nursing c. Rules and regulations of the Louisiana Nurse Practice Act d. The National Association of Practical Nurse Education and Service ANS: B Each state has different guidelines for areas of care planning, intravenous therapy, teaching, and delegation. The Texas State Board of Nursing is the most reliable source. PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory) TOP: Nursing Process KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 12. The nurse adds a nursing order to the care plan related to a patient with a problem statement/nursing diagnosis of altered nutrition/Nutrition: Less Than Body Requirements Related to Nausea and Vomiting. Which nursing order should the nurse include in the plan of care? a. Medicate with an antiemetic before each meal. b. Offer crackers and iced drink before each meal. c. Change diet to clear liquids. d. Give nothing by mouth until nausea subsides. ANS: B Offering crackers and iced drinks are within the scope of nursing; the other options would require a medical order to complete. PTS: 1 DIF: Cognitive Level: Application REF: 18 OBJ: 11 (clinical) TOP: Nursing Orders KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 13. After evaluating the nursing care plan, the nurse finds lack of progress toward the goal. What action should the nurse take next? a. Create a more accessible goal. b. Revise the nursing interventions. c. Change the problem statement/nursing diagnosis. d. Use a new evaluation plan. ANS: B When lack of progress to reach the goal is seen on evaluation, the interventions are reviewed and/or revised. PTS: 1 DIF: Cognitive Level: Application REF: 26 OBJ: 10 (clinical) TOP: Evaluation KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care14. During an intake interview, the nurse observes the patient grimacing and holding his hand over his stomach. The patient previously denied having any pain. What action should the nurse take next? a. Examine the history closely for etiology of pain. b. Ask the patient if he is experiencing abdominal pain. c. Record that patient seems to be having abdominal discomfort. d. Physically examine the patient’s abdomen. ANS: B The nurse should try to resolve any incongruence between body language and verbal responses. PTS: 1 DIF: Cognitive Level: Application REF: 20, Box 2-5 OBJ: 7 (clinical) TOP: Patient Interview KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 15. While conducting an admission interview, the nurse questions the patient about pain. The patient responds, “No. I’m pretty wobbly.” Which action should the nurse take next? a. Repeat the question about pain. b. Ask the patient to clarify his meaning. c. Record that the patient denied pain. d. Record that the patient stated he was wobbly. ANS: B The nurse should ask for clarification if unsure of what is meant by one of the patient’s responses. PTS: 1 DIF: Cognitive Level: Application REF: 20, Box 2-5 OBJ: 7 (clinical) TOP: Patient Interview KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 16. The nurse is caring for a patient with a goal/outcome statement of Patient will sleep for 5 hours uninterrupted each night. Which nursing intervention should the nurse include? a. Medicate with sedative each night. b. Offer warm fluids frequently. c. Arrange for a large meal at supper. d. Discourage daytime napping. ANS: D Discouraging daytime napping increases the probability of sleep. Giving medication is a collaborative intervention as it requires an order. Large meal and large fluid intakes may interrupt sleep. PTS: 1 DIF: Cognitive Level: Application REF: 25 OBJ: 11 (clinical) TOP: Nursing Intervention KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 17. The nursing team is prioritizing the problem statement/nursing diagnoses of an overweight hospital patient. Which problem statement/nursing diagnosis would be most important for this patient? a. Risk for dehydration related to vomiting. b. Activity intolerance related to shortness of breath. c. Knowledge deficit related to weight reduction diet. d. Altered self-image related to excessive weight. ANS: B Activity intolerance is the highest priority as it has to do with activities that are essential to life. The second is Knowledge deficit related to weight reduction diet, followed by Altered self-image related to excessive weight, and the last is Risk for dehydration related to vomiting. PTS: 1 DIF: Cognitive Level: Analysis REF: 23 OBJ: 11 (clinical) TOP: Setting Priorities KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 18. The nurse is explaining the components of a complete problem statement/nursing diagnosis. In addition to the NANDA stem and etiology, which other component should the diagnosis include?a. A time reference for meeting the need b. A designation of what the patient should do c. Signs and symptoms of the problem assessed d. A specifically worded medical diagnosis ANS: C A complete problem statement/nursing diagnosis must have a NANDA stem, etiology, and signs and symptoms (etiology) of the problem. PTS: 1 DIF: Cognitive Level: Knowledge REF: 23 OBJ: 4 (theory) TOP: Nursing Diagnosis KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance 19. Which statement explains the reason for inclusion of potential problems in the nursing care plan? a. To alert nursing staff to prevent potential complications. b. To remind the family of potential problems. c. To broaden the assessment of the caregiver. d. To educate the patient to aspects of her health. ANS: A Addressing potential problems prevents complications by early action rather than waiting for a problem to materialize. PTS: 1 DIF: Cognitive Level: Comprehension REF: 23 OBJ: 7 (clinical) TOP: Potential Health Problems KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance 20. The nurse is completing the medication reconciliation form for a patient. Which information is most important for the nurse to include? a. The patient reports taking Ginkgo biloba daily for the last 6 months. b. The patient reports having high hematocrit levels during his last hospital stay. c. The patient reports he has been diabetic for 10 years. d. The patient reports having a recent infection. ANS: A As part of the medication reconciliation form, all home medications (including herbal preparations like Gingko biloba) are listed and reviewed by the provider, pharmacist, and nurses. The information gathered during the completion of this form may impact care that the patient will receive. Abnormal lab work and history of chronic or acute illnesses are important components of the patient’s history but should not be part of the medication reconciliation form. PTS: 1 DIF: Cognitive Level: Application REF: 20 OBJ: 7 (clinical) TOP: Alternative Medicine KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 21. The LPN/LVN adheres to facility policy regarding core measures by performing which interventions during patient care? a. Administering the ordered amount of insulin to a patient with type 1 diabetes. b. Performing a thorough patient assessment upon admission to the health care facility. c. Documenting accurately and at appropriate intervals in the patient’s record. d. Providing patient teaching regarding proper diet for the patient diagnosed with renal failure. ANS: A Core measures are interventions that are based on scientifically researched, evidence-based standards of care, and are used to treat the majority of patients with a specific illness that often develops complications. Insulin administration for diabetics is evidence-based researched practice. The remaining options are good practice but are not considered core measures. PTS: 1 DIF: Cognitive Level: Analysis REF: 25 OBJ: 4 (theory) TOP: Core Measures KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Management of Care 22. The nurse is caring for a patient with pneumonia who complains of shortness of breath. Further assessment reveals an oxygen saturation of 89% on room air, 28 respirations/min with bilateral crackles in lung bases, blood pressure of 160/94, and a pulse rate of 102 beats/min. Which nursing diagnosis is priority for this patient?a. Activity Intolerance b. Impaired Gas Exchange c. Ineffective Cardiopulmonary Tissue Perfusion d. Self-Care Deficit: Bathing and Hygiene ANS: B While all nursing diagnoses may apply to this patient, impaired gas exchange is the highest priority because this is the underlying problem for the other nursing diagnoses, as well as physiologically the highest priority. PTS: 1 DIF: Cognitive Level: Analysis REF: 23 OBJ: 11 (clinical) TOP: Nursing Diagnosis KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Management of Care MULTIPLE RESPONSE 23. The nurse explains to the nursing student that the application of critical thinking to patient care involves which factor(s)? (Select all that apply.) a. Identification of a patient problem b. Setting priorities c. Concentrating on the patient rather than family needs d. Use of logic and intuition e. Expansion of thought beyond the obvious ANS: A, B, D, E Critical thinking as applied to nursing care requires setting priorities of patient problems and needs by using logic and intuition. Inclusion of the family in the care makes the approach family oriented. Critical thinking should go beyond the obvious. PTS: 1 DIF: Cognitive Level: Comprehension REF: 15 OBJ: 7 (clinical) TOP: Critical Thinking KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 24. Which statement(s) demonstrates application of the nursing process? (Select all that apply.) a. Performing a head-to-toe assessment. b. Updating the patient care plan on a weekly basis. c. Evaluating if patient goals have been met. d. Determining if nursing interventions need to be changed based on lack of patient progress toward meeting goals. e. Ensuring that all personnel caring for the patient are implementing the care plan and working toward the same goal. ANS: A, C, D, E The nursing care plan should be updated as necessary, not just on a weekly basis. Concepts of the nursing process are demonstrated by performing orderly, logical head-to-toe assessments, as well as ongoing evaluation of patient goals and interventions to meet those goals. PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 8 (clinical) TOP: Nursing Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 25. Which example(s) demonstrate patient care that reflects knowledge of the National Patient Safety Goals? (Select all that apply.) a. Identifying the patient prior to medication administration by asking the patient to state his or her name. b. Reporting any sentinel event to the facility’s quality assurance team. c. Assessing the patient’s heartrate prior to administration of digoxin. d. Performing hand hygiene prior to performing a patient assessment. e. Documenting the appropriate time of medication administration. ANS: C, D, E Assessing the patient’s heart rate prior to administration of digoxin demonstrates knowledge of medication actions and prevention of adverse effects; hand hygiene is required before any patient care, including assessment; and documentation of the time of medication administration is necessary to prevent medication errors. To meet National Patient Safety Goals, the nursemust use at least two methods of patient identification prior to medication administration. Reporting a sentinel event is required but demonstrates that National Patient Safety Goals were not met. PTS: 1 DIF: Cognitive Level: Application REF: 4, 23 OBJ: 4 (theory) TOP: National Patient Safety Goals KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control COMPLETION 26. The nursing student demonstrates knowledge of the proper use of the ___________ when determining that it is safe to administer meperidine (Demerol) and promethazine (Phenergan) together. ANS: Medication Reconciliation Form The Medication Reconciliation Form tracks all medications the patient is taking as prescribed by different physicians and can identify overdoses or drugs that are not compatible. PTS: 1 DIF: Cognitive Level: Application REF: 20 OBJ: 8 (clinical) TOP: Medication Reconciliation Form KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 27. Shortness of breath due to emphysema would be a major component of the _________ care plan. ANS: interdisciplinary An interdisciplinary care plan involves all members of the health care team and is based on the medical diagnosis rather than a problem statement/nursing diagnosis. PTS: 1 DIF: Cognitive Level: Application REF: 26 OBJ: 8 (clinical) TOP: Interdisciplinary Care Plan KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance MATCHING Place the steps of the nursing process in their proper sequence. a. Evaluation b. Assessment c. Implementation d. Planning e. Problem statement/nursing diagnosis 28. Step 1 29. Step 2 30. Step 3 31. Step 4 32. Step 5 28. ANS: B PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory) TOP: Applying the Nursing Process KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance 29. ANS: E PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory) TOP: Applying the Nursing Process KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance 30. ANS: D PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory) TOP: Applying the Nursing Process KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance 31. ANS: C PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory) TOP: Applying the Nursing ProcessKEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance 32. ANS: A PTS: 1 DIF: Cognitive Level: Comprehension REF: 17 OBJ: 4 (theory) TOP: Applying the Nursing Process KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance Chapter 03: Fluid, Electrolytes, Acid-Base Balance, and Intravenous Therapy deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition MULTIPLE CHOICE 1. The nurse uses a diagram to demonstrate how in dehydration the water is drawn into the plasma from the cells by which process? a. Distillation b. Diffusion c. Filtration d. Osmosis ANS: D The process of osmosis accomplishes the movement of water from the cells into the plasma, causing dehydration. PTS: 1 DIF: Cognitive Level: Knowledge REF: 32 OBJ: 3 (theory) TOP: Dehydration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse assessing a patient with vomiting and diarrhea observes that the urine is scant and concentrated. Which controlling factor is responsible for compensatory reabsorption of water? a. Osmoreceptors in the hypothalamus b. Antidiuretic hormone in the posterior pituitary c. Baroreceptors in the carotid sinus d. Insulin from the pancreas ANS: B The antidiuretic hormone controls how much water leaves the body by reabsorbing water in the renal tubules. PTS: 1 DIF: Cognitive Level: Comprehension REF: 30 OBJ: 2 (theory) TOP: Regulation of Body Fluids KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse uses a picture to show how ions equalize their concentration by which passive transport process? a. Osmosis b. Filtration c. Titration d. Diffusion ANS: D Diffusion is the process by which substances move back and forth across compartment membranes until they are equally divided. PTS: 1 DIF: Cognitive Level: Knowledge REF: 31 OBJ: 2 (theory) TOP: Diffusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. Which term describes the active transport process that moves sodium and potassium into or out of cells? a. Filtration b. Sodium pump c. Diffusion d. Osmosis ANS: B The sodium pump is the mechanism by which sodium and potassium are moved into or out of cells regardless of the concentration.PTS: 1 DIF: Cognitive Level: Knowledge REF: 32 OBJ: 2 (theory) TOP: Active Transport KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The patient taking furosemide (Lasix) to correct excess edema shows a weight loss of 5.5 pounds in 24 hours. The nurse calculates that this weight loss is equivalent to how many liters (L) of fluid? a. 1 L b. 1.5 L c. 2.0 L d. 2.5 L ANS: D Each kilogram (2.2 pounds) of weight loss is equivalent to 1 liter of fluid. Therefore, 5.5 pounds ÷ 2.2 pounds = 2.5 liters. PTS: 1 DIF: Cognitive Level: Application REF: 33, Clinical Cues OBJ: 1 (clinical) TOP: Fluid Loss KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. The nurse is caring for a patient with a potassium level of 2.9 mEq/L. The nurse should carefully monitor the patient for which potential problem? a. Excessive urinary output b. Abdominal distention c. Increased reflexes d. Hyperactive bowel sounds ANS: B A potassium level lower than 3.5 mEq/L results in reduced urine output, cardiac dysrhythmia, muscle weakness, abdominal pain and distention, paralytic ileus, lethargy, and confusion. PTS: 1 DIF: Cognitive Level: Application REF: 41, Table 3-4 OBJ: 15 (clinical) TOP: Hypokalemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 7. While the nurse is washing the face of a patient in renal failure, the patient demonstrates a spasm of the lips and face. Which laboratory value corresponds with the nurse’s assessment findings? a. Potassium of 3.4 mEq/L b. Calcium of 7.9 mg/dL c. Sodium of 140 mEq/L d. Phosphorus of 2.8 mg/dL ANS: B Chvostek sign is a signal of hypocalcemia. It occurs when the facial nerve is tapped or stroked about an inch in front of the earlobe and results in unilateral twitching of the face. Hypocalcemia occurs when the calcium level drops below 8.4. A potassium level of 3.4 mEq/L and a sodium level of 140 mEq/L are findings within normal limits. A patient in renal failure is most likely to have a high phosphorus level rather than a low phosphorus level, and 2.8 mg/dL is within the range consistent with hypophosphatemia. PTS: 1 DIF: Cognitive Level: Analysis REF: 43, Table 3-4 OBJ: 4 (theory) TOP: Chvostek Sign KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. Which finding is most important for the nurse to confirm prior to hanging an intravenous (IV) bag containing potassium? a. Verify a blood pressure of at least 60 mm Hg diastolic. b. Check for urine output of at least 30 mL/hr. c. Ensure filter placement on the IV line. d. Verify a pulse of at least 50 beats/min. ANS: B An adequate urine output must be present prior to the administration of potassium to ensure adequate excretion of potassium, preventing hyperkalemia.PTS: 1 DIF: Cognitive Level: Application REF: 43, Safety Alert OBJ: 10 (theory) TOP: Administration of IV Potassium KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 9. Which statement demonstrates that the patient accurately understands the nurse’s teaching related to a low-sodium diet? a. “I can have all the dried fruits I want.” b. “I’m looking forward to a tall glass of tomato juice.” c. “I’m going to eat my favorite avocado and orange salad.” d. “I’m going to eat a cheeseburger with extra ketchup.” ANS: C Avocado and oranges have no significant sodium content. Dried fruits, tomato juice, cheese, and ketchup are foods with high sodium content that should be limited or avoided. PTS: 1 DIF: Cognitive Level: Application REF: 43, Nutrition Considerations OBJ: 4 (clinical) TOP: Low-Sodium Diet KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 10. The nurse is caring for an 80-year-old patient. Which finding is the best early indicator of dehydration in this patient? a. Reduced skin turgor b. Constipation c. Increased temperature d. Thirst ANS: B The nurse understands that this patient’s age places him at greater risk for dehydration. Constipation is the best early indicator of dehydration in the older adult. Older adults have age-related poor skin turgor. Increased temperature and thirst are later signs of dehydration. PTS: 1 DIF: Cognitive Level: Analysis REF: 33-34 OBJ: 5 (theory) TOP: Dehydration in the Older Adult KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 11. The patient with long-term obstructive pulmonary disease has a pH of 7, HCO3– of 18 mEq/L, and a PaCO2 of 40 mm Hg. These laboratory values are consistent with which acid-base imbalance? a. Respiratory alkalosis b. Metabolic alkalosis c. Respiratory acidosis d. Metabolic acidosis ANS: D These results are indicative of metabolic acidosis. PTS: 1 DIF: Cognitive Level: Application REF: 46 OBJ: 15 (clinical) TOP: Respiratory Acidosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 12. The nurse is caring for a young patient with asthma. Which activity should the nurse encourage in order to help prevent respiratory acidosis? a. Engage in deep-breathing exercises every 2 hours. b. Drink 8 ounces of fluid every 4 hours. c. Ambulate for 15 minutes twice a day. d. Sleep with the head of the bed elevated 45 degrees. ANS: A Deep breathing blows off CO2, which reduces the acid ions, thus preventing respiratory acidosis. Drinking fluids prevents dehydration and keeps secretions moist and thin, and sleeping with the head of the bed elevated will ease breathing and improve gas exchange. Ambulating 15 minutes twice a day does not have an impact on respiratory acidosis.PTS: 1 DIF: Cognitive Level: Analysis REF: 46 OBJ: 8 (theory) TOP: Respiratory Acidosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. The patient who has had diarrhea for the last 3 days has blood gases of pH of 7.1, HCO3- of 20 mEq/L, and PCO2 of 36 mm Hg. These laboratory values are consistent with which acid-base imbalance? a. Respiratory alkalosis b. Metabolic alkalosis c. Respiratory acidosis d. Metabolic acidosis ANS: D Metabolic acidosis shows a low pH, low HCO3-, and normal CO2. PTS: 1 DIF: Cognitive Level: Application REF: 46 OBJ: 8 (theory) TOP: Metabolic Acidosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 14. The nurse is caring for a patient with metabolic acidosis. Which assessment finding reveals that the compensatory mechanism to correct this imbalance is in effect? a. Increased urinary output b. Reduced abdominal distention c. Kussmaul respirations d. Decreased blood pressure ANS: C Kussmaul respirations, or deep and rapid respirations, are blowing off carbon dioxide to reduce an acidotic state. PTS: 1 DIF: Cognitive Level: Application REF: 47 OBJ: 7 (theory) TOP: Metabolic Acidosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. The nurse assesses the patient’s IV insertion site and observes that the vein is hard, the skin is red and tender, and a blood return in the IV line. After removing the IV catheter, which action should the nurse take next? a. Obtain an arm board to properly secure the IV. b. Elevate the arm above the level of the heart. c. Clean the site with alcohol and apply cool compresses. d. Apply a warm moist pack. ANS: D These are signs and symptoms of phlebitis and should be treated with a warm moist pack to increase blood flow to the area. The IV has been discontinued, so an arm board for stabilization is unnecessary. Elevation of the arm would be helpful to reduce swelling. A cool compress would be indicated for other issues related to IV infusion problems, such as extravasation. PTS: 1 DIF: Cognitive Level: Application REF: 51 OBJ: 18 (clinical) TOP: Phlebitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 16. Because there are no IV pumps available for the immediate infusion of an IV medication, the nurse must calculate the flow rate for 500 mL to run for 4 hours, using a set that delivers 15 gtt/mL. Which flow rate is correct? a. 30 gtt/min b. 35 gtt/min c. 40 gtt/min d. 45 gtt/min ANS: A 500 mL to be given in 4 hours equals 125 mL/hr. 125 mL ÷ 60 minutes = 2 mL/min × 15 gtt/mL = 30 gtt/min. PTS: 1 DIF: Cognitive Level: Application REF: 53 OBJ: 12 (theory) TOP: Calculation of IV Flow Rate KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort17. The count of the solution in the IV container at the beginning of the shift is 800 mL. A new 1000-mL bag was hung during the shift and has 650-mL left at the end of the shift. What amount should the nurse record as the IV fluid intake for the shift? a. 1000 mL b. 1050 mL c. 1100 mL d. 1150 mL ANS: D 800 mL + 350 mL from second bag = 1150 mL. PTS: 1 DIF: Cognitive Level: Application REF: 53-54 OBJ: 12 (theory) TOP: Calculating IV Fluid Intake KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 18. After selecting an appropriate fluid, which action should the nurse take to correctly flush a PRN lock? a. Flush forcefully to clear the lumen. b. Use slow, gentle pressure to clear the lumen. c. Flush hard enough to clear resistance. d. Aspirate for blood return prior to flushing. ANS: B The standard of care utilizes slow, gentle pressure. The nurse should stop the flush if resistance is met. Resistance may indicate a clot and force would break the clot loose. Aspiration is not necessary. PTS: 1 DIF: Cognitive Level: Application REF: 54 OBJ: 18 (clinical) TOP: Flushing PRN Lock KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 19. The nurse is caring for a patient who has been on total parenteral nutrition (TPN) for 48 hours. Which action demonstrates effective nursing care? a. Checking the patient’s blood glucose level according to facility protocol. b. Increasing the infusion rate if the prescribed intake falls behind. c. Informing the patient that TPN can only be administered via a central line for 1 week. d. Monitoring the peripheral IV site of TPN infusion for signs of infiltration at least every 8 hours. ANS: A The hypertonic solution causes difficulty with glucose tolerance, so monitoring of blood glucose level is imperative. The infusion rate should never be increased to “catch up” because of the likelihood of fluid overload caused by the hypertonicity of the TPN. TPN can be administered for more than 1 week and it is almost always administered via a central line rather than a peripheral line. PTS: 1 DIF: Cognitive Level: Application REF: 55 OBJ: 19 (clinical) TOP: TPN KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 20. The nurse is assessing a patient with renal failure and notes fatigue, muscle cramps, confusion, and headache. Which laboratory abnormality corresponds with these findings? a. Potassium of 3.3 mEq/L b. Sodium of 129 mEq/L c. Calcium of 8.2 mg/dL d. Chloride of 105 mEq/L ANS: B The patient is demonstrating signs and symptoms of hyponatremia; therefore, the nurse should assess the patient’s sodium level. PTS: 1 DIF: Cognitive Level: Application REF: 40, Table 3-4 OBJ: 15 (clinical) TOP: Hyponatremia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Management of CareMULTIPLE RESPONSE 21. The nurse is assessing the hydration status of the patient. Which action(s) demonstrates knowledge of proper assessment? (Select all that apply.) a. Monitoring the patient’s daily weight. b. Assessing the patient’s skin turgor on the back of the hand. c. Checking the patient’s blood glucose level four times a day. d. Assessing for skin tenting on the patient’s forehead. e. Asking the patient if he is experiencing thirst. ANS: A, D, E The skin of the abdomen, forearm, sternum, forehead, and thigh can be “tented” as a test for skin turgor by gently pinching up a fold of skin and observing the delay in return to normal. Assessment of skin turgor is not reliable on the back of the hand. Weight and experiencing thirst can be indicators of hydration status, along with further assessment. The patient’s blood glucose level is not an assessment parameter for hydration status. PTS: 1 DIF: Cognitive Level: Application REF: 33 OBJ: 13 (clinical) TOP: Assessment Data: Skin Turgor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 22. The nurse is caring for a patient that has a potassium level of 5.0. The nurse should carefully monitor the patient for which signs and symptoms? (Select all that apply.) a. Muscle weakness b. Cardiac dysrhythmias c. Decreased reflexes d. Urinary retention e. Hypotension ANS: A, B, E Normal potassium level is 3.5 to 5.0 mEq/L. Because the patient is on the highest end of normal, the nurse should monitor for signs of hyperkalemia. Muscle weakness, cardiac dysrhythmias, and hypotension are signs of hyperkalemia. Decreased reflexes and urinary retention are signs of hypokalemia. PTS: 1 DIF: Cognitive Level: Application REF: 43 OBJ: 15 (clinical) TOP: Hyperkalemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 23. The primary care provider writes an order for the patient to receive an IV of a solution that has the same osmotic pressure as intracellular fluid. The nurse would correctly question which IV order(s)? (Select all that apply.) a. 5% dextrose in water b. 0.45% sodium chloride c. 5% dextrose in 0.9% sodium chloride d. Lactated Ringer solution e. 0.9% sodium chloride ANS: B, C The solution being prescribed is an isotonic solution. 5% dextrose in water, lactated Ringer solution, and 0.9% sodium chloride are all isotonic solutions, whereas 0.45% sodium chloride is a hypotonic solution, and 5% dextrose in 0.9% sodium chloride is a hypertonic solution. PTS: 1 DIF: Cognitive Level: Analysis REF: 48-49 OBJ: 11 (theory) TOP: Isotonic Solutions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 24. The nurse is caring for a newly admitted patient with uncontrolled nausea and vomiting. The patient has a history of alcoholism and diabetes. After receiving these orders from the health care provider, which order(s) should the nurse question? (Select all that apply.) a. Administer 10 mg prochlorperazine maleate (Compazine), IM every 4 to 6 hours for nausea and vomiting. b. Administer diphenoxylate atropine (Lomotil), two tabs, by mouth after first occurrence of nausea and vomiting.c. Administer furosemide (Lasix) 40 mg by slow IV push. d. Monitor the patient’s intake and output every 4 hours. e. Obtain patient’s weight every morning and record. ANS: A, B, C A primary concern in a patient with uncontrolled vomiting includes monitoring hydration status. Intake and output and daily weights are indicators of hydration status and should be assessed. Prochlorperazine maleate (Compazine) should not be given with alcohol intake. Because the patient has a history of alcoholism, it would be best to administer an antiemetic that is not contraindicated with possible alcohol intake. Diphenoxylate atropine (Lomotil) is an antidiarrheal, not an antiemetic. Lasix is a powerful loop diuretic that would exacerbate the patient’s volume depletion. PTS: 1 DIF: Cognitive Level: Analysis REF: 33, Box 3-2, 36, Table 3-2, 50, Table 3-6 OBJ: 13 (clinical) TOP: Hydration Status KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 25. The nurse demonstrates knowledge of IV solutions by identifying that the IV solution which provides free water, as well as 340 calories/L, is ______________. ANS: 10% dextrose in water 10% dextrose in water provides free water with no electrolytes and 340 calories/L. PTS: 1 DIF: Cognitive Level: Comprehension REF: 50, Table 3-6 OBJ: 12 (theory) TOP: IV Fluids KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 26. The nurse explains to the 85-year-old patient with a temperature that, with each degree of fever, the body loses _____% of water. ANS: 10 With each degree of fever, the body has an insensible loss of 10% of its water. PTS: 1 DIF: Cognitive Level: Comprehension REF: 32 OBJ: 5 (theory) TOP: Insensible Loss KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 27. The nurse reminds the patient that the three body mechanisms that attempt to compensate to correct acid-base imbalances are the __________ system, the __________ system, and the __________. ANS: buffer; respiratory; kidneys buffer; kidneys; respiratory respiratory; buffer; kidneys respiratory; kidneys; buffer kidneys; respiratory; buffer kidneys; buffer; respiratory The buffer system, the respiratory system, and the kidneys contribute unique compensations to correct an acid-base imbalance. PTS: 1 DIF: Cognitive Level: Comprehension REF: 44 OBJ: 8 (theory) TOP: Acid-Base Compensatory Mechanisms KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation MATCHINGThe nurse explains that the chain of events that results in hypocalcemia for the patient in early renal failure occurs in which order? (Match the events to the proper sequence.) a. Loss of calcium ions b. Vitamin D not activated c. Bone loss d. Retention of phosphates e. Loss of absorption of calcium from the gastrointestinal tract 28. Step 1 29. Step 2 30. Step 3 31. Step 4 32. Step 5 28. ANS: D PTS: 1 DIF: Cognitive Level: Analysis REF: 43 OBJ: 4 (theory) TOP: Hypocalcemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 29. ANS: A PTS: 1 DIF: Cognitive Level: Analysis REF: 43 OBJ: 4 (theory) TOP: Hypocalcemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 30. ANS: B PTS: 1 DIF: Cognitive Level: Analysis REF: 43 OBJ: 4 (theory) TOP: Hypocalcemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 31. ANS: E PTS: 1 DIF: Cognitive Level: Analysis REF: 43 OBJ: 4 (theory) TOP: Hypocalcemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 32. ANS: C PTS: 1 DIF: Cognitive Level: Analysis REF: 43 OBJ: 4 (theory) TOP: Hypocalcemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation Chapter 04: Care of Preoperative and Intraoperative Surgical Patients deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who has received epoetin alfa (Epogen) 2 to 3 weeks prior to a scheduled surgery. Which statement best explains the goal for Epogen administration prior to surgery? a. The patient will only require a single antibiotic immediately prior to surgery. b. The patient will have greater numbers of white blood cells (WBCs) following surgery. c. The patient will not require a blood transfusion during surgery. d. The patient will maintain stable potassium levels during surgery. ANS: C Epoetin alfa (Epogen) is given to increase red blood cell production prior to surgery with the goal of having a bloodless surgery. Epoetin alfa (Epogen) will not affect the need for an antibiotic preoperatively, nor will it affect WBCs or serum potassium levels. PTS: 1 DIF: Cognitive Level: Application REF: 62 OBJ: 1 (theory) TOP: Bloodless Surgery KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance 2. The nurse is performing a preoperative assessment on a patient scheduled for surgery today. The patient reports drinking two glasses of wine daily, smoking one pack of cigarettes daily ´ 20 years, completing a round of corticosteroids for asthma control 2 days ago, and taking a dose of passion flower extract yesterday. Which action should the nurse take next? a. Supply the patient with information on a smoking cessation class.b. Educate the patient regarding the dangers of drinking alcohol on a daily basis. c. Provide the patient with information regarding the dangers of using herbal medications. d. Notify the physician immediately regarding the patient’s recent use of corticosteroids. ANS: D The use of corticosteroids reduces the body’s response to infection and delays healing. Surgery may need to be delayed until the patient has been off the drug approximately 7 days. Providing the patient with information regarding smoking cessation is advisable but is not a priority at this time. Drinking two glasses of wine daily may not be a problem if not contraindicated by the patient’s health status. Passion flower extract does not interfere with the surgery and poses no apparent problems. PTS: 1 DIF: Cognitive Level: Analysis REF: 65, Table 4-2 OBJ: 2 (theory) TOP: Perioperative Management KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 3. The nurse is caring for a presurgical patient. The patient asks the nurse why her height and weight are recorded. How should the nurse respond? a. “This information helps us to correctly calculate the anesthesia dose.” b. “Height and weight are important predictors of blood loss.” c. “This information is used to assess respiratory volume.” d. “Height and weight help us anticipate your fluid needs.” ANS: A Height and weight are used to calculate anesthesia dosages. PTS: 1 DIF: Cognitive Level: Comprehension REF: 76 OBJ: 3 (theory) TOP: Presurgical Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 4. The nurse is reviewing the presurgical patient’s laboratory reports and notes an elevated aspartate aminotransferase (AST) and bilirubin. The nurse understands that this patient is most at risk for which potential complication? a. Excessive bleeding during or after surgery b. An increased serum albumin level c. Postsurgical respiratory infection d. Delayed wound healing ANS: A The AST and bilirubin are liver studies. Elevated levels may indicate a dysfunctional liver. The liver is directly involved with clotting factors; therefore, this patient would be at risk for excessive bleeding. The serum albumin level would most likely be decreased if the liver is not functioning properly. Postsurgical wound infection and delayed wound healing risks are not directly related to liver function. PTS: 1 DIF: Cognitive Level: Analysis REF: 64, Box 4-2, 65, Table 4-2 OBJ: 2 (theory) TOP: Preoperative Lab Studies KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 5. The patient received a preoperative dose of lorazepam (Ativan) 20 minutes ago. Which safety precaution should the nurse take? a. Monitor respiratory status. b. Raise the bed rails. c. Elevate the head of the bed 30 degrees. d. Take seizure precautions. ANS: B Raising the bed rails is a safety precaution against the dizziness and hypotension caused by this drug. PTS: 1 DIF: Cognitive Level: Application REF: 71, Safety Alert OBJ: 12 (clinical) TOP: Preoperative Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential6. The nurse is caring for an 82-year-old presurgical patient. Which abnormal finding is most important for the nurse to report immediately? a. Respiratory rate of 22 breaths/min b. Report of extreme thirst c. Dizziness d. Temperature of 99.8° F ANS: D When assessing the presurgical patient, any significant deviations from normal range should be brought to the attention of the surgeon. An elevated temperature might indicate an infection that would need to be brought under control before surgery. Respiratory status is important, but a rate of 22 breaths/min is minimally abnormal. Borderline tachypnea, thirst, and dizziness are not necessarily indicative of a larger underlying problem. PTS: 1 DIF: Cognitive Level: Analysis REF: 63 OBJ: 2 (theory) TOP: Assessment of Surgical Risk Factors KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 7. The patient refuses to take off her diamond wedding band prior to going to the operating room. What action should the nurse take first? a. Document the patient’s refusal to remove the jewelry. b. Tape the ring to finger, covering the ring. c. Request that the patient sign a waiver to release the hospital from responsibility. d. Alert the surgery team to the presence of the jewelry. ANS: B Taping the ring will protect the ring and secure it to the finger. Care must be taken not to wrap the tape too tightly. The nurse will also need to document the presence of the ring on the preoperative checklist or in the nurse’s notes. There is no need for a signature on a waiver. Most facilities have policies in which the patient signs a release of responsibility for valuables. There is no need to notify the surgical team of the presence of the ring. PTS: 1 DIF: Cognitive Level: Comprehension REF: 71 OBJ: 3 (theory) TOP: Immediate Preoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 8. The nurse is caring for an Asian patient who received atropine as a preoperative drug. For which problem should the nurse should carefully monitor the patient? a. Oliguria b. Hyperventilation c. Hypotension d. Tachycardia ANS: D Asians often metabolize atropine differently from other populations. The drug can greatly accelerate the heart rate in the Asian patient. PTS: 1 DIF: Cognitive Level: Application REF: 71, Cultural Considerations OBJ: 2 (theory) TOP: Immediate Preoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 9. Which patient statement indicates a need for further instruction about the emotional preparation for surgery? a. “I’m going to hug my surgeon tomorrow.” b. “My fate is in the hands of my surgeon. I’m frightened about the outcome.” c. “I’ll be ready for a cheeseburger when I get back.” d. “I know I may have some pain, but this gallbladder will be gone when I wake up.” ANS: B This response demonstrates the patient’s fear and insecurity, which warrant further discussion. Providing additional information or answering patient questions may help alleviate the patient’s emotional unpreparedness for surgery. The plan for a cheeseburger indicates a potential need to further review nutrition in the postoperative period. The other responses demonstrate positive statements regarding the upcoming postsurgical period.PTS: 1 DIF: Cognitive Level: Analysis REF: 69 OBJ: 3 (theory) TOP: Planning KEY: Nursing Process Step: Evaluation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 10. Which action should the nurse take prior to administering the preoperative doses of Demerol and atropine? a. Ensure that a family member is present. b. Remove the patient’s underwear. c. Verify that a consent form is signed. d. Raise each of the bed rails. ANS: C Consent forms must be signed prior to giving any sedative or preoperative drug. Removal of underwear and the raising of the side rails can be done after the administration of the drug. The family member does not have to present. PTS: 1 DIF: Cognitive Level: Comprehension REF: 68 OBJ: 12 (clinical) TOP: Obtaining Consent KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 11. Which person is responsible for verifying that the consent form is signed and that the surgical site? a. The scrub nurse b. The surgeon c. The anesthesiologist d. The circulating nurse ANS: D The circulating nurse is responsible for confirming a signature on the consent form and marking the site for surgery. PTS: 1 DIF: Cognitive Level: Comprehension REF: 74, Box 4-4 OBJ: 7 (theory) TOP: Circulating Nurse Duties KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 12. The nurse warns the patient that, in order to retard the growth of microorganisms, the operating room temperature must be maintained in which range? a. 60 to 65° F b. 66 to 70° F c. 71 to 74° F d. 75 to 77° F ANS: B The operating suite is kept at a temperature of 66 to 70° F to discourage microbial growth. PTS: 1 DIF: Cognitive Level: Knowledge REF: 73 OBJ: 3 (theory) TOP: The Surgical Suite KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 13. The nurse is caring for a patient in the immediate preoperative period. Which action best demonstrates compliance with the National Patient Safety Goals protocol? a. The nurse accompanies the patient to the operating room. b. The nurse raises all side rails and elevates the head of the bed to 30 degrees. c. The nurse verifies and marks the surgical site. d. The nurse identifies all prosthetic devices before the time-out. ANS: C The National Patient Safety Goals require that the patient be identified, the surgical consent be signed and correct, and the surgical site be marked. PTS: 1 DIF: Cognitive Level: Application REF: 74, Box 4-4 OBJ: 3 (theory) TOP: Immediate Preoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care14. The nurse clarifies the difference between regional anesthesia and procedural sedation anesthesia. Which statement about procedural sedation anesthesia is true? a. Procedural sedation anesthesia uses both intravenous (IV) sedation and regional anesthesia. b. Procedural sedation anesthesia uses both general anesthesia and IV sedation. c. Procedural sedation anesthesia uses both alternative medicine herbs and regional anesthesia. d. Procedural sedation anesthesia uses both IV sedation and local anesthesia. ANS: A Procedural sedation anesthesia uses both IV sedation and regional anesthesia. PTS: 1 DIF: Cognitive Level: Comprehension REF: 75, Table 4-3 OBJ: 8 (theory) TOP: Types of Anesthesia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 15. During the course of surgery, a patient exhibits tachycardia, diaphoresis, and rising body temperature. Which is the circulating nurse’s priority intervention? a. Monitor the patient for any further changes in condition. b. Note the patient’s oxygen saturation and blood pressure. c. Ask the scrub nurse to verify the assessment findings. d. Alert the anesthesiologist and surgeon immediately. ANS: D These are signs of malignant hyperthermia, along with arrhythmias, muscle rigidity, and hypotension. The anesthesiologist and surgeon should be notified immediately because malignant hyperthermia is a medical emergency. The nurse should continue to monitor the patient. The nurse should verify the patient’s oxygen saturation and blood pressure in conjunction with the anesthesiologist and surgeon. PTS: 1 DIF: Cognitive Level: Analysis REF: 76 OBJ: 13 (clinical) TOP: Malignant Hyperthermia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 16. The nurse is caring for a postsurgical patient whose surgical procedure lasted 3 hours. Which complication should the nurse anticipate? a. Thrombophlebitis b. Muscle spasms c. Joint pain d. Hyperthermia ANS: C Long-term immobility places the patient at risk for pressure damage to skin and underlying tissues. Joint complaints are common after a long surgery. Thrombophlebitis, muscle spasms, and hyperthermia are complications that are not expected to occur. PTS: 1 DIF: Cognitive Level: Application REF: 77 OBJ: 4 (theory) TOP: Intraoperative Complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 17. The nurse is caring for a patient who has just been given medication to reverse neuromuscular blocking agents. The nurse is aware that the patient is in which general anesthetic stage? a. Induction b. Introduction c. Emergence d. Maintenance ANS: C Emergence is the stage of surgery in which surgery is completed and the patient is prepared to return to consciousness, and neuromuscular blocking agents are reversed. PTS: 1 DIF: Cognitive Level: Comprehension REF: 76 OBJ: 8 (theory) TOP: Stages of General Anesthesia KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation18. The nurse is planning care for four postoperative patients. Which patient is most likely to develop postoperative complications? a. 36-year-old with a history of controlled diabetes b. 62-year-old with a history of hypothyroidism c. 49-year-old with a history of a myocardial infarction (MI) d. 76-year-old with mild osteoarthritis ANS: D Patients over the age of 75 are three times more likely to experience surgical complications. An older adult is less able to adjust and compensate for the stress of surgery, as physiologic reserves (cardiac, respiratory, and renal) have already declined with age. PTS: 1 DIF: Cognitive Level: Analysis REF: 62, Older Adult Care Points OBJ: 4 (theory) TOP: Postoperative Complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 19. The LPN/LVN is in the patient’s room while the charge nurse is obtaining the patient’s signature on the surgical consent form. The patient states, “I didn’t really understand what my surgeon explained, but I trust him completely.” How should the nurse respond? a. “I need to contact your surgeon so your questions can be answered.” b. “I can answer any questions that you might have regarding your surgery.” c. “As long as you are comfortable, then you may sign the consent form.” d. “Maybe we should call your surgeon to be sure it is okay to sign the consent.” ANS: A An informed consent means that the surgeon has supplied information regarding the procedure itself, as well as the risks and benefits, and that the patient understands this information. The nurse’s responsibility is witnessing the signing of the form and ensuring the patient understands what the surgeon has discussed, not providing information if the patient has no understanding of the procedure. PTS: 1 DIF: Cognitive Level: Application REF: 68 OBJ: 3 (theory) TOP: Informed Consent KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Management of Care MULTIPLE RESPONSE 20. The patient questions the nurse about robotics surgery. Which information should the nurse include? (Select all that apply.) a. “Robotics gives the surgeon greater magnification than the human eye.” b. “Robotics allows the surgeon to be more precise than normal.” c. “Robotics allows for a smaller incision.” d. “Robotics increases healing time.” e. “Robotics procedures generally cause less postoperative pain.” ANS: A, B, C, E Robotics have 12 times magnification of the operative site, steady “hands,” and use a smaller incision, which results in less postoperative pain. Healing time is decreased with robotics. PTS: 1 DIF: Cognitive Level: Comprehension REF: 60-62 OBJ: 1 (theory) TOP: Robotic Surgery KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 21. Which physiological change(s) explain why the older adult is at greater surgical risk? (Select all that apply.) a. Fewer physiologic reserves b. Greater probability of a chronic illness c. Greater vulnerability to fluid loss d. Less tolerance for pain e. Less psychological stamina ANS: A, B, CThe older adult does have less physiologic reserves, more probability for a chronic illness, and more vulnerability to fluid loss. There is no indication that the older adult has less tolerance for pain or less psychological stamina. PTS: 1 DIF: Cognitive Level: Comprehension REF: 62, Older Adult Care Points OBJ: 4 (theory) TOP: Older Adult Surgical Patient KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. What are the purposes of preoperative medication? (Select all that apply.) a. To reduce anxiety b. To decrease mucus secretion c. To counteract nausea d. To synergize anesthesia e. To enhance ventilation ANS: A, B, C, D Preoperative medications are given to reduce anxiety, decrease mucus production, counteract nausea, and enhance anesthesia. Many preoperative medications depress ventilation. PTS: 1 DIF: Cognitive Level: Comprehension REF: 71 OBJ: 3 (theory) TOP: Preoperative Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 23. Which responses indicate to the nurse that the patient understands preoperative teaching? (Select all that apply.) a. “I will need to sign a consent form before I am given my medications prior to my surgery.” b. “The surgeon will want me to ambulate as soon as possible after my surgery.” c. “My nurse will want me to take the deepest breaths I can tolerate following my surgery.” d. “I may experience some constipation if I am taking much pain medication after my surgery.” e. “The general anesthesia will prevent me from having pain for the first 24 hours after surgery.” ANS: A, B, C, D Consent forms must be signed before preoperative pain medications are administered; early ambulation is common with most surgeries; deep breaths prevent postoperative respiratory complications; and constipation is common with the use of narcotic analgesics. General anesthesia does not prevent pain 24 hours after surgery, so this statement demonstrates the need for further preoperative teaching. PTS: 1 DIF: Cognitive Level: Application REF: 66 OBJ: 5 (theory) TOP: Preoperative Teaching KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 24. Which factor(s) may contribute to hypothermia during surgery? (Select all that apply.) a. Warm atmosphere of the operating room b. Infusion of cool IV fluids c. Inhalation of cool anesthetic gases d. Exposure of body surfaces e. Lowered metabolism ANS: B, C, D, E The infusion of cool IV fluids, inhalation of cool anesthetic gases, exposure of body surfaces, and lowered metabolism predispose patients to hypothermia during surgery. The operating room is kept cool to inhibit growth of organisms. PTS: 1 DIF: Cognitive Level: Application REF: 76 OBJ: 3 (theory) TOP: Potential Intraoperative Complications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. The nurse is providing preoperative teaching to a patient who is scheduled for a needle biopsy of the breast. Which statement(s) demonstrate(s) a need for further preoperative teaching? (Select all that apply.) a. “This procedure will help the doctor determine if I have breast cancer.” b. “I will most likely have general anesthesia since this is a painful procedure.” c. “The surgeon will need to perform this procedure within the next 24 to 48 hours.”d. “I will have less breast pain after having this procedure performed.” e. “I will not require any further treatment after this procedure is performed.” ANS: B, C, D, E A needle breast biopsy is a diagnostic procedure that is used to determine if cancer cells are present. This procedure typically requires only a local or regional anesthetic; procedures that must be performed within 24 to 48 hours are considered urgent procedures for immediate life-threatening conditions; indicating that less pain will be experienced describes a palliative procedure; and indicating that less breast pain will occur describes a curative procedure. PTS: 1 DIF: Cognitive Level: Application REF: 61, Table 4-1 OBJ: 5 (theory) TOP: Preoperative Teaching KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 26. The nurse reminds the patient that in laparoscopic surgery, with the small incision and less tissue trauma, there is less pain because of the diminished ______________. ANS: inflammatory response There is less trauma, therefore less inflammatory response, which reduces pain. PTS: 1 DIF: Cognitive Level: Comprehension REF: 60 OBJ: 1 (theory) TOP: Laparoscopic Surgery KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 27. A(n) ________________ allows a patient to donate her own blood to be used during or after surgery. ANS: autologous transfusion An autologous transfusion is one in which the patient has donated her own blood to be used during or after surgery. PTS: 1 DIF: Cognitive Level: Comprehension REF: 62 OBJ: 1 (theory) TOP: Autologous Transfusion KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 28. The _____________functions within the sterile area of the operating room and maintains sterile technique. ANS: scrub nurse scrub person The scrub nurse is a licensed nurse or surgery technician who functions in the sterile area of the operating room and maintains sterility throughout the operative procedure. PTS: 1 DIF: Cognitive Level: Knowledge REF: 74, Box 4-3 OBJ: 7 (theory) TOP: Scrub Nurse Duties KEY: Nursing Process Step: N/A MSC: NCLEX: N/A Chapter 05: Care of Postoperative Patients deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition MULTIPLE CHOICE 1. The postanesthesia care unit (PACU) nurse determines that the patient’s Aldrete score is 9. Which statement correctly describes the meaning of this score? a. The patient is at an increased risk for postoperative respiratory complications.b. The patient’s condition warrants close monitoring. c. The patient is experiencing severe pain. d. The patient will soon be transferred to the postoperative unit. ANS: D The Aldrete scoring system is a method of determining readiness for a surgery patient to be transferred from PACU to the postoperative unit. Scores are given for activity, respiration, circulation, consciousness, skin color, and oxygen saturation. A score of 9 or 10 indicates readiness for transfer. PTS: 1 DIF: Cognitive Level: Application REF: 81 OBJ: 5 (clinical) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 2. The nurse is caring for a patient recovering in the PACU. The patient awakens confused and disoriented. What action should the nurse take first? a. Take the patient’s vital signs. b. Encourage the patient to return to sleep. c. Reorient and reassure the patient. d. Document that the patient is awake and disoriented. ANS: C The patient should be reoriented and assured when awaking from anesthesia. PTS: 1 DIF: Cognitive Level: Comprehension REF: 81 OBJ: 1 (theory) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. The PACU nurse is caring for a semiconscious patient immediately following abdominal surgery. The nurse correctly places the patient in which position? a. Supine b. Semi-Fowler c. Lateral d. Trendelenburg ANS: C Aspiration is a high-risk complication during this phase of recovery and can best be prevented by placing the unconscious or semiconscious patient on the side with head turned to the side. PTS: 1 DIF: Cognitive Level: Application REF: 83 OBJ: 6 (clinical) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 4. The PACU nurse is caring for an unconscious patient. Assessment reveals diminished breath sounds bilaterally. Which action should the nurse take? a. Hyperventilate the patient with an Ambu bag. b. Increase bi-nasal oxygen to 3 L/min. c. Elevate the head of bed 45 degrees. d. Document “diminished breath sounds in both lower lobes.” ANS: D Mild atelectasis is an expected sign after anesthesia for the first 48 hours after surgery. This finding is considered a normal finding while the patient is in the PACU and would require no further intervention unless other signs and symptoms, such as decreased oxygen saturation, were present. PTS: 1 DIF: Cognitive Level: Application REF: 83, 91 OBJ: 4 (theory) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse is caring for a patient during the first postoperative day. Which goal works to prevent atelectasis and is most appropriate for the nursing care plan?a. Patient will turn, cough, and deep-breathe every 4 hours. b. Patient will “huff-cough” every 2 hours. c. Patient will use the incentive spirometer twice a day. d. Patient will resume diet as soon as possible. ANS: B Bi-hourly coughing will help prevent atelectasis. The patient should turn, cough, and deep-breathe every 2 hours, and the incentive spirometer should ideally be used every hour. Resuming diet does not prevent atelectasis, and as soon as possible is not a measurable amount. PTS: 1 DIF: Cognitive Level: Analysis REF: 91, Table 5-2 OBJ: 3 (theory) TOP: Maintenance of Ventilation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. The nurse is caring for a 90-year-old postoperative patient whose oxygen saturation is frequently dropping below 90%. Which age-related change is most likely related to this finding? a. Prolonged use of a walker b. Poor fluid intake c. Weakened respiratory muscles d. Increased elasticity of costal cartilages ANS: C Age-related changes that interfere with respiration in the older adult are weakened respiratory muscles and calcified costal cartilages. PTS: 1 DIF: Cognitive Level: Application REF: 83, Older Adult Care Points OBJ: 4 (theory) TOP: Maintenance of Ventilation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. Which assessment finding on a patient who had a right total knee replacement this morning should be reported to the charge nurse immediately? a. Pain level of 8 at operative site b. Capillary refill of right toe of 7 seconds c. Right foot warm to touch d. Swelling of right knee ANS: B Capillary refills should be brisk, less than 3 seconds. Pain and swelling are expected at this early postoperative time. A warm foot is a normal finding. PTS: 1 DIF: Cognitive Level: Application REF: 84 OBJ: 5 (clinical) TOP: Maintenance of Circulation KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. Anti-embolic stockings are in place on the obese postsurgical patient. Which statement accurately describes the standard of care in regard to anti-embolic stockings? a. The stockings should remain in place continually for the first 24 hours. b. The stockings should fit tightly at the knee and ankle. c. The stockings should be removed approximately 20 minutes every shift. d. The stockings should be removed when ambulating. ANS: C Stockings should be removed approximately 20 minutes each shift for skin care. PTS: 1 DIF: Cognitive Level: Knowledge REF: 84 OBJ: 1 (theory) TOP: Maintenance of Circulation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. The nurse has been assigned to care for several postoperative patients. Which patient is most likely to develop thrombophlebitis?a. A patient status post outpatient cholecystectomy with a history of blood clots. b. A patient who is 6 days postoperative for total right hip replacement with a history of left-sided stroke. c. A patient who underwent major abdominal surgery and was dehydrated upon admission. d. A patient who is 2 days postoperative for hernia repair with a history of diabetes. ANS: B Although all of these patients are at varying degrees of risk for thrombophlebitis, the hip replacement surgery places a patient at high risk for thrombophlebitis due to limited mobility, especially after the fifth postoperative day. This patient is at even higher risk of thrombophlebitis because of a history of left-sided stroke. PTS: 1 DIF: Cognitive Level: Analysis REF: 84 OBJ: 5 (theory) TOP: Maintenance of Circulation KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. The patient’s initial vital signs immediately on return from surgery include: blood pressure (BP) of 140/90; pulse (P) of 80; respirations (R) of 14; and temperature (T) of 98° F. One hour later the vital signs are: BP of 130/84; P of 72; R of 16; and T of 96.8° F. What action should the nurse take next? a. Add a blanket for warmth to the patient. b. Notify the charge nurse of a probable hemorrhage. c. Raise the head of the bed 45 degrees. d. Document the assessment findings. ANS: D These findings are normal. The nurse should document the normal recovery assessment and continue to monitor. There is no indication of chilling, hemorrhage, or respiratory distress, which respectively would require blanket application, charge nurse notification, or raising the head of the bed. PTS: 1 DIF: Cognitive Level: Analysis REF: 82, Assignment Considerations OBJ: 5 (clinical) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. The nurse is caring for a patient who has had spinal anesthesia. The nurse correctly questions which order? a. Patient to lie flat for 6 to 8 hours. b. Resume diet as tolerated. c. Use incentive spirometer every hour while awake. d. Notify physician immediately if headache occurs. ANS: D One of the goals during the postoperative period is to prevent or treat spinal headache. The headache can be treated with nursing interventions such as keeping the patient flat if a headache is reported and increasing fluid intake. If the headache becomes severe or does not improve, the physician could be notified. Lying flat for 6 to 8 hours reduces the risk of spinal headache and allows time for feeling to return to the legs; full diets can usually be resumed; and an incentive spirometer will reduce the chance of respiratory complications resulting from spinal anesthetic effects. PTS: 1 DIF: Cognitive Level: Analysis REF: 85 OBJ: 6 (clinical) TOP: Prevention of Injury KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 12. The nurse is caring for a patient who had spinal anesthesia. Which drink is the best choice for the nurse to offer the patient? a. Tea b. Orange juice c. Milk d. Water ANS: A Caffeinated beverages like tea or coffee increase the vascular pressure and help seal the punctured area. Orange juice, milk, or water would not achieve the same goal. PTS: 1 DIF: Cognitive Level: Application REF: 85 OBJ: 5 (theory) TOP: Prevention of InjuryKEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 13. When caring for a 10-hour postabdominal surgery patient, which finding the nurse should report to the charge nurse? a. 20 mL of clear green emesis b. Pain level of 5/10 c. No urine output since surgery d. A weak cough ability ANS: C The postsurgical patient should void in 4 to 8 hours after surgery. Scant emesis, moderate pain, and a weak cough are expected findings after abdominal surgery and do not require immediate report to the charge nurse. PTS: 1 DIF: Cognitive Level: Application REF: 85 OBJ: 5 (clinical) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 14. The nurse is caring for a surgical patient who complains of excessive gas. Which action should the nurse take? a. Offer iced fluids. b. Arrange for large meal servings. c. Provide a straw for drinking fluids. d. Ambulate the patient in the hall. ANS: D Ambulation, eating small meals, drinking tepid drinks, and avoiding the use of straws help eliminate gas. PTS: 1 DIF: Cognitive Level: Application REF: 86 OBJ: 6 (clinical) TOP: Promotion of Gastrointestinal Function KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 15. The postoperative patient complains of pain only 1 hour after having been medicated with an opioid, which cannot be repeated for three more hours. What action should the nurse take? a. Give one-half of the prescribed dose now. b. Contact the prescriber. c. Ambulate the patient in the hall. d. Reposition the patient. [Show More]

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