Chapter 1: Introduction to Medical-Surgical Nursing
Chapter 1: Introduction to Medical-Surgical Nursing
Test Bank
MULTIPLE CHOICE
1. Which action demonstrates that the nurse understands the purpose of the Rapid Response Team?
a. Monitoring the client for changes in postoperative status such as wound
infection
b. Documenting all changes observed in the client and maintaining a
postoperative flow sheet
c. Notifying the physician of the client’s change in blood pressure from
140 to 88 mm Hg systolic
d. Notifying the physician of the client’s increase in restlessness after
medication change
ANS: C
The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to
clients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code
Team, which responds to client arrests, it intervenes rapidly for those who are beginning to decline
clinically. It would be appropriate for the RRT to intervene when the client has experienced a 52point drop in blood pressure. Monitoring the client’s postoperative status, maintaining a
postoperative flow sheet, and notifying the physician of a change in the client’s status after a
medication change would not be considered activities of the Rapid Response Team.
DIF: Cognitive Level: Comprehension/Understanding REF: pp. 2-3
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with
Interdisciplinary Team)
MSC: Integrated Process: Nursing Process (Assessment)
2. The Joint Commission focuses on safety in health care. Which action by the nurse reflects The
Joint Commission’s main objective?
a. Performing range-of-motion exercises on the client three times each day
b. Ensuring that the client is eating 100% of the meals served to him or
her
c. Assessing the client’s respirations when administering opioids
d. Delegating to the nursing assistant to give the client a complete bath
daily
ANS: C
It is important for the nurse to assess respirations of the client when administering opioids because
of the possibility of respiratory depression. The other interventions may or may not be necessary in
the care of the client and do not focus on safety.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control)
MSC: Integrated Process: Nursing Process (Assessment)
3. Which action by the nurse shows an understanding of the principle of self-determination?
a. Allowing a postoperative client to decide to take medication with fruit
juice rather than water
b. Allowing a teenager to decide not to go to a clinic when there is
evidence that she is having profuse vaginal bleeding
c. Allowing a parent to decide not to proceed with a lifesaving operation
for a 12-year-old client
d. Allowing an older client with dementia to decide not to take cardiac
medication throughout the shift
ANS: A
Respect for people is one of three basic ethical principles that nurses and other health care
professionals should use as a basis for clinical decision making. Respect implies that clients are
treated as autonomous individuals capable of making informed decisions about their care. This
client autonomy is referred to as self-determination, or self-management, and is best illustrated by
allowing a client to decide to take medication with fruit juice rather than water. The other answer
choices would not illustrate self-determination appropriately and might possibly endanger the
client’s life.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Nursing Process (Assessment)
4. The nurse is initiating a series of teaching sessions with an older client. What is the nurse’s
highest-priority, client-centered action before beginning the session?
a. Ensure that the client’s family is present and will participate.
b. Make certain that the client is wearing his glasses.
c. Have printed handouts ready to use during the session.
d. Schedule the session for early evening after the client’s meal.
ANS: B
The most important client-centered action is to ensure that the client is wearing his or her glasses.
The ability to see adequately will outweigh the need for family presence, use of printed handouts,
and hunger (or lack thereof).
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
5. Which action best demonstrates the nurse using client-centered care when planning a menu for a
Vietnamese client who is newly diagnosed with diabetes?
a. Asking the client what food he or she would eat on a standard diabetic
menu
b. Asking family members to make selections for the client from a
diabetic menu
c. Ordering a typical diabetic meal for the client and planning diet
teaching
d. Researching the Vietnamese culture before discussing diabetic meal
planning
ANS: D
Client-centered care is best illustrated by the nurse researching Vietnamese culture and native
cooking before discussing meal planning. This shows that the nurse is interested and is involved in
the client’s care. The nurse can then suggest foods from the standard diabetic menu to the client and
his or her family.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration)
MSC: Integrated Process: Teaching/Learning
6. The Institute for Healthcare Improvement (IHI) identified interventions to save client lives.
Which actions are within the scope of nursing practice to improve quality of care?
a. Insert a central line to give intravenous fluid to a dehydrated client.
b. Use sterile technique when changing dressings on a new surgical site.
c. Intubate a client whose oxygen saturation is 92%.
d. Prescribe aspirin for a client who presents with an acute myocardial
infarction
ANS: B
The only intervention identified within the scope of nursing practice is to use sterile technique.
Central line insertion, intubation, and prescription are functions of the physician.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Legal Rights and
Responsibilities)
MSC: Integrated Process: Nursing Process (Implementation)
7. Which action by the nurse demonstrates the best practice for nursing documentation on a
computerized record?
a. Deleting all documentation errors on the computerized record
b. Using red font to denote all significant events that have occurred
c. Waiting until the end of the shift to record a summary of information
d. Documenting assessment data at the point of care
ANS: D
The best practice for nursing documentation is to document as soon as the assessment is completed.
The other practices listed are ineffective and are not recommended.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Legal Rights and
Responsibilities)
MSC: Integrated Process: Communication and Documentation
8. A client is scheduled for a mastectomy. As she is about to receive the preoperative medication,
she tells the nurse that she does not want to have her breast removed but wants a lumpectomy.
Which response indicates that the nurse is acting as a client advocate?
a. Telling the client her surgeon is excellent and knows what is best for
her condition
b. Calling the surgeon to come and explain all treatment options to the
client
c. Holding the client’s hand and offering to pray with her for a good
outcome
d. Arranging for a postoperative visit from a cancer survivor
ANS: B
Clients have the right to be fully informed about their treatment plans and to change their minds. A
client who expresses doubt, uncertainty, or a change of feeling about a treatment plan should be
supported by the nurse and heard by the health care provider, and should serve as an active
participant in treatment planning. The nurse would be functioning best as a client advocate by
notifying the surgeon that the client wants a different treatment option. The nurse would not be
acting as a client advocate by providing vague reassurance, arranging for a cancer survivor to come
meet with the client, or offering to pray with the client because none of these options would address
the client’s desire for a different treatment option. Calling the surgeon to come and explain all
treatment options also promotes communication and client advocacy.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Caring
9. What priority assessment data should be shared with the interdisciplinary team from a client
admitted to the emergency department with a lacerated artery?
a. Information regarding next of kin to notify in case the client dies
b. History about what medications the client is currently taking
c. Measurement of blood pressure and pulse
d. Assessment of rate and depth of respirations
ANS: C
In establishing an emergency database, assessment first focuses on the immediate problem,
especially with a high probability for a life-threatening consequence. Assessing vital signs such as
blood pressure and pulse, which indicate the client’s hemodynamic status, is the priority
intervention. Determining the client’s current medications, notifying next of kin, or measuring the
rate and depth of respirations is of less importance at this time.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Assessment)
10. Which intervention can the client expect to receive from a medical-surgical nurse in an
ambulatory care setting?
a. Drawing blood for routine or preoperative testing
b. Teaching the client how to change a dressing on an incision
c. Obtaining the client’s signature on a surgical consent form
d. Performing a comprehensive physical examination
ANS: B
Client teaching is a primary role of the medical-surgical nurse. Obtaining a surgical consent is
usually the responsibility of the person performing the surgery. Blood drawing and performing
physicals may be done by the nurse but are not primary nursing responsibilities.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)
MSC: Integrated Process: Nursing Process (Planning)
11. An emergency department (ED) nurse gives report on a client who is being transferred to the
medical-surgical floor. Because of an identified risk for suicide, the ED nurse suggests that the floor
nurse contact a sitter and behavioral health. This statement represents which part of the SBAR
hand-off?
a. Situation
b. Background
c. Assessment
d. Recommendation
ANS: D
The ED nurse is giving recommendations to the medical-surgical floor nurse about interventions to
start for the client who is being transferred. No communication is provided in the SBAR report
about the situation, background, or assessment.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 4
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)
MSC: Integrated Process: Communication and Documentation
12. The nurse is present when the physician discusses the potential effects of a chemotherapy
regimen for a client with cancer. Weighing the benefits of the chemotherapy against possible side
effects is an example of which ethical principle?
a. Paternalism
b. Beneficence
c. Justice
d. Autonomy
ANS: B
Beneficence stresses the importance of preventing harm and promoting the client’s well-being.
When benefits versus negative effects of an intervention are compared, the client is better informed
and can evaluate what could be done in his or her best interest. Autonomy implies selfdetermination, justice refers to equality, and paternalism refers to the male head of the family for
decision making.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 4
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Caring
13. The physician prescribes warfarin (Coumadin) 15 mg daily. The nurse notes that this is three
times the normal dose for this client based on the client’s medication profile and laboratory work.
What does the nurse do first?
a. Give the dose and document the concern.
b. Call the pharmacy for a consultation.
c. Call the physician to question the order.
d. Hold the medication for that day.
ANS: C
Communication between the physician and the nurse should be the first step in medication
administration to ensure safety in client care. The pharmacy can be consulted but not as the first
step. The other answers are not safe practices for the nurse.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Error
Prevention)
MSC: Integrated Process: Communication and Documentation; Nursing Process (Evaluation)
14. Which statement best describes the process of nursing case management?
a. The coordination of care services to at-risk populations
b. A collaborative process to promote quality and cost-effective care
c. The implementation of care to acutely ill, underserved populations
d. A cost-effective care delivery model meeting the needs of specially
defined groups
ANS: B
The process of case management involves collaboration to assess, plan, implement, coordinate,
monitor, and evaluate services to meet health care needs in a manner that promotes quality and
cost-effective outcomes. It does not solely involve coordination of care services to at-risk
populations, implementation of care to acutely ill and underserved clientele, nor a cost-effective
model of care delivery that will meet the needs of specially defined groups.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 4
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)
MSC: Integrated Process: Nursing Process (Planning)
15. Which client is best served by a case manager?
a. An older woman with chronic cystitis
b. A middle-aged man with moderate hypertension
c. An older woman with chronic heart failure and diabetes mellitus
d. A young adult with a fractured ankle from a sports injury
ANS: C
The case management process is reserved for clients who have complex health problems (high risk)
and incur a high cost to the health care system. Clients with chronic cystitis, moderate
hypertension, or a fractured ankle probably would not incur high costs to the health care system.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 4
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)
MSC: Integrated Process: Nursing Process (Planning)
16. The client with a stroke was admitted to a medical-surgical unit. Which tasks does the nurse
delegate to the unlicensed assistive personnel?
a. Complete the nursing care plan.
b. Assist the client with meals.
c. Evaluate the pulse oximetry reading.
d. Assess level of consciousness.
ANS: B
The nurse needs to know the five rights of delegation: right task, right circumstances, right person,
right communication, and right supervision. Unlicensed assistive personnel can help with feeding,
but only the nurse can care plan, assess the level of consciousness, and evaluate the oxygenation of
the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Delegation) MSC:
Integrated Process: Communication and Documentation
MULTIPLE RESPONSE
1. The nurse on a medical-surgical unit notices that there has been an increase in the number of
client falls. Which methods would be effective in promoting quality improvement on this issue?
(Select all that apply.)
a. Identify causes of falls on the unit by looking at specific client cases.
b. Look at the research and the literature on prevention of falls.
c. Complain to the manager that team members are neglecting the clients.
d. Use sit and stand alarms because they seem to be working on other
units.
e. Try more frequent rounding on clients as suggested by co-workers.
ANS: A, B, D, E
Quality improvement requires individual and systematic evaluation. Evidence-based practice in the
form of research and literature can aid in revision of care processes. After review of ways that falls
can be prevented, specific recommendations can be made to improve care on the unit. Complaining
does not facilitate the resolution of a problem.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Planning, Evaluation)
2. Which settings would require maximum implementation of the nurse supervisor role? (Select all
that apply.)
a. Acute care setting
b. Home care setting
c. Skilled nursing facility
d. Assisted-living facility
e. Rehabilitation facility
ANS: A, B, C, D, E
In all of the listed facilities and settings, numerous unlicensed assistive personnel are delegated
various tasks. The registered nurse is responsible for overseeing the actions of such personnel and
therefore would implement the supervisor role to its maximal extent.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 5
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Concepts of
Management) MSC: Integrated Process: Nursing Process (Planning)
3. Which activities are within the role of the case manager? (Select all that apply.)
a. Gathering and organizing data about a client from client records and
interviews
b. Planning care for a client with emphasis on client satisfaction
c. Coordinating care among a variety of health care professionals and
settings
d. Promoting the client’s interests while negotiating necessary health care
e. Advocating for the client and the family throughout the continuum of
care
f.
Using resources for appropriate client health care services
ANS: A, C, D, E, F
Primary roles of the nursing case manager include wide-reaching assessment, planning for timely
and cost-effective outcomes, facilitation, and advocacy. Roles of the nursing case manager do not
include planning care for a client with emphasis on client satisfaction.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 4
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Concepts of
Management) MSC: Integrated Process: Nursing Process (Planning)
4. A client has metastatic lung cancer and is hospitalized for chemotherapy. Which intervention
does the nurse delegate to the unlicensed assistive personnel? (Select all that apply.)
a. Assist the client with repositioning.
b. Teach the client to use the incentive spirometer.
c. Take vital signs every 4 hours.
d. Record intake and output measurements.
e. Promote the expression of grief and loss.
ANS: A, C, D
UAP can perform vital signs, record intake and output measurements, and aid in turning and
positioning. Teaching and promoting client expression of feelings related to the grieving process
are within the role of the nurse.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Delegation) MSC:
Integrated Process: Communication and Documentation
Chapter 2: Introduction to Complementary and Alternative Therapies
Chapter 2: Introduction to Complementary and Alternative Therapies
Test Bank
MULTIPLE CHOICE
1. The nurse wishes to learn more about the client’s use of natural products and their effectiveness.
The nurse consults the National Center for Complementary and Alternative Medicine because it is
known that this center serves which function?
a. Educates health professionals about complementary therapies
b. Educates new mothers on the benefits of massage
c. Engages in fundraising to offset client expenses with medical care
d. Provides a scholarship for a student to study naturopathy
ANS: A
The purposes of the National Center for Complementary and Alternative Medicine (NCCAM) are
to fund studies examining the effectiveness of various complementary therapies, advance
knowledge about complementary therapies of health professionals, and serve as a clearinghouse for
information about these therapies. It does not fund scholarships, nor is it a nonprofit organization. It
focuses on advancing knowledge for health professionals rather than the general public.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 9
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort
Interventions)
MSC: Integrated Process: Teaching/Learning
2. A client is anxious about having a dressing change. Which statement indicates that the nurse is
promoting appropriate complementary therapy?
a. “I’ll call the doctor and ask for a larger dose of pain medication before
the dressing change.”
b. “As we begin the next dressing change, I want you to think of a
beautiful, calm place where you feel happy and peaceful.”
c. “I’ll get another nurse to stay in the room with us during the dressing
change so that you have a hand to hold during the procedure.”
d. “Are you familiar with acupuncture? It’s a very effective technique.”
ANS: B
Because the client’s primary problem is anxiety rather than pain at this point, the use of guided
visual imagery should be the most effective intervention. Calling the physician for more pain
medication and having another nurse present to help comfort the client will not address the main
problem of the client. Acupuncture is used for relief of pain; an experienced practitioner is required
to implement this technique.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort
Interventions)
MSC: Integrated Process: Nursing Process (Planning)
3. The nurse has designed a treatment plan that includes the use of massage. Which intervention
will the nurse implement first?
a. Assess the client to determine the most effective type of massage
technique to use.
b. Inspect the skin over the tissue to be massaged to ensure that it is not
infected or bruised.
c. Determine whether a licensed therapist will be needed to carry out the
massage technique
d. Obtain permission from the client to implement this type of technique.
ANS: D
Permission to use the procedure must be obtained from the client before any of the other
interventions can be implemented.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort
Interventions)
MSC: Integrated Process: Nursing Process (Assessment)
4. A client who has been using which therapy requires the most immediate intervention by the
nurse?
a. Aromatherapy to treat depression
b. Herbal preparations to treat hypertension
c. Therapeutic touch to decrease level of pain
d. Tai Chi to improve joint flexibility
ANS: B
The client who has been using herbal preparations to treat hypertension may have endangered his
or her life by inadvertently ingesting a substance that interacts poorly with another drug or that can
be toxic. Aromatherapy may be used as a complementary therapy to treat depression. Therapeutic
touch has been shown to decrease pain, and Tai Chi may assist in mobility. These therapies are
appropriate and are not life threatening.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications)
MSC: Integrated Process: Nursing Process (Assessment)
5. A client scheduled for surgery has been taking garlic supplements. Which action is most
important for the nurse to take?
a. No action is necessary because the herbal agent is harmless.
b. Notify the charge nurse that the client has been taking garlic.
c. Note the information on the client’s record and place in the chart.
d. Notify the surgeon that the client has been taking garlic capsules.
ANS: D
Because garlic acts as an antiplatelet agent and has the potential to decrease clotting, much in the
same way as aspirin, the surgeon will have to decide whether the surgery will be postponed. The
nurse should never assume that any herbal supplement is “harmless” because many can interact
with medications and diet. The nurse will note the information on the client’s chart, but the most
important action is to notify the surgeon. Informing the charge nurse about the garlic is not
necessary if the surgeon is notified.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Planning)
6. For which client does the nurse arrange animal-assisted therapy?
a. Middle-aged adult in a psychiatric facility with a history of
schizophrenia
b. Older adult client with end-stage lung cancer in hospice care
c. Older adult client in a nursing home who is unresponsive
d. Adolescent in a drug treatment facility with a history of violent
outbursts
ANS: B
A client in hospice care may benefit from animal-assisted therapy because this type of therapy may
decrease stress. A client in a psychiatric facility who has schizophrenia may not yet be stable
enough to experience this type of therapy. A client who is unresponsive and is not interacting with
the environment is not likely to benefit from this therapy. A client who is prone to violent outbursts
would not be able to benefit from this type of therapy.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Environment)
MSC: Integrated Process: Nursing Process (Assessment)
7. Which statement indicates that the nurse understands the risks associated with herbal
preparations?
a. Herbs are guaranteed to be safe and effective but are not necessarily
natural.
b. Herbs require a different type of prescription than is required for
standard prescribed medications.
c. Herbs are not classified as drugs and are regulated less strictly by the
U.S. Food and Drug Administration (FDA).
d. Herbs are guaranteed to be all natural and of high quality but are not
necessarily effective.
ANS: C
Herbal preparations are regulated as food and nutritional supplements by the FDA. They do not
require a prescription because they are not medications. Unfortunately, herbs are not under
regulation by the government as drugs, and are not guaranteed to be natural, safe, or effective. This
is one of the major disadvantages of herbal therapy.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 9
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Teaching/Learning
8. A client asks the nurse to pray with him. The nurse is an atheist. Which statement by the nurse is
the correct response?
a. “Yes, let’s pray together.”
b. “No, I’m sorry, I can’t do that.”
c. “No, I don’t believe in prayer.”
d. “I’ll hold your hand while you pray.”
ANS: D
By stating that he will hold the client’s hand, the nurse offers support for the client’s choice without
compromising his beliefs. The nurse should not participate in any activity that goes against his or
her beliefs. The nurse should not just state that he or she can’t do this or tell the client personal
views or preferences.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Nursing Process (Implementation)
9. The client has been diagnosed with cancer and is experiencing depression and insomnia as side
effects of chemotherapy. The client tells the nurse that she has been supplementing her
antidepressant medication with lavender oil and sandalwood but they aren’t working. Which
statement by the nurse is the best response?
a. “Tell me more about exactly what you are taking, how much you take,
and when you take the antidepressants and use the oils.”
b. “Perhaps you’re not using enough of the oil or are using it incorrectly.”
c. I’ll speak with your doctor to get you some medication that you can
take while continuing the aromatherapy.”
d. “You don’t want your doctor to put you on sleeping pills and
antidepressants. Keep using them.”
ANS: A
The nurse should continue the assessment of the client to determine exactly what medications the
client is taking and the specific type of complementary therapy the client is using, to determine
whether the regimen is dangerous.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Assessment)
10. The client is undergoing treatment for cancer and is experiencing a high level of anxiety. The
client expresses interest in complementary therapies that might decrease the level of anxiety. Which
action is the best choice for the nurse to implement with this client?
a. Direct the client to an imaginative peaceful setting using imagery.
b. Provide assistance in finding an acupuncturist.
c. Suggest Tai Chi during chemotherapy treatments.
d. Encourage the use of acupressure over tumor sites.
ANS: A
Nurses traditionally have used a number of mind-body therapies such as prayer, imagery,
meditation, music, and pet therapy to decrease anxiety in clients. Acupuncture and acupressure are
pain relief therapies that usually require special education. Tai Chi is a body-based therapy that
requires energy that may not be appropriate during chemotherapy sessions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort
Interventions)
MSC: Integrated Process: Nursing Process (Implementation)
11. Which clients would benefit most from relaxation therapy?
a. Middle-age client who is undergoing chemotherapy treatments
b. Young client who is diagnosed with schizophrenia
c. Older client who is comatose and unresponsive
d. Young client who is diagnosed with major depression
ANS: A
By reducing physical, mental, and emotional tension, relaxation is believed to result in changes
opposite those of the “fight-or-flight” mechanism. Relaxation is helpful during painful procedures
but may not be helpful with certain mental health problems or unresponsive clients because
relaxation requires action from the client to relieve the tension.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort
Interventions)
MSC: Integrated Process: Nursing Process (Evaluation)
12. A nurse is assisting a client in preparing for surgery by using progressive muscle relaxation.
Which rationale best supports the use of this therapy at this time?
a. It rebalances or repatterns a person’s energy field.
b. It improves flexibility and assists with positioning during surgery.
c. It applies pressure, releasing congestion and promoting energy flow.
d. It uses intentional tensing and releasing of successive muscle groups.
ANS: D
Progressive muscle relaxation provides intentional tensing and releasing of successive muscle
groups, thereby promoting relaxation and decreasing anxiety. Anxiety reduction would be the best
rationale for a client preparing for surgery. The other statements are inaccurate descriptions of
progressive muscle relaxation and its use.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 11
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort
Interventions)
MSC: Integrated Process: Caring; Nursing Process (Implementation)
13. A client tells the nurse that he or she is considering using herbal supplements. What is the
nurse’s best response?
a. “Herbs are not classified as drugs in the United States, so there is no
contraindication to using them.”
b. “Herbs have pharmacologic effects on the body and can interact with
some prescription medications.”
c. “It is never permissible to use herbal supplements with prescription
medications.”
d. “I will refer you to an herbalist, who can help you decide which
medications you can take.”
ANS: B
Although herbs are not classified as drugs, they do possess pharmacologic properties. In caring for
a client, the nurse should inquire whether the client takes herbal preparations and, if so, for what
purpose. Many herbal preparations have not been adequately studied, and some can interact with
prescription medications, causing toxic effects. The nurse should not refer the client to an herbalist.
The client should be instructed that there are contraindications to herbal usage, but that herbs can
be used with prescription medications, depending on the medication, the herbal substance, and the
condition of the client.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 9
TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)
MSC: Integrated Process: Nursing Process (Implementation)
14. A client who is status post aortic valve replacement takes sodium warfarin (Coumadin) daily
and has started taking Ginkgo biloba. What is the priority action for the nurse to take?
a. Encourage the use of Ginkgo biloba to enhance the client’s systemic
circulation.
b. Assess the client for any bruising or petechiae.
c. Explain that replacing Ginkgo biloba with garlic would be much safer.
d. Assess for any forgetfulness or inappropriate speech.
ANS: B
Taking Ginkgo biloba with warfarin increases the client’s risk of bleeding. Therefore, the client
should be monitored first for bruising or bleeding associated with use of this combination. Ginkgo
biloba is purported to reduce memory problems and dementia and has vasodilator properties, but
these uses cannot be supported if the client is on an anticoagulant for the heart valve replacement.
Garlic would not be a safer choice because it can act as an antiplatelet agent and would increase the
risk of bleeding with warfarin (Coumadin).
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC:
Integrated Process: Nursing Process (Planning)
15. Which statement indicates that the client needs further teaching about complementary therapy?
a. “I’ve decided to use herb therapy for cancer treatment, so I can cancel
my radiation treatments.”
b. “I’m hoping that massage therapy will help reduce the amount of pain
medication I use for my myalgia.”
c. “I think it helps me get better faster when I picture the drugs punching
out the germs in my body.”
d. “I intend to pray about my cancer treatment several times a day. It
makes me feel so much better.”
ANS: A
Complementary therapies are intended to be used with, rather than to replace, traditional forms of
therapy to integrate mind, body, and spirit into the healing process. The client must have this
information clarified, so that he will follow his recommended regimen for cancer treatment. The
other statements appropriately indicate that the client understands the purpose of complementary
therapy.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Assessment)
16. Which teaching strategy is appropriate for a client who wishes to use mind-body
complementary therapy to supplement traditional treatment for cancer?
a. Instruct the client to make a follow-up appointment with the health care
provider after using mind-body treatments to assess the client’s
response to treatment.
b. Instruct the client never to use alternative or complementary treatments
for serious illnesses.
c. Explain to the client that physicians and nurses are not prepared to
recommend and monitor alternative treatments.
d. Explain to the client that physicians and nurses do not incorporate such
treatments into their practice.
ANS: A
Complementary or alternative treatments may be used in association with traditional therapy. The
client who uses complementary or alternative therapy should be advised to make a follow-up visit
to the health care provider to assess the client’s response to therapy and to detect any adverse
effects.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
17. Which complementary or alternative therapy would the nurse recommend to a client with “stiff
joints” to improve mobility?
a. Imagery
b. Animal-assisted therapy
c. Tai Chi
d. Aromatherapy
ANS: C
Tai Chi is an active holistic therapy that integrates body movements, concentration, muscle
relaxation, and breathing to improve body function, such as flexibility and posture. Imagery has
been used successfully to reduce pain, nausea and vomiting, and anxiety. Animal-assisted therapy
generally is used with clients who need to improve motor skills or the ability to concentrate.
Aromatherapy uses essential oils to achieve relaxation, improve concentration, and ease depression.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort
Interventions)
MSC: Integrated Process: Teaching/Learning
18. A client is experiencing nausea and vomiting from chemotherapy. Which alternative or
complementary therapy would be best for the nurse to explore with the client?
a. Meditation
b. Imagery
c. Yoga
d. Music therapy
ANS: B
Imagery has been used frequently to help clients reduce nausea and vomiting. Meditation, yoga,
and music therapy are more useful for chronic pain, for hypertension, and in improving emotional
health.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort
Interventions)
MSC: Integrated Process: Nursing Process (Assessment)
19. The nurse is working in the community and completes home visits with older adult clients.
Which statement by a client demonstrates a need for further instruction about the use of
complementary and alternative therapies?
a. “My doctor monitors my kidney function since I started taking
calcium.”
b. “I always talk to my doctor first before starting an herbal preparation.”
c. “I heard that St. John’s wort is good for any type of depression.”
d. “I may start a Tai Chi program to help with my mobility and lift my
spirits.”
ANS: C
The client needs some education regarding the use of St. John’s wort for depression. It is advisable
to seek the advice of a physician and to be evaluated for psychotherapy and/or drug therapy. Often
older women consume too much calcium, and this can result in renal calculi. It is recommended
that the older adult should have calcium levels monitored, as well as kidney function. All clients
need to inform their health care team about any use of herbal preparations because of possible
interactions with medications and possible side effects. Tai Chi is to be encouraged in the older
adult to improve physical and mental health.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)
MSC: Integrated Process: Teaching/Learning
MULTIPLE RESPONSE
1. During an initial health assessment interview, the nurse learns that the client is taking warfarin
(Coumadin) for a history of deep vein thrombosis. Later, the client admits to taking several herbal
preparations as well. Which herbal preparations would the nurse caution the client to avoid? (Select
all that apply.)
a. Ginkgo biloba
b. Garlic
c. Ginseng
d. Zinc
e. St. John’s wort
ANS: A, B, C
Ginkgo biloba may increase the anticoagulant effects of warfarin. Garlic and ginseng have been
found to affect the international normalized ratio (INR).
DIF: Cognitive Level: Knowledge/Remembering REF: Table 2-2, p. 10
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Assessment)
2. The nurse wishes to start music therapy with an older adult client who has high anxiety and
hypertension. What essential elements should be considered when music is used with this client?
(Select all that apply.)
a. Assess the client’s preferences in choice of music.
b. Use fast tempo music to energize and motivate the client.
c. Consider rap music to provide diversion.
d. Consider live or recorded music such as music performed on a harp.
e. Consider generation-specific music.
ANS: A, D, E
In music therapy, the nurse is encouraged to provide generation-appropriate music and to evaluate
the client’s preference. Live harp music may have a calming effect with anxious clients. Rap music
is not generation-appropriate for older clients. Music with a fast tempo may escalate the client’s
anxiety and increase blood pressure.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Stress Management)
MSC: Integrated Process: Nursing Process (Planning)
Chapter 3: Common Health Problems of Older Adults
Chapter 3: Common Health Problems of Older Adults
Test Bank
MULTIPLE CHOICE
1. An older client is agitated and develops new-onset confusion on admission to the long-term care
unit. What is the best action for the nurse to take to minimize relocation stress syndrome for this
client?
a. Provide reorientation during hourly rounding.
b. Obtain a certified sitter to remain with the client.
c. Speak to the client as little as possible to avoid overstimulation.
d. Provide adequate sedation to lessen fear-provoking situations.
ANS: A
Many nursing interventions can prove helpful to older adults who experience relocation stress
syndrome. If the client becomes confused, agitated, or combative, the nurse should reorient the
client to his or her surroundings. The nurse also can encourage family members to visit often, keep
familiar objects at the client’s bedside, and work to establish a trusting relationship with the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Stress Management)
MSC: Integrated Process: Nursing Process (Implementation)
2. Which intervention would best support a client who relates a feeling of “loss of control” after
having a mild stroke?
a. Explain that such feelings are normal, but that expectations for
rehabilitation must be realistic.
b. Encourage the client to perform as many tasks as possible and to
participate in decision making.
c. Further assess the client’s mental status for other signs of denial or
psychopathology.
d. Obtain an order for physical and occupational therapy evaluations.
ANS: B
Older adults can experience various losses that affect their sense of control over their lives,
including a decrease in physical mobility. The nurse should support the client’s self-esteem and
increase feelings of competency by encouraging activities that assist in maintaining some degree of
control, such as participation in decision making and performing tasks that he or she can manage.
Obtaining an order for therapy evaluations is a normal part of the rehabilitation process. The other
choices imply that the client’s sense of loss is abnormal after a stroke.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms; Grief and Loss)
MSC: Integrated Process: Nursing Process (Implementation)
3. What will the nurse teach the older client with hypertension who complains that “food does not
taste good without salt”?
a. Salt can be used as long as blood pressure remains controlled.
b. All salt should be removed from the diet to preserve kidney function.
c. Table salt can be used in small amounts in conjunction with diuretics.
d. Herbs and spices can be substituted to season food.
ANS: D
Physical changes associated with aging can affect the intake of nutrients. Diminished senses of
taste and smell, particularly a decline in the ability to taste sweet and salty, may lead the older adult
to overuse sugar and salt. In such cases, the nurse should recommend that the client use herbs and
spices to season food.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
4. What is a priority nursing intervention to prevent falls for an older adult client with multiple
chronic diseases?
a. Providing assistance to the client in getting out of the bed or chair
b. Placing the client in restraints to prevent movement without assistance
c. Keeping all four siderails up while the client is in bed
d. Requesting that a family member remain with the client to assist in
ambulation
ANS: A
Advanced age and multiple illnesses, particularly those that result in alterations in sensation, such
as diabetes, predispose this client to falls. The nurse should provide assistance to the client with
transfer and ambulation to prevent falls. The client should not be restrained or maintained on
bedrest without adequate indication. Although family members are encouraged to visit, their
presence around the clock is not necessary at this point.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
5. An older adult client is in physical restraints. Which intervention by the nurse is the priority?
a. Assess the client hourly while keeping the restraints in place.
b. Assess the client every 30 to 60 minutes, releasing restraints every 2
hours.
c. Assess the client once each shift, releasing the restraints for feeding.
d. Assess the client twice each shift while keeping the restraints in place.
ANS: B
The application of restraints can have serious consequences. Thus, the nurse should check the client
every 30 to 60 minutes, releasing the restraints every 2 hours for positioning and toileting. The
other answers would not be appropriate because the client would not be assessed frequently
enough, and circulation to the limbs could be compromised. Assessing every hour and releasing the
restraints every 2 hours is in compliance with federal policy for monitoring clients in restraints.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Use of
Restraints/Safety Devices)
MSC: Integrated Process: Nursing Process (Implementation)
6. An older adult client has become agitated and combative toward health care personnel on the
unit. What is the first action that the nurse will take?
a. Obtain an order for a sedative-hypnotic medication to reduce combative
behavior.
b. Attempt to soothe the client’s fears and reorient the client to
surroundings.
c. Obtain an order to place the client’s arms in restraints to protect
personnel.
d. Arrange for the client to be transferred to a mental health facility.
ANS: B
The nurse should establish a trusting relationship with the client, soothe the client’s fears, and
reorient the client to the facility before resorting to physical or chemical restraints. Restraints, both
physical and chemical, may be overused in certain situations. Sedative-hypnotic drugs may have
adverse effects in older adults and should be used sparingly. Physical restraints also can have
serious repercussions. Transfer to a mental health facility requires evaluation by psychiatric staff
and may not be appropriate here.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
7. An older adult client presents with signs and symptoms related to digoxin toxicity. Which age-
related change may have contributed to this problem?
a. Increased total body water
b. Decreased renal blood flow
c. Increased gastrointestinal motility
d. Decreased ratio of adipose tissue to lean body mass
ANS: B
Decreased renal blood flow and reduced glomerular filtration can result in slower medication
excretion time, potentially leading to toxic drug accumulation. Aging results in decreased total
body water and gastrointestinal motility and an increase in the ratio of adipose tissue to lean body
mass, but is not related to digoxin toxicity.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 20
TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)
MSC: Integrated Process: Nursing Process (Assessment)
8. A nurse is assessing a client’s understanding of medication therapy. Which statement indicates
that the client needs further instruction?
a. “My husband is on the same medication, so we always take our
medications together in the morning.”
b. “I prepare all my medication for the week and place the pills in a
container labeled for each day.”
c. “When I don’t sleep well at night, I take two thyroid pills the next day
instead of just one.”
d. “I take my Coumadin every day when the noon news comes on the
television.”
ANS: C
Changing the dose of medication without a correct understanding of the drug’s use and appropriate
schedule can cause serious problems. The other statements indicate good understanding of selfadministering medications.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
9. An older adult client is being discharged from the hospital on several medications. Which
intervention best reinforces medication teaching for this client?
a. Have the client actively participate in drug administration during
hospitalization.
b. Include the client’s children in discussions regarding medication
administration.
c. Give the client a pamphlet with the actions, side effects, and doses of all
drugs.
d. Make a chart showing which drugs should be taken at specified times
during the day.
ANS: A
Supervised self-administration of medications allows accurate assessment of the client’s
capabilities and hands-on learning opportunities for instruction or reinforcement.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
10. An older adult client’s spouse has died, and the family expresses concern that the client has lost
weight recently and now refuses to attend the annual family reunion. The nurse should assess this
client further for what clinical condition?
a. Psychosis
b. Depression
c. Dementia
d. Delirium
ANS: B
Situational depression can result after a loss and is defined as a mood disorder with cognitive,
affective, and physical symptoms. Dementia is characterized by a gradual decline in intellectual
functioning that is chronic and progressive compared with delirium, which is an acute state of
confusion that is short term and reversible. Psychosis is a mental health problem that usually is not
driven by loss.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss)
MSC: Integrated Process: Nursing Process (Assessment)
11. Which behavior exhibited by an older adult client alerts the nurse to the possibility that the
client is experiencing delirium?
a. Becoming confused within 24 hours after hospital admission
b. Displaying a cheerful attitude despite a poor prognosis
c. Becoming withdrawn and sleeping most of the day
d. Beginning to use slurred speech and losing coordination
ANS: A
Delirium is characterized by acute confusion that is usually short term. Delirium can result from
placement in unfamiliar surroundings, such as being hospitalized. Depression is characterized by an
increase in sleep and lack of social contact. Slurred speech may indicate a stroke.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 23
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
12. A client with Alzheimer’s disease has been hospitalized for dehydration. In making an
assessment, the nurse notes the presence of a cluster of bruises on the client’s buttocks. What is the
nurse’s priority action?
a. Call the local police to report a crime.
b. Notify the client’s physician and social worker.
c. Confront the client’s caregiver with the suspicions.
d. Alert security to prevent visits by the client’s caregiver.
ANS: B
If a nurse suspects elder abuse or neglect, the nurse notifies the physician and the social worker to
begin an investigation of the situation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Abuse/Neglect) MSC: Integrated Process: Nursing Process (Assessment)
13. An older adult client is suspected of being neglected by the caregiver. What assessment provides
the nurse with the best information about this possibility?
a. Inspect skin in the “bathing suit zone” for bruises.
b. Assess the client for orientation to person, place, and time.
c. Compare the client’s current weight with prior recorded weights.
d. Perform orthostatic pulse and blood pressure readings.
ANS: C
Neglect is often manifested by dehydration, undernutrition, pressure ulcers, or contractures. Injuries
raise the suspicion for abuse, whereas disorientation and rapid heart rate/high blood pressure can be
the result of disease processes. Noting the client’s weight trend would be a helpful assessment
related to this suspicion.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Abuse/Neglect)
MSC: Integrated Process: Nursing Process (Assessment)
14. A nurse is caring for an older adult client who lives alone. Which economic situation presents
the most serious problem for this client?
a. Stock market fluctuations
b. Increased provider benefits
c. Social Security as the basis of income
d. Costs of creating a living will
ANS: C
Older adults on fixed incomes are unable to adjust their income to meet rising costs associated with
meeting basic needs.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 18
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration)
MSC: Integrated Process: Nursing Process (Planning)
15. An older adult client is in the hospital. To what government resource would the nurse refer the
client to help meet the cost of health care?
a. Preferred provider organizations
b. Health maintenance organizations
c. Medicare Part A
d. Medicare Part B
ANS: C
Medicare is a federal insurance program designed to assist older adults to meet the cost of health
care in the hospital. Medicare Part B covers a certain percentage of outpatient services and is paid
for by the older adult. Preferred provider organizations and health maintenance organizations are
private providers of health care.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advocacy) MSC:
Integrated Process: Nursing Process (Planning)
16. A nurse is assessing a client at risk for dehydration. Which statement by the client indicates that
more education by the nurse is required?
a. “I try to limit coffee to one cup in the morning and one cup in the early
evening.”
b. “During the day I drink at least six to seven glasses of water.”
c. “Alcohol causes me to frequently urinate so I cut it out of my diet.”
d. “I stop drinking fluids in the afternoon to avoid bathroom trips at
night.”
ANS: D
Older adults have less body water than younger adults. It is recommended that the older client drink
at least six glasses of water each day to avoid dehydration. Caffeine and alcohol intake can
stimulate more loss of fluid from the body, further increasing the risk for dehydration. The older
client needs to continue to drink fluids throughout the day and should not limit fluids because of
mobility problems, diuretic use, or incontinence.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
17. An older adult recently had a hysterectomy and has requested some medication for pain. The
physician leaves an order for meperidine (Demerol). Which action by the nurse is most
appropriate?
a. Assess the client’s pain 1 hour after giving the medication.
b. Call the physician and request a different pain medication.
c. Assess the client’s respiratory rate often after administering the
Demerol.
d. Ensure that the client does not receive iron supplements at the same
time.
ANS: B
Meperidine (Demerol) is included among the Beers criteria for potentially inappropriate medication
use in older adults. Morphine, codeine, and hydromorphone are acceptable medications for the
older adult that the nurse could suggest to the physician. Assessing the client’s pain and monitoring
respiratory rate are important interventions for any client receiving narcotic analgesics, but in this
case, client safety is best ensured by not administering inappropriate drugs. Iron supplements can
be administered without regard to Demerol.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Planning)
18. A nurse manager is planning a comprehensive care plan for older clients admitted to the
medical-surgical unit. To decrease hospital stays and lessen the pain that older clients experience,
which standard intervention should the manager include in the care bundle for this population?
a. Assess all clients for depression.
b. Obtain a dietary consult for nutrition assessment.
c. Perform medication reconciliation on admission.
d. Screen all clients for alcohol and drug use.
ANS: A
All actions would be important parts of a care bundle for older adult clients admitted to a hospital.
However, depression is the most common mental health/behavioral health problem among older
adults in the community. Early detection can prevent the effects of depression, including worsening
of medical conditions, increased pain and disability, and delayed recovery from illness. Failure to
diagnose and treat depression can result in risk of physical illness, alcoholism, and suicide.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Planning)
MULTIPLE RESPONSE
1. What conditions predispose an older adult client to acute confusion or delirium? (Select all that
apply.)
a. Alcoholism
b. Chronic pain
c. Acute infection
d. Electrolyte imbalances
e. Multi-infarct cerebrovascular disease
f.
Change in drug regimen
ANS: C, D, F
Alcoholism and increased pain and disability more commonly lead to depression. Multi-infarct
cerebrovascular disease is associated with progressive dementia. Infection, imbalanced electrolytes,
and drug therapy changes are likely to cause acute confusion.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 23
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Planning)
2. An older adult client has been admitted to a skilled nursing facility following surgery. What
interventions should the nurse add to this client’s care plan to assist with adjusting to this situation?
((Select all that apply.)
a. Make sure the client has hearing aids and glasses.
b. Offer the anxiolytic that the physician has prescribed.
c. Encourage the family to bring in favorite pictures.
d. Ask where the client wants the room furnishings placed.
e. Encourage the client to eat meals alone in his or her room.
f.
Set a daily schedule for the client that includes group activities.
ANS: A, C, D
An anxiolytic may increase the difficulty that the client has in interpreting new surroundings.
Encouraging the client to eat alone and setting a daily schedule for the client discourages decision
making about activities of daily living. Making sure that the client can see and hear will help in
environmental interpretation, familiar possessions will provide a sense of identity, and having some
input into the organization of his or her immediate surroundings helps develop a sense of control.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)
MSC: Integrated Process: Nursing Process (Planning)
3. The nurse is assessing several clients. Which clients does the nurse identify as being at high risk
for falls? (Select all that apply.) The client:
a. With visual impairment such as presbyopia
b. Who is reluctant to use a cane while walking
c. Who performs Tai Chi exercise daily
d. Who wears a hearing aid and glasses
e. Who has difficulty arising from a sitting position
f.
Who is male and over 55 years of age
ANS: A, B, E
Vision, hearing, and mobility difficulties are associated with increased fall risk. Tai Chi improves
balance and mobility. Wearing a hearing aid and glasses would lessen problems with auditory
impairment. Being a male over 55 years of age is not considered a risk factor for falls.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Assessment)
4. What interventions can the nurse apply to help an older adult client who is having trouble
sleeping while in the hospital? (Select all that apply.)
a. Changing the client’s sheets each night before sleep
b. Decreasing the level of light surrounding the client’s bed
c. Attempting to keep the client awake during the daytime
d. Keeping staff conversations as quiet as possible
e. Administering sleeping pills at night
f.
Administering pain medication before bedtime
g. Asking the client if he or she would like to pray
ANS: B, C, D, F
Sleep disorders are common in hospitalized clients, especially older adults. The primary
contributing factors for clients who have trouble sleeping are pain, chronic disease, environmental
noise and lighting, and staff conversations. To help clients get adequate rest, the nurse should try to
keep the client awake in the daytime to ensure that she or he is tired at night. Dimming the lights
and keeping conversations quiet and farther from clients’ rooms will help eliminate some of the
environmental factors, and administering pain medication at bedtime will enhance the client’s
ability to fall asleep without pain.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Rest and Sleep)
MSC: Integrated Process: Nursing Process (Implementation)
5. An 89-year-old is admitted to the medical-surgical floor. The nurse is formulating the client’s
plan of care. In assessing the client, which findings would be considered part of the clinical
syndrome of frailty? (Select all that apply.)
a. Increased appetite
b. Weight loss
c. Weakness
d. Decreased sleep
e. Slowed gait
ANS: B, C, E
Frailty as a clinical syndrome is characterized by unintentional weight loss, weakness, exhaustion,
and slowed physical activity such as walking. Increased appetite and decreased sleep are not
necessarily part of this syndrome.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 16
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
Chapter 4: Cultural Aspects of Health and Illness
Chapter 4: Cultural Aspects of Health and Illness
Test Bank
MULTIPLE CHOICE
1. The nurse is caring for a client from another culture. Which action would demonstrate the first
step of developing cultural competence?
a. Avoiding assuming that members of the same culture all share the same
beliefs and values
b. Developing an understanding of his or her own cultural heritage,
feelings, and experiences
c. Becoming bilingual to communicate effectively with the population of
clients served
d. Developing an understanding of the religious beliefs of clients served
by the nurse
ANS: B
Becoming culturally competent first requires the nurse to examine his or her feelings and
experiences regarding diversity and to start with an understanding of the nurse’s own heritage.
General assumptions about cultural groups are similar to stereotyping and should be avoided. It is
difficult to become fluent in many languages, because the area in which the nurse works may serve
many different populations. After examining personal views, the nurse will need to learn more
about specific cultural differences to develop an appreciation for the values and beliefs of clients
and co-workers.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Cultural Diversity)
MSC: Integrated Process: Caring
2. The nurse is developing a teaching plan on cultural sensitivity for colleagues who are caring for
clients from other cultures. What action by the nurse might a client of another culture interpret as
culturally insensitive?
a. Making sure that an Arab female client is covered during assessment
b. Avoiding making direct eye contact with a male American Indian client
c. Not encouraging a Japanese-American client to express feelings openly
d. Hugging an Egyptian-American female client who has received bad
news
ANS: D
The nurse should avoid physical touch with clients of cultures other than his or her own because
touch by strangers may be unacceptable, even in stressful situations. It is always acceptable practice
to make sure that clients are completely covered when providing care and carrying out assessment.
Although eye contact in American culture is a positive communication technique, it may be viewed
as disrespectful in other cultures. If a client is from another culture, it is good practice to research
how he or she might respond to a specific intervention before implementation.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 31
TOP: Client Needs Category: Psychosocial Integrity (Cultural Diversity)
MSC: Integrated Process: Caring
3. A Mexican-American client is insistent that her family members stay with her in her hospital
room while she is recovering from surgery. What will be the priority action of the nurse?
a. Explain the policy of the hospital regarding visitors.
b. Ask the Spanish-speaking chaplain to help explain why this is
unacceptable.
c. Arrange for additional beds to accommodate family members’
overnight stay.
d. Notify the physician of the client’s anxiety and suggest a prescription.
ANS: C
If a client asks that family members stay, the nurse should facilitate this process by making
arrangements and notifying administration. Although it is important for visitors to understand
hospital policies, it is possible that the administration will be willing to change policies, within
reason, to meet client needs. It is always acceptable to arrange for interpreters if there is difficulty
communicating with a multicultural client in his or her language. However, in this case, the
chaplain does not have to explain why it is unacceptable because the request is within reason. The
physician can be notified that the client is upset, but if allowing the family to stay decreases the
client’s anxiety, then antianxiety medication usually is not necessary.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Cultural Diversity)
MSC: Integrated Process: Caring
4. A nurse is caring for a lesbian client. What is a priority assessment question for this client?
a. “When was your last complete physical examination?”
b. “How much alcohol do you consume?”
c. “Do you smoke?”
d. “Do you use recreational drugs?”
ANS: A
Because there is a higher incidence of at-risk behavior in this population, it is important that the
nurse find out about health care screening practices. The other questions could be asked at a later
date if additional teaching is needed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Cultural Diversity)
MSC: Integrated Process: Nursing Process (Assessment)
5. The nurse is providing discharge instructions on medications to an older adult client. The client
has expressed concern about paying the hospital bills. What will the nurse emphasize on the basis
of best cultural practice?
a. The client should be prepared to demonstrate filling the daily pill
planner at the next appointment.
b. The client should keep a daily diary of side effects experienced from the
medications.
c. The client must adhere to the medication regimen, unless the cost
becomes prohibitive.
d. The client should ask the pharmacist for the generic version of
medications to keep costs to a minimum.
ANS: D
Older adults may be less likely to follow the prescribed therapy because of drug costs. The client
should be encouraged to adhere to the medication regimen by using generic medications to save
money. Filling a daily pill planner and recording side effects of medications are important aspects
of discharge planning but are not the priority teaching points because expense is an expressed issue
with this client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Teaching/Learning
6. What can health care agencies do to assist in meeting the cultural goals of Healthy People 2020?
a. Ensure accurate recording of a client’s race and/or ethnicity in the
medical record.
b. Hire physicians and nurses from culturally diverse backgrounds.
c. Provide magazines written in more than one language in waiting areas
of clinics.
d. Improve access to health care by establishing clinics closer to low-
income housing.
ANS: D
A major initiative of Healthy People 2020 consists of promoting assessment of major health risks,
reducing disparities in health care, and expanding access to health care in the community. The other
actions only demonstrate sensitivity to cultural differences.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC:
Integrated Process: Caring
7. The nurse is assessing a new home health client. What observation would be relevant for a
cultural assessment?
a. The client asks the nurse how to obtain assistance with his utility bills.
b. The client’s wife reports that the children are having difficulty in
school.
c. The client tells the nurse that he would like to move into public
housing.
d. The client’s wife corrects the husband’s response to questions about his
parents.
ANS: D
Interaction among family members can give important clues to culture and cultural influence. In
many cultures, the husband is the authority of the household and wives do not express opinions or
question the validity of the husband’s statements. But in this case, the wife seems to have the ability
to give constructive criticism. The other responses do not reflect any specific aspects of an
individual’s beliefs, values, customs, norms, or habits.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Cultural Diversity)
MSC: Integrated Process: Caring
8. The client states, “I cannot receive blood transfusions, because it is against my beliefs. I am
concerned about having this surgery.” What is the nurse’s best response?
a. “You should allow your health care team to do whatever is needed.”
b. “The blood supply in this country is the safest in the world.”
c. “There really is nothing unacceptable about blood transfusion.”
d. “There are good alternatives to transfusions that we can discuss.”
ANS: D
The client’s rights and wishes should be respected while accurate information is provided for
reassurance. In this case, stating that there are alternatives to transfusions is the best response. The
health care provider should not attempt to persuade the client to go against his or her wishes or
religious beliefs. Even though the blood supply is safe, the nurse should realize while working with
the client that this is not the issue. The nurse should not try to change the client’s views or
practices.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Religious and Spiritual Influences on Health)
MSC: Integrated Process: Caring
9. A nurse is working with a new group of immigrants and wants to learn more about their culture.
Which method of cultural assessment should the nurse perform to gain a long-term understanding
of this culture?
a. Interview a client.
b. Observe a group.
c. Participate in the community.
d. Visit a group of clients.
ANS: C
Participating in a community that has a large number of members from a particular culture provides
insight into the particular cultural group as a whole, rather than from an individual point of view.
The nurse can passively learn about an individual or a group through interview, observation, and
visitation, but active participation in a community can create a long-lasting understanding of the
group’s ways of life.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Cultural Diversity)
MSC: Integrated Process: Caring
10. The client expresses distress over missing religious services while in the hospital. What is the
nurse’s best action?
a. Tell the client that he or she shouldn’t worry about it right now.
b. Ask the client’s spouse or family member to pray with the client.
c. Ask the hospital’s professional chaplain to talk to the client.
d. Encourage the client to reschedule procedures for another day.
ANS: C
When the client is experiencing spiritual distress, it is best for the nurse to collaborate with the
professional chaplain in managing the client’s religious concerns. The client’s family may also help
ease spiritual distress, but it is hard to plan for this without knowing the family’s comfort in open
display of religion. The other responses are not therapeutic interventions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Religious and Spiritual Influences on Health)
MSC: Integrated Process: Caring
11. The nurse is caring for a homeless client after surgery. Which statement by the nurse indicates
the best understanding of this special population?
a. “When you receive your prescription, fill the medication at the nearest
pharmacy.”
b. “To prevent the risk of infection, you need to bathe daily and keep the
incision clean.”
c. “Tell me about your home situation and access to food and
medications.”
d. “To help with healing, be sure to eat meals high in protein and low in
fat and cholesterol.”
ANS: C
The nurse must be aware of the challenges of the homeless client. This individual is not able to
easily fill prescriptions because of lack of funds and can be challenged to find shelter in which
daily bathing is possible. The diet of the homeless client often is high in saturated fats, sodium, and
cholesterol. Asking the client about his or her ability to find food and housing will give the nurse
concrete data that can lead to consultation with social services and other needed resources.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC:
Integrated Process: Nursing Process (Assessment)
MULTIPLE RESPONSE
1. Which factors are included as part of Purcell’s domains for assessing cultural groups or persons?
(Select all that apply.)
a. Nutrition and communication
b. Family roles and organization
c. Elementary education
d. Biofeedback
e. Death rituals and spirituality
f.
Alternative and complementary therapies
ANS: A, B, E, F
The following are part of Purcell’s domains for assessing cultural groups or persons:
• Nutrition
• Communication
• Family roles and organization
• Workforce issues
• Biocultural ecology
• High-risk behaviors
• Overview (such as heritage)
• Pregnancy and childbirth practices
• Death rituals
• Spirituality
• Health care practices
• Health care practitioners
DIF: Cognitive Level: Comprehension/Understanding REF: Table 4-2, p. 32
TOP: Client Needs Category: Psychosocial Integrity (Cultural Diversity)
MSC: Integrated Process: Caring
2. Which statement by the nurse would potentially offend a client in a predominantly Hispanic
clinic? (Select all that apply.)
a. “Did you know that your child has the most beautiful eyes that I have
ever seen?”
b. “So I can best treat you, could you share your beliefs on the hot/cold
theory of healing?”
c. “Whom do you consider your primary source of healing and
treatment?”
d. “How can you believe that eating ice cream will stop the bleeding after
having a baby?”
e. “Why do you say that arthritis in older age is caused by childbirth as a
young woman?”
ANS: A, D, E
Some people in the Hispanic culture believe that if a person is excessively admired, evil will be
imparted to him or her. It is offensive to belittle the values and beliefs of another culture such as
mal de ojo, the belief that cold foods will cause bleeding to stop, and that if the vagina is exposed to
cold after childbirth, arthritis may occur as an adult. In a therapeutic assessment of a member of the
Hispanic culture, the nurse would assess beliefs regarding health care practices and practitioners.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Caring
Chapter 5: Pain: The Fifth Vital Sign
Chapter 5: Pain: The Fifth Vital Sign
Test Bank
MULTIPLE CHOICE
1. The nurse is caring for a client who was medicated for pain 1 hour ago. The client states that the
medication is not working and the pain is still present. What is the first action that the nurse will
take?
a. Assess the client to determine a pain score.
b. Believe the client’s report of pain.
c. Wait until it is time for the next pain medication dose.
d. Teach the client how to use guided imagery.
ANS: B
Health care providers often do not believe the client’s report of pain. The nurse’s primary role in
pain management is to advocate for the client by believing reports of pain. It is important to
remember that self-reporting is always the most reliable indication of pain. After the clinician
believes that the client is in pain, the client can be assessed to obtain a pain score and can be taught
nonpharmacologic methods of relieving pain. The nurse needs to take action to alleviate the pain
and should not wait until the next medication dosage is due.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advocacy) MSC:
Integrated Process: Nursing Process (Analysis)
2. When is the nurse correct in decreasing the dose of pain medication in a client with end-stage
cancer?
a. The spouse is worried that the client may become addicted.
b. The client wants to remain alert during the visit of a long-time friend.
c. The client has lost considerable weight and does not want to eat.
d. The client is becoming combative at night.
ANS: B
The client has the right to choose whether to take the pain medication. The analgesic regimen
should not interfere with the client’s sleep, rest, appetite, level of physical mobility, or driving
ability. Close relationships are important in providing ongoing support for effective pain
management intervention.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advocacy) MSC:
Integrated Process: Nursing Process (Implementation)
3. A client with chronic pain is being discharged from the hospital. When planning the client’s pain
relief regimen for home, it is most important for the nurse to communicate with which member of
the health care team?
a. Advanced practice nurse
b. Home health care nurse
c. Primary physician
d. Psychologist
ANS: B
All members of the listed health care team are important. However, the home health care nurse will
provide immediate home supervision and assistance to the client and family. The home health care
nurse can refer to other health care team members as necessary. For the home health care nurse to
carry out the role, it is essential that the acute care nurse communicate the client’s physical
condition and support network, and any issues with pain management.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 62
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with
Interdisciplinary Team)
MSC: Integrated Process: Communication and Documentation
4. A client with arthritic pain is considering taking an herbal supplement to relieve arthritic pain.
What teaching is most important for the nurse to carry out with this client?
a. Inform any health care providers about the use of this supplement.
b. Practice imagery along with taking the herbal supplement.
c. Take only herbal supplements that are prescribed.
d. Take herbal supplement at the onset of pain.
ANS: A
Always ask the client about the use of herbal supplements, because some can cause serious
interactions with other pharmacologic agents. The other responses are not considered the most
important.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
of Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Teaching/Learning
5. What instruction should the nurse include in the discharge teaching plan of a client who has a
transcutaneous electrical nerve stimulation (TENS) unit?
a. “Pain relief is sustained when stimulation is stopped.”
b. “The current is adjusted by the physician.”
c. “The electrodes are placed away from the painful site.”
d. “You can perceive a pins and needles sensation.”
ANS: D
The TENS unit works through electrodes that are placed near the painful area site. These electrodes
are connected to a small box that contains the current needed for pain relief. The current can be
adjusted by any health care provider. Adjustment of this current can cause a pins and needles
sensation. Pain relief with cutaneous therapy generally is sustained only as long as the stimulation
continues.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 59
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
6. Why does the nurse always ask the client his or her pain level after taking routine vital signs?
a. To determine whether pain is influencing blood pressure and heart rate
b. To determine the need for more frequent vital sign measurement
c. To ensure that pain assessment occurs on a regular basis
d. To follow McCaffery’s guidelines on pain management
ANS: C
Making pain the fifth vital sign allows more frequent and accurate assessment, which can
contribute to better pain management.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 46
TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC:
Integrated Process: Nursing Process (Assessment)
7. A client with cholecystitis has pain in the right shoulder area and asks, “What is happening to
me? What did I do to my shoulder?” What is the nurse’s best response?
a. “You are weak from staying in bed.”
b. “Does your other arm hurt too?”
c. “Sometimes pain from a certain organ is referred elsewhere in the
body.”
d. “I am going to hold your medication until we can determine what is
happening.”
ANS: C
Many types of visceral pain can be felt in body areas other than the originating site. This is known
as referred pain. Pain originating in the gallbladder can be referred to the right posterior shoulder.
The client should be reassured that this is normal and should be medicated appropriately.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
8. The nurse is assigned to care for the following four clients who have the potential for having
pain. Which client is most likely not to be treated adequately for this problem?
a. Middle-aged woman with a fractured arm
b. Client with expressive aphasia
c. Younger adult with metastatic cancer
d. Client who has undergone an appendectomy
ANS: B
Populations at highest risk for inadequate pain treatment include older adults, minorities, and those
with a history of substance abuse. Nonverbal clients are very difficult to assess for pain because
self-report is not possible, and the nurse needs to rely on client behaviors or surrogate reporting.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advocacy) MSC:
Integrated Process: Nursing Process (Assessment)
9. The physician orders a dose of medication that does not resolve the client’s chronic pain. When
the nurse questions the order, the physician explains that he or she fears the client will develop an
addiction with higher drug dosages. What is the nurse’s best response?
a. Administer the medication as ordered.
b. Assist the client to use guided imagery.
c. Consult with the pain control specialist.
d. Explain to the client that lower doses are better.
ANS: C
A health care provider may underprescribe medications for clients in pain for many reasons, such as
regulatory scrutiny and cultural and societal attitudes. Undertreatment of pain is a serious problem
in the United States and in the rest of the world. The nurse can act as an advocate for the client in
pain by consulting with a pain care specialist.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Implementation)
10. A client who has been taking oxycodone (OxyContin) for an extended period of time comes to
the clinic reporting that the drug is no longer relieving his pain. Which category would be given to
the client’s complaint?
a. Addiction
b. Physical dependence
c. Pseudoaddiction
d. Tolerance
ANS: D
Tolerance is a state of the body’s adaptation to a drug so that it takes an increase in dosage to
produce similar effects. This differs from addiction, which is characterized by compulsive craving
for a medication, or physical dependence that manifests as the appearance of withdrawal symptoms
when a drug is abruptly stopped or an antagonist is administered. Pseudoaddiction is the strong
desire for a medication related to undertreatment of pain.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 44
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Nursing Process (Assessment)
11. A home care client who is taking morphine for pain management abruptly stops taking the
medication. Which symptom would indicate physical dependence?
a. Abdominal cramping
b. Craving for morphine
c. Decreased heart rate
d. Elevated temperature
ANS: A
Physiologic dependence on opioids such as morphine allows tissues to adapt to their presence.
When opioids are suddenly removed, the dependent tissues stimulate an autonomic nervous system
response that includes nausea and vomiting, abdominal cramping, muscle twitching, profuse
perspiration, delirium, and convulsions.
DIF: Cognitive Level: Comprehension/Understanding REF: pp. 44-45
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Assessment)
12. A home care client who is currently on hydromorphone (Dilaudid) for pain management
presents to the hospital reporting abdominal cramping, nausea, and sweating. When taking the
client’s history, the nurse asks which question first?
a. “Are you currently in severe pain?”
b. “Did you take more Dilaudid than prescribed?”
c. “When did you take your last dose of Dilaudid?”
d. “When was your last bowel movement?”
ANS: C
Physical dependence occurs in everyone who takes opioids over a period of time. Withdrawal
syndrome occurs when the client abruptly stops taking the medication. Symptoms include
abdominal cramping, nausea, sweating, delirium, and convulsions. Although the other distractors
may be asked about as part of the admission assessment, they are not of priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Assessment)
13. The nurse is assessing a client with a long-term history of arthritic pain. Assessment reveals a
heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the nurse
carry out first?
a. Administer blood pressure medication.
b. Administer a drug to lower the heart rate.
c. Assess whether the client needs anti-arthritis medication.
d. Continue to assess for possible causes of elevated vital signs.
ANS: D
Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking the
sympathetic nervous system; this normally causes tachycardia and increased blood pressure.
Therefore, this client’s high blood pressure and heart rate are not caused by chronic pain and may
be a result of a more acute type of pain. Therefore, the best intervention is for the nurse to establish
whether the client is having pain other than arthritic pain, and then to decide which intervention
should be carried out.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
14. The nurse is caring for four clients who are reporting pain. Based on the following assessments
and histories, which client’s pain is most likely chronic in nature?
a. Foley catheter inserted 30 minutes ago with a heart rate of 100
beats/min
b. History of heart disease with a heart rate of 120 beats/min
c. History of fibromyalgia with a blood pressure of 110/70 mm Hg
d. Hip replacement surgery with a blood pressure of 170/90 mm Hg
ANS: C
The definition of chronic pain involves the length of time the pain is experienced and/or the
progressive nature of the problem causing the pain. Both heart disease and fibromyalgia could fit
into this category. However, pain of a chronic nature does not call the sympathetic nervous system
into play. Therefore, a rise in heart rate and blood pressure is not seen in a client who has chronic
pain. The client with fibromyalgia who is having pain is not experiencing the increased blood
pressure that would be seen with acute pain.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Analysis)
15. When a client is assessed, which behavior best indicates that he or she is experiencing changes
associated with acute pain?
a. Anger and hostility
b. Expressed hopelessness
c. Inability to concentrate
d. Psychosocial withdrawal
ANS: C
The characteristics most common to chronic pain are psychosocial withdrawal, anger and hostility,
depression, and hopelessness. The inability to concentrate is associated much more with acute pain,
before any physiologic or behavioral adaptation has occurred.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 41
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Assessment)
16. The nurse anticipates that the client who rates pain as 10 on a scale of 1 to 10 has undergone
which surgical procedure?
a. Cranial surgery
b. Leg surgery
c. Neck surgery
d. Upper abdominal surgery
ANS: D
In general, intrathoracic and upper intra-abdominal surgical approaches are associated with more
severe pain. Muscle-splitting procedures generally are far more painful than muscle-stretching
procedures.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 41
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Assessment)
17. Which assessment finding is cause for concern in a client who has taken 4 grams of
acetaminophen (Tylenol) to relieve back pain?
a. Difficulty with urination
b. Decreased respiratory rate
c. Gastrointestinal bleeding
d. Increased liver function tests
ANS: D
Tylenol has few anti-inflammatory properties. Therefore, it will not cause bleeding. Unlike nerve
blocks and opioid drugs, it does not affect the respiratory rate or cause difficulty with urination. It
can cause liver toxicity, especially in higher doses and taken more frequently than every 4 hours for
long-term use.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Analysis)
18. During preoperative assessment, the client tells the nurse about taking NSAIDs for years. What
question is most important for the nurse to ask?
a. “Did you ever have a problem with bleeding?”
b. “Do you bruise easily?”
c. “How many tablets do you take every day?”
d. “When was the last time you took your NSAID?
ANS: D
NSAIDs can prevent platelet aggregation; this results in a tendency toward bleeding. Before
notifying the surgeon, the nurse should find out the last time the client took the medication and
should check the chart to see whether there is a note that clarifies the surgeon’s awareness of the
client’s use of this medication.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Assessment)
19. The client is taking an oxycodone-acetaminophen combination (Tylox) at home daily for
chronic pain management. What instruction does the nurse give this client?
a. “Avoid taking aspirin while you are on this medication.”
b. “Drink plenty of water and eat foods high in fiber.”
c. “Stop this medication after 3 days if the pain persists.”
d. “Weigh yourself daily to determine whether you are retaining sodium or
water.”
ANS: B
Opioid agonists, like oxycodone, act on systemic and neural opioid receptors and decrease
gastrointestinal motility. Constipation is common and can be an aggravating problem. Fluids and
foods high in fiber can prevent constipation. The other instructions would not be appropriate for
this medication.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Teaching/Learning
20. The client was given 15 mg of morphine IM for postsurgical pain. When the nurse checks the
client for pain relief 1 hour later, the client is sleeping and has a respiratory rate of 10 breaths/min.
What is the nurse’s first action?
a. Administering naloxone (Narcan) IV push
b. Administering oxygen by nasal cannula
c. Arousing the client by calling his or her name
d. Documenting the findings and continuing to monitor
ANS: C
Many clients experience some degree of respiratory depression with opioid analgesics. If the client
can be aroused with minimally intrusive techniques and the rate of respiration is increased
spontaneously, no further intervention is required.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes)
MSC: Integrated Process: Nursing Process (Implementation)
21. The nurse accidentally administers 10 mg of morphine intravenously to a client who had been
given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action must the nurse be
prepared to take?
a. Administer naloxone (Narcan).
b. Administer oxygen.
c. Assist with intubation.
d. Monitor pain level.
ANS: A
A combined dose of 15 mg of morphine may cause severe respiratory depression in some clients.
Naloxone is an opioid antagonist that can be used (intravenously) as the first intervention to reverse
respiratory depression due to a morphine overdose. Then administration of oxygen may be needed
if the client’s oxygen saturation decreases. Intubation may occur if the client does not respond to
the Narcan, and respiratory depression becomes a respiratory arrest. Naloxone may be repeated, but
the pain level of the client needs to be monitored because Narcan can promote withdrawal
symptoms.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Planning)
22. A client is admitted to the hospital with a history of oxycodone (Percodan) abuse. For which
clinical manifestations does the nurse observe the client?
a. Anorexia and weight loss
b. Decreased heart rate and respirations
c. Muscle twitching and profuse perspiration
d. Sedation and constipation
ANS: C
Physiologic dependence on opioids allows tissues to adapt to their presence. When opioids are
suddenly removed, the dependent tissues stimulate an autonomic nervous system response that
includes nausea and vomiting, abdominal cramping, muscle twitching, profuse perspiration,
delirium, and convulsions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Chemical and Other Dependencies)
MSC: Integrated Process: Nursing Process (Assessment)
23. Which client would the nurse suggest should try subcutaneous opioid analgesia for pain
management?
a. Client who has had a surgical procedure
b. Client with back pain who likes to walk
c. Client with cancer who is nauseous
d. Client experiencing acute chest pain
ANS: C
Subcutaneous opioid analgesia is recommended for cancer clients who cannot take anything by
mouth. It is not recommended for acute pain, such as pain from a surgical procedure, because
subcutaneous boluses have slower onset and a lower peak effect than IV boluses. It also requires
the use of an ambulatory infusion pump, which may not always be acceptable to someone who is
physically active.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Analysis)
24. A client with colon cancer is discharged to home with morphine for pain management. He is
having episodes of nausea and vomiting. Which route of morphine administration would be most
advantageous to use?
a. Oral
b. Rectal
c. Intravenous
d. Intramuscular
ANS: B
Rectal administration of opioids is recommended for clients who are NPO, nauseated, or at home.
Oral agents are the preferred route of analgesia in many cases. However, because of his nausea and
vomiting, this client does not have the functional GI system needed for good absorption of oral
agents. Intramuscular agents are not recommended for cancer pain. Intravenous agents are
recommended when oral and rectal routes fail to provide pain control.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 5-7, p. 55
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Assessment)
25. The nurse is caring for four clients. Which client assessment is the most indicative of having
pain?
a. Blood pressure 150/70 mm Hg and sleeping
b. Client stating that he is “anxious”
c. Heart rate of 105 beats/min and restlessness
d. Postoperative client with a neck incision
ANS: C
At times clients are unable to verbalize that they are in pain but there are indicators that the client
may have acute pain such as increased heart rate, increased blood pressure, increased respirations,
sweating, restlessness, and overall distress. All the other distractors could indicate clients who have
the potential for being in pain, but restlessness with tachycardia is the most indicative.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Analysis)
26. A client has a history of alcohol abuse. Which pain relief regimen does the nurse anticipate if
morphine (MS Contin) is given for pain?
a. A higher dose of opioids will be needed to provide effective pain relief.
b. A lower dose of opioids will be needed to provide effective pain relief.
c. The appropriate drug selection is an opioid agonist-antagonist
combination.
d. The client will receive no pain relief from the morphine.
ANS: A
People who drink significant amounts of alcohol daily have elevated liver enzyme activity that
degrades morphine and morphine agonists. As a result, these clients frequently have tolerance for
opioid analgesics and require higher doses of agonists to achieve an acceptable level of pain relief
during acute pain episodes.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Analysis)
27. Which instruction is the most accurate for the nurse to give a client who has a patient-controlled
analgesia device (PCA) after abdominal surgery?
a. “Instruct your visitors to press the button for you when you are
sleeping.”
b. “Push the button every 15 minutes whether you feel pain at that time or
not.”
c. “Push the button when you first feel pain instead of waiting until pain is
severe.”
d. “Try to go as long as you possibly can before you press the button.”
ANS: C
Clients should be instructed to push the button to release medication when the pain begins rather
than waiting until the pain becomes so great that the dose given by the pump cannot control the
pain. No one should push the button for the client. Clients should not be instructed to bear the pain
as long as possible before using PCA.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 54
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Pharmacological Pain Management)
MSC: Integrated Process: Teaching/Learning
28. The nurse assesses several postoperative clients receiving patient-controlled epidural analgesia
(PCEA). Which client does the nurse prioritize to assess first?
a. Client receiving bupivacaine (Marcaine) describing “inability to move
legs”
b. Client receiving fentanyl (Sublimaze) describing “itchy arms”
c. Client receiving hydromorphone (Dilaudid) describing “full feeling”
d. Client receiving morphine describing “difficulty staying awake”
ANS: A
Epidural analgesia can cause sensory and motor deficits. The inability to move the legs could mean
that the client is receiving too high a dose of the drug or that damage has been done to the spinal
cord. This requires immediate intervention. Itchy arms, a full feeling, and difficulty staying awake
could be side effects of the medications, but they are not matters of priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Planning)
29. A client has epidural analgesia with bupivacaine (Marcaine) for pain relief. For which condition
should the nurse assess this client?
a. Extremity itching
b. Inability to raise legs off the bed
c. Nausea and vomiting
d. Respiratory rate of 8 breaths/min
ANS: B
Lower motor weakness is more common when an epidural local anesthetic (such as bupivacaine) is
used. The other three problems are seen more often when opioids are used.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Planning)
30. When assessing a client who is taking long-term ibuprofen (Motrin) for pain, the nurse finds
numerous areas of bruising. What is the nurse’s first action?
a. Assess for gastric discomfort.
b. Assess for the presence of pain.
c. Continue to monitor bruising.
d. Place client on falls precaution.
ANS: A
NSAIDs can cause gastrointestinal disturbances and can prevent platelet aggregation, which results
in GI bleeding. Therefore, clients should be observed for gastric discomfort or vomiting and
bleeding.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Reactions/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Evaluation)
31. Which statement made by a nurse represents the need for further education regarding pain
management in older adult clients?
a. “Older adults are at greatest risk for undertreated pain.”
b. “Older adults tend to report pain less often than younger adults.”
c. “Older clients usually have more experience with pain than younger
clients.”
d. “Older clients have a different pain mechanism and do not feel it as
much.”
ANS: D
There is no evidence to support the idea that older adult clients perceive pain any differently than
younger clients. The other statements are accurate regarding older clients and pain.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Adaptation (Physiological Adaptation—Pathophysiology) MSC:
Integrated Process: Teaching/Learning
32. Before surgery, the nurse observes the client listening to music on the radio. Based on this
observation, the nurse may try which nonpharmacologic intervention for pain relief in the
postoperative setting?
a. Cutaneous skin stimulation
b. Hypnosis
c. Imagery
d. Radiofrequency ablation
ANS: C
Imagery is a form of distraction in which the client is encouraged to visualize about some pleasant
or desirable feeling, sensation, or event. Behaviors that are helpful in assessing a client’s capacity
for imagery include being able to listen to music or other auditory stimuli.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort
Interventions)
MSC: Integrated Process: Nursing Process (Assessment)
33. A client who is at the end of life is being given morphine for pain management. The family
expresses concern that the morphine may cause the client to stop breathing and die. What is the
nurse’s best response?
a. “He needs the morphine to prevent pain.”
b. “His respirations are not affected by the morphine.”
c. “We will decrease the dose if his breathing slows.”
d. “We will give him oxygen to help with his breathing.”
ANS: B
Because clients become tolerant to the respiratory effects of an opioid, it does not hasten death
unless the dose was not properly and gradually titrated. Decreasing the drug would cause pain to
occur, and oxygen will not help with his rate of respirations.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Reactions/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Teaching/Learning
34. A client is stating that he has the sensation of burning, aching, and dullness. Which afferent
nerve fibers should be transmitting the pain?
a. A delta fibers
b. C fibers
c. A alpha fibers
d. A beta fibers
ANS: B
The sensation of burning, aching, and dullness is transmitted by the C fibers in contrast to the A
delta fibers, which carry rapid, sharp, pricking, or piercing sensations. A alpha and A beta fibers are
large-diameter fibers that may close the gate and decrease pain.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 43
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
35. A client is postoperative day one and has a patient-controlled analgesia (PCA) pump with a
continuous basal dose for pain control. Currently, the client is stating that the operative pain is
escalating. What is the first action of the nurse?
a. Try diversion to take the client’s mind off the pain.
b. Ask the client to ambulate around the unit.
c. Assess the client’s pain according to PQRST.
d. Call the physician to request an order to increase the basal dose.
ANS: C
Assessment is the first step in the nursing process. The nurse will need the information gleaned
from the assessment using PQRST (factors precipitating the pain, quality of the pain, region and
radiation of the pain, severity of the pain, and timing of the pain) to request a change in medication
order. Diversion and ambulation can be used in client care but will not control escalating pain in the
postoperative client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication
Administration) MSC: Integrated Process: Nursing Process (Assessment)
36. Which client does the nurse assess first for pain control?
a. Older client with chronic rheumatoid arthritis
b. Client postoperative day three walking in the hallway
c. Sleeping client with an epidural pump
d. Quiet client with pancreatic cancer curled up in bed
ANS: D
The pain of pancreatic cancer is usually severe. This client should be assessed first because the
client’s present behavior may indicate suffering and pain. The client with arthritis has had this
condition for a while and may not be experiencing severe pain. The client who is walking in the
hallway and the client who is sleeping do not demonstrate nonverbal pain behaviors.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication
Administration) MSC: Integrated Process: Nursing Process (Assessment)
MULTIPLE RESPONSE
1. Which is most indicative of pain in an older client who is confused? (Select all that apply.)
a. Decreased blood pressure
b. Screaming
c. Facial grimace
d. Restlessness
e. Crying
f.
Decreased respirations
ANS: B, C, D, E
No one scale has been found to be the best tool to use in pain assessment for adults with cognitive
impairment. Facial expression, motor behavior, mood, socialization, and vocalization are common
indicators of pain in cognitively impaired adults. In acute pain, nonverbal indicators of pain could
include increased blood pressure and respirations.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 49
TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)
MSC: Integrated Process: Nursing Process (Assessment)
2. An older client just returned from surgery and is rating pain as “8” on a 0 to 10 scale. Which
medications are unsafe choices for treatment of severe pain in this older adult?
a. Meperidine (Demerol)
b. Methadone (Dolophine)
c. Propoxyphene (Darvocet)
d. Morphine (Durmorph)
e. Codeine
ANS: A, B, C, E
Meperidine, propoxyphene, and codeine are not recommended for older clients because toxic
metabolites may accumulate. Codeine may cause constipation as well. Methadone has an extremely
long half-life (24 to 36 hours) and has a high potential for sedation and respiratory depression.
Morphine is considered the gold standard and may be used in the older adult while monitoring for
sedation and respiratory depression is conducted.
DIF: Cognitive Level: Comprehension/Understanding REF: Chart 5-1, p. 45
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Planning)
Chapter 6: Genetic Concepts for Medical-Surgical Nursing
Chapter 6: Genetic Concepts for Medical-Surgical Nursing
Test Bank
MULTIPLE CHOICE
1. Which statement by the nurse indicates correct understanding of the purpose of a pedigree?
a. “It is used for genetic counseling of the client by the geneticist.”
b. “It is used to show family history of a trait over at least three
generations.”
c. “It is used to show a specific pattern of inheritance of a trait.”
d. “It is used to identify penetrance of a gene in a family.”
ANS: B
A pedigree is a graph of a family history for a specific trait or health problem over several
generations. The other statements are inaccurate descriptions of the purpose of a pedigree.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 72
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
2. The client exhibits a trait that has appeared in every generation of his or her family. This is an
example of which type of inheritance?
a. Autosomal recessive
b. Sex-linked recessive
c. Autosomal dominant
d. Sex-linked dominant
ANS: C
Autosomal dominant (AD) single-gene traits require that the gene alleles controlling the trait be
located on an autosomal chromosome. A dominant gene allele is expressed even when only one
allele of the pair is dominant. Other criteria for AD patterns of inheritance include that the trait
appears in every generation with no skipping. Autosomal recessive, sex-linked recessive, and sexlinked dominant types of inheritance do not require that the trait appear in every generation of a
family. Rather, in the case of sex-linked traits, the gender of family members determines whether a
trait will appear in a family.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 73
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
3. The client has a family history of breast cancer. The physician has recommended that she
undergo genetic testing. What action is most important for the nurse to take before scheduling the
client for the procedure?
a. Making certain the client is prepared for the risk of psychological side
effects
b. Obtaining informed consent from the client and placing it on the chart
c. Simultaneously scheduling genetic counseling with an advanced
practice nurse
d. Carefully explaining the procedure to the client and assuring her
confidentiality
ANS: B
Informed consent is required before genetic testing is undertaken. The person tested is the one who
gives consent, even though genetic testing always gives information about a family and family
members, not just the client. Although the procedure must be explained to the client and she must
be prepared for the psychological effect of undergoing testing, the procedure cannot occur without
an informed consent.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Informed Consent)
MSC: Integrated Process: Communication and Documentation
4. The client undergoes genetic testing but chooses not to be told the results of the testing once it is
completed. Which action is most important for the nurse to implement?
a. Encourage the client to ask for the results of the genetic testing.
b. Share the results of the testing with the client’s family members.
c. Explain to the client how this choice may affect other family members.
d. Respect the client’s right to not know the results of the testing.
ANS: D
The right to know genetic risk versus the right to not know is the individual client’s choice. The
nurse should respect the client’s rights. It would not be appropriate for the nurse to encourage the
client to ask for the results because this is a personal issue. The nurse would never share results
with others because this is a violation of the Health Insurance Portability and Accountability Act
(HIPAA). The client probably realizes that this choice affects other family members. The nurse
would not have to explain this.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Client Rights)
MSC: Integrated Process: Caring
5. The nurse has been working with a client who has asked to receive the results of genetic testing.
What will the nurse do before discussing the results with the client?
a. Obtain a signed and witnessed informed consent form and place it on
the client’s chart.
b. Assess the client’s ability to communicate clearly with the nurse and
other personnel.
c. Reassure the client that it is not necessary to inform other family
members of the test results.
d. Encourage the client to agree to undergo several sessions of further
counseling.
ANS: B
The nurse has to assess the client’s ability to receive and process information before giving results.
Informed consent forms are obtained before blood is obtained for testing. The nurse would not
reassure the client that it was not necessary to tell family members. This is something the client will
need to decide. The nurse can suggest counseling, if necessary, but does not have to encourage the
client to have counseling before giving him or her the results of testing.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
6. Which client needs to undergo carrier genetic testing?
a. A middle-aged man whose father died at age 48 of colorectal cancer
b. A young woman who has all the symptoms of rheumatoid arthritis
c. A middle-aged woman whose mother died at age 52 of breast cancer
d. A young woman of Eastern European Jewish ancestry
ANS: D
The client who is of Eastern European Jewish ancestry would be given the highest priority to
undergo carrier genetic testing. It is known that Ashkenazi Jews carry several genetic disorders.
The client with a family history of breast cancer and colorectal cancer would undergo
predisposition testing. The client with symptoms of rheumatoid arthritis would undergo
symptomatic diagnostic testing.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
7. The client has just completed the first session of genetic counseling. Which intervention will the
nurse perform next?
a. Assessing the phase of the grieving process most applicable to the client
at this time
b. Asking the client to explain the various terms used in the discussion
c. Determining whether the client has adequate coping methods to deal
with the counseling process
d. Asking the client to explain expectations and how they may have
changed after the session
ANS: D
After any discussion about genetic risk or genetic testing, the nurse would assess the client’s
understanding of what was said and how the information may affect decisions in the future. The
client may not be in the grieving process at this time. The nurse does not have to ask the client to
explain each term after the session. However, the nurse should have encouraged the client to ask
questions throughout the session. Although it is important to assess coping in the client, this is
usually done after understanding is assessed. Support can then be offered to the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
8. The client has just completed genetic testing and received a negative result. The client tells the
nurse that he feels guilty because so many of his family members are carriers of a genetic disease
but he is not. What is the nurse’s best response?
a. Make certain that the client recognizes that although he is not a carrier
of the disease, he could still be symptomatic.
b. Encourage the client to undergo a second round of testing to verify that
the result was accurate.
c. Arrange for the client to undergo counseling and offer support to him
during this time.
d. Emphasize to the client the importance of revealing his test results to
other family members.
ANS: C
Clients who have negative genetic test results need counseling and support. Some clients may have
an unrealistic view of what a negative result means for their general health. Others may feel guilty
that they were “spared” when some family members were not. The client will not be symptomatic if
he is not a carrier of the disease. A second round of testing is not recommended, because falsenegatives are rare with this type of testing. It is the client’s choice to reveal test results to family
members; the nurse should not encourage him to do this.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Support Systems)
MSC: Integrated Process: Caring
9. A client is not certain whether she and her family should participate in a genetic screening plan.
She asks the nurse why the X-linked recessive disorder that has been noted in some of her family
members is expressed in males more frequently than in females. What is the nurse’s best response?
a. “The disease tends to show up in males because they don’t have a
second X chromosome to balance expression of the gene.”
b. “One X chromosome of a pair is always inactive in females. This
inactivity effectively negates the effects of the gene.”
c. “Females are known to have more effective DNA repair mechanisms
than males, thus negating the damage caused by the recessive gene.”
d. “Expression of genes from the male’s Y chromosome does not occur in
females, so they are essentially immune to the effects of the gene.”
ANS: A
Because the number of X chromosomes in males and females is not the same (1:2), the number of
X-linked chromosome genes in the two genders is also unequal. Males have only one X
chromosome, a condition calledhemizygosity, for any gene on the X chromosome. As a result, Xlinked recessive genes have a dominant expressive pattern of inheritance in males and a recessive
expressive pattern of inheritance in females. This difference in expression occurs because males do
not have a second X chromosome to balance the expression of any recessive gene on the first X
chromosome. It is incorrect to say that one X chromosome of a pair is always inactive in females,
or that females have more effective DNA repair mechanisms than males. Also, it is not true that
females can be immune to the effects of a gene because genes from the male’s Y chromosome are
not expressed in females.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 74
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
10. The client has been found to have a genetic mutation that increases the risk for colon cancer.
The client does not want any family to know about this result. What is the nurse’s best response?
a. “It is required by law that you inform your siblings and your children
about this result so that they also can be tested and monitored for colon
cancer.”
b. “It is not necessary to tell your siblings because they are adults, but you
should tell your children so that they can be tested before they decide to
have children of their own.”
c. “It is not required that you tell anyone about this result. However,
because your siblings and children may also be at risk for colon cancer,
you should think about how this information might help them.”
d. “It is your decision to determine with whom, if anyone, you discuss this
test result. However, if you do not tell any of your family members and
they get colon cancer, you could be held liable.”
ANS: C
This situation represents an ethical dilemma. It is the client’s decision whether to disclose the
information. However, the information can affect others in the client’s family. The law does not
require the client to tell family members about the results, nor can the client be held liable for not
telling them. The nurse may consider it ethically correct for the client to tell family members so that
they can take action to prevent the development of cancer, but the nurse must respect the client’s
decision.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Communication and Documentation
11. Which response is accurate regarding a client who has type O blood? The client has:
a. A genotype of AO
b. A genotype of OO
c. Heterozygous alleles
d. A different genotype and phenotype
ANS: B
The blood type O allele is recessive, and both alleles must be type O (homozygous) for the person
to express type O blood. In type O blood, the genotype and the phenotype are the same. If only one
allele is a type O allele and the other allele is type A or type B, the dominant allele will be
expressed and the O allele, although present, will not be expressed. When a person has
heterozygous alleles for a trait, the phenotype and the genotype are not always the same as with
type AB blood.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 70
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
12. Which statement regarding genotype and phenotype is accurate?
a. For autosomal recessive traits, the phenotype is the same as the
genotype.
b. The only trait in which phenotype always follows genotype is
physiologic gender.
c. When a phenotype is fully penetrant, the trait is expressed in the
heterozygous person.
d. Genotype changes as a person ages, whereas phenotype is not affected
by the aging process.
ANS: A
Genotype refers to the exact alleles of a single gene trait. Phenotype refers to the observable
characteristics present when a gene is expressed. For recessive traits, because both alleles must be
the same (homozygous) for the gene to be expressed, the phenotype and the genotype are the same.
Dominant traits are expressed in the phenotype, even when the person’s genotype is heterozygous
for the alleles. Physiologic gender is not the only trait in which phenotype always follows
genotype, nor is a trait necessarily expressed in the heterozygous person because a phenotype is
fully penetrant. Also, both phenotype and genotype, as with other aspects of the genetic makeup of
the individual, are affected by the aging process. The other statements are inaccurate descriptions of
genotype and phenotype.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 70
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
13. Which statement best describes the concept of multifactorial inheritance?
a. A mutation in a single gene results in the expression of problems in a
variety of tissues and organs.
b. Susceptibility to a problem is inherited as a single gene trait, but
development of the problem is enhanced by environmental conditions.
c. A mutated gene is inherited, but the results of expression of that gene
are not evident until middle or late adulthood.
d. Several genes are responsible for the mechanism of hearing, and a
mutation in any one of them results in hearing impairment.
ANS: B
Multifactorial inheritance indicates an interaction between a genetic predisposition and the
environment. Although the predisposition to developing a health problem may be inherited,
whether the problem is ever expressed is determined by environmental influences, including
lifestyle. Some common adult health problems that are multifactorial include hypertension, obesity,
diabetes mellitus, and some types of cancer. Multifactorial inheritancedoes not refer to mutations in
one gene that result in problems in many tissues and organs. Although it is true that a gene mutation
may not become evident until later in life, this is not the definition of multifactorial inheritance. It
does not refer to mutations in several genes or to conditions in which several genes are involved.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 74
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
14. A client’s father has hemochromatosis. Which type of genetic testing would be the primary type
that is most appropriate for the client to have?
a. Presymptomatic
b. Predisposition
c. Diagnostic
d. Carrier
ANS: D
Hereditary hemochromatosis is an autosomal recessive disorder. The purpose of genetic testing for
this client would be to determine whether he or she has one mutated gene allele (is a carrier) and
could transmit this disorder to his or her children. All genetic testing is diagnostic in nature.
Presymptomatic genetic testing is used with Huntington disease. Predisposition testing is used with
colorectal cancer and breast cancer.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 6-4, p. 75
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Nursing Process (Assessment)
15. Which disorder qualifies a client for presymptomatic diagnostic genetic testing?
a. Colorectal cancer
b. Huntington disease
c. Hemophilia
d. Tay Sachs disease
ANS: B
Of the disease processes listed, the only one that would make a client a candidate for
presymptomatic diagnostic genetic testing is Huntington disease.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 6-4, p. 75
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Nursing Process (Assessment)
16. Which disorder presents a need for predisposition genetic testing?
a. Huntington disease
b. Sickle cell disease
c. Hemophilia
d. Breast cancer
ANS: D
Of the disease processes listed, the only one that would make a client a candidate for predisposition
diagnostic genetic testing is breast cancer.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 6-4, p. 75
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Nursing Process (Assessment)
17. The client, whose mother has Huntington disease, is considering genetic testing but is not sure
whether she really wants to know the results. She asks what the nurse would do in her situation.
What is the nurse’s best response?
a. “I would have the test so I could decide whether to have children or to
adopt children.”
b. “I can only tell you the benefits and the risks of testing. You must make
this decision yourself.”
c. “Because there is no cure for this disease and testing would not be
beneficial, I would not have the test.”
d. “You need to check with your brothers and sisters to determine whether
testing for this disease would be appropriate for you.”
ANS: B
Any level of genetic counseling requires the counselor to be nondirective. The counselor must
ensure that the client has adequate and accurate information on which to base the decision but
cannot suggest or direct the client to test or not to test. The client may wish to discuss the issue with
her family, but ultimately the decision about testing can be made only by the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Communication and Documentation
18. The client, who has been found to have a mutation in the BRCA1 gene allele and to be at
increased risk for breast and ovarian cancer, has asked the nurse to be present when she discloses
this information to her adult daughter. What is the nurse’s role in this situation?
a. To act as the primary health care provider
b. To function as a genetic counselor
c. To serve as a client advocate
d. To provide client support
ANS: D
The nurse should be supporting the client emotionally while the client tells her daughter the
information she has learned about the test results. The nurse should not interpret the results nor
counsel the client or her daughter. The nurse should refer the client for counseling or support, if
necessary.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Support Systems)
MSC: Integrated Process: Nursing Process (Implementation)
19. After genetic testing, a client is found to have a specific mutation in the a1AT gene (alpha1-
antitrypsin). What is the best action for the nurse to take to guide the client?
a. Advise scheduling an annual mammogram and ovarian ultrasound.
b. Assess whether close family members have other identified genetic
problems.
c. Suggest limiting exposure to secondhand smoke and other respiratory
irritants.
d. Advise that cancer may be a risk but not a certainty for this mutation.
ANS: C
The a1AT gene mutation increases risk for developing early-onset emphysema. By limiting
exposure to smoke and other respiratory irritants, there is less environmental influence that may
aggravate an early onset of emphysema. This gene mutation does not promote cancer, nor does it
occur with other identified genetic problems. The BRCA1 gene mutation gives the client a higher
risk for developing breast cancer. Because of the higher risk of this type of cancer, mammogram
and ovarian ultrasound are advised to be performed yearly.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC:
Integrated Process: Teaching/Learning
20. Which client response best indicates that the client has concerns about a genetic link to a
specific condition?
a. “Heart disease in women seems to be a growing concern in the United
States.”
b. “Obesity is prevalent in the elementary school age population.”
c. “My grandmother died of both breast and bone cancer at age 50.”
d. “Both my aunt and my second cousin have osteoarthritis.”
ANS: C
The first two responses are general statements about health problems in the United States.
Osteoarthritis is not necessarily a genetically linked problem. Breast cancer with metastasis is
considered an autosomal dominant inherited condition that may prompt a client to inquire about
genetic testing and counseling. The nurse may be the first person to verify information that has
genetic implications for the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC:
Integrated Process: Teaching/Learning
MULTIPLE RESPONSE
1. What client diagnosis indicates a need for carrier genetic testing? (Select all that apply.)
a. Colorectal cancer
b. Huntington disease
c. Sickle cell disease
d. Hemophilia
e. Breast cancer
f.
Cystic fibrosis
g. Tay Sachs disease
ANS: C, D, F, G
Of the disease processes listed, the ones that would make the client a candidate for carrier genetic
testing would be sickle cell disease, hemophilia, cystic fibrosis, and Tay Sachs disease. Although
colorectal cancer, Huntington disease, and breast cancer all have genetic components, there is no
evidence that carrier genetic testing would be beneficial in diseases such as these.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 6-4, p. 75
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Nursing Process (Assessment)
2. The client has just been typed and crossmatched for a unit of blood. Which statements by the
nurse indicate a need for further genetic education? (Select all that apply.)
a. “The client can receive any unit of blood because all blood types are
basically the same.”
b. “Blood type is formed from three possible gene alleles: A, B, and O.”
c. “Each blood type allele is inherited from the mother or the father.”
d. “If the client’s blood type is AB, then the client is homozygous for that
trait.”
e. “If the client has a dominant and a recessive blood type allele, only the
dominant will be expressed.”
ANS: A, D
All blood types are not the same. There are three possible gene alleles: A, B, and O. The blood type
OO is homozygous in contrast to the blood type AB, which is heterozygous. In the blood type AO,
the gene allele A is dominant and will be expressed as blood type A. It is true that each blood type
allele is inherited from the mother or the father.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 68
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
3. In the hospital, the nurse is caring for a client of Asian descent who was just started on warfarin
(Coumadin). What would be the best plan of care for the client? (Select all that apply.)
a. Start warfarin at a high dose to decrease the chance for further clotting
problems.
b. Monitor international normalized ratio (INR) once a day in the hospital.
c. Teach the client to frequently check for any bruising.
d. Initiate fall precautions and strict activity limitations.
e. Start warfarin at a lower-than-normal dose owing to slower metabolism
of the drug.
ANS: B, C, E
Most individuals of Asian heritage have a single nucleotide polymorphism in the CYP2C19 gene
that results in low activity of the enzyme produced. This mutation greatly reduces the metabolism
of warfarin, leading to increased bleeding risks and other serious side effects. Any person of Asian
heritage who needs anticoagulation therapy should be started on very low dosages of warfarin and
should have his or her international normalized ratio (INR) monitored more frequently. The nurse
can always teach about the risk of bleeding and can monitor for any bruising. It is not necessary to
initiate fall precautions and to limit activity based on the administration of warfarin.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication
Administration) MSC: Integrated Process: Nursing Process (Planning)
4. A client recently underwent genetic testing that revealed that she has a BRCA1 gene mutation for
breast cancer. What are the best actions of the nurse? (Select all that apply.)
a. Encourage genetic counseling for self and family.
b. Disclose the information to the medical insurance company.
c. Recommend self–breast examination every week.
d. Assess the client’s response to the test results.
e. Aid in making a plan for prevention and risk reduction.
ANS: A, D, E
The medical-surgical nurse can assess the client’s response to the test results and encourage genetic
counseling for self and family. For some positive genetic test results, such as having a BRCA1 gene
mutation, the risk for developing breast cancer is high but is not a certainty. Because the risk is
high, the client should have a plan for prevention and risk reduction. One form of prevention is
early detection. Self–breast examinations are helpful when performed monthly, but those performed
every week may not be useful, especially around the time of menses. A client who tests positive for
a BRCA1 mutation should have at least yearly mammograms and ovarian ultrasounds to detect
cancer at an early stage, when it is more easily cured. Owing to confidentiality, the nurse would
never reveal any information about a client to an insurance company without the client’s
permission.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
MSC: Integrated Process: Nursing Process (Planning)
Chapter 7: Evidence-Based Practice in Medical-Surgical Nursing
Chapter 7: Evidence-Based Practice in Medical-Surgical Nursing
Test Bank
MULTIPLE CHOICE
1. The cardiac nurse wants to know about the best practices to prevent pneumonia after open-heart
surgery. What does the nurse do first?
a. Critically appraise relevant evidence.
b. Implement acceptable recommendations.
c. Ask clinical experts for their opinions.
d. Search for evidence to answer the question.
ANS: D
The process of evidence-based practice (EBP) is systematic and consists of several steps. After
asking “burning” clinical questions, the next step is to find the very best evidence to try to answer
the question.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 80
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Nursing Process (Evaluation)
2. The nurse is identifying clinical practice problems on a cardiac unit. What question is a
foreground question?
a. “What is the pathophysiology of congestive heart failure?”
b. “How does smoking affect the internal lumens of arteries?
c. “What is the best treatment for a myocardial infarction?
d. “How are a client’s vital signs affected by anxiety?”
ANS: C
A foreground question asks a question of relationship and may be controversial (best treatment). All
other questions are background questions, which ask for a fact.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 80
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Nursing Process (Planning)
3. The nursing student asks, “What is the difference between qualitative and quantitative clinical
questions?” What is the nurse’s best response?
a. “Qualitative questions utilize a strict statistical analysis of information.”
b. “Quantitative questions identify relationships between measurable
concepts.”
c. “Qualitative questions ask about associations among defined
phenomena.”
d. “Quantitative questions analyze the content of what a person says or
does.”
ANS: B
Quantitative questions ask about the relationship between or among defined, measurable
phenomena and include statistical analysis of information that is collected to answer a question.
Qualitative questions focus on the meanings and interpretations of human phenomena or
experiences of people and usually analyze the content of what a person says during an interview or
what a researcher observes.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 80
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Teaching/Learning
4. The nurse is assessing the following PICO(T) question: In a 60-year-old woman with
osteoarthritis, can a COX-2 inhibitor decrease the risk of gastrointestinal bleeding compared with
other NSAIDs? What is the comparison component in this question?
a. Osteoarthritis
b. COX-2 inhibitor
c. NSAIDs
d. Gastrointestinal bleeding
ANS: C
The comparison component of the clinical question may be the standard or the current treatment, or
may be another intervention against which the innovative practice is compared. In this question, the
standard or current practice is other NSAIDs. The innovative practice (COX-2 inhibitor) is
compared against this standard.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 80
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Nursing Process (Planning)
5. The nurse is looking for the best interventions for postoperative pain control. When are the
facility’s policies and procedures an appropriate source of evidence?
a. When policies are based on high-quality clinical practice guidelines
b. When evidence is derived from a valid and reliable quantitative
research study
c. When procedures originated from opinions of the facility’s chief
surgeon
d. When evidence is founded on recommendations from experienced
nurses
ANS: A
Facility policies and procedures can be used as evidence of specific nursing practice in the clinical
setting if the policies are based on high-quality evidence. Clinical practice guidelines are based on
systematic reviews, which provide the highest level of evidence. Policies based on quantitative
research, opinions, and experience should not be used because they are not founded on evidence of
highest quality.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 81
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Nursing Process (Assessment)
6. The nurse researcher is evaluating clinical questions. Which is a qualitative question?
a. What factors affect clients’ responses to postoperative pain?
b. Do wound vacuum systems improve surgical wound healing time?
c. What are the effects of hourly rounding on client fall rates?
d. Do chlorhexidine swabs decrease central line site infections?
ANS: A
A qualitative question focuses on the participant’s interpretations of or responses to an experience.
Understanding factors that influence a client’s response to a situation would be a qualitative
evaluation. The other questions focus on quantitative or numeric indicators, instead of on the
meaning or interpretation of an event. These questions would be quantitative questions.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 80
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Teaching/Learning
7. The nurse is searching for evidence related to a PICOT question. What source provides the best
evidence?
a. Medline database
b. Cochrane library
c. CINAHL database
d. Library of Congress
ANS: B
The top level of evidence consists of systematic reviews. The major purpose of systematic reviews
is to provide high-quality evidence to busy clinicians who do not have the time to spend finding
original studies and then reviewing, critiquing, and synthesizing evidence from each study. These
reviews can be found in the Cochrane library; the Medline and CINAHL databases provide single
studies that are not reviewed, critiqued, or synthesized for the clinician. The Library of Congress
houses the world’s largest collection of historical and cultural references; it does not provide best
evidence related to health care PICOT questions.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 82
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Nursing Process (Assessment)
8. A hospice nurse routinely uses Therapeutic Touch to promote comfort. A current client
demonstrates anxiety when this intervention is offered. What is the nurse’s best response?
a. Provide pain medication to manage the client’s comfort and pain.
b. Continue with the intervention because it has worked with other clients.
c. Search for alternative interventions to better meet the client’s needs.
d. Share research that supports Therapeutic Touch with the client.
ANS: C
Evidence-based practice integrates best evidence with the clinician’s experience and client
preferences. If a client is not receptive to an intervention, the best nursing response is to search for
an alternative evidence-based intervention that is congruent with the client’s preferences.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Nursing Process (Planning)
9. The health care facility is implementing a new evidence-based nursing protocol. What is
necessary to ensure successful implementation?
a. Tools to evaluate the protocol are valid and reliable.
b. Support from the nurses implementing the protocol is present.
c. Recommendations for the protocol are obtained from senior
administrators.
d. The evidence-based protocol is cost-effective for the facility.
ANS: B
Complete buy-in from the people who will be involved in implementing the new protocol is
essential for the success of implementation.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 83
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Nursing Process (Planning)
MULTIPLE RESPONSE
1. The nurse is developing a clinical question in a PICOT format. What components are included in
the question? (Select all that apply.)
a. Population
b. Comparison
c. Observation
d. Intervention
e. Technique
ANS: A, B, D
The major components of a PICOT question are population, intervention, comparison, and
outcome, with an added time component when appropriate.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 80
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Teaching/Learning
2. The intervention component of an evidence-based question pertains to the therapeutic
effectiveness of a treatment. Which are possible types of interventions? (Select all that apply.)
a. Exposure to disease
b. A high-risk behavior
c. Age, gender, or ethnicity
d. A prognostic factor
e. A client response
ANS: A, B, D
The intervention component pertains to the therapeutic effectiveness of a new treatment and may
include the following: 1) exposure to disease or harm, 2) a prognostic factor, or 3) a risk behavior
or factor.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 80
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Nursing Process (Intervention)
3. A nurse who wants to incorporate evidence-based practices into client care on a medical unit is
meeting resistance. What barriers prevent nurses from engaging in evidence-based practices?
(Select all that apply.)
a. Difficulty accessing research materials
b. Difficulty understanding client needs
c. Lack of value for research in practice
d. Lack of value for client preferences
e. Inadequate available time
f.
Inadequate nurse-client ratios
ANS: A, C, E
Major barriers that prevent nurses from engaging in evidence-based practice include lack of time, lack of value
for research in practice, lack of understanding of organization or structure of electronic databases, difficulty
accessing research materials, lack of computer skills, and difficulty understanding research articles.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 81
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)
MSC: Integrated Process: Nursing Process (Planning)
Chapter 8: Rehabilitation Concepts for Chronic and Disabling Health
Problems
Chapter 8: Rehabilitation Concepts for Chronic and Disabling Health Problems
Test Bank
MULTIPLE CHOICE
1. A paraplegic client is being evaluated for transfer to a rehabilitation unit. The nurse refers the
client to which interdisciplinary team member for evaluation of activities of daily living?
a. Physical therapist
b. Occupational therapist
c. Recreational therapist
d. Vocational therapist
ANS: B
The occupational therapist is responsible for ADL training, the physical therapist for muscle
strength, the vocational therapist for job training, and the recreational therapist for hobbies or
pastime activities.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 91
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Referrals) MSC:
Integrated Process: Nursing Process (Planning)
2. The nurse is teaching a client who is a paraplegic about prescribed rehabilitation. The client
verbalizes that he doesn’t know why he should go. What is the nurse’s best response?
a. “Your doctor ordered rehabilitation, and he does know what is best for
you.”
b. “When new discoveries are made, people in rehabilitation programs
benefit first.”
c. “Rehabilitation will teach you how to maintain the functional ability
you have.”
d. “You are right. It will not benefit you. I will cancel the orders for
rehabilitation.”
ANS: C
There are many purposes for participating in rehabilitation programs, including disability
prevention, maintenance of functional ability, and restoration of function. Without the special
knowledge learned through rehabilitation, the client with a newly acquired disability may never
learn the skills needed to prevent long-term problems or conserve energy.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 90
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Implementation)
3. The nurse is caring for a client who has long-standing chronic obstructive pulmonary disease
(COPD) and is recovering from a stroke. Which intervention is a priority when activity tolerance is
assessed during rehabilitation?
a. Assess vital signs before, during, and after activity.
b. Perform a daily cognitive assessment.
c. Consult physical therapy to ambulate the client.
d. Monitor the client’s progress in self-care ability.
ANS: A
To see whether a client is tolerating activity, vital signs are measured before, during, and after the
activity. If the client is not tolerating activity, heart rate may increase more than 20 beats/min, blood
pressure may increase over 20 mm Hg, and vital signs will not return to baseline within 5 minutes
after the activity. A cognitive assessment is not necessary before basic activities are performed. A
consultation would not provide data on activity tolerance, and monitoring of self-care ability does
not directly reflect tolerance as vital signs do.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Evaluation)
4. A client with a past history of angina had a total knee replacement. What will the nurse teach the
client before rehabilitation activities are begun?
a. “Use analgesics even if you are not in pain.”
b. “Take nitroglycerin prophylactically before beginning activity.”
c. “Take anti-inflammatory medications before exercising.”
d. “Do not exercise if you have knee pain.”
ANS: B
Participation in exercise may increase myocardial oxygen demand beyond the ability of the
coronary circulation to deliver enough oxygen to meet the increased need. Nitroglycerin dilates
coronary arteries within 5 minutes of use, ensuring that they will be ready to meet the demand
during exercise.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Teaching/Learning
5. The rehabilitation nurse is caring for an obese client with new bilateral leg amputations. The
nurse is planning to move the client from the bed to the chair. What is the best approach?
a. Use the bear-hug method to transfer the client safely.
b. Ask several members of the health care team to assist.
c. Utilize the facility’s mechanical lift to move the client.
d. Consult physical therapy before performing all transfers.
ANS: C
Use mechanical lifts to minimize staff work-related musculoskeletal injuries. The bear-hug method
and the use of several members of the team do not eliminate staff injuries. Physical therapy should
be consulted but cannot be depended on for all transfers. Nursing staff must be capable of
transferring a client safely.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Ergonomic
Principles)
MSC: Integrated Process: Nursing Process (Implementation)
6. The nurse is caring for a client in a rehabilitation center. Which test will best assist the nurse in
determining the severity of a client’s disability?
a. Instrumental activities of daily living (IADL)
b. Minimum data set (MDS)
c. Functional independence measure (FIM)
d. Independent living skills test (ILST)
ANS: C
The FIM attempts to quantify what the person actually does, whatever the diagnosis or impairment.
Categories for assessment consist of self-care, sphincter control, mobility, locomotion,
communication, and cognition. The functional independence measure is a uniform data set used for
outcome data collection in the United States. IADL is a functional assessment tool carried out by
numerous members of the interdisciplinary team in the health care setting. The MDS is used to
assess nursing home residents in areas of motor ability, sensation, and cognition, as well as overall
health status.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 94
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Assessment)
7. The nurse is planning care for a client who is newly wheelchair bound owing to a spinal cord
injury. What priority intervention should the nurse include in the plan of care to assist the client in
transferring from the bed to the wheelchair?
a. A diet high in protein and low in calories
b. An occupational therapy consult
c. Bowel and bladder retraining
d. Upper arm strengthening exercises
ANS: D
With impaired mobility and use of a wheelchair, the client tends to gain weight. During
rehabilitation, the client should be on a high-protein diet but not calorie restriction. The increased
weight requires greater upper body strength for movement. The nurse should encourage the client
to perform exercises that strengthen the upper arms. The nurse should consult physical therapy to
assist with these exercises. Occupational therapy would not be involved in movement of the client
but would be involved with ADLs. Bowel and bladder retraining may prevent skin breakdown but
has nothing to do with the client’s ability to transfer to the wheelchair.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Assessment)
8. The nurse is performing passive range-of-motion exercises on a semiconscious client and meets
resistance while attempting to extend the right elbow more than 45 degrees. What action by the
nurse is best?
a. Splint the joint and continue passive range of motion to the shoulder
only.
b. Progressively increase joint motion 5 degrees beyond resistance each
day.
c. Apply weights to the right distal extremity before initiating any joint
exercise.
d. Continue to move the joint only to the point at which resistance is met.
ANS: D
Moving a joint beyond the point at which the client feels pain or resistance can damage the joint.
The nurse should move the joint only to the point of resistance. Splinting the joint will not assist the
client’s range of motion. The client’s joint should not be forced. Applying weights to the extremity
will not increase range of motion of the joint but most likely will cause damage.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Mobility/Immobility) MSC:
Integrated Process: Nursing Process (Intervention)
9. The nurse is caring for a client with decreased mobility. What intervention should the nurse
include in the care plan to best help this client decrease the risk of fracture?
a. Apply shoes to improve foot support.
b. Perform weight-bearing activities.
c. Increase calcium-rich foods in the diet.
d. Use pressure-relieving devices.
ANS: B
Weight-bearing activity reduces bone mineral loss and promotes bone uptake of calcium,
contributing to maintenance of bone density and reducing the risk for bone fracture. Although
increasing calcium in the diet is a good intervention, this alone will not reduce the client’s
susceptibility to bone fracture. A foot support and pressure-relieving devices will not help prevent
fracture, but may help with mobility and skin integrity.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
10. The nurse assesses a client admitted for rehabilitation. The client has generalized weakness and
needs assistance with activities of daily living. Which exercise should the nurse implement?
a. Passive range of motion
b. Active range of motion
c. Resistive range of motion
d. Aerobic exercise
ANS: B
Active range of motion is a part of a restorative nursing program. Active range of motion will
promote strength, range of motion, and independence with activities of daily living.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
11. The nurse is caring for a bedridden client. Which intervention will the nurse implement to
prevent pressure ulcer formation?
a. Adjust nutritional intake based on serum albumin levels.
b. Measure the ulcer diameter and depth every shift.
c. Change the gauze dressing whenever drainage is observed.
d. Apply antibiotic ointment to all excoriated skin areas.
ANS: A
Assessing serum albumin levels helps determine the client’s nutritional status and allows care
providers to alter the diet, as needed, to prevent pressure ulcers. All other options are treatment
oriented rather than prevention oriented.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
12. The nurse is caring for a client who is undergoing rehabilitation. Which nursing intervention
would be best to prevent venous stasis and thrombus formation?
a. Range-of-motion exercises
b. Foot support while in bed
c. Increased dietary calcium intake
d. Avoidance of sudden position changes
ANS: A
Range-of-motion exercises involve skeletal muscle contraction of the upper and lower extremities.
Muscle contraction promotes venous return, preventing stasis and thrombus formation. Foot
support can help prevent contractures and foot drop. Increased calcium is not related to venous
stasis and thrombus formation, nor is avoiding sudden position changes.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
13. The nurse is caring for a rehabilitation client. Which activity plan should the nurse implement to
best conserve a client’s energy without compromising physical or mental health?
a. Reduce hygiene activities and restrict visitors.
b. Ensure that the client toilets before and after planned activities.
c. Schedule energy-intensive activities when energy levels are high.
d. Schedule as many activities as possible in a small block of time.
ANS: C
Some of the best techniques for energy conservation include spacing activities with a rest period in
between, and individualizing the scheduling of more energy-intensive activities to the time of day
when the client knows or feels that his or her energy levels are higher.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Rest and Sleep)
MSC: Integrated Process: Nursing Process (Implementation)
14. A nurse catheterizes a client immediately after voiding. The residual volume is 50 mL. What
will the nurse do next?
a. Notify the physician.
b. Insert an indwelling catheter.
c. Document the finding in the chart.
d. Modify the bladder training program.
ANS: C
This finding is normal. Therefore, the nurse should document the finding and continue with the
present bladder training program. The goals of a bladder training program are to avoid the use of an
indwelling catheter and to keep the residual volume at less than 100 mL.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Elimination)
MSC: Integrated Process: Nursing Process (Evaluation)
15. The client who is performing intermittent self-catheterization at home is concerned about the
cost of the catheters. What is the nurse’s best response?
a. “I will try to find out whether you qualify for money to purchase these
necessary supplies.”
b. “Even though it is expensive, the cost of taking care of urinary tract
infections would be even higher.”
c. “Instead of purchasing new catheters, you can boil the catheters and
reuse them up to 10 times each.”
d. “You can reuse the catheters at home. Clean technique, rather than
sterile technique, is acceptable.”
ANS: D
At home, clean technique for intermittent self-catheterization is sufficient to prevent cystitis and
other urinary tract infections. The nurse would refer the client to the social worker to explore
financial concerns. The nurse should not threaten the client, nor should the client be instructed to
boil the catheters.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 102
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Elimination)
MSC: Integrated Process: Teaching/Learning
16. The nurse is providing education for a client at risk for urinary tract infection. Which beverage
should the nurse encourage the client to drink?
a. Carbonated beverages
b. Citric juices
c. Milk
d. Tomato juice
ANS: D
Some organisms, such as Escherichia coli, do not grow well in an acidic environment. Fluids that
promote an acidic urine include cranberry juice, prune juice, bouillon, tomato juice, and water.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Implementation)
17. The nurse delegates the unlicensed nursing assistant (UAP) to ambulate an older adult client.
What information must the nurse communicate to the UAP when delegating this task?
a. “The client has skid-proof socks, so there is no need to use your gait
belt.”
b. “Teach the client how to use her walker while you are ambulating up
the hall.”
c. “Sit the client on the edge of the bed with legs dangling before
ambulating.”
d. “Ask the client if she needs pain medication before you walk her in the
hall.”
ANS: C
Before the client gets out of bed, have the client sit on the bed with legs dangling on the side. This
will enhance safety for the client. The UAP cannot assess the client’s pain or teach the client to use
a walker. A gait belt should be used for all clients.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Communication & Documentation
18. The nurse is obtaining an admission history of a client with hip problems. The client asks, “Why
are you asking about my bowels and bladder?” What is the nurse’s best response?
a. “To plan your care based on your normal elimination routine.”
b. “So we can help prevent side effects of your medications.”
c. “We need to evaluate your ability to function independently.”
d. “To schedule your activities around your elimination pattern.”
ANS: A
Bowel elimination varies from client to client and must be evaluated on the basis of the client’s
normal routine. The nurse asks about bowel and bladder to develop a client-centered plan of care.
The other answers are correct but are not the best response. Oral analgesics may cause constipation,
but they do not interfere with bladder control. Elimination usually is scheduled around
rehabilitation activities but should be taken into consideration when a plan of care is developed.
The client is in rehabilitation to assist her or his ability to function independently.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Communication & Documentation
19. The nurse is planning care for a client who is beginning a structured cardiac rehabilitation
program. Before starting the program, what should the nurse do first?
a. Administer nitroglycerin to increase blood flow to the heart.
b. Assess the client for orthostatic hypotension.
c. Start oxygen at 2 L/min via nasal cannula.
d. Determine the level of activity before shortness of breath occurs.
ANS: D
The level of activity that can be accomplished without experiencing shortness of breath needs to be
established before activity is begun. This will alleviate fear and anxiety and will prevent the
occurrence of cardiac symptoms. Oxygen should be started only if the pulse oximetry reading is
below 90%, or if electrocardiographic changes or cardiac symptoms occur, none of which is
indicated in this question. Nitroglycerin should be given only if the client has a history of angina.
Orthostatic hypotension should be assessed before a client is ambulated, but this assessment does
not provide information specific to the client’s cardiac rehabilitation program.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
20. The nurse is caring for a client with a spinal cord injury at level T3. How will the nurse assist
the client with bladder dysfunction?
a. Insert an indwelling urinary catheter.
b. Stroke the medial aspect of the thigh.
c. Use the Credé maneuver every 3 hours.
d. Apply a Texas catheter with leg bag.
ANS: C
If the spinal cord injury is above T12, the client is unaware of a full bladder and does not void or is
incontinent. Therefore, the client would not benefit from a Texas catheter with a leg bag. Two
techniques are used to facilitate voiding in a client with a flaccid bladder: the Valsalva maneuver
and the Credé maneuver. Indwelling urinary catheters generally are noted used because of the
increased incidence of urinary tract infection. Stroking the medial aspect of the thigh facilitates
voiding in clients with upper motor neuron problems.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
21. A client with a flaccid bladder is undergoing bladder training. The nurse begins the client’s
bladder training using which technique?
a. Stroking the medial aspect of the thigh
b. Valsalva maneuver
c. Self-catheterization
d. Frequent toileting
ANS: B
With a flaccid bladder, the voiding reflex arc is not intact and additional stimulation may be needed
to initiate voiding—the Valsalva and Credé maneuvers. Intermittent catheterization may be used
after the previous maneuvers are attempted. In reflex bladder, the voiding arc is intact and voiding
can be initiated by any stimulus, such as stroking the medial aspect of the thigh. A consistent
toileting routine is used to re-establish voiding continence with an uninhibited bladder.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Planning)
22. The nurse is caring for a client after a stroke. The client has a right facial droop, drools
continuously, and chokes on her own saliva. What rehabilitation team member should the nurse
consult to ensure client safety?
a. Speech-language pathologist
b. Nutritionist
c. Rehabilitation case manager
d. Cognitive therapist
ANS: A
Speech-language pathologists (SLPs) evaluate and retrain clients with speech, language, or
swallowing problems. Nutritionists may be needed to ensure that clients meet their nutritional
needs. Rehabilitation case managers coordinate the efforts of health care team members. Cognitive
therapists, usually neuropsychologists, work primarily with clients who have experienced head
injury with cognitive impairment.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with
Interdisciplinary Team)
MSC: Integrated Process: Communication & Documentation
MULTIPLE RESPONSE
1. The nurse collaborates with a physical therapist when providing care for a rehabilitation client.
The role of the physical therapist is to help the client with which activities? (Select all that apply.)
a. Achieve mobility.
b. Attain independence with dressing.
c. Use a walker in public.
d. Learn techniques for transferring.
e. Perform activities of daily living.
f.
Complete job training.
ANS: A, C, D
The role of the physical therapist is to assist in muscle strength development and ambulation. The
occupational therapist deals with ADLs, dressing, and activities needed for job training.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 91
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with
Interdisciplinary Team)
MSC: Integrated Process: Nursing Process (Implementation)
2. An older adult client tells the nurse, “I tire easily.” Which activities best assist the client to
conserve energy? (Select all that apply.)
a. Perform all tasks in the morning.
b. Take frequent rest periods.
c. Gather all supplies needed for a chore.
d. Use a cart, bag, or tray to carry items.
e. Push objects rather than lifting them.
f.
Break large activities into smaller parts.
g. Hire someone to assist with chores.
ANS: B, C, D, E, F
Major tasks should be performed in the morning, when energy levels are high. Lesser tasks should
be done throughout the day after frequent rest periods. Gathering equipment before performing a
chore decreases unneeded steps. Carrying more than one or two items at a time saves time and
energy. It takes less energy to push items than to carry them. Breaking larger chores into smaller
ones allows rest periods between activities and gives the client a sense of completion if unable to
complete the whole task. Someone should be hired to do the chores only if the client cannot do
them. The outcome should be achieving independence as close as possible to the pre-disability
level.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Implementation)
3. The nurse is caring for a client who is wheelchair bound. Which interventions will the nurse
implement to prevent skin breakdown? (Select all that apply.)
a. Change the client’s position every 1 to 2 hours.
b. Place pillows under the client’s heels.
c. Have the client do wheelchair pushups.
d. Remove the client’s shoes to check for pressure areas.
e. Assess the client’s lower legs for pressure from the wheelchair.
f.
Massage the client’s calves and feet with lotion.
ANS: A, C, D
Clients who sit for prolonged periods in a wheelchair need to be repositioned at least every 1 to 2
hours. Wheelchair push-ups should be done for at least 10 seconds every hour. If the client is
wearing tennis shoes to prevent foot drop, the shoes should be removed every 2 hours to check for
pressure areas. The lower legs, where the wheelchair could rub against the legs, also needs to be
assessed. Pillows under the heels could exert pressure on the heels. It is better to place the pillow
under the ankle. The calves of a client with no or decreased lower extremity mobility should not be
massaged because of the risk of embolization or thrombus.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Implementation)
4. The nurse is caring for a client with a disabling condition. Which abnormal findings would alert
the nurse to an increased risk for skin breakdown? (Select all that apply.)
a. Low serum albumin level
b. High serum transferrin level
c. Low serum carboxyhemoglobin
d. High serum hematocrit
e. Increased weight gain
f.
Incontinence
g. Poor fluid intake
ANS: A, E, F, G
A low serum albumin level indicates less than adequate nutrition, especially of proteins; this greatly
increases the risk for skin breakdown and reduces the rate of wound healing. Protein is a critical
nutrient for stimulating DNA synthesis, cell division, and tissue repair. Increased weight gain
makes it more difficult to move and puts more pressure on pressure areas. Incontinence of bowel or
bladder irritates the skin, making it more prone to breakdown.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
5. The nurse is caring for a client with left-sided weakness. Which gait-training techniques will the
physical therapist and the nurse use when assisting the client to walk with a cane? (Select all that
apply.)
a. Place the cane in the client’s left hand.
b. Hold the cane with the client’s stronger hand.
c. Move the cane forward, followed by legs stepping forward.
d. Take one step forward, followed by the cane moving forward.
e. Step forward with the stronger leg, then the weaker leg.
f.
Move the weaker leg one step forward, followed by the stronger leg.
ANS: B, C, F
Placing the cane in the client’s weaker hand does not provide sufficient stability. After the cane in
the stronger hand is moved ahead, the cane and the stronger leg provide a stable base for movement
of the weaker leg.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
6. The nurse is implementing nutritional changes to reduce the risk for skin breakdown in a client
with impaired physical mobility. Which dietary modifications will the nurse reinforce? (Select all
that apply.)
a. High-protein
b. Low-protein
c. High-carbohydrate
d. Low-carbohydrate
e. High-fat
f.
Low-fat
ANS: A, C, F
The goal of nutrition therapy is to provide sufficient nutrients to promote wound healing, prevent
skin breakdown, and avoid gaining excessive weight. The two most important nutrients to stimulate
cell division and prevent loss of muscle mass are carbohydrates and proteins.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration)
MSC: Integrated Process: Nursing Process (Implementation)
Chapter 9: End-of-Life Care
Chapter 9: End-of-Life Care
Test Bank
MULTIPLE CHOICE
1. The client tells the nurse that even though it has been 4 months since her sister’s death, she
frequently finds herself crying uncontrollably. The client is afraid that she is “losing her mind.”
What is the nurse’s best response?
a. “Most people move on within a few months. You should see a grief
counselor.”
b. “Whenever you start to cry, distract yourself from thoughts of your
sister.”
c. “You should try not to cry. I’m sure your sister is in a better place now.”
d. “Your feelings are completely normal and may continue for a long
time.”
ANS: D
Frequent crying is not an abnormal response. The nurse should let the client know that this is
normal and okay. Although the client may benefit from talking with a grief counselor, it is not
unusual for her to still be grieving after a few months. The other responses are not as therapeutic
because they justify or minimize the client’s response.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Caring
2. The nurse is discussing advance directives with a client. Which statement by the client indicates
good understanding of the purpose of an advance directive?
a. “An advance directive will keep my children from selling my home
when I’m old.”
b. “An advance directive will be completed as soon as I’m incapacitated
and can’t think for myself.”
c. “An advance directive will specify what I want done when I can no
longer make decisions about health care.”
d. “An advance directive will allow me to keep my money out of the reach
of my family.”
ANS: C
An advance directive is a written document prepared by a competent individual that specifies what,
if any, extraordinary actions a person would want taken when he or she can no longer make
decisions about personal health care. It does not address issues such as the client’s residence in his
or her own home.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 108
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advance
Directives) MSC: Integrated Process: Nursing Process (Assessment)
3. The nurse is caring for a client who is considering being admitted to hospice. What is the nurse’s
best response?
a. “Hospice admission has specific criteria. You may not be a viable
candidate, so we will look at alternative plans for your discharge.”
b. “Hospice care focuses on a holistic approach to health care. It is
designed not to hasten death, but rather to relieve symptoms.”
c. “Hospice care will not help with your symptoms of depression. I will
refer you to the facility’s counseling services instead.”
d. “You seem to be experiencing some difficulty with this stage of the
grieving process. Let’s talk about your feelings.”
ANS: B
As both a philosophy and a system of care, hospice care uses an interdisciplinary approach to
assess and address the holistic needs of clients and families to facilitate quality of life and a
peaceful death. This holistic approach neither hastens nor postpones death but provides relief of
symptoms experienced by the dying client.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 108
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
4. A hospitalized American Indian client is approaching death. Family members who are standing
vigil in the client’s room begin to divide up his possessions among themselves as his symptoms
progress. What is the nurse’s most important intervention?
a. Ask the family members to step outside the room so the client cannot
hear them.
b. Tell the family that they are being insensitive and their behavior is
inappropriate.
c. Recognize that this is a culturally appropriate activity and document it
in the chart.
d. Report these activities to the client’s physician and the nursing
supervisor.
ANS: C
American Indians often disperse material possessions before or after death to friends and family
members. Recognizing this culturally appropriate activity would not be consistent with removing
the family, stopping the activity, or reporting the client’s family’s behaviors.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Cultural Diversity)
MSC: Integrated Process: Caring
5. The spouse of a dying client states that she is concerned that her husband is choking to death.
What is the nurse’s best response?
a. “Do not worry. The choking sound is normal during the dying process.”
b. “I will administer more morphine to keep your husband comfortable.”
c. “I can ask the respiratory therapist to suction secretions out through his
nose.”
d. “I will have another nurse assist me to turn your husband on his side.”
ANS: D
The choking sound or “death rattle” is common in dying clients. The nurse should acknowledge the
spouse’s concerns and provide interventions that will reduce the choking sounds. Repositioning the
client onto one side with a towel under the mouth to collect secretions is the best intervention.
Morphine will assist with comfort but will not decrease the choking sounds. Nasal tracheal
suctioning is not appropriate in a dying client. The nurse should not minimize the spouse’s
concerns.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
6. The terminally ill client is prescribed morphine to help cope with increasing discomfort. A family
member expresses concern that the client is on “too much morphine.” What is the nurse’s best
response?
a. “What has the physician told you about your family member’s illness?”
b. “Don’t worry about that. We’re following the physician’s plan of care.”
c. “Tell me more about what you mean by too much morphine.”
d. “You should talk with your physician about this when he makes
rounds.”
ANS: C
Asking family members to explain what they mean by “too much morphine” serves to gain more
information for the nurse. The other questions will not help the nurse obtain more information
about the client’s care or the family’s concerns.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Caring and Communication
7. The nurse is teaching a family member about various types of complementary therapies that
might be effective for relieving the dying client’s anxiety and restlessness. Which statement by the
family member indicates understanding of the nurse’s teaching?
a. “Maybe we should just hire a round-the-clock sitter to stay with
Grandmother.”
b. “I have some of her favorite hymns on a CD that I could bring for music
therapy.”
c. “I don’t think that she’ll need pain medication along with her herbal
treatments.”
d. “I will burn therapeutic incense in the room so we can stop the anxiety
pills.”
ANS: B
Music therapy is a complementary therapy that may produce relaxation by quieting the mind and
removing a client’s inner restlessness. Complementary therapies are used in conjunction with
traditional therapy. The complementary therapy would not replace pain or anxiety medication but
may help decrease the need for these medications. Hiring an around-the-clock sitter does not
demonstrate that the client’s family understands complementary therapies.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort
Interventions) MSC: Integrated Process: Caring
8. A terminally ill client has just died in a hospital setting with family members at the bedside. The
health care provider is also present. What should be the nurse’s priority intervention as postmortem
care begins?
a. Call for emergency assistance so that resuscitation procedures can
begin.
b. Ask the family members if they would like to spend time alone with the
client.
c. Ensure that a death certificate has been completed by the physician.
d. Request family members to prepare the client’s body for the funeral
home.
ANS: B
Before moving the client’s body to the funeral home, the nurse should ask family members if they
would like to be alone with the client. Emergency assistance will not be necessary. Although it is
important to ensure that a death certificate has been completed before the client is moved to the
mortuary, the nurse first should ask family members if they would like to be alone with the client.
The client’s family should not be expected to prepare the body for the funeral home.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
9. The nurse is providing care for a hospice client who is in the last stages of the dying process. The
client develops a pressure ulcer on her sacrum, and family members tell the nurse that they would
like a specialist consulted to treat the ulcer. When the nurse discusses this with the client, the client
states that the ulcer does not bother her, that it is not causing her pain, and that she’d rather not
have additional caregivers at this time. What should the hospice nurse do next?
a. Tell the family the wound care specialist will be consulted and
treatment will begin.
b. Ask the social worker and the chaplain to talk with family members
about the dying process.
c. Explain the client’s desires to the family, emphasizing that the client
will be made as comfortable as possible.
d. Ask the agency mental health nurse to speak with the client about
refusing treatment.
ANS: C
When palliative care is provided to the dying client, symptoms will be actively treated only if they
are causing the client distress. In this case, the client has stated that the pressure ulcer is not causing
her distress, and she does not want further intervention.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
10. The nurse is being trained in hospice care. Which intervention by the nurse is most compatible
with the goals of end-of-life care for the client?
a. Administer influenza and pneumococcal vaccinations.
b. Prevent the client with chronic obstructive pulmonary disease from
smoking.
c. Perform passive range-of-motion exercises to prevent contractures.
d. Permit the client with diabetes mellitus to have a serving of ice cream.
ANS: D
When a client is near the end of life, nursing interventions should be focused toward facilitating
peaceful death by granting the client’s wishes and identifying his or her needs. Allowing a client
who wishes to have something that is not permitted in the diet can be comforting if he or she has a
craving or a desire for that food. There is no reason to withhold it at this time.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
11. The nurse is assessing the dying client. Which manifestations of a dying client should the nurse
assess to determine whether the client is near death?
a. Level of consciousness
b. Respiratory rate
c. Bowel sounds
d. Pain level on a 0 to 10 scale
ANS: B
All of these assessments should be performed during the dying process. As the peripheral
circulation decreases, the client’s level of consciousness and bowel sounds decrease. The client is
unable to provide a numeric number on a pain scale. The nurse should continue to assess
respiratory rate throughout the dying process. As the rate drops significantly and breathing becomes
agonal, death is near.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
12. The wife is concerned because her terminally ill husband does not want to eat. What is the
nurse’s best response?
a. “Let him know that food is available if he wants it, but do not insist that
he eat.”
b. “A feeding tube can be placed in the nose to provide important
nutrients.”
c. “Force him to eat even if he does not feel hungry, or he will die sooner.”
d. “He is getting all the nutrients he needs through his intravenous
catheter.”
ANS: A
When family members understand that the client is not suffering from hunger and is not “starving
to death,” they may allow the client to determine when, what, or if to eat. Often, as death
approaches, metabolic needs decrease and clients do not feel the sensation of hunger. Forcing them
to eat frustrates the client and the family.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
13. The family members of a client with a terminal illness tell a nurse that the client keeps asking if
she is dying. What is the nurse’s best response?
a. “Whenever she asks about dying, change the subject.”
b. “Tell her the truth in as gentle a way as possible.”
c. “Tell her that she will get better eventually.”
d. “Ask her if she is afraid to die.”
ANS: B
Being honest and truthful at such a time is important. It helps the client develop trust in those
caring for her. Changing the subject will frustrate the client and may make her distrustful.
Providing false hope is not a realistic intervention. Asking a pointed question often will not elicit
the information that you want from the client. It is better to ask open-ended questions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
14. The client’s family members are concerned that the client should have a urinary catheter placed
because of her decreasing urinary output. What is the hospice nurse’s best response?
a. “A Foley catheter is inserted only if she is taking medications that affect
output.”
b. “I will insert a Foley catheter if her urinary output drops below 500
mL/day.”
c. “A Foley catheter will be inserted if her bladder becomes distended.”
d. “I will insert a Foley catheter if she becomes incontinent of urine.”
ANS: C
Insertion of an indwelling catheter is acceptable if the client is unable to void, has a distended
bladder, and would be more comfortable not moving. The other statements are not appropriate uses
for an indwelling catheter in a hospice setting.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
15. The health care provider suggests inpatient hospice for a client. The family members are
concerned that their loved one will receive only custodial care. What is the nurse’s best response?
a. “The goal of palliative care is to provide the greatest degree of comfort
possible and help the dying person enjoy whatever time is left.”
b. “Palliative care will release you from the burden of having to care for
someone in the home. It does not mean that curative treatment will
stop.”
c. “A palliative care facility is like a nursing home and costs less than a
hospital because only pain medications are given.”
d. “Your relative is unaware of her surroundings and will not notice the
difference between her home and a palliative care facility.”
ANS: A
Palliative care provides an increased level of personal care designed to manage symptom distress.
The focus is on pain control and helping the relative die with dignity.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 110
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
16. A dying client’s family members are spending time with the client. What instruction is best to
give to family members regarding noise in the client’s room?
a. “Remember that she cannot hear you.”
b. “Try to get her to talk or respond to you.”
c. “Avoid making any noise when you are with her.”
d. “Talk in your normal speaking voice.”
ANS: D
The sense of hearing may remain intact, even when it appears that the client is totally unresponsive
to any sort of stimuli. The family member should speak to the client as if she were fully aware.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
17. A client who is near death appears to be having difficulty breathing. What is the nurse’s highest-
priority intervention?
a. Teach the family how to perform nasotracheal suctioning.
b. Request that the physician order morphine sulfate.
c. Document the finding in the client’s chart.
d. Call a respiratory therapist to intubate the client.
ANS: B
Morphine sulfate is the standard treatment for dyspnea near death; it relieves the psychological and
physiologic distress that accompanies breathlessness. Suctioning or intubation may cause the client
discomfort. Documentation is important, but it is not the priority intervention because it does
nothing to relieve the client’s distress.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
18. The nurse is caring for a dying client who becomes very agitated. What is the nurse’s best
response?
a. Use music therapy to promote relaxation.
b. Increase the dose of intravenous opioids.
c. Provide a second antipsychotic medication.
d. Assess the client for urinary retention.
ANS: D
Dying clients become agitated when they are in pain or have some discomfort. Before
administering medications or other therapies to decrease discomfort, the nurse should assess for
potential causes of discomfort including urinary retention.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
19. An experienced hospice nurse is training a new nurse in the practices of palliative care. What
statement by the new nurse indicates understanding about drug therapy for end-of-life care?
a. “I can administer as much pain medication as I want because the client
is dying.”
b. “The administration of these medications will hasten the client’s death.”
c. “I can administer medication per the protocol to relieve the client’s
symptoms.”
d. “The purpose of palliative sedation is to relieve family members’
distress.”
ANS: C
Palliative care nurses follow protocols when administering medications. These protocols are
standing prescriptions from the provider that identify the appropriate medication, dose, and
situation for administration. The nurse cannot administer more than is prescribed. The medications
are given to promote comfort and if administered per protocol will not hasten death.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Nursing Process (Evaluation)
20. An older client was admitted to hospice owing to impending death in approximately 6 weeks.
After 2 months, the family remains at the bedside but is becoming increasingly impatient and
irritable. What is the best nursing intervention?
a. Ask the family to leave and not return until they are calmer.
b. Sit with the family and listen to their concerns and fears.
c. Tell the family members not to worry, the client will die soon.
d. Consult the chaplain to come and pray with the client’s family.
ANS: B
Death cannot be accurately predicted. The nurse should sit with the family and listen to their
concerns. The nurse should not provide false hope or reassurance. Family members should remain
with the client as long as they would like. The chaplain should be consulted if the family requests.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Caring
21. An intensive care nurse is discussing withdrawal of care with a client’s family. The family
expresses concerns related to discontinuation of therapy. What is the nurse’s best response?
a. “I understand your concerns, but in this state, discontinuation of care is
not a form of active euthanasia.”
b. “You will need to talk to the provider because I am not legally allowed
to participate in the withdrawal of life support.”
c. “I realize this is a difficult decision. Discontinuation of therapy will
allow the client to die a natural death.”
d. “There is no need to worry. Most religious organizations support the
client’s decision to stop medical treatment.”
ANS: C
The nurse should validate the family’s concerns and provide accurate information about the
discontinuation of therapy. The other statements address specific issues related to the withdrawal of
care but do not provide appropriate information about its purpose. If the client’s family asks for
specific information about euthanasia, legal, or religious issues, the nurse should provide unbiased
information about these topics.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
MULTIPLE RESPONSE
1. The hospice nurse is caring for a dying client and her family members. What nursing
interventions are appropriate to use? (Select all that apply.)
a. Teach family members about physical signs of impending death.
b. Encourage the management of adverse symptoms.
c. Assist family members by offering an explanation for their loss.
d. Encourage reminiscence by both client and family members.
e. Avoid spirituality because the client’s and the nurse’s beliefs may not be
congruent.
f.
Do not encourage hope for the terminally ill client.
ANS: A, B, D
The nurse should teach family members about the physical signs of death, because family members
often become upset when they see physiologic changes in their loved one. Palliative care includes
management of symptoms so that the peaceful death of the client is facilitated. Reminiscence will
help both the client and family members cope with the dying process. The nurse is not expected to
explain why this is happening to the family’s loved one. The nurse can encourage spirituality if the
client is agreeable, regardless of whether her religion is the same.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
2. The nurse is providing care for a dying client. The nurse would place highest priority on treating
which symptoms? (Select all that apply.)
a. Anorexia
b. Weight loss
c. Pain
d. Agitation
e. Nausea
f.
Hair loss
g. Dyspnea
ANS: C, D, E, G
Only symptoms that cause distress for a dying client should be treated. Such symptoms include
pain, nausea and vomiting, dyspnea, and agitation. These problems interfere with the client’s
comfort. Even when symptoms, such as anorexia or weight loss, disturb the family, they should be
treated only if the client is distressed by their presence. The nurse should provide education to the
family and the client related to normal symptoms of dying.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
3. The nurse is admitting a new client to the hospital and needs to determine the plan of care. What
criterion is required for the client to make his own medical decisions? (Select all that apply.)
a. Can communicate his treatment preferences
b. Is able to read and write at an 8th grade level
c. Is oriented enough to received information
d. Can evaluate and deliberate information
e. Has completed an advance directive
ANS: A, C, D
To have decision-making ability, a person must be able to perform three tasks: receive information
(but not necessarily oriented 4); evaluate, deliberate, and mentally manipulate information; and
communicate a treatment preference. The client does not have to read or write at a specific level.
Education can be provided at the client’s level, so that he can make the necessary decisions. The
client does not need to complete an advance directive to make his own medical decisions. An
advance directive will be necessary if he wants to designate someone to make medical decisions
when he is unable to.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 107
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advance
Directives) MSC: Integrated Process: Nursing Process (Assessment)
Chapter 10: Concepts of Emergency and Trauma Nursing
Chapter 10: Concepts of Emergency and Trauma Nursing
Test Bank
MULTIPLE CHOICE
1. While assessing a client in the emergency department, the nurse identifies that the client has been
raped. Which health care team member should the nurse collaborate with when planning this
client’s care?
a. Emergency medicine physician
b. Case manager
c. Forensic nurse examiner
d. Psychiatric crisis nurse
ANS: C
All other members of the health care team listed may be used in the management of this client’s
care. However, the forensic nurse examiner is educated to obtain client histories and collect
evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing
with the victim of an assault.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 122
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with
Interdisciplinary Team)
MSC: Integrated Process: Nursing Process (Planning)
2. On admission to the emergency department, a client states that he feels like killing himself. When
planning this client’s care, it is most important for the nurse to coordinate with which member of
the health care team?
a. Case manager
b. Forensic nurse examiner
c. Physician
d. Psychiatric crisis nurse
ANS: D
The psychiatric crisis nurse interacts with clients and families in crisis. This health care team
member can offer valuable expertise to the emergency health care team, which also includes the
case manager and the physician.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 122
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with
Interdisciplinary Team)
MSC: Integrated Process: Nursing Process (Planning)
3. The emergency department team is performing cardiopulmonary resuscitation on a client when
the client’s spouse arrives at the emergency department. What should the nurse do next?
a. Request that the client’s spouse sit in the waiting room.
b. Ask the spouse if he wishes to be present during the resuscitation.
c. Suggest that the spouse begin to pray for the client.
d. Refer the client’s spouse to the hospital’s crisis team.
ANS: B
If resuscitation efforts are still under way when the family arrives, one or two family members may
be given the opportunity to be present during lifesaving procedures. The other options do not give
the spouse the opportunity to be present for the client or to begin to have closure.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Crisis Intervention)
MSC: Integrated Process: Caring
4. The emergency department nurse is assigned an older adult client who is confused and agitated.
Which intervention should the nurse include in the client’s plan of care?
a. Administer a sedative medication.
b. Ask a family member to stay with the client.
c. Use restraints to prevent the client from falling.
d. Place the client in a wheelchair at the nurses’ station.
ANS: B
Older adults who are confused are at increased risks for falls. Fall prevention includes measures
such as siderails up, reorientation, call light in reach, and, in some cases, asking the family member,
significant other, or sitter to stay with the client to prevent falls.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Planning)
5. An emergency department nurse is transferring a client to the medical-surgical unit. What is the
most important nursing intervention in this situation?
a. Triage the client to determine the urgency of care.
b. Clearly communicate client data to the unit nurse.
c. Evaluate the need for ongoing medical treatment.
d. Perform a thorough assessment of the client.
ANS: B
The emergency nurse needs to be able to triage, assess, and evaluate. However, these steps have
already been carried out in the early phases of the emergency department (ED) admission. When a
client is ready to be transferred from the ED, communication with staff nurses from the inpatient
units is essential. This report should be a concise but comprehensive report of the client’s ED
experience.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)
MSC: Integrated Process: Communication and Documentation
6. The nurse manager is assessing current demographics of the facility’s emergency department
(ED) clients. Which population would most likely present to the ED for treatment of a temperature
and a sore throat?
a. Older adults
b. Immunocompromised people
c. Pediatric clients
d. Underinsured people
ANS: D
The ED serves as an important safety net for clients who are ill or injured but lack access to basic
health care. Especially vulnerable populations include the underinsured and the uninsured, who
may have nowhere else to go for health care.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 122
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)
MSC: Integrated Process: Communication and Documentation
7. The emergency department (ED) nurse is caring for the following clients. Which client does the
nurse prioritize to see first?
a. 22-year-old with a painful and swollen right wrist
b. 45-year-old reporting chest pain and diaphoresis
c. 60-year-old reporting difficulty swallowing and nausea
d. 81-year-old with a respiratory rate of 28 breaths/min and a temperature
of 101° F
ANS: B
A client experiencing chest pain and diaphoresis would be classified as emergent and would be
triaged immediately to a treatment room in the ED. The other clients are more stable.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Assessment)
8. A nurse is triaging clients in the emergency department. Which client complaint would the triage
nurse classify as nonurgent?
a. Chest pain and diaphoresis
b. Decreased breath sounds due to chest trauma
c. Left arm fracture with palpable radial pulses
d. Sore throat and a temperature of 104° F
ANS: C
A client in a nonurgent category can tolerate waiting several hours for health care services without
a significant risk of clinical deterioration. The client with chest pain and diaphoresis and the client
with chest trauma are emergent owing to the potential for clinical deterioration and would be seen
immediately. The client with a high fever may be stable now but also has a risk of deterioration.
The client with an arm fracture and palpable radial pulses is currently stable, is not at significant
risk of clinical deterioration, and would be considered nonurgent.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Assessment)
9. A client has been injured in a stabbing incident. Assessment reveals the following:
Blood pressure: 80/60 mm Hg
Heart rate: 140 beats/min
Respiratory rate: 35 breaths/min
Bleeding from stabbing wound site
Client is lethargic
Based on these assessment data, to which trauma center should the nurse ensure transport of the
client?
a. Level I
b. Level II
c. Level III
d. Level IV
ANS: A
The Level I trauma center is able to provide a full continuum of care for all client areas. Level II
can provide care to most injured clients, but given the extent of his injuries, a Level I center would
be better if it is available. Both Levels III and IV can stabilize major injuries, but transport to a
higher-level center is preferred, when possible.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)
MSC: Integrated Process: Nursing Process (Assessment)
10. The emergency medical technicians (EMTs) arrive at the emergency department with an
unresponsive client with an oxygen mask in place. What will the nurse do first?
a. Assess that the client is breathing adequately
b. Insert a large-bore intravenous line
c. Place the client on a cardiac monitor
d. Assess for best neurologic response
ANS: A
The highest-priority intervention in the primary survey is to establish that the client is breathing
adequately. Even though this client has an oxygen mask on, he may not be breathing, or he may be
breathing inadequately with the device in place.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Assessment)
11. A client arrives at the emergency department following a motor vehicle collision. The client is
not awake and is being bagged with a bag-valve-mask by paramedics. The client has sustained
obvious injuries to the head and face, as well as an open right femur fracture that is bleeding
profusely. What will the nurse do first?
a. Splint the right lower extremity.
b. Apply direct pressure to the leg.
c. Assess for a patent airway.
d. Start two large-bore IVs.
ANS: C
The highest-priority intervention in the primary survey is to establish a patent airway. Without an
adequate airway to supply oxygen to the cells, a cerebral injury could progress to anoxic brain
death. After an airway is established, resuscitation may continue to B for breathing and C for
circulation assessment.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Assessment)
12. The nurse is providing care for a client admitted for suicidal precautions. What priority
intervention should the nurse implement first?
a. Administer prescribed anti-anxiety drugs.
b. Decrease the noise level and the harsh lighting.
c. Remove oxygen tubing from the room.
d. Set firm behavioral limits.
ANS: C
The first priority in caring for a mentally ill client is providing a safe environment. This would
include removing any item that the client could use to harm himself or herself (or others). All the
other interventions can be used in providing a therapeutic environment. However, they are not as
imperative as the safety of the client and staff.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
13. A trauma client with multiple open wounds is brought to the emergency department in cardiac
arrest. What should the nurse do before providing advanced cardiac life support?
a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic.
ANS: B
Nurses must recognize and plan for a high risk of contamination with blood and body fluids when
engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation
situations and at other times when exposure to blood and body fluids is likely. Proper attire consists
of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Planning)
14. The nurse is triaging clients in the emergency department. Which client should be considered
urgent?
a. 20-year-old female with a chest stab wound and tachycardia
b. 45 year-old homeless man with a skin rash and sore throat
c. 75-year-old female with a cough and of temperature of 102° F
d. 50-year-old male with new-onset confusion and slurred speech
ANS: C
A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration
and needs to be seen quickly, but is not in an immediately life-threatening situation. Clients with a
chest stab wound and tachycardia, and with new-onset confusion and slurred speech, should be
triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and
would be triaged as nonurgent.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Planning)
15. A client in the emergency department has died from a suspected homicide. What is the nurse’s
priority intervention?
a. Remove all tubes and wires in preparation for the medical examiner.
b. Limit the number of visitors to minimize the family’s trauma.
c. Consult the bereavement committee to follow up with the grieving
family.
d. Communicate the client’s death to the family in a simple and concrete
manner.
ANS: D
When dealing with clients and families in crisis, communicate in a simple and concrete manner to
minimize confusion. Tubes must remain in place for the medical examiner. Family should be
allowed to view the body. Offering to call for additional family support during the crisis is
suggested. The bereavement committee should be consulted, but this is not the priority at this time.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss)
MSC: Integrated Process: Caring
16. A new nurse is orienting to the emergency department (ED). Which statement made by the
nurse would indicate the need for further education by the preceptor?
a. “The emergency medicine physician coordinates care with all levels of
the emergency health care team.”
b. “Emergency departments have specialized teams that deal with high-
risk populations of patients.”
c. “Many older adults seek emergency services when they are ill because
they do not want to bother their primary health care provider.”
d. “Emergency departments are responsible for public health surveillance
and emergency disaster preparedness.”
ANS: A
The emergency nurse is one member of the large interdisciplinary team that provides care for
clients in the ED. A collaborative team approach to emergency care is considered a standard of
practice. In this setting, the nurse coordinates care with all levels of health care team providers,
from prehospital emergency medical services (EMS) personnel to physicians, hospital technicians,
and professional and ancillary staff.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with
Interdisciplinary Team)
MSC: Integrated Process: Communication and Documentation
17. An unresponsive client with poor ventilator effort and a pulse rate of 120 beats/min arrives at
the emergency department. What should the nurse do first?
a. Place the client on a non-rebreather mask.
b. Begin bag-valve-mask ventilation.
c. Initiate cardiopulmonary resuscitation.
d. Prepare for chest tube insertion.
ANS: B
Apneic clients and those with poor ventilatory effort need bag-valve-mask (BVM) ventilation for
support until endotracheal intubation is performed and a mechanical ventilator is used. A nonrebreather mask would be appropriate only if the client had adequate spontaneous ventilation.
Cardiopulmonary resuscitation is necessary only if the client is pulseless. Chest tubes are inserted
for decompression and pneumothorax.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
18. The nurse is triaging clients in the emergency department (ED). Which is true about the
presentation of client symptoms?
a. Older adults frequently have symptoms that are vague or less specific.
b. Young adults present with nonspecific symptoms for serious illnesses.
c. Diagnosing children’s symptoms often keeps them in the ED longer.
d. Symptoms of confusion always represent neurologic disorders.
ANS: A
Older adults present with symptoms that often are different or less specific than those of younger
adults. For example, increasing weakness, fatigue, and confusion may be the only admission
concerns. These vague symptoms can be caused by serious illness, such as an acute myocardial
infarction (MI), urinary tract infection, or pneumonia. Diagnosing older adults often keeps them in
the ED for extended periods of time.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 126
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
19. The emergency department (ED) nurse is assigned to triage clients. What is the purpose of
triage?
a. Treat clients on a first-come, first-serve basis.
b. Identify and treat clients with low acuity first.
c. Prioritize clients based on illness severity.
d. Determine health needs from a complete assessment.
ANS: C
ED triage is an organized system for sorting or classifying clients into priority levels, depending on
illness or injury severity. The key concept is that clients who present to the ED with the greatest
acuity needs receive the quickest evaluation, treatment, and prioritized resource utilization. A
person with a lower-acuity problem may wait longer in the ED because the higher-acuity client is
moved to the “head of the line.”
DIF: Cognitive Level: Knowledge/Remembering REF: p. 127
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Assessment)
20. The nurse is caring for a homeless client and consults the emergency department (ED) case
manager. What can the ED case manager do for this client?
a. Communicate client needs and restrictions to support staff.
b. Prescribe low-cost antibiotics to treat community-acquired infection.
c. Provide referrals to subsidized community-based health clinics.
d. Offer counseling for substance abuse and mental health disorders.
ANS: C
Case management interventions include facilitating referrals to primary care providers who are
accepting new clients or to subsidized community-based health clinics for clients or families in
need of routine services. The ED nurse is accountable for communicating pertinent staff
considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation
precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician
prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional
behaviors or mental illness and facilitates the follow-up treatment plan, including possible
admission to an appropriate psychiatric facility.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 129
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with
Interdisciplinary Team)
MSC: Integrated Process: Nursing Process (Planning)
MULTIPLE RESPONSE
1. The emergency department (ED) nurse is preparing to transfer a client to the critical care unit.
What information should the nurse include in the nurse-to-nurse hand-off report? (Select all that
apply.)
a. Allergies
b. Vital signs
c. Immunizations
d. Marital status
e. Isolation precautions
ANS: A, B, E
Hand-off communication should be comprehensive so that the nurse can continue care for the client
fluidly. Communication should be concise and should include only the most essential information
for a safe transition in care. Hand-off communication should include the client’s situation (reason
for being in the ED), brief medical history, assessment and diagnostic findings, transmission-based
precautions needed, interventions provided, and response to those interventions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)
MSC: Integrated Process: Communication and Documentation
2. The nurse is discharging an older adult client home from the emergency department (ED) after an
acute episode of angina. What should the nurse do to ensure client safety upon discharge? (Select
all that apply.)
a. Reconcile the client’s prescription and over-the-counter medications
b. Screen the client for functional and cognitive abilities, as well as risk
for falls
c. Consult physical therapy to organize for home health services
d. Arrange for the client’s car keys to be taken to prevent an accident
e. Review discharge instructions with the client and a family member
ANS: A, B, E
Before discharge, the nurse should ensure that the client’s prescription and over-the-counter
medications are evaluated to determine whether the drug regimen should be continued. Discharge
education should be provided to the client and a significant other or family member. To prevent
future ED visits, screen older adults per agency policy for functional assessment, cognitive
assessment, and risk for falls. Case management should be consulted to organize home health
services. The nurse should emphasize safety when driving but cannot organize to take the client’s
keys away.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)
MSC: Integrated Process: Teaching/Learning
3. Which interventions will be performed during the primary survey for a trauma client? (Select all
that apply.)
a. Removing wet clothing
b. Splinting open fractures
c. Initiating IV fluids
d. Endotracheal intubation
e. Foley catheterization
f.
Needle decompression
g. Laceration repair
ANS: A, C, D, F
The primary survey for a trauma client organizes the approach to the client so that life-threatening
injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic
ABC, with an added Dand E: A, airway and cervical spine control; B, breathing; C, circulation; D,
disability; and E, exposure. After completion of primary diagnostic studies and laboratory studies,
and insertion of gastric and urinary tubes, the secondary survey, a complete head-to-toe assessment,
can be carried out.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
OTHER
1. The nurse is assessing clients on site at a multi-vehicle accident. Triage clients in the order they
should receive care. (Place in order of priority.)
a. A 50-year-old with chest trauma and difficulty breathing
b. A mother frantically looking for her 6-year-old son
c. An 8-year-old with a broken leg in his father’s arms
d. A 60-year-old with facial lacerations and confusion
e. A pulseless male with a penetrating head wound
ANS:
a, d, b, c, e
Clients should be prioritized with ABCs and emergent, urgent, and nonurgent status. The client
with chest trauma and difficulty breathing is the priority because no clients have an airway
problem, and this is the only client with a breathing problem. The client with confusion should be
seen next. Confusion can be caused by lack of oxygen to the brain due to a circulation problem.
The pulseless client with a penetrating head wound is seen last because there are multiple clients to
be seen, and care for this client would be futile. The client with a broken leg is nonurgent and can
wait. The mother looking for her son should be seen third. Finding the child is urgent to identify
potential injuries.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Assessment)
2. In what sequence would a client move through the process of admission to disposition in
emergency care? (Place in order of priority.)
a. Client is transported to the medical-surgical floor.
b. Emergency department (ED) nurse gives a report on the client.
c. Paramedics arrive and start IV access.
d. Nurse and other health care provider(s) perform assessment.
e. Emergency medical technicians (EMTs) provide oxygen and vital sign monitoring.
f. Laboratory technician obtains blood specimens.
ANS:
e, c, d, f, b, a
When clients are in an emergency situation, EMTs arrive on the scene first. EMTs apply oxygen
and obtain vital signs to determine a baseline for further care. EMTs can provide basic life support
measures and can assess ABCs. Second on the scene are paramedics. Starting IV access and
performing advanced life support is within the paramedic’s scope of practice. The client is then
transported to an ED, where nurses and other health care providers perform an initial assessment.
Laboratory technicians are notified and appropriate blood specimens are obtained for diagnostic
testing. When the client is stable, the ED nurse gives report to the medical-surgical unit nurse, and
the client is finally transferred to an inpatient room.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
Chapter 11: Care of Patients with Common Environmental
Emergencies
Chapter 11: Care of Patients with Common Environmental Emergencies
Test Bank
MULTIPLE CHOICE
1. While the nurse is visiting the community pool, an adult swimmer is pulled out of the pool,
unconscious and cyanotic. What is the priority action of the nurse?
a. Begin chest compressions.
b. Move from the pool area.
c. Give two rescue breaths.
d. Check for a carotid pulse.
ANS: C
The highest priority is to maintain ventilatory support until the victim can breathe on his or her
own. The other options are important, but maintaining the airway and breathing are always priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
2. The nurse working at a first aid booth during a summer marathon sees several runners. Which
runner should be seen first? A runner who:
a. Has fallen several times
b. Is fatigued
c. Thinks he has the flu
d. Has tachypnea
ANS: A
Hot, dry skin, tachycardia, tachypnea, and hypotension are signs of heat stroke. A marathon runner
who has fallen several times may have a thermal injury to the brain, causing loss of coordination.
Mental status changes from thermal injury to the brain include confusion, bizarre behavior,
seizures, and even coma. The nurse should prioritize the client with potential thermal brain injury
over the other clients.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Planning)
3. The nurse is working at a first aid booth for a spring training game on a hot day. A spectator
comes in, reporting that he is not feeling well. Vital signs are temperature 104.1° F (40.1° C), pulse
132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his
feet as the nurse leads him to a cot. What is the priority action of the nurse?
a. Encourage drinking of cool water or sports drinks.
b. Sponge the victim with cool water and remove his shirt.
c. Administer Tylenol (acetaminophen), 650 mg orally.
d. Encourage rest, and reassess in 15 minutes.
ANS: B
The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be
transported to the emergency department as quickly as possible. The nurse should take actions to
lower his body temperature in the meantime by removing his shirt and sponging his body with cool
water. Lowering body temperature by drinking cool fluids or taking acetaminophen is not as
effective in an emergency situation. The client needs to be cooled quickly and is a priority for
treatment.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
4. The emergency department nurse assesses a client in extreme pain with an apparent snakebite of
the leg. Vital signs are stable. What is the priority action of the nurse?
a. Call the regional poison control center.
b. Administer IV pain medication.
c. Place a tourniquet around the leg.
d. Apply an immobilization splint.
ANS: D
Treatment involves immobilization to minimize the spread of venom. A tourniquet should not be
used because it impairs arterial blood flow. Pain medication should be administered and
collaboration with the regional poison control center begun after the leg is immobilized.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
5. The nurse is teaching a wilderness survival class. Which statement by a participant indicates that
additional teaching is needed?
a. “If I get too cold, I can have some brandy to help me get warmed up.”
b. “My climbing partner should let me know right away if my nose turns
white.”
c. “If my partner can’t think straight, we should descend to a lower
altitude.”
d. “It is okay to feel a little short of breath when I am climbing, but not at
rest.”
ANS: A
Alcohol will increase the risk of cold-related injuries and should be avoided. The other options all
show good understanding of the education.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
6. A community nurse assesses a client, who has an allergy to bees, after a bee sting. The client’s
lips are swollen, and wheezes are audible. What is the priority action of the nurse?
a. Elevate the site and notify the client’s next of kin.
b. Remove the stinger with tweezers and encourage rest.
c. Administer diphenhydramine (Benadryl) and apply ice.
d. Administer an EpiPen from the first aid kit and call 911.
ANS: D
The student’s swollen lips indicate that anaphylaxis may be developing, and this is a medical
emergency. 911 should be called immediately, and the client transported to the emergency
department as quickly as possible. If an EpiPen is available, it should be administered at the first
sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat
airway obstruction due to anaphylaxis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
7. While on a camping trip, the nurse provides care for a camper who was bitten by a black widow
spider. What is the priority action of the nurse?
a. Apply ice to the site of the bite.
b. Apply a loose tourniquet to the limb.
c. Give acetaminophen (Tylenol) for pain.
d. Cover the camper with a warm blanket.
ANS: A
Ice inhibits the action of neurotoxin and should be the first intervention provided to a client bitten
by a black widow spider. A tourniquet should not be used because it impairs arterial blood flow.
Tylenol and covering the camper do not treat the neurotoxic effect of the black widow spider’s bite.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
8. A client presents to the emergency department after prolonged exposure to the cold. The client is
shivering, has slurred speech, and is slow to respond to questions. Which treatment will the nurse
prepare for this client?
a. Dry clothing and warm blankets
b. Administration of warmed IV fluids
c. Peritoneal lavage with warmed normal saline
d. Continuous arteriovenous rewarming
ANS: A
Mild hypothermia is manifested by shivering, slurred speech, poor muscular coordination, and
impaired cognitive abilities. Mild hypothermia may be treated with dry clothing and warm
blankets. Rewarming should occur slowly by removing wet clothing and providing dry warm
blankets first. Other treatments are secondary and should be used to treat moderate to severe
hypothermia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Planning)
9. The emergency department nurse assesses a middle-aged mountain climber who reports
headache, nausea, vomiting, and “feeling winded.” What is the nurse’s priority intervention?
a. Administer acetazolamide (Diamox).
b. Administer prochlorperazine (Compazine).
c. Perform a neurologic assessment.
d. Assess for bowel sounds.
ANS: A
The client is exhibiting signs of mountain sickness. Acetazolamide (Diamox, Apo-Acetazolamide)
is used to prevent and treat acute mountain sickness. The other interventions will not treat mountain
sickness.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Nursing Process (Planning)
10. A nurse is at the scene of a lightning strike during a thunderstorm. Which is the priority action
of the nurse?
a. Make sure that victims are not electrically charged.
b. Assess victims for second- and third-degree burns.
c. Start emergency resuscitation on anyone not breathing.
d. Move victims and first aid responders to a sheltered area.
ANS: D
Victims of a lightning strike are not electrically charged afterward. Cardiopulmonary resuscitation
(CPR) should be started once victims and first aid responders are in a sheltered area, because the
thunderstorm presents a continued threat of lightning strikes.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
11. On a hot, humid day, several clients present to the emergency department with symptoms of
heat exposure. Which client will be treated first? A client who:
a. Has normal mental status and flu-like symptoms
b. Is diaphoretic with nausea and vomiting
c. Is hypotensive and tachycardic
d. Is anxious and confused
ANS: D
Normal mental status, flu-like symptoms, diaphoresis, nausea and vomiting, hypotension, and
tachycardia all are symptoms of heat exhaustion. The differentiating symptom between heat
exhaustion and exertional heat stroke is the presence of mental status changes, which indicate
thermal injury to the brain and represent an emergency situation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Planning)
12. The nurse is teaching a community health class about water safety. Which statement by a
participant indicates that additional teaching is needed?
a. “I can go swimming all by myself because I am a certified lifeguard.”
b. “I cannot leave my toddler alone in the bathtub for even a minute.”
c. “I will appoint one adult to supervise the pool at all times during a
party.”
d. “I will make sure that there is a phone near my pool in case of an
emergency.”
ANS: A
People should never swim alone, regardless of lifeguard status. The other statements indicate good
understanding of the teaching.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention) MSC: Integrated Process: Teaching/Learning
13. The nurse is assessing a client recently bitten by a coral snake. Which assessment is the
priority?
a. Peripheral edema and swelling
b. Evaluation of clotting times
c. Respiratory rate and depth
d. Electrocardiogram rhythm
ANS: C
Manifestations of coral snake envenomation are the result of its neurotoxic properties. The
physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced
perception of pain, and, ultimately, respiratory paralysis. The nurse should monitor for respiratory
rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur
with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
14. The nurse is teaching a client with severe allergies how to prevent bug bites. Which statement
by the client indicates that additional teaching is needed?
a. “I will avoid wearing perfume when I go outside.”
b. “I will put the picnic food out when we are ready to eat.”
c. “I will keep my car windows up at all times.”
d. “I will wear sandals whenever I go outside.”
ANS: D
Shoes rather than sandals should be worn outside to prevent insect bites. The other statements
indicate good understanding of the teaching.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
15. The nurse is planning care for a client admitted with a snakebite to the right leg. With whom
should the nurse collaborate?
a. The facility’s neurologist
b. The regional poison control center
c. The physical therapy department
d. A herpetologist (snake specialist)
ANS: B
Contact the regional poison control center immediately for specific advice on antivenom
administration and client management.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 141
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with
Interdisciplinary Team)
MSC: Integrated Process: Nursing Process (Implementation)
16. The nurse is caring for a client who had a near-drowning incident in a lake. Which action will
the nurse take to monitor for possible complications?
a. Assess the client’s temperature every 4 hours.
b. Check the client’s blood glucose level before meals.
c. Assess the client’s bowel sounds three times daily.
d. Check the client’s skin for petechiae daily.
ANS: A
Chemicals, algae, microbes, sand, and mud found in lake water put the client at risk for developing
a lung infection. The client’s temperature should be assessed every 4 hours. A near-drowning victim
will not be at risk for glucose or bowel complications. Assessing for petechiae is not necessary.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
17. The nurse is working in the emergency department on a hot, humid day, when a hiker is brought
in after collapsing. The hiker is confused and tachycardic with a temperature of 105.6° F (40.9° C).
Which IV solution and medication will the nurse have ready for the client?
a. Normal saline and methylprednisolone (Solu-Medrol)
b. Lactated Ringer’s solution and morphine sulfate
c. Normal saline and lorazepam (Ativan)
d. Dextrose 5% and diphenhydramine (Benadryl)
ANS: C
The client has heat stroke and is at risk for developing seizures, so the nurse should be prepared to
administer lorazepam (Ativan) as needed. The optimal solution for clients with heat stroke is IV
normal saline. Ringer’s lactate solution cannot be used because the liver is unable to metabolize
lactate during hyperthermia. Methylprednisolone and diphenhydramine would not be used to treat
heat stroke.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Nursing Process (Planning)
18. The nurse is assessing a client admitted with a brown recluse spider bite. What priority
assessment should the nurse perform?
a. Ask the client about pruritus at the bite site.
b. Inspect for a bluish purple vesicle.
c. Assess for redness and swelling.
d. Obtain the client’s temperature.
ANS: D
Fever and chills indicate systemic toxicity, which can lead to hemolytic reactions, renal failure,
pulmonary edema, cardiovascular collapse, and death. Assessing for a fever should be the nurse’s
priority. All other symptoms are normal for a brown recluse bite. These should be assessed, but they
do not provide information about complications from the bite and therefore are not the priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
19. The nurse is providing emergency care to a client with frostbite. Which intervention is
performed first?
a. Wrap the affected area in a warm, dry blanket to rewarm.
b. Rewarm the affected area in a 104° F water bath.
c. Elevate the affected area above the heart to decrease tissue edema.
d. Use a splint to immobilize the affected area.
ANS: B
Rewarming of the client with frostbite must occur first. Rapid rewarming in a water bath at a
temperature of 104° F is preferable. If a warm bath is not available, warm wet towels can be used,
but not warm dry blankets. After rewarming the affected area, elevate and apply an immobilization
splint.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Intervention)
20. The nurse is caring for a drowning victim after resuscitation. What focused assessment will the
nurse perform to identify complications from drowning?
a. Palpation of abdominal cavity
b. Inspection of skin color
c. Auscultation of lungs
d. Palpation of pulse strength
ANS: C
Auscultation of the lungs will assist the nurse to identify complications from drowning, including
pulmonary infection and acute respiratory distress syndrome (ARDS). All other assessments are
important, but the nurse must focus on the respiratory system as most likely to demonstrate
complications.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction in Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
MULTIPLE RESPONSE
1. The nurse is assessing a group of clients. Which clients are at greater risk for hypothermia or
frostbite? (Select all that apply.)
a. A young man who has just consumed six martinis
b. A young man with a body mass index (BMI) of 42
c. An older man who smokes a pack of cigarettes a day
d. A young woman who is anorexic
e. An older woman with hypertension
f.
A young woman who is diabetic
ANS: A, C, D, F
Clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk for
hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral circulation have a
higher incidence of frostbite.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 148
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
2. The nurse is providing health education at a community center. Which instructions should the
nurse include in teaching about prevention of lightning injuries during a storm? (Select all that
apply.)
a. Seek shelter inside a building or vehicle.
b. Seek shelter under a tall tree.
c. Do not take a bath or shower.
d. Turn off the television.
e. Remove body piercings.
f.
Put down golf clubs or gardening tools.
ANS: A, C, D, F
When you hear thunder, seek shelter in a safe area such as a building or an enclosed vehicle.
Electrical equipment such as TVs and stereos should be turned off. Stay away from plumbing and
water, and metal objects. Do not stand under an isolated tall tree or a structure such as a flagpole.
Body piercings will not increase a person’s chances of being struck by lightning.
DIF: Cognitive Level: Knowledge/Remembering REF: Chart 11-6, p. 147
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
3. An emergency department nurse moves to a new city, where heat-related illnesses are common.
Which clients should the nurse anticipate as at higher risk for heat-related illness? (Select all that
apply.)
a. Homeless individuals
b. Illicit drug users
c. Whites
d. Hockey players
e. Older adults
ANS: A, B, E
Some of the most vulnerable, at-risk populations for heat-related illness include older adults; blacks
(more than whites); people who work outside, such as construction and agricultural workers (more
men than women); homeless people; illicit drug users (especially cocaine users); outdoor athletes
(recreational and professional); and members of the military who are stationed in countries with hot
climates (e.g., Iraq, Afghanistan).
DIF: Cognitive Level: Knowledge/Remembering REF: pp. 136-137
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
Chapter 12: Concepts of Emergency and Disaster Preparedness
Chapter 12: Concepts of Emergency and Disaster Preparedness
Test Bank
MULTIPLE CHOICE
1. The nurse has been assigned the role of triage nurse after a weather-related disaster. What is the
priority action of the nurse?
a. Call in additional staff to assist with care of the victims.
b. Splint fractures and clean and dress lacerations.
c. Perform a rapid assessment of clients to determine priority of care.
d. Provide psychological support to staff and family members.
ANS: C
The triage nurse classifies victims of the explosion into priority of care based on illness or injury
severity. Calling in additional staff more likely would be done by the hospital incident commander
or designee. Physical care is provided to victims after triage occurs. Psychological support should
be an ongoing part of the disaster plan but is not included in triage responsibilities; this ensures that
the greatest good is provided to the greatest number of people.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
2. A client who is hospitalized with burns after losing the family home in a fire becomes angry and
screams at the nurse when dinner is served late. What is the nurse’s best response?
a. “Do you need something for pain right now?”
b. “Please stop yelling. I brought dinner as soon as I could.”
c. “I suggest that you get control of yourself.”
d. “You seem upset. I have time to talk if you like.”
ANS: D
Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event.
The nurse establishes rapport through active listening and honest communication and by
recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first
response closes the door to open communication and limits the client’s options. Simply telling the
client to gain control does nothing to promote therapeutic communication.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Communication and Documentation
3. A client is receiving follow-up care after surviving a tornado. The client reports insomnia and the
nurse notes that the client jumped as the nurse entered the room. Which action by the nurse is most
appropriate?
a. Document findings on the client’s chart and inform the physician.
b. Perform additional assessments for post-traumatic stress disorder.
c. Educate the client on nonpharmaceutical methods to promote sleep.
d. Plan to initiate a referral to a psychologist experienced in survivor
issues.
ANS: B
An individual may experience physical symptoms as a normal response to profound grief or loss,
particularly after a traumatic incident. Manifestations such as insomnia, being startled easily,
having flashbacks, or feelings of numbness may indicate post-traumatic stress disorder, and the
nurse should first assess for this problem. The nurse should document assessment findings, but only
after performing a more thorough assessment. A referral may be necessary, but the nurse does not
have enough information yet to initiate it. If assessment reveals that methods to assist with sleep
would be helpful, the nurse could provide that education.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)
MSC: Integrated Process: Nursing Process (Assessment)
4. An industrial accident has occurred near the hospital, and many victims are brought to the
emergency department (ED) for treatment of their injuries. The nurse triages the victim with which
injury with a red tag?
a. Dislocated right hip and an open fracture of the right lower leg
b. Large contusion to the forehead and a bloody nose
c. Closed fracture of the right clavicle and arm numbness
d. Multiple fractured ribs and shortness of breath
ANS: D
Clients who have an immediate threat to life are given the highest priority, are placed in the
emergent or class I category, and are given a red triage tag. The client with multiple rib fractures
and shortness of breath most likely has developed a pneumothorax, which may be fatal if not
treated immediately. The client with the hip and leg problem and the client with the clavicle
fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2
hours for definitive care. The client with facial wounds would be considered the “walking
wounded” and classified as nonurgent.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Assessment)
5. The nurse is working with a paramedic who just finished assisting at the scene of a school
shooting where several students were killed. Which statement by the nurse is most therapeutic?
a. “Would you like to talk about what happened?”
b. “Surely the department will give you the day off tomorrow.”
c. “At least the gunman was taken into custody.”
d. “Let’s just sit here for a while quietly.”
ANS: A
Allowing staff members to ventilate their feelings about the incident can facilitate recovery and
effective coping afterward. The other choices do not facilitate open communication because the
nurse is not providing the opportunity for the paramedic to talk.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Caring
6. A young man comes into the foyer of the hospital and says that he has a container of anthrax,
which he opens and pours on the floor. Which is the priority action for the nurse who first comes
upon the scene?
a. Don a protective gown, mask, and goggles.
b. Escort the man to the decontamination room.
c. Begin to evacuate the immediate area.
d. Notify the local health department of a biohazard situation.
ANS: C
The highest priority is to remove people from immediate danger, so the nurse should evacuate the
immediate area and prevent injury to those near the spill. Donning personal protective equipment
would probably take the nurse away from the scene to obtain the equipment and would not help
protect those in immediate danger. The man may need to be escorted to a decontamination area
after people are removed from the scene. Reporting the incident to the health department should be
done after the scene is secured and could be delegated to someone else.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Handling
Hazardous and Infectious Materials)
MSC: Integrated Process: Nursing Process (Implementation)
7. Which is the priority action for the emergency department charge nurse in the event of a mass
casualty situation?
a. Directing medical-surgical and case management nurses to assist
emergency department (ED) staff with critically injured victims
b. Calling additional medical-surgical and critical care nursing staff to
come to the hospital to assist when victims are brought in
c. Informing the incident commander at the mass casualty scene about
how many victims may be handled by the ED
d. Directing medical-surgical and critical care nurses to assist with clients
who are already in the ED while the ED staff prepares to receive the
mass casualty victims
ANS: D
The ED charge nurse should direct additional nursing staff to help care for current ED clients while
the ED staff prepares to receive the mass casualty victims; however, they should not be assigned to
the most critically ill or injured clients. The hospital incident commander is responsible for
mobilizing resources and would have the responsibility for calling in staff. The medical command
physician would be the person best able to communicate with on-scene personnel regarding the
ability to take more clients.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Concepts of
Management) MSC: Integrated Process: Nursing Process (Planning)
8. An accident has occurred near the hospital, and a victim is brought to the emergency department
with severe chest pain, a pulse of 120 beats/min, blood pressure of 100/60 mm Hg, and a
respiratory rate of 28 breaths/min. The nurse assesses shortness of breath and diaphoresis. Which
color tag does the nurse use when triaging this client?
a. Red
b. Yellow
c. Green
d. Black
ANS: A
The client in the emergent triage category has a condition that may post an immediate threat to life
or limb and is given the highest priority. Clients who should be treated emergently receive a red tag.
Yellow tags signify major but stable injuries that can wait 30 minutes to 2 hours for definitive care.
Green tags designate “walking wounded” who can wait longer than 2 hours to receive care. Black
tags are used to designate those who are dead or who are expected to die.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Assessment)
9. A nurse is working at the scene of a catastrophic natural event. Which person does the nurse
attend to first?
a. Distraught mother looking for her children
b. Person walking about with a bleeding head wound
c. Supine person with pale, cool, clammy skin
d. Child with a deformed lower leg crying in pain
ANS: C
The person with pale, cool, clammy skin is in shock and needs immediate medical attention. The
mother does not have injuries and so would be the lowest priority. The other two people need
medical attention soon, but not at the expense of a person in shock.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
10. The hospital is overwhelmed when caring for victims after an earthquake that occurred 48 hours
ago. Which responsibility of the nursing supervisor is most important at this time?
a. Assuming leadership for implementation of the hospital emergency plan
b. Releasing updates of client conditions to the media
c. Converting the physical therapy clinic into a treatment area for the
injured
d. Arranging relief and coordinating breaks so nursing staff can rest and
eat
ANS: D
The nursing supervisor should ensure that the staff is not becoming dangerously overtired by
working long shifts without food or rest. Overall leadership for implementing the emergency plan
and re-designating areas for client care would fall under the job of hospital incident commander.
The community relations/public information officer would work with the media.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Concepts of
Management)
MSC: Integrated Process: Nursing Process (Implementation)
11. The nurse is teaching nursing students about personal emergency preparedness. Which
statement by a student indicates that further teaching is indicated?
a. “I will get a prescription for antibiotics just in case I have to work in an
area that has been infected with anthrax.”
b. “I should keep an extra uniform in my locker in case I get stuck at
work.”
c. “I may be torn between caring for my young daughter and caring for
victims at work.”
d. “I should make plans for my family to evacuate our house in case of
tornado or earthquake.”
ANS: A
The student would have no reason to obtain a prescription for anthrax unless he or she demonstrates
clinical evidence of anthrax infection or has been exposed to a substance that tests positive for
anthrax. Statements about planning to keep an extra uniform at work, recognizing the moral
dilemmas he or she might encounter when working in a disaster situation, and understanding
personal preparation for disasters all indicate that the student comprehends information about
disaster planning and emergency preparedness.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Emergency
Response Plan) MSC: Integrated Process: Teaching/Learning
12. The hospital administration has arranged for critical incident stress debriefing for the staff after
a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this
situation?
a. “You are free to express your feelings; whatever is said here stays
here.”
b. “Let’s determine what we can do better the next time we have this
situation.”
c. “This session is only for nursing and medical staff, not for ancillary
personnel.”
d. “Let’s pass around the written policy compliance form for everyone.”
ANS: A
Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable
sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and
discussing policies would occur during an administrative review. Any employee present during a
mass casualty situation is eligible for critical incident stress management services.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 162
TOP: Client Needs Category: Psychosocial Integrity (Stress Management)
MSC: Integrated Process: Communication and Documentation
13. The nurse is caring for a client whose wife just died in an accident. The client says to the nurse,
“I can’t believe that my wife is gone and I am left to raise my children all by myself.” Which
response by the nurse is most appropriate?
a. “Please accept my sympathy for your loss.”
b. “I can call the hospital chaplain if you wish.”
c. “You sound anxious about being a single parent.”
d. “At least your children still have you in their lives.”
ANS: C
Therapeutic communication includes active listening and honesty. This statement demonstrates that
the nurse recognizes the client’s distress and has provided an opening for discussion. Extending
sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings.
Stating that the children still have one parent discounts the client’s feelings and situation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Communication and Documentation
14. The emergency department nurse manager is explaining concepts of emergency and disaster
preparedness to a group of students. Which statement by the nurse manager is most accurate?
a. “An internal disaster is something that occurs inside the health care
facility.”
b. “An external disaster occurs when someone not employed here disrupts
our operations.”
c. “A multi-casualty event involves disasters at several different
locations.”
d. “The Joint Commission requires that we participate in a disaster drill
once a year.”
ANS: A
An internal disaster is something that occurs within the health care facility, such as a fire. External
disasters, such as a tornado or a hurricane, occur outside the health care facility. A multi-casualty
event can be managed with hospital resources. The Joint Commission requires hospitals to
participate in two disaster drills a year.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 155
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency
Response Plan) MSC: Integrated Process: Teaching/Learning
15. The emergency department (ED) is expecting a large number of casualties after a bridge
collapse. Which is a priority consideration for the ED leadership when activating the disaster plan?
a. Responding paramedics and rescue personnel will notify the ED about
exactly how many victims to expect.
b. Responding paramedics and rescue personnel will triage all victims at
the bridge collapse site before bringing them to the ED.
c. The ED may receive many unexpected victims with minor injuries from
the bridge collapse.
d. Victims who have been contaminated with gasoline will be
decontaminated by rescue personnel before arriving at the ED.
ANS: C
Paramedics may not note all the “walking wounded” to give the ED an accurate count of victims to
expect because these people might evacuate themselves from the accident scene without being seen
by paramedics or rescue personnel. They may then secure their own transportation to the hospital
and could overwhelm an ED that is already handling many severely injured victims who have been
brought in by emergency medical services (EMS).
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency
Response Plan) MSC: Integrated Process: Nursing Process (Planning)
16. A nursing administrator is evaluating the hospital’s response to a recent internal disaster. The
administrator assesses that goals for disaster planning have been met when which outcome is
assessed?
a. The hospital was able to maintain client, staff, and visitor safety during
the disaster.
b. Supplies were readily available and were transported rapidly where
needed.
c. The hospital incident command officer successfully utilized ancillary
areas for client care.
d. All employees followed the chain of command and established policies
and procedures.
ANS: A
The most important outcome of any internal disaster is maintenance of safety for the hospital’s
clients, staff, and visitors. Other outcomes listed would be part of a successful disaster response,
but are all too narrow to meet this objective.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency
Response Plan) MSC: Integrated Process: Nursing Process (Evaluation)
17. A nursing administrator is reviewing a hospital’s disaster planning. The administrator evaluates
the plan that addresses which component as being the best?
a. Internal disasters such as fires or power outages
b. All possible catastrophes in the community
c. The Joint Commission’s assessment of possible disasters
d. Responses to all types of weather-related emergencies
ANS: B
When The Joint Commission–accredited health care facilities are planning disaster preparedness
programs, they need to take an “all-hazards approach” (versus planning by strict guidelines) and to
plan for all credible threats to the community that could result in a disaster. This means planning for
all events that could conceivably happen in that geographic area, including possible weather events.
Planning only for internal disasters is too limited and does not account for weather- or terroristrelated threats. The Joint Commission does not assess what disasters are possible in the areas that
accredited hospitals serve.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency
Response Plan) MSC: Integrated Process: Nursing Process (Planning)
18. A nursing instructor is debriefing students who participated in a community-wide disaster drill.
Several students are upset with the black-tagged triage category. Which statement by the nursing
instructor is best?
a. “To do the greatest good for the greatest number of people, it is
necessary to sacrifice some.”
b. “Not everyone will survive a disaster, so it is best to identify those
people early and move on.”
c. “In a disaster, extensive resources are not used for one person at the
expense of many others.”
d. “With black tags, volunteers can identify those who are dying and can
give them comfort care.”
ANS: C
In a disaster, military style triage is used; this approach identifies the dead or expectant dead with
black tags. This practice helps to maintain the goal of triage, which is doing the most good for the
most people. Precious resources are not used for those with overwhelming critical injury or illness,
so that they can be allocated to others who have a reasonable expectation of survival. Clients are
not “sacrificed.” Telling students to move on after identifying the expectant dead belittles their
feelings and does not provide an adequate explanation. Clients are not black-tagged to allow
volunteers to give comfort care.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 157
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency
Response Plan) MSC: Integrated Process: Teaching/Learning
19. A nurse wants to become involved in community disaster preparedness and is interested in
helping set up and staff first aid stations or community acute care centers in the event of a disaster.
Which organization is the best fit for this nurse’s interests?
a. The Medical Reserve Corps
b. The National Guard
c. The Health Department
d. A Disaster Medical Assistance Team
ANS: A
The Medical Reserve Corps (MRC) consists of volunteer medical and public health care
professionals who support the community during times of need. They may help staff hospitals,
establish first aid stations or special needs shelters, or set up acute care centers in the community.
The National Guard often performs search and rescue operations and law enforcement. The Health
Department focuses on communicable disease tracking, treatment, and prevention. A Disaster
Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of
relief services.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 159
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency
Response Plan)
MSC: Integrated Process: Nursing Process (Implementation)
20. A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned
about maintaining licensure in several different states. What statement by the nursing supervisor
best addresses these concerns?
a. “Deployed DMAT providers are federal employees, so their licenses are
good in all 50 states.”
b. “The government has a program for quick licensure activation wherever
you are deployed.”
c. “During a time of crisis, licensure issues would not be the government’s
priority concern.”
d. “If you are deployed, you will be issued a temporary license in the state
in which you are working.”
ANS: A
When deployed, DMAT health care providers are acting as agents of the government, and so are
considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an issue
that the government would be concerned with, but no programs for temporary licensure or rapid
activation are available.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 159
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency
Response Plan) MSC: Integrated Process: Teaching/Learning
21. A community disaster has occurred and the hospital’s emergency department (ED) has
efficiently triaged, treated, and transferred most clients to appropriate units. The hospital incident
command officer wants to “stand down” from the emergency plan. Which question by the nursing
supervisor is most beneficial at this time?
a. “Are you sure no more victims are coming into the ED?”
b. “Do all other areas of the hospital have the supplies and personnel they
need now?”
c. “Have all ED staff had the chance to eat and rest recently?”
d. “Are all other incident command officers and house supervisors in
agreement with you?”
ANS: B
Before “standing down,” the incident command officer ensures that the needs of the other hospital
departments have been taken care of because they may still be stressed and may need continued
support to keep functioning. Many more “walking wounded” victims may present to the ED; that
number may not be predictable. Giving staff the chance to eat and rest is important, but all areas of
the facility need that too. Although agreement among incident officers is important, it is not the
priority concern before standing down.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency
Response Plan)
MSC: Integrated Process: Communication and Documentation
22. A hospital has “stood down” from a mass casualty disaster. The staff have rested and eaten.
Which action by the nursing supervisor takes priority?
a. Restocking the emergency department (ED)
b. Making rounds on each unit to check staffing
c. Determining which staff can go home
d. Planning a critical incident stress debriefing
ANS: A
Inventorying and stocking the ED are high-priority actions because the usual flow of emergency
clients may not be lessened in the wake of a disaster. Supplies may be low or exhausted, and it
would be vital to resupply the area. Rounding on inpatient units, determining the staff who can be
relieved, and planning a debriefing are certainly important items, but they do not take priority over
getting the ED ready for more clients.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 162
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency
Response Plan) MSC: Integrated Process: Nursing Process (Planning)
23. A family in the emergency department is overwhelmed at the loss of several family members
due to a shooting incident in the community. Which intervention by the nurse is most beneficial?
a. Offer the family choices as appropriate and possible.
b. Call the hospital chaplain to stay with the family.
c. Do not allow visiting of the victims until the bodies are prepared.
d. Provide privacy for law enforcement to interview the family.
ANS: A
Offering choices when appropriate and when possible gives some personal control back to
individuals. The family may or may not want the assistance of religious personnel; the nurse should
assess for this before calling anyone. Visiting procedures should take into account the needs of the
family. The family may appreciate privacy, but this is not as helpful as allowing choices when the
family is able to make them.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss)
MSC: Integrated Process: Caring
24. An emergency department (ED) supervisor has noted an increase in sick calls and bickering
among the ED staff after a week with multiple trauma incidents. What action by the supervisor is
most helpful?
a. Organize a pizza party for each shift.
b. Remind staff of facility sick-leave policy.
c. Arrange critical incident stress debriefing.
d. Talk individually with staff members.
ANS: C
The staff may be suffering from critical incident stress and needs to have a debriefing by the critical
incident stress management team to prevent the consequences of long-term, unabated stress. The
other interventions may be helpful as well but are not as important as a debriefing.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Stress Management)
MSC: Integrated Process: Caring
25. A client has been treated in the emergency department after a tornado and is awaiting discharge
instructions. This client is close to losing control, although other family members are attempting to
calm him down. Which response by the nurse is most helpful?
a. Call security and have them standing by in case they are needed.
b. Instruct the person to leave the area until he can calm down.
c. Offer the client the choice of waiting in the treatment room or the
waiting room.
d. Ask the family to help move the client out of the treatment area.
ANS: C
Offering people choices often is a good way to get them to focus on something other than their
distress. Calling security and telling the person to leave might escalate the situation, although if all
other methods fail, the safety of staff, clients, and other visitors takes priority. Asking the family to
help move the client puts him in a difficult position and may end up causing them injury.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Stress Management)
MSC: Integrated Process: Caring
MULTIPLE RESPONSE
1. A large number of victims arrive at the emergency department after a bus is hit by a train. Which
interventions are performed immediately for red-tagged victims? (Select all that apply.)
a. Splinting a closed tibial fracture
b. Intubating a cyanotic client in respiratory distress
c. Initiating IV fluids for a client with a blood pressure of 96/60 mm Hg
and a pulse of 144 beats/min
d. Attaching an external pacemaker for a client with a heart rate of 44
beats/min
e. Performing postmortem care for a client who has just died
f.
Removing glass that is embedded in a client’s arm
ANS: B, C, D
Priority interventions are those that must be performed to save the client’s life, including intubation,
IV fluid replacement for shock, and pacemaker placement. Splinting a fracture and removing glass
from a client’s arm can wait until after life-threatening injuries are cared for. Postmortem care
would wait until after all clients have been cared for.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
2. The triage nurse is assessing a client who has been brought to the emergency department (ED) by
emergency medical services (EMS) following a mass casualty incident. Which assessment
questions are used to determine the appropriate triage category for the client? (Select all that
apply.)
a. “Can you wiggle your toes?”
b. “Are you having any difficulty breathing?”
c. “Are you allergic to any medications?”
d. “Does your family know that you are here?”
e. “Can you tell me what day it is?”
f.
“Do you have any abdominal or back pain?”
ANS: A, B, E, F
The triage nurse should assess for possible spinal cord injury, shortness of breath, abdominal or
back pain, and disorientation when the client is brought to the ED. Determining allergies, although
important, does not assist in categorizing clients, nor does inquiring about the client’s family.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
3. Emergency medical services (EMS) brings a large number of clients to the emergency
department following a mass casualty incident. The nurse identifies clients with which injuries with
yellow tags? (Select all that apply.)
a. Partial-thickness burns covering both legs
b. Open fractures of both legs with absent pedal pulses
c. Neck injury and numbness of both legs
d. Small pieces of shrapnel embedded in both eyes
e. Head injury and difficult to arouse
f.
Bruising and pain in the right lower abdomen
ANS: A, C, D, F
Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated
within 30 minutes to 2 hours, and therefore should be identified with yellow tags. The client with
the open fracture and the client with the head injury would be classified as urgent with red tags.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
4. A hospital is receiving large numbers of casualties from a disaster. Which clients does the
supervisor identify as appropriate for discharge or transfer to another facility? (Select all that
apply.)
a. Client who had open reduction and internal fixation of a femur fracture
3 days ago
b. Client who had a colostomy 4 days ago and whose daughter is a
registered nurse
c. Client admitted last night with community-acquired pneumonia
d. Infant admitted 2 days ago for fever of unknown origin
e. Client in the medical decision unit for evaluation of chest pain
ANS: A, B
The client with the femur fracture could be transferred to a rehabilitation facility and the RN could
provide care and teaching to her father. The newly admitted client with pneumonia would not be a
good choice because culture results are not yet available and antibiotics have not been administered
long enough. Also, the infant has not been in the hospital long enough for cultures to return for a
definitive diagnosis. The client in the medical decision unit should be identified for dismissal if
diagnostic testing reveals a noncardiac source of chest pain.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Emergency
Response Plan) MSC: Integrated Process: Nursing Process (Assessment)
5. The nurse working with survivors of a disaster wants to assess them for post-traumatic stress
disorder. For which clients does the nurse perform further assessment before administering the
Impact of Event Scale–Revised?(Select all that apply.)
a. Older adult survivor with minor injuries
b. Woman who lost both her children
c. Middle-aged victim with multiple medical problems
d. Young adult who had serious orthopedic injuries
e. Older adolescent who had a traumatic brain injury
ANS: A, E
The Impact of Event Scale–Revised tool should not be used with people who have short-term
memory loss, so the nurse should assess the older adult survivor and the client with the brain injury
for this problem before administering the tool. The other clients do not have medical issues that
would preclude use of this tool.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Stress Management)
MSC: Integrated Process: Nursing Process (Assessment)
6. A wing of a hospital is on fire. Which actions by the nurse promote safe evacuation of clients?
(Select all that apply.)
a. Direct ambulatory clients on where to go to be safe.
b. Use ambulatory clients to help push clients in wheelchairs.
c. Use oxygen tanks for all clients who are on oxygen.
d. Manually ventilate clients who are on ventilators.
e. Move bedridden clients in their beds if possible.
ANS: A, B, D, E
Ambulatory clients can evacuate themselves with direction or could be used to help push
wheelchair-bound clients. Clients on ventilators need to be removed from the ventilator and
“bagged” until evacuated, then they can be put back on the ventilator if one is available. Bedridden
clients should be moved in their beds or on stretchers, or carried if needed. Any client who can
breathe without oxygen should have it removed for the evacuation because oxygen is an accelerant.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Emergency
Response Plan)
MSC: Integrated Process: Nursing Process (Implementation)
Chapter 13: Assessment and Care of Patients with Fluid and
Electrolyte Imbalances
Chapter 13: Assessment and Care of Patients with Fluid and Electrolyte Imbalances
Test Bank
MULTIPLE CHOICE
1. The nurse observes skin tenting on the back of the older adult client’s hand. Which action by the
nurse is most appropriate?
a. Notify the physician.
b. Examine dependent body areas.
c. Assess turgor on the client’s forehead.
d. Document the finding and continue to monitor.
ANS: C
Skin turgor cannot be accurately assessed on an older adult client’s hands because of age-related
loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older
client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather
than merely examining dependent body areas. Further assessment is needed rather than only
documenting, monitoring, and notifying the physician.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC:
Integrated Process: Nursing Process (Assessment)
2. The client is taking a medication that inhibits aldosterone secretion and release. The nurse
assesses for what potential complication?
a. Fluid retention
b. Hyperkalemia
c. Hyponatremia
d. Hypervolemia
ANS: B
Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the
reabsorption of water and sodium in the kidney at the same time that it promotes excretion of
potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client’s
risk for excessive water loss and increased potassium reabsorption. The client would not be at risk
for overhydration or sodium imbalance.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Assessment)
3. Which assessment does the nurse use to determine the adequacy of circulation in a client whose
blood osmolarity is 250 mOsm/L?
a. Measuring urine output
b. Measuring abdominal girth
c. Monitoring fluid intake
d. Comparing radial versus apical pulses
ANS: A
The blood osmolarity is low. The client could be dehydrated (hypo-osmolar dehydration) or
overhydrated with dilution of blood solute. The most sensitive noninvasive indicator of circulation
adequacy is urine output. Measuring abdominal girth, comparing pulses, and monitoring fluid
intake would not be accurate assessment techniques for this client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
4. Which statement made by the older adult client alerts the nurse to assess specifically for fluid and
electrolyte imbalances?
a. “My skin is always so dry, especially here in the Southwest.”
b. “I often use a glycerin suppository for constipation.”
c. “I don’t drink liquids after 5 PM so I don’t have to get up at night.”
d. “In addition to coffee, I drink at least one glass of water with each
meal.”
ANS: C
Restricting fluids without a medical reason can lead to dehydration. Many older clients believe that
restricting fluids will prevent incontinence and reduce the number of times that they wake up
during the night. The increased osmolarity of the urine in response to reducing fluid intake
increases irritation of the bladder and sphincter, increasing the sensation of needing to urinate. The
other statements do not indicate practices that could potentially lead to dehydration.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
5. A client has been taught to restrict dietary sodium. Which food selection by the client indicates to
the nurse that teaching has been effective?
a. Chinese take-out, including steamed rice
b. A grilled cheese sandwich with tomato soup
c. Slices of ham and cheese on whole grain crackers
d. A chicken leg, one slice of bread with butter, and steamed carrots
ANS: D
Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and
those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh
produce. The Chinese food likely would have soy sauce, the tomato soup is processed, and the
crackers are a snack food—a category of foods often high in sodium.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
6. A client is on a potassium-restricted diet. Which protein choice by the client indicates a good
understanding of the dietary regimen?
a. 1% or 2% milk
b. Grilled salmon
c. Poached eggs
d. Baked chicken
ANS: C
Eggs contain few cells and have one of the lowest potassium contents among high-protein foods.
Meat and fish have cells that contain large amounts of potassium. Dairy products are also high in
potassium.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
7. Which assessment finding obtained while taking the history of an older adult client alerts the
nurse that the client needs further assessment for fluid or electrolyte imbalance?
a. “I am often cold and need to wear a sweater.”
b. “I seem to urinate more when I drink coffee.”
c. “In the summer, I feel thirsty more often.”
d. “My rings seem to be tighter this week.”
ANS: D
A change in ring size over a relatively short period of time may indicate a change in body fluid
amount or distribution rather than a change in body fat. The other statements are not indicators of a
fluid or electrolyte imbalance.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC:
Integrated Process: Nursing Process (Assessment)
8. Which client is at greatest risk for dehydration?
a. Younger adult client on bedrest
b. Older adult client receiving hypotonic IV fluid
c. Younger adult client receiving hypertonic IV fluid
d. Older adult client with cognitive impairment
ANS: D
Older adults, because they have less total body water than younger adults, are at greater risk for
development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids
independently or cannot make his or her need for fluids known is at high risk for dehydration.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 174
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration)
MSC: Integrated Process: Nursing Process (Assessment)
9. Which question does the nurse ask the client who has isotonic dehydration to determine a
possible cause?
a. “Do you take diuretics, or ‘water pills’?”
b. “What do you normally eat over a day’s time?”
c. “How many bowel movements do you have daily?”
d. “Have you been diagnosed with diabetes mellitus?”
ANS: A
Misuse or overuse of diuretics is a common cause of isotonic dehydration. The other statements are
not indicative of causes of isotonic dehydration.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Assessment)
10. Which intervention in a client with dehydration-induced confusion is most likely to relieve the
confusion?
a. Measuring intake and output every four hours
b. Applying oxygen by mask or nasal cannula
c. Increasing the IV flow rate to 250 mL/hr
d. Placing the client in a high Fowler’s position
ANS: B
Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing
confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum.
Increasing the IV flow rate would increase perfusion. However, depending on the degree of
dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
11. A client is being treated for dehydration. Which statement made by the client indicates
understanding of this condition?
a. “I must drink a quart of water or other liquid each day.”
b. “I will weigh myself each morning before I eat or drink.”
c. “I will use a salt substitute when making and eating my meals.”
d. “I will not drink liquids after 6 PM so I won’t have to get up at night.”
ANS: B
Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or
fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other
statements are not indicative of practices that will prevent dehydration.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
12. What intervention is most important to teach the client about identifying the onset of
dehydration?
a. Measuring abdominal girth
b. Converting ounces to milliliters
c. Obtaining and charting daily weight
d. Selecting food items with high water content
ANS: C
Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or
fluid retention. Obtaining and charting accurate daily weights is the most sensitive and costeffective way of monitoring fluid balance in the home. The other options would not be useful for
early detection of dehydration.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Implementation)
13. A nurse is caring for several clients with dehydration. The nurse assesses the client with which
finding as needing oxygen therapy?
a. Tenting of skin on the back of the hand
b. Increased urine osmolarity
c. Weight loss of 10 pounds
d. Pulse rate of 115 beats/min
ANS: D
Severe dehydration can decrease circulating volume and decrease cardiac output, placing vital
organs at risk for hypoxia, anoxia, and ischemia. Whenever cardiac output is decreased with
dehydration, oxygen therapy is indicated.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Assessment)
14. Which action does the nurse teach a client to reduce the risk for dehydration?
a. Restricting sodium intake to no greater than 4 g/day
b. Maintaining an oral intake of at least 1500 mL/day
c. Maintaining a daily oral intake approximately equal to daily fluid loss
d. Avoiding the use of glycerin suppositories to manage constipation
ANS: C
Although a fixed oral intake of 1500 mL daily is good, the key to prevention of dehydration is to
match all fluid losses with the same volume for fluid intake. This is especially true in warm or dry
environments, or when conditions result in greater than usual fluid loss through perspiration or
ventilation.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 174
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
15. Which item of assessment data obtained by the home care nurse suggests that an older adult
client may be dehydrated?
a. The client has dry, scaly skin on bilateral upper and lower extremities.
b. The client states that he gets up three or more times during the night to
urinate.
c. The client states that he feels lightheaded when he gets out of bed or
stands up.
d. The nurse observes tenting on the back of the hand when testing skin
turgor.
ANS: C
Orthostatic or postural hypotension can be caused by or worsened by dehydration. The other
statements are not as indicative of the severe degree of dehydration as dizziness on standing.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 175
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
16. A client is being discharged with mild dehydration. Which statement by the client indicates an
understanding of measures to prevent mild dehydration from becoming more severe?
a. “I will weigh myself at the same time daily wearing the same clothes.”
b. “When I feel lightheaded, I will drink a full glass of water.”
c. “I will decrease my fluid intake if my urine output increases.”
d. “If I forget to take my diuretic, I will take twice the dose next time.”
ANS: B
Feeling lightheaded or dizzy is an indication of low blood pressure and poor perfusion. Mild
dehydration can cause these problems, and increasing fluid intake at the first sign of dehydration
may prevent it from becoming worse. The other options would not prevent mild dehydration from
progressing.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
17. During assessment of hydration status, the client tells the nurse that she usually drinks 3 quarts
of liquids each day. Which question by the nurse is best?
a. “Do you usually drink liquids that are hot or cold?”
b. “How much salt do you add to your food?”
c. “What kinds of liquids do you usually drink?”
d. “Do you drink fluids with meals or between meals?”
ANS: C
It is just as important to determine the types of fluids ingested as the amount, because fluids vary
widely in their osmolarity. In addition, some liquids, such as those that contain alcohol or caffeine,
can contribute to fluid and electrolyte imbalances.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
18. A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client
with which finding first?
a. Has had diabetes mellitus for 12 years
b. Uses sodium-containing antacids frequently
c. Just received 3 units of packed red blood cells
d. Had abdominal surgery and has a nasogastric tube
ANS: C
Blood replacement therapy involves intravenous fluid administration, which inherently increases
the risk for overhydration. The fact that the fluid consists of packed red blood cells greatly
increases the risk, because this fluid increases the colloidal oncotic pressure of the blood, causing
fluid to move from interstitial and intracellular spaces into the plasma volume. An older adult may
not have sufficient cardiac or renal reserve to manage this extra fluid.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Assessment)
19. A client has been diagnosed with overhydration and is confused. Which intervention does the
nurse include in the client’s plan of care to relieve the confusion?
a. Measuring intake and output every shift
b. Slowing the IV flow rate to 50 mL/hr
c. Administering diuretic agents as prescribed
d. Placing the client in Trendelenburg position
ANS: C
Overhydration most frequently leads to poor neuronal function, causing confusion as a result of
electrolyte imbalances (usually sodium dilution). Eliminating fluid excess is the best way to reduce
confusion. The other interventions would not relieve the client’s confusion.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—Expected
Actions/Outcomes)
MSC: Integrated Process: Nursing Process (Implementation)
20. The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is
the nurse’s priority?
a. Document the observation in the chart.
b. Measure urine specific gravity and volume.
c. Assess the pulse and blood pressure.
d. Assess the client’s deep tendon reflexes.
ANS: C
Neck veins in the normovolemic person are full in the supine position and flat in the sitting
position. Full neck veins in the sitting position are an indicator of overhydration. Checking the
pulse and blood pressure can help determine whether overhydration is present. Urine specific
gravity is not as important a measure of volume status and deep tendon reflexes and does not give
information on volume status at all. The nurse needs to document the finding, but interventions
should not end there.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
21. A client in the emergency department has potassium of 2.9 mEq/L. For which disease process or
condition does the nurse assess the client?
a. Diabetes mellitus
b. Addison’s disease
c. Hyperaldosteronism
d. Diabetes insipidus
ANS: C
Hyperaldosteronism results in increased reabsorption of sodium and water while enhancing
excretion of potassium. Therefore, any client with this condition is at high risk for the development
of hypokalemia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
22. A client is taking furosemide (Lasix) and becomes confused. Which potassium level does the
nurse correlate with this condition?
a. 2.9 mEq/L
b. 3.8 mEq/L
c. 5.0 mEq/L
d. 6.0 mEq/L
ANS: A
Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to
perform problem-solving tasks, disorientation, and coma. Normal potassium levels are 3.5 to 5.0
mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to neurologic manifestations.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
23. A client has hypokalemia. Which question by the nurse obtains the most information on a
possible cause?
a. “Do you use sugar substitutes?”
b. “Do you use diuretics or laxatives?”
c. “Do you have any kidney disease?”
d. “Have your bowel habits changed recently?”
ANS: B
Misuse and overuse of diuretics, especially high-ceiling (loop) and thiazide diuretics, and laxatives
are common causes of hypokalemia in older adults and in clients with eating disorders. Sugar
substitutes and bowel habits are not related to hypokalemia. The client with kidney disease would
be more likely to have hyperkalemia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Assessment)
24. A client has been treated for hypokalemia. Which clinical manifestation or condition indicates
that treatment has been effective?
a. Having a bowel movement daily
b. Gaining 2 lb during the past week
c. Electrocardiogram (ECG) showing inverted T-waves
d. Fasting blood glucose level of 106 mg/dL
ANS: A
Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who
have hypokalemia have reduced or absent bowel sounds and are constipated. The other answer
options are not applicable to hypokalemia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Evaluation)
25. The nurse notes that the handgrip of the client with hypokalemia has diminished since the
previous assessment one hour ago. Which intervention by the nurse is the priority?
a. Assess the client’s respiratory rate, rhythm, and depth.
b. Measure the client’s pulse and blood pressure.
c. Document findings and monitor the client.
d. Call the health care provider.
ANS: A
In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing
severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory
insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure
that the client is not in immediate jeopardy. Next, the nurse would call the health care provider to
obtain orders for potassium replacement.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
26. The client is receiving an intravenous infusion of 60 mEq of potassium chloride in a 1000 mL
solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns.
What intervention does the nurse perform first?
a. Notify the physician.
b. Assess for a blood return.
c. Document the finding.
d. Stop the IV infusion.
ANS: D
Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the
potassium and discontinue the IV altogether, in which case the client would need another site
started. Assessing for a blood return may or may not be successful. The solution could be diluted
(less potassium) and the rate could be slowed once it is determined that the needle is in the vein.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
27. A client has been taught to increase potassium in the diet. What dietary meal selection indicates
to the nurse that teaching has been effective?
a. Toasted English muffin with butter and blueberry jam, and tea with
sugar
b. Two scrambled eggs, a slice of white toast, and a
c.
Sausage, one slice of whole wheat toast,
milk
cup of strawberries
cup of raisins, and a glass of
d. Bowl of oatmeal with brown sugar,
cup of sliced peaches, and coffee
ANS: C
Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals,
sugar, and some fruits (berries, peaches) are low in potassium. The menu selection of sausage,
toast, raisins, and milk has the greatest number of items with higher potassium content.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
28. Which client statement indicates the need for more teaching regarding identification of the early
manifestations of hypokalemia?
a. “I have been weighing myself every day.”
b. “When I am constipated, I drink more fluids.”
c. “When my muscles feel weak, I eat a banana.”
d. “I check my pulse each morning and each night.”
ANS: B
The intestinal tract is relatively sensitive to decreasing potassium levels. Common manifestations
of hypokalemia are decreased peristalsis and constipation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
29. A nurse is caring for several clients. Which client does the nurse assess most carefully for
hyperkalemia?
a. Client with heart failure using a salt substitute
b. Client taking a thiazide diuretic for hypertension
c. Client taking nonsteroidal anti-inflammatory drugs daily
d. Client with type 2 diabetes taking an oral antidiabetic agent
ANS: A
Many salt substitutes are composed of potassium chloride. Heavy use can contribute to the
development of hyperkalemia. The client should be taught to read labels and to choose a salt
substitute that does not contain potassium. NSAIDs promote the retention of sodium but not
potassium.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
30. A client at risk for continuing hyperkalemia states that she is upset because she cannot eat fruit
every day. Which response by the nurse is best?
a. “You are correct. Fruit is usually very high in potassium.”
b. “If you cook the fruit first, that lowers the potassium.”
c. “Berries, cherries, apples, and peaches are low in potassium.”
d. “Fresh fruit is higher in potassium than dried fruit.”
ANS: C
Not all fruit is potassium rich. Fruits that are relatively low in potassium and can be included in the
diet include apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in
potassium include bananas, kiwi, cantaloupe, oranges, and dried fruit. Cooking fruit does not alter
its potassium content.
DIF: Cognitive Level: Comprehension/Understanding REF: Chart 13-8, p. 188
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
31. A client is being discharged and needs to self-monitor for the development of hyperkalemia.
Which intervention is most important for the nurse to teach the client?
a. Weighing self daily at the same time of day
b. Assessing radial pulse for a full minute twice a day
c. Ensuring an oral intake of a least 3 L of fluids per day
d. Restricting sodium as well as potassium intake
ANS: B
As potassium levels rise, dysrhythmias can develop. By being vigilant for changes in pulse rate,
rhythm, and quality, the client can seek medical attention before hyperkalemia becomes severe.
Taking a daily weight will help determine fluid retention, but this is not an accurate indicator of
potassium increase or decrease. Fluid intake should be based on body weight. Sodium restriction
may not be necessary.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
32. A client is admitted with hyponatremia. Four hours after the initial assessment, the nurse notes
that the client has new hyperactive bowel sounds in all four quadrants. What analysis about the
client’s condition is correct?
a. The hyponatremia is worse.
b. The hyponatremia is the same.
c. The hyponatremia is better.
d. The client now has hypernatremia.
ANS: A
Clinical manifestations of hyponatremia are most evident in excitable tissues and include lethargy,
decreased blood pressure, increased gastric motility, and diminished deep tendon reflexes. Bowel
sounds that are more hyperactive than on a previous assessment indicate that the condition is
worsening.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
33. A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at greatest risk
for developing hyponatremia?
a. Client who is NPO receiving intravenous D 5W
b. Client taking a sulfonamide antibiotic
c. Client taking ibuprofen (Motrin)
d. Client taking digoxin (Lanoxin)
ANS: A
D5W contains no electrolytes. Because the client is not taking any food or fluids by mouth, normal
sodium excretion can lead to hyponatremia. The antibiotic, Motrin, and digoxin will not put a client
at risk for hyponatremia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Assessment)
34. The nurse is providing discharge teaching for a client who is at risk for mild hypernatremia.
What action is most important for the nurse to teach the client?
a. “Weigh yourself every morning and every night.”
b. “Check your radial pulse twice a day.”
c. “Read food labels to determine sodium content.”
d. “Bake or grill the meat rather than frying it.”
ANS: C
Most prepackaged foods have high sodium content. Teaching the client how to read labels and
calculate the sodium content of food can help him or her adhere to the prescribed sodium restriction
and can prevent hypernatremia. Daily self-weighing and checking the pulse are methods of
identifying manifestations of hypernatremia, but they do not prevent it. The addition of substances
during cooking increases the sodium content of a meal, not the method of cooking.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 183
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
35. A client has a history of hypothyroidism. Which laboratory value is the nurse most concerned
about?
a. Na+ 146 mEq/L
b. K+ 3.6 mEq/L
c. Ca2+ 8.2 mg/dL
d. Mg2+ 1.1 mEq/L
ANS: C
A common cause of hypocalcemia is hypothyroidism. The calcium value is low, correlating with
this condition. The sodium level is only slightly high, and hypothyroidism is not related to sodium
imbalances. The potassium level is normal. The magnesium level is low, but hypothyroidism can
cause hypermagnesemia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Analysis)
36. When taking the blood pressure of a very ill client, the nurse observes that the client’s hand
undergoes flexion contractions. Which intervention is most appropriate?
a. Administer isotonic intravenous fluids.
b. Remove the blood pressure cuff and give oxygen.
c. Ensure the client has a patent intravenous line.
d. Document the finding in the client’s chart.
ANS: C
Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and
tetany. Flexion contractions that occur during blood pressure measurement are indicative of
hypocalcemia and are referred to as a positive Trousseau’s sign. Client safety is a priority, and the
nurse must ensure that the client has a working intravenous line. Seizure precautions and
decreasing environmental stimuli are also important.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
37. A client has the following laboratory values: Ca2+ 8.7 mg/dL; K+ 4.2 mEq/L; Na+ 142 mEq/L.
Which intervention by the nurse is most appropriate?
a. Prepare to administer IV potassium chloride.
b. Ask the lab to redraw and rerun the tests.
c. Document findings and continue to assess.
d. Prepare to administer aluminum hydroxide.
ANS: D
The client’s calcium is low. Treatment for hypocalcemia includes calcium replacement,
administering drugs that increase calcium absorption, and giving medications to control bothersome
neuromuscular effects. Aluminum hydroxide helps the body absorb calcium. The client’s potassium
is normal, so giving potassium is not warranted. Asking the laboratory to rerun the tests will not
help the client’s problem, although if this seems contradictory to the client’s condition, it might be
an option. Documenting findings and performing ongoing assessments will not help the client’s
problem.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
38. A client has a history of hypocalcemia. What intervention is most important for the nurse to add
to this client’s care plan?
a. Push fluids to 2 L/day.
b. Strain all urine output.
c. Use nonslip footwear to get out of bed.
d. Position the client supine twice a day.
ANS: C
Clients with long-standing hypocalcemia have brittle bones that may fracture easily. Safety needs
are a priority. Having the client wear nonslip footwear to get out of bed can help prevent falls. The
other interventions would not provide safety for this client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Assessment)
39. Which client is at greatest risk for developing hypercalcemia?
a. Client taking furosemide (Lasix) for heart failure
b. Client with long-standing osteoarthritis
c. Woman who is pregnant with twins
d. Client with hyperparathyroidism
ANS: D
The parathyroid glands secrete parathyroid hormone. The actions of parathyroid hormone include
increasing intestinal absorption of calcium, decreasing renal excretion of calcium, and increasing
calcium resorption from the bones. All these actions increase the serum calcium level.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 13-10, p. 190
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
40. A client has a calcium level of 14 mg/dL. Which intervention is the priority?
a. Forcing fluids to 2 L/day
b. Placing the client on a cardiac monitor
c. Assessing for Chvostek’s sign every 2 hours
d. Administering IV calcium chloride
ANS: B
This client has hypercalcemia. Both forcing fluids and providing cardiac monitoring are
appropriate, but because calcium has significant cardiac effects, placing the client on a cardiac
monitor takes priority. Assessing for Chvostek’s sign and administering calcium would be
appropriate for the client with hypocalcemia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
41. A client is admitted with multiple fractures from a motor vehicle crash (MVC). Which of the
client’s previous or concurrent health problems is most likely to increase the client’s risk for
hypophosphatemia?
a. Chronic alcoholic pancreatitis
b. 50–pack-year smoking history
c. Prostate cancer history
d. Heart surgery 8 years ago
ANS: A
Chronic alcoholism leads to malnutrition. Malnutrition is a major contributing factor to the
development of hypophosphatemia. None of the other conditions contribute to hypophosphatemia.
DIF: Cognitive Level: Knowledge/Remembering REF: Table 13-11, p. 192
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
42. A client with hypophosphatemia is being discharged. Which activity demonstrated by the client
indicates that discharge teaching has been effective?
a. Assessing radial pulse rate and rhythm
b. Interspersing daily activities with periods of rest
c. Selecting foods high in phosphorus and low in calcium
d. Weighing himself or herself correctly at the same time each day
ANS: C
Chronic hypophosphatemia can be managed with nutrition therapy. The client needs to increase his
or her ingestion of phosphorus and to decrease ingestion of calcium because phosphorus and
calcium exist in the blood in a balanced inverse relationship.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Maintenance and Promotion (Self-Care)
MSC: Integrated Process: Nursing Process (Implementation)
43. The nurse observes that the handgrip of the client with hypophosphatemia has diminished in
strength since the last assessment 2 hours ago. What is the nurse’s primary intervention?
a. Document the finding and continue to assess.
b. Assess respiratory status immediately.
c. Request an order for a serum calcium level.
d. Administer a rapid bolus of intravenous phosphorus.
ANS: B
Decreased handgrip strength indicates worsening of hypophosphatemia and general muscle
weakness. Muscle weakness can impair respiratory effort and reduce gas exchange to the point that
the client becomes hypoxemic. IV phosphorus is given slowly to avoid rebound
hyperphosphatemia. Phosphorus and calcium exist in an inverse relationship, and the nurse might
want to know the calcium level, but this is less important than ensuring that the client has adequate
respiratory function. Simply documenting the finding without intervening would not help the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Evaluation)
MULTIPLE RESPONSE
1. Which ethnic groups should the nurse screen specifically for hypocalcemia? (Select all that
apply.)
a. Whites
b. Blacks
c. Asians
d. Hispanics
e. American Indians
ANS: B, C, E
Lactose intolerance can lead to hypocalcemia because people avoid milk and dairy products to
control their symptoms. Although anyone can have lactose intolerance, the incidence is between
75% and 90% among Asians, blacks, and American Indians.
DIF: Cognitive Level: Comprehension/Understanding
REF: Cultural Awareness Box, p. 188
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
Chapter 14: Assessment and Care of Patients with Acid-Base
Imbalances
Chapter 14: Assessment and Care of Patients with Acid-Base Imbalances
Test Bank
MULTIPLE CHOICE
1. In a client with less than the normal amount of bicarbonate in the blood and other extracellular
fluids, what response does the nurse anticipate?
a. Increased risk for acidosis
b. Decreased risk for acidosis
c. Increased risk for alkalosis
d. Decreased risk for alkalosis
ANS: A
Bicarbonate (H2CO3–) is a weak base with an overall negative charge. When hydrogen ions are
present in slight or mild excess (mild acidosis), bicarbonate can buffer or absorb the excess
hydrogen ions, reducing the hydrogen ion concentration and bringing the pH back up to normal. If
the total body bicarbonate concentration is low, especially in the blood, the action of buffering or
absorbing excess hydrogen ions is reduced, and the person is at increased risk for acidosis.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 202
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
2. Which response is an example of compensation for an acid-base imbalance?
a. Increase in the rate and depth of respirations when exercising
b. Increased urinary output when blood pressure increases during exercise
c. Increased thirst when spending time in an excessively dry environment
d. Increased release of acids from kidneys during exacerbation of chronic
obstructive pulmonary disease (COPD)
ANS: A
The respiratory system increases its activity by blowing off excess carbon dioxide. This occurs as a
result of the occurrence of lactic acidosis in skeletal muscle, when blood flow and oxygenation are
insufficient to meet the increased demand for oxygen (oxygen debt) created during increased
skeletal muscle metabolism. The other three options are not compensatory mechanisms for acidbase imbalances.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 200
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
3. When a client has an arterial blood pH of 7.48, which buffer action will bring the pH back to
normal?
a. Absorption of bicarbonate ions from the blood
b. Release of bicarbonate ions into the blood
c. Absorption of hydrogen ions from the blood
d. Release of hydrogen ions into the blood
ANS: D
Buffers can act as an acid (releasing a hydrogen ion) or as a base (absorbing a hydrogen ion) to
assist in keeping the pH and hydrogen ion concentration of body fluids within the normal range. An
arterial pH of 7.48 indicates a deficiency of hydrogen ions. This situation would cause buffers to
act like acids and release hydrogen ions into the blood.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 200
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
4. A client has moderate acidosis. Which assessment does the nurse perform first?
a. Take the client’s pulse and blood pressure, and analyze the
electrocardiogram (ECG) strip.
b. Assess respiratory rate and depth and work of breathing.
c. Perform assessments of musculoskeletal strength.
d. Determine whether the client is awake, alert, and oriented.
ANS: A
Priority assessments for the client with acidosis relate to the cardiovascular system. Acidosis can
lead to lethal cardiac dysrhythmias.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Assessment)
5. In the client with hypoventilation, which change in arterial blood gases does the nurse evaluate to
determine whether treatment measures are being effective?
a. Decreased arterial blood pH
b. Decreased arterial blood carbon dioxide
c. Increased arterial blood bicarbonate
d. Increased arterial blood oxygen
ANS: C
Because kidneys regulate pH by controlling bicarbonate concentration and the lungs regulate pH by
controlling carbon dioxide loss, loss of one function can be at least partially compensated for by the
other function. When pulmonary function is decreased, so that adequate amounts of carbon dioxide
are not excreted, the pH falls, stimulating the kidneys to reabsorb more bicarbonate to balance the
increased acid production.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Evaluation)
6. In a client 4 minutes post cardiac arrest, the nurse correlates the largest source of excess
hydrogen ions with which cause?
a. Excess renal retention of carbon dioxide due to hypoxia
b. Release of intracellular acids due to widespread tissue destruction
c. Anaerobic metabolism, leading to the buildup of lactic acid
d. Using fat as a fuel source, resulting in increased fat degradation
ANS: C
Glucose metabolism continues under anaerobic conditions to supply the body with chemical energy
(adenosine triphosphate [ATP]). However, this metabolism is incomplete, stopping at lactic acid
production instead of continuing into the Krebs’ cycle. This results in a large buildup of lactic acid,
which releases excessive amounts of hydrogen ions into the blood.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 202
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
7. A client has mild acidosis but after a day has not compensated for it. Which action by the nurse is
best?
a. Review the client’s daily hemoglobin and hematocrit.
b. Ask the laboratory to rerun today’s arterial blood gases.
c. Document the finding and notify the physician.
d. Apply 2 L of oxygen via nasal cannula.
ANS: A
Hemoglobin is part of the buffering system. Low hemoglobin affects acid-base balance by
decreasing the body’s ability to compensate for mild acidosis. Rerunning the specimen would take
time and might require another sample. The nurse may need to notify the physician but would need
more information to report, such as hemoglobin and hematocrit values. Adding 2 liters of oxygen
would not help the client as much as he or she would be helped if the cause of the refractory
acidosis was determined.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
8. A client has an arterial blood gas pH of 7.48. How does the nurse interpret this client’s acid-base
status?
a. An unknown acid-base balance status
b. A normal blood hydrogen ion concentration
c. A deficit in blood hydrogen ion concentration
d. An excess in blood hydrogen ion concentration
ANS: C
The pH is the negative log of the hydrogen ion concentration. The normal pH of arterial blood
ranges between 7.35 and 7.45. A pH of 7.48 indicates a decrease in the hydrogen ion concentration
(alkalosis).
DIF: Cognitive Level: Knowledge/Remembering REF: p. 198
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Evaluation)
9. The nurse reads in the medical record that a client has Kussmaul respirations. Which assessment
finding is consistent with this condition?
a. Deep, rapid respirations
b. Respirations with an irregular pattern
c. Shallow, grunting respirations
d. Use of accessory muscles when breathing
ANS: A
Kussmaul respirations are described as deep and rapid and are the body’s attempt to compensate for
acidosis by “blowing off” excess H+ in the form of carbon dioxide.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 205
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
10. The nurse monitors for which acid-base imbalance in a client who has hypoxemia?
a. Reduced carbon dioxide production leading to alkalosis
b. Reduced carbon dioxide retention leading to alkalosis
c. Excess carbon dioxide production leading to acidosis
d. Excess carbon dioxide retention leading to acidosis
ANS: C
Hypoxemia (lower than normal blood oxygen level) causes some organs, tissues, and cells to have
anaerobic metabolism. This situation leads to a buildup of carbon dioxide. Elevated levels of
carbon dioxide lead to an increase in blood hydrogen ion levels and acidosis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
Related to Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
11. A client has been placed on a ventilator. The physician has ordered that the ventilator be set to
deliver a respiratory rate set of 28 breaths/min. The nurse questions the order, citing concerns about
which acid-base problem?
a. Acid deficit: alkalosis
b. Base excess: alkalosis
c. Acid excess: acidosis
d. Base deficit: acidosis
ANS: A
A ventilator set at too high a ventilation rate and/or too high a tidal volume will cause the client to
lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Evaluation)
12. The nurse monitors for which acid-base problem in a client who is taking furosemide (Lasix) for
hypertension?
a. Acid excess secondary to respiratory acidosis
b. Acid deficit secondary to respiratory alkalosis
c. Acid excess secondary to metabolic acidosis
d. Acid deficit secondary to metabolic alkalosis
ANS: D
Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess
acid loss through the renal system. This situation is an acid deficit of metabolic origin.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Assessment)
13. The nurse expects to find renal compensation for an acid-base imbalance in which situation?
a. Mild to moderate dehydration in a middle-aged client who jogged for 2
hours
b. Acute asthma attack with wheezing of 6 hours’ duration in an older man
c. Food poisoning with vomiting for 12 hours in a middle-aged woman
d. Hypoxemia for 4 days from pneumonia in an adult woman
ANS: D
Renal compensation (change in excretion or reabsorption of hydrogen ions and bicarbonate ions)
for an acid-base imbalance is very potent and requires from many hours up to several days to begin.
It does not provide immediate compensation, nor does it respond to acute imbalances. For a person
who has been hypoxemic for several days, renal compensation with increased excretion of
hydrogen ions and increased reabsorption of bicarbonate would have been initiated.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 201
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
14. A client has moderate metabolic alkalosis. What is the priority intervention for the nurse?
a. Monitor daily laboratory values.
b. Assess the client’s muscle strength.
c. Determine the cause of the problem.
d. Teach the client preventive measures.
ANS: B
Although all options are viable nursing interventions, the priority is providing for client safety.
Clients with metabolic alkalosis have muscle weakness and thus are at risk for falling.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
15. A client has acute pancreatitis and a risk for acid-base imbalance. The nurse plans to assess for
which manifestation consistent with this condition?
a. Agitation
b. Kussmaul respirations
c. Seizures
d. Positive Chvostek’s sign
ANS: B
The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic
acidosis through underproduction of bicarbonate ions. Manifestations of acidosis include lethargy
and Kussmaul respirations. Agitation, seizures, and a positive Chvostek’s sign are manifestations of
the electrolyte imbalances that accompany alkalosis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
16. The nurse assesses for acidosis in the client with which assessment data?
a. Serum sodium level of 130 mEq per liter and peripheral edema
b. Serum sodium level of 144 mEq per liter and tachycardia
c. Serum potassium level of 6.5 mEq per liter and flaccid paralysis
d. Serum potassium level of 4.5 mEq per liter and hyperactive deep
tendon reflexes
ANS: C
When acidosis is present, the hydrogen ion concentration of the extracellular fluid (ECF) is
increased above normal. The physiologic action to reduce the ECF hydrogen ion concentration is to
move the hydrogen ions into the cells in exchange for potassium ions, thereby maintaining the
electroneutrality of the intracellular fluid. As a result, acidosis is accompanied by hyperkalemia,
which diminishes nerve and skeletal muscle excitability, causing flaccid paralysis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Alterations in Body
Systems) MSC: Integrated Process: Nursing Process (Assessment)
17. The hand grasps of a client with acidosis have diminished since the previous assessment 1 hour
ago. What action does the nurse take next?
a. Assess client’s rate, rhythm, and depth of respiration.
b. Measure the client’s pulse and blood pressure.
c. Document findings and continue to monitor.
d. Notify the physician as soon as possible.
ANS: A
Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle
weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to
hyperkalemia) but these would best be assessed with cardiac monitoring. Findings should be
documented, but simply continuing to monitor is not sufficient. Before notifying the physician, the
nurse needs to have more data to report.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
Related to Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
18. In evaluating the electrocardiogram (ECG) in a client with acidosis, the nurse correlates which
ECG change with effectiveness of therapy?
a. Small U-waves present after each complex
b. Heart rate decreased to 62 beats/min
c. T-waves present, normal height
d. P-wave preceding the QRS complex
ANS: C
Acidosis and accompanying hyperkalemia affect cardiac conduction, inducing tall T-waves,
widened QRS complexes, and prolonged PR intervals. When T-waves return to a height of less than
3 mm, acidosis and hyperkalemia are resolving.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Evaluation)
19. A client has the following arterial blood results: pH 7.12, HCO 3– 22 mEq/L, PCO2 65 mm Hg,
PO2 56 mm Hg. The nurse correlates these values with which clinical situation?
a. Diabetic ketoacidosis in a person with emphysema
b. Tracheal obstruction related to aspiration of a hot dog
c. Anxiety-induced hyperventilation in an adolescent
d. Diarrhea for 36 hours in an older, frail woman
ANS: B
Arterial blood gas values indicate that the client is in acidosis and has normal levels of bicarbonate,
suggesting that the problem is not metabolic. Arterial concentrations of oxygen and carbon dioxide
are abnormal, with low oxygen and high carbon dioxide levels. Thus, this client has respiratory
acidosis from inadequate gas exchange. The fact that the bicarbonate level is normal indicates that
this is an acute respiratory problem rather than a chronic problem, because no renal compensation
has occurred.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Analysis)
20. Which client does the nurse assess for potential metabolic acidosis?
a. Client admitted after collapsing during a marathon run
b. Young adult following a carbohydrate-free diet
c. Older adult with asthma who is on long-term steroid therapy
d. Older client on antacids for gastroesophageal reflux disease
ANS: B
One cause of acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a
diet increases the rate of fat catabolism and results in the formation of excessive ketoacids.
Dehydration is not directly associated with acid-base disorders. In the client with asthma, acid-base
status will be determined by a combination of depth of respirations and oxygen saturation.
Excessive intake of sodium bicarbonate may increase the risk of metabolic alkalosis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
21. The nurse interprets which arterial blood gas values as partially compensated metabolic
acidosis?
a. pH 7.28, HCO3– 19 mEq/L, PCO2 45 mm Hg, PO2 96 mm Hg
b. pH 7.45, HCO3– 22 mEq/L, PCO2 40 mm Hg, PO2 98 mm Hg
c. pH 7.32, HCO3– 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg
d. pH 7.48, HCO3– 28 mEq/L, PCO2 45 mm Hg, PO2 92 mm Hg
ANS: C
The pH is lower than normal, indicating mild acidosis. The acidosis is metabolic in origin, as
indicated by the normal arterial oxygen partial pressure and the low bicarbonate level. The
decreased carbon dioxide level indicates an increased respiratory rate, causing the carbon dioxide to
be blown off and bringing the pH closer to normal (but not completely normal). Thus, the
metabolic acidosis is only partially compensated for by the respiratory effort.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Assessment)
22. A client has just experienced a 90-second tonic-clonic seizure and has these arterial blood gas
values: pH 6.88, HCO3– 22 mEq/L, PCO2 60 mm Hg, PO2 50 mm Hg. Which intervention by the
nurse is most appropriate?
a. Apply oxygen by mask or nasal cannula.
b. Apply a paper bag over the client’s nose and mouth.
c. Administer 50 mL of sodium bicarbonate intravenously.
d. Administer 50 mL of 20% glucose and 20 units of regular insulin.
ANS: A
The client has experienced a combination of metabolic and acute respiratory acidosis through
heavy skeletal muscle contractions and no gas exchange. When the seizures have stopped and the
client can breathe again, the fastest way to return to acid-base balance is to administer oxygen.
Sodium bicarbonate should not be administered because the client’s arterial bicarbonate level is
normal. Applying a paper bag over the client’s nose and mouth would worsen the acidosis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
23. A client who was malnourished is being discharged. The nurse evaluates that teaching to
decrease risk for the development of metabolic acidosis has been effective when the client states, “I
will:
a. Increase my milk intake to at least three glasses daily.”
b. Be sure to eat three well-balanced meals and a snack daily.”
c. Avoid taking pain medication and antihistamines together.”
d. Not add salt to food when cooking or during meals.”
ANS: B
Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells to
switch to using fats for fuel and by creating ketoacids as a by-product of excessive fat metabolism.
Eating sufficient calories from all food groups helps reduce this risk.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
24. The nurse assesses the client with which condition most carefully for the risk of developing
acute respiratory acidosis?
a. Allergic rhinitis and sinusitis on sulfa antibiotics
b. Type 1 diabetes and urinary tract infection
c. Emphysema and undergoing nasogastric (NG) tube suctioning
d. On patient-controlled analgesia after abdominal surgery
ANS: D
Respiratory acidosis often occurs as the result of underventilation. The client who is taking
narcotics, especially IV narcotics, is at risk for respiratory depression. The client may also be
breathing more shallowly than usual to prevent pain. This gives the client two risk factors for
developing hypoventilation and subsequent respiratory acidosis. None of the other clients are at risk
for ineffective ventilation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
Related to Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
25. The nurse correlates which condition with the following arterial blood gas values: pH 7.48,
HCO3– 22 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg?
a. Diarrhea and vomiting for 36 hours
b. Anxiety-induced hyperventilation
c. Chronic obstructive pulmonary disease
d. Diabetic ketoacidosis and emphysema
ANS: B
The elevated pH indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial
pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to
hyperventilation. Diarrhea and vomiting would cause metabolic alterations, COPD would lead to
respiratory acidosis, and the person with emphysema most likely would have combined metabolic
acidosis on top of a mild, chronic respiratory acidosis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Assessment)
26. A postoperative client received six units of packed red blood cells (PRBCs) for intraoperative
blood loss. The nurse monitors the client for which acid-base imbalance?
a. Metabolic alkalosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Respiratory acidosis
ANS: A
Citrate is a substance used as a preservative in blood products. It is not only a base, it is also a
precursor for bicarbonate (bicarbonate can be formed from citrate). Rapid administration of blood
products can cause metabolic alkalosis by infusing large amounts of citrate intravenously. Although
this problem is more likely to occur with administration of whole blood or blood plasma, multiple
transfusions with packed red cells can also result in excessive amounts of citrate being received by
the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Assessment)
27. A client has severe metabolic alkalosis. Which nursing diagnosis does the nurse choose as the
client’s priority problem?
a. Fluid volume excess related to reduced kidney function
b. Fluid volume deficit related to increased insensitive fluid loss through
lungs
c. Risk for impaired skin integrity related to accompanying peripheral
edema
d. Risk for injury related to increased neuronal sensitivity from
hypocalcemia
ANS: D
Metabolic alkalosis is manifested by a high pH, which causes serum calcium to bind and reduces
the concentration of free calcium. This relative hypocalcemia increases the risk for increased
neuromuscular activity, including tetany and seizures.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Diagnosis)
28. A client has respiratory acidosis. The nurse evaluates that treatment is being effective with
which arterial blood gas values?
a. pH 7.28, HCO3– 12 mEq/L, PCO2 45 mm Hg, PO2 96 mm Hg
b. pH 7.32, HCO3– 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg
c. pH 7.35, HCO3– 36 mEq/L, PCO2 65 mm Hg, PO2 78 mm Hg
d. pH 7.48, HCO3– 12 mEq/L, PCO2 35 mm Hg, PO2 85 mm Hg
ANS: C
A pH of 7.35 is normal, indicating acid-base balance (fully compensated). A respiratory problem
with carbon dioxide retention and inadequate gas exchange is apparent from the high PCO 2 and the
low PO2. The bicarbonate level is greatly elevated, indicating renal synthesis and reabsorption of
HCO3–, a powerful acid-base compensatory mechanism. Thus, the amount of bicarbonate (base) in
the blood adequately compensates for the increased carbon dioxide level, so that the pH is normal,
although no other arterial blood gas value is normal.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Evaluation)
29. The nurse monitors the client with which condition most carefully for metabolic alkalosis?
a. A critical illness receiving total parenteral nutrition
b. Type 1 diabetes on once-daily insulin therapy
c. Metastatic breast cancer on continuous IV morphine
d. Asthma using an adrenergic agonist inhaler
ANS: A
The IV fluid mixture for total parenteral nutrition (TPN) has an overall basic pH. One common
substance in TPN is lactate, which is rapidly converted in the body to bicarbonate. In addition, the
TPN mixture is often administered as a continuous slow infusion. A client with diabetes would be
at higher risk of metabolic acidosis. The client on IV morphine is more at risk for respiratory
acidosis, as is the client with asthma.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Assessment)
30. A client is in the emergency department after an overdose of an unknown substance. Which
assessment findings does the nurse correlate with possible salicylate poisoning?
a. Increased deep tendon reflexes
b. Increased rate and depth of respiration
c. Decreased capillary refill
d. Decreased intestinal motility and paralytic ileus
ANS: B
Salicylates are acidic, and salicylate poisoning increases the rate and depth of ventilation in two
ways. First, salicylates directly stimulate the respiratory centers. Second, by causing a metabolic
acidosis and reducing the pH of the blood, the respiratory centers are stimulated to compensate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
31. A client has a prolonged fever. For which acid-base imbalance does the nurse assess the client
further?
a. Metabolic acidosis from excess bicarbonate production
b. Metabolic alkalosis from dehydration and hyperkalemia
c. Metabolic acidosis from increased production of hydrogen ions
d. Respiratory alkalosis from impaired gas exchange
ANS: C
Increased body temperature is associated with hypermetabolism and increases the rate at which
hydrogen ions are produced. Increased bicarbonate production would lead to metabolic alkalosis.
Hyperkalemia leads to metabolic acidosis. Having a fever would not directly lead to gas exchange
problems.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
32. The nurse is providing discharge teaching. Which statement by the client indicates the need for
further teaching regarding increased risk for metabolic alkalosis?
a. “I don’t drink milk because it gives me gas and diarrhea.”
b. “I have been taking digoxin every day for the last 15 years.”
c. “I take sodium bicarbonate after every meal to prevent heartburn.”
d. “In hot weather, I sweat so much that I drink six glasses of water each
day.”
ANS: C
Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause a
metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to increased risk
of metabolic alkalosis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
33. A client with chronic respiratory acidosis is receiving oxygen by nasal cannula at 6 L/min. The
client’s respiratory rate is 8 breaths/min. Which action by the nurse is the priority?
a. Notify the Rapid Response Team and prepare for intubation.
b. Change the nasal cannula to a mask and reassess in 10 minutes.
c. Place the client in Fowler’s position if he or she is able to tolerate it.
d. Decrease the flow rate of oxygen to 2 to 4 L/min, and reassess.
ANS: A
The primary trigger for respiration in a client with chronic respiratory acidosis is a decreased
arterial oxygen level (hypoxic drive). Oxygen therapy can inhibit respiratory efforts in this case,
eventually causing respiratory arrest and death. The nurse could decrease the oxygen flow rate;
eventually, this might improve the client’s respiratory rate, but the priority action would be to call
the Rapid Response Team whenever a client with chronic carbon dioxide retention has a respiratory
rate less than 10. Changing the cannula to a mask does nothing to improve the client’s hypoxic
drive, nor would it address the client’s most pressing need. Positioning will not help the client
breathe at a normal rate nor maintain client safety.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
34. A client is being discharged from the emergency department with several broken ribs. For which
acid-base imbalance does the nurse provide discharge teaching?
a. Respiratory alkalosis from anxiety and hyperventilation
b. Respiratory acidosis from inadequate ventilation
c. Metabolic acidosis from calcium loss from broken bones
d. Metabolic alkalosis from taking base-containing analgesics
ANS: B
Pain from broken ribs often causes the client to breathe more shallowly to avoid moving his or her
ribs and increasing pain. If respiration is shallow enough, ventilation is inadequate, leading to poor
gas exchange and respiratory acidosis. Hyperventilation would more likely cause respiratory
alkalosis. The calcium loss from broken ribs probably would not affect acid-base balance. Taking
analgesics as prescribed for pain probably also would not affect acid-base balance.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Implementation)
35. The nurse prepares to administer bicarbonate intravenously to the client with which clinical
manifestations?
a. pH 7.28, HCO3– 22 mEq/L, PCO2 52 mm Hg, PO2 82 mm Hg secondary
to an acute asthma attack
b. pH 7.28, HCO3– 16 mEq/L, PCO2 45 mm Hg, PO2 98 mm Hg secondary
to excessive diarrhea
c. Client with chronic emphysema and bronchitis who has the following
arterial blood gases: pH 7.30, HCO 3– 30 mEq/L, PCO2 60 mm Hg, PO2
72 mm Hg secondary to chronic bronchitis and emphysema
d. pH 7.31, HCO3– 20 mEq/L, PCO2 34 mm Hg, PO2 96 mm Hg secondary
to a urinary tract infection and type 2 diabetes
ANS: B
The only client who has lower than normal bicarbonate levels is the client with diarrhea. This
deficit is most likely the result of an actual bicarbonate loss, and bicarbonate should be replaced to
help return this client’s acid-base balance to normal. Giving bicarbonate to any of the other clients
listed would be adding too much base and would risk the development of alkalosis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes)
MSC: Integrated Process: Nursing Process (Implementation)
36. A client has metabolic alkalosis. Which laboratory results is the nurse most likely to assess as
consistent with this condition?
a. Na+ 134 mg/dL
b. Mg2+ 1.5 mg/dL
c. K+ 3.1 mEq/L
d. Ca2+ 11.5 mg/dL
ANS: C
Both potassium and hydrogen ions carry or express an overall positive charge (cations). Body fluids
maintain electroneutrality by keeping the number of positive ions matched with an equal number of
negative ions (anions). A compensation of alkalosis is the movement of hydrogen ions into cells
inside the blood and other extracellular fluids. To prevent the blood from expressing too many
positive charges, another positive ion must leave the blood and enter the cells. Potassium is the
positive ion that usually is exchanged for a hydrogen ion. Thus, a relative hypokalemia usually
accompanies alkalosis as extracellular potassium ions move into cells in exchange for intracellular
hydrogen ions entering the extracellular fluid.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
37. A client is admitted with mixed respiratory and metabolic acidosis secondary to bronchitis and
diabetic ketoacidosis. The nurse evaluates that teaching about the client’s confusion was effective
when a family member makes which statement?
a. “It is too early to tell if the ketoacidosis will cause permanent changes.”
b. “Her memory will improve, but loss of some brain cells has occurred.”
c. “The confusion should clear when oxygen and electrolyte levels are
normal.”
d. “The confusion should clear when blood glucose levels and other
laboratory tests are normal.”
ANS: C
The pH abnormality alone is not responsible for the confusion. Most of the confusion is caused by
hypoxia in combination with electrolyte imbalances that accompany severe combined acidosis.
None of the other options address the client’s hypoxia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Teaching/Learning
38. A client is being discharged and continues to be at risk for developing metabolic alkalosis.
Which statement by the client indicates to the nurse that teaching has been effective?
a. “I will avoid excess use of antacids.”
b. “I’ll drink at least three glasses of milk daily.”
c. “I’ll avoid medications containing aspirin.”
d. “I will not add salt to my food during meals.”
ANS: A
Many antacids contain bicarbonate or calcium carbonate, both of which (when taken in excess) can
increase the bicarbonate content of the blood and other extracellular fluids, increasing the risk for
alkalosis even further. None of the other options address a risk factor for developing metabolic
alkalosis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Assessment)
39. In clients with any type of acid-base imbalance, the nurse places the priority on monitoring
which electrolyte?
a. Sodium
b. Calcium
c. Potassium
d. Magnesium
ANS: C
Any type of acid-base imbalance usually alters the blood potassium level. Both potassium and
hydrogen ions carry or express an overall positive charge (cations). Body fluids maintain
electroneutrality by keeping the number of positive ions matched with an equal number of negative
ions (anions). In acidosis, hydrogen ions enter cells in exchange for potassium ions. Thus, a relative
hyperkalemia accompanies acidosis. In alkalosis, hydrogen ions leave the cells and enter the blood
in exchange for potassium ions. Thus, a relative hypokalemia usually accompanies alkalosis as
extracellular potassium ions move into cells in exchange for intracellular hydrogen ions entering
the extracellular fluid. The normal potassium level of the blood has a narrow range (3.5 to 5.0
mEq/L). When blood potassium levels are too high, lethal cardiac dysrhythmias may occur. When
blood potassium levels are too low, skeletal muscle weakness and respiratory failure may occur.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
40. A client has acidosis. Which laboratory finding is of greatest concern to the nurse?
a. Sodium 154 mEq/L
b. Potassium 5.9 mEq/L
c. Calcium 8.9 mg/dL
d. Magnesium 2.1 mg/dL
ANS: B
In the client with acidosis, intracellular buffering leads to entry of hydrogen ions (H +) into cells,
and in return potassium leaves the cell. This leads to elevated serum potassium levels. Many severe
problems with acidosis are due to the accompanying hyperkalemia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Assessment)
41. A client has the following arterial blood gases: pH 7.30, HCO 3– 17 mEq/L, PCO2 25 mm Hg,
PO2 98 mm Hg. Which intervention by the nurse is most appropriate?
a. Prepare to give intravenous sodium bicarbonate.
b. Document the findings and continue to assess.
c. Assist the physician in determining the cause.
d. Administer oxygen at 2 L per nasal cannula.
ANS: C
The client has a partially compensated metabolic acidosis. Interventions are aimed at reducing or
eliminating the cause. The nurse needs to assist in determining the cause so that proper
interventions can be initiated. Sodium bicarbonate is rarely used for acidosis unless the pH is life
threatening, or for specific causes of acidosis wherein bicarbonate deficit is known to be the
problem. Simply documenting the findings will not help the client. Because the client’s PO 2 is 98
mm Hg, oxygen therapy is not indicated on the basis of these arterial blood gases.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
42. A client has the following arterial blood gases (ABGs): pH 7.30, HCO 3– 22 mEq/L, PCO2 55
mm Hg, PO2 86 mm Hg. Which intervention by the nurse takes priority?
a. Assessing the airway
b. Administering bronchodilators
c. Administering mucolytics
d. Providing oxygen
ANS: A
All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs.
However, the priority is assessing and maintaining an airway. Without a patent airway, other
interventions will not be helpful.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
43. A client has been NPO after a colectomy with nasogastric (NG) suction in place. On assessment,
the nurse finds the client reporting cramps in the calves. Which action by the nurse is most
appropriate?
a. Document findings and notify the physician.
b. Stop suction and request that the laboratory draw arterial blood gases.
c. Prepare to administer lorazepam (Ativan).
d. Raise the siderails and notify the physician.
ANS: D
The client has a metabolic alkalosis probably caused by prolonged suctioning. The client also is
experiencing tetany, caused by the accompanying hypocalcemia, and is at risk for seizures. The
priority is to maintain the client’s safety; this includes raising the siderails and then notifying the
physician. Documentation is important but not as important as providing safety. The nurse would
not stop the suction without an order. The client may need lorazepam if he or she has seizures, but
this is not the first action the nurse would perform.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
MULTIPLE RESPONSE
1. In the client with alkalosis, the nurse assesses for which clinical manifestations? (Select all that
apply.)
a. Positive Chvostek’s sign
b. Positive Trousseau’s sign
c. Hyporeflexia
d. Bradycardia
e. Elevated blood pressure
f.
Elevated urinary output
ANS: A, B, D
The client with alkalosis demonstrates signs of hypocalcemia and decreased heart rate. Many
symptoms are the result of low calcium levels (hypocalcemia) and low potassium levels
(hypokalemia), which usually occur with alkalosis. These problems change the function of the
nervous, neuromuscular, cardiac, and respiratory systems.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 208
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
Chapter 15: Infusion Therapy
Chapter 15: Infusion Therapy
Test Bank
MULTIPLE CHOICE
1. Before the administration of intravenous fluid, it is most important for the nurse to obtain which
information from the health care provider’s orders?
a. Intravenous catheter size
b. Osmolarity of the solution
c. Vein to be used for therapy
d. Specific type of IV fluid
ANS: D
An order for infusion therapy must contain the following to be complete: specific type of fluid, rate
of administration, and drugs added to the solution. Osmolarity of the solution is not necessary
because it is incorporated into the specific type of fluid. It is the nurse’s independent decision about
the most appropriate vein to cannulate and the catheter size to use.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 212
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Error
Prevention) MSC: Integrated Process: Nursing Process (Assessment)
2. Which IV order does the nurse question?
a. Flush Groshong catheter with 10 mL normal saline every 8 hours.
b. Infuse 20 mEq potassium chloride in 1000 mL D 5W at 50 mL/hr.
c. Infuse 500 mL normal saline over 1 hour.
d. Infuse 0.9% normal saline at keep vein open (KVO) rate.
ANS: D
To be complete, IV orders for infusion fluids should specify the rate of infusion. This order does
not specify the rate of infusion and is not considered complete.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Error
Prevention) MSC: Integrated Process: Nursing Process (Analysis)
3. Which infusion device does the nurse select for the older adult client with a medical diagnosis of
“dehydration”?
a. Cassette pump
b. Elastomeric balloons
c. Volumetric controller
d. Syringe pump
ANS: A
An older adult client who has dehydration will require a large fluid volume that is accurately
measured by using a cassette pump during the infusion. Volumetric controllers count drops for
administered volume and are inherently inaccurate because of variation in drop size. A syringe
pump is accurate but not appropriate for a large volume. Elastomeric balloons are used to deliver
intermittent medications.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Error
Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
4. A nursing administrator is concerned about the incidence of complications related to IV therapy,
including bloodstream infection. Which action by the administrator would have the biggest impact
on decreasing complications?
a. Investigate initiating a dedicated IV team.
b. Require inservice education for all RNs.
c. Limit IV starts to the most experienced nurses.
d. Perform quality control testing on skin preparation products.
ANS: A
The Centers for Disease Control and Prevention (CDC) recommends having a dedicated IV team to
reduce complications, save money, and improve client satisfaction and outcomes. In-service
education would always be helpful, but it would not have the same outcomes as an IV team.
Limiting IV starts to the most experienced nurses does not allow newer nurses to gain this
expertise. The quality of skin preparation products is only one aspect of IV insertion that could
contribute to infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
5. The nurse wants to find written standards for IV therapy. The nursing manager suggests that the
nurse investigate publications from which resource?
a. IV Therapy Nursing Society
b. Infusion Nurses Society
c. Nurse’s State Board of Nursing
d. Hospital’s IV solutions vendor
ANS: B
The Infusion Nurses Society publishes guidelines and standards related to IV therapy and offers a
national certification examination. The State Board of Nursing publishes legal information related
to nursing practice, and the solutions vendor would have written information pertaining only to
specific products. The IV Therapy Nursing Society does not exist, and the other organizations listed
do not provide standards and guidelines related to IV therapy.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 211
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of
Equipment)
MSC: Integrated Process: Nursing Process (Implementation)
6. The RN assigned a new nurse to a client who was receiving chemotherapy through an
intravenous extension set attached to a Huber needle. Which information about disconnecting the
Huber needle is most important for the RN to provide to the new nurse?
a. “Apply topical anesthetic cream to the area after discontinuing the
system.”
b. “Be aware of a rebound effect when discontinuing the system.”
c. “Be sure to flush the system with saline after removing the Huber
needle.”
d. “Place pressure over the site to prevent bleeding.”
ANS: B
Huber needles are used to access implanted ports placed under the skin. Because the dense septum
holds tightly to the needle, a rebound can occur when it is pulled from the septum, often resulting in
needle stick injury to the nurse. Topical anesthetic cream can be used when accessing the system.
Flushing is carried out when the system is accessed and once monthly. Because the implanted port
is not being removed, there is no need for a pressure dressing.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
7. After discontinuing a nontunneled, percutaneous central catheter, it is most important for the
nurse to record which information?
a. Application of a sterile dressing
b. Length of the catheter
c. Occurrence of venospasms
d. Type of ointment used to seal the tract
ANS: B
After removal of a catheter, measure the catheter length and compare it with the length documented
on insertion. If the entire length has not been removed, the nurse should contact the physician
immediately because some of the catheter may still be in the client’s vein.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
8. When assessing the client’s peripheral IV site, the nurse observes a streak of red along the vein
path and palpates a 4-cm venous cord. What is the most accurate documentation of this finding?
a. Grade 3 phlebitis at IV site
b. Infection at IV site
c. Thrombosed area at IV site
d. Infiltration at IV site
ANS: A
The presence of a red streak and palpable cord indicates grade 3 phlebitis. No information in the
description indicates that infection, infiltration, or thrombosis is present.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 15-6, p. 233
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Assessment)
9. What information is most important to teach the client going home with a peripherally inserted
central catheter (PICC) line?
a. “Avoid carrying your grandchild with the arm that has the IV.”
b. “Be sure to place the arm with the IV in a sling during the day.”
c. “Flush the IV line with normal saline daily.”
d. “You can use the arm with the IV for most of the activities of daily
living.”
ANS: A
A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client considerable
freedom of movement. Clients can participate in most activities of daily living; however, heavy
lifting can dislodge the catheter or occlude the lumen. Although it is important to keep the insertion
site and tubing dry, the client can shower. The device is flushed with heparin.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
10. A client is to receive 10 days of antibiotic therapy for urosepsis. The nurse plans to insert which
type of intravenous catheter?
a. Hickman
b. Midline
c. Nontunneled central
d. Short peripheral
ANS: B
Midline catheters are used for therapies lasting from 1 to 4 weeks. Short peripheral catheters can be
inserted by the nurse for use with antibiotic therapy, but they can stay in only for up to 96 hours. If
the length of IV therapy is longer than 6 days, a midline catheter should be chosen. Nontunneled
central catheters and Hickman catheters are inserted by a physician.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 215
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
11. A client is admitted to the hospital for excessive nausea and vomiting, and a blood pressure of
90/50 mm Hg. A catheter of which gauge is most appropriate for the nurse to choose for this
client’s peripheral IV?
a. 24
b. 22
c. 20
d. 18
ANS: C
The nurse selects the access device most appropriate for the designated purpose. In this case,
because a large amount of fluid will be needed as a result of excessive fluid loss, the appropriate
needle is the 20-gauge catheter IV, because this is the most commonly used size in adults and it can
be used for all fluids. The 22- and 24-gauge catheters will have a slower rate of flow, which may
not be desirable with excessive fluid losses and low blood pressure. The 18-gauge catheter allows
rapid flow of IV fluids. However, it requires a large vein and is more prone to irritation to the vein
wall.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
12. To prevent infection when infusing an intermittent “piggyback” line, which intervention does
the nurse implement?
a. Backpriming the secondary container from the primary line
b. Detaching and capping the secondary line after use
c. Using a new secondary container with each drug infused
d. Using sterile gloves when administering medication
ANS: A
The backpriming method allows multiple drugs to be infused through the same secondary set. This
method allows the primary and secondary sets to remain connected together as an infusion system
and allows the nurse to adhere to the Infusion Nurses Society (INS) standards of practice. The
client is at increased risk for infection whenever the catheter is disconnected from the tubing.
Sterile gloves are not necessary for IV administration of medication.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
13. The nurse finishes administering an intermittent medication through a Groshong catheter. What
is the nurse’s next action?
a. Clamping the catheter
b. Flushing the line with saline
c. Flushing with heparin
d. Removing the access needle
ANS: B
The Groshong catheter is a type of midline catheter. After intermittent use, the catheter is to be
flushed with saline. The manufacturer’s instructions state that the catheter should not be clamped to
maintain the integrity of the catheter valve. If a heparin flush is ordered, it is given after the catheter
has been flushed with saline. The access needle is used for implanted ports.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
14. The nurse is assessing several clients receiving intravenous therapy. Which client situation
requires immediate intervention?
a. Completion of an intermittent medication into a Groshong catheter
b. Physician’s order to discontinue a peripheral intravenous catheter
c. Nonaccessed implanted port placed 1 month ago without problem
d. Peripheral IV catheter dated 5 days ago used for once-daily antibiotics
ANS: A
A Groshong catheter is a peripherally inserted catheter that needs to be flushed with saline after
intermittent use. Peripheral IV catheters should be discontinued after 4 days, so this one should be
changed; however, this is not the priority. An order to discontinue the peripheral catheter requires
intervention, but flushing of the Groshong catheter is more of an immediate intervention to prevent
clotting of the catheter. A nonaccessed implanted port site needs to be assessed, but this is not an
immediate intervention.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
15. In examining a peripheral IV site, the nurse observes a red streak along the length of the vein,
and the vein feels hard and cordlike. What action by the nurse takes priority?
a. Applying continuous heat
b. Continuing to monitor site
c. Elevating the extremity
d. Removing the catheter
ANS: D
The clinical manifestations described are those associated with phlebitis. Phlebitis is an
inflammation of the vein. Its presence in a vein being used for IV therapy may be caused by
mechanical forces associated with the IV device, or by chemical factors related to the composition
and osmolarity of the drug solution. The key manifestation is that symptoms are directly associated
with the vein, and the catheter must be removed. Warm compresses can be applied for 20 minutes
four times daily after the catheter is removed. The site needs to be monitored after the catheter is
removed. The arm is not swollen. Therefore, elevation of the extremity is not a correct option.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
16. When an IV pump alarms because of pressure, what action does the nurse take first?
a. Check for kinking of the catheter.
b. Flush the catheter with a thrombolytic enzyme.
c. Get a new infusion pump.
d. Remove the IV catheter.
ANS: A
Fluid flow through the infusion system requires that pressure on the external side be greater than
pressure at the catheter tip. Fluid flow can be slowed for many reasons. A common reason, and one
that is easy to correct, is a kinked catheter. If this is not the cause of the pressure alarm, the nurse
may have to ascertain whether a clot has formed inside the catheter lumen, or if the pump is no
longer functional.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
17. The nurse is caring for four clients receiving IV therapy. Which client does the nurse assess
first?
a. Client with a newly inserted peripherally inserted central catheter
(PICC) line waiting for x-ray
b. Client with a peripheral catheter for intermittent infusions
c. Older adult client with a nonaccessed implanted port
d. Older adult client with normal saline infusion
ANS: D
Older adults are more prone to fluid overload and resulting congestive heart failure. Because this
client is receiving continuous IV fluid, he or she is at risk for fluid overload and needs to be
assessed. All other clients would need to be assessed for complications of IV catheters. However,
they do not need immediate assessment.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Analysis)
18. A client who is having a tunneled central venous catheter inserted begins to report chest pain
and difficulty breathing. What action does the nurse take first?
a. Administer the PRN pain medication.
b. Prepare to assist with chest tube insertion.
c. Place a sterile dressing over the IV site.
d. Place the client in the Trendelenburg position.
ANS: B
An insertion-related complication of central venous catheters is a pneumothorax. Signs and
symptoms of a pneumothorax include chest pain and dyspnea. Treatment includes removing the
catheter, administering oxygen, and placing a chest tube. Pain is caused by the pneumothorax,
which must be taken care of with a chest tube insertion. Use of a sterile dressing and placement of
the client in a Trendelenburg position are not indicated for the primary problem of a pneumothorax.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
19. A client who has just had an IV started in the right cephalic vein tells the nurse that the wrist and
the hand below the IV site feel like “pins and needles.” Which action by the nurse is best?
a. Document the finding and continue to monitor the IV site.
b. Check for the presence of a strong blood return.
c. Discontinue the IV and restart it at another site.
d. Elevate the extremity above the level of the heart.
ANS: C
The sensation that the client has described is related to the IV needle touching the nerve or possibly
transecting the nerve. This problem can lead to loss of function and the potential for permanent
disability in the distal extremity. It is considered an emergency and the IV must be discontinued.
Continuing just to monitor the IV site may lead to loss of function. The presence of blood return
does not indicate absence of nerve damage. Elevation of the affected extremity does not ensure that
the IV catheter has moved away from the nerve.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
20. The home care nurse is about to administer intravenous medication to the client and reads in the
chart that the peripherally inserted central catheter (PICC) line in the client’s left arm has been in
place for 4 weeks. The IV is patent, with a good blood return. The site is clean and free from
manifestations of infiltration, irritation, and infection. Which action by the nurse is most
appropriate?
a. Notify the physician.
b. Administer the prescribed medication.
c. Discontinue the PICC line.
d. Switch the medication to the oral route.
ANS: B
A PICC line that is functioning well without inflammation or infection may remain in place for
months or even years. Because the line shows no signs of complications, it is permissible to
administer the IV antibiotic. The physician does not have to be called to have the IV route changed
to an oral route.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
21. Which assessment finding for a client with a peripherally inserted central catheter (PICC) line
requires immediate attention?
a. Initial dressing over site is 3 days old.
b. Line has been in for 4 weeks.
c. A securement device is absent.
d. Upper extremity swelling is noted.
ANS: D
Upper extremity swelling could indicate infiltration, and the PICC line will need to be removed.
The initial dressing over the PICC site should be changed within 24 hours. This does not require
immediate attention, but the swelling does. The dwell time for PICC lines can be months or even
years. Securement devices are being used more often now to secure the catheter in place and
prevent complications such as phlebitis and infiltration. The IV should have one, but this does not
take priority over the client whose arm is swollen.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Unexpected Response to
Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
22. A nurse is changing the administration set on a client’s central venous catheter. Which
intervention is most important for the nurse to complete?
a. Have the client hold his breath during the set change.
b. Keep the slide clamp on the catheter extension open.
c. Position the client in a high Fowler’s position.
d. Position in the client in a semi-Fowler’s position.
ANS: A
An air embolus is less likely to form if the exit site is lower than the level of the heart, and if
pressure in the thoracic cavity is greater when the disconnection occurs. Having the client perform
the Valsalva maneuver and maintain it during disconnection and reconnection helps maintain higher
intrathoracic pressure. The slide clamp on the catheter extension should be kept clamped. The client
should be placed in the flat position when administration sets are changed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
23. When assessing a client’s peripheral IV site, the nurse notices edema and tenderness above the
site. What action does the nurse take first?
a. Apply cold compresses to the IV site.
b. Elevate the extremity on a pillow.
c. Flush the catheter.
d. Stop the infusion of IV fluids.
ANS: D
Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of
infiltration include edema and tenderness above the site. The nurse should stop the infusion and
remove the catheter. Cold compresses and elevation of the extremity can be done after the catheter
is discontinued to increase client comfort. Alternatively, warm compresses may be prescribed by
institutional policy and may help speed circulation to the area.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Unexpected Response to
Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
24. What action does the nurse take to prevent infection in the older adult receiving IV therapy?
a. Applying skin protectant before applying the dressing
b. Avoiding the use of alcohol pads when removing tape
c. Shaving the skin before attempting the venipuncture
d. Using maximum friction to cleanse the skin
ANS: A
The skin of an older adult may be more delicate and compromised. Avoidance of a disruption in
skin integrity lessens the chance of an infection occurring with an IV catheter. A barrier applied to
the skin before the IV dressing is placed helps maintain skin integrity. Using alcohol pads makes it
easier to remove tape and avoid skin tears. The skin should never be shaved before venipuncture
because micro-abrasions may occur, and these can lead to infection. Excessive friction may damage
fragile skin and compromise skin integrity.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
25. The nurse is caring for a client who is receiving an epidural infusion for pain management.
Which action has the highest priority?
a. Assessing the respiratory rate
b. Changing the dressing over the site
c. Using various pain management therapies
d. Weaning the pain medication
ANS: A
Complications from an epidural infusion can be caused by the type of medication being infused, or
they can be related to the catheter. When used for pain management, the client needs to be assessed
for level of alertness, respiratory status, and itching. Dressings are not routinely changed because
the catheter is used for only short periods. Using other pain management therapies and weaning the
pain medication are important, but monitoring respiratory status has the highest priority in the
nursing care of this client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
26. The nurse is caring for a client with a radial arterial catheter. Which assessment takes priority?
a. Amount of pressure in fluid container
b. Date of catheter tubing change
c. Checking for heparin in infusion container
d. Presence of an ulnar pulse
ANS: D
An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased
perfusion to the extremity. Assessment of ulnar pulse is one way to assess circulation to the arm in
which the catheter is located. The nurse would note that there is enough pressure in the fluid
container to keep the system flushed, and would check to see whether the catheter tubing needs to
be changed. However, these are not assessments of greatest concern. Because of heparin-induced
thrombocytopenia, heparin is not used in most institutions for an arterial catheter.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
27. Five days after the start of intraperitoneal therapy, the client reports abdominal pain and “feeling
warm.” The nurse prepares to assess the client further for evidence of which condition?
a. Allergic reaction
b. Bowel obstruction
c. Catheter lumen occlusion
d. Infection
ANS: D
Fever, abdominal pain, abdominal rigidity, and rebound tenderness may be present in the client who
has peritonitis related to intraperitoneal therapy. Peritonitis is preventable by using strict aseptic
technique in handling all equipment and infusion supplies. An allergic reaction would occur earlier
in the course of treatment. Bowel obstruction and catheter lumen occlusion can occur but would
present clinically in different ways.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Unexpected Response to
Therapies) MSC: Integrated Process: Nursing Process (Analysis)
28. Which client is the best candidate to receive hypodermoclysis for IV therapy?
a. Client requiring 4000 mL normal saline in 24 hours
b. Client with an extensive burn injury
c. Client with allergy to hyaluronidase
d. Client receiving pain management
ANS: D
Subcutaneous therapy (hypodermoclysis) involves the slow infusion of isotonic fluids into the
client’s subcutaneous tissue. Most often, it is used in hospices for pain management. It should not
be used if fluid replacement needs exceed 3000 mL/day. To be used, the client must have sufficient
areas of intact skin. Hyaluronidase is frequently used to help absorb the fluid during therapy.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 234
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Assessment)
29. The nurse is caring for a client with an intraosseous catheter placed in the leg 20 hours ago.
Which assessment is of greatest concern?
a. Length of time catheter is in place
b. Poor vascular access in upper extremities
c. Affected leg cool to touch
d. Site of intraosseous catheter placement
ANS: C
Compartment syndrome is a condition in which increased tissue perfusion in a confined anatomic
space causes decreased blood flow to the area. A cool extremity can signal the possibility of this
syndrome. All other distractors are important. However, the possible development of a
compartment syndrome requires immediate intervention because the client could require
amputation of the limb if the nurse does not pick up this perfusion problem.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 235
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Assessment)
30. A client is receiving an infusion of amiodarone (Cordarone), and the nurse notes that the client’s
arm has begun to blister around the IV site. This manifestation is consistent with which condition?
a. Extravasation
b. Infiltration
c. Infection
d. Phlebitis
ANS: A
Certain medications, including amiodarone, vancomycin, and ciprofloxacin, are venous irritants
that can cause tissue sloughing and necrosis if the IV infiltrates. The other three complications are
possible with any infusion and are not specific to amiodarone.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 211
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
31. A client is to receive a blood transfusion. Before the transfusion, what action by the nurse takes
priority?
a. Verifying the client’s identity
b. Ensuring that the blood bank has enough blood
c. Establishing a peripheral IV site
d. Feeding the client before starting the blood
ANS: A
Blood transfusion reactions can be devastating and can be prevented in large measure by positive
client identification. This is accomplished by two professionals using two different client
identifiers. Ensuring that the blood bank has enough blood would not be a normal nursing action,
and transfusions can be given without regard to food and drink.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Error
Prevention)
32. The nurse has just performed an IV start on a client. After the catheter has been threaded its full
length in the client’s vein, which action does the nurse perform next?
a. Secure the IV with a securement device or tape.
b. Dispose of the IV needle in the sharps container.
c. Engage the safety mechanism of the IV catheter
d. Note the date and time of the dressing application over the insertion
site.
ANS: C
A federal law enacted in 2000 requires health care facilities to use IV catheters with an engineered
safety mechanism to prevent needle sticks, which can be a source of contamination by bloodborne
pathogens. This priority action would help keep the nurse safe. Securing the IV and dating/timing
the dressing are also important actions, but engaging the safety mechanism comes first. After
engaging the safety mechanism, safely dispose of the needle in the sharps container.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of
Equipment)
33. A new nurse is preparing to start an IV on a client who is dehydrated and needs significant fluid
volume. The new nurse selects a butterfly needle for the infusion. What action by the supervising
nurse is best?
a. Help the new nurse with the procedure as needed.
b. Make sure the new nurse has the correct dressing.
c. Stop the new nurse and review the procedure in private.
d. Get the ultrasonic vein finder to help illuminate veins.
ANS: C
Winged (butterfly) needles generally are used for single doses of medications or for blood
sampling. They would not be used for large volumes of fluid or kept in for any length of time. The
other options do not acknowledge that the new nurse’s actions are incorrect and should be stopped.
DIF: Cognitive Level: Application/Applying or higher
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
34. A nursing student asks why midline catheters need strict sterile dressing changes when short
peripheral IVs do not. Which answer by the experienced nurse is most accurate?
a. “Because of the length of time they stay inserted.”
b. “They really don’t need strict sterile technique.”
c. “Because the tip is in the right atrium of the heart.”
d. “The tonicity of the fluids used promotes infection.”
ANS: A
Midline catheters can stay in place for as long as 4 weeks, so dressing changes must be done with
strict sterile technique to reduce the incidence of infection. The tip does not lie in the right atrium; it
resides no farther than the axillary vein. These catheters are used for a wide range of fluids and
medications, so tonicity would not be a factor in infection risk.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 216
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
35. A nurse is preparing to administer two drugs at the same time to a client via a double-lumen
midline catheter. Which action by the nurse is most important?
a. Check the two drugs for compatibility.
b. Compare the recommended infusion times.
c. Schedule any post-infusion lab draws.
d. Flush both lumens with saline before starting the infusion.
ANS: A
Because midline catheters dwell in the peripheral, not central, circulation, incompatible drugs
should not be given together via a double-lumen midline catheter because the flow rate of the blood
is not high enough to dilute the drugs before they mix. The other options are valid interventions
before starting the infusion, but they do not take precedence over determining whether the drugs
may be infused at the same time.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
36. A client has just had a central venous access line inserted. What is the nurse’s next action?
a. Beginning the prescribed infusion as soon as possible
b. Confirming placement of the catheter by x-ray
c. Having the infusion team start the IV therapy
d. Confirming that solutions are appropriate for the central line
ANS: B
A central venous access device, once placed, needs an x-ray confirmation of proper placement
before it is used. The bedside nurse would be responsible for beginning the infusion once
placement has been verified. Any IV solution can be given through a central line.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of
Equipment)
MSC: Integrated Process: Nursing Process (Implementation)
37. A new nurse is securing the connections on a new IV administration set connected to a
peripherally inserted central catheter (PICC) line with tape. Which action by the precepting nurse is
most appropriate?
a. Make sure the tape being used is from a sterile IV start kit.
b. Stop the nurse and confirm that the Luer-Lok connections are tight.
c. Help the new nurse document the set change appropriately.
d. Show the new nurse how to turn back the corner of the tape for easy
removal.
ANS: B
PICC line administration sets must be secured using the Luer-Lok to help prevent air emboli. Using
tape is not sufficient. When starting peripheral IVs, nurses must use the tape from the sterile IV
start kit when possible, instead of using tape that might be dirty. Documentation is a critical
function, but it does not take priority over doing a procedure correctly, nor does showing the new
nurse time- and work-saving tips.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—
Parenteral/Intravenous Therapies)
38. The nurse is preparing to administer an infusion of dopamine (Intropin) using a smart pump.
After programming the pump and attaching the IV to the client, what action by the nurse is most
important?
a. Start the infusion as ordered.
b. Hand-calculate the infusion rate.
c. Ensure that the pump is plugged in.
d. Place a “time tape” on the IV bag.
ANS: B
Using a smart pump does not relieve the nurse of the responsibility of ensuring that the rate is
correct. Pumps can malfunction or can be programmed incorrectly, and concentrations of solution
can change and differ from the pump’s drug library. The nurse must hand-calculate the rate before
starting the infusion, then must ensure that the pump is plugged into an electrical source. “Time
tapes” on the sides of IV bags are no longer used to show approximate volume infused.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—
Parenteral/Intravenous Therapies)
39. A student nurse is preparing to take a blood pressure (BP) on a client who has a peripheral IV
line in the left arm. What instruction by the faculty member is most important?
a. “Use the arm that doesn’t have the IV site in it.”
b. “Don’t inflate the cuff too high if you use the left arm.”
c. “Make sure the IV line is secure before taking the BP.”
d. “While the BP is taken, a little backflow of the IV is okay.”
ANS: A
Nurses should not take blood pressure on arms that have IVs because increased pressure can cause
infiltration and can cause fluid to leak from the insertion site. Because the affected arm should not
be used for BP, none of the other options can be correct.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 224
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—
Parenteral/Intravenous Therapies)
40. The nurse preparing to insert an IV on an older adult client notices that the client’s skin is
extremely fragile. Which action by the nurse is best?
a. Use a blood pressure cuff to cause the vein to distend.
b. Slap the skin vigorously to cause the vein to rise.
c. Place a gauze pad under the tourniquet before tightening.
d. Avoid the use of a tourniquet if the vein is already hard.
ANS: A
The skin of older adults is often fragile, and a tourniquet may leave an ecchymotic area after the IV
insertion. One option for fragile skin is to inflate a blood pressure cuff to a reading just slightly less
than the client’s diastolic pressure. Tapping the skin lightly may help distend a vein, but avoid
slapping vigorously. Gauze padding would not prevent bruising. Veins that are already distended
may be cannulated without using a tourniquet, but they must be assessed first, and hard or cordlike
veins need to be avoided.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
41. The nurse is caring for a client admitted yesterday with an intraosseous (IO) infusion after a car
crash. Which action by the nurse takes priority?
a. Ensure that the IV flow rate has been recalculated for an IO infusion.
b. Plan to insert another kind of IV line during the shift.
c. Determine which IV medications can be given safely via the IO.
d. Monitor the site and dressings routinely for hemorrhage.
ANS: B
IO infusions, although valuable in an emergency, should be left in place for only 24 hours. The
nurse should plan to insert a peripheral IV sometime during the shift. IV solutions, flow rates, and
medications are given the same way that they are given IV. Hemorrhage is not a complication of IO
infusion.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
MULTIPLE RESPONSE
1. The RN is working with an experienced LPN (licensed practical nurse) who has been assigned
several clients receiving IV therapy. What actions guide the RN in delegating aspects of IV therapy
to the LPN? (Select all that apply.)
a. Look up and read the State Nurse Practice Act.
b. Check facility policy regarding LPNs and IV therapy.
c. Ask the LPN what he or she is comfortable performing.
d. Supervise the LPN when performing IV therapy.
e. Divide the clients up between the two of them.
ANS: A, B
The State Nurse Practice Act will have the information the RN needs, and in some states, LPNs are
able to perform specific aspects of IV therapy. However, in a client care situation, it may be
difficult and time-consuming to find it and read what LPNs are permitted to do, so another good
solution would be for the nurse to check facility policy and follow it.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Delegation)
2. The nurse is preparing to administer a medication IV push. What information does the nurse need
to know before beginning the infusion? (Select all that apply.)
a. Any dilution required
b. Rate of administration
c. Compatibility with infusions
d. Other routes of administration
e. Specific monitoring needed
ANS: A, B, C, E
Giving IV push medications requires specific knowledge about each drug, including dilution, rate
of administration, compatibility, and monitoring. pH and osmolarity and specific infusion sites
appropriate for giving the specific drug are also important to know. When giving an IV push
medication, it is not necessary to know whether other routes of administration are possible.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 212
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
3. A client has a peripherally inserted central catheter (PICC) line and the primary nurse is updating
the care plan. For which common complications does the nurse assess? (Select all that apply.)
a. Phlebitis
b. Pneumothorax
c. Thrombophlebitis
d. Excessive bleeding
e. Extravasation
ANS: A, C
Although the complication rate with PICC lines is fairly low, the most common complications are
phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Pneumothorax, excessive
bleeding, and extravasation are not common complications.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Diagnostic Tests/Treatments/Procedures)
4. The nurse is preparing to give a client an IV push medication through an intermittent IV set
(saline lock) using a needleless system. Which actions by the nurse are most appropriate? (Select
all that apply.)
a. Cleanse the access port vigorously for at least 30 seconds.
b. Use an antimicrobial agent when cleansing the port.
c. Clean the ridges in the Luer-Lok connection well.
d. Rinse the antimicrobial agent off with saline.
e. Allow the antimicrobial agent to dry before using IV.
ANS: A, B, C
Needleless systems need careful cleansing before use. Guidelines include scrubbing the connection
vigorously with an antimicrobial agent for 30 seconds, and paying special attention to the ridges in
the Luer-Lok device. Rinsing and drying are not necessary.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Diagnostic Tests/Treatments/Procedures)
SHORT ANSWER
1. A client is scheduled to receive 1000 mL of normal saline in 24 hours. The nurse should set the
infusion pump to deliver how many milliliters per hour? _____________ mL/hr
ANS:
42
1000 mL divided by 24 hours = 41.6 mL/hr
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
2. If a client is to receive an entire 250-mL bag of saline over the next 4 hours and the drop rate of
the IV tubing chamber is 15 drops/mL, at what drop rate per minute will the nurse set this IV?
____________ drops/min
ANS:
16
Drops per minute = volume  drop factor ÷ total minutes
250  15 = 15.625
4 (hours)  60 (minutes/hour)
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
OTHER
1. The nurse is caring for an older adult client who has been admitted for dehydration and needs IV
fluids. Which location does the nurse choose to place a peripheral IV on this client?
ANS:
B [basilic vein]
The most appropriate veins for peripheral IV therapy include the dorsal venous network and the
basilic, cephalic, and median veins. However, an older client has poor skin turgor on the back of the
hand, making this a poor selection. The palmar side of the wrist should be avoided because the
median nerve is located there, causing increased pain and difficulty with stabilization. The cephalic
vein, although large and prominent in most people, is not the best choice because the sensory
branch of the median nerve intersects with it up to three times. The best choice is the basilic vein.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
2. The nurse is preparing to flush a PICC line. The protocol specifies using 50 units of heparin.
Available is a multidose vial containing heparin, 10 units/mL. Which syringe does the nurse use to
draw up and administer the heparin?
ANS:
D [the 10-mL syringe]
Always use a 10-mL syringe when flushing PICC lines because a smaller syringe creates higher
pressure, which could rupture the lumen of the PICC line.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control-Safe Use of
Equipment)
MSC: Integrated Process: Nursing Process (Implementation)
Chapter 16: Care of Preoperative Patients
Chapter 16: Care of Preoperative Patients
Test Bank
MULTIPLE CHOICE
1. A client voluntarily signed the operative consent form. What is the nurse’s next action?
a. Teach the client about the surgery.
b. Have family members witness the signature.
c. Sign under the client’s name as a witness.
d. Call for the physician to sign the form.
ANS: C
The nurse’s signature as a witness indicates that the consent form was signed by the client
voluntarily. None of the other steps are necessary.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Informed Consent)
MSC: Integrated Process: Communication and Documentation
2. The nurse is caring for an older adult client with a history of chronic lung disease who will be
undergoing surgery the following day. When postoperative care is planned, which potential
problem is the highest priority for this client?
a. Maintaining oxygenation
b. Tolerating activity
c. Anxiety and fear
d. Hypovolemia
ANS: A
Breathing problems take priority over the other problems listed. This would be compounded in a
client with any chronic lung disorder.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Analysis)
3. The nurse is completing preoperative teaching for a client, and it becomes apparent that the client
does not understand the surgery that will be performed. What is the priority action for the nurse?
a. Obtain informed consent from the client.
b. Continue teaching the client about the surgery.
c. Revise the teaching plan for the client.
d. Notify the surgeon and document the finding.
ANS: D
The surgeon should be notified right away so that the client can be instructed about the surgery to
be performed. The client cannot give informed consent unless he or she understands the procedure.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Informed Consent)
MSC: Integrated Process: Teaching/Learning
4. During the preoperative assessment, the client tells the nurse that he smokes three packs of
cigarettes daily. Which action by the nurse is best?
a. Call the surgeon to cancel the surgery.
b. Have baseline laboratory studies drawn.
c. Perform a respiratory assessment.
d. Give a nebulizer treatment.
ANS: C
Smoking increases the client’s risk for atelectasis and hypoxia. The nurse should assess the client
for signs of respiratory disease. The physician will need to know this information but will not
necessarily cancel the operation. Baseline laboratory studies need to be ordered by the physician.
There is no indication for giving a nebulizer to this client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Intervention)
5. When the nurse brings a client’s preoperative medications, the client responds, “I don’t need that.
I had a good night’s sleep last night.” What is the nurse’s best response?
a. “The doctor ordered this medication so you should take it.”
b. “I will make a note that you refused to take the medication.”
c. “I will ask your surgeon if you have to take the medication.”
d. “Let me teach you about your medications for surgery.”
ANS: D
Preoperative medications can include sedatives but are often given to prevent laryngospasm and to
help reduce pharyngeal and gastric secretions. The client must be fully aware of the rationale for all
medications and the risks of not taking them.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes)
MSC: Integrated Process: Communication and Documentation
6. A client receiving preoperative medication tells the nurse that she took all the following vitamins
and herbs last night before going to bed. Which one does the nurse report to the surgical team as a
priority?
a. Valerian root
b. St. John’s wort
c. Garlic
d. Chamomile
ANS: C
Garlic interferes with coagulation, increasing the client’s risk for bleeding during and after the
surgical procedure. This would be a critical piece of information for the surgical team to know.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Intervention)
7. The nurse reviews a client’s laboratory results before surgery and notes a fasting blood glucose of
120 mg/dL, a prothrombin time (PT) of 25 seconds, and potassium (K +) of 3.8 mEq/L. Which
action by the nurse is best?
a. Ask the surgeon for additional laboratory studies.
b. Administer a potassium supplement of 20 mEq.
c. Increase the IV infusion of D5W to 100 mL/hr.
d. Record laboratory results on the preoperative assessment.
ANS: A
The prothrombin time is elevated, which could lead to bleeding during or after surgery. The
surgeon and the anesthesiologist should be notified of this laboratory test result right away, and
additional coagulation studies will be needed. The potassium is within normal limits. The blood
glucose level is elevated but not critically so. The surgeon should be notified of all laboratory work,
and the client may need an IV solution without glucose. The results should be recorded, but the
surgery will likely be cancelled owing to the coagulation problem, which is the priority concern
with this client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Analysis)
8. A client is brought to the emergency department (ED) after a motorcycle accident. The client has
suffered a ruptured spleen. What is the immediate priority?
a. Emergent surgery to control bleeding
b. Aggressive pain control
c. Calling the family members
d. Assessment of neurologic status
ANS: A
Emergent surgery is indicated when the client may die without immediate intervention. Other
interventions are appropriate but do not have the priority because controlling hemorrhage via
surgery is the priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
9. The nurse has just completed preoperative teaching with a client who will be having surgery the
following day. Which statement by the client indicates that additional teaching is needed?
a. “When I brush my teeth before surgery, I will be sure to spit out the
water.”
b. “I will go to the bathroom as soon as I receive all my preoperative
medications.”
c. “I will remember to wear my glasses tomorrow instead of my contact
lenses.”
d. “I won’t have to worry about putting my makeup on tomorrow
morning.”
ANS: B
The client should void before receiving any preoperative medication. The medication could make
the client sleepy and at risk for falling. The other statements are correct.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention) MSC: Integrated Process: Teaching/Learning
10. The nurse is performing preoperative teaching with an older adult client who will be having
colon resection surgery the following day. The surgeon has ordered bowel preparation the night
before. Which action is a priority?
a. Administer antibiotics with a sip of water.
b. Encourage the client to drink plenty of juice.
c. Teach the client to eat only low-fat foods the night before surgery.
d. Tell the client not to get up and go to the bathroom alone.
ANS: D
Safety is the priority, and the older adult client can become exhausted and may fall. Antibiotics, if
ordered, would be administered with a sip of water, but this is not the priority. The client would not
be encouraged to drink juice, because this is not a clear liquid.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
11. When examining an adult client’s preoperative laboratory results, the nurse notes that the
potassium level is 2.9 mEq/mL. What is the nurse’s priority action?
a. Document the finding.
b. Alter the client’s diet to include fruit.
c. Increase the IV flow rate.
d. Notify the surgeon.
ANS: D
The normal range for serum potassium is 3.5 to 5.0 mEq/L or mmol/L. A value of 2.9 represents
hypokalemia, which must be corrected before surgery. The surgeon should be notified of this
finding. The finding should be documented; however, notifying the surgeon is the priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Implementation)
12. What recently learned information about a client who is scheduled to have surgery within the
next 2 hours is the nurse certain to communicate to the surgical team?
a. An allergy to cats
b. Hearing problem
c. Consumption of a glass of wine 12 hours ago
d. Taking 2000 mg of vitamin C each day
ANS: B
The team will need to communicate with the client in the surgical holding area, in the operating
room, and in the postanesthesia recovery unit. Any problem with communication, such as a hearing
impairment, should be stressed, so that team members can use alternative means to ensure accurate
communication with the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
13. A client will be undergoing palliative surgery. The client’s daughter asks what this means. What
is the nurse’s best response?
a. “The surgery will relieve the symptoms but will not cure your father.”
b. “There are fewer risks with this type of surgery.”
c. “There is no guarantee of the outcome of the surgery.”
d. “The surgery must be performed immediately to save your father’s
life.”
ANS: A
The purpose of palliative surgery is to improve the client’s quality of life by reducing or eliminating
distressing symptoms. It does not cure a health problem and often does not prolong life.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 16-1, p. 242
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort
Measures)
MSC: Integrated Process: Communication and Documentation
14. Twenty minutes after a client has received a preoperative injection of atropine and midazolam
(Versed), the client tells the nurse that he must be allergic to the medication because his mouth is
dry and his heart seems to be beating faster than normal. What is the nurse’s priority action?
a. Document the findings.
b. Assess the client’s pulse and blood pressure.
c. Administer diphenhydramine (Benadryl).
d. Explain to the client that these symptoms are expected.
ANS: B
Although these are expected physiologic responses to the preoperative medication, whenever the
client states that he or she can feel a change in normal cardiac function, he should be assessed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes)
MSC: Integrated Process: Nursing Process (Implementation)
15. A client undergoing preoperative assessment informs the nurse that he takes medication for high
blood pressure and for asthma. What is the nurse’s best action?
a. Tell the client not to take the medication on the day of surgery.
b. Notify the surgeon and the anesthesiologist.
c. Document the information in the client’s record.
d. Tell the client to take medications preoperatively with a sip of water.
ANS: B
Medications for cardiac and respiratory problems usually are given with sips of water before
surgery. However, the nurse should notify the surgeon and the anesthesiologist before giving the
client any advice. While some medications can be given with a sip of water, other medications must
be held for a specified time before surgery. Documentation should occur, but only after the nurse
has consulted with the physician and anesthesiologist and has spoken to the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
16. Which action is most appropriate during a preoperative chart review?
a. Ensure that the consent form is signed, dated, and witnessed.
b. Call the surgeon if the client has any food allergies.
c. Make sure all marks are washed off the surgical site.
d. Make sure the client understands the procedure.
ANS: A
During the preoperative chart review, the nurse should make sure that the consent form is signed,
dated, and witnessed. The nurse does not have to call the surgeon for food allergies, nor should the
marks be washed off the surgical site. The client should be taught about the procedure before the
preoperative chart review.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 259
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
17. The nurse is caring for a client who will be undergoing emergency surgery as soon as possible.
Which information is most important for the nurse to teach the client at this time?
a. How the surgery will be performed
b. Importance of early ambulation after surgery
c. What to expect in the operating and recovery rooms
d. Complications that may occur after surgery
ANS: C
With only a few minutes before surgery, the nurse should tell the client what to expect in the
operating room and in the recovery room to minimize his or her anxiety. Although the other
information is important, the nurse needs to start with what is vital for the client to know right now.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Teaching/Learning
18. A client tells the nurse that he has an advance directive with durable power of attorney for
health care. The client asks how the advance directive will affect the surgery. What is the nurse’s
best response?
a. “You will not be intubated during general anesthesia for the surgery.”
b. “There will be no effect on your surgery.”
c. “The surgical staff will resuscitate only if your heart stops during the
operation.”
d. “If you are unable to make a decision, your designee will be asked.”
ANS: D
The advance directive with durable power of attorney indicates whom the client wishes to designate
for medical decisions if he is unable to make decisions for himself. An advance directive with
power of attorney does not eliminate the need for intubation during surgery. Although the document
does not affect the procedure, simply acknowledging that fact does not help the client understand. If
the client’s heart stops during the operation and the client has not made his or her wishes known
about that situation, the power of attorney would be consulted.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 252
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advance Directives
MSC: Integrated Process: Communication and Documentation
19. A client is brought to the hospital unconscious and needs emergency surgery. The client’s only
family member cannot come to the hospital before the surgery. Which is the best option for
obtaining informed consent for the client’s emergent surgery?
a. Proceed with surgery and have the family member sign the consent as
soon as possible.
b. Contact the family member by phone and obtain verbal consent with
two witnesses.
c. Obtain written consultation with two surgeons that the surgery is
needed.
d. Have the hospital administrator appoint a temporary legal guardian.
ANS: B
In the event that a family member cannot come to the hospital before the surgery needs to begin,
verbal consent should be obtained over the phone with two witnesses.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Informed Consent)
MSC: Integrated Process: Communication and Documentation
20. Four clients are scheduled for surgery. Which client does the nurse determine is at highest risk
for postsurgical complications?
a. 89-year-old scheduled for a knee replacement
b. 40-year-old requiring gallbladder surgery
c. 19-year-old requiring a laparoscopy
d. 10-year-old admitted for a tonsillectomy
ANS: A
The older client is at highest risk for postoperative complications. Older adults often have multiple
medical conditions, take several medications, are slightly dehydrated, and may have cognitive or
physical impairments that potentially could hinder their recovery from an operation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
21. The nurse is conducting preoperative assessments. Which client does the nurse teach about the
possibility of developing a venous thromboembolism (VTE)?
a. Client with a latex allergy
b. Client with body mass index (BMI) of 19
c. Client with an international normalized ratio (INR) of 2.2
d. Client undergoing hip replacement surgery
ANS: D
The client will have limited mobility following hip replacement surgery, increasing the risk of
postoperative venous thromboembolism (VTE). The other conditions will not increase the risk of
VTE.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
22. The nurse applies antiembolism stockings to a client preoperatively. When the client says that
they are uncomfortably tight, what is the nurse’s best action?
a. Remove the stockings for an hour to relieve the pressure.
b. Pull the stockings down so that they are not constricting.
c. Measure the client’s calf to ensure that they are the correct size.
d. Teach the client the purpose of wearing the stockings.
ANS: D
Thromboembolic disease (TED) stockings should feel slightly tight on the legs to promote venous
return and prevent the client from developing venous thromboembolism (VTE). The nurse should
not remove the stockings nor pull them down. The calf would have been measured before the
stockings were obtained.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
MULTIPLE RESPONSE
1. The nurse is assessing a client before surgery. Which assessments contraindicate the client having
surgery as scheduled? (Select all that apply.)
a. Potassium level of 2.8 mEq/L
b. International normalized ratio (INR) of 4
c. Prothrombin time (PTT) of 30 seconds
d. Calcium level of 8.8 mEq/dL
e. Positive pregnancy test
f.
Platelet count of 150,000
ANS: A, B, E
Hypokalemia, elevated bleeding times, and a positive pregnancy test could all contradict the client
having surgery as scheduled and could lead to complications. Normal PTT, normal calcium, and
normal platelet count would not contradict surgery.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Assessment)
2. Which medications does the nurse correctly administer preoperatively? (Select all that apply.)
a. Hydroxyzine (Atarax, Vistaril) for sedation
b. Lorazepam (Ativan) for anxiety
c. Hydromorphone (Dilaudid) to decrease postoperative secretions
d. Metoclopramide (Reglan) to increase stomach emptying
e. Aspirin to decrease blood clotting postoperatively
f.
Cimetidine (Tagamet) to prevent infection
ANS: A, B, D
The nurse will administer hydroxyzine (Atarax) for sedation, lorazepam (Ativan) for anxiety, and
metoclopramide (Reglan) to increase stomach emptying. Hydromorphone is given for pain, and
cimetidine (Tagamet) decreases histamine. Aspirin would not be administered preoperatively
because it can increase bleeding.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Nursing Process (Assessment)
3. The nurse is conducting preoperative teaching with a client who will be undergoing pelvic
surgery. What teaching is essential for this client? (Select all that apply.)
a. “Wearing elastic stockings and using pneumatic compression devices
are essential after surgery.”
b. “Extended bedrest will help you heal after this type of surgery.”
c. “Coughing and deep breathing will help to decrease postoperative
complications.”
d. “Turning and moving your legs after surgery will help prevent clots
from forming.”
e. “You will need to have your abdomen shaved before surgery.”
f.
“You cannot wear your hearing aid into the surgical suite.”
ANS: A, C, D
A pneumatic compression device and elastic stockings will help prevent clots after pelvic surgery.
Coughing and deep breathing will help to decrease postoperative respiratory complications.
Turning and moving legs after surgery will also help prevent clots. Hearing aids can be worn into
the surgical suite because this will help communication before surgery. Extended bedrest is not
helpful, and shaving would not be necessary.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
4. What data are essential for the nurse to assess on a client who is scheduled for surgery? (Select
all that apply.)
a. Use of tobacco
b. Current medications
c. Use of herbal or over-the-counter therapy
d. Mental status examination
e. Power of attorney
f.
Allergies
g. Date of last tetanus shot
ANS: A, B, C, D, F
The client should be screened for things that may increase the risk of complications during surgery.
Smoking, certain medications and herbs, and allergies may increase a client’s risk. Mental status
examination is essential to determine competency and ability to teach. The date of the client’s last
tetanus shot is not required information from a preoperative chart review.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 242
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Communication and Documentation
OTHER
1. The nurse is preparing to transfer a client to the operating room for surgery. Put the interventions
in order for the nurse to perform. (List in order of priority.)
a. Take a full set of vital signs.
b. Have the client go to the bathroom to void.
c. Ask the client to state his or her name and check the ID band.
d. Administer ordered preoperative sedation.
ANS:
c, b, a, d
First, the nurse should identify the client using two identifiers to ensure that the correct client is
being prepped for surgery. Next, the nurse should assist the client to the bathroom, then take vital
signs, then finally administer preoperative sedation once the client is in bed.
DIF: Cognitive Level: Application/Applying or higher
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
Chapter 17: Care of Intraoperative Patients
Chapter 17: Care of Intraoperative Patients
Test Bank
MULTIPLE CHOICE
1. Which observed action indicates that the nurse is performing the surgical scrub correctly?
a. A small brush is used to scrub under nails and wedding ring.
b. The surgical mask is put on before starting the surgical scrub.
c. The soap is rinsed off so that the water runs down to the hands.
d. A paper towel is used to turn off the faucet handle.
ANS: B
The facemask must be donned before the surgical scrub is started. Jewelry is removed before
scrubbing. The hands and the arms are positioned so that water falls away from them and does not
run “up” or “down” the hands and arms. Water flow is controlled by foot pedals.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 270
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
2. A client is having epidural anesthesia for knee replacement surgery. Which action by the nurse is
the priority during this surgery?
a. Provide emotional support for the client.
b. Position the client comfortably and safely.
c. Stay with the client until sedation is effective.
d. Teach the client cough and deep-breathing exercises.
ANS: B
The client’s safety is the nurse’s priority during this surgery. The other actions are appropriate but
are not the highest priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
3. Which action indicates to the operating room supervisor that the scrub nurse requires additional
teaching about sterile technique?
a. A small amount of sterile saline is poured out before it is poured into
the basin.
b. The nurse disposes of any equipment packages that are in poor
condition.
c. Sterile surgical supplies are placed in the center of the sterile field.
d. The sterile saline bottle cap is placed in the center of the sterile field.
ANS: D
The outside of the bottle cap is not sterile and should not be placed on the sterile field. The other
actions indicate good understanding of sterile technique.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
4. What is the priority action for the scrub person at the conclusion of a surgical procedure?
a. Assist with transferring the client to the postanesthesia care unit.
b. Document the procedure in the client’s medical record.
c. Set up the sterile field and drape the client appropriately.
d. Document how many sponges and sharps have been utilized.
ANS: D
The scrub person or nurse should document how many sponges and sharps are utilized after the
procedure. The scrub person may assist with transferring, but the client will not leave the operating
room until the counts are correct. Documentation is important and ongoing, but at the conclusion of
an operation, counting supplies is vital to prevent accidentally leaving them in the client. Draping
the client and setting up the field are done before the surgical procedure is begun.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Accident/Injury
Prevention) MSC: Integrated Process: Nursing Process (Planning)
5. Before a client’s surgery begins, the circulating nurse notes that the nurse anesthetist did not
perform a surgical scrub before coming into the operating room. Which action by the circulating
nurse is most appropriate?
a. Direct the nurse anesthetist to perform the surgical scrub immediately.
b. Proceed with positioning the client on the operating bed.
c. Notify the nursing supervisor that sterile technique has been violated.
d. Proceed with setting up the instruments to be used during surgery.
ANS: B
The nurse anesthetist does not need to perform a sterile scrub before the client’s surgery is
performed. The circulating nurse can proceed with positioning the client on the operating room bed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
6. A client is having spinal anesthesia for knee surgery. Which statement by the client indicates a
good understanding of this type of anesthesia?
a. “I won’t have to worry about having an allergic reaction.”
b. “I will be able to walk sooner after your surgery.”
c. “I will have less risk of developing pneumonia after surgery.”
d. “I will have less risk of bleeding with epidural anesthesia.”
ANS: C
With epidural anesthesia, the client remains conscious, respiratory function is unaffected, and
intubation is not necessary. This results in less risk for atelectasis or pneumonia after surgery.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
7. The client is to have a surgical procedure under (moderate) conscious sedation. The client is
anxious and asks the nurse what to expect. What is the nurse’s best response?
a. “You will be awake and alert during the procedure but you will feel no
pain.”
b. “You will not be able to move your feet or toes during the procedure.”
c. “You will not be able to swallow or talk during the procedure.”
d. “You will be very sleepy and we will monitor you closely.”
ANS: D
A physician or a specially credentialed registered nurse may administer agents for conscious
sedation. This rapid and short-acting type of anesthesia, used for brief but uncomfortable
procedures, does not render the client completely unconscious. Clients have a reduction in intensity
or awareness of the pain without loss of defensive reflexes.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 276
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes)
MSC: Integrated Process: Communication and Documentation
8. The nurse is caring for a client who has had conscious sedation. What is the primary advantage of
this type of anesthesia?
a. The client can talk through the procedure.
b. The client is able to follow directions.
c. No respiratory support is needed.
d. No defensive reflexes are lost.
ANS: C
The client undergoing a moderate sedation procedure will not need respiratory support; this is the
first and foremost advantage of this kind of sedation. The client will be able to follow directions
during the procedure, but maintaining his or her own airway and not requiring mechanical
ventilation decrease potential complications.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 276
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Analysis)
9. Before the nurse brings the client to the operating room (OR) for knee surgery, the client reports
to the nurse that he did not mark the operative knee with the surgeon. What is the priority action of
the nurse?
a. Proceed with transferring the client to the OR as planned.
b. Call a “time out” so the site can be marked before surgery begins.
c. Call the surgeon to mark the site with the client before transfer to the
OR.
d. Have the client mark the site before transfer to the OR.
ANS: C
According to The Joint Commission, the surgical site should be marked by both the client and the
surgeon before anesthesia is administered and surgery begins when the surgery involves a specific
side.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Error
Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
10. The nurse is preparing to bring a young female client to the operating room for a total
abdominal hysterectomy (TAH). The client says to the nurse, “I am so glad that I will still be able
to have children after this surgery.” What is the nurse’s best response?
a. “That is very good news. How many children do you want?”
b. “Weren’t you taught about your surgery earlier?”
c. “You must have misunderstood your surgeon.”
d. “I will call the surgeon to speak with you before surgery.”
ANS: D
TAH includes removal of the uterus, which will leave the client unable to have children. The
surgeon should be called to speak with the client and explain the surgery before the client is moved
to the operating room.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Informed Consent)
MSC: Integrated Process: Nursing Process (Implementation)
11. An older adult client is being positioned on the operating bed for surgery. Which action is the
highest priority for the nurse?
a. Placing gel pads under the client’s shoulders and head
b. Placing a soft pillow between the client’s knees
c. Ensuring that the head is elevated to working height
d. Assessing skin condition for the need for additional padding
ANS: D
The older adult client needs to be assessed and skin integrity evaluated. Older adults are at higher
risk and need increased precautions. The client may need pads under the shoulders and head and
between the knees, but the nurse should assess all areas for the need for additional padding. Raising
the bed is not a priority action and in fact might increase risk for the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
12. An anesthetized client must be repositioned from the supine to the prone position midway
through a surgical procedure. What is the priority action of the nurse?
a. Log roll the client to prevent dislocation of the shoulder.
b. Keep the client covered to maintain dignity and minimize heat loss.
c. Ensure that the client’s endotracheal tube does not become dislodged or
kinked.
d. Make sure that the client’s indwelling catheter is kept lower than the
bladder.
ANS: C
Maintenance of a secure airway is the highest priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
13. Which action by the surgical nursing staff indicates that additional teaching is required about
nurses’ roles and responsibilities in the operating room?
a. The circulating nurse and the anesthesiologist accompany the client to
the postanesthesia care unit.
b. The circulating nurse goes to the blood bank to pick up 2 units of fresh-
frozen plasma for the client.
c. The scrub nurse monitors the amount of irrigation fluid that is used
during surgery.
d. The circulating nurse prepares the surgical site before the client is
covered with sterile drapes.
ANS: B
The circulating nurse should not leave the operating room to pick up fresh-frozen plasma and
should delegate the job to unlicensed personnel instead. The other actions are appropriate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Delegation) MSC:
Integrated Process: Nursing Process (Implementation)
14. The nurse is helping to position a client on the operating bed when the client states, “I am really
nervous about having the breathing tube put down my throat.” What is the nurse’s best response?
a. “I will give you some medication so that it won’t hurt.”
b. “The tube is very small and you will hardly know it is there.”
c. “The anesthesiologists are experts at this procedure.”
d. “The anesthetist will put the tube in your throat after you are asleep.”
ANS: D
Reassuring the client that the endotracheal tube (ET) will be placed after the administration of
general anesthesia and will be removed before awakening will help allay the client’s fears.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 17-2, p. 272
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Caring
15. Which statement indicates accountability by the scrub nurse during a surgical procedure?
a. “The client should have epidural anesthesia rather than general
anesthesia.”
b. “The client’s endotracheal tube is secured and all monitors are in
place.”
c. “I will have retention sutures ready for the surgeon.”
d. “A surgical sponge is missing so I will do a re-count.”
ANS: D
The scrub nurse is responsible (with the circulating nurse) for counting all surgical supplies used
during a procedure. Re-counting the surgical sponges demonstrates accountability.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
16. The nurse is assisting a client to the operating bed and notes that the client is hyperventilating
and cannot keep still. The client states, “I am really very anxious right now.” What is the nurse’s
best action?
a. Call the chaplain to calm the client down.
b. Tell the client you will stay with him or her.
c. Inform the surgeon so the procedure can be cancelled.
d. Inform the anesthesiologist and suggest antianxiety medication.
ANS: B
The nurse should reassure the client that anxiety is normal before surgery, and that the nurse will
stay with the client until anesthesia is administered. Calling the chaplain does not show the nurse
acting as a client advocate. The procedure does not need to be cancelled, nor does the client need an
antianxiety medication right now. If the client cannot be calmed, other options can be explored at
that time.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Caring
17. Surgery is almost completed for an obese client with diabetes, and the surgeon prepares to close
a large abdominal incision. What is the scrub nurse’s best action?
a. Count the number of sponges used.
b. Ask the circulating nurse to count sponges.
c. Assist the surgeon with retention sutures.
d. Administer an antibiotic.
ANS: C
The obese client with diabetes is at high risk for poor wound healing. Retention sutures would be
appropriate to reduce the risk of dehiscence or evisceration. It would not be appropriate to stop and
count the sponges now, nor would it be the time to administer an antibiotic.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Planning)
18. The nurse is caring for a client who will be having surgery with spinal anesthesia. The client
says to the nurse, “I changed my mind—I don’t want to be awake during surgery!” What is the
nurse’s best response?
a. “Spinal anesthesia is safer than being put to sleep with general
anesthesia.”
b. “The anesthesiologist has already determined this is best for your
surgery.”
c. “It’s too late to change now because all the equipment is in place.”
d. “I will call the anesthesiologist to come and talk to you.”
ANS: D
The nurse should recognize the client’s concerns and pass them on to the anesthesiologist. The
nurse should not try to convince the client or to teach him or her at this time.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Nursing Process (Implementation)
19. A client is recovering from abdominal surgery and reports unusual muscle pain. The nurse
reviews the operative record and notes that the client received propofol (Diprivan) and ketamine
(Ketalar). Which action by the nurse is most appropriate?
a. Request a physical therapy consult.
b. Encourage the client to ambulate.
c. Administer the ordered pain medication.
d. Call the surgeon and request a potassium level.
ANS: D
Propofol can cause propofol infusion syndrome, which is characterized by rhabdomyolysis, renal
failure, hyperkalemia, and cardiovascular collapse. The muscle pain should have alerted the nurse
to the possibility of rhabdomyolysis. The other options would be correct once a serious problem has
been ruled out.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Analysis)
MULTIPLE RESPONSE
1. Before undergoing general anesthesia, the client states, “My brother and my father had bad
reactions to anesthesia. I hope that doesn’t happen to me!” What are the nurse’s best actions?
(Select all that apply.)
a. Hook up leads to a temporary pacemaker.
b. Have a nasogastric tube ready for insertion.
c. Assess the client’s chest x-ray before surgery.
d. Have a cooling blanket ready.
e. Obtain a chest tube insertion kit.
f.
Have a Foley catheter kit ready.
g. Provide an emergency tracheostomy kit at the bedside.
h. Inform the anesthesiologist and the surgeon of the client’s statement.
ANS: B, D, F, H
Malignant hyperthermia is a dangerous reaction to general anesthesia that is caused by a genetic
disorder and is more common in males. The nurse should be prepared to insert a Foley catheter and
nasogastric tube and to apply a cooling blanket for the client if the reaction occurs.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Planning)
2. A client is undergoing an operation under general anesthesia. What are the nurse anesthetist’s
best actions to prevent hypoventilation during the operation? (Select all that apply.)
a. Monitor breathing and circulation continuously.
b. Monitor blood pressure and heart rate every 5 minutes.
c. Make sure the anesthesia provider remains in the room.
d. Elevate the head of the client’s bed or stretcher.
e. Monitor the cardiac rhythm every 30 minutes.
ANS: A, B, C
Best practice standards to prevent hypoventilation have been established jointly by the American
Society of Anesthesiologists and the American Association of Nurse Anesthetists. These standards
include continuous monitoring of breathing, circulation, and cardiac rhythms; blood pressure and
heart rate recordings every 5 minutes; and the continuous presence of an anesthesia provider during
the case. The head of the bed or stretcher may not be able to be elevated, depending on the surgical
case. The cardiac rhythm should be monitored continuously.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 282
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
3. Which clients does the nurse determine have the highest risk for wound infection? (Select all that
apply.)
a. Client who has psoriasis
b. Middle-aged woman with a body mass index (BMI) of 30
c. Older adult client with a creatinine level of 4.0
d. Client with a family history of malignant hyperthermia
e. Client with peripheral vascular disease
f.
Teenager with diabetes mellitus type 1
ANS: B, C, E, F
Diabetes mellitus, obesity, and renal failure are all risk factors for wound infection. In addition,
peripheral vascular disease can lead to decreased circulation and wound healing.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 281
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
4. A client is having an operation. Which assessment findings concern the nurse the most? (Select
all that apply.)
a. Potassium level of 4.2 mEq/dL
b. Calcium level of 12 mg/dL
c. Heart rate of 110 beats/min
d. Oxygen saturation of 95%
e. pH of 7.37
f.
Blood pressure of 90/40 mm Hg
ANS: B, C, F
Malignant hyperthermia is an emergency situation for an intraoperative client. Assessment findings
in malignant hyperthermia include elevated calcium, dysrhythmias, and hypotension. Potassium,
oxygen saturation, and pH levels are all normal.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Analysis)
Chapter 18: Care of Postoperative Patients
Chapter 18: Care of Postoperative Patients
Test Bank
MULTIPLE CHOICE
1. The nurse is caring for a client who had surgery 24 hours ago. He is alert and oriented when
awakened and reports pain, but goes back to sleep when not being stimulated. He is on patientcontrolled analgesia (PCA). What is the nurse’s next action?
a. Push the PCA control for the client.
b. Discontinue the PCA immediately.
c. Assess the client’s respiratory status.
d. Keep the client awake as much as possible.
ANS: C
The client should be assessed further before action is taken. If the client cannot stay awake 24 hours
after surgery, there may be other problems. The nurse should assess respiratory rate and depth and
lung sounds, as well as oxygen status. The nurse should never push the PCA for the client, and pain
should be assessed before decisions are made and interventions taken.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
2. Postoperatively, a client has a heart rate of 120 beats/min, with dysrhythmias noted on the ECG
monitor and a respiratory rate of 34 breaths/min, and is very difficult to arouse. Which action by the
nurse is most appropriate?
a. Accompany the client to the postanesthesia care unit (PACU).
b. Keep the client in the surgical suite.
c. Call a code or the Rapid Response Team.
d. Transfer the client to the intensive care unit (ICU).
ANS: D
Clients in critical condition are transferred from the operating room directly to the ICU. This client
is not stable with elevated heart and respiratory rates, dysrhythmias, and difficulty in arousal.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
3. A client has been transferred to the postanesthesia care unit (PACU). Which action does the
receiving nurse perform first?
a. Complete a nursing assessment sheet.
b. Change the client’s arm band.
c. Enter client data into the computer.
d. Participate in a hand-off report.
ANS: D
After the surgery is completed, the circulating nurse and the anesthesia provider accompany the
client to the PACU. A hand-off report that meets National Patient Safety Goal 2 requires effective
communication between health care professionals.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)
MSC: Integrated Process: Communication and Documentation
4. The nurse is performing a hand-off report in the PACU. What is the best action for the nurse to
perform during the hand-off report?
a. Write all information on a chart and hand it to the nurse who will
assume care of the client.
b. Follow the nurse assigned to the new client and give a verbal report that
does not interrupt care.
c. Focus on the report and sit with the nurse receiving the client to give a
detailed report.
d. Finish the report quickly so the nurse can assume care of the client.
ANS: C
The hand-off report is a time when errors can potentially occur. The nurse should sit with the
receiving nurse to give report. That way, both nurses will be focused on the report. Simply handing
the information to the new nurse does not ensure that he or she will read or understand it.
Following the accepting nurse around and giving report while he or she provides care for other
clients would be distracting. The hand-off nurse should not hurry through this report and should
provide a report that allows for two-way communication between nurses.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)
MSC: Integrated Process: Communication and Documentation
5. The nurse reviews the initial postanesthesia care unit (PACU) flow record and notes that the
client is alert and oriented 3 when stimulated, pulse is 88 per minute and regular, respirations are
12 per minute and unlabored, and oxygen saturation is 95% on 2 LPM of nasal oxygen. What is the
nurse’s priority action at this time?
a. Examine the surgical site; obtain blood pressure and temperature.
b. Suction the client and assess anterior and posterior lung sounds.
c. Assess urinary output, the IV site, and the client’s pain.
d. Turn the client and perform chest physiotherapy.
ANS: A
Initial assessment on the client entering the PACU that should be recorded on the flow chart record
includes level of consciousness, temperature, pulse, respirations, oxygen saturation, and blood
pressure. In addition, the nurse should examine the surgical area for bleeding. These items were
missing from the initial assessment.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Assessment)
6. A client who has just been transferred to the postanesthesia care unit (PACU) from surgery is
very restless and confused. What is the nurse’s first action?
a. Orient the client and remain with him or her.
b. Call the surgeon for an intraoperative report.
c. Notify the physician on call.
d. Assess the client’s level of pain.
ANS: A
The client who is not oriented is at risk of falling. The nurse should remain with the client to ensure
safety, and should assign another staff member to the client if care has to be given to others. The
client should not be left alone.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
7. A client had surgical repair of a fractured ankle under local anesthesia and is being transferred
from the postanesthesia care unit (PACU) to the surgical floor. Once admitted, what is the nurse’s
priority action?
a. Assess pressure points for breakdown.
b. Assess the client’s pain.
c. Insert an IV for antibiotic therapy.
d. Assess a full set of vital signs.
ANS: D
On admission to the surgical floor from the PACU, the nurse should assess vital signs every 15
minutes 4, then every 30 minutes 4 and every 2 hours 4. After vital signs, the nurse would
continue with assessments, including the surgical site and pain. An IV should already be inserted
before arrival to the surgical unit.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
8. The nurse is assessing a client admitted to the postanesthesia care unit (PACU) after abdominal
surgery. The client’s respiratory rate is 8 breaths/min and breath sounds are decreased in the bases.
What is the nurse’s priority action?
a. Prepare to administer naloxone (Narcan).
b. Assess oxygen saturation and level of consciousness.
c. Call a code or the Rapid Response Team.
d. Turn the client and perform chest physiotherapy.
ANS: B
Additional data are needed to determine respiratory status, so the nurse must finish the assessment
with an oxygen saturation (SaO 2) and check the client’s level of consciousness. A respiratory rate of
less than 10 could indicate an emergency, especially if the SaO 2 drops below 95%. A respiratory
rate of less than 10 breaths/min may indicate anesthetic-induced depression. Naloxone should not
be administered unless there are clear indications for it, and performing chest physiotherapy may
not be warranted. Calling a code or the Rapid Response Team may be needed, but only after a
complete assessment.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiologic Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
9. The nurse assesses a client who has just been brought to the postanesthesia care unit (PACU). In
the operating room, the client’s blood pressure was 136/80 mm Hg; it is now 110/80 mm Hg. Urine
output was 40 mL/hr and is now 10 mL/hr. Which action by the nurse is best?
a. Awaken the client and encourage oral fluids.
b. Increase the IV of 0.9 NS as ordered to 100 mL/hr.
c. Put the client in Trendelenburg position.
d. Assess the client’s levels of consciousness and pain.
ANS: B
One of the most sensitive and earliest indicators of vascular volume loss is decreased urine output.
The nurse is concerned about urinary output less than 30 mL/hr because this may indicate that the
kidneys are not being perfused. The nurse should increase the IV rate. Oral fluids are not an option
at this point because the client has not recovered from the anesthesia. Placing the client in
Trendelenburg position is not warranted because this puts pressure on the heart and lungs, limiting
their effectiveness. Assessing consciousness and pain can wait until later.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Intervention)
10. The nurse is caring for a client who has just been brought to the postanesthesia care unit
(PACU) after surgery. The client’s oxygen saturation is 92% and his hemoglobin is 14 g/dL. What
is the nurse’s first action?
a. Assess the client’s pain response.
b. Determine whether the client is alert and oriented.
c. Increase oxygen and auscultate lung sounds.
d. Assess vital signs and temperature.
ANS: C
Oxygen saturation is the most definitive assessment finding for whether or not the client is
adequately oxygenated. However, because oxygen saturation is based on the amount of hemoglobin
in the blood, this indicator needs to be evaluated, in addition to the saturation. If a client has low
hemoglobin, even if the percentage of saturation is high, the client is still underoxygenated. Oxygen
should be increased and further respiratory assessment performed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Assessment)
11. A client is brought to the postanesthesia care unit (PACU) after surgery that took place with the
client in the lithotomy position. Which action does the nurse take after assessing vital signs?
a. Assess for sacral decubiti.
b. Assess dorsalis pedis pulses.
c. Turn the client on the left side.
d. Put the client in the Trendelenburg position.
ANS: B
The lithotomy position can compromise the client’s peripheral circulation in the lower extremities,
leading to weak pedal pulses. The nurse should check dorsalis pedis pulses. The client would not
need to be assessed for decubiti, turned on the side, nor placed in the Trendelenburg position.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Diagnostic Tests, Procedures, and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
12. A client is being transferred to the postanesthesia care unit (PACU) after surgery. The client has
an endotracheal tube (ET) in place. On assessment, the client has oxygen saturation of 95%,
respiratory rate of 14 breaths/min, and asymmetric chest wall expansion. What is the nurse’s best
action?
a. Attempt to awaken the client.
b. “Bag” the client with a resuscitation bag.
c. Increase the client’s fraction of inspired oxygen (FIO 2).
d. Auscultate lung sounds bilaterally.
ANS: D
The ET tube could have slipped into the right mainstem bronchus. Auscultating the lungs will help
to confirm this; then the nurse should call the health care provider because the tube will need to be
pulled back. Attempting to awaken the client will not change the asymmetric chest wall expansion,
neither will “bagging” the client or increasing the fraction of inspired oxygen (FIO 2). Because the
client’s oxygen saturation is still within an acceptable range, this is not warranted.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
13. A client who is being admitted to the postanesthesia care unit (PACU) has weak hand grasps on
assessment and is unable to lift his head off the bed. During hand-off report, the nurse notes that the
client has received a neuromuscular-blocking agent. What is the nurse’s best action?
a. Document the finding.
b. Check the client’s pulses.
c. Place the client in Fowler’s position.
d. Auscultate the lungs.
ANS: D
When neuromuscular blocking agents are used, the client is at risk that these agents could be
retained. The primary concern is the client’s airway owing to muscular weakness. Because the
client cannot raise the head and has a weak hand grasp, this may be a potential problem. The nurse
should document all assessment findings. Placing the client in Fowler’s position and checking the
pulses is not warranted.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
14. The nurse is caring for clients in the postanesthesia care unit (PACU). Which client does the
nurse intervene for first?
a. Client with a pulse deficit of 15
b. Client who is reporting leg pain
c. Client with dementia who is confused
d. Client who is reporting a headache
ANS: A
The client with an apical radial pulse deficit could be having dysrhythmias, which may be
indicative of volume deficit, acidosis, electrolyte imbalances, or hypothermia. All clients must be
assessed and cared for according to their needs, but this client would be the nurse’s highest priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
15. The nurse is caring for several clients on the postoperative unit. Which client does the nurse
determine has the highest risk of respiratory complications after general anesthesia?
a. Older woman taking a calcium channel blocker for hypertension
b. Middle-aged man with a deviated nasal septum
c. Middle-aged woman taking St. John’s wort daily for depression
d. Young adult with a body mass index of 40
ANS: D
Clients who are extremely obese have heavy chest walls that make it difficult to expand the lungs
fully. The other clients would not have an elevated risk of respiratory complications.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
16. One hour after admission to the postanesthesia care unit (PACU), the postoperative client has
become very restless. What is the nurse’s first action?
a. Assess for bladder distention.
b. Assess the oxygen saturation level.
c. Call the surgeon to assess the client.
d. Administer pain medication as ordered.
ANS: B
The most common causes of restlessness in the immediate postoperative period are hypoxemia and
pain. Although pain control is very important, determining the adequacy of ventilation in this case
has higher priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Assessment)
17. The nurse is caring for a client in the postanesthesia care unit (PACU) 2 hours after abdominal
surgery. The nurse auscultates the client’s abdomen and notes that there are no bowel sounds. What
action does the nurse take?
a. Position the client on the left side with the bed flat.
b. Insert a nasogastric tube to low intermittent suction.
c. Palpate the bladder and measure abdominal girth.
d. Document the finding and continue to monitor.
ANS: D
Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that should be
documented. No intervention specific to this finding is needed at this time.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Nursing Process (Assessment)
18. The nurse is changing the client’s dressing on the second postoperative day and notes a small
amount of serosanguineous drainage. What is the nurse’s best action?
a. Cleanse the suture line and apply a sterile dressing.
b. Culture the drainage and leave the incision open to air.
c. Cover the incision with a transparent dressing.
d. Notify the surgeon to assess the client.
ANS: A
A small amount of serosanguineous drainage is a normal assessment finding on the second
postoperative day. The incision should be cleaned and dressed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
19. The nurse is caring for a client who had abdominal surgery 3 days ago. He tells the nurse, “I felt
something ‘give way’ when I coughed.” What is the nurse’s best response?
a. “It is good that you are coughing and deep-breathing to prevent
pneumonia.”
b. “That is a normal feeling in the incision whenever you are moving.”
c. “Be sure to splint the incision with a pillow or your hands when you
cough.”
d. “Lie down flat on the bed with your knees up and let me examine your
incision.”
ANS: D
Although wound dehiscence is not a common complication after surgery, it is usually painless and
the client feels as if something has split or given way. This frequently occurs after coughing. Any
client report of such a sensation should be assessed immediately.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
20. A client reports pain 8 hours after surgery. The client has already received an opioid within the
past 2 hours. What is the nurse’s best action?
a. Assess the pain further.
b. Administer naloxone (Narcan).
c. Call the surgeon.
d. Document the finding.
ANS: A
Opioids are short acting. The client may be undermedicated. The nurse should further assess
location, intensity, etc., of the pain. If the client has no respiratory depression, it is possible that the
dose can be increased. The nurse would not call the surgeon until the pain is further assessed.
Narcan is used to reverse opioid effects but would not be appropriate in this case. Documentation is
important, but the higher priority is a more complete assessment of the client’s pain.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Nursing Process (Assessment)
21. A client with diabetes mellitus type 1 underwent surgery 24 hours ago. Which precaution does
the nurse take to help prevent postoperative complications for this client?
a. Order a high-protein diet.
b. Observe the incision frequently.
c. Have suction available at the bedside.
d. Instruct the client to use an electric razor.
ANS: B
The client with diabetes is at higher risk for impaired wound healing and the development of
wound infection. The nurse should observe the incision for drainage and changes in appearance.
The client does not need a high-protein diet, suction, nor an electric razor owing to diabetes.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
22. The nurse is providing discharge teaching for a client who will be going home with a Jackson-
Pratt (JP) drain. Which statement indicates that the client understands how to care for the drain
correctly?
a. “I will flush the tubing to make sure that it stays open.”
b. “I will measure the drainage before I discard it.”
c. “I will close the drain valve and then compress the bulb to create
suction.”
d. “I will pull it out once the surgeon says I don’t need it anymore.”
ANS: B
The drainage from the JP should be measured before it is discarded. The client does not have to
flush the tubing. The tubing is sutured in place, and the client should not pull on it. The bulb should
be compressed, then the drain valve closed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Prevention and/or Early Detection of Health
Problems—Self-Care) MSC: Integrated Process: Teaching/Learning
23. The nurse is caring for a client who has had surgery the previous day. The client tells the nurse,
“Breathing in using this thing (incentive spirometer) is a ridiculous waste of time.” What is the
nurse’s best response?
a. “The spirometer will help you cough effectively.”
b. “The spirometer will help your lungs expand.”
c. “The spirometer will help prevent blood clots.”
d. “The spirometer will improve blood flow in your lungs.”
ANS: B
The primary purpose of using an incentive spirometer is to promote lung expansion. The incentive
spirometer assists the client in seeing how much air he or she can inhale. The nurse can encourage
the client by setting a volume and encouraging the client to reach it. Although many clients may
cough while using this, it does not help them cough. Clients begin to cough after taking deep
breaths. The spirometer will help with airflow into the lungs, not with blood flow.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 294
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
24. After discharge from the postanesthesia care unit (PACU), the client returned to the surgical
nursing unit at 10 AM. It is now 6 PM, and the client is not experiencing any complications. How
often does the nurse assess the client’s vital signs?
a. Every 15 minutes
b. Every 30 minutes
c. Every hour
d. Every 4 hours
ANS: D
Once the client leaves the PACU, the nurse should monitor vital signs every 15 minutes 4, every
30 minutes 4, every hour 4, then every 4 to 8 hours for the next 24 to 48 hours. It has been 8
hours since the client returned to the surgical nursing unit, so vital signs should be monitored every
4 hours at this point.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 286
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Planning)
25. The nurse is caring for clients in the postanesthesia care unit (PACU). Which client is ready to
be extubated?
a. Client with an oxygen saturation of 90%
b. Client with a respiratory rate of 14 breaths/min
c. Client who is alert and oriented
d. Client who is coughing and gagging
ANS: D
Coughing and gagging on the endotracheal (ET) tube indicates readiness for extubation; the client
should be further assessed to see whether he or she meets other extubation criteria. Often these
criteria include ability to raise and hold the head up and evidence of thoracic breathing. An oxygen
saturation of 90% is abnormal. Respiratory rate and orientation status are not sufficient criteria for
extubation.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 294
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Therapeutic Procedures)
MSC: Integrated Process: Nursing Process (Assessment)
26. The nurse is working in the postanesthesia care unit (PACU) and receives a client from the
operating room (OR). What does the nurse assess first?
a. Client’s endotracheal tube
b. Client’s nasogastric tube
c. Client’s Foley catheter
d. Hemovac drain at the incision site
ANS: A
The first priority for this client is to assess airway, breathing, and circulation postoperatively.
Therefore, the patency of the client’s endotracheal (ET) tube should be determined first. All other
drains should be assessed, but they are not the priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
27. The nurse is caring for a client whose wound dehisces after vomiting. What is the nurse’s first
action?
a. Prepare the client for emergency surgery.
b. Cover the wound with sterile moist dressings.
c. Give the client medication for nausea.
d. Call the surgeon and the operating room.
ANS: B
The dehisced wound should be covered immediately with sterile moist dressings. Then the nurse
should call the surgeon.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
28. The nurse is changing the dressing on a postoperative client’s abdominal incision. A Jackson-
Pratt (JP) drain is present, along with a moderate amount of serosanguineous drainage. What is the
best product for the nurse to use in performing wound care?
a. Half hydrogen peroxide and half sterile saline
b. Sterile water and antibacterial ointment
c. Betadine swabs or alcohol wipes
d. Sterile normal saline
ANS: D
Sterile saline should be used to clean wounds because it is not harmful to granulating tissues.
Hydrogen peroxide, Betadine, and alcohol are all harmful to new tissue. Sterile water is not isotonic
so is not recommended. The incision should be cleaned from the least contaminated area to the
most contaminated area, from inside the incision toward the surrounding skin.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Therapeutic Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
29. The nurse is preparing a client for discharge. The client has a large draining wound. What is the
nurse’s best action?
a. Arrange a nurse to come to the house to change the dressing after
discharge.
b. Have the client come back to the clinic daily to have the dressing
changed.
c. Teach the client and family how to change the dressing.
d. Apply a hydrocolloid dressing and change once a week.
ANS: C
The nurse should teach the client and family members to change the dressing as necessary. If they
are not able to perform this task, a referral can be made for home health nursing. A daily trip to the
clinic would be inconvenient; this would increase the chance of noncompliance. A hydrocolloid
dressing is not indicated for this wound.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
30. A postsurgical client’s urinary output via the Foley catheter is 30 mL in 3 hours. What is the
nurse’s first action?
a. Increase the IV infusion rate.
b. Assess the client’s skin turgor.
c. Weigh the client.
d. Check the patency of the catheter.
ANS: D
The nurse should check to ensure that the client’s catheter tubing is patent. If the catheter is patent,
the nurse should increase the IV flow rate if there are orders to do so, or should call the surgeon to
report the information and request more fluids. Assessing the skin turgor would give information on
hydration status, but this would not be the first intervention. Weighing the client probably would
not give relevant information related to this client because the concern has arisen in the last 3 hours.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
31. The nurse is assisting a client to ambulate several hours after his surgery. The client coughs and
says to the nurse, “I feel like something ripped in my incision.” A large amount of blood is
suddenly apparent on the client’s gown near the incision. What action does the nurse take first?
a. Ease the client to the floor and call for assistance.
b. Put immediate pressure over the incision with the hands.
c. Call the Rapid Response Team to assess the client.
d. Lift up the gown and take off the dressing.
ANS: A
The first action of the nurse should be to ease the client to the floor to reduce tension on the
incision. This will help keep organs within the abdominal cavity and will help prevent the client
from fainting and falling to the floor. The nursing staff should return the client to bed, and the nurse
needs to reinforce the dressing while leaving the original one intact. The surgeon or the Rapid
Response Team should be notified.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
32. A client is scheduled for an operation. What does the nurse teach the client about postoperative
pain control?
a. “You should not ask for IV pain medication more than once every 4 or 5
hours.”
b. “You should not take the pain medication if you are nauseated.”
c. “You will not get pain medication until you are transferred to the floor.”
d. “You should ask for pain medication before the pain becomes severe.”
ANS: D
Pain medications are most effective when they are administered before the pain becomes severe. IV
pain medications often are given every 1 to 2 hours. If the client is nauseated, the IV route can be
used. The client will receive pain medication as needed in the postanesthesia care unit (PACU).
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
33. The nurse is caring for several postoperative clients on the unit. Which client does the nurse
assess first?
a. Client with 200 mL dark drainage from the nasogastric tube in an hour
b. Client who received oral pain medication 20 minutes ago
c. Client who has not yet ambulated after surgery 4 hours ago
d. Client requiring discharge teaching and whose family is present
ANS: A
200 mL of dark drainage from the nasogastric tube in an hour should be assessed and
communicated to the physician because it may indicate a bleed. Oral pain medication needs more
than 20 minutes to be effective, and the nurse should re-assess the client when the pain medication
has had time to take effect. Four hours is probably too soon for a client to ambulate after an
operation. The nurse should include the family in discharge teaching, but the client with the
nasogastric (NG) drainage needs to be seen first.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Analysis)
34. The nurse is reviewing postoperative medication orders. Which order can the nurse implement?
a. Acetaminophen orally PRN pain
b. Meperidine (Demerol) 75-100 mg every 3-4 hours PRN pain
c. MS .5 mg subcutaneously every 1-3 hours PRN pain
d. Hydromorphone hydrochloride (Dilaudid) 1 mg orally every 4 hours
PRN pain
ANS: D
The acetaminophen order does not have a frequency (PRN is not sufficient). The Demerol order
does not have a route. MS must be spelled out (morphine sulfate), and the dosage must be written
as 0.5 mg. The Dilaudid order includes the drug name, dosage, route, and frequency—all correctly
written out.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Error
Prevention)
MSC: Integrated Process: Communication and Documentation
35. The nurse is caring for a client who is reporting severe postoperative pain. The physician’s order
states that the client is to receive “hydromorphone hydrochloride (Dilaudid) 10-15 mg every 1-2
hours PRN pain.” What is the nurse’s priority action?
a. Call the physician to clarify the order.
b. Give the medication as ordered.
c. Refuse to give the medication.
d. Call the hospital pharmacist.
ANS: A
The order must be clarified before the medication is given because the Dilaudid dosage is beyond
safe parameters. The nurse can consult the pharmacist, but then would still need to call the
physician to determine the specific route of administration and eliminate the “ranges” in the order.
Refusing to give the medication will not help the client obtain pain relief.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Error
Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
36. Which instruction does the nurse provide to a client to prevent postoperative venous
thromboembolism?
a. “Cough and deep-breathe six times every hour after surgery.”
b. “Use your incentive spirometer hourly.”
c. “Get up and walk as much as possible.”
d. “Keep the sterile dressing on your incision.”
ANS: C
Ambulation will help prevent formation of blood clots in the legs, the most common site for
postoperative venous thromboembolism. Coughing and deep breathing will help prevent atelectasis,
and sterile dressings will help prevent wound infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Teaching/Learning
37. The nurse is assessing clients in the postanesthesia care unit (PACU). A client is shivering and
has a temperature of 95.4° F (35.2° C). What is the nurse’s best action?
a. Get the client warm blankets.
b. Elevate the head of the bed.
c. Auscultate the client’s lungs.
d. Assess the client’s oxygen saturation.
ANS: D
Hypothermia can cause shivering and hypoxemia. The nurse first should assess the client’s oxygen
saturation, then should apply warm blankets to bring the client’s temperature up to a normal level.
The other two actions may be needed but not as a priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
38. The nurse assesses clients in the postanesthesia care unit (PACU). Which client does the nurse
intervene for first?
a. Client with a respiratory rate of 12 breaths/min
b. Client with an oxygen saturation of 92%
c. Client who is reporting pain (5 out of 10)
d. Client with audible stridor
ANS: D
Stridor, a high-pitched crowing sound, indicates airway obstruction resulting from tracheal or
laryngeal spasms or edema or other airway blockage. Opening the airway is the highest priority.
The other clients are stable, although the client with pain may need pain medication. However, this
does not take priority over caring for the client with stridor.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
39. A client is being discharged after abdominal surgery. What information about the diet does the
nurse teach the client?
a. “Be sure to monitor your fluid intake.”
b. “Eat foods high in protein and vitamin C.”
c. “Call the physician if you develop gas.”
d. “You will need to limit your carbohydrates.”
ANS: B
Postoperatively, a diet high in calories, protein, and vitamin C promotes healing. There is no need
to monitor fluid intake, to call the physician for gas, or to limit carbohydrates.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 299
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration)
MSC: Integrated Process: Teaching/Learning
40. A client has received an overdose of a benzodiazepine. What medication does the nurse
anticipate an order for?
a. Flumazenil (Romazicon)
b. Naloxone (Narcan)
c. Acetylcysteine (Mucomyst)
d. Digoxin immune fab (Digibind)
ANS: A
Romazicon is the most commonly used antidote for benzodiazepine overdose. Narcan is used to
treat overdoses of narcotics, Mucomyst can be used for acetaminophen overdose, and Digibind is
used for digoxin overdoses.
DIF: Cognitive Level: Knowledge/Remembering
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes)
MSC: Integrated Process: Nursing Process (Implementation)
MULTIPLE RESPONSE
1. Which clients are at increased risk for postoperative nausea and vomiting? (Select all that apply.)
a. Older adult with a history of hypertension
b. Client who was in the lateral position during surgery
c. Middle aged client with a body mass index (BMI) of 46
d. Woman who has undergone a cholecystectomy
e. Young adult who received 3 L of IV fluid during surgery
f.
Man who has a history of seasickness
g. Man who has a nasogastric tube to suction
ANS: C, D, F
Obesity, motion sickness, and general anesthesia carry increased risk for postoperative nausea and
vomiting.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 290
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
2. A postoperative client is receiving morphine for pain. For which side effects does the nurse
monitor this client? (Select all that apply.)
a. Hypotension
b. Respiratory depression
c. Constipation
d. Increased intracranial pressure
e. Altered bleeding times
ANS: A, B, C
Morphine can cause hypotension, respiratory depression, constipation, and urinary retention.
Increased intracranial pressure is a side effect of butorphanol tartrate (Stadol), and altered bleeding
times can occur owing to combination drugs that contain aspirin or ibuprofen.
DIF: Cognitive Level: Knowledge/Remembering REF: Chart 18-6, p. 298
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Assessment)
OTHER
1. A surgical procedure has just been concluded for a client who received a general anesthetic. Place
the interventions in order of implementation. (Select in order of priority.)
a. Determining pain response
b. Assessing the IV
c. Taking the client’s vital signs
d. Applying warmed blankets
ANS:
d, c, a, b
First, warm blankets are applied for client comfort, because the client will start shivering as an
effect of the general anesthesia. Next, vital signs should be taken, then pain assessed. Finally, the
nurse can assess the IV.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
SHORT ANSWER
1. The nurse is caring for a postoperative client with a nasogastric (NG) tube to suction. The
collection container was marked at 125 mL at 7 AM. At 3 PM, 675 mL was in the container. During
the shift, the nurse used 45 mL of saline to irrigate the tube three times as prescribed by the
physician. What is the total amount of drainage from the NG tube that is entered into the client’s
record? ___________ mL
ANS:
415
675 mL – 125 mL = 550 mL of drainage
45 mL  3 = 135 mL of irrigant
550 mL – 135 mL = 415 mL of actual drainage from the NG tube
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Assessment)
2. The nurse is to administer 1 mg of butorphanol tartrate (Stadol) IV to a postoperative client.
Stadol is available as 2 mg/mL. How much Stadol does the nurse administer to the client?
________ mL
ANS:
0.5 mL
1 mg  1 mL/2 mg = 0.5 mL
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication
Administration)
MSC: Integrated Process: Nursing Process (Implementation)
3. A client is receiving morphine via patient-controlled analgesia (PCA) pump. Morphine is
available in a 5-mg/mL solution. The basal rate is 0.8 mg/hr. What is the total volume the client will
receive in 24 hours? _________ mL
ANS:
3.8 mL
0.8 mg/5 mg  1 mL = 0.16 mL/hr  24 = 3.8 mL/24 hr
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication
Administration) MSC: Integrated Process: Nursing Process (Assessment)
Chapter 19: Inflammation and the Immune Response
Chapter 19: Inflammation and the Immune Response
Test Bank
MULTIPLE CHOICE
1. A client has a reduction in immune function. What is the nurse’s priority action for this client?
a. Determine whether it is temporary or permanent.
b. Take the client’s vital signs every 4 hours.
c. Teach family members to receive the flu shot yearly.
d. Wash hands before entering the room.
ANS: D
The nurse should take precautions to prevent infection in the client who has a reduction in immune
function. It does not matter whether it is temporary or permanent. Teaching the family what to do
after the client is discharged from the hospital would not be the primary action. Taking vital signs
would be an important action but would not prevent infection, which is the priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
2. Which client is at highest risk of compromised immunity?
a. Client who has just had surgery
b. Client with extreme anxiety
c. Client who is awaiting surgery
d. Client who just delivered a baby
ANS: A
Intact skin is a defense to prevent infection; however, a client who has recently had surgery has a
portal for organisms to enter the body and cause infection.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 303
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
3. A client who has an extensive burn injury develops inflammation that covers the entire body.
What is the nurse’s best action?
a. Notify the health care provider immediately.
b. Document the assessment.
c. Take the client’s temperature.
d. Ask for an order for antibiotic therapy.
ANS: B
The inflammatory response depends on how severe the initiating event was. It would not be
unexpected to have an extensive inflammatory reaction to a severe burn injury. The nurse would
not have to notify the health care provider immediately, because this would not signal an
emergency. This does not necessarily indicate a fever or an infection; however, the client with
extensive burns would be prone to developing infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
4. A client’s absolute neutrophil count (ANC) is 550/mm 3. What is the nurse’s best action?
a. Use Standard Precautions.
b. Place the client on antibiotic therapy.
c. Place client on a low-sodium diet.
d. Administer chemotherapy.
ANS: A
The ANC is low. The client who has a low ANC is at risk of developing infection. The client would
not need to be started on antibiotic therapy, and a low-salt diet would not help the client.
Administering chemotherapy would further lower the ANC and would not be appropriate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
5. The nurse receives a report that a client’s laboratory results show a left shift or an increase in
circulating band neutrophils. What is the nurse’s best action?
a. Keep the client on bedrest.
b. Prepare the client for surgery.
c. Increase the client’s oxygen flow rate.
d. Assess the client’s vital signs.
ANS: D
A left shift indicates that the client cannot produce a sufficient number of mature neutrophils. One
condition that can cause this to happen is sepsis. Assessing vital signs, including temperature, can
assist the nurse in planning the next action. There would be no reason to keep the client on bedrest,
to prepare the client for surgery, or to increase the client’s oxygen at this point. The most
appropriate action is assessing for a problem.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Nursing Process (Implementation)
6. A client has an injury to the right ankle. On assessment, the nurse notes that it is red and
inflamed. The nurse adds interventions to the care plan that address which factor?
a. An injury that is infected
b. Inflammation without infection
c. A secondary infection
d. Dermatitis around the ankle
ANS: B
Inflammation can occur without infection. A joint sprain or injury can cause inflammation of the
joint. The nurse should not assume that there is an infection just because inflammation is evident.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
7. The nurse is teaching a client with a leg injury and warmth around the injured area. Which
statement by the client indicates a good understanding?
a. “The warmth indicates an infection.”
b. “The warmth indicates increased blood flow.”
c. “Warmth indicates that the tissues are rebuilding.”
d. “Warmth results from localized vasoconstriction.”
ANS: B
Injured tissues secrete histamine, serotonin, and kinins, which dilate the arterioles in the area of
injury, increasing blood flow and delivery of nutrients and causing warmth.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Teaching/Learning
8. A client enters the emergency department (ED) with an injury to the wrist. In assessment, the
nurse notes that the area is red, warm, and edematous. What is the nurse’s best action?
a. Apply a heating pad to the area.
b. Inject pain medication directly at the site.
c. Start an IV infusion of a vasoconstrictive drug.
d. Assess circulation and elevate the extremity.
ANS: D
Blood flow to the area of injury is increased, causing edema. Edema at the site of injury protects the
area from further injury by creating a cushion. A heating pad would enhance circulation to the area.
Injecting pain medication and starting an IV infusion of a vasoconstricting drug would not be
warranted. The best action is to elevate the extremity after ensuring adequate circulation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
9. The nurse is assessing a client who has a wound on the left calf. Drainage is coming from the
wound. What does the nurse tell the client about this finding?
a. “Exudate or drainage is a natural occurrence with inflammation.”
b. “Exudate or drainage means the wound is infected.”
c. “Drainage from a wound is never a good sign.”
d. “All wounds result in bleeding and pus formation.”
ANS: A
Inflammation can lead to exudate or drainage, so it is an expected finding, not a bad sign. It does
not mean the wound is infected. All wounds do not result in bleeding and pus formation.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 308
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
10. The nurse is caring for a client who has undergone a kidney transplant. The client asks the nurse
what will happen when his body realizes that the kidney is not “his.” What is the nurse’s best
response?
a. “The immune system will try to destroy the kidney if we don’t suppress
it.”
b. “As long as the kidney is a ‘match’ to your blood type, there will be no
problem.”
c. “You will develop a fever or other complications from the transplant.”
d. “Within a week, your body will ‘adjust’ to the new organ.”
ANS: A
Because a solid organ transplanted into a host is seldom a perfectly identical match of human
leukocyte antigens (unless the organ is obtained from an identical sibling) between the donated
organ and the recipient host, the client’s immune system cells recognize a newly transplanted organ
as non-self. Without intervention, the host’s immune system starts inflammatory and immunologic
actions to destroy or eliminate these non-self cells. The immune response is suppressed so that the
body will not attack the new organ.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 315
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Teaching/Learning
11. The nurse assesses a cut that is 24 hours old and finds that the site is swollen, red, and tender to
the touch. Which cell types are responsible for these assessment findings?
a. Erythrocytes and platelets
b. Basophils and eosinophils
c. Plasma cells and B-lymphocytes
d. Natural killer cells
ANS: B
Basophils and eosinophils release histamine, kinins, and other substances that cause the
manifestations of inflammation. Erythrocytes carry oxygen, and platelets help stop bleeding.
Plasma cells and B-lymphocytes produce antibodies to help fight infection, and natural killer cells
destroy invading bacteria.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 306
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
12. A client had a splenectomy. Which fact is most important to teach the client regarding immune
function?
a. “You won’t get a fever with infection, so you need to learn to identify
other symptoms.”
b. “It will no longer be necessary for you to worry about developing
allergies.”
c. “Avoid people who are ill because it will be harder for you to develop
antibodies.”
d. “You will need to be assessed yearly for the risk of developing cancer.”
ANS: C
The spleen is involved in B-lymphocyte maturation. People who undergo splenectomies for any
reason may have a decreased antibody-mediated immune response and thus would be more
susceptible to infection. Clients will still develop fever after splenectomy and are not at increased
risk for allergies or fever.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Teaching/Learning
13. A client’s white blood cell (WBC) count value is 10,000 cells/mm 3. The nurse reviews the
differential. Which counts or percentages is the nurse sure to report to the provider?
a. Eosinophils, 200/mm3
b. A left shift in the white count
c. Segmented neutrophils, 6000/mm3
d. Basophils 100/mm3
ANS: B
A left shift in the WBC count indicates that the client is experiencing a continuing infection and
that the client’s bone marrow cannot produce the required neutrophils, so it is now releasing
immature neutrophils into the blood. The eosinophil count, the segmented neutrophil count, and the
basophil count are all within normal ranges.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Nursing Process (Assessment)
14. The nurse is assessing a client who cannot synthesize suppressor T-cells. For what other
condition does the nurse assess the client?
a. Increased seasonal allergies
b. Multiple sclerosis
c. Leukemia
d. Graft-versus-host disease
ANS: A
Suppressor T-cells function to limit the actions of general and specific responses. These cells
prevent overreactions to the presence of “foreign proteins” within a person’s environment. People
who are deficient in suppressor T-cell activity have more severe hypersensitivity reactions,
allergies, and autoimmune responses. Low numbers of T-suppressor lymphocytes would not
increase the client’s risk for multiple sclerosis (MS), leukemia, or graft-versus-host disease.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
15. An older adult client tells the nurse that her granddaughter has chickenpox. The client is afraid
to visit because she is afraid of getting shingles from her granddaughter. What is the nurse’s best
response?
a. “If you already had chickenpox, you cannot get shingles.”
b. “If you already had shingles, you cannot get them again.”
c. “If you already had chickenpox, you can safely visit your
granddaughter.”
d. “Shingles is caused by a different virus than the chickenpox virus.”
ANS: C
Shingles is not transmitted from a person with chickenpox. Shingles (herpes zoster) is an infection
that manifests later in life because of residual virus retained in the dorsal root ganglia of sensory
nerves after a client has had chickenpox.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Teaching/Learning
16. A client recovering from hepatitis A asks whether he should take the vaccine to avoid
contracting the disease again. What does the nurse say?
a. “Yes, because now you are more susceptible to this infection.”
b. “Yes, because the hepatitis A virus changes from year to year.”
c. “No, your liver and immune system are too impaired at this time.”
d. “No, having the infection has done the same thing a vaccination
would.”
ANS: D
Vaccination with hepatitis A vaccine is an artificial way of stimulating the immune system to make
antibodies against hepatitis A (artificially acquired active immunity). This client’s immune system
has responded to an actual infection with hepatitis A by making many antibodies to hepatitis A
(naturally acquired active immunity); therefore he does not need a vaccination for this virus.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Teaching/Learning
17. A client reports severe hay fever and allergic rhinitis. Which finding does the nurse expect to see
in this client’s laboratory results?
a. Band neutrophils outnumber segmented neutrophils.
b. The basophil count is 50/mm3.
c. The eosinophil count is 20%.
d. The white count is 7500/mm3.
ANS: C
During allergic episodes, the eosinophil count is elevated both to respond to the presence of
allergens and to limit the tissue level responses of inflammatory cells by releasing enzymes capable
of degrading the vasoactive amines secreted by other leukocytes.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
18. A client has been diagnosed with a deficiency of complement proteins. Which assessment is the
item of highest priority for the nurse to perform?
a. Joint stiffness and range of motion
b. Enlarged lymph nodes and night sweats
c. Rhinorrhea and conjunctivitis
d. Lung sounds, cough, and oxygen saturation
ANS: D
The complement system attaches to viruses and bacteria so that they are more easily phagocytosed
by white blood cells (WBCs). Without an effective complement system, the client is susceptible to
bacterial and viral infections such as pneumonia. Pneumonia might manifest with abnormal lung
sounds, productive cough, and decreased oxygen saturation. Joint stiffness and limited range of
motion would suggest arthritis; enlarged lymph nodes and night sweats might indicate lymphoma;
rhinorrhea and conjunctivitis might indicate seasonal allergies.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
19. The nurse prepares to administer a tetanus toxoid vaccination to a client who has suffered a
puncture wound. The client reports that he had a tetanus shot just 1 year ago. What is the nurse’s
best action?
a. Give the vaccination because strains of tetanus change yearly.
b. Refrain from giving the vaccination if the client is reliable.
c. Give a smaller dose because antibody production slows down with
aging.
d. Give the shot because it won’t hurt to receive an extra dose of the
toxoid.
ANS: B
Tetanus toxoid boosters should be administered routinely every 10 years. In some cases, emergency
departments use 5 years as the cutoff for re-vaccination. If the client’s medical records substantiate
that he did indeed receive a tetanus toxoid booster 1 year ago, or if the client seems to be a reliable
historian, he does not need another one now.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication
Administration)
MSC: Integrated Process: Nursing Process (Implementation)
20. The nurse is caring for an older postoperative client. Which assessment finding causes the nurse
to assess further for a wound infection?
a. Moderate serosanguineous drainage is seen on the dressing.
b. The client is now confused but was not confused previously.
c. The white blood cell differential indicates a right shift.
d. The white blood cell count is 8000/mm3.
ANS: B
Older adult clients often do not demonstrate typical signs and symptoms of infection because of the
diminished immune function seen with aging. Often, the first sign of infection is mental status
changes. Any change in mental status in the older postoperative client should lead the nurse to
assess for a wound infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
21. The nurse is providing discharge teaching for a client following a liver transplant. Which
statement by the client indicates that additional teaching is needed?
a. “If I develop an infection, I should stop taking the steroid preparation.”
b. “If I have tenderness in my abdomen, I will call the physician.”
c. “I should avoid people who are ill or who have an infection.”
d. “Cyclosporine (Sandimmune) won’t work as well if I change the
routine.”
ANS: A
Immunosuppressive agents should not be stopped without consultation with the transplantation
physician, even if an infection is present. Stopping immunosuppressive therapy endangers the
transplanted organ.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes MSC: Integrated Process: Teaching/Learning
22. The nurse is caring for a client who is depressed because of acute rejection following a kidney
transplant. What is the nurse’s best response?
a. “This is what happens when you don’t take your transplant
medications.”
b. “At least you can still have dialysis, unlike people who receive liver
transplants.”
c. “One acute rejection episode does not mean that you will lose the new
kidney.”
d. “You can always find another donor and get another kidney transplant.”
ANS: C
An episode of acute rejection does not automatically mean that the client will lose the transplant.
Pharmacologic manipulation of host immune responses at this time can limit damage to the organ
and allow the graft to be maintained.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Caring
23. When an antibody titer to varicella zoster virus is performed on a nurse, the titer is negative.
Which result and action by the nurse’s supervisor are most appropriate?
a. The nurse has chickenpox and is contagious. The supervisor sends the
nurse home.
b. The nurse has never been infected with varicella zoster virus. The
supervisor assigns another nurse to care for clients with chickenpox.
c. The nurse had a subclinical case of herpes at least 5 years ago and is
now immune to the disease. The supervisor assigns the nurse to a client
with chickenpox.
d. The nurse has never been infected with varicella zoster virus and is
susceptible to herpes. The supervisor assigns another nurse to a client
with herpes.
ANS: B
The nurse does not have detectable levels of antibodies to the varicella zoster virus. The most likely
explanation for this is that she or he has never been infected with the virus, although it is possible
the infection occurred at such a young age that the nurse was unable to generate sufficient
antibodies.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
24. Which type of immunity does the hepatitis B immune globulin provide for the nurse?
a. Passive
b. Artificial active
c. Natural active
d. Cell-mediated
ANS: A
Passive immunity occurs when the individual is given antibodies that were created in the laboratory
or by another person. Active immunity occurs after exposure of the host to an antigen or
vaccination. Cell-mediated immunity is carried out by T-cells in response to specific antigens.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 313
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
25. The nurse is teaching a client who has recently given birth about immunity that has been passed
to the newborn. Which statement by the client indicates that additional teaching is needed?
a. “My baby received some antibodies from me before birth, and I will
give him more when I breast-feed.”
b. “I had the measles, so my baby will be protected against it until he is
old enough to receive the MMR vaccine.”
c. “I had chickenpox and am immune to it, so my baby will not need to
have the chickenpox vaccine.”
d. “Only certain antibodies were able to cross the placenta to protect my
baby.”
ANS: C
The baby receives passive immunity from antibodies that are passed through the placenta in utero.
Maternal passive immunity is temporary and will last for only a short time after birth.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Teaching/Learning
26. The nurse reviews the laboratory results of a client and finds that the white blood cell (WBC)
count is 1500/mm3. What is the priority action of the nurse?
a. Have the client wear a mask at all times.
b. Obtain a urine sample for culture and sensitivity.
c. Administer two units of fresh-frozen plasma.
d. Institute reverse isolation precautions.
ANS: D
A white cell count of 1500/mm3 indicates that the client is severely neutropenic and does not have
sufficient protection against invasion by bacteria and other organisms. Reverse isolation should be
initiated for his or her protection. A urine sample is not needed because the client is not being
evaluated for infection with a low WBC, but would be with a high one. Fresh-frozen plasma will
not increase the client’s WBC count. In reverse isolation, the client does not need to wear a mask.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
27. The nurse has sustained a needle stick injury and received a dose of hepatitis B immune
globulin. Which statement indicates that the nurse understands this intervention?
a. “I don’t need to receive the hepatitis B vaccine because I already had
the immune globulin.”
b. “I will need to receive only two doses of the hepatitis B vaccine because
I had one dose of the immune globulin.”
c. “I need to start the hepatitis B vaccination series as soon as possible.”
d. “I will make an appointment to start the hepatitis B vaccination series in
6 weeks.”
ANS: C
The hepatitis B immune globulin will provide only temporary protection against hepatitis B; the
student should begin the vaccination series as soon as possible to ensure long-lasting protection
against the virus.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Teaching/Learning
MULTIPLE RESPONSE
1. For which clients does the nurse assess for inflammation? (Select all that apply.)
a. Client who reports pain
b. Client diagnosed with an ear infection
c. Client who has sunburn
d. Client taking vitamin C 500 mg daily
e. Client with nausea
f.
Client reporting reflux
g. Client with frostbite
ANS: B, C, F, G
Ear infection, sunburn, acid reflux, and frostbite all cause inflammation. Inflammation causes pain.
Taking 500 mg vitamin C daily and having nausea do not cause inflammation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
2. The nurse is teaching a class about the immune system. The nurse asks the class to list various
functions of antibodies. Which class responses does the nurse evaluate as indicating a good
understanding? (Select all that apply.)
a. “They release chemicals to cause blood vessels to dilate.”
b. “They deactivate toxins that are released in an infection.”
c. “They tag bacteria so the macrophages know to eat them up.”
d. “They cause the person to have a fever.”
e. “They tell cells to make collagen for scar tissue.”
f.
“They turn on the complement system.”
ANS: B, C, F
Antibodies can neutralize viruses and bacterial toxins, can mark bacteria for destruction via
opsonization, and can activate the complement system. Antibodies do not secrete chemicals that
cause vasodilation, induce a febrile response, nor release collagen for scar tissue.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Teaching/Learning
3. The nurse suspects acute graft rejection after a client has undergone a kidney transplant. What
assessment findings confirm this diagnosis? (Select all that apply.)
a. Temperature of 100.6° F
b. Blood urea nitrogen (BUN) 56 mg/dL
c. Creatinine 3.2 mg/dL
d. Urine output 20 mL/hr
e. Extreme pain in the lower back
f.
Edematous ankles
ANS: A, B, C, D
Low-grade fever, elevated blood urea nitrogen (BUN), elevated creatinine, and decreased urine
output could all signal acute graft rejection of a kidney. The other answers do not.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
Chapter 20: Care of Patients with Arthritis and Other Connective
Tissue Diseases
Chapter 20: Care of Patients with Arthritis and Other Connective Tissue Diseases
Test Bank
MULTIPLE CHOICE
1. The nurse is teaching a community health class about health promotion techniques. Which
statement by a student indicates a strategy to help prevent the development of osteoarthritis?
a. “I will keep my BMI under 24.”
b. “I will switch to low-tar cigarettes.”
c. “I will start jogging twice a week.”
d. “I will have a family tree done.”
ANS: A
Obesity increases the stress on weight-bearing joints and contributes to the development of
degenerative joint disease. Smoking does not decrease risk for osteoarthritis. Jogging increases the
risk because of increased wear and tear on the joints. There is a genetic link to osteoarthritis;
creating a family tree might help the client discover if there is any familial link but will not help
prevent the disorder.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
2. The nurse is teaching a client who has osteoarthritis ways to slow progression of the disease.
Which statement indicates that the client understands the nurse’s instruction?
a. “I will eat more vegetables and less meat.”
b. “I will avoid exercising to minimize wear on my joints.”
c. “I will take calcium with vitamin D every day.”
d. “I will start swimming twice a week.”
ANS: D
Swimming is an excellent form of exercise for clients with arthritis because it involves minimal
weight bearing and stress on the joints from gravity. Eating more vegetables will not decrease the
progression of osteoarthritis. Taking calcium with vitamin D will decrease the risk of osteoporosis,
not osteoarthritis. Gentle exercise is important to help slow progression of the disease.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
3. The nurse is working with a client who will be taking 20 mg of prednisone daily for rheumatoid
arthritis. Which precautions does the nurse give the client about taking this medication?
a. “Take this medication at bedtime because it will make you sleepy.”
b. “Take calcium and vitamin D supplements daily.”
c. “Eat a high-fiber diet with lots of lean meats.”
d. “Wash your face twice a day with an antibacterial soap.”
ANS: B
Long-term steroid use is associated with many complications, including diabetes, infection, and
osteoporosis, among others. The client should be instructed to take calcium and vitamin D
supplements to help prevent osteoporosis. Prednisone does not cause constipation, so increased
fiber would not be helpful. Prednisone should be taken in the morning because it may interfere with
sleep if taken at bedtime. Washing the face with antibacterial soap may cause skin dryness and
breakdown.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
4. An older adult client is scheduled for knee replacement surgery. Which statement by the client
indicates a need for further preoperative instruction?
a. “I need to keep my leg positioned away from my body.”
b. “I may have a continuous passive motion machine for a few days.”
c. “I may need more pain medicine than I did with my hip replacement.”
d. “I probably can get back to work within 2 to 3 weeks.”
ANS: A
Dislocation is not a problem with knee replacement surgery, so the client does not need to keep his
or her leg abducted. The other statements indicate accurate understanding of the instructions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Evaluation)
5. A client returns to the medical-surgical unit after a total hip replacement with a large wedge-
shaped pillow between his legs. The client’s daughter asks the nurse why the pillow is in place.
What is the nurse’s best response?
a. “It will help prevent bedsores from developing.”
b. “It will help prevent nerve damage and foot drop.”
c. “It will keep the new hip from becoming dislocated.”
d. “It will prevent climbing out of bed if he becomes confused.”
ANS: C
Adduction of the operative leg beyond the midline could dislocate the new hip. The wedge pillow
will help prevent this from happening. The wedge will not prevent bedsores from developing
because it does not prevent pressure. The pillow will not prevent foot drop, because it is placed
between the legs. The pillow is not a restraining device, and it will not prevent the client from
climbing out of bed.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 325
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Communication and Documentation
6. The nurse is caring for a postoperative client on the medical-surgical unit following a total left
hip replacement the previous day. During the assessment, the nurse notes that the client’s left leg is
cool, with weak pedal pulses. What is the nurse’s first action?
a. Assess circulatory status of the right leg.
b. Notify the surgeon immediately.
c. Measure leg circumference at the calf.
d. Check for bilateral Homans’ signs.
ANS: A
The symptoms may represent impaired circulation or may be normal for this client. Before the
surgeon is notified, the status of the nonoperative leg should be assessed and assessment findings
on both legs compared with the client’s baseline. Homans’ sign (pain in the calf on dorsiflexion of
the foot) is not always indicative of a deep vein thrombosis and should not be evaluated until other
assessments are made. Measuring calf circumference would provide additional data related to deep
vein thrombosis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
7. A client is admitted for a total hip replacement. Past medical history includes diabetes mellitus
type 2, a heart attack 5 years ago, and allergies to sulfa drugs. The client currently takes insulin on a
sliding scale and celecoxib (Celebrex). Before administering the client’s medications, which action
by the nurse is most appropriate?
a. Take the client’s blood pressure in both arms.
b. Call the physician to clarify the orders.
c. Schedule a preoperative electrocardiogram.
d. Review the client’s laboratory values.
ANS: B
Celebrex is a cyclooxygenase (COX)-2 inhibitor. These drugs are thought to cause serious adverse
reactions such as myocardial infarction and renal problems. This client already has coronary artery
disease and a past myocardial infarction, so the nurse should discuss the order with the physician
before giving the medication. Reviewing laboratory results could indicate renal impairment, but
taking the client’s blood pressure and scheduling an electrocardiogram (ECG) would not take
priority over discussion with the physician.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
8. A client is receiving warfarin (Coumadin) daily following total hip replacement surgery. Which
laboratory value requires intervention by the nurse?
a. Potassium (K+), 4.2 mEq/L
b. International normalized ratio (INR), 5.1
c. Prothrombin time (PT), 13.4 seconds
d. Hemoglobin (Hg), 16 g/dL
ANS: B
Blood levels of Coumadin will be monitored by checking daily PT and INR (in some places, only
INR). The INR is critically high. The K+ is normal and is not monitored for Coumadin therapy. The
PT is used in some facilities to monitor Coumadin therapy. Hemoglobin would be important to
assess because a side effect of Coumadin is bleeding, and a dropping hemoglobin level would
indicate that bleeding was occurring. PT and hemoglobin are within the normal range.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Assessment)
9. The nurse is caring for a client who is 1 day post total hip replacement. The nurse is instructing
the client about how to perform quadriceps-setting exercises correctly. Which direction does the
nurse provide to the client?
a. “Straighten your legs and push the back of your knees into the
mattress.”
b. “Straighten your legs and bring each leg separately off the mattress 6
inches.”
c. “Raise each leg 10 inches off the bed, keep it straight, and make ankle
circles.”
d. “Bend each knee, and rapidly point your toes downward and then
upward.”
ANS: A
Quadriceps-setting exercises are done by straightening the leg as much as possible by attempting to
push the back of the knees into the mattress. The other exercises may be performed by the client as
tolerated, but these items do not describe quadriceps-setting exercises.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 327
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Teaching/Learning
10. The home care nurse is making a follow-up visit to a client who had total hip replacement
surgery 2 weeks ago. Which client statement indicates a need for clarification regarding
postoperative routine?
a. “My daughter helps me put on my elastic TED (thromboembolic
deterrent) hose every day.”
b. “I take 200 mg of Motrin (ibuprofen) at bedtime so that I can sleep.”
c. “Now that my hip doesn’t hurt, I can cross my legs like a lady again.”
d. “Each day, I try to increase my walking time by at least 10 minutes.”
ANS: C
Crossing the legs beyond midline can dislocate the new hip joint and should be avoided at all times.
The other statements demonstrate correct behavior and understanding.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
11. A client who has had bilateral total knee replacements is prescribed enoxaparin sodium
(Lovenox) injections twice daily for the next 3 weeks. The client asks the nurse why she has to
have the medication. What is the nurse’s best response?
a. “To prevent swelling within your new knee joints.”
b. “To prevent the formation of blood clots in your legs.”
c. “To prevent arthritis from developing in your new knee joints.”
d. “To prevent an infection from developing in your new knee joints.”
ANS: B
Lovenox is an anticoagulant that will help prevent formation of postoperative deep vein thrombosis
(DVT). Lovenox does not decrease or prevent swelling, it does not prevent arthritis, and it is not an
antibiotic.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 327
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Teaching/Learning
12. The nurse is caring for a client who had right total knee replacement surgery 3 days ago. During
the assessment, the nurse notes that the client’s right lower leg is twice the size of the left. What is
the nurse’s priority intervention?
a. Elevate the client’s right leg.
b. Apply antiembolism stockings.
c. Assess the client’s respiratory status.
d. Check the client’s pedal pulses.
ANS: C
A common complication after total knee replacement (TKR) is the formation of a thrombus below
the surgical site. This complication can lead to a pulmonary embolus and can be life threatening.
Before notifying the surgeon or the emergency team, assess the client’s pulmonary status to
determine whether he or she has any manifestations of an embolus. The client’s leg may be elevated
and pedal pulses palpated, but respiratory assessment must be done first. TED hose should not be
applied to a leg with suspected deep vein thrombosis (DVT).
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
13. A client had a total knee replacement earlier in the day and has a continuous femoral nerve
blockade (CFNB). When entering the room to assess the client, the nurse notes that the television
volume is quite loud. The client explains that it is hard to hear with “all the ringing in my ears.”
What action by the nurse takes priority?
a. Perform a neurovascular assessment on the operative extremity.
b. Call another nurse to notify the anesthesiologist immediately.
c. Take a full set of vital signs and discontinue the CFNB.
d. Pad the siderails and instituting other seizure precautions.
ANS: B
CFNB can enter the systemic circulation, causing tinnitus, nervousness, slurred speech,
bradycardia, hypotension, bradypnea, and seizures. Because the client is exhibiting signs the CFNB
has entered his or her circulation, the client is at risk for seizures and critical alterations in vital
signs. The nurse should stay with the client and should continue to assess him or her while another
nurse notifies the surgeon or the anesthesiologist.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
14. A client who has had total hip replacement surgery asks the nurse when she will be able to use a
regular-height toilet seat again. What is the nurse’s best response?
a. “As soon as you are able to walk without a limp.”
b. “As soon as the staples are removed from the incision.”
c. “When you are off pain medication and warfarin (Coumadin).”
d. “When you can hold your leg 6 inches off the bed for 5 full minutes.”
ANS: A
When the client is able to walk without a limp, the artificial joint is seated sturdily enough in place
that it will not be dislocated or dislodged by overflexing it. At that time, the client will no longer
need assistive devices or ambulatory aids. With staples removed, holding the leg off the bed and
taking Coumadin do not affect readiness to bend the hip enough to use a regular toilet seat.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 328
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
15. The nurse is caring for a client who has had hip replacement surgery 2 days before. The client
reports severe pain at the surgical site despite having received 2 Vicodin (acetaminophen and
hydrocodone) tablets 2 hours previously. The client is requesting IV pain medication. What is the
nurse’s primary intervention?
a. Assess the surgical site for signs of infection.
b. Administer 2 more Vicodin tablets.
c. Apply a large ice bag to the operative site.
d. Reassure the client that the Vicodin will work soon.
ANS: A
Most clients do not need IV pain medication after the first day. If the client seems to be having
unusual pain, the nurse should first assess the client for other problems, such as a joint infection. If
findings are normal, applying ice to the hip will help to reduce swelling and pain. It is not time for
another dose of Vicodin, because it has only been 2 hours. The nurse would not contact the surgeon
unless all pain methods tried did not work. The Vicodin should have worked within 2 hours, so the
nurse should not tell the client that the Vicodin will work shortly.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort
Interventions)
MSC: Integrated Process: Nursing Process (Implementation)
16. A client is suspected to have rheumatoid arthritis. Which manifestations does the nurse assess
this client carefully for?
a. Crepitus when the client moves the shoulders
b. Numbness and tingling in the client’s fingers
c. Client has cool feet, with weak pedal pulses
d. Low-grade fever, fatigue, anorexia with weight loss
ANS: D
Low-grade fever is common with rheumatoid arthritis because of the inflammatory response.
Fatigue, anorexia, and weight loss are also common symptoms. Impaired neurologic status,
popping sounds with range of motion (ROM), and poor circulation are not common symptoms of
rheumatoid arthritis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
17. The nurse is teaching a client how to reduce the pain that she often experiences with
fibromyalgia. Which statement does the nurse include in the teaching?
a. “Wear gloves outdoors in cooler temperatures.”
b. “Avoid exercising when your muscles are sore.”
c. “Make sure that you get enough sleep every night.”
d. “Stay out of the sun as much as possible.”
ANS: C
In many clients, the pain of fibromyalgia occurs as a direct response to sleep deprivation.
Encouraging the client to get sufficient sleep every night can drastically reduce the amount of pain
experienced. Wearing gloves will not decrease the pain of fibromyalgia, but it may help a disease
such as Raynaud’s phenomenon. Weight-bearing activities should not increase pain in a client with
fibromyalgia. Similarly, sun exposure has not been identified as a causative pain factor.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort
Interventions)
MSC: Integrated Process: Teaching/Learning
18. A client with a history of rheumatoid arthritis will be starting drug therapy with etanercept
(Enbrel). What is most important for the nurse to teach the client?
a. The correct technique for subcutaneous injections
b. How to self-monitor blood glucose levels
c. How to set up and prime the IV tubing
d. How to calculate the dosage based on symptoms
ANS: A
Enbrel is a parenteral medication that is given by subcutaneous injection. The client and/or the
family will need to be taught how to give a subcutaneous injection correctly. Blood glucose levels
should not be affected by this medication. The medication is not administered IV. Drug dosages are
not changed and recalculated by the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
19. The nurse provides discharge teaching for a client to prevent a new attack of gout. Which
statement by the client indicates that additional teaching is required?
a. “I will keep a food and symptom diary for a few weeks.”
b. “If I get a headache, I will take Tylenol instead of aspirin.”
c. “I hate to start limiting my fluid intake so much!”
d. “Citrus juices and milk may keep me from having kidney stones.”
ANS: C
Nutritional therapy for gout is controversial; however, clients do need to increase their fluid intake
to prevent kidney stones. Certain foods may precipitate an acute attack, so clients should learn to
determine which foods trigger their gout. Aspirin is well known to trigger gout attacks. Increasing
the intake of alkaline ash foods such as citrus juices and milk might prevent the formation of
kidney stones.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
20. The school nurse is working with a group of high school students who will be going on a field
trip to a nature center. Which student is at highest risk for a tick bite?
a. Male student with a beard and a baseball cap
b. Female student with long hair pulled back in a ponytail
c. Male student wearing a long-sleeved shirt and shorts
d. Female student who is wearing scented hand lotion
ANS: C
Long pants should be worn and tucked into socks or boots to help prevent tick bites. Facial hair,
hats, ponytails, and scented body products do not increase the risk for tick bites.
DIF: Cognitive Level: Comprehension/Understanding REF: Chart 20-15, p. 353
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
21. The school nurse removes a tick embedded in a student’s scalp by the hairline. Which follow-up
instruction is the nurse sure to provide to the mother?
a. “Call your pediatrician right away if a fever or a red rash develops at
the bite.”
b. “If your child does not have symptoms within 2 weeks, you can relax.”
c. “Call your pediatrician tomorrow to get antibiotics to prevent Lyme
disease.”
d. “Keep the site clean, but you don’t have to worry about further
problems.”
ANS: A
The mother should be instructed to monitor for early symptoms of Lyme disease (fever, rash at the
site, other flulike symptoms) following a tick bite. Symptoms can appear for up to 30 days after the
bite. Antibiotics are not prescribed as a preventive measure. Because Lyme disease can cause
serious complications, the mother needs to monitor the child’s condition carefully.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Teaching/Learning
22. The nurse has taught a client with lupus about skin protection in the clinic. Later, the nurse sees
the client at an outdoor music festival. Which observation by the nurse indicates that the client
requires further instruction?
a. Client is wearing a thin, long-sleeved shirt.
b. Client is wearing a hat with a full brim.
c. Client is discussing her new perm.
d. Client is seen applying sunscreen twice.
ANS: C
Alopecia is common; the client should use gentle shampoo and avoid any harsh chemical
treatments, such as a permanent wave. The other observations show good skin protection practices
by the client.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 346
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Assessment)
23. A client with diagnosed osteoarthritis comes to the clinic reporting a low-grade fever, fatigue,
and bilateral joint pain. What action by the nurse is most appropriate?
a. Assess the client for a systemic infection.
b. Discuss increasing the dose of anti-arthritis drugs.
c. Prepare the client for a laboratory draw for rheumatoid factor.
d. Teach the client joint protection activities.
ANS: C
Osteoarthritis is generally a unilateral disease. The manifestations that this client exhibits are more
consistent with rheumatoid arthritis, so the nurse will prepare the client for a blood draw. The nurse
may need to teach joint protection measures, but an accurate diagnosis is most important.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
24. The nurse is working in a primary care clinic and sees a young male client. The client is athletic
and is well over 6 feet tall, with size 14 shoes. What diagnostic test does the nurse facilitate for the
client?
a. Coagulation studies
b. Echocardiography
c. Electromyelography
d. Genetic testing
ANS: B
Marfan syndrome is seen in athletic clients who are very tall and have large hands and feet.
Echocardiography should be done for clients who may have Marfan syndrome to monitor for mitral
valve prolapse and aortic aneurysm. Marfan disease has a genetic component, and genetic testing
may be done, but the priority is monitoring the client for cardiac complications.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
25. The nurse is working in a clinic when a young male client presents with reports of pain with
urination. The client wants testing for sexually transmitted diseases (STDs). The nurse notes that
the client’s eyes are red and inflamed. What question by the nurse is most important?
a. “Do you have more than one sexual partner?”
b. “Do you have any new joint pain?”
c. “What eyedrops have you used for your red eyes?”
d. “Are you allergic to any antibiotics?”
ANS: B
The client has two symptoms of Reiter’s syndrome (urethritis and conjunctivitis). The nurse should
ask about joint pain because this is the third classic manifestation of this disease. All other
questions are appropriate, but before treatment is started, the client needs an accurate diagnosis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Integrity—Pathophysiology)
MSC: Integrated Process: Nursing Process (Planning)
26. A client presents with painful, inflamed fingers with small, hard, yellow nodules that have a
sandy yellow drainage. Which medication does the nurse prepare to administer to the client?
a. Colchicine (Colasalide)
b. Allopurinol (Zyloprim)
c. Methotrexate (Rheumatrex)
d. Aspirin
ANS: B
The client is presenting with symptoms of chronic gout, and allopurinol would be the drug of
choice to reduce uric acid levels. Colchicine is used to treat acute gout attacks. Methotrexate and
aspirin are not used to treat chronic gout.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Nursing Process (Planning)
27. A client had a total knee replacement this morning and has a continuous passive motion (CPM)
machine. What activity related to the CPM does the RN delegate to the unlicensed assistive
personnel?
a. Placing controls out of the reach of confused clients
b. Assessing the client’s response to the CPM
c. Teaching the client’s family the rationale for the CPM
d. Assessing neurovascular status of the leg in the CPM
ANS: A
All activities are appropriate for the client with a CPM, but the nurse can delegate only the task of
keeping controls out of reach of the confused client. All other activities would need to be performed
by the RN.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Delegation) MSC:
Integrated Process: Communication and Documentation
28. A client with chronic gout takes probenecid (Benemid) and comes to the clinic reporting
frequent severe headaches and a new gout flare. The client is frustrated because the gout had been
under good control. Which question by the nurse is most helpful?
a. “What do you take for your headaches?”
b. “Do you know what triggers your gout?”
c. “Have you been following your diet?”
d. “Did you switch from wine to beer lately?”
ANS: A
The nurse needs to assess what has changed for this client. The new onset of headaches should
prompt the nurse to question the client about pain medications because aspirin inactivates
probenecid. Gout can have triggers, but the client probably knows them by now if it has been well
controlled. Nutritional therapy for gout remains controversial. Excessive alcohol can trigger an
episode, but beer does not contribute any more than wine.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Assessment)
29. The nurse is caring for a pregnant client who is taking Humira (adalimumab) to control
symptoms of rheumatoid arthritis. The client mentions the pain and inconvenience of the
subcutaneous injections and asks, “While I’m pregnant, can I take this drug by mouth instead?”
What is the nurse’s best response?
a. “I will ask the physician to write a prescription for you today.”
b. “Humira takes much longer to work when it is given orally.”
c. “Humira can be given only by subcutaneous injection.”
d. “You can switch from Humira to oral leflunomide (Arava).”
ANS: C
Humira is given by subcutaneous injection only. Arava causes birth defects; clients taking it must
be on strict birth control and must inform their health care providers if pregnancy occurs.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Teaching/Learning
30. A female client with rheumatoid arthritis has taken Rheumatrex (methotrexate) for the past year
to control her symptoms. The client comes to the clinic and tells the nurse that a home pregnancy
test was positive. What is the nurse’s best response?
a. “You need to schedule a prenatal appointment with your obstetrician
right away.”
b. “Stop taking Rheumatrex immediately. I’ll tell the physician you are
pregnant.”
c. “Continue taking the Rheumatrex, and increase the dose if you have a
flare.”
d. “See a genetic counselor to determine whether your baby will have
rheumatoid arthritis.”
ANS: B
Rheumatrex is highly teratogenic and should not be taken during pregnancy. A prenatal
appointment should be made right away, but the first priority is to stop taking methotrexate.
Genetic counseling is not appropriate because the counselor will not be able to determine whether
the baby will develop rheumatoid arthritis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
31. The nurse is instructing a client about management of discoid lupus erythematosus (DLE).
Which statement indicates that the client requires additional teaching?
a. “I will be sure to apply sunscreen whenever I am outside.”
b. “I will apply small amounts of the steroid cream to my face twice a
day.”
c. “I will take Plaquenil (hydroxychloroquine sulfate) with breakfast each
morning.”
d. “Steroids weaken the immune system, so I will wash my hands
frequently.”
ANS: D
Steroid creams used for the treatment of discoid lupus will not weaken the immune system because
they should be applied in small amounts to affected areas. The client will be more sensitive to sun
exposure while using the steroid cream, so sunscreen should be used whenever the client goes
outside. The client should use only small amounts of the cream on her face. Plaquenil should be
taken with meals or a glass of milk.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Teaching/Learning
32. Which statement by a client indicates that additional teaching is needed in the management of
fibromyalgia?
a. “I will switch to decaffeinated coffee in the mornings.”
b. “Water aerobics classes will be a good form of exercise.”
c. “Limiting my physical activity will reduce my fatigue.”
d. “I will take my sertraline (Zoloft) right before I go to bed.”
ANS: C
Clients with fibromyalgia should be encouraged to exercise regularly, particularly performing
activities that are low impact. Sleep disturbances are common in fibromyalgia, and anything that
interferes with sleep, such as caffeine, should be avoided. Zoloft can cause drowsiness and should
be taken daily at bedtime.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
33. The nurse is caring for a client who has dysphagia caused by systemic sclerosis. What is the best
intervention for the nurse to implement for this client?
a. Encourage frequent, high-protein, easy to swallow foods.
b. Teach the client to lie flat after meals to prevent reflux.
c. Thicken liquids to a nectar or honey consistency.
d. Have the client hyperextend his or her neck while swallowing.
ANS: A
Clients with dysphagia frequently have esophageal motility problems, and swallowing becomes
difficult. This, combined with malabsorption, leads to a malnourished client. Frequent small meals
consisting of high-protein and easy to swallow foods are best. Clients should eat only in an upright
position to reduce choking. Thickening liquids may help, but this does not address the malnutrition.
Hyperextending the neck may help, but specific techniques should be determined by a swallowing
study.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration)
MSC: Integrated Process: Nursing Process (Implementation)
34. The nurse is instructing a client about the management of systemic sclerosis. Which statement
indicates that the client requires additional teaching?
a. “I will let my doctor know right away if I develop a fever.”
b. “Ice packs will help relieve the aching pain in my hips and knees.”
c. “I will wear mittens when I am in the freezer section of the grocery
store.”
d. “I will apply a rich moisturizer to my skin every morning after my
shower.”
ANS: B
Ice packs should not be used by clients with systemic sclerosis because the cold can trigger
symptoms of Raynaud’s phenomenon. The client should wear mittens whenever his or her hands
are exposed to cold temperatures, and moisturizer should be applied daily. The client should notify
the doctor if a fever develops.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
35. The nurse is working at a clinic, where several clients are waiting to be seen. Which client does
the nurse assess first?
a. Client with temporal arteritis with new onset of blurry double vision
b. Client with polymyalgia rheumatica with low-grade fever and fatigue
c. Client with polymyositis reporting generalized rash and joint pain
d. Client with ankylosing spondylitis who presents with back pain and
weight loss
ANS: A
Vision changes in a client with temporal arteritis are a dangerous sign that warrants immediate
medical attention. The other clients’ signs and symptoms are commonly seen with their conditions
and may be addressed on a more routine basis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
36. The nurse is caring for a female client who has a history of chronic fatigue syndrome. Which
finding is the nurse surprised to see in the client’s record?
a. Hemoglobin, 7.2 g/dL
b. Serum creatinine, 0.9 mg/dL
c. Multiple tender lymph nodes
d. Newly red, swollen, warm knee
ANS: A
Laboratory values are typically normal for chronic fatigue syndrome, and no laboratory test can
confirm the disease. A hemoglobin level of 7.2 is very low and is not seen with chronic fatigue
syndrome. The creatinine value is normal. Tender lymph nodes and inflamed joints are normal
findings in chronic fatigue syndrome.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
37. A client with rheumatoid arthritis had abdominal surgery and has returned to the postoperative
nursing unit. The client is unable to use the incentive spirometer correctly, demonstrating limited
lung volume and fatiguing easily. What action by the nurse takes priority?
a. Notify the physician immediately.
b. Have respiratory therapy re-instruct the client.
c. Assess for pain and medicate if necessary.
d. Let the client rest for a few hours.
ANS: A
Clients with rheumatoid arthritis can have cervical spine involvement resulting in subluxation. This
may lead to decreased respiratory function and can be life threatening. This client was recently
intubated for an operation and so is at higher risk for this problem. The nurse should notify the
physician immediately and continue assessing the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Analysis)
38. A nurse is caring for a client who has had rheumatoid arthritis (RA) for 5 years. Which
laboratory value requires the most immediate intervention by the nurse?
a. White blood cell count (WBC), 3800/mm 3
b. Hemoglobin (Hg), 10.6 g/dL
c. Blood urea nitrogen (BUN), 16 mg/dL
d. Creatinine, 3.2 mg/dL
ANS: D
Clients with RA usually have pancytopenia, or a decrease in all cell types. WBC and hemoglobin
are low, consistent with this condition. BUN is normal. Creatinine is very high; this indicates renal
disease. This client may have renal consequences of his or her RA, which should be investigated.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Analysis)
39. The nurse is caring for an older adult client who will be discharged after being hospitalized for a
total hip replacement. Which statement indicates that arrangements may have to be made to have
the client’s medications supervised at home?
a. “I will take my Coumadin pill every day just before the evening news.”
b. “My wife takes iron too, so we will take our pills together every
morning.”
c. “I prepare all my pills for the week and will place them in a labeled
medi-set.”
d. “If my legs get swollen, I will take an extra Coumadin pill that day.”
ANS: D
Warfarin (Coumadin) is an anticoagulant prescribed to prevent venous thromboembolism after joint
replacement surgery. It is not used for edema. The other statements show that the client has an
appropriate plan for self-administration of his medications.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Assessment)
40. The nurse is working with a client who has severe rheumatoid arthritis in her hands. The client
states that she is frustrated at mealtime because it is difficult for her to manage cups and silverware.
What is the nurse’s best response?
a. “I’ll have the nursing assistants set up your meal trays while you are in
the hospital.”
b. “Let’s see if the occupational therapist can provide you with some
utensils that are easier for you to use.”
c. “I’ll arrange for a home nursing assistant to help you with your meals
after you are discharged from the hospital.”
d. “Let’s see if the physical therapist can suggest some muscle
strengthening exercises for you.”
ANS: B
The client wishes to be more independent at mealtimes; adaptive eating utensils from the
occupational therapist will help her meet this goal. Muscle-strengthening exercises will not be as
effective for the client’s mealtime needs. The client wishes to remain as independent as possible, so
a home nursing assistant should not be suggested.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with
Interdisciplinary Team) MSC: Integrated Process: Caring
41. The nurse is caring for an older adult client who will be discharged home to live with an adult
daughter. The client will be given prescriptions for four new medications for rheumatoid arthritis.
How does the nurse ensure that the client will be able to take the medications correctly at home?
a. Monitor the client self-administering medications while in the hospital.
b. Include the client’s daughter when teaching the client about the
medications.
c. Provide the client with pamphlets and information about all the
medications.
d. Make a chart showing which medications the client should take at
different times.
ANS: B
Because the client will be living with the daughter, she should be included in the teaching plan
about the medications. Providing pamphlets or charts about the medications does not ensure that
the client knows how to take them correctly at home. Self-administering medications may or may
not be permitted by hospital policy and might be helpful, but including the daughter would be the
best option.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Assessment)
42. The nurse is caring for an older adult client who has fallen and fractured her hip. The client will
have hip replacement surgery followed by extensive rehabilitation. The client confides in the nurse,
“I feel like I don’t have any control over anything anymore now that I am old.” What is the nurse’s
best response?
a. “I’ll make sure that the physical and occupational therapists see you
after surgery to help get your strength back.”
b. “It’s normal to feel this way, but hopefully you will be back on your feet
after a stay in rehab.”
c. “It’s important to control what you can right now, like making out your
menu every day and working with the therapists.”
d. “I sense that you are feeling depressed about the situation. I will ask the
doctor to prescribe an antidepressant for you.”
ANS: C
The nurse should support the client’s self-esteem and increase feelings of competency by
encouraging activities that assist in maintaining some degree of control, such as participation in
decision making and performance of tasks that he or she can manage. The nurse should provide
immediate control options for the client, rather than waiting until after rehabilitation. The client’s
desire for control does not indicate depression, so an antidepressant is not indicated. Therapy
referrals are appropriate but do not address the client’s desire for control.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)
MSC: Integrated Process: Caring
43. The nurse is caring for an older adult client who has had a hip replacement 2 days previously.
Which assessment finding is the best indicator that the client does not need pain medication at this
time?
a. The client received 2 pain pills 2 hours ago.
b. The client states that she has no pain.
c. The client is sleeping quietly.
d. The client’s vital signs are stable.
ANS: B
The client’s report of pain is the best indicator of pain level, rather than vital signs, sleeping, or
time of last pain medication.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Assessment)
44. The nurse is caring for a client who has a history of severe rheumatoid arthritis. The client
becomes combative and abusive to the staff when she is unable to perform personal care
independently. What is the best statement the nurse can make to the client at this time?
a. “I will have to restrain your hands if you cannot keep them to yourself.”
b. “I will ask your doctor for a psychiatrist to talk to you about anger
management.”
c. “You seem frustrated. Would you like to try to dress again in a few
minutes?”
d. “Would you like me to get an order for medication to help you settle
down?”
ANS: C
The client is acting out her frustration over her chronic illness and loss of use of her hands. The
nurse should acknowledge this frustration. Allowing the client to make decisions regarding care
will help the client regain some sense of control and will help improve self-esteem. Requesting
sedation, suggesting psychiatric therapy, or threatening use of restraints is not appropriate, because
the client is expressing frustration over the situation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Caring
MULTIPLE RESPONSE
1. What interventions does the nurse recommend for a client who is to be discharged home
following total hip replacement surgery? (Select all that apply.)
a. Continuous passive motion machine
b. Elevated toilet seat
c. Walker
d. Crutches
e. TED hose
f.
Heating pad
ANS: B, C, E
The client will be using a walker, because crutches are used only by younger clients. TED hose
should be worn until the client regains full mobility and Coumadin is discontinued. A walker will
be needed until the client regains full strength and is able to walk with full weight bearing on the
operative side. Crutches are not used because they do not provide enough support for the client
during ambulation and pose a risk for falls. Heating pads increase blood flow to the area and may
increase pain. Ice packs should be used instead, as needed. Continuous passive motion machines
are not used after hip surgery.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
2. After hip replacement surgery, a client receives two doses of enoxaparin (Lovenox) during the
day shift. What orders does the nurse anticipate for the client? (Select all that apply.)
a. Laboratory draw for platelet count
b. Laboratory draw for prothrombin time (PTT)
c. Laboratory draw for international normalized ratio (INR)
d. Order for protamine sulfate
e. Order for vitamin K
ANS: A, D
Lovenox is a low–molecular-weight heparin. Side effects can include thrombocytopenia. The
antidote for all heparin products is protamine sulfate, although it will not be as effective for
Lovenox as it is for unfractionated heparin.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Analysis)
3. The nurse is teaching a client with rheumatoid arthritis (RA) about joint protection principles.
What information does the nurse include? (Select all that apply.)
a. Use smaller joints to rest the larger ones.
b. Hold objects with two hands, not one.
c. Sit most often in a reclining chair.
d. Use assistive-adaptive devices.
e. Bend at your knees to lift objects.
ANS: B, D, E
Clients with RA should use large joints to protect smaller ones, should hold objects with two hands
instead of one, should sit in chairs with straight backs, should not bend at the waist but rather bend
the knees while keeping the back straight, and should use assistive-adaptive devices wherever
possible.
DIF: Cognitive Level: Comprehension/Understanding REF: Chart 20-6, p. 332
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
Chapter 21: Care of Clients with HIV Disease and Other Immune
Deficiencies
Chapter 21: Care of Clients with HIV Disease and Other Immune Deficiencies
Test Bank
MULTIPLE CHOICE
1. Which action by the nurse is most effective to prevent becoming exposed to the human immune
deficiency virus (HIV)?
a. Always use Standard Precautions with all clients in the workplace.
b. Place clients who are HIV positive in Contact Precautions.
c. Wash hands before and after contact with clients who are HIV positive.
d. Convert parenteral medications to an oral form for clients who are HIV
positive.
ANS: A
The best prevention for health care providers is the consistent use of Standard Precautions with all
clients, as recommended by the Centers for Disease Control and Prevention (CDC). Contact
Precautions are not indicated unless the client has an infection such as Clostridium difficile or
MRSA (methicillin-resistant Staphylococcus aureus).
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
2. The nurse is caring for a young client who has acquired immune deficiency syndrome (AIDS)
and a very low CD4+ cell count. The nurse is teaching the client how to avoid infection at home.
Which statement by the client indicates that additional teaching is needed?
a. “I will let my sister clean my pet iguana’s cage from now on.”
b. “My brother will change the kitty litter box from now on.”
c. “It will seem funny but I’ll run my toothbrush through the dishwasher.”
d. “I will not drink juice that has been sitting out for longer than an hour.”
ANS: A
Immune compromised clients should avoid having reptiles or turtles as pets and should avoid
changing cat litter to help prevent opportunistic infections. Drinking juice that has been at room
temperature for longer than 1 hour can lead to opportunistic infection and should be avoided.
Clients should clean their toothbrushes daily by running them in the dishwasher or rinsing them in
liquid laundry bleach.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
3. The nurse is working with a client at a public health clinic. The client says to the nurse, “The
doctor said that my CD4+ count is 450. Is that good?” What is the nurse’s best response?
a. “Your count is high so you can cut back on your medication.”
b. “Your count is normal because your medications are working well.”
c. “Your count is a bit low and you are susceptible to infection.”
d. “Your count is very low and you actually now have AIDS.”
ANS: C
A CD4+ T-cell count of 450 cells/mm3 of blood is low, and the client is at increased risk for
developing an infection. Normal CD4+ counts range from 800 to 1000 cells/mm 3. To be diagnosed
with AIDS, a client must have a CD4+ T-cell count of <200 cells/mm 3 (or a CD4+ T-cell percentage
of <4%) and/or an opportunistic infection.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 360
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Teaching/Learning
4. The nurse is caring for a young woman at the primary health care clinic. Which assessment
finding leads the nurse to question the client about risk factors for HIV?
a. Six vaginal yeast infections in the last 12 months
b. Unable to become pregnant for the last 2 years
c. Severe cramping and irregular periods
d. Very heavy periods and breakthrough bleeding
ANS: A
Persistent or recurrent vaginal candidiasis may be the first symptom of HIV in women. Decreased
immune function allows overgrowth of this fungus. Infertility, heavy periods, and cramping are not
generally indicative of HIV.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 361
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
5. A client who is positive for HIV presents with confusion, fever, headache, blurred vision, nausea,
and vomiting. What does the nurse do first?
a. Assess the client’s deep tendon reflexes.
b. Ask the client to place his chin on his chest.
c. Start an IV line with normal saline.
d. Assess the client’s pupil reaction.
ANS: B
The client’s symptoms are associated with cryptococcal meningitis, so the nurse should first ask the
client to place the chin on his or her chest. The presence of nuchal rigidity (pain when flexing the
chin to the chest) helps confirm the diagnosis. An IV line may be started after the neurologic
assessment is completed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
6. The nurse is caring for a client with AIDS who has just been diagnosed with cryptococcal
meningitis. Which is the best nursing intervention for this client?
a. Initiate respiratory isolation for the next 72 hours.
b. Initiate seizure precautions with padded siderails.
c. Thicken the client’s liquids to honey consistency.
d. Administer IV pentamidine isethionate (Pentam).
ANS: B
Cryptococcosis is a debilitating form of meningitis that can cause seizures, so seizure precautions
should be initiated. Respiratory isolation is not indicated. Dysphagia is not seen with cryptococcal
meningitis, so thickened liquids are not indicated. Pentam is given for Pneumocystis jiroveci
pneumonia (PJP).
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
7. A client with AIDS has been admitted with fever, night sweats, and weight loss of 6 pounds in 2
weeks. The client’s purified protein derivative (PPD) test, placed 3 days ago in the clinic, is
negative. Which action by the nurse is most appropriate?
a. Place the client in Airborne Precautions.
b. Facilitate the client’s chest x-ray.
c. Initiate a 3-day calorie count.
d. Start an IV of normal saline.
ANS: A
The client’s symptoms are indicative of tuberculosis (TB). With AIDS, the client’s CD4+ T-cell
count is so low that the client cannot mount an immune response to the PPD; thus it appears
negative. The client needs to be placed in Airborne Precautions until other diagnostic tests rule out
TB. The other interventions are appropriate, but they do not take priority over infection control
principles.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Analysis)
8. The nurse is caring for a newly diagnosed HIV-positive client who will be taking enfuvirtide
(Fuzeon). Which precaution is important for the nurse to communicate to this client?
a. “Stop taking the medication if you develop a fever.”
b. “Rotate the sites where you will be giving the injections.”
c. “Take this medication with a snack or a small meal.”
d. “Do not drive or operate machinery while taking this drug.”
ANS: B
Fuzeon is available only as a subcutaneous injection and can cause injection site reactions and
nodules. The client should be taught the subcutaneous technique, including rotation of sites. The
client should not stop taking this medication for fever, it can be given without regard to food, and
the drug will not make the client sleepy or drowsy, so caution with driving or operating machinery
is not needed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication
Administration) MSC: Integrated Process: Teaching/Learning
9. A client who is receiving highly active antiretroviral therapy (HAART) tells the nurse, “The
doctor said that my viral load is reduced. What does this mean?” What is the nurse’s best response?
a. “The HAART medications are working well right now.”
b. “You are not as contagious as you were anymore.”
c. “Your HIV infection is becoming resistant to your medications.”
d. “You are developing an opportunistic infection.”
ANS: A
The fact that the amount of virus is reduced means that the HAART regimen is working well to
suppress viral replication. The risk of becoming infected by an HIV-positive person is always
present. The reduced viral load is not related to an opportunistic infection or to resistance to
medication.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 370
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes)
MSC: Integrated Process: Communication and Documentation
10. The nurse is seeing clients at a drop-in primary health clinic. Which client does the nurse teach
about the risks of acquiring HIV?
a. Middle-aged woman with a new sexual partner
b. Young male who has male sexual partners
c. All clients who come to the clinic
d. Young woman having her first gynecologic examination
ANS: C
All sexually active people should know their HIV status, and all people need to have education on
their risk of acquiring HIV infection. Anyone who engages in sexual activity has some risk.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 362
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Teaching/Learning
11. An HIV-positive client is taking lopinavir/ritonavir (Kaletra) and reports nausea, abdominal
pain, and diarrhea. What orders does the nurse anticipate?
a. Renal function studies
b. Liver enzymes
c. Blood glucose monitoring
d. Albumin and prealbumin
ANS: B
Kaletra can cause liver complications, and clients taking it should have liver function studies. The
client’s symptoms could indicate a liver problem. Renal function and blood glucose are not affected
by Kaletra. The client may have an albumin and a prealbumin drawn if he or she has lost a great
deal of weight and malnutrition is suspected, but the more common diagnostic test for a client
taking Kaletra would be liver function studies.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
12. The nurse has been exposed to HIV through splashing of urine from a client who is HIV
positive with a low viral load. The urine came into contact with the nurse’s face. Which drug
regimen does the nurse prepare to initiate?
a. Retrovir (zidovudine) for 14 days
b. Retrovir (zidovudine) for 28 days
c. Retrovir (zidovudine) and Epivir (lamivudine) for14 days
d. Retrovir (zidovudine) and Epivir (lamivudine) for 28 days
ANS: D
The Centers for Disease Control and Prevention have developed guidelines for postexposure
prophylaxis (PEP). This nurse’s exposure requires basic PEP with two drugs for 28 days.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Planning)
13. The nurse is teaching a client how to prevent transmitting HIV to his sexual partner. Which
statement by the client indicates that additional teaching is needed?
a. “I can throw the condoms in the trash after I have used them.”
b. “I will store my condoms in my wallet so they are always handy.”
c. “Water-based lubricants are best to prevent condom breakage.”
d. “The condom needs to stay on until I withdraw my penis.”
ANS: B
Condoms should be stored in a cool, dry place. Wallets are not recommended because body heat
can weaken the latex in the condom. The condom should stay on the penis until it is completely
withdrawn. Condoms should be used only once and then discarded. Oil-based lubricants can
weaken latex, possibly causing tearing or leakage, so only water-based lubricants are
recommended.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors)
MSC: Integrated Process: Teaching/Learning
14. The nurse is teaching a seminar about preventing the spread of HIV. Which statement by a
student indicates that additional teaching is required?
a. “A woman can still get pregnant if she is HIV positive.”
b. “I won’t get HIV if I only have oral sex with my partner.”
c. “Showering after intercourse will not prevent HIV transmission.”
d. “People with HIV are still contagious even if they take HAART drugs.”
ANS: B
HIV may be transmitted via oral sex when mucous membranes or nonintact skin comes in contact
with infected body fluids (semen or vaginal secretions) or blood. Women who are HIV positive
may get pregnant, and showering after intercourse will not reduce the risk of HIV transmission.
HAART will lower viral loads, but the client will still be able to transmit the HIV virus to others.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors)
MSC: Integrated Process: Teaching/Learning
15. The nurse is teaching a client who has AIDS how to avoid infection at home. Which statement
indicates that additional teaching is needed?
a. “I will wash my hands whenever I get home from work.”
b. “I will make sure to have my own tube of toothpaste at home.”
c. “I will run my toothbrush through the dishwasher every evening.”
d. “I will be sure to eat lots of fresh fruits and vegetables every day.”
ANS: D
The client should avoid eating raw fruits, vegetables, and salads because of the risk of infection.
Hands should be washed whenever returning home, and immune compromised clients should not
share toothbrushes or toothpaste. Toothbrushes should be run through the dishwasher nightly.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
16. The nurse is teaching a postmenopausal client about the risk of acquiring HIV infection. The
client states, “I’m an old woman! I cannot possibly get HIV.” What is the nurse’s best response?
a. “Your vaginal walls become thicker after menopause, which increases
your risk.”
b. “Women in your age-group are the fastest growing population of AIDS
clients today.”
c. “Hormonal fluctuations after menopause make it harder to fight off
infection.”
d. “You might be right. How often do you engage in sexual activities?”
ANS: B
Women are the fastest growing group with HIV infection and AIDS. Infection with HIV can occur
at any age, and postmenopausal women experience thinning of vaginal tissue along with an agerelated (not hormonal) decline in immune function. This places the older woman at higher risk of
acquiring HIV infection. The frequency of sexual activity is not as relevant as the sexual activities
the person practices.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 361
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Teaching/Learning
17. A client has selective immune globulin A (IgA) deficiency. The provider orders an infusion of
immune globulin (IVIG). Which action by the nurse is best?
a. Start a second IV line for the client’s antibiotics.
b. Call the physician to clarify the order.
c. Review the client’s renal panel before administration.
d. Obtain baseline vital signs and another set after 15 minutes.
ANS: B
Clients with selective IgA deficiency are not treated with IVIG because it contains very little IgA,
and because the risk of allergic reactions is high. The nurse should contact the provider to clarify
what medications the client will be taking.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
18. The nurse is working with a client who has AIDS-related dementia and will soon be discharged
to the care of family members. What teaching topic is best for the nurse to include in the discharge
plan?
a. Feed the client when he will not do it by himself.
b. Make sure that a clock and a calendar are easily visible.
c. Remove locks from bathroom and bedroom doors.
d. Do not allow the client to smoke when he is alone.
ANS: B
Having a clock and a calendar easily visible will help the client keep track of the date and time and
will assist with reorientation. Banning smoking, removing locks, and feeding the client will not
facilitate reorientation when the client is confused.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Behavioral Interventions)
MSC: Integrated Process: Teaching/Learning
19. A client with HIV who is taking highly active antiretroviral therapy (HAART) medications is in
radiology waiting for a chest x-ray when medications are due. What action by the nurse is best?
a. Call radiology to see when the client will be brought back to the nursing
unit.
b. Send the nursing assistant to radiology to bring the client back to the
nursing unit.
c. Take the client’s medications to radiology and administer them there if
possible.
d. Stagger the next dose of the medication if the current dose is given late.
ANS: C
HAART medications must be given on time and in the correct dose when an HIV client is in the
hospital. Missing or delaying even a few doses can lead to drug resistance. The best option would
be for the nurse to administer the medications in radiology as the client continues to wait for the xray. Calling the radiology department might give the nurse information but does not ensure that the
client receives the medication on time. Bringing the client back to the nursing unit might delay the
x-ray.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication
Administration)
MSC: Integrated Process: Nursing Process (Implementation)
20. An HIV-positive client verbalizes concerns about the high cost of antiretroviral medications.
What is the nurse’s best response?
a. “The medications are actually less expensive than they used to be.”
b. “These medications are the best course of treatment for you.”
c. “You should be glad the medications will help prolong your life.”
d. “Let’s talk to the social worker about getting financial assistance for
you.”
ANS: D
This response demonstrates the nurse’s role as client advocate by identifying resources to help meet
the client’s needs. The nurse should not belittle the client’s concerns by telling the client to be glad
the medications are working, or that they are less expensive than previously.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with
the Interdisciplinary Team) MSC: Integrated Process: Caring
21. The nurse is caring for a client who is HIV positive. The client has become confused over the
course of the shift, and the client’s pupils are no longer reacting to light equally. The nurse
anticipates an order for which medication?
a. Prednisone (Deltazone)
b. Trimethoprim/sulfamethoxazole (Bactrim)
c. Pentamidine isethionate (Pentam)
d. Ketoconazole (Nizoral)
ANS: A
Confusion and changes in pupillary assessment in an HIV-positive client indicate increased
intracranial pressure (ICP). Increased ICP in these clients is managed with corticosteroids like
prednisone. Bactrim is an antibiotic, Pentam is an antiprotozoal, and Nizoral is an antifungal
medication.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Nursing Process (Analysis)
22. A client verbalizes a fear of contracting HIV because she has a history of intravenous substance
abuse. What instructions does the nurse provide to the client to help minimize this risk?
a. “Boil all needles and syringes for at least 20 minutes before using them
again and be sure not to share them.”
b. “Rinse used needles and syringes with water followed by laundry
bleach after using them.”
c. “Rinse used needles and syringes with rubbing alcohol before and after
using them.”
d. “Run all needles and syringes through the dishwasher with an extra
rinse cycle before using them again.”
ANS: B
To minimize the risk for HIV transmission, needles should be cleaned with laundry bleach after
use. Boiling needles and syringes and rinsing with alcohol are not recommended. Running needles
and syringes through the dishwasher will not sanitize them sufficiently. The client should be
encouraged not to share needles and syringes.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 362
TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors)
MSC: Integrated Process: Teaching/Learning
23. The nursing supervisor is working with an HIV-positive nurse who has open weeping blisters on
her arms after being exposed to poison ivy. Which instructions should the nursing supervisor
provide to the nurse before she starts her shift?
a. “You should reassure your clients that you are not contagious.”
b. “You should work phone triage at the desk today rather than taking
clients.”
c. “You should wear a long-sleeved scrub jacket today while working with
clients.”
d. “You should not care for clients who are immune compromised or in
isolation.”
ANS: B
HIV-positive health care workers should not perform direct client care when they have open sores.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Planning)
24. The nurse is caring for an HIV-positive client. What assessment finding assists the nurse in
confirming progression of the client’s diagnosis to AIDS?
a. Generalized lymphadenopathy
b. HIV-positive status for 8 years
c. Low-grade fever for the last 10 days
d. Thick white patches on the client’s tongue
ANS: D
Candidiasis, which presents with thick white patches on the tongue and oral mucosa, is associated
with the development of AIDS after HIV infection. The fact that the client has been positive for 8
years or has a low-grade fever is not significant.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
25. A nursing assistant asks the nurse if respiratory isolation is needed for a client with
Pneumocystis jiroveci pneumonia. What is the nurse’s best response?
a. “This type of pneumonia is an opportunistic infection, so the staff is not
at risk.”
b. “You should wear a mask and a gown to provide care.”
c. “Yes, please institute respiratory isolation because this is very
contagious.”
d. “You are not at risk for this infection if you have had a vaccination.”
ANS: A
Pneumocystis jiroveci pneumonia is an opportunistic infection that will not cause disease in staff
with healthy immune systems. Standard Precautions should be used for this client. Contact,
Airborne, or Droplet Precautions are not indicated for this client. Health care staff do not get
vaccinated for this infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
26. When obtaining a sexual history from a client in a clinic setting, the nurse notes that the client
appears very uncomfortable and pauses for long periods before answering the nurse’s questions.
What is the nurse’s best response?
a. “I am sorry that my questions are making you very uncomfortable.”
b. “Don’t worry. We’ll be done with these questions in no time at all.”
c. “Take your time. I realize that this is a very private topic to talk about.”
d. “These questions are making you uncomfortable, so we’ll finish next
time.”
ANS: C
The client should be given time to collect his or her thoughts and composure before answering
questions. The nurse should not apologize for asking pertinent questions about the client’s health
history. The sexual history should not be deferred until the next appointment. Recognizing the
difficulty the client may be experiencing is helpful in establishing a therapeutic relationship.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communications)
MSC: Integrated Process: Caring
27. The nurse asks a young adult client if she is sexually active. The client asks why the nurse needs
to know. What is the nurse’s best response?
a. “I just need to make sure that the information you are providing is
reliable.”
b. “I have to fill in answers to all of the questions on the health history
form.”
c. “If you are sexually active, we should talk about ways to prevent getting
HIV.”
d. “I will have to notify your partner if you have a sexually transmitted
disease.”
ANS: C
The nurse should assess whether the client is sexually active to determine whether it is appropriate
to teach about safer sex practices. The nurse would not notify the client’s sexual partners if a
sexually transmitted disease were diagnosed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)
MSC: Integrated Process: Caring
28. The nurse is completing a health history for a client and begins to obtain a sexual history. What
is the nurse’s best opening question?
a. “How long have you been sexually active?”
b. “Are you in a monogamous relationship with your spouse?”
c. “How do you feel about answering questions about your sexual
history?”
d. “Have you noticed any problems with your ability to have or enjoy
sex?”
ANS: C
The nurse should begin with an assessment of the client’s comfort level with the topic. The nurse
should not assume that the client is sexually active or start with questions about the client’s spouse.
The nurse also should not use words like “monogamous,” which frequently are misunderstood by
the public. The question about sexual ability and enjoyment is a closed-ended question, and if the
client answers “no,” it will be awkward for the nurse to continue discussing this topic.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communications)
MSC: Integrated Process: Caring
29. The nurse is caring for a client with HIV who has been prescribed didanosine (Videx EC).
Which action by the nurse is most appropriate?
a. Help the client plan specific meal and dosing times.
b. Explain that the client will have frequent complete blood counts
(CBCs) drawn.
c. Advise the client to take Videx EC with milk or a small meal.
d. Tell the client to take Tylenol (acetaminophen) for any abdominal pain.
ANS: A
Videx EC must be taken on an empty stomach 30 minutes before or 2 hours after a meal. The nurse
should assist the client in planning a daily schedule that includes meals and drug doses. Videx does
not affect bone marrow, so frequent CBCs are not needed. A client on this drug who reports
abdominal pain should be assessed for pancreatitis, a common adverse effect.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
MULTIPLE RESPONSE
1. The nurse is caring for a hospitalized client who has AIDS and is severely immune compromised.
Which interventions are used to help prevent infection in this client? (Select all that apply.)
a. Use sterile gloves and gowns whenever the nursing staff is in contact
with the client.
b. Provide an incentive spirometer to encourage coughing and deep
breathing by the client.
c. Keep a blood pressure cuff, thermometer, and stethoscope in the client’s
room for his or her use only.
d. Use N95 respirators (all nursing staff) when in the client’s room.
e. Request that the family take home the fresh flowers that are at the
client’s bedside.
f.
Assist the client with meticulous oral care after meals and at bedtime.
ANS: B, C, E, F
The nursing staff should encourage coughing and deep breathing to prevent pneumonia, and
incentive spirometry will be helpful. Assessment equipment such as thermometers and blood
pressure cuffs should be kept in the room only for the use of this client, rather than being used by
other clients on the unit as well. Fresh flowers can harbor microorganisms and should be removed
from the room. Meticulous oral care will help to prevent infection by Candida.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
SHORT ANSWER
1. The nurse is to give a client ganciclovir (Cytovene) for cytomegalovirus (CMV) retinitis. The
dosage is 5 mg/kg IV every 12 hours. The client weighs 185 pounds. How many milligrams of
ganciclovir does the client receive per dose? mg/dose
ANS:
420
185 lb  1 kg/2.2 lb  5 mg/kg = 420 mg/dose
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication
Administration)
MSC: Integrated Process: Nursing Process (Implementation)
2. The nurse is to give a client rifampin (Rifadin) for tuberculosis. The dosage is 10 mg/kg/day. The
client weighs 198 lb, and the medication is available in 150-mg capsules. How many capsules of
rifampin does the client receive daily? __________ capsules/day
ANS:
6
198 lb  1 kg/2.2  10 mg/kg = 900 mg  1 capsule/150 mg = 6 capsules/day
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication
Administration)
MSC: Integrated Process: Nursing Process (Implementation)
Chapter 22: Care of Patients with Immune Function Excess:
Hypersensitivity (Allergy) and Autoimmunity
Chapter 22: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and
Autoimmunity
Test Bank
MULTIPLE CHOICE
1. Which characteristic is common to all types of hypersensitivity reactions?
a. Decreased inflammatory responses
b. Presence of tissue-damaging reactions
c. Enhanced natural killer cell activity
d. Inability to recognize extraneous cells
ANS: B
The defining difference between a normal immune response and that termed hypersensitivity is that
the immune system reacts excessively or inappropriately, with resultant tissue damage and
pathology.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 383
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
2. What intervention does the nurse implement to provide for client safety during intradermal
allergy testing?
a. Stay with the client and ensure that emergency equipment is in the
room.
b. Pretreat the skin area to be tested with a cortisone-based cream.
c. Apply oxygen by mask or nasal cannula before injecting the test agent.
d. Cover the examination table and pillow with plastic or an ultrafine
mesh.
ANS: A
Although it is usually a safe procedure, intradermal testing increases the risk for an adverse
reaction, including anaphylaxis. Emergency equipment should be available. Pretreating the skin
with cortisone will not decrease the risk of anaphylaxis. Applying oxygen will not help prevent a
reaction. Covering the examination table will also not prevent allergic reactions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
3. What is most important for the nurse to teach the client with allergic rhinitis and glaucoma?
a. “If your heartbeat increases, be sure to contact your health care
provider.”
b. “Avoid allergy drugs containing pseudoephedrine or phenylephrine.”
c. “Be sure to drink plenty of water with antihistamines.”
d. “You should use an eye-moistening agent such as Restasis.”
ANS: B
Ephedrine, phenylephrine, and pseudoephedrine may cause vasoconstriction, increase blood
pressure, and increase intraocular pressure. The client should avoid these drugs. An increased heart
rate is not a reason to call the health care provider. The client may be thirstier when on allergy
medications, or the client may need an eye-moistening agent, but these are not the most important
things for the nurse to teach.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
4. A client has received diphenhydramine (Benadryl) and is currently oriented but drowsy. What is
the best action for the nurse to take?
a. Perform a neurologic assessment every 2 hours.
b. Document the response and continue to monitor.
c. Prepare to administer epinephrine subcutaneously.
d. Have the nursing assistant stimulate the client every hour.
ANS: B
The client is experiencing normal side effects of the medication. The nurse will continue to monitor
for additive effects. Performing a neurologic assessment is not necessary, nor is administration of
epinephrine. There is no reason for the client to be stimulated hourly.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
5. Which condition is a type II hypersensitivity reaction?
a. Allergic rhinitis
b. Positive purified protein derivative (PPD) test for tuberculosis
c. Transfusion reaction to improper blood type
d. Serum sickness after receiving immune globulin
ANS: C
Common clinical situations caused by type II hypersensitivities include hemolytic transfusion
reactions. Type II hypersensitivity reactions are caused by antibodies directed against body tissues
that have some form of non-self (foreign) protein attached to them. Allergic rhinitis is an example
of a type I hypersensitivity. A positive PPD test is an example of a type IV reaction. Serum sickness
is a type III reaction.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 391
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
6. A client is receiving an IV infusion of an antibiotic. The client calls the nurse about feeling
uneasy and uncomfortable owing to congestion. Which action by the nurse is most appropriate?
a. Elevate the head of the client’s bed to 45 degrees.
b. Have another nurse call the Rapid Response Team.
c. Prepare to administer diphenhydramine (Benadryl).
d. Slow the rate of the IV infusion.
ANS: B
This client has early signs of anaphylaxis. The nurse must notify the Rapid Response Team but also
needs to stay with the client in case of cardiovascular collapse. The nurse’s best action is to ask
another nurse to call the Team while he or she continues to assess the client. The nurse will prepare
to administer epinephrine. Slowing the IV rate will not help the situation; if the client is reacting to
the antibiotic, the nurse should change the IV tubing and solution. If the client is not hypotensive,
the nurse can raise the head of the bed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
7. Which client characteristic places her or him at high risk for latex hypersensitivity?
a. Allergy to shellfish
b. History of spina bifida
c. Total hip replacement
d. Taking oral contraceptives
ANS: B
People who have spina bifida have lifelong exposure to latex products and frequently develop latex
hypersensitivities. An allergy to shellfish does not put a person at increased risk for latex allergies.
A total hip replacement will not place a client at risk for latex hypersensitivity, nor does use of oral
contraceptives.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 391
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
8. What dose of epinephrine does the nurse prepare for a client in anaphylaxis who is 6 feet 3 inches
tall and weighs 250 lb?
a. 0.2 mL of a 1:1000 solution
b. 0.5 mL of a 1:1000 solution
c. 0.3 mL of a 1:10,000 solution
d. 0.5 mL of a 1:10,000 solution
ANS: B
Adult doses of epinephrine for anaphylaxis range between 0.3 and 0.5 mL of a 1:1000 solution.
Because this client is large, the nurse should be prepared to give the higher dose initially.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Dosage
Calculation)
MSC: Integrated Process: Nursing Process (Implementation)
9. Which intervention is most important for the nurse to teach the client who is recovering from an
allergic reaction to a bee sting?
a. How to use an EpiPen
b. Wearing a medical alert bracelet
c. Avoiding contact with the allergen
d. Keeping diphenhydramine (Benadryl) available
ANS: A
If an anaphylactic reaction starts, the client will need to self-medicate very rapidly with the EpiPen.
He or she should carry it at all times and should be proficient in its assembly and use. This is the
highest priority intervention. The client should get a medical alert bracelet and keep away from
bees if at all possible. It is also advised that diphenhydramine be kept on hand in case of a less
severe reaction.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Implementation)
10. A client has angioedema of the lower face. What will the nurse assess next?
a. Pulse oximetry
b. Airway patency
c. Breath sounds
d. Chest wall symmetry
ANS: B
Angioedema of the lower face includes the mouth and can rapidly lead to laryngeal edema and
obstruction of the airway. Other assessments of the client’s respiratory status could be done after
the airway is assessed, such as pulse oximetry, breath sounds, and chest symmetry.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
11. A mother brings her child to the clinic requesting “genetic testing” to determine whether her
child suffers from the same multiple allergies as herself. What action by the nurse is most
appropriate?
a. Provide a referral to an allergist so the child can be tested.
b. Refer the mother to a geneticist for genetic testing on the child.
c. Ask the mother about specific symptoms the child may have had.
d. Have the mother list her allergies and the symptoms they cause her.
ANS: C
Allergic tendencies can be inherited, but no single gene has been identified that causes allergies,
and allergies to specific items are not inherited. The nurse should ask the mother about any
symptoms the child has that seem related to allergies. The child will not be tested by an allergist
simply because the mother has allergies, and a geneticist will not be able to identify an “allergy
gene” in the child. Because specific allergies are not inherited, having the mother list her allergies
will not be beneficial.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
12. A client states that he is “allergic” to poison ivy. Which statement by the client indicates a good
understanding of this type of sensitivity?
a. “Drinking 3 liters of water a day will prevent kidney damage.”
b. “I will always wear a medical alert bracelet for this allergy.”
c. “I need to try to avoid coming into contact with poison ivy.”
d. “I should carry diphenhydramine (Benadryl) with me at all times.”
ANS: C
Reactions to poison ivy are a type IV hypersensitivity reaction. They are cell mediated by Tlymphocytes in the skin. Avoidance of the offending allergen is the most appropriate intervention.
The complexes do not form or precipitate in the kidney. This type of hypersensitivity does not
represent an immediate life-threatening emergency and does not respond to histamine antagonists
(diphenhydramine).
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Evaluation)
13. A client is hospitalized with Goodpasture’s syndrome. Which intervention by the nurse takes
priority?
a. Monitor urine output and renal function tests.
b. Teach the client to manage peritoneal dialysis.
c. Administer antibiotics strictly on time.
d. Have separate IV access for immune globulin (IVIG) administration.
ANS: A
The main cause of death in clients with Goodpasture’s syndrome is renal failure. The nurse must
monitor renal function meticulously. Some, but not all, clients need dialysis and IVIG infusions.
Antibiotics are not used in the management of this condition.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
14. A client is in the clinic having had rhinorrhea and headache for the last 2 weeks. Which
laboratory value alerts the nurse to the possibility of a type I hypersensitivity reaction?
a. White blood cell count, 8900/mm3
b. Eosinophils, 10%
c. Neutrophils, 65%
d. Hemoglobin, 14 g/dL
ANS: B
An increase in eosinophils indicates an allergic reaction (type I) or allergic rhinitis. Normal
eosinophil count is 1% to 2%. The other laboratory values are normal.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Assessment)
15. How does the type V hypersensitivity reaction differ from other reactions?
a. It is cell mediated rather than antibody mediated.
b. It is an immediate response rather than a delayed response.
c. It produces a stimulatory response to normal tissues.
d. It results in more severe tissue damage than is caused by other types of
reactions.
ANS: C
Type V hypersensitivity reactions are known as stimulatory responses. The classic example of type
V hypersensitivity is Graves’ disease, in which the person makes a large amount of antibody that
binds to the thyroid-stimulating hormone receptor antibody (TSHr-Ab) on thyroid tissue. The
binding of this antibody to the TSH receptor activates the receptor, greatly stimulating the thyroid
gland and causing severe hyperthyroid symptoms. This type of reaction is not cell mediated. It is
not an immediate response, nor does it cause more severe tissue damage.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 392
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
16. A nurse is planning care for a client with Sjögren’s syndrome. At what point does the nurse
determine that priority outcomes have been met?
a. The client states that he or she is not as fatigued as previously.
b. The client dresses attractively despite gaining a large amount of weight.
c. The oral mucosa is intact and no systemic signs of infection are present.
d. The client is able to complete activities of daily living with minimal
shortness of breath.
ANS: C
The major symptoms associated with Sjögren’s syndrome include dry eyes caused by insufficient
tear production and dry mucous membranes of the nose, mouth, and vaginal tissues. Increased
dryness reduces the tissues’ natural defenses against infection. If the client shows no signs of
infection, priority outcomes have been met. The other observations do not meet a priority outcome.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Analysis)
17. An unknown unconscious client with an elevated temperature is ordered intravenous penicillin.
What is the best action for the nurse to take?
a. Administer the medication.
b. Check the chart for allergies.
c. Look for medical alert identification.
d. Notify the nursing supervisor.
ANS: C
Allergies need to be identified before medications are administered. This client cannot talk and is
unknown, so a chart cannot be retrieved. Clients with allergies are taught to carry medical alert
identification.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
18. A nurse suspects that a client has serum sickness. For which manifestation does the nurse assess
the client?
a. Joint pain
b. Allergic rhinitis
c. Stridor
d. Wheezing
ANS: A
Serum sickness is a delayed reaction, type III. Signs and symptoms include fever, arthralgia, fever,
rash, malaise, and lymphadenopathy. The other signs and symptoms are related to type I allergic
reactions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
19. The nurse enters a client’s room and observes the manifestations shown below. What action
should the nurse take first?
a. Prepare to administer diphenhydramine (Benadryl).
b. Prepare to administer epinephrine.
c. Assess the client’s respiratory status.
d. Get a full set of vital signs.
ANS: C
This client has angioedema, and the priority action is to assess her respiratory status because
respiratory collapse may follow. The nurse should have someone else notify the Rapid Response
Team and prepare to administer epinephrine.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care-Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
MULTIPLE RESPONSE
1. A client is admitted for a cardiac catheterization. It is essential for the nurse to ask the client
about which allergies? (Select all that apply.)
a. Penicillin
b. Latex
c. Iodine
d. Shellfish
e. Keflex
f.
Dilantin
g. Bananas
ANS: B, C, D, G
It is important to check for all allergies, but for a cardiac catheterization, the nurse needs to
question about shellfish, iodine, latex, and bananas specifically. The contrast used contains iodine,
and the equipment in the laboratory frequently contains latex. Information concerning these
allergies needs to be passed on to laboratory personnel before the client goes to the laboratory. This
will prevent the client from having an anaphylactic reaction during the procedure.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Assessment)
2. The nurse is preparing to administer a medication when the client states, “I’m allergic to that.”
How will the nurse proceed? (Select all that apply.)
a. Check the chart for allergies.
b. Notify the health care provider.
c. Ask what reaction the client gets.
d. Continue to give the medication.
e. Perform a skin test first.
f.
Notify the pharmacist.
g. Document the allergy on the chart.
ANS: A, B, C, F, G
If a client states that he or she has an allergy to a medication, the nurse should not administer the
medication. The nurse should find out what reaction the client experiences from the medication and
then should notify the health care provider and the pharmacist of the client’s response. The nurse
should document the allergy on the chart, including the reaction to the medication and notification
of the provider and the pharmacist, and should indicate what other drug was ordered in its place.
Before administering any drug, the nurse should have already checked the chart for allergies.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
SHORT ANSWER
1. The nurse is to give a client 80 mg of diphenhydramine (Benadryl) by IV push. The vial contains
a solution with a concentration of 25 mg/mL. How many milliliters of diphenhydramine does the
nurse administer? __________ mL
ANS:
3.2
Ratio and proportion:
80 mg is to x mL as 25 mg is to 1 mL.
80/25 = 3.2 mL
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Dosage
Calculation)
MSC: Integrated Process: Nursing Process (Implementation)
Chapter 23: Cancer Development
Chapter 23: Cancer Development
Test Bank
MULTIPLE CHOICE
1. The nurse includes which information about benign tumors when presenting an in-service on
cancer?
a. They can wander far throughout the body.
b. They are smaller than 2 cm.
c. They retain a small nuclear-to-cytoplasmic ratio.
d. They look different from the tissue they arose from.
ANS: C
Benign tumors are made up of normal cells growing in the wrong place or growing when they are
not needed. Benign tumors retain the characteristics of normal cells in that they do not migrate in
the body, they retain a small nuclear-to-cytoplasmic ratio, and they look similar to the tissue from
which they arose. Size is not related to malignancy or to being benign.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 398
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Teaching/Learning
2. In reviewing the pathophysiology of a particular type of cancer, the nurse correlates the
generation time for cancer development with which description?
a. The rate at which cancer cells are able to migrate and metastasize to
different sites
b. How long it takes for a malignant tumor to double in size by mitotic
cell divisions
c. The period of time needed for one cell to divide into two cells by
mitosis
d. The period of time between cell damage and expression of a
malignancy
ANS: C
Generation time is defined as the period of time necessary for one cell to complete a round of cell
division.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 397
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
3. Which biologic characteristic is specific to normal differentiated adult cells but not to cancer
cells?
a. Anaplasia
b. Hypertrophy
c. Aneuploidy
d. Loose adherence
ANS: B
Some normal tissues increase in size by having individual cells get larger, a process called
hypertrophy. Cancer cells tend to grow by hyperplasia. The other characteristics are associated with
cancer cells.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 397
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
4. A client states that his brain tumor is benign and does not need to be removed. What is the
nurse’s best response?
a. “As your tumor grows, it can damage your brain, so it should be
removed.”
b. “Benign tumors consist of normal cells, so removal is only for cosmetic
purposes.”
c. “Benign tumors turn into cancer, so they should be removed as soon as
possible.”
d. “Because benign tumors can migrate, they should be removed before
they spread.”
ANS: A
Even though benign tumors do not migrate (metastasize) or become cancerous, they can
compromise or even destroy surrounding normal tissue. This is particularly a problem when a
benign tumor arises in a location that does not expand to accommodate growth, such as in the skull.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
5. Which comment made by a client with breast cancer indicates a need for clarification regarding
cancer causes and prevention?
a. “I will eat a low-fat, high-fiber diet from now on.”
b. “Probably nothing I did or didn’t do caused this cancer.”
c. “I hope my daughter doesn’t develop breast cancer.”
d. “Regular mammograms on my other breast will prevent cancer.”
ANS: D
Regular mammography can help detect breast cancer at an early stage, but it does not prevent
breast cancer. For the most part, the specific cause of many cancers is unknown. Some associations
have been noted with dietary habits. High fat, low fiber, high intake of red meat, and eating food
with preservatives and other additives all have been suspected to contribute to carcinogenesis.
Breast cancer has familial and hereditary forms.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)
MSC: Integrated Process: Teaching/Learning
6. Malignant cell growth is uncontrolled because of which action?
a. Cancer cells always divide more rapidly than normal cells.
b. Mitosis of malignant cells usually produces more than two daughter
cells.
c. Malignant cells bypass one or more phases of the cell cycle during cell
division.
d. Malignant cells enter the cell cycle frequently, making cell division
continuous.
ANS: D
Malignant cells have bypassed the normal control mechanisms that restrict entry into the cell cycle,
so they re-enter the cell cycle as soon as they finish a round of cell division. Thus, cancer cell
division is relentless.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 399
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
7. A client has known lung cancer and has been admitted for abdominal pain and jaundice. A
computed tomography (CT) scan reveals tumors in the client’s liver. The client is distraught and
says, “So now I have liver cancer too?” Which response by the nurse is most appropriate?
a. “Yes, liver cancer is common in people who already have lung cancer.”
b. “Yes, your chemotherapy left you vulnerable to a virus that causes liver
cancer.”
c. “No, the tumors are actually from your lung cancer, which has
metastasized.”
d. “No, having tumors in two different organs is rare; you probably have
hepatitis.”
ANS: C
When a cancer metastasizes to another organ, it is still the same cancer from the original spot. This
client has lung cancer that has metastasized to the liver.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Communication and Documentation
8. An occupational health nurse is working with management in a firm that provides commercial
building restoration, including asbestos removal. Which action does the nurse recommend to
management?
a. Provide annual screening chest x-rays for those exposed to asbestos.
b. Purchase protective gear and develop policies mandating its use.
c. Offer “stop smoking” programs on site several times a year.
d. Routinely distribute testing kits for occult fecal blood.
ANS: B
Asbestos is a powerful carcinogen. Chronic exposure, even to small amounts of loose asbestos
fibers, increases the risk for development of lung cancer. Employees should wear personal
protective gear when working with asbestos. Management should provide this gear and should
develop policies requiring employees to use it. Stop-smoking programs would not be as beneficial
in preventing cancer in this group of people as would limiting asbestos exposure. Routine chest xrays and fecal occult blood testing will not prevent cancer.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
9. The nurse correlates “initiation” in cancer development with which action?
a. Inflicting mutations that lead to excessive cell division
b. Increasing the capacity of the transformed cell for error-free DNA
repair
c. Stimulating contact inhibition in cells damaged by a carcinogen
d. Making cancer cells appear more normal to escape immune surveillance
ANS: A
The process of initiation induces changes in the genes that allow proto-oncogenes to be activated to
oncogene status and to be expressed.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 399
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
10. The middle-aged client with lung cancer asks whether his adult children are at increased risk for
this cancer. What is the nurse’s best response?
a. “This disease is a random event and there is no way to prevent it.”
b. “This disease is inherited, so your children have a 50% risk for
developing it.”
c. “Smoking is the main cause. Helping your children not smoke decreases
their risk.”
d. “They can avoid cancer by decreasing the fat they eat and by exercising
more.”
ANS: C
Long-term cigarette smoking is the major risk factor for lung cancer. Not smoking is the best way
to prevent it.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors)
MSC: Integrated Process: Teaching/Learning
11. An adult client who has a suspicious mammogram says that her mother died of bone cancer
when she was around the same age. Which is the most important question for the nurse to ask this
client?
a. “Have any other members of your family had bone cancer?”
b. “Did your mother ever have any other type of cancer?”
c. “How old were you when you started your periods?”
d. “Did your mother have regular mammograms?”
ANS: B
Breast cancer often spreads to the bone. Many laypersons do not understand that breast cancer in
the bone is still breast cancer. It would be very important to know whether this client’s mother had
breast cancer because a genetic component is associated with it. Asking about other family
members who have had bone cancer may give the nurse useful information but would not be as
important as finding out about other cancers. Menstrual cycle and mammogram information also
would not provide as relevant information as inquiring about other types of cancer, specifically
breast cancer.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
12. A client with prostate cancer says that he is now having a lot of pain in his lower back and legs.
The nurse educates the client about which intervention?
a. X-rays of the spine and legs
b. Administering ibuprofen (Motrin) for pain
c. Referral to the pain control specialist
d. Referral to physical therapy
ANS: A
The primary site of metastasis for prostate cancer is the bone of the spine and legs. Pain in these
areas in a client with prostate cancer is highly suggestive of cancer progression and metastasis. The
client needs x-rays to assess for metastasis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
13. A middle-aged client is having a physical examination and is worried about cancer risk. Which
question is most important for the nurse to ask?
a. “How much time do you spend in the sun?”
b. “How many servings of fruits and vegetables do you eat every day?”
c. “How often do you eat processed meats like bologna?”
d. “Do you smoke cigarettes or have you ever used tobacco products?”
ANS: D
Tobacco is related to about 30% of all cancers in North America and is the most important source
of preventable carcinogen exposure. The other questions are related to carcinogenesis, but not to
the degree that tobacco is.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors)
MSC: Integrated Process: Nursing Process (Assessment)
14. The nurse is counseling a client who smokes and drinks heavily about cancer risk. The client is
adamant that he or she will never stop smoking. Which question by the nurse is most appropriate?
a. “Would you be willing to stop drinking alcohol?”
b. “Have you ever tried the nicotine patch?”
c. “Why are you so determined to continue smoking?”
d. “Do you understand that smoking is the leading cause of cancer?”
ANS: A
Both tobacco and alcohol are carcinogenic, but their effects are multiplied when ingested together.
Because the client is refusing to stop smoking, the nurse could help him or her reduce cancer risk
by not drinking. Although it is not as beneficial as avoiding tobacco, this could at least decrease the
risk. The client does not want to stop smoking, so asking about the nicotine patch, the reasons
behind continued smoking, and knowledge regarding cancer risk might only serve to make the
client more resolved to continue the habit or might make the client angry.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (High-Risk Behaviors)
MSC: Integrated Process: Nursing Process (Assessment)
15. A client’s cancer is staged by the TNM classification as T1, N3, M1. What is the nurse’s
interpretation of this classification?
a. The client has a large tumor involving the lymph nodes, but no distant
metastasis.
b. The client has a tumor, and metastasis cannot be determined by the
staging method.
c. The client has a 2-cm tumor, one involved lymph node, and local
metastasis.
d. The client has a small tumor, many involved lymph nodes, and distant
metastasis.
ANS: D
T = primary tumor. T1 indicates that a primary tumor is detectable but still relatively small. N =
regional lymph nodes. N3 indicates that several regional lymph nodes are involved. M = distant
metastasis. M1 indicates that distant metastasis is evident in at least one site.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Nursing Process (Analysis)
16. A client says that she has heard that the origin of most cancers is genetic and wants “genetic
testing because of a family history of cancer.” What is the nurse’s best response?
a. “I will ask your physician about a referral for genetic testing.”
b. “Let’s look at your family history back to your grandparents’
generation.”
c. “Genetic testing is so expensive; let’s talk about reducing your risk
instead.”
d. “Inherited cancers are much more common in males than in females.”
ANS: B
Genetic testing for the risk of developing a few specific cancers is available but is expensive. The
nurse should first assess the client’s family cancer history by creating a three-generation family
tree. If the client actually does have a strong family history of cancers with a genetic component,
the nurse can facilitate testing for the client. Teaching the client to reduce risk is always important,
but simply telling the client about the expense involved in testing belittles the client’s concerns.
Genetically related cancers are not more prevalent in men than in women, and again, this response
belittles the client’s concerns.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
17. In preparing a community teaching program, which information does the nurse plan to present
to address secondary cancer prevention?
a. Receiving cancer treatment with chemotherapy
b. Annual measurement of prostate-specific antigen levels
c. Avoiding known cancer-causing substances or conditions
d. Having adolescent children receive the Gardasil vaccination
ANS: B
Secondary prevention focuses on screening and early diagnosis. Annual prostate-specific antigen
(PSA) levels are a screening tool for prostate cancer. Chemotherapy is tertiary prevention
(treatment and rehabilitation). Both avoiding carcinogens and receiving the Gardasil vaccination
are primary preventions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
MSC: Integrated Process: Teaching/Learning
18. The nurse correlates the role of suppressor genes in cancer development with which action?
a. The presence of suppressor genes increases risks for gene damage by
carcinogens.
b. People with a greater number of suppressor genes are at increased risk
for getting cancer.
c. Suppressor genes enhance immune function, suppressing cancer
development.
d. Suppressor genes limit cell division, reducing risks for developing
cancer.
ANS: D
Suppressor genes are responsible for ensuring that cell division occurs only when needed. Cancer
cells lose this inhibition and re-enter the cell cycle frequently, leading to rapid growth.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 397
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
19. The nurse most likely would construct a three-generation pedigree for a client who had a
relative treated for which cancer?
a. Lung cancer
b. Prostate cancer
c. Cervical cancer
d. Bone cancer
ANS: B
Prostate cancer has a sporadic form and a familial form. If a client has relatives diagnosed with
prostate cancer, the nurse should assess for a genetic risk because the risk for this cancer can be
inherited. The place to start this assessment is with a family tree.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
20. The nurse counsels a woman who has a BRCA1 gene that she has what chance for developing
breast cancer during her lifetime?
a. None; this gene has a protective effect
b. Same as the general population
c. Lower than the general population
d. Higher than the general population
ANS: D
BRAC1 is a genetic mutation that increases risk for both breast and ovarian cancer.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 407
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
21. The nurse wishes to present a cancer program to a group of people at high risk for cancer. In
planning the program, which group does the nurse consider the priority?
a. Older adults
b. People who smoke
c. Clients with family histories of cancer
d. People with poor immune function
ANS: A
Advancing age is the single most important risk factor for cancer because of age-related decline in
immune function and accumulated exposure to carcinogens. All of the people listed are at some
increased risk for cancer, but older adults have the highest risk overall.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)
MSC: Integrated Process: Nursing Process (Planning)
22. The nurse is planning a cancer education event in an Asian community center. The nurse plans
to present information specifically on which types of cancer?
a. Breast and colorectal
b. Skin and lymphoma
c. Liver and stomach
d. Uterine and ovarian
ANS: A
Asians have higher rates of breast, colorectal, prostate, lung, and stomach cancers than are seen in
the general population.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Planning)
23. In preparing a cancer risk reduction pamphlet for African-American clients, it is most important
that the nurse include information on prevention and early detection for which types of cancer?
a. Lung and prostate
b. Bone and leukemia
c. Skin and lymphoma
d. Stomach and esophageal
ANS: A
African Americans have higher incidences of lung, prostate, breast, colorectal, and uterine cancers
than are seen in the general population.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Planning)
24. The nurse is seeing clients in a clinic. Which client does the nurse assess further for the
development of cancer?
a. Client with a cough that has lasted for 4 months
b. Client whose mother died of lung cancer
c. Client with a 10-pound weight gain
d. Woman whose last mammogram was 3 years ago
ANS: A
The seven warning signs of cancer include changes in bowel/bladder habits, a sore that does not
heal, unusual bleeding or discharge, thickening or a lump in the breast or elsewhere, indigestion or
difficulty swallowing, obvious change in a wart/mole, and nagging cough/hoarseness. The other
clients do not have warning signs of cancer.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
MSC: Integrated Process: Nursing Process (Assessment)
25. It is most important that the nurse include which activity for the young adult client with Down
syndrome?
a. Encouraging more fruit and leafy green vegetables in the diet
b. Teaching him how to perform testicular self-examination
c. Assessing the skin for unusual bruises and petechiae
d. Testing the client’s stool for occult blood
ANS: C
All screening and prevention activities are appropriate. However, people with Down syndrome
have an increased lifetime risk for the development of leukemia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
26. The nurse is interested in primary prevention for cancer. Which activity does the nurse most
likely participate in?
a. Distributing occult fecal blood test kits to people at the shopping mall
b. Arranging transportation volunteers for clients undergoing radiation
therapy
c. Teaching high school students the dangers of using tobacco
d. Educating adolescent girls about getting an annual Papanicolaou (PAP)
smear
ANS: C
Primary prevention focuses on activities that occur before an illness, such as education and
vaccinations. Occult fecal blood testing and PAP smears are secondary prevention activities
designed for screening and early diagnosis. Arranging transportation for a client who is undergoing
radiation therapy is tertiary prevention.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC:
Integrated Process: Teaching/Learning
27. The nurse assesses which client most carefully for cancer development?
a. Young man receiving radiation therapy for a brain tumor
b. Young adult woman who recently had postpartum hemorrhage
c. Adolescent male recently diagnosed with acquired immune deficiency
syndrome (AIDS)
d. Older woman undergoing chemotherapy for bowel cancer
ANS: D
Age and immune suppression are two of the greatest risk factors for cancer development. The
young man with brain cancer and the adolescent are at increased risk, but their risk is not as great as
that of the older woman undergoing chemotherapy for bowel cancer. Postpartum hemorrhage is not
related to cancer development.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
MULTIPLE RESPONSE
1. A client has colorectal cancer. Which activities are especially important for the nurse to conduct
for this client? (Select all that apply.)
a. Monitor liver function studies.
b. Maintain accurate intake and output.
c. Obtain daily weight using the same scale.
d. Palpate lymph nodes at each clinic visit.
e. Ask the client about changes in belly size.
ANS: A, D, E
Common sites of metastasis for colorectal cancer include the liver, lymph nodes, and adjacent
structures such as the abdominal cavity. Intake and output and daily weights would not provide data
related to possible metastases.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
Chapter 24: Care of Patients with Cancer
Chapter 24: Care of Patients with Cancer
Test Bank
MULTIPLE CHOICE
1. What statement indicates that the client understands teaching about neutropenia?
a. “I need to use a soft toothbrush.”
b. “I have to wear a mask at all times.”
c. “My grandchildren may get an infection from me.”
d. “I will call my doctor if I have an increase in temperature.”
ANS: D
Bone marrow suppression leads to neutropenia and increases the client’s risk for infection.
Decreased numbers of neutrophils and other white blood cells can minimize the clinical
manifestations of infection. For this reason, the client may not develop a high temperature, even
with severe infection, and any elevation of temperature should be reported immediately to the
health care provider. The client does not need to wear a mask or use a soft toothbrush (although if
the client has low platelets, he or she should use a soft toothbrush to avoid causing trauma). The
client is not contagious.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Evaluation)
2. A client is undergoing radiation therapy and asks the nurse about skin care for the exposed area.
Which statement by the nurse is most accurate?
a. “No products work well to reduce the skin reactions you get from
radiation.”
b. “No one product works best, so you can choose what you would like to
use.”
c. “The only medication that works well for skin reactions is very
expensive.”
d. “No good studies on skin care with radiation have been conducted to
date.”
ANS: B
A recent placebo-controlled study showed that none of three products used to manage radiationrelated skin reactions was superior to the others. Researchers concluded that clients should use
products that are easy to obtain and use and are within the client’s budget. Simply stating that no
one product works well does not give the client enough information to make an informed choice.
Prescription medications for skin reactions can be expensive, but again this response does not help
the client make a decision.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 414
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
3. A client who has just had a mastectomy is crying. When the nurse asks about her crying, the
client responds, “I know I shouldn’t cry because this surgery may well save my life.” What is the
nurse’s best response?
a. “It is all right to cry. Mourning this loss will help make you stronger.”
b. “I know this is hard, but your chances of survival are better now.”
c. “I can arrange for someone who had a mastectomy to come visit if you
like.”
d. “How have you coped with difficult situations in the past?”
ANS: C
Often, cancer surgery involves the loss of a body part or a decrease in function. Mourning or
grieving for a body image alteration is a healthy part of adapting or adjusting to a new image.
Visiting with someone who has experienced the same situation as the client is very helpful in
showing the client that many aspects of life can be the same afterward. If the opportunity to arrange
this type of visit is available, this would be the nurse’s best response. The other options do not
provide any assistance to the client in coping with her new body image and grieving for her loss.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 411
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communications)
MSC: Integrated Process: Caring
4. In evaluating dietary teaching for a client with chemotherapy-induced neutropenia, the nurse
becomes concerned when the client makes which food choice?
a. Fruit salad
b. Applesauce
c. Steamed broccoli
d. Baked potato
ANS: A
The client who is neutropenic should be taught to eat a low-bacteria diet. This includes avoiding
raw fruits or vegetables and undercooked meat, eggs, or fish.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
5. What teaching is essential for a client who has received an injection of iodine-131?
a. “Do not share a toilet with anyone else or let anyone clean your toilet.”
b. “You need to save all your urine for the next week.”
c. “No special precautions are needed because this type of radiation is
weak.”
d. “Avoid all contact with other people until the radiation device is
removed.”
ANS: A
The radiation source is an unsealed isotope that is eliminated from the body in waste products,
especially urine and feces. This material is radioactive for about 48 hours after instillation of the
isotope. Having the client not share a toilet with other people or allowing anyone to clean the
client’s toilet for a specific period of time ensures that the isotope has been completely eliminated,
and that the client’s wastes are no longer radioactive.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Handling
Hazardous and Infectious Materials)
MSC: Integrated Process: Nursing Process (Implementation)
6. A client has bone cancer. What intervention does the nurse implement as a priority for this client?
a. Using a lift sheet when repositioning the client
b. Positioning the client’s heels to keep them from touching the mattress
c. Providing small, frequent meals rich in calcium and phosphorus
d. Applying pressure for 5 minutes after intramuscular injections
ANS: A
Bone metastasis of cancer can cause such bone destruction that grasping or pulling a client can
result in a pathologic fracture. Using a lift sheet spreads the client’s weight more evenly, preventing
excessive force on any one body area. Preventing pressure on the heels will help prevent pressure
ulcers; this is a good intervention for all clients but does not take priority over preventing fractures.
Adding calcium and phosphorus to meals will not prevent fractures. Applying pressure after IM
injections is not related to this client’s condition.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
7. A client is undergoing radiation therapy and says, “I will be so glad when this is over and I don’t
have to worry about my skin.” What response by the nurse is most appropriate?
a. “Unfortunately, your skin will be permanently damaged from the
radiation.”
b. “You need to protect your skin from the sun for at least a year
afterward.”
c. “You can get a prescription for special lotions that reduce the effects of
radiation.”
d. “You’re having skin problems? That is unusual; let me take a look at
your skin.”
ANS: B
Skin that has been in the path of external radiation is more susceptible to sun damage and must be
protected from the sun for at least a year after completion of radiation therapy. Skin changes due to
radiation are common but may not be permanent, depending on the amount of radiation absorbed.
No one skin care product has been shown to significantly help radiation-related skin problems.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 413
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
of Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Teaching/Learning
8. A client scheduled to undergo radiation therapy for breast cancer asks why 6 weeks of daily
treatment is necessary. What is the nurse’s best response?
a. “Your cancer is widespread and requires more than the usual amount of
radiation treatment.”
b. “Giving larger doses of radiation for a shorter period of time does not
produce better effects and has worse side effects.”
c. “Research has shown that more cancer cells are killed if radiation is
given in smaller doses over a longer time period.”
d. “It is less likely that your hair will fall out or that you will become
anemic if radiation is given in this manner.”
ANS: C
Because of varying responses of all cancer cells within a given tumor, small doses of radiation are
given on a daily basis for a set period of time. This method allows multiple opportunities to destroy
cancer cells while minimizing damage to normal tissues.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 411
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
9. A client’s radiation implant has become dislodged overnight, and the nurse finds it in the client’s
bed. What does the nurse do first?
a. Assess the client’s skin for radiation burns.
b. Use tongs to put the implant into the radiation container.
c. Notify the safety officer and move the client to a different room.
d. Don gloves and attempt to replace the implant.
ANS: B
The implant does emit radiation and should be placed into the secure, lead-lined container in the
client’s room. The nurse does not directly touch this implant but uses long-handled tongs for this
purpose. The nurse does not need to assess the client’s skin, nor should he or she attempt to replace
the source. Moving the client is not necessary, although in keeping with facility policy, the radiation
safety officer may need to be notified.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Handling
Hazardous and Infectious Materials)
MSC: Integrated Process: Nursing Process (Implementation)
10. A client is receiving a chemotherapeutic agent intravenously through a peripheral line. What is
the nurse’s first action when the client reports burning at the site?
a. Check for a blood return.
b. Slow the rate of infusion.
c. Discontinue the infusion.
d. Apply a cold compress.
ANS: C
Both irritants and vesicants can cause tissue damage. If the nurse suspects extravasation, he or she
should immediately stop the infusion. Even if the IV has a good blood return, some of the
chemotherapeutic agent can still be leaking into the tissues. Slowing the rate of infusion is not
sufficient to prevent further leakage and damage. Applying a cold compress may or may not be the
correct action, depending on the specific agent. However, the compress would be applied only after
the infusion has been discontinued.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Implementation)
11. A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask,
gloves, and gown while administering drugs to the client. What is the nurse’s best response?
a. “These coverings protect you from getting an infection from me.”
b. “I am preventing the spread of infection from you to me or any other
client here.”
c. “The policy is for any nurse giving these drugs to wear a gown, gloves,
and mask.”
d. “The clothing protects me from accidentally absorbing these drugs.”
ANS: D
Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result,
health care workers who prepare or give these drugs, especially nurses and pharmacists, are at risk
for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can affect health.
The Oncology Nursing Society and the Occupational Safety and Health Administration (OSHA)
have specific guidelines for using caution and wearing protective clothing whenever preparing,
giving, or disposing of chemotherapy drugs.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Handling
Hazardous and Infectious Materials)
MSC: Integrated Process: Teaching/Learning
12. A client’s spouse reports that the last time the client received lorazepam (Ativan) before
receiving chemotherapy, the client was extremely drowsy and didn’t remember the trip home.
Which is the nurse’s best action?
a. Hold the dose of lorazepam for this round of chemotherapy.
b. Explain that this is a normal response to the drug.
c. Perform a Mini-Mental State Examination.
d. Document the response in the client’s chart.
ANS: B
Lorazepam, a benzodiazepine, induces sedation and amnesia, in addition to having antiemetic
effects. Many clients have little if any memory about events occurring within a few hours after
receiving lorazepam. This is an expected side effect and does not denote any permanent reduced
cognition in the client. Both the client and the spouse should be aware of this effect so that the
client is not at risk for injury. Driving, cooking, or operating mechanical equipment should not be
performed until the drug’s effects have worn off.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Teaching/Learning
13. A client is on chemotherapy and has a platelet count of 25,000. Which intervention is most
important to teach this client?
a. “Eat a low-bacteria diet.”
b. “Take your temperature daily.”
c. “Use a soft-bristled toothbrush.”
d. “Avoid alcohol-based mouthwashes.”
ANS: C
This client has thrombocytopenia, which is a common side effect of chemotherapy. This increases
the client’s risk for prolonged bleeding in response to even minor injury, especially from highly
vascular areas such as the gums. The client should be taught to use a soft toothbrush. A low-bacteria
diet and daily temperature monitoring would be used in a client who is neutropenic. Alcohol-based
mouthwashes will dry mucous membranes.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
14. A client with chemotherapy-induced bone marrow suppression has received filgrastim
(Neupogen). Which laboratory finding indicates that this therapy is effective for the client?
a. Hematocrit is 28%.
b. Hematocrit is 38%.
c. Segmented neutrophil count is 2500/mm 3.
d. Segmented neutrophil count is 3500/mm 3.
ANS: D
Filgrastim is a single-lineage growth factor that stimulates the maturation and release of only
segmented neutrophils. This drug is not given unless the neutrophil count is dangerously low. The
near-normal range of neutrophils indicates effective therapy.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Nursing Process (Evaluation)
15. What is the priority problem for a client experiencing chemotherapy-induced anemia?
a. Risk for injury related to fatigue
b. Fatigue related to decreased oxygenation
c. Body image problems related to skin color changes
d. Inadequate nutrition related to anorexia
ANS: A
Safety is always a client priority. The client who is anemic will be fatigued and may need assistance
with activity to prevent injury. The other problems may apply; however, they do not take priority
over safety.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Analysis)
16. A client is hospitalized for chemotherapy. The registered nurse intervenes when observing
which action by the nursing assistant?
a. Allowing the client to rest instead of making him or her perform oral
hygiene
b. Helping the client wash the groin and axillary areas every 12 hours
c. Cutting food and opening food packages when the client’s meal tray
arrives
d. Reminding the client to use the incentive spirometer every hour while
awake
ANS: A
The biggest dangers to clients on chemotherapy are neutropenia and the risk of serious infection or
sepsis. Most infections arise from overgrowth of the client’s own normal flora, so personal hygiene
is critical. The client must perform hygiene measures on a schedule, even if he or she is very tired.
Instead of allowing the client to rest, the nursing assistant should help the client perform oral
hygiene and other measures. The other actions would be acceptable.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
17. The student nurse overhears several staff members referring to a client who is receiving
chemotherapy as having “chemo brain.” The student asks the instructor what that means. Which
response by the instructor is best?
a. “That is an awful thing to say and the staff should not call a client by
that name.”
b. “It refers to the client’s brain as being irreversibly damaged by the
chemotherapy.”
c. “The client has reduced cognitive function that may last for several
years.”
d. “The client has delirium related to the toxic effects of the
chemotherapy.”
ANS: C
“Chemo brain” refers to the changes in concentration, memory, and learning that sometimes
accompany chemotherapy. It usually is not present at 3 years after chemotherapy has been
completed, so clients should be reassured that this is a temporary condition. Although the staff
should be more sensitive, simply criticizing them does not help the student understand the situation.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 424
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Teaching/Learning
18. A client with prostate cancer is taking estrogen daily to control tumor growth. He reports that
his left calf is swollen and painful. Which is the nurse’s best action?
a. Instruct the client to keep the leg elevated.
b. Measure and compare calf circumferences.
c. Apply ice to the calf after massaging it.
d. Document this expected response.
ANS: B
An adverse reaction to hormonal manipulation therapy is the development of thrombus formation.
The nurse should measure both calf circumferences and compare them; the side with a
thromboembolism will be larger. Elevation may be helpful, but first the nurse needs to assess the
situation. Massaging a calf that is swollen and painful is never correct, because this action might
break a clot to form an embolus, which could then travel to the lungs.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
19. A client is receiving interleukin-2 (IL-2) for cancer. Which drug is the nurse prepared to
administer if needed?
a. Lorazepam (Ativan)
b. Meperidine (Demerol)
c. Furosemide (Lasix)
d. Epoetin alfa (Epogen)
ANS: B
Clients receiving IL-2 therapy usually experience chills, fever, and rigors during the infusion,
especially the first time that they receive the drug. These reactions are a normal response to the
administration of biological response modifiers such as IL-2. Clients are treated symptomatically
for the discomfort. Demerol is used to treat the chills and rigor. The other medications would not
treat a side effect of IL-2 therapy.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Nursing Process (Analysis)
20. A nurse manager on an oncology nursing unit notes an increased incidence of infection and
serious consequences for clients on the unit. Which action by the nursing manager is most
beneficial in this situation?
a. Review asepsis policies at a mandatory in-service for staff.
b. Spot-check all staff for good handwashing practices.
c. Develop standard protocols to identify and treat clients with infection.
d. Institute protective precautions for all clients receiving chemotherapy.
ANS: C
Treatment delays have a serious negative impact on neutropenic clients with infection. Nursing
units should have standardized protocols to obtain cultures and diagnostic tests, and to start
antibiotics as soon as a client is suspected of having an infection. In-services and spot-checking for
good handwashing practice are good ideas as part of a comprehensive infection control practice but
are not as important as standard protocols that ensure rapid diagnosis and treatment. Not all clients
on chemotherapy will need protective precautions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Planning)
21. A client has small cell lung cancer. Which laboratory result requires immediate intervention by
the nurse?
a. Serum potassium of 5.1 mEq/L
b. Serum sodium of 118 mEq/L
c. Hematocrit of 45%
d. Blood urea nitrogen (BUN) of 10 mg/dL
ANS: B
In the syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH), secretion of
antidiuretic hormone (ADH) from the posterior pituitary gland is increased, causing the client to
reabsorb water from the distal convoluted tubule and collecting duct. As a result, weight increases,
and serum sodium and hematocrit levels are diluted. Blood urea nitrogen (BUN) and hematocrit are
normal. Potassium is slightly high, but very low sodium places the client at risk for seizures and
even death.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Analysis)
22. A client with advanced cancer is being treated with intravenous mithramycin (Mithracin).
Which clinical manifestation indicates that the treatment is effective?
a. Bowel sounds are active in all four quadrants.
b. The client’s serum sodium level is 138 mEq/L.
c. The pulse rate is 68 beats/min and bounding.
d. Urine output has increased to 30 mL/hr.
ANS: A
Mithramycin is used to treat hypercalcemia, which is seen most often in oncology clients who have
bone metastases. Hypercalcemia reduces excitable membrane activity, causing decreased intestinal
motility. Return of intestinal motility is an indication that serum calcium levels are decreasing.
Mithramycin has no direct effect on serum sodium levels or urine output. The pulse rate most likely
would be rapid and irregular with hypercalcemia and would normalize as calcium levels return to
normal.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Nursing Process (Evaluation)
23. A nurse is reviewing the white blood cell count with differential for a client receiving
chemotherapy for cancer. Which finding alerts the nurse to the possibility of sepsis?
a. Total white blood cell count is 9000/mm 3.
b. Lymphocytes outnumber basophils.
c. “Bands” outnumber “segs.”
d. Monocyte count is 1800/mm3.
ANS: C
Normally, mature segmented neutrophils (“segs”) are the major population of circulating
leukocytes, constituting 55% to 70% of the total white blood cell count. Less than 3% to 5% of
circulating white blood cells should be the less mature band neutrophils. A left shift occurs when
the bone marrow releases more immature neutrophils than mature neutrophils. This condition
indicates severe infection with possible sepsis and must be explored further.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Assessment)
24. A client is receiving high-dose chemotherapy for multiple myeloma. Which intervention is most
important for the nurse to implement to prevent complications during chemotherapy?
a. Ensure that the client’s fluid intake is 3000 to 5000 mL/day.
b. Monitor telemetry every hour during therapy.
c. Apply pressure to all injection sites for 5 minutes.
d. Assist the client in all ambulatory activities.
ANS: A
This client is at high risk for tumor lysis syndrome. Tumor lysis syndrome is the precipitation of
intracellular products released when tumor cells are destroyed rapidly. These products, particularly
purines, can increase uric acid crystal precipitation in the kidney tubules and may cause acute
tubular necrosis. In addition, serum potassium levels can become high. Maintaining adequate
hydration and urine output is essential in preventing complications.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
25. The nurse teaches a client with superior vena cava syndrome that improvement is characterized
by which clinical manifestation?
a. The client’s hands are less swollen.
b. Breath sounds are clear bilaterally.
c. The client’s back pain is relieved.
d. Pedal edema is present.
ANS: A
With superior vena cava syndrome, blood flow through the vena cava is compromised as a result of
tumor growth. Blood backs up into the periphery, and the client experiences upper body swelling,
including the hands and feet. Compression of the superior vena cava has no effect on breath sounds.
This would occur when blood is impeded from leaving the lungs, and with disorders that affect the
left side of the heart. Back pain is not associated with this disorder.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 432
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Evaluation)
26. A client has late-stage colon cancer with metastasis to the spine and bones. Which nursing
intervention does the nurse add to the care plan to address a priority problem?
a. Provide six small meals and snacks daily.
b. Offer the client prune juice twice a day.
c. Ensure that the client gets adequate rest.
d. Give the client pain medications around the clock.
ANS: D
Although all interventions might be appropriate, a client with late-stage cancer and bone metastases
is at risk for severe pain. Giving the client pain medication around the clock is the best way to
manage this type of pain.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Analysis)
27. After receiving change-of-shift report, which client does the nurse assess first?
a. Client with leukemia who needs an antiemetic before chemotherapy
b. Client with breast cancer scheduled for external beam radiation
c. Client with xerostomia associated with laryngeal cancer
d. Client with neutropenia who has just been admitted with a possible
infection
ANS: D
The most complex, potentially unstable client is the one with neutropenia with suspected infection.
Because the onset of infection is insidious in clients with neutropenia, this client is at risk for
sepsis. All other clients are stable.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Analysis)
28. The nurse questions which activity for the client with thrombocytopenia?
a. Application of warm compresses to bruises
b. Cleaning teeth with a soft-bristled brush
c. Taking acetaminophen (Tylenol) for pain
d. Using stool softeners daily for constipation
ANS: A
Ice should be applied to areas of bruising or trauma to decrease bleeding. Warm compresses would
lead to vasodilation and potentially to more bleeding. It is important to implement measures to
decrease the risk of bleeding. A soft-bristled toothbrush decreases trauma to gums, which could
cause bleeding. Straining at the stool could increase risk for rectal bleeding, so stool softeners may
be prescribed. Acetaminophen does not affect platelet function and bleeding as do aspirin products.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
29. The nurse prioritizes which intervention in a client with xerostomia secondary to radiation
therapy to the neck area?
a. Applying lotions and oils to affected areas
b. Wearing a hat to decrease heat loss
c. Providing oral care after meals and at bedtime
d. Monitoring vital signs every 4 hours
ANS: C
Head and neck radiation may damage the salivary glands, may cause dry mouth (xerostomia), and
may increase the client’s lifelong risk for tooth decay. Instruct clients to avoid using lotions or
ointments in these areas unless the radiologist prescribes them. Xerostomia is not associated with
hair loss, which might require a hat. Monitoring vital signs is important for any client receiving
radiation therapy but is not a priority for the client with xerostomia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Test/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
30. Which statement indicates that the client needs more teaching about mucositis?
a. “I will rinse my mouth with water after every meal.”
b. “I will use a soft-bristled toothbrush to prevent trauma.”
c. “I should use an alcohol-based mouth rinse to kill bacteria.”
d. “I cannot use floss because it may irritate my gums.”
ANS: C
Mouthwashes that contain alcohol are drying and can exacerbate mucosal irritation, leading to
painful mouth sores. Rinsing the mouth with water or normal saline is indicated. Interventions
aimed at decreasing risk for trauma or irritation are matters of priority because of inflammation
associated with mucositis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Test/Treatments/Procedures)
MSC: Integrated Process: Teaching/Learning
MULTIPLE RESPONSE
1. In planning a teaching session for a client undergoing photodynamic therapy for lung cancer, the
nurse includes which statements? (Select all that apply.)
a. “This is a palliative treatment that should decrease your pain.”
b. “Avoid exposure to the sun for 1 to 3 months after the treatment.”
c. “Do not eat or drink anything before your treatments.”
d. “Do not remove skin markings between treatments.”
e. “You need to wear sunglasses to protect your eyes after treatments.”
f.
“Make sure you keep your curtains closed at home afterward.”
ANS: B, E, F
Phototherapy causes general sensitivity to light for up to 12 weeks. During this time, the client is at
high risk for light sensitivity and eye pain. After the procedure, the client is taught to decrease
exposure to sunlight (to the point of being homebound).
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention) MSC: Integrated Process: Teaching/Learning
2. The nurse is planning care for a client with hypercalcemia secondary to bone metastasis. Which
interventions are included in the plan? (Select all that apply.)
a. Increase oral fluids.
b. Place an oral airway at the bedside.
c. Monitor for Chvostek’s sign.
d. Implement seizure precautions.
e. Assess for hyperactive reflexes.
f.
Observe for muscle weakness.
ANS: A, F
Early manifestations of hypercalcemia include fatigue, loss of appetite, nausea, vomiting,
constipation, and polyuria (increased urine output). More serious problems include severe muscle
weakness, loss of deep tendon reflexes, paralytic ileus, dehydration, and electrocardiographic
changes. An oral airway is not needed. Chvostek’s sign is an assessment for hypocalcemia. Seizures
and hyperactive reflexes do not occur with hypercalcemia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
3. The nurse is caring for a client who has a sealed radiation implant for cervical cancer. Which
activities by the nurse are appropriate? (Select all that apply.)
a. Inform the supervisor of the nurse’s positive pregnancy test.
b. Obtain the dosimeter badge from the nurse going off shift.
c. Keep the client’s door open for frequent observation.
d. Dispose of dirty linen in a red “biohazard” bag.
e. Wear a lead apron while providing client care.
ANS: A, E
Pregnant nurses should never care for clients with sealed implants of radioactive material, so if the
nurse suspects she is pregnant, she should inform her supervisor and request a different assignment.
Nurses should wear lead aprons while providing care, ensuring that the apron always faces the
client. Each nurse should have his or her own dosimeter film badge. The client’s door should be
kept closed whenever possible and dirty linens kept in the client’s room until the radiation source is
removed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Handling
Hazardous and Infectious Materials)
MSC: Integrated Process: Nursing Process (Implementation)
Chapter 25: Care of Patients with Infection
Chapter 25: Care of Patients with Infection
Test Bank
MULTIPLE CHOICE
1. After an infection control in-service, which statement by the nurse demonstrates an accurate
understanding of the mode of transmission of influenza?
a. “I will not develop the infection unless I have physical contact with the
client.”
b. “I should wear an N95 respirator to provide care for the client with
influenza.”
c. “I should try to stay at least 3 feet away from the client, if at all
possible.”
d. “The infection is spread through droplets suspended in the air and
inhaled.”
ANS: C
Influenza is transmitted via droplets. Droplets are produced when a person talks or sneezes and
travel short distances (up to 3 feet) but are not suspended in the air for long. Staff should stay at
least 3 feet (1 m) away from a client with droplet infection. Actual physical contact with the client
is not necessary for infection to occur. It is not necessary for staff to wear an N95 respirator mask
for Droplet Precautions; these masks are used in the care of clients with tuberculosis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Planning)
2. The nurse is told that a client with measles is being admitted. Which action by the nurse is best?
a. Implement Contact Precautions.
b. Check negative airflow monitors.
c. Ensure that hand sanitizer is readily available.
d. Place the client in a room with another measles client.
ANS: B
Clients with measles require Airborne Precautions, which include being placed in a room with
specially monitored negative airflow. Before admitting the client with measles, the nurse should
ensure that the airflow monitors are working properly. Contact Precautions are not used for
measles. Having hand sanitizer is always a good idea, but it is not the most important action.
Placing the client with another measles client is a possible action if more than one case is present
(e.g., during an outbreak), but the most important thing is to ensure that Airborne Precautions can
be maintained for safety.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Planning)
3. A client and his family are waiting for the results of clinical tests to determine whether the client
has an infection. They are becoming anxious. What is the most important assessment that the nurse
should make of the client and family members?
a. Understanding of insurance reimbursement for testing
b. Use of appropriate coping mechanisms for anxiety
c. Understanding of the infectious disease process
d. Understanding of the diagnostic procedures
ANS: D
Assess the client’s and family’s level of understanding about various diagnostic procedures and the
time required to obtain test results. This is more important than whether the family has any
understanding of their insurance and will help reduce anxiety if understanding is accurate. The
client with an infectious disease often has psychosocial concerns. Delay in diagnosis caused by the
need to wait for clinical test results produces anxiety. Plan education on infection risk reduction
when the client and the family are ready to learn.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Nursing Process (Assessment)
4. The nurse is preparing to administer a prescribed IV antibiotic to a client admitted with a serious
infection. Which action by the nurse is most important?
a. Check the IV for patency.
b. Assess the client for allergies.
c. Double check the “five rights.”
d. Teach the client about the drug.
ANS: B
All actions are appropriate and important before administering any medications. However, client
safety is the priority. The nurse should first assess the client for medication allergies by asking the
client or checking the chart (or both). Ensuring a patent IV and checking the five rights will not
protect the client from an allergic reaction.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
5. A client is being treated with acetaminophen (Tylenol). Which assessment finding is most likely
to occur after a dose of the medication?
a. A febrile seizure
b. Nausea and vomiting
c. Episodes of sweating
d. Syncope
ANS: C
Be alert for waves of sweating after each dose. Sweating may be accompanied by a fall in blood
pressure, followed by return of fever. These unpleasant side effects of antipyretic therapy often can
be alleviated by liberal administration of fluids and by regular scheduling of drug administration.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 446
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Assessment)
6. Which client does the nurse consider to be at increased risk for infection?
a. Young adult who wears contact lenses
b. Adult with type 1 diabetes mellitus
c. Adult with known hypersensitivity to latex
d. Adolescent using analgesics for migraine headaches
ANS: B
Clients with diabetes are at greater risk for infection for many reasons. The disease affects the
vascular system, preventing normal immune defenses from reaching sites of injury or invasion. The
elevated glucose level in the extracellular fluid provides a rich growth medium for microorganisms,
especially bacteria and fungi. Wearing contact lenses might put a client at slightly higher risk for
eye infection. Hypersensitivity to latex puts a client at risk for anaphylaxis, but not at increased risk
for infection. The use of analgesics will not put a client at risk for infection.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 444
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
7. The nurse is assigned to work with a new nursing assistant. Which action by the nursing assistant
requires intervention by the registered nurse?
a. Using an alcohol-based hand rub after caring for a client with diarrhea
b. Washing hands for 20 seconds using warm water and friction
c. Cleaning especially carefully under fingernails and around a wedding
band
d. Using chlorhexidine for handwashing when caring for clients on
neutropenic precautions
ANS: A
Alcohol-based hand rubs are not effective against spore-forming organisms such as Clostridium
difficile, which is a common cause of diarrhea among hospitalized clients. The nursing assistant
should wash hands with soap after caring for such clients in case they have an undiagnosed
infection with this bacterium. The other actions are appropriate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Communication and Documentation
8. The nurse is caring for a client with a large leg wound that has been slow to heal. Which action
by the nurse is most appropriate?
a. Use Contact Precautions when caring for the client.
b. Double-glove when providing wound care.
c. Help the client choose high-protein items at meals.
d. Assess the client’s knowledge of causative factors.
ANS: C
Good nutrition is important for any client with infection, and protein is critical for wound healing.
No information in the question would lead the nurse to use Contact Precautions, and doublegloving is not needed for wound care. Assessing knowledge of causative factors may help prevent
another wound, but does not take priority over ensuring good nutrition.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration)
MSC: Integrated Process: Nursing Process (Implementation)
9. A client comes to the emergency department with a fever, diarrhea, and general malaise. Which
information obtained during assessment does the nurse communicate immediately to the health care
provider?
a. Blood pressure of 110/90 mm Hg
b. Allergy to aspirin
c. The client having just returned from a 14-day trip to Asia
d. A blood transfusion 12 years ago
ANS: C
Travel can expose the client to infectious organisms that he or she might not ordinarily encounter in
the local community, increasing the chance that infection could lead to illness. The client’s diastolic
blood pressure is slightly high but would not need to be reported immediately. The aspirin allergy
should be noted on the client’s chart but most likely will not be a factor in the client’s immediate
problem. A blood transfusion 12 years ago would not likely be the cause of the client’s current
problems.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
10. While sponging a client who has a high fever, the nurse observes the client shivering. Which is
the nurse’s priority action?
a. Administering oral acetaminophen
b. Placing a heated blanket on the client
c. Stopping sponging the client
d. Warming up the water and continuing sponging
ANS: C
Shivering is an indication that the client is being cooled too fast. The nurse should stop the
sponging and immediately assess the client’s temperature. The sponging should not continue, even
if the temperature of the water is increased. Acetaminophen should not be administered without
knowledge of the client’s temperature, nor should a heated blanket be applied.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Planning)
11. The new nurse is caring for a client with a high temperature. Which action by the nurse warrants
intervention by the new nurse’s preceptor?
a. Sponging the client while monitoring for shivering
b. Applying cool packs to the client’s axillae and groin
c. Monitoring the client’s temperature more often than ordered
d. Obtaining a fan from central supply for the client’s room
ANS: D
The use of fans is discouraged to promote cooling in a febrile client because the fan can disperse
pathogens. The other actions are appropriate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Communication and Documentation
12. A client has been admitted with suspected Clostridium difficile infection. Which medication
does the nurse plan to administer as a priority?
a. Metronidazole (Flagyl)
b. Acetaminophen (Tylenol)
c. Tetracycline (Sumycin)
d. Doxycycline (Vibramycin)
ANS: A
Metronidazole and vancomycin are the antibiotics of choice for C. difficile infection. Tylenol might
be used if the client is febrile. The other two antibiotics are not appropriate.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 449
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Effects/Outcomes) MSC: Integrated Process: Nursing Process (Planning)
13. An older adult client is admitted with an infection. On assessment, the nurse finds the client
slightly confused. Vital signs are as follows: temperature 99.2° F (37.3° C), blood pressure 100/60
mm Hg, pulse 100, and respiratory rate 20. Which action by the nurse is most appropriate?
a. Perform a Mini-Mental Status Examination.
b. Assess the client for other signs of infection.
c. Document the findings and continue to monitor.
d. Assess the client’s pain level and treat if needed.
ANS: B
Because of an age-related decline in immune function, an older adult’s normal temperature may be
1° to 2° lower than normal. A temperature of 99.2° F may be a fever in this population. Often a
change in mental status is an early sign of illness for the older adult. The nurse should assess for
other indications of infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)
MSC: Integrated Process: Nursing Process (Assessment)
14. A client is being treated at home for vancomycin-resistant Enterococcus (VRE). The client and
the family are worried about spreading the infection. Which action by the nurse is best?
a. Instruct the client to use a separate bathroom.
b. Encourage the family to stay 3 feet away from the client.
c. Tell the client to cough into tissues and dispose of them immediately.
d. Teach the family ways to increase their immune system functioning.
ANS: A
VRE can live on surfaces for days or even weeks. Inanimate objects such as toilet seats or door
handles can easily become contaminated and spread infection. The other actions are not necessary.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Teaching/Learning
15. A client has scabies. In addition to Standard Precautions, which information is most important to
communicate to visitors and health care providers?
a. Do not allow children to visit.
b. Wear gloves when entering the room.
c. Wear a mask when within 3 feet of the client.
d. Keep head covered when providing care.
ANS: B
Contact Precautions are necessary when providing care to a client infected with the skin parasite
scabies. Gloves are required when entering a contact isolation room.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Planning)
16. Before discharge, the nurse confirms that the client understands antibiotic therapy for a wound
infection by which statement?
a. “I should take the antibiotic until my temperature is normal.”
b. “If my temperature elevates, I should increase my dose of antibiotic.”
c. “If my drainage is clear, I do not need the antibiotic.”
d. “I need to take the medication until the prescription is finished.”
ANS: D
Antibiotic therapy is most effective when the client takes the prescribed medication for the entire
course—not just when symptoms are present. A major nursing responsibility is to reinforce to
clients the necessity of completing the antibiotic regimen to ensure that the organism is eradicated.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
17. A client has been admitted for the second time to treat tuberculosis (TB). Which referral does
the nurse initiate as a priority?
a. Social worker to see if the client can afford the medications
b. Visiting nurses to arrange directly observed therapy on dismissal
c. Psychiatric nurse liaison to assess reasons for noncompliance
d. Infection control nurse to arrange testing for drug resistance
ANS: B
The client has a risk of noncompliance as evidenced by the second admission to treat TB. When the
client is dismissed, he or she most likely will need to be placed on directly observed therapy to
ensure compliance. The other referrals may be appropriate depending on the client’s needs.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Referrals) MSC:
Integrated Process: Nursing Process (Planning)
18. The nurse is caring for a client with a suspected infection. Which action by the nurse is most
appropriate?
a. Give antibiotics as soon as possible to prevent sepsis.
b. Obtain all required cultures, then administer the antibiotic.
c. Wait for culture results to give the most appropriate antibiotic.
d. Defer cultures unless the client shows signs of drug resistance.
ANS: B
The best diagnostic test for infection is a culture and sensitivity. The nurse should first collect any
ordered cultures. Then the nurse should administer the ordered antibiotic. Because final culture
results take 72 hours, empiric antibiotic therapy should be started before the results are back.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
19. The nurse reviews laboratory results for a client and notes that the erythrocyte sedimentation
rate (ESR) is 32 mm/hr. What action by the nurse is best?
a. Document the findings and call the health care provider.
b. Assess the client for any manifestations of infection or inflammation.
c. Review the client’s chart to see what medications have been given.
d. Call the physician and request blood cultures and a chest x-ray.
ANS: B
The ESR is elevated (normal is <20 mm/hr) and indicates inflammation, which could be the result
of an infectious process. The nurse should assess the client for manifestations of infection or
inflammation before notifying the health care provider. Documentation is always important.
Medications would not affect the ESR. Cultures and x-rays may be ordered, but not until the client
has been thoroughly assessed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Analysis)
20. The nurse works in a long-term care facility. Which resident does the nurse assess most
carefully for manifestations of infection?
a. Resident who has long-standing dementia
b. Resident with incontinence
c. Resident who eats a lot of sweets and little protein
d. Resident whose family won’t allow an influenza vaccination
ANS: B
All older clients are at increased risk for infection owing to age-related decreased immune function.
Each of these clients has special reasons for being at increased risk. However, the one at highest
risk is the client with incontinence because this is a chronic condition that is a daily problem,
leaving his or her skin vulnerable to breakdown and bacterial entry. Poor perineal care also
increases the risk for urinary tract infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
21. A client is diagnosed with varicella (chickenpox). The nurse places the client on which
precautions?
a. Airborne
b. Standard
c. Contact
d. Droplet
ANS: A
Chickenpox infection is transmitted via the airborne route. Clients with chickenpox must be placed
on Airborne Precautions.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 442
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
MULTIPLE RESPONSE
1. A client is admitted with infection and a high fever. Which assessments by the nurse take
priority? (Select all that apply.)
a. Blood pressure
b. Mental status
c. Pulse quality
d. Respiratory effort
e. Skin turgor
f.
Bowel sounds
ANS: A, B, C, E
Dehydration can accompany fever, especially if the client is sweating profusely. Blood pressure,
pulse quality, and skin turgor are assessments of fluid status. Mental status changes can accompany
fluid losses, especially in older clients.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
2. The nurse is assessing a client’s skin for local signs of infection. Which signs does the nurse
assess for? (Select all that apply.)
a. Fever
b. Redness
c. Warmth
d. Pain
e. Swelling
f.
Increased erythrocyte sedimentation rate (ESR)
ANS: B, C, D, E
Localized signs of infection include redness, warmth, pain, swelling, heat, and pus. Fever and
increased ESR are systemic signs of infection.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 444
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
Chapter 26: Assessment of the Skin, Hair, and Nails
Chapter 26: Assessment of the Skin, Hair, and Nails
Test Bank
MULTIPLE CHOICE
1. The nurse is planning care for an older client who has very thin skin on the backs of the hands
and arms. What is the client’s priority problem?
a. Risk for injury
b. Infection
c. Poor self-image
d. Discomfort
ANS: A
Thinning skin, with decreased attachment between the dermis and the epidermis, is at increased risk
for injury in response to even minimal trauma or shearing events. If injury occurred, infection
would be a possible problem. Thin skin should not cause discomfort. Poor self-image does not take
priority over the risk for injury.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)
MSC: Integrated Process: Nursing Process (Planning)
2. A client has a suspected superficial fungal infection. The nurse prepares the client for a culture by
explaining the procedure. Which statement by the client indicates a correct understanding of the
procedure?
a. “The doctor will shave off a small piece of the lesion.”
b. “You will be performing what is called a punch biopsy.”
c. “A sample is obtained by simply scraping the lesion.”
d. “You’ll squeeze material from the lesion to send to the laboratory.”
ANS: C
A superficial fungal culture is obtained by gently scraping the lesion with a tongue blade. The other
techniques are not used for a suspected superficial fungal infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Teaching/Learning
3. The nurse observes yellow-tinged sclera on a client with dark skin. Based on this observation,
what is the nurse’s best action?
a. Evaluate the client further for hepatitis.
b. Examine the soles of the client’s feet.
c. Inspect the client’s oral mucosa.
d. Place the client in contact isolation.
ANS: C
The nurse can best observe jaundice in clients with dark skin by inspecting the oral mucosa,
especially the hard palate, for yellow discoloration. Sclera may have subconjunctival fat deposits
that show a yellow hue. Before considering hepatitis, the nurse must do a more thorough
assessment. The soles of the feet may appear yellow simply from calluses, so this is not the best
place to assess. No need to isolate the client has been identified.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC:
Integrated Process: Nursing Process (Assessment)
4. A client has a bluish tinge to the palms, soles, and conjunctivae. Based on these assessment data,
what does the nurse do next?
a. Take a medication history.
b. Assess pulse oximetry.
c. Assess the client’s personal hygiene.
d. Palpate the soles and palms.
ANS: B
Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis
can be seen because the palms, soles, and conjunctivae have a bluish tinge. The nurse should assess
for systemic oxygenation before continuing with other assessments.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific
Assessments) MSC: Integrated Process: Nursing Process (Assessment)
5. An older client with age spots is fearful of contracting skin cancer but wants to continue his
hobby of outdoor gardening. Which statement by the client indicates a good understanding of the
teaching about this issue?
a. “I will avoid staying outside during the day.”
b. “I can use only oil-based tanning lotion.”
c. “I have to start growing plants indoors.”
d. “I will wear a hat and gloves when gardening.”
ANS: D
Freckles, birthmarks, and age spots are caused by patches of melanin in the skin. Melanin protects
against the harmful effects of sun exposure. Hyperpigmentation can occur in sun-exposed areas and
can lead to skin cancer. For clients who spend time outdoors, the best protection from skin cancer is
decreasing the amount of skin exposed to sunlight.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
6. An older client expresses concern about developing new “age spots.” Which instruction is most
important for the nurse to provide to the client?
a. “Limit the time you spend in the sun.”
b. “Monitor for signs of infection.”
c. “Monitor spots for color change.”
d. “Use skin creams to prevent drying.”
ANS: C
The ABCDE method (check for asymmetry, border irregularity, color variation, diameter, and
evolving [changing] in any feature) should be used to assess lesions for signs associated with
cancer. Any positive finding using this method requires the lesion to be examined by a
dermatologist or a surgeon. The other options are good instructions for clients too, but this client is
worried about lesions that are already present.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Implementation)
7. A client is seen in the clinic for a persistent hand rash. When taking the client’s history, the nurse
places priority on obtaining information related to which topic?
a. Age
b. Gender
c. Occupation and hobbies
d. Socioeconomic status
ANS: C
The location of the rash suggests contact dermatitis. This condition is most often caused by contact
with irritating substances such as might be found in industrial settings or associated with specific
hobbies. Socioeconomic status may be related to the rash, particularly if it is associated with poor
hygiene, but age and gender are not related to rashes.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific
Assessments) MSC: Integrated Process: Nursing Process (Assessment)
8. A client is admitted with inflamed soft tissue folds around his nail plates. Which question by the
nurse elicits the most useful information about the possible condition?
a. “What do you do for a living?”
b. “Do you keep your nails manicured?”
c. “Do you have diabetes?”
d. “Have you had any fungal nail infections?”
ANS: A
The condition, chronic paronychia, is common in people with frequent intermittent exposure to
water, such as homemakers, bartenders, and laundry workers.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
9. A client has multiple bruises on the arms. Which question provides the nurse with the most
information?
a. “Are you using lotion on your skin?”
b. “Do you have a family history of this?”
c. “Do your arms itch?”
d. “What medication are you taking?”
ANS: D
Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising,
which can result in ecchymosis. The other options would not provide information about bruising.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Assessment)
10. A client had an excisional biopsy on a neck lesion. Which information does the nurse include in
the discharge instructions?
a. “Stay in bed today to prevent excessive bleeding from the incision.”
b. “Do not drive until you have recovered from the anesthesia.”
c. “You will need to change the dressing daily for a week.”
d. “Keep the dressing on until tomorrow, then you may remove it.”
ANS: D
This client has no reason to avoid going about normal activities as long as the site stays covered for
a day with a dressing. Movement should not cause excessive bleeding, and general anesthesia
would not have been used.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
11. A client asks the nurse if a Wood’s light examination is painful. Which response by the nurse is
accurate?
a. “A local anesthetic will be used to prevent pain.”
b. “The pain lasts only a few seconds.”
c. “Some clients feel a pressure-like sensation.”
d. “The examination does not cause discomfort.”
ANS: D
The Wood’s light examination consists of use of a black light and a darkened room to assist with
physical examination of the skin. The examination does not cause discomfort.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 468
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific
Assessments) MSC: Integrated Process: Teaching/Learning
12. A client expresses concern about a rash located beneath her breast. What statement by the client
indicates a good understanding of this condition?
a. “This rash is probably due to fluid overload.”
b. “I need to wash this daily with antibacterial soap.”
c. “I can use powder to keep this area dry.”
d. “I will schedule a mammogram as soon as I can.”
ANS: C
Rashes limited to skin-fold areas (e.g., on the axillae, beneath the breasts, in the groin) may reflect
problems related to excessive moisture. The client needs to keep the area dry; one option is to use
powder. Good hygiene is important, but the rash does not need an antibacterial soap. The other two
options are not related to rashes in skin folds.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Teaching/Learning
13. A client comes to the clinic reporting pain and itching from blisters on both arms. This finding
indicates an abnormality in which layer of the skin?
a. Adipose tissue
b. Dermis
c. Epidermis
d. Stratum corneum
ANS: B
The dermis or dermal layer of the skin contains sensory nerves that transmit sensations of touch,
pressure, temperature, pain, and itch.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 453
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
14. A client has two skin lesions, each the size of a nickel, on his chest. Both lesions are flat and are
a darker color than the rest of the client’s skin. How does the nurse document this finding?
a. Two 2-cm hyperpigmented patches
b. Two 1-inch erythematous plaques
c. Two 2-mm pigmented papules
d. Two 1-inch moles
ANS: A
Patches are larger flat areas of the skin. The information provided does not indicate a mole or the
presence of erythema.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 460
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Assessment)
15. The nurse reads in the chart that a client has a fine, macular rash on the lower extremities. The
nurse inspects the client’s skin, looking for lesions that can be described with which term?
a. Flat
b. Raised
c. Rough
d. Blood-filled
ANS: A
A rash that is flat is described as macular. The other descriptions are not accurate.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 463
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Assessment)
16. On assessing a client’s lower extremities, the nurse notices that one leg is pale and cooler to the
touch. Which assessment does the nurse perform next?
a. Ask about a family history of skin disorders.
b. Palpate the client’s pedal pulses bilaterally.
c. Check for the presence of Homans’ sign.
d. Assess the client’s skin for adequate skin turgor.
ANS: B
Localized, decreased skin temperature and pallor indicate interference with vascular flow to the
region. The nurse should assess bilateral pedal pulses to screen for vascular sufficiency. Without
adequate blood flow, the client’s limb could be threatened. Asking about a family history of skin
problems would not take priority over assessing blood flow. Homans’ sign is a screening tool for
deep vein thrombosis and is often inaccurate. Skin turgor gives information about hydration status.
This assessment may be needed but certainly does not take priority over assessing for blood flow.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Assessment)
17. The nurse observes hirsutism in a female client. What does the nurse do next?
a. Assess for deepening of the voice.
b. Assess personal hygiene habits.
c. Document the finding.
d. Prepare the client for a biopsy.
ANS: A
Increased hair growth on the face and chest of a female client (hirsutism) is one manifestation of
hormonal imbalance. The nurse looks for additional associated changes in fat distribution and
capillary fragility (Cushing’s syndrome) or clitoral enlargement and deepening of the voice
(possible ovarian dysfunction). The other options are not related to this condition.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Assessment)
MULTIPLE RESPONSE
1. The nurse is assessing for skin changes in an older woman. Which findings require immediate
referral? (Select all that apply.)
a. Excessive moisture under axilla
b. Increased hair thinning
c. Increased presence of fungal toenails
d. Lesion with various colors
e. Spider veins on legs
f.
Asymmetric 6-mm dark lesion on forehead
ANS: D, F
The asymmetric 6-mm dark lesion, as well as the lesion with various colors, fits two of the
American Cancer Society’s hallmark signs for cancer according to the ABCD method. Other
manifestations are variants of normal seen in various age-groups.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
Chapter 27: Care of Patients with Skin Problems
Chapter 27: Care of Patients with Skin Problems
Test Bank
MULTIPLE CHOICE
1. A client has very dry skin. Which is the best intervention for the nurse to teach the client?
a. “Be sure to use lots of moisturizer several times a day.”
b. “Avoid wearing stockings or other constricting clothing.”
c. “Use antimicrobial soap so scratching won’t cause infection.”
d. “After you bathe, put lotion on before your skin is totally dry.”
ANS: D
The client should bathe in warm water for at least 20 minutes and then apply lotion immediately
because this will keep the moisture in the skin. Just using moisturizer will not be as helpful because
the moisturizer is not what rehydrates the skin; it is the water. Constricting clothing is not related to
dry skin, and antimicrobial soaps are actually more drying than other kinds of soap.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Personal Hygiene)
MSC: Integrated Process: Teaching/Learning
2. Which intervention best assists a client with pruritus?
a. “Keep your fingernails cut short and keep them clean.”
b. “Drinking extra fluids decreases stimulation of itch receptors.”
c. “Wear soft, breathable clothing made from material like cotton.”
d. “Avoid immersing the areas in water and dry thoroughly after bathing.”
ANS: A
The focus of nursing care is to improve client comfort and to prevent injury to the skin from
scratching. Keeping nails short will help prevent injury, and keeping them clean will help prevent
infection should injury to the skin occur. Extra fluids do not change the sensations felt at the itch
receptors. Cotton clothing does nothing to help extreme itching, and skin should be lubricated after
bathing before drying off.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
3. A client has urticaria and has been prescribed diphenhydramine (Benadryl). Which information is
most important for the nurse to teach the client?
a. “Wear sunscreen when you are outside.”
b. “Avoid drinking alcoholic beverages.”
c. “Do not take aspirin-containing drugs.”
d. “Take this medicine on a full stomach.”
ANS: B
Benadryl is an antihistamine that will decrease itching. For most people, diphenhydramine causes
drowsiness. This side effect is intensified when alcohol is also consumed, placing the client at
increased risk for injury and falls. Aspirin will not interact with this medication. Sun exposure and
timing related to meals should not affect administration of the drug.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
4. When changing the dressing on a partial-thickness wound, a nurse observes small, pale pink
bumps within the wound bed. Which action by the nurse is best?
a. Remove the bumps with a sterile scalpel.
b. Document and continue the current treatment.
c. Clean the wound vigorously to remove the bumps.
d. Culture the wound and place the client in isolation.
ANS: B
The small, pale pink bumps consist of granulation tissue characteristic of new capillary bed growth
(capillary buds)—an indication of proper wound healing. The nurse should continue current
treatment and assessments. Attempting to remove the bumps in any way can interfere with healing.
No reason for culturing the wound or placing the client in isolation is known.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
5. Which nursing intervention is best for the nurse to use to enhance healing of a 1-week-old
partial-thickness wound?
a. Ensure that the client is systemically oxygenated.
b. Restrict the client’s movement with bedrest.
c. Cover the wound with an airtight dressing.
d. Apply hydrocortisone cream as ordered.
ANS: A
Wounds heal best in tissue that is well oxygenated and hydrated, and is kept free of
microorganisms. Ensuring that the client is well oxygenated will help bring oxygen and cellular
nutrition to the wound. Covering the wound will deprive the new tissue of nutrition and will not
enhance healing. Although the client may need to limit the motion of an affected extremity to avoid
further trauma, placing a client on bedrest will lead to complications of immobility. Hydrocortisone
cream may decrease itching but will not enhance healing.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
6. A client is going home with a surgical wound on the coccyx that is to heal by second intention.
Which priority problem must the nurse address in the teaching plan?
a. Pain
b. Infection
c. Poor body image
d. Dehydration
ANS: B
Any wound left to heal by second intention is an open wound and is at risk for infection. This
wound is especially prone to infection owing to its location. The client may have pain and that
would need to be addressed, but the risk for infection takes priority. No information indicates that
fluid volume is a problem. The client could have a poor body image in this situation, although
wounds on the coccyx are not visible to the public. However, the priority in this situation is to
prevent infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Analysis)
7. Which nursing intervention best assists a bedridden client to keep skin intact?
a. Apply talcum powder to the perineal area.
b. Turn the client every 2 to 4 hours.
c. Use a foam mattress pad.
d. Use a lift sheet to move the client in bed.
ANS: D
Friction forces are generated when the client is dragged or pulled across bed linen; this often leads
to altered skin integrity. Using a lift sheet will prevent friction. Keeping the skin clean and dry is an
important intervention, but powders should not be used in the perineal area. To minimize
vasoconstriction and possible pressure ulcer development from dependency, the client should be
turned at a minimum of every 2 hours. A foam mattress will not significantly decrease pressure to
an area.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
8. The nurse determines that a client has a Braden Scale score of 9. Which is the nurse’s best
intervention related to this assessment?
a. Document the finding per protocol.
b. Reassess the client in 3 days.
c. Increase the client’s fluid intake.
d. Consult with the health care provider.
ANS: D
A score of 11 or less on the Braden Scale indicates severe risk for pressure ulcer development in
terms of decreased sensory perception, exposure to moisture, decreased independent activity,
decreased mobility, poor nutrition, and chronic exposure to friction and shear. The nurse needs to
consult with the health care provider to relay this information and to obtain more aggressive skin
protection measures than are currently provided.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction in Risk Potential—Potential for Alterations in
Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
9. Which client does the nurse assess to be at greatest risk for pressure ulcer development?
a. Client who has pneumonia
b. Client who requires assistance with ambulation
c. Client with hypertension on multiple medications
d. Incontinent client with limited mobility
ANS: D
Being immobile and being incontinent are two significant risk factors for the development of
pressure ulcers. Clients with pneumonia and hypertension do not have specific risk factors. The
client who needs assistance with ambulation might be at moderate risk if he or she does not move
about much, but having two risk factors makes the last option the person at highest risk.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction in Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
10. Which dressing choice does the nurse make to protect a heavily draining deep pressure ulcer?
a. Wet-to-dry gauze
b. Dry cotton gauze
c. Alginate packing, dry gauze cover
d. Hydrocolloidal transparent film cover
ANS: C
Alginates are highly absorbent materials that do not damage healthy tissue. They require a top
dressing to stay in place. Because this wound is draining heavily, this is the best choice. A wet-todry gauze is not used for this type of ulcer. A transparent dressing would hold in the drainage. Dry
cotton gauze would quickly become saturated.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
11. When getting a client up in a chair, the nurse notices that the pressure-relieving mattress overlay
has deep imprints of the client’s buttocks, heels, and scapulae. Which is the nurse’s best action?
a. Turn the mattress overlay to the opposite side.
b. Do nothing because this is an expected occurrence.
c. Apply a different pressure-relieving device.
d. Reinforce the overlay with extra cushions.
ANS: C
“Bottoming out,” as evidenced by deep imprints in the mattress overlay, indicates that this device is
not appropriate for this client, and a different device or strategy should be implemented to prevent
pressure ulcer formation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of
Equipment) MSC: Integrated Process: Nursing Process (Evaluation)
12. A client has a deep wound covered with a wet-to-damp dressing. Which intervention does the
nurse include on this client’s care plan?
a. Change the dressing every 6 hours around the clock.
b. Leave the dressing intact until next week.
c. Change the dressing when the current dressing is saturated.
d. Apply a new dressing when the seal breaks and the dressing leaks.
ANS: A
Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum débridement. Synthetic
dressings can be left in place for extended periods of time but need to be changed if the seal breaks
and the exudate is leaking. Dry gauze dressings should be changed when the outer layer becomes
saturated.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
13. A client has a wound that is draining heavily. Which type of dressing does the nurse use on this
wound?
a. Hydrophilic
b. Synthetic
c. Hydrophobic
d. Biologic
ANS: A
Hydrophilic dressings draw excessive drainage away from the wound surface, helping to promote
healing. The other dressing types are not appropriate for this type of wound.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
14. Which client is receiving appropriate treatment?
a. Client with an ulcer and slight necrosis receiving whirlpool treatment
b. Client with an eschar-covered sacral ulcer receiving whirlpool therapy
c. Client with sunburn and erythema soaking in warm water for 20
minutes
d. Client with urticaria instructed to take warm showers twice a day
ANS: A
Necrotic tissue should be removed so that healing can take place. Whirlpool treatment can gently
remove the necrosis. A wound covered with eschar most likely needs surgical débridement. Warm
water would not be recommended for a client with erythema. A client with urticaria would be
instructed to use cool water to decrease inflammation and itching.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Evaluation)
15. The nurse observes a small opening that is draining purulent material on the skin over the
trochanter area of a bedridden client. Which is the nurse’s next best action?
a. Probe for a larger pocket of necrotic tissue.
b. Apply a transparent film dressing.
c. Measure the reddened area on the skin surface.
d. Apply alginate dressing daily.
ANS: A
This “hidden” wound may first be observed as a small opening in the skin through which purulent
drainage exudes. Applying a transparent film dressing would not help this type of wound to heal.
Measuring the reddened area would not assist in determining the actual size of the wound, because
internal damage has occurred. Alginate dressings could not be applied if the area were not opened.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific
Assessments) MSC: Integrated Process: Nursing Process (Assessment)
16. A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the
perimeter, and bone is exposed. Which is the nurse’s best action?
a. Document as a stage I pressure ulcer and apply a transparent dressing.
b. Document as a stage II pressure ulcer and start wet-to-dry gauze
treatments.
c. Document as a stage III pressure ulcer and start antibiotic therapy.
d. Document as a stage IV pressure ulcer and prepare the client for
débridement.
ANS: D
A stage IV ulcer is one in which skin loss is full thickness, with extensive destruction, tissue
necrosis, and/or damage to muscle, bone, or supporting structures. Eschar may be present. When
the bone of the trochanter area is visible, tissue loss includes muscle loss. A potential intervention
consists of débridement of the necrotic tissue and a possible graft to promote healing.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Therapeutic Procedures)
MSC: Integrated Process: Nursing Process (Analysis)
17. A client presents with a pressure ulcer on the ankle. Which is the first intervention that the nurse
implements?
a. Draw blood for albumin, prealbumin, and total protein.
b. Prepare for and assist with obtaining a wound culture.
c. Place the client in bed and instruct him or her to elevate the foot.
d. Assess the affected leg for pulses, skin color, and temperature.
ANS: D
A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area.
This begins with assessment of pulses and color and temperature of the skin. The nurse can also
assess for pulses noninvasively with a Doppler if unable to palpate with his or her fingers.
Elevation of the foot would impair the ability of arterial blood to flow to the area. Wound cultures
are done after it has been determined drainage, odor, and other risks for infection are present. Tests
to determine nutritional status and risk assessment would be completed after the initial assessment
is done.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Assessment)
18. Which finding puts a client at greatest risk for wound infection?
a. Immune compromised status
b. Presence of a deep wound
c. Severely reddened skin
d. Coexisting medical conditions
ANS: A
A compromised immune system puts a client at greatest risk for infection. Although all the other
options might increase the client’s susceptibility, the one with the greatest potential impact is being
immune compromised.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 479
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Assessment)
19. A client has a chronic wound that is being treated with a vacuum-assisted wound closure (VAC)
device. Which intervention by the nurse takes priority?
a. Provide pain medication as needed.
b. Assess the VAC every 2 hours for bleeding.
c. Check the integrity of the dressing seal every 4 hours.
d. Document the wound size with each dressing change.
ANS: B
VACs have been associated with serious bleeding complications. All of these interventions are
important, but assessing for bleeding takes priority because it enhances client safety.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of
Equipment) MSC: Integrated Process: Nursing Process (Intervention)
20. Which statement made by the caregiver of a home care client indicates a need for clarification
regarding pressure ulcer prevention and treatment?
a. “I help him shift his position every hour when he sits in the chair.”
b. “I massage his tailbone every morning when he gets up because it is
red.”
c. “I apply lotion to his arms and legs every evening because they are so
dry.”
d. “He drinks a nutritional supplement between meals to maintain his
weight.”
ANS: B
Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is
contraindicated because the pressure of the massage can cause damage to the skin and
subcutaneous tissue layers.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
21. A client has been identified as being at risk for formation of pressure ulcers. Which dietary
choices by the client indicate a good understanding of teaching related to this condition?
a. Low-fat diet with whole grains and cereals and vitamin supplements
b. High-protein diet with vitamins and mineral supplements
c. Vegetarian diet with nutritional supplements and fish oil capsules
d. Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet
ANS: B
The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat
is also needed to ensure formation of cell membranes, so any of the options with low fat would not
be good choices. A vegetarian diet would not provide fat and high levels of protein.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
22. A client with a pressure ulcer has the following laboratory values: white blood count 8000/mm 3,
prealbumin 15.2 mg/dL, albumin 4.2 mg/dL, and lymphocyte count 2000/mm 3. Which action by the
nurse is most appropriate?
a. Document the findings.
b. Request a dietary consult.
c. Place the client in isolation.
d. Assess the client’s vital signs.
ANS: B
Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The
albumin and lymphocyte counts given are normal. The white blood cell count is not directly related
to nutritional status. The prealbumin count is low and is a more specific indicator of nutritional
status than is the albumin count. This puts the client at risk for impaired wound healing, so the
nurse should request a dietary consult.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Analysis)
23. The nurse sees a client with which condition first to evaluate for wound infection?
a. Pending blood cultures
b. Thin serous wound drainage
c. White blood cell count of 23,000/mm 3
d. Decrease in wound size
ANS: C
A client with an elevated white count should be evaluated for sources of infection. Thin drainage, a
decrease in wound size, and pending cultures are not indications that the client may have an
infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Planning)
24. A client has been admitted for vacuum-assisted wound closure (VAC) treatment for a chronic
leg wound. The client’s past medical history includes atrial fibrillation and stroke, and medications
include warfarin sodium (Coumadin) and sotolol (Betapace). Which action by the nurse is most
appropriate?
a. Place the client on continuous telemetry monitoring.
b. Call the health care provider with this information.
c. Let the wound care nurse know that the client has arrived.
d. Order the VAC and gather other needed supplies.
ANS: B
A client on anticoagulants is not a candidate for VAC because of the incidence of bleeding
complications. The health care provider needs this information quickly to plan other therapy for the
client’s wound.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of
Equipment)
MSC: Integrated Process: Nursing Process (Implementation)
25. The nurse assesses the client with which condition first?
a. Folliculitis
b. Furuncles
c. Cellulitis
d. Stage II ulcer
ANS: C
The client with cellulitis has a generalized infection with Staphylococcus or Streptococcus that
involves deep connective tissue. The client with folliculitis has a superficial infection of the upper
portion of the follicle, and the client with furuncles has a deeper infection in the hair follicle. A
client with a stage II ulcer with no infection is less of a priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Planning)
26. Which client should be placed in isolation awaiting possible diagnosis of infection with
methicillin-resistant Staphylococcus aureus (MRSA)?
a. Client admitted from a nursing home with furuncles and folliculitis
b. Client with a leg cut and other trauma from a motorcycle crash
c. Client with a rash noticed after participating in sporting events
d. Client transferred from intensive care with an elevated white count
ANS: A
The client in long-term care and other communal environments is at high risk for MRSA. The
presence of furuncles and folliculitis is also an indication that MRSA may be present. A client with
an open wound from a motorcycle crash would have the potential to develop MRSA, but no signs
are visible at present. A client with an elevated white count has the potential for infection but
should be at lower risk for MRSA than the client admitted from the communal environment. The
rash could be caused by several different things.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
27. The occupational health nurse is seeing several nurses with skin problems. The nurse with
which condition was most likely infected by a client?
a. A herpes simplex virus 1 (HSV-1) oral lesion
b. Herpetic whitlow of the fingertip
c. Herpes zoster on one side of the body
d. Severe postherpetic neuralgia
ANS: B
Herpetic whitlow is a form of herpes simplex infection that occurs in health care personnel who
have come into contact with viral secretions. This can be spread to other clients as well, and
precautions must be taken. HSV-1 infection is most likely a recurring cold sore. Herpes zoster is
caused by the reactivation of a virus dormant in the body. Postherpetic neuralgia occurs after an
outbreak of herpes zoster and is not contagious.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 492
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
28. A client had a skin graft with a pedicle flap. Which is the priority nursing intervention for this
client in the early postoperative phase?
a. Monitor the donor site to detect hemorrhage.
b. Check the flap edges for adequate perfusion.
c. Turn the client often to prevent pressure ulcers.
d. Perform interventions to prevent contractures.
ANS: B
The most serious common complication in the early postoperative period after skin grafting is
failure to engraft. If the pedicle flap demonstrates delayed capillary refill when blanching,
perfusion is being compromised. Hemorrhage is not a common complication post skin grafting.
Pressure ulcer formation and contracture development would not occur quickly after grafting.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests, Procedures, and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
29. A home care client with a leg wound is unable to climb stairs to the second floor, where the
bathtub is located. Which is the nurse’s best intervention?
a. “I’ll show you how to use a syringe to cleanse the wound.”
b. “It is not necessary to clean this wound because it is not infected.”
c. “You can use the kitchen sink and clean tap water for this purpose.”
d. “You will have to come to the hospital each day for hydrotherapy.”
ANS: A
Mechanical débridement can be accomplished using the forceful ejection of tap water from a 35mL syringe. Soaking in a tub is not essential. The client does not have to travel to the hospital.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 488
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
30. A client has a furuncle in the axilla. Which statement by the client indicates a good
understanding of how to care for this condition?
a. “I’ll apply cortisone cream to reduce the inflammation.”
b. “I will squeeze the lesion until all pus is removed.”
c. “I’ll keep my arm down at my side to prevent spread.”
d. “I will cleanse the area and apply warm compresses and antibiotic
cream.”
ANS: D
Cortisone cream reduces the inflammatory response but increases the infectious process. Squeezing
the lesion may introduce infection to deeper tissues and cause cellulitis. Keeping the arm down
increases moisture in the area and promotes bacterial growth. Cleansing and topical antibiotics can
eliminate the infection. Warm compresses enhance comfort and open the lesion, allowing better
penetration of the topical antibiotic.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
31. The home care nurse is visiting an older adult client who has diabetes and “skinned his shin”
yesterday. An intact scab is seen over the abrasion, and the skin around it is red, warm, and hard.
Which is the nurse’s best action?
a. Teaching the client how to apply cold compresses to the area
b. Lifting an area of scab to see whether any exudate can be expressed
c. Measuring the length and width of the red area
d. Calling the health care provider for a prescription to treat cellulitis
ANS: D
The clinical manifestations indicate cellulitis, a bacterial tissue infection that can spread rapidly and
deeply, especially in a client who has diabetes. Cold compresses would not be effective in allowing
the lesion to heal.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
32. An older client is observed scratching and rubbing white ridges on the skin between fingers, on
the wrists, in the axillae, and around the waist. Which is the nurse’s priority intervention?
a. Placing the client in a single room
b. Administering an antihistamine
c. Assessing for allergies
d. Applying cold compresses
ANS: A
The client’s presentation is most likely to be scabies, a contagious mite infestation. The client needs
to be admitted to a single room and treated for the infestation. Secondary interventions may include
medication to decrease the itching. Cold compresses would not be indicated, and this is not an
allergic manifestation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
33. The home health nurse is visiting a client who is treating a chronic wound. The nurse assesses
that the client only performs daily wound care twice a week owing to cost. Which statement by the
nurse best addresses this issue?
a. “You can use tap water instead of sterile saline to clean your wound.”
b. “If you don’t clean the wound properly, you could end up in the
hospital.”
c. “Sterile procedure is necessary to keep this wound from getting bigger.”
d. “The only thing that really matters is good handwashing with wound
care.”
ANS: A
For chronic wounds in the home, clean tap water and nonsterile supplies are acceptable and serve
as cheaper alternatives to sterile supplies. Good handwashing is important, but it is not the only
consideration. Of course, if the wound becomes grossly infected, the client may end up in the
hospital, but this response does not provide any helpful information.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 490
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Teaching/Learning
34. Which statement by a client with psoriasis indicates a need for further teaching?
a. “At the next family reunion, I’m going to ask my relatives if they have
psoriasis.”
b. “I have to make sure I keep my lesions covered, so I do not spread this
to others.”
c. “I expect that these patches will get smaller when I lay out in the sun.”
d. “I should continue to use the cortisone ointment as the patches shrink
and dry out.”
ANS: B
Psoriasis is not a contagious disorder. The client does not have to worry about spreading the
condition to others. It is a condition that has hereditary links, and the patches will decrease in size
with ultraviolet light exposure.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Evaluation)
35. Which question does the nurse ask to identify a possible trigger for worsening of a client’s
psoriatic lesions?
a. “Have you eaten a large amount of chocolate lately?”
b. “Have you been under a lot of stress lately?”
c. “Have you used a public shower recently?”
d. “Have you been out of the country recently?”
ANS: B
Systemic factors, hormonal changes, psychological stress, medications, and general health factors
can aggravate psoriasis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
36. The nurse notes that a client who has been using psoralens–ultraviolet A (PUVA) therapy for
psoriasis for 1 month has darkening of the skin. Which is the nurse’s best action?
a. Document this assessment finding.
b. Instruct the client to reduce the dose.
c. Instruct the client to drink more water.
d. Instruct the client to apply cortisone cream.
ANS: A
Darkening of the skin is an expected and normal response to PUVA therapy. No other intervention
is necessary.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Therapeutic Procedures)
MSC: Integrated Process: Nursing Process (Evaluation)
37. The nurse is teaching a community group of older adults about skin problems. Which
intervention by the nurse is most important?
a. Encourage them to get Zostavax.
b. Instruct them to monitor skin dryness.
c. Teach them how to moisturize skin.
d. Discuss how skin disorders are spread.
ANS: A
The Centers for Disease Control and Prevention recommend that all adults older than age 60 with
healthy immune systems get a dose of Zostavax, the immunization for shingles. Monitoring
dryness, applying moisturizer, and providing education on disease transmission are all important,
but protecting health via immunizations takes priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)
MSC: Integrated Process: Teaching/Learning
38. A client has a group of vesicles on top of a red base on the trunk. The nurse prepares the client
for which intervention?
a. Venipuncture for blood cultures
b. Tzanck smear and viral cultures
c. Cotton swab culture of the vesicles
d. Scraping of the lesions for examination
ANS: B
Grouped vesicles on a reddened base are characteristic of infection with herpes simplex virus 1.
Tzanck smear and viral cultures are indicated. Blood cultures would be done only with suspected
systemic infection. Swab cultures of pustules in bacterial infections are obtained. Scraping the
lesions would be part of the microscopic examination for fungal infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Nursing Process (Implementation)
39. An African-American woman had a breast biopsy 1 year ago. The incision site is elevated, dark,
and protruding. Which information does the nurse provide to the client?
a. A keloid has formed over the biopsy scar.
b. The benign tumor has undergone malignant changes.
c. A deep infection has probably become symptomatic.
d. Chronic inflammatory changes have occurred in the skin.
ANS: A
A keloid is a benign, noninfectious overgrowth of a scar resulting from excessive accumulation of
collagen and ground substance after skin trauma. Although anyone can form a keloid, the
propensity is more common among people with dark skin. This is a benign condition.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 501
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Teaching/Learning
40. A client at a community skin screening has numerous skin lesions. Which one does the nurse
evaluate first?
a. Beige freckles on the backs of both hands
b. Irregular blue mole with white specks on the lower leg
c. Large cluster of pustules in the right axilla
d. Raised, tubular, white areas on the inner aspects of the wrists
ANS: B
This mole fits two of the criteria for being cancerous or precancerous: variation of color within one
lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with the
potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an infection, but
it is more important to take care of the potentially cancerous lesion first.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
MSC: Integrated Process: Nursing Process (Assessment)
41. A client has methicillin-resistant Staphylococcus aureus (MRSA) and is receiving vancomycin
(Vancocin) 500 mg IV every 6 hours. What is an important nursing intervention related to this
drug?
a. Administering it over 30 minutes using an IV pump
b. Giving the client diphenhydramine (Benadryl) before the drug
c. Assessing the IV site at least every 2 hours for thrombophlebitis
d. Ensuring that the client has increased oral intake during therapy
ANS: C
Vancomycin is very irritating to the veins and can easily cause thrombophlebitis. This drug is given
over at least 60 minutes; although it can cause histamine release (leading to “red man syndrome”),
it is not customary to administer diphenhydramine before starting the infusion. Increasing oral
intake is not specific to vancomycin therapy.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Reactions/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Intervention)
42. The nurse inspects the site where a client’s basal cell carcinoma has been treated with
cryosurgery and finds that the area is red, with a blister in the center. Which action does the nurse
take?
a. Culture the site.
b. Notify the surgeon.
c. Apply hydrocortisone cream.
d. Reassure the client.
ANS: D
This skin reaction is the expected and normal response to cryosurgery. No other intervention is
necessary other than continued assessment.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Assessment)
43. A client presents to the clinic with a swollen arm lesion that contains old blood and a sunken-in
center. Which question by the nurse yields the most useful information?
a. “Have you traveled out of the country recently?”
b. “What do you do for a living or for hobbies?”
c. “Do you hike or engage in outdoor activities?”
d. “Are you exposed to places where spiders might be?”
ANS: B
This lesion has the manifestations of cutaneous anthrax. People at risk for anthrax are farm
workers, veterinarians, and people exposed to tanning (of hides) or working with wool. The other
questions will not give good information about possible exposure to this disease.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
44. Which is the most important question for the nurse to ask a young adult woman about to begin
taking isotretinoin (Accutane)?
a. “Do you spend a great deal of time in the sun?”
b. “Have you or any family members ever had skin cancer?”
c. “Which method of contraception are you using?”
d. “Do you drink alcoholic beverages?”
ANS: C
Isotretinoin has many side effects. It is a known teratogen and can cause severe birth defects. A
pregnancy test is required before therapy is initiated, and strict birth control measures must be used
during therapy.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Reactions/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Assessment)
45. A client has a widespread fungal infection. For which drug does the nurse anticipate an order?
a. Clindamycin (Cleocin)
b. Acyclovir (Zovirax)
c. Linezolid (Zyvox)
d. Ketoconazole (Nizoral)
ANS: D
Ketoconazole is an antifungal. Clindamycin and linezolid are antibiotics. Acyclovir is an antiviral
drug.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 494
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Nursing Process (Analysis)
46. Which characteristic regarding leprosy is true?
a. A few cases have been found in underdeveloped countries.
b. Affected clients must be confined away from the general population.
c. Treatment with multiple antibiotic agents is necessary.
d. Treatment of leprosy involves immunosuppressive drugs.
ANS: C
Leprosy is a communicable disease caused by mycobacteria. It is present in most areas of the
world, including the United States. It can be controlled with a long course of multiple antibiotics
and does not require the client to be isolated.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 509
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes)
MSC: Integrated Process: Nursing Process (Implementation)
47. A client who has had a rhinoplasty is swallowing frequently and belching. Which action does
the nurse take?
a. Notify the surgeon.
b. Raise the head of the bed.
c. Assist the client with liquids.
d. Continue to assess.
ANS: A
Repeated swallowing followed by belching after rhinoplasty is a sign of postnasal bleeding. This
sign should be reported immediately to the surgeon.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests, Procedures, and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
48. A client is at high risk for developing skin cancer but will not perform total skin self-
examination (TSSE) consistently. Which nursing intervention is the most important?
a. Reinforce previous teaching on the TSSE technique.
b. Teach the client the dangers of skin cancer.
c. Determine whether the client has a partner to help.
d. Carefully document all existing skin lesions.
ANS: C
Research shows that an important factor in compliance with TSSE is having a partner with whom
to work while performing the assessment.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific
Assessments) MSC: Integrated Process: Nursing Process (Implementation)
49. The nurse assessing a client notices a lesion on the skin as shown in the photograph below. For
which diagnostic test does the nurse prepare the client?
a. Punch skin biopsy
b. Viral cultures
c. Wood’s lamp examination
d. Diascopy
ANS: A
This lesion is suspicious for skin cancer and a biopsy is needed. A viral culture would not be
appropriate. A Wood’s lamp examination is used to determine if skin lesions have characteristic
color changes. Diascopy eliminates erythema, making skin lesions easier to examine.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential-Diagnostic Tests)
MSC: Integrated Process: Nursing Process (Assessment)
MULTIPLE RESPONSE
1. The nurse is prioritizing care to prevent pressure sores for a client who is immobilized. Which
interventions are appropriate? (Select all that apply.)
a. Place a small pillow between bony surfaces.
b. Elevate the head of the bed to 45 degrees.
c. Limit fluids and proteins in the diet.
d. Use a lift sheet to assist with repositioning.
e. Reposition the client who is in a chair every 2 hours.
f.
Keep the heels off the bed surfaces.
g. Use a rubber ring to decrease sacral pressure when up in the chair.
ANS: A, D, F
A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases
friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they
should be kept off hard surfaces. Head of the bed elevation greater than 30 degrees increases
pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity.
Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary
blood flow, increasing the risk for a pressure sore.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests, Procedures, and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
2. In preparation for a client being admitted with herpes zoster, what does the nurse do? (Select all
that apply.)
a. Prepare a room for reverse isolation.
b. Assess staff for a history of or vaccination for chickenpox.
c. Check the admission orders for analgesia.
d. Choose a roommate who also is immune suppressed.
e. Ensure that gloves are available in the room.
ANS: B, C, E
Herpes zoster (shingles) is caused by reactivation of the same virus, varicella zoster, in clients who
have previously had chickenpox. Anyone who has not had the disease or has been vaccinated for it
is at high risk for getting chickenpox. It is a disease of immune suppression, so no one who is
immune suppressed should be in the same room. It is best to put this client in a private room. Use
of gloves and good handwashing are sufficient to prevent spread. It is very painful and requires
analgesia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
3. Which preventive measures does the nurse use to prevent skin lesions in older adults? (Select all
that apply.)
a. Use a lift sheet when moving the client in bed.
b. Avoid tape when applying dressings.
c. Avoid any type of restraining device.
d. Avoid whirlpool therapy.
e. Use loose dressing on all wounds.
f.
Apply dressings only when wounds are draining.
ANS: A, B
Using a lift sheet will prevent shearing forces from tearing skin. Tape should be avoided so that the
skin won’t tear. Restraining devices may need to be used, but they should not be applied tightly. No
contraindication to using whirlpool therapy for the older client is known.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
4. In assessing a client’s wound, which finding assists the nurse in determining that the wound is
infected? (Select all that apply.)
a. It is open.
b. It has granulation tissue.
c. It is inflamed.
d. It has an odor.
e. It has heavy exudates.
f.
It contains necrotic tissue.
ANS: C, D, E
A wound that is open can be contaminated but not necessarily infected. Granulation tissue is a
healthy response. The presence of inflammation, odor, and exudate is an indication that the wound
should be cultured to assess for infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Assessment)
Chapter 28: Care of Patients with Burns
Chapter 28: Care of Patients with Burns
Test Bank
MULTIPLE CHOICE
1. The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most
important for the RN to provide the LPN?
a. Administer the prescribed tetanus toxoid vaccine.
b. Assess wounds for signs of infection.
c. Have the client cough and breathe deeply.
d. Wash hands on entering the client’s room.
ANS: D
Infection can occur when microorganisms from another person or from the environment are
transferred to the client. Although all of the interventions listed can help reduce the risk for
infection, handwashing is the most effective technique for preventing infection transmission.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
2. When providing care for a client with an acute burn injury, which nursing intervention is most
important to prevent infection by autocontamination?
a. Avoid sharing equipment such as blood pressure cuffs between clients.
b. Change gloves between wound care on different parts of the client’s
body.
c. Use the closed method of burn wound management for all wound care.
d. Use proper and consistent handwashing by all members of the staff.
ANS: B
Autocontamination is the transfer of microorganisms from one area to another area of the same
client’s body, causing infection of a previously uninfected area. Although all techniques listed can
help reduce the risk for infection, only changing gloves between carrying out wound care on
different parts of the client’s body can prevent autocontamination.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
3. The nurse is teaching burn prevention to a community group. Which information shared by a
member of the group causes the nurse the greatest concern?
a. “I get my chimneys swept every other year.”
b. “My hot water heater is set at about 120 degrees.”
c. “Sometimes I wake up at night and smoke.”
d. “I use a space heater when it gets below zero.”
ANS: C
House fires are a common occurrence and often lead to serious injury or death. The nurse should be
most concerned about a person who wakes up at night and smokes. The nurse needs to question this
person about whether he or she gets out of bed to do so, or if this person stays in bed, which could
lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys
swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if
the person does not burn wood frequently. Water heaters should be set below 140° F. Space heaters
should be used with caution, and the nurse may want to ensure that the person does not allow it to
get near clothing or bedding. But the most immediate concern is the person’s smoking upon waking
up at night.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Lifestyle Choices)
MSC: Integrated Process: Teaching/Learning
4. The nurse is conducting a home safety class. It is most important for the nurse to include which
information in the teaching plan?
a. Have an escape route everyone knows about.
b. Keep a smoke detector in each bedroom.
c. Use space heaters instead of gas heaters.
d. Use carbon monoxide detectors in the garage.
ANS: B
Everyone should use smoke detectors and carbon monoxide detectors in their home environment
(just not in a garage). Recommendations are that each bedroom should have a separate smoke
detector. Smoke detectors should also be placed in the hallway of each story, in the kitchen, in each
stairwell, and by each entrance. Space heaters can be a cause of fire if clothing, bedding, and other
flammable objects are nearby. An escape route is very important, but successfully escaping also
depends on early recognition of a fire, which is assisted by smoke detectors.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 520
TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC:
Integrated Process: Teaching/Learning
5. A client with facial burns asks the nurse if he will ever look the same. Which response is best for
the nurse to provide?
a. “With reconstructive surgery, you can look the same.”
b. “We can remove the scars with the use of a pressure dressing.”
c. “You will not look exactly the same but cosmetic surgery will help.”
d. “You shouldn’t start worrying about your appearance right now.”
ANS: C
Many clients have unrealistic expectations of reconstructive surgery and envision an appearance
identical or equal in quality to the preburn state. The nurse should provide accurate information that
includes something to hope for. Pressure dressings prevent further scarring. They cannot remove
scars. The client and the family should be taught the expected cosmetic outcomes.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss)
MSC: Integrated Process: Teaching/Learning
6. The nurse has provided instruction on the facial pressure garment to a client with facial burns.
Which statement indicates that the client understands these instructions?
a. “My scars should be less severe with the use of this mask.”
b. “The mask will help protect my skin from sun damage.”
c. “This treatment will help prevent infection.”
d. “Using the mask will keep scars from being permanent.”
ANS: A
The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent
hypertrophic scarring and contractures from forming. Scars will still be present. Although the mask
does provide protection of sensitive, newly healed skin and grafts from sun exposure, this is not the
purpose of wearing the mask. The pressure garment will not alter the risk for infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Evaluation)
7. Which finding indicates to the nurse that a client with a burn injury has a positive perception of
his appearance?
a. Allowing family members to change the dressings
b. Discussing future surgical reconstruction
c. Performing morning care independently
d. Wearing the pressure dressings as ordered
ANS: C
Indicators that the client with a burn injury has a positive perception of his appearance include his
or her willingness to touch the affected body part. Self-care activities such as morning care foster
feelings of self-worth, which are closely linked to body image. Allowing others to change the
dressing and discussing future reconstruction would not indicate a positive perception of
appearance. Wearing the dressing will assist in decreasing complications but will not enhance selfperception.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)
MSC: Integrated Process: Nursing Process (Evaluation)
8. Which statement best exemplifies a client’s understanding of rehabilitation after a full-thickness
burn injury?
a. “I am fully recovered when all the wounds are closed.”
b. “I will eventually be able to perform all my former activities.”
c. “My goal is to achieve the highest level of functioning that I can.”
d. “Full recovery from a major burn injury never occurs.”
ANS: C
Although a return to preburn functional levels is rarely possible, burned clients are considered fully
recovered or rehabilitated when they have achieved their highest possible level of physical, social,
and emotional functioning. The technical rehabilitative phase of rehabilitation begins with wound
closure and ends when the client returns to her or his highest possible level of functioning.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Evaluation)
9. Which finding indicates to the nurse that a client understands the psychosocial impact of a severe
burn injury?
a. “It is normal to feel some depression.”
b. “I will go back to work immediately.”
c. “I will not feel anger about my situation.”
d. “Once I get home, things will be normal.”
ANS: A
During the recovery period, and for some time after discharge from the hospital, clients with severe
burn injuries are likely to have psychological problems that require intervention. Depression is one
of these problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur.
Clients need to know that problems of physical care and psychological stresses may be
overwhelming.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss)
MSC: Integrated Process: Nursing Process (Evaluation)
10. A client is in the emergency department after being rescued from a house fire. After the initial
assessment, the client develops a loud, brassy cough. What intervention by the nurse takes priority?
a. Apply oxygen and continuous pulse oximetry.
b. Allow the client to suck on small quantities of ice chips.
c. Request an antitussive medication from the physician.
d. Have the respiratory therapist provide humidified room air.
ANS: A
Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by
the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous
pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are
not warranted.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Analysis)
11. A client has burns on both legs. These areas appear white and leather-like. No blisters or
bleeding is present, and the client describes just a “small amount of pain.” How does the nurse
categorize this injury?
a. Partial thickness deep
b. Partial thickness superficial
c. Full thickness
d. Superficial
ANS: C
The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black,
brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partialthickness superficial burns appear pink to red and are painful. Partial-thickness burns are deep red
to white and painful, and superficial burns are pink to red and are also painful.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 515
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
12. A client has a large burned area on the right arm. The burned area appears pink, has blisters, and
is very painful. How does the nurse categorize this injury?
a. Full thickness
b. Partial thickness superficial
c. Partial thickness deep
d. Superficial
ANS: B
The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color
that is pink or red; blisters; and pain. Blisters are not seen with full-thickness and superficial burns
and are rarely seen with deep partial-thickness burns. Deep partial-thickness burns appear red to
white.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 514
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
13. A client with a new burn injury asks the nurse why he is receiving intravenous cimetidine
(Tagamet). What is the nurse’s best response?
a. “Tagamet will stimulate intestinal movement so you can eat more.”
b. “Tagamet can help prevent hypovolemic shock, which can be fatal.”
c. “This will help prevent stomach ulcers, which are common after burns.”
d. “This drug will help prevent kidney damage caused by dehydration.”
ANS: C
Ulcerative gastrointestinal disease (Curling’s ulcer) may develop within 24 hours after a severe
burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This
process occurs because of the sympathetic nervous system stress response. Cimetidine inhibits the
production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and
does not prevent hypovolemic shock or kidney damage.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 517
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Teaching/Learning
14. A client who is burned is drooling and is having difficulty swallowing. Which action does the
nurse take first?
a. Assess level of consciousness and pupillary reactions.
b. Ascertain the time food or liquid was last consumed.
c. Auscultate breath sounds over the trachea and mainstem bronchi.
d. Measure abdominal girth and auscultate bowel sounds.
ANS: C
Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty
swallowing can mean that the client is about to lose his airway because of this injury. Absence of
breath sounds over the trachea and mainstem bronchi indicates impending airway obstruction and
demands immediate intubation. Knowing the level of consciousness is important in assessing
oxygenation to the brain. Ascertaining the time of last food intake is important, in case intubation is
necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange
is the most important intervention at this time. Measuring abdominal girth is not relevant in this
situation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
15. On assessment, the nurse notes that a client has burns inside the mouth and is wheezing. Several
hours later, the wheezing is no longer heard. What is the nurse’s next action?
a. Document the findings and reassess in 1 hour.
b. Loosen any constrictive dressings on the chest.
c. Raise the head of the bed to a semi-Fowler’s position.
d. Gather appropriate equipment and prepare for intubation.
ANS: D
Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose
effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath
sounds. These clients can lose their airways very quickly, so prompt action is needed. The client
requires establishment of an emergency airway. Swelling usually precludes intubation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
16. A client who is receiving fluid resuscitation per the Parkland formula after a serious burn
continues to have urine output ranging from 0.2 to 0.25 mL/kg/hour. After the health care provider
checks the client, which order does the nurse question?
a. Increase IV fluids by 100 mL/hr.
b. Administer furosemide (Lasix) 40 mg IV push.
c. Continue to monitor urine output hourly.
d. Draw blood for serum electrolytes stat.
ANS: B
Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland
formula. However, needs vary among clients, and the final fluid volume needed is adjusted to
maintain hourly urine output at 0.5 mL/kg/hr. Based on this client’s inadequate urine output, fluids
need to be increased. The other orders are appropriate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
17. A client is 24 hours post burn and has the following laboratory results. Which result does the
nurse report to the health care provider immediately?
a. Arterial pH, 7.32
b. Hematocrit, 52%
c. Serum potassium,7.5 mEq/L
d. Serum sodium, 131 mEq/L
ANS: C
The serum potassium level is changed to the degree that serious life-threatening responses could
result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe
cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same
degree of severity; they would be expected in the emergent phase after a burn injury.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Analysis)
18. Ten hours after a client with 50% burns is admitted, her blood glucose level is 152 mg/dL. What
action by the nurse is most appropriate?
a. Document the finding.
b. Obtain a family history for diabetes.
c. Repeat the glucose measurement.
d. Stop IV fluids containing dextrose.
ANS: A
Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases
liver glucose production and release. An acute rise in the blood glucose level is an expected client
response and is helpful in the generation of energy needed for the increased metabolism that
accompanies this trauma. A family history of diabetes could place her at higher risk for the disease,
but this is not a priority at this time. The glucose level is not high enough to warrant retesting. The
cause of her elevated blood glucose is not the IV fluid.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
19. A client who was burned has crackles in both lung bases and a respiratory rate of 40 breaths/min
and is coughing up blood-tinged sputum. Which action by the nurse takes priority?
a. Administer digoxin.
b. Perform chest physiotherapy.
c. Document and reassess in an hour.
d. Place the client in an upright position.
ANS: D
Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even
in a young healthy person. Placing the client in an upright position can relieve lung congestion
immediately before other measures can be carried out. Digoxin may be given later to enhance
cardiac contractility to prevent backup of fluid into the lungs. Chest physiotherapy will not get rid
of fluid.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
20. A client who is admitted after a thermal burn injury has the following vital signs: blood
pressure, 70/40; heart rate, 140 beats/min; and respiratory rate, 25 breaths/min. He is pale, and it is
difficult to find pedal pulses. Which action does the nurse take first?
a. Begin intravenous fluid resuscitation.
b. Check pulses with a Doppler device.
c. Obtain a complete blood count (CBC).
d. Obtain an electrocardiogram (ECG).
ANS: A
Hypovolemic shock is a common cause of death in the emergent phase of clients with serious
injury. Fluids can treat this problem. ECG and CBC will be taken to ascertain whether a cardiac or
bleeding problem is causing these vital signs. However, these are not actions that the nurse would
take immediately. Checking pulses would indicate perfusion to the periphery, but this is not an
immediate nursing action.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Analysis)
21. A client is brought to the emergency department by an emergency medical services (EMS)
squad after being burned with unknown chemicals. The client’s body is covered with a white,
powdery substance, and the client cries out, “Get this stuff off me! It’s burning me!” Which action
by the nurse is most appropriate?
a. Have the client take a shower, and bag all clothing.
b. Brush the substance off the client and remove clothes.
c. Call poison control to try to identify the chemical.
d. Start an IV line and prepare to administer analgesics.
ANS: B
A priority first action in burn care is to stop the burning process. Chemicals can continue to burn
the client even after they have been removed, so removing them from the client is an important
action. With unknown dry substances, adding water could potentiate their action, so the best action
is to brush off as much of the chemical as possible from the client and clothing, then remove the
clothing. Calling poison control would take too long if the chemical could be identified, and
analgesics should be given after the burning process has been halted by removal of the offending
substance.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
22. A client suffered a 45% total body surface area (TBSA) burn and was intubated. Twelve hours
later, bowel sounds were absent in all four abdominal quadrants. Which is the nurse’s best action?
a. Administer a laxative.
b. Document the finding.
c. Prepare to insert a nasogastric (NG) tube.
d. Reposition the client on the right side.
ANS: C
Decreased or absent peristalsis is a frequent response during the emergent phase of burn injury as a
result of neural and hormonal compensation to the stress of injury. The result is often a paralytic
ileus. Clients who have burns greater than 25% TBSA or who are intubated generally need to have
an NG tube inserted.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
23. A client has experienced an electrical injury of the lower extremities. Which priority assessment
data should be obtained from this client?
a. Range of motion in all extremities
b. Heart rate, rhythm, and electrocardiogram (ECG)
c. Respiratory rate and pulse oximetry
d. Orientation to time, place, and person
ANS: B
The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse
oximetry are not priority assessments. Electrical current travels through the body from the entrance
site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage
from electrical injury includes irregular heart rate and rhythm, and ECG changes. Range-of-motion
and neurologic assessments are important; however, the priority is to make sure that the heart rate
and rhythm are adequate to support perfusion to the brain and other vital organs.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
24. A client is receiving fluid resuscitation after a burn. Which finding indicates that fluid
resuscitation is adequate for this client?
a. Hematocrit = 60%
b. Heart rate = 130 beats/min
c. Increased peripheral edema
d. Urine output = 50 mL/hr
ANS: D
The fluid remobilization phase improves renal blood flow, increases diuresis, and restores blood
pressure and heart rate, as well as laboratory values, to more normal levels.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Analysis)
25. The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired
outcome of the procedure, which action does the nurse perform first?
a. Apply silver sulfadiazine (Silvadene) ointment.
b. Cover the area with an elastic wrap.
c. Place a synthetic dressing over the area.
d. Remove loose nonviable tissue.
ANS: D
All steps are part of the nonsurgical wound care for clients with burn injuries. The first step in this
process consists of removing exudates and necrotic tissue. This promotes wound healing.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
26. Which nursing intervention is likely to be most helpful in providing adequate nutrition while a
client is recovering from a thermal burn injury?
a. Allowing the client to eat whenever he or she wants
b. Beginning parenteral nutrition high in calories
c. Including 3000 kcal/day of calories with meals
d. Providing a low-protein, high-fat diet
ANS: A
Clients should request food whenever they think they can eat, not just according to the hospital’s
standard meal schedule. The nurse needs to work with a dietitian to provide a high-calorie, highprotein diet to help with wound healing. Clients who can eat solid foods should ingest as many
calories as possible; they may need as many as 5000 kcal/day. Specific caloric requirements can be
determined by the dietitian. Parenteral nutrition may be given as a last resort because it is invasive
and can lead to infectious and metabolic complications.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
27. The family of a client who has been burned asks when the client will no longer be at greater risk
for infection. What is the nurse’s best response?
a. “As soon as the antibiotics have been finished.”
b. “As soon as albumin levels returns to normal.”
c. “When fluid remobilization has started.”
d. “When the burn wounds are closed.”
ANS: D
Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much
time has passed since the burn injury, the client remains at high risk for infection as long as any
area of skin is open.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 512
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Teaching/Learning
28. A client with open burn wounds begins to have diarrhea. The client is found to have a below-
normal temperature, with a white blood cell count of 4000/mm 3. Which action by the nurse is most
appropriate?
a. Continue to monitor the client.
b. Increase the temperature in the room.
c. Increase the rate of intravenous fluids.
d. Prepare to do a workup for sepsis.
ANS: D
These findings are associated with systemic Gram-negative infection and sepsis. To verify that
sepsis is occurring, cultures of the wound and blood must be taken to determine the appropriate
antibiotic to be started. Continuing just to monitor the situation can lead to septic shock. Increasing
the temperature in the room may make the client more comfortable, but the priority is finding out
whether the client has sepsis and treating it before it becomes a shock situation. The rate of
intravenous fluids may be increased to replace fluid losses associated with diarrhea, but this is not
the priority action.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
29. The nurse uses topical gentamicin sulfate (Garamycin) on a client’s burn injury. Which
laboratory value does the nurse monitor?
a. Creatinine
b. Red blood cells
c. Sodium
d. Magnesium level
ANS: A
Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect
kidney function. Any client receiving gentamicin by any route should have kidney function
monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium
level.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Implementation)
30. The nurse has been teaching a client about skin grafting procedures. What statement indicates
that the client needs further education about allografts?
a. “Because the graft is my own skin, there is no chance it won’t ‘take.’”
b. “For a few days after surgery, the donor sites will be painful.”
c. “I will have some scarring in the area where the skin is removed.”
d. “I am still at risk for infection after the procedure until the burn heals.”
ANS: A
Factors other than tissue type, such as circulation and infection, influence whether and how well a
graft will work. The client should be prepared for the possibility that not all grafting procedures
will be successful. Donor sites will be painful after surgery, scarring can occur in the area where
skin is removed for grafting, and the client is still at risk for infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Evaluation)
31. Which intervention by the nurse is most appropriate to reduce a client’s pain after a burn injury?
a. Administering morphine sulfate 4 mg intravenously
b. Administering morphine sulfate 4 mg intramuscularly
c. Applying ice to the burned area for 20 minutes
d. Avoiding tactile stimulation near the burned area
ANS: A
Drug therapy for pain management requires opioid and non-opioid analgesics. The IV route is used
because of problems with absorption from the muscle and the stomach. Tactile stimulation can be
used for pain management. For the client to avoid shivering, the room must be kept warm, and ice
should not be used. Ice would decrease blood flow to the area.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes)
MSC: Integrated Process: Nursing Process (Implementation)
32. The nurse assesses a client in the burn unit after the client was repositioned by the nursing
assistant. The nurse intervenes after finding the client repositioned in what manner?
a. Supine with one pillow behind the head
b. Semi-Fowler’s position with arms elevated
c. Wrists extended to 30 degrees in a splint
d. A towel roll placed under the neck or shoulder
ANS: A
Clients must be positioned to prevent contractures. The function that would be disrupted by a
contracture to the posterior neck is flexion. The client should not be positioned with a pillow behind
the head; this would increase flexion. The nurse must intervene and position the client so that neck
flexion does not occur. The other options include proper positioning techniques that will help
prevent contracture.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
33. A client has severe burns around the right hip. Which position does the nurse instruct the
nursing assistant to use to maintain maximum function of this joint?
a. Hip maintained in 30-degree flexion
b. Hip at zero flexion with leg flat
c. Knee flexed at 30-degree angle
d. Leg abducted with foam wedge
ANS: B
Maximum function for ambulation occurs when the hip and the leg are maintained at full extension
with neutral rotation. Although the client does not have to spend 24 hours in this position, he or she
should be in this position (in bed or standing) longer than with the hip in any degree of flexion.
DIF: Cognitive Level: Comprehension/Understanding REF: Chart 28-6, p. 537
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
34. A client who suffered burns in a house fire reports a headache and is not consistently oriented to
time. Which intervention by the nurse is most appropriate?
a. Increase the client’s oxygen and obtain blood gases.
b. Draw blood for a carboxyhemoglobin level.
c. Increase the client’s intravenous fluid rate.
d. Perform a thorough Mini-Mental Status Examination.
ANS: B
These manifestations are consistent with moderated carbon monoxide poisoning. This client is at
risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other
options will not provide information related to carbon monoxide poisoning.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Tests) MSC:
Integrated Process: Nursing Process (Analysis)
35. A client who has had a full-thickness burn is being discharged from the hospital. Which
information is most important for the nurse to provide before discharge?
a. How to maintain home smoke detectors
b. Joining a community reintegration program
c. Learning to perform dressing changes
d. Options available for scar removal
ANS: C
Critical for the goal of progression toward independence for the client is teaching clients and family
members to perform care tasks such as dressing changes. All of the other options are important in
the rehabilitation stage. However, dressing changes have priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Implementation)
36. An older adult client with burns has a white blood cell count of 10,000/mm 3. The client is
afebrile with a heart rate of 110 beats/min, a respiratory rate of 20 breaths/min, and blood pressure
of 112/68 mm Hg. The client’s wound is pale, and edema is noted in the surrounding tissues. Which
intervention by the nurse is most appropriate?
a. Assess the client’s skin for signs of adequate perfusion.
b. Calculate intake and output ratio for the last 24 hours.
c. Prepare to obtain blood and wound cultures.
d. Place the client in an isolation room.
ANS: C
Older clients have a decreased immune response, so they may not exhibit signs that their immune
system is actively fighting an infection such as fever or an increased white blood cell count. They
also are at higher risk for sepsis arising from a localized wound infection. The wound shows signs
of local infection, so the nurse should assess for this and for systemic infection before the client
manifests sepsis. The other options would yield important data but do not take priority over
determining whether the client has an infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Analysis)
SHORT ANSWER
1. A client who weighs 90 kg and had a 50% burn injury at 10 AM arrives at the hospital at noon.
Using the Parkland formula, calculate the rate that the nurse should use to deliver fluid when the IV
is started at noon.
ANS:
1500 mL/hr
The Parkland formula is 4 mL/kg/%total body surface area (TBSA) burn. This client needs 18,000
mL of fluid during the first 24 hours post burn. Half of the calculated fluid replacement needs to be
administered during the first 8 hours after injury, and half during the next 16 hours. This client was
burned at 10 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the
next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during
the first 8 post burn hours.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
OTHER
1. A client is in the emergency department with a burn calculated to be 35% TBSA. The nurse
prepares the client for an IV insertion in which location?
ANS:
A [subclavian vein]
Clients with burns greater than 25% TBSA are at great risk for hypovolemic shock and need fluid
resuscitation. The large volume of fluids this client needs will be delivered at a very rapid rate, so
the IV needs to be a central venous catheter instead of a peripheral IV. All other sites are peripheral
sites.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
Chapter 29: Assessment of the Respiratory System
Chapter 29: Assessment of the Respiratory System
Test Bank
MULTIPLE CHOICE
1. A client has undergone a thoracentesis. Which assessment finding requires immediate action by
the nurse?
a. Decreased level of consciousness
b. Tachycardia
c. Increased temperature
d. Slowed respiratory rate
ANS: B
An increased heart rate may indicate that the client is developing a pneumothorax or hypoxia.
Although it is important to note immediately whether the client is experiencing a decreased level of
consciousness, increased temperature, or a slowed respiratory rate, none of these is as indicative of
a life-threatening complication as tachycardia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Assessment)
2. The nurse assesses a client after an open lung biopsy. Which assessment finding is matched with
the correct intervention?
a. Client feels “dizzy;” nurse applies oxygen and pulse oximeter.
b. Client’s heart rate is 55 beats/min; nurse withholds pain medication.
c. Client has reduced breath sounds; nurse calls physician immediately.
d. Client’s respiratory rate is 18 breaths/min; nurse decreases oxygen flow
rate.
ANS: C
A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or
absent breath sounds. The physician needs to be notified immediately. Dizziness after the procedure
is not an expected finding. If the client’s heart rate is 55 beats/min, no reason is known to withhold
pain medication. A respiratory rate of 18 breaths/min is a normal finding and would not warrant
changing the oxygen flow rate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
3. The nurse is caring for four clients who had arterial blood gases (ABGs). Which laboratory value
warrants immediate intervention by the nurse?
a. HCO3– of 25 mEq/L
b. SpO2 of 96%
c. pH of 7.38
d. PaCO2 of 48 mm Hg
ANS: D
Although the nurse should note the results of all laboratory work, only a PaCO 2 of 48 mm Hg is
likely to culminate in serious symptoms for the client. HCO 3–, SpO2, and pH levels as assessed
would not be life threatening, nor would they be indicative of serious complications that would
override the importance of the PaCO2 level.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Assessment)
4. The nurse is calculating a client’s smoking history in pack-years. The client has recently been
diagnosed with lung cancer. Which is the nurse’s priority intervention during the interview?
a. Encourage the client to quit smoking to stop further cancer
development.
b. Encourage the client to be completely honest about both tobacco and
marijuana use.
c. Maintain a nonjudgmental attitude to avoid causing the client to feel
guilty.
d. Avoid giving the client false hope regarding cancer treatment and
prognosis.
ANS: C
Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled
substances. Ask the client whether any of these substances are used now or were used in the past.
Assess whether the client has passive exposure to smoke in the home or workplace. If the client
smokes, ask for how long, how many packs a day, and whether he or she has quit smoking (and
how long ago). Document the smoking history in pack-years (number of packs smoked daily
multiplied by the number of years the client has smoked). Because the client may have guilt or
denial about this habit, assume a nonjudgmental attitude during the interview. This will encourage
the client to be honest about the exposure.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Teaching/Learning
5. When assessing a client’s respiratory status, which information is of highest priority for the nurse
to obtain?
a. Average daily fluid intake
b. Neck circumference
c. Height and weight
d. Occupation and hobbies
ANS: D
Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a
client’s occupation and hobbies. Although it will be important for the nurse to assess the client’s
fluid intake, height, and weight, these will not be as important as determining his occupation and
hobbies. Determining the client’s neck circumference will not be an important part of a respiratory
assessment.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 548
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
6. The nursing assistant reports to the nurse that an African-American client’s pulse oximetry
reading is 93%. The client has no complaints. Which action by the nurse is most appropriate?
a. Replace the sensor probe of the oximeter.
b. Place the probe on another finger.
c. Assess other signs of respiratory adequacy.
d. Prepare to obtain arterial blood gases.
ANS: C
Normal pulse oximetry readings are 95% to 100%. However, people with dark skin can have
readings that are 3% to 5% lower owing to the darker coloration of the nail bed. The nurse should
assess other signs of respiratory adequacy because this may be a normal finding for this client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Nursing Process (Analysis)
7. The nurse is caring for an older adult client with a pulmonary infection. Which nursing action is a
priority with this client?
a. Encouraging the client to increase fluid intake
b. Assessing the client’s level of consciousness
c. Raising the head of the bed to at least 45 degrees
d. Providing the client with humidified oxygen
ANS: B
Assessing the client’s level of consciousness will be most important because it will show how the
client is responding to the presence of the infection. Although it will be important for the nurse to
encourage the client to turn, cough, and breathe deeply frequently; to raise the head of the bed; and
to humidify the oxygen administered, none of these actions will be as important as assessing the
level of consciousness. Also, the client who has a pulmonary infection may not be able to cough
effectively if an area of abscess is present.
DIF: Cognitive Level: Comprehension/Understanding REF: Chart 29-1, p. 549
TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)
MSC: Integrated Process: Nursing Process (Assessment)
8. The nurse is assessing a client’s breath sounds. Which assessment finding has been correctly
linked to the nurse’s primary intervention?
a. Hollow sounds heard over trachea; increase oxygen flow rate.
b. Crackles heard in bases; have the client cough forcefully.
c. Wheezes heard in central areas; administer inhaled bronchodilator.
d. Vesicular sounds heard over the periphery; have the client breathe
deeply.
ANS: C
Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages.
Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are
heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing
forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery
are normal and require no interventions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
9. A client has a long-standing history of chronic obstructive pulmonary disease (COPD). Which
laboratory finding does the nurse correlate with this condition?
a. White blood cell count, 7500/mm3
b. Hemoglobin, 22 g/dL
c. Neutrophils, 6000/ mm3
d. Monocytes, 600/mm3
ANS: B
Normal hemoglobin for a female is 12 to 16 g/dL. Clients with COPD have chronic hypoxia, which
stimulates the production of erythropoietin and thus raises the red blood cell count and hemoglobin
and hematocrit levels. All other values are normal.
DIF: Cognitive Level: Comprehension/Understanding REF: Chart 29-3, p. 557
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Assessment)
10. The nurse is caring for several clients on a respiratory unit. Which client does the nurse see
first?
a. Older adult with an SaO2 of 96% on room air
b. Adult client with an SaO2 of 94% on 2 L/min
c. Young adult with an arterial oxygen level of 85%
d. Young adult with an arterial oxygen level of 94%
ANS: C
The young adult with an impaired arterial oxygen level should be seen first. A level of 90% to
100% is a normal level for this age-group. The older adult with a pulse oxygen of 96% is within
normal limits, as is an adult with a pulse oxygen of 94%. An arterial oxygen level of 94% would
also be seen as normal.
DIF: Cognitive Level: Comprehension/Understanding REF: Chart 29-3, p. 557
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC:
Integrated Process: Nursing Process (Assessment)
11. A client with a history of chronic obstructive pulmonary disease (COPD) presents to the clinic
with increased cough and low-grade temperature. Which question by the nurse elicits the most
useful information?
a. “How long have you been sick?”
b. “Has your sputum changed color?”
c. “Is anyone else in your house sick?”
d. “Do you take any medications?”
ANS: B
Clients with COPD usually have a productive cough. If the color has changed, that is a noteworthy
finding. If the client’s sputum is yellow or green, this may indicate a pulmonary infection. The
other questions are also appropriate to ask but will not help in gathering information specific to a
pulmonary problem.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
12. A client tells the nurse that he usually expectorates about 2 ounces of thin, clear, colorless
sputum each day, mostly in the morning after getting out of bed. What is the nurse’s initial action
after gaining this information?
a. Ask the client to provide a morning sputum sample for laboratory
analysis.
b. Obtain a specimen of the sputum in a sterile container for culture.
c. Monitor for an increase in sputum production or a change in color.
d. Notify the health care provider and prepare the client for possible
bronchoscopy.
ANS: C
Sputum production is a normal function of the respiratory tract. Most healthy people produce about
90 mL of sputum/day. This sputum should be thin, clear, and odorless, and should have minimal or
no color. The nurse’s only action should be to monitor the client for an increase in sputum
production or a change in color. It will not be necessary at this time to obtain a specimen for
analysis or to prepare for a bronchoscopy.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
13. The nurse observes that a client’s anteroposterior (AP) chest diameter is the same as his lateral
chest diameter. What is the nurse’s most important question for the client in response to this
finding?
a. No questions are needed regarding this normal finding.
b. “Do you have any chronic breathing problems?”
c. “How often do you perform aerobic exercise?”
d. “What is your occupation and what are your hobbies?”
ANS: B
The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP
diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest. Most
commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as
chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who
have lived at a high altitude for many years. Therefore, an AP chest diameter that is the same as the
lateral chest diameter should be rechecked but is not as indicative of underlying disease processes
as an AP diameter that exceeds the lateral diameter.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific
Assessments) MSC: Integrated Process: Nursing Process (Assessment)
14. A client with long-standing pulmonary problems is classified as having class III dyspnea. Based
on this classification, what type of assistance does the nurse anticipate providing for ADLs?
a. Dyspnea is minimal and the client requires no additional assistance.
b. The client may require rest periods during performance of ADLs.
c. The client requires assistance for some but not all tasks.
d. Owing to severe dyspnea, this client cannot participate in any self-care.
ANS: B
Class III dyspnea occurs during usual activities, such as showering, but the client does not require
assistance from others. The client may need to rest during activities. A client with class I dyspnea
would likely need no assistance. A client with class IV dyspnea may require assistance for some but
not all tasks. A client with class V dyspnea cannot participate in any self-care.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Planning)
15. A postoperative client has an oxygen saturation of 96% but is pale and dyspneic and says, “I
can’t get enough air!” The client’s lung sounds are clear. Which action by the nurse is most
appropriate?
a. Call the physician and request a hemoglobin and hematocrit level.
b. Notify respiratory therapy and request a breathing treatment.
c. Encourage the client to cough and deep breathe 10 times each hour.
d. Take the client’s temperature and give antipyretics if needed.
ANS: A
A normal pulse oximetry reading is 95% to 100%. Pulse oximetry measures the percent of
hemoglobin saturated with oxygen. However, if the client’s hemoglobin level is low, the pulse
oximetry reading may not correlate with his or her condition. A postoperative client is at risk for
bleeding, so the nurse should request a hemoglobin and hematocrit level. Respiratory treatment is
not indicated. Coughing and deep breathing are appropriate but are not the priority. Monitoring for
and treating fevers is also appropriate but is not the priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
16. A client had a flexible bronchoscopy 2 hours ago and has become mildly cyanotic despite the
application of oxygen. When giving change-of-shift report, which question by the oncoming nurse
elicits the most useful information?
a. “How long was the client sedated for the procedure?”
b. “Were the oximetry readings during the test normal?”
c. “Are you sure the client was NPO before the bronchoscopy?”
d. “What kind of topical anesthetic was used on the client?”
ANS: D
Benzocaine spray can be used as a topical anesthetic before bronchoscopy to numb the throat.
However, its use is associated with methemoglobinemia. Methemoglobin does not carry oxygen,
and a clue to this problem is increasing cyanosis refractory to oxygen. Chocolate brown blood is
another characteristic of this problem. The other options are all appropriate but are not the priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Assessment)
17. A client is scheduled to undergo a thoracentesis. What is the nurse’s priority intervention?
a. Measure oxygen saturation before and after a 12-minute walk.
b. Verify that the client understands all possible complications.
c. Explain the procedure in detail to the client and the family.
d. Verify that informed consent has been given by the client.
ANS: D
A thoracentesis is an invasive procedure with many potentially serious complications. Verifying
that the client understands complications and explaining the procedure to be performed will be
done by the physician, not the nurse. Measurement of oxygen saturation before and after a 12minute walk is not a procedure unique to a thoracentesis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Informed Consent)
MSC: Integrated Process: Communication and Documentation
18. The nurse is caring for a client after a thoracentesis. Which assessment finding by the nurse
warrants immediate action?
a. Client rates pain as 5/10 at the site of the procedure.
b. Small amount of drainage is noted from the site.
c. Pulse oximetry is 93% on 2 liters of oxygen.
d. Trachea is deviated toward opposite side of the neck.
ANS: D
A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency.
The other findings are normal or near-normal.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
19. A client had a bronchoscopy 2 hours ago and is requesting water to drink. Which action by the
nurse is most appropriate?
a. Call the physician and request an order for food and water.
b. Give the client ice chips instead of a drink of water.
c. Assess the client’s gag reflex before giving anything.
d. Let the client have a small sip to see whether he or she can swallow.
ANS: C
The topical anesthetic used during the procedure will have affected the client’s gag reflex. Before
allowing the client anything to eat or drink, the nurse must check for the return of this reflex.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Assessment)
20. A client is scheduled for pulmonary function tests (PFTs) in the morning. The nurse calls the
client to teach about the procedure. Which statement by the client indicates a need for further
teaching?
a. “I should not smoke for at least 6 hours before the test.”
b. “PFTs can determine whether my lung problem has gotten worse.”
c. “I should use my inhaler anytime during the test if I need it.”
d. “If I get really short of breath, I’ll tell the technician.”
ANS: C
Bronchodilators may need to be held before PFTs. The client should not plan to use them at any
time during the test if he or she experiences dyspnea. The other options show adequate
understanding.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Teaching/Learning
Chapter 30: Care of Patients Requiring Oxygen Therapy or
Tracheostomy
Chapter 30: Care of Patients Requiring Oxygen Therapy or Tracheostomy
Test Bank
MULTIPLE CHOICE
1. The nurse is caring for a client with a new tracheostomy. Which assessment finding requires the
nurse’s immediate action?
a. Cuff pressure readings consistently between 14 and 20 mm Hg.
b. Need to change Velcro tube holders three times in 1 day.
c. Crackling sensation around the neck when skin is palpated.
d. Small amount of bleeding around the incision for the first few days.
ANS: C
Subcutaneous emphysema occurs when an opening or tear occurs in the trachea and air escapes into
fresh tissue planes of the neck. Air can also progress through the chest and other tissues into the
face. Inspect and palpate for air under the skin around the new tracheostomy. If the skin is puffy
and you can feel a crackling sensation, notify the physician immediately. Cuff pressures should be
maintained between 14 and 20 mm Hg or between 20 and 28 cm H 2O. Tracheostomy ties need to be
changed at least once a day or whenever soiled. It is not uncommon for a client with a new
tracheostomy to have heavy secretions that would necessitate changing them. It is not unusual to
have a small amount of bleeding around the incision for the first few days after surgical placement.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Analysis)
2. A client has a new tracheostomy and is receiving 60% oxygen via tracheostomy collar. Which
assessment finding requires immediate action by the nurse?
a. Constant, nonproductive coughing
b. Blood-tinged sputum
c. Rhonchi in upper lobes
d. Dry mucous membranes
ANS: A
Causes and manifestations of lung injury from oxygen toxicity include nonproductive cough,
substernal chest pain, GI upset, and dyspnea. Blood-tinged sputum is expected in clients with new
tracheostomies. Rhonchi in upper lobes indicates sputum that can be expectorated and is not an
emergent problem. Dry mucous membranes should be lubricated, and the client’s hydration status
can be checked.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
3. A client has been placed on 6 L of humidified oxygen via nasal cannula. Which action by the
nurse is most appropriate?
a. Drain condensation back into the humidifier, maintaining a closed
system.
b. Keep the water sterile by draining it from the water trap back into the
humidifier.
c. Turn down the humidity when condensation begins to collect in the
tubing.
d. Remove condensation in the tubing by disconnecting and emptying it
appropriately.
ANS: D
Condensation often forms in the tubing when a client receives humidified high-flow oxygen.
Remove this condensation as it collects by disconnecting the tubing and emptying the water. Some
humidifiers and nebulizers have a water trap that hangs from the tubing so the condensation can be
drained without disconnecting. To prevent bacterial contamination, never drain the fluid back into
the humidifier or the nebulizer. Do not turn down the humidity because the physician has ordered it
and the client needs it. Minimize how long the tubing is disconnected because the client does not
receive oxygen during this period.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
4. A client is being discharged with a tracheostomy and voices concern about his appearance. What
discharge teaching will assist the client with maintaining a positive body image?
a. “Tell people how sick you were when they ask about the tracheostomy.”
b. “Your clothing can help hide the tracheostomy so it is not as
noticeable.”
c. “You can put a bandage around your tracheostomy so no one will see
it.”
d. “You have to ignore comments that people make about your
appearance.”
ANS: B
The client may have an alteration in body image because of the tracheostomy stoma. Encourage the
client to wear loose-fitting shirts and collars to help hide the appearance of the stoma. Clients
should not be encouraged to tell people about their illness, because they should not be made to
“justify” their appearance. You should not bandage the tracheostomy, because airflow would be
impaired. Ignoring comments will not help the client’s self-image.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)
MSC: Integrated Process: Caring
5. A client is becoming frustrated because of an inability to communicate with a tracheostomy.
Which intervention by the nurse most effectively enhances communication?
a. Explain to the client that speech will be clear and distinct with a
fenestrated tube.
b. Reassure the client that in time he or she will get used to the speech
difficulties.
c. Place a sign above the client’s bed indicating that the client cannot
speak.
d. Provide the client with a communication board and call light within
easy reach.
ANS: D
A communication board and the call light will reassure the client that needs will be communicated
and met. It is doubtful that the client with a tracheostomy will ever speak clearly and distinctly, no
matter what type of tube he or she uses. Reassuring the client that he or she will get used to the
speech difficulties does nothing to alleviate the discomfort and fear associated with impaired
communication. Placing a sign above the client’s bed indicating that he cannot speak will not
enhance his ability to communicate, although it may help staff remember that the client has
impaired communication.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)
MSC: Integrated Process: Caring
6. A client is receiving oxygen via Venturi mask at 40%. On assessment the nurse finds the client
cyanotic with labored respirations. Which action does the nurse perform first?
a. Remove bedding from around the adaptor opening.
b. Listen to lung sounds and obtain a respiratory rate.
c. Call respiratory therapy to check oxygen saturation.
d. Notify the provider or Rapid Response Team immediately.
ANS: A
The Venturi mask works by drawing in a specific amount of air to mix with the oxygen through
holes in an adaptor fitted at the bottom of the mask. Holes of different sizes allow different amounts
of room air to be entrained, changing the amount of oxygen delivered. Bedding (or clothing)
wrapped around those holes would effectively change the FiO 2. The nurse should ensure that the
holes remain unobstructed. Other options are appropriate but are not the first choice, because this
simple step may be what solves the problem.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of
Equipment)
MSC: Integrated Process: Nursing Process (Implementation)
7. A client requires oxygen received via a face mask but wants to remain as mobile as possible once
discharged home. Which intervention by the home health nurse best provides the client with
maximal mobility?
a. Arrange a consultation with pulmonary rehabilitation to decrease
oxygen needs.
b. Encourage the client to remove the mask occasionally to assess
tolerance.
c. Add extra connecting pieces of tubing to the client’s existing oxygen
setup.
d. Change the face mask to a nasal cannula occasionally, such as at
mealtimes.
ANS: C
To increase mobility, up to 50 feet of connecting tubing can be used with connecting pieces. A
client with a chronic respiratory condition needing home oxygen may not be able to decrease
oxygen needs through pulmonary rehabilitation, but that would not increase mobility with an
oxygen device. The nurse should not independently encourage the client to remove the mask for
periods of time or change to a cannula.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Planning)
8. A client has been brought in by the rescue squad to the emergency department. The client is
having an acute exacerbation of chronic obstructive pulmonary disease (COPD) and is severely
short of breath. On arrival, the client is on 15 L/min of oxygen via rebreather mask. Which action
by the nurse takes priority?
a. Immediately reduce the oxygen flow to 2 to 4 L/min via nasal cannula.
b. Perform a thorough respiratory assessment and attach pulse oximetry.
c. Call the laboratory to obtain arterial blood gases as soon as possible.
d. Obtain a stat chest x-ray, then slowly wean the client’s oxygen down.
ANS: B
Oxygen-induced hypoventilation can occur in clients with chronically elevated PCO 2 levels, such
as those seen in COPD. Giving oxygen can eliminate their hypoxic drive to breathe and can cause
respiratory arrest. However, hypoxemia is a greater threat to an acutely ill client than is the
potential for oxygen-induced hypoventilation, and clients should be given the amount of oxygen
they require. The nurse should perform a thorough respiratory assessment and should monitor the
client for signs of this problem, rather than automatically reducing oxygen delivery. Blood gases
and a chest x-ray will also be obtained, but they do not take priority over assessing and monitoring
the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
9. The nurse is caring for a client with orders for oxygen at 5 L/min. Approximately how much FiO 2
is the client receiving?
a. 24%
b. 28%
c. 36%
d. 40%
ANS: D
A nasal cannula can provide oxygen at 0.5 to 6 L/min, corresponding to an FiO 2 range of 25% to
40%. At 5 L/min, the client is receiving 40% oxygen.
DIF: Cognitive Level: Knowledge/Remembering REF: Table 30-1, p. 566
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Analysis)
10. A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory
problem is becoming increasingly confused. What does the nurse do first?
a. Notify the health care provider.
b. Assess the client’s pulse oximetry.
c. Document the observation.
d. Raise the head of the bed.
ANS: B
Cerebral hypoxia is a cause of confusion and is a sensitive indicator that the client needs more
oxygen. Although you would want to notify the provider of the change in the client’s condition, the
best action is first to assess pulse oximetry and then to increase the oxygen. You would not just
document the assessment finding without intervening. Raising the head of the bed would not help
the client oxygenate better.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
11. The nurse assesses a client who is receiving oxygen via a partial rebreather mask. Which
assessment finding does the nurse intervene to correct?
a. The bag is two thirds inflated during inhalation.
b. The client’s pulse oximetry reading is 93%.
c. The oxygen flow rate is 2 L/min.
d. The arterial oxygen level is 90%.
ANS: C
Flow rate should be 6 to 11 L/min. A flow rate of 2 L/min will not adequately inflate the bag. A bag
that is two thirds inflated is desired. A pulse oximetry reading of 93% and higher is adequate, as is
an arterial oxygenation of 90%.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
12. A client is to be discharged home on oxygen therapy. What information does the nurse teach the
client?
a. “Carry the H cylinder tank on short trips.”
b. “Only use the E tank when stationary.”
c. “The D or C cylinder can be carried.”
d. “Roll the tank gently when transporting.”
ANS: C
The D and C cylinders are small enough to be carried. The H cylinder cannot be carried. The E tank
can be transported. The tanks should not be rolled and should be carried only in a stand or a rack.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 570
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
13. The nurse assesses a client with a new tracheotomy, and the tracheostomy tube is pulsating in
synchrony with the client’s heartbeat. Which is the nurse’s priority action?
a. Notify the health care provider immediately.
b. Stabilize the tube by reapplying the ties.
c. Change the inner cannula of the tube.
d. Increase the inflation pressure of the cuff.
ANS: A
If a tracheostomy tube is pulsating with the client’s heart rate, this could indicate proximity to the
innominate artery and may cause erosion of the artery if left in this position. The provider should be
notified immediately. Reapplying the ties, changing the inner cannula, and increasing the inflation
pressure of the cuff are all interventions that will not solve the immediate problem of proximity of
the tube to the innominate artery.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
14. A client is 24 hours postoperative after a tracheostomy has been performed. The nurse finds the
client cyanotic, with the tracheostomy tube lying on his chest. Which action by the nurse takes
priority?
a. Auscultate breath sounds bilaterally.
b. Ventilate with a resuscitation bag and mask.
c. Call a code or the Rapid Response Team.
d. Insert a new obturator into the neck.
ANS: B
Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract
has not matured and replacement is difficult. First, ventilate the client using a manual resuscitation
bag and facemask while another nurse calls for help. Although auscultation of breath sounds is
important, the client’s airway must be opened and ventilation started. Ventilation should begin
while another nurse calls the code. Reinsertion of a fresh tracheostomy tube will require the
physician’s intervention.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
15. While suctioning a client who had a tracheostomy placed 4 days ago, the nurse notes particles of
food in the tracheal secretions. Which action by the nurse is most appropriate?
a. Increase the inflation pressure in the tracheostomy cuff.
b. Add blue dye to a beverage to assess for aspiration.
c. Make the client NPO and notify the health care provider.
d. Perform a more thorough assessment of the client.
ANS: D
Before calling the provider, the nurse needs more data, such as lung sounds, presence of cough,
pulse oximetry reading, and possibly mental status. The nurse could temporarily make the client
NPO while conducting this assessment, but calling the provider must wait until he or she has more
complete data. The nurse should not decide to increase the inflation pressure in the tracheostomy
cuff on his or her own. Adding dye to food, drink, or tube feeding formulas was commonly done in
the past but should be avoided because the dye is toxic to lung tissues if aspirated.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
16. The nurse is teaching a client about his fenestrated tracheostomy tube. Which statement by the
client indicates an accurate understanding of the tube?
a. “I’m glad I will still be able to talk with this tube in place.”
b. “It is great that this tube does not have to be cleaned regularly.”
c. “This tube will not get dislodged because it never needs suctioning.”
d. “Because I can’t swallow, I will need another tube for eating.”
ANS: A
The client can speak with a fenestrated tube, which has a hole in it and allows air to flow over the
vocal cords. The tube still needs to be cleaned and suctioned. The tube may become dislodged, and
the client is able to swallow.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)
MSC: Integrated Process: Teaching/Learning
17. The nurse observes a nursing student suctioning a client. Which intervention by the student
nurse requires the supervising nurse to intervene?
a. Checking oxygen saturation post suctioning
b. Hyperoxygenating the client after removal of the catheter
c. Applying intermittent suction during catheter removal
d. Applying suction when the catheter is inserted
ANS: D
Applying suction as the catheter is introduced allows the tubing to adhere to the airway and
destroys cells. The other options are appropriate actions on the part of a nurse or student who is
suctioning a client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
18. The nurse assesses a client during suctioning. Which finding indicates that the procedure should
be stopped?
a. Heart rate increases from 86 to 102 beats/min.
b. Respiratory rate increases from 16 to 20 breaths/min.
c. Blood pressure increases from 110/70 to 120/80 mm Hg.
d. Heart rate decreases from 78 to 40 beats/min.
ANS: D
A decrease in heart rate indicates that the client is not tolerating the procedure, and the vasovagal
reflex may be stimulated. An increase in heart rate may be stimulated by suctioning and is
expected, as is a slight increase in blood pressure. A slight increase in respiratory rate after the
procedure might be caused by the feeling of oxygen being suctioned from the client’s airway, along
with secretions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Analysis)
19. A client is being discharged home with a tracheostomy. Which action does the nurse teach the
client to decrease the risk for aspiration while eating?
a. Swallow quickly.
b. Thicken all liquids.
c. Rinse all food with water.
d. Chew food completely.
ANS: B
Thickening liquids may assist the client in swallowing and may help prevent aspiration.
Swallowing quickly will not decrease the risk of aspiration and may actually put the client at
greater risk. It is not recommended that the client drink water to wash down food. Chewing food
completely will help prevent choking but will not decrease aspiration risk.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
20. The nursing student is performing tracheostomy care on a client. Which action by the student
leads the supervising nurse to intervene?
a. Using folded gauze dressings on both sides of the stoma
b. Cutting a slit in a gauze 4  4 pad to fit around the stoma
c. Applying new tracheostomy ties before removing old ones
d. Tying the twill tape in a square knot on the side of the neck
ANS: B
Tracheostomy dressings should be made from gauze pads with a manufactured slit in them that fits
around the tube. If none are available, use two gauze pads folded in half placed on either side of the
tube. Cutting a piece of gauze could result in entry of tiny shreds of the gauze the tracheostomy.
The other interventions are appropriate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
21. A client receiving high-flow oxygen has new crackles and diminished breath sounds since the
last assessment 1 hour ago. Which action by the nurse is most appropriate?
a. Call respiratory therapy and request a bronchodilator treatment.
b. Instruct the client to use the spirometer and to cough and deep breathe.
c. Consult with the health care provider and request an order for diuretics.
d. Ensure that the ordered FiO 2 is what is being provided.
ANS: B
A client who is receiving high rates of oxygen is at risk for absorption atelectasis, in which the
normal nitrogen in the air becomes diluted and the alveoli collapse. Hallmarks of this condition
include new onset of crackles and diminished breath sounds. Spirometer use, coughing, and deepbreathing exercises would help to re-expand the alveoli. None of the other options are appropriate
choices.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Analysis)
22. Which statement by a client indicates an accurate understanding of home self-care of a
tracheostomy?
a. “The stoma should be left uncovered during the day to dry.”
b. “I need to put normal saline in my airway twice daily.”
c. “While showering, I need to keep water out of my airway.”
d. “I don’t need to use tracheostomy ties on a daily basis.”
ANS: C
The client should put a shield over the tracheostomy to keep water from entering the airway. The
airway should remain covered during the day with cotton or foam. Saline should be put in the
airway 10 to 15 times daily. Tracheostomy ties should be used daily.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
23. A client is being weaned from a tracheostomy tube and has tolerated capping of the tube for 24
hours. Which action by the nurse is most appropriate?
a. Collect all materials needed for suturing the stoma shut.
b. Place a dry dressing over the stoma and tape it securely.
c. Assess the client for air leaking around the tube.
d. Select a smaller tracheostomy tube to be inserted.
ANS: B
The tube will be able to be removed after the client has tolerated capping of it for 24 hours.
Therefore, a dry dressing will be able to be placed over the stoma. The stoma will not be sutured. It
will heal on its own with a small scar. Airflow should be adequate around the capped tube. The
physician will not likely insert the next smallest size tube but instead will remove the existing tube.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
24. The nurse is preparing to receive a postoperative client who just had a tracheostomy. Which
action by the nurse takes priority?
a. Obtain report from the postanesthesia care unit.
b. Place a second tracheostomy tube and obturator at the bedside.
c. Review orders for postoperative pain medications.
d. Order supplies for tracheostomy care for 24 hours.
ANS: B
The nurse must ensure that a second tracheostomy tube with obturator is available at the bedside in
case of accidental decannulation, because tube dislodgment in the first 72 hours is an emergency.
Obtaining report and understanding pain medication orders are important for any postoperative
client, but for the tracheostomy client, having the extra material on hand is critical. Obtaining
supplies for tracheostomy care is not as high a priority as the other three.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Planning)
25. A family member has been taught to provide oral care to a client with a tracheostomy. Which
statement by the family member indicates an accurate understanding of the correct way to provide
mouth care?
a. “I can use glycerin swabs.”
b. “I’ll use water and a toothette.”
c. “I can use hydrogen peroxide.”
d. “It is okay to use mouthwash.”
ANS: B
The best choice for mouth care is water and a toothette because these are the least irritating.
Glycerin swabs, hydrogen peroxide, and mouthwash all are too irritating to the mucous membranes
of the mouth.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 576
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Personal Hygiene)
MSC: Integrated Process: Teaching/Learning
26. The nurse is teaching a family member how to suction the client’s tracheostomy at home. Which
information does the nurse include in the teaching plan?
a. Always suction using sterile technique.
b. Suction the mouth first and then the airway.
c. Be prepared to recannulate the tube frequently.
d. Suctioning with clean technique is acceptable.
ANS: D
The family member can suction using clean technique because fewer organisms are present in the
home than in the hospital. Never suction the mouth first because airway pathogenic organisms
could be introduced into the airway. The family member should not be required to recannulate the
tube except in an emergency.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 578
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
MULTIPLE RESPONSE
1. Which interventions help to prevent aspiration during eating for a client with a tracheostomy?
(Select all that apply.)
a. Provide close supervision for the client during eating and drinking.
b. Add liquids to foods to make them thinner and easier to swallow.
c. Inflate the tracheostomy cuff tube to maximum pressure before starting.
d. Let the client indicate readiness for another bite when being fed.
e. Have the client tuck the chin down and forward while swallowing.
f.
Instruct the client to dry swallow to clear food particles from the throat.
g. Place the client in a semi-Fowler’s position for an hour after eating.
ANS: A, D, E, F
The client with a tracheostomy will require close supervision, even if the client is feeding himself
or herself. Do not rush the client. Allow him or her to indicate when ready for another bite.
Teaching interventions should include instructing the client to tuck the chin down and forward
while swallowing to encourage food to move down smoothly. Dry swallowing helps remove food
residue. Food may actually become easier to aspirate if it is thinner in texture. The nurse should not
initiate adding air to inflate the cuff of a tracheostomy tube further without a physician’s order; if
possible, the cuff should be deflated during eating. Placing the client in a semi-Fowler’s position
after the meal will not prevent aspiration.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
Chapter 31: Care of Patients with Noninfectious Upper Respiratory
Problems
Chapter 31: Care of Patients with Noninfectious Upper Respiratory Problems
Test Bank
MULTIPLE CHOICE
1. A high school athlete has suffered a nasal fracture. What is the priority action of the nurse caring
for the client?
a. Assess for pain.
b. Pack the nares to prevent blood loss.
c. Assess for bone displacement.
d. Assess for airway patency.
ANS: D
A patent airway is the priority. The nurse first should make sure that the airway is patent, then
should determine whether the client is in pain, and whether bone displacement or blood loss has
occurred.
DIF: Cognitive Level: Application/Applying or higher
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
2. After facial trauma, a client has a nasal fracture and is reporting constant nasal drainage, a
headache, and difficulty with vision. What is the nurse’s first action?
a. Collect the nasal drainage on a piece of filter paper.
b. Send the client for a facial x-ray.
c. Perform a vision test.
d. Palpate all facial areas for crepitus.
ANS: A
The client with nasal drainage after facial trauma could have a skull fracture that has resulted in
leakage of cerebral spinal fluid (CSF). CSF can be differentiated from regular drainage by the fact
that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not
as high a priority as assessing for CSF. A CSF leak would increase the client’s risk for infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
3. What is the nurse’s most important action after a client’s gag reflex has returned post
rhinoplasty?
a. Teach the client to change position every 2 hours.
b. Tell the client to put heating pads on the face.
c. Instruct the client to lay flat.
d. Have the client drink at least 2500 mL/day.
ANS: D
Once the gag reflex has returned, the client should drink at least 2 1/2 liters per day. The client
should not change position frequently; the best position is semi-Fowler’s. Ice rather than heat
should be applied. Lying flat is not recommended.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
4. A client reports waking up feeling very tired, even after 8 hours of good sleep. What is the
nurse’s best action?
a. Ask for an order for sleep medication.
b. Tell the client not to drink beverages with caffeine.
c. Tell the client not to lie flat at night.
d. Ask the client whether he or she has ever been evaluated for sleep
apnea.
ANS: D
Clients are usually unaware that they have sleep apnea, but it should be suspected in people who
have persistent daytime sleepiness and report waking up tired. Causes of the problem should be
assessed before the client is offered suggestions for treatment.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
5. A client had a partial laryngectomy and has received instructions on the supraglottic method of
swallowing. Which action by the nurse is most appropriate?
a. Place a chart in the client’s room detailing the steps in the process.
b. Order a dynamic swallow study.
c. Repeat the instruction each day.
d. Have the client demonstrate swallowing.
ANS: A
The client who is status post partial laryngectomy should be taught alternative methods of
swallowing, and a chart should be placed in the client’s room to reinforce teaching. A dynamic
swallow study is performed to guide rehabilitation for swallowing. Repeating the steps each shift is
not as effective as showing the client a chart. Having the client demonstrate swallowing may not
verify that he or she correctly understands supraglottic swallowing. A chart in the room will be
most effective in helping both client and staff with this method.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Teaching/Learning
6. A client has open vocal cord paralysis. Which technique does the nurse teach the client to do to
prevent aspiration?
a. Tilt the head back as far as possible when swallowing.
b. Tuck the chin down when swallowing.
c. Breathe slowly and deeply while swallowing.
d. Keep the head very still and straight while swallowing.
ANS: B
The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in
his or her chin during swallowing to prevent aspiration. Tilting the head back would increase the
chance of aspiration. Breathing slowly would not decrease the risk of aspiration, but holding the
breath would. Keeping the head still and straight would not decrease the risk for aspiration.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Teaching/Learning
7. Which client does the nurse safely delegate to the LPN/LVN who has been assigned to the unit
for the first time?
a. Young adult who is 6 hours post radical neck dissection
b. Older adult client with esophageal cancer who is awaiting gastric tube
placement
c. Client who is status post laryngectomy and is awaiting discharge
teaching
d. Client who is awaiting preoperative teaching for laryngeal cancer
ANS: B
The nurse can delegate stable clients to the LPN. The client who is 6 hours post surgery is not yet
stable. The RN is the only one who can perform discharge and preoperative teaching. Teaching
cannot be delegated.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Delegation) MSC:
Integrated Process: Teaching/Learning
8. A client has a closed fracture of the nose. Which intervention is best when encouraging self-care
for this client?
a. Advise the client not to eat or drink for 24 hours after sustaining the
fracture.
b. Teach the client how to apply cold compresses to the area to reduce
swelling.
c. Urge the client to sleep without a pillow to hasten resolution of the
swelling.
d. Reassure the client that his or her appearance will normalize after the
swelling is gone.
ANS: B
After a closed fracture of the nose, the nurse will encourage rest and the use of cool compresses on
the nose, eyes, or face to help reduce swelling and bruising. Avoiding eating or drinking and
sleeping without a pillow will not hasten resolution of the swelling. Reassuring the client regarding
his or her appearance is not included in self-care.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
9. Which statement indicates that the client needs more teaching regarding rhinoplasty?
a. “I will take my temperature twice each day and will report any fever to
my doctor.”
b. “I will wait a few weeks to have my photograph taken, when the
swelling is gone.”
c. “I will take acetaminophen instead of aspirin for pain to avoid excessive
bleeding.”
d. “I will drink at least 3 quarts of liquids a day and will use a stool
softener.”
ANS: B
Explain that edema and bruising may last for weeks, and that the final surgical result will be
evident in 6 to 12 months. The client should take his or her temperature and report fever in case of
infection. The client should take acetaminophen because risk of bleeding is less than with aspirin.
Fluids and stool softeners will decrease the risk of straining.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
10. What is the highest priority for the nurse to teach the client who is being discharged after a fixed
centric occlusion for a mandibular fracture?
a. How to use wire cutters
b. Eating six soft or liquid meals each day
c. How to irrigate the mouth every 2 hours
d. Sleeping in semi-Fowler’s position postoperatively
ANS: A
The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she
may aspirate. Although the client will need to sleep in a semi-Fowler’s position to assist in avoiding
aspiration if vomiting does occur, this will not be as high a priority as knowing how to cut the
wires.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Teaching/Learning
11. Which client is at greatest risk for development of obstructive sleep apnea?
a. Woman who is 8 months pregnant
b. Middle-aged man with gastroesophageal reflux disease
c. Middle-aged woman who is 50 pounds overweight
d. Older man with type 2 diabetes and a history of sinus infections
ANS: C
The client at highest risk would be the one who is extremely overweight. None of the other clients
have risk factors for sleep apnea.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 584
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
12. Which clinical manifestation in a client with paralysis of one vocal cord alerts the nurse to the
possibility of aspiration?
a. Oxygen saturation is decreased.
b. Voice is weak and tremulous.
c. The client coughs immediately after swallowing.
d. An audible wheeze is present on exhalation.
ANS: C
The client with open vocal cord paralysis is at risk for aspiration because the airway may not close
during swallowing. Coughing may indicate that the client’s airway is irritated from aspirated
contents. Decreased oxygen saturation can occur for a number of reasons. A weak voice may
indicate weak muscles, and wheezing may indicate swelling or inflammation in the airways.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 585
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
13. Which statement made by the client who is prescribed “voice rest” therapy for vocal cord
polyps indicates the need for more teaching?
a. “I will stay out of rooms and places where people are smoking.”
b. “When I speak at all, I will whisper rather than use a normal tone of
voice.”
c. “For the next several weeks, I will not lift more than 10 pounds.”
d. “I will drink at least 3 quarts of water each day and will use stool
softeners.”
ANS: B
Treatment for vocal cord polyps includes not speaking, no lifting, and no smoking. The client has to
be educated not to even whisper when resting the voice. It is also appropriate for the client to stay
out of rooms where people are smoking, and to stay hydrated and use stool softeners.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
14. A client states that he is going to relax on the beach between radiation treatments for laryngeal
cancer to help his “mental status.” What is the nurse’s best response?
a. “You deserve to do something for yourself.”
b. “Make sure someone is with you because you shouldn’t be alone right
now.”
c. “Your skin can become severely burned, and you should not be out in
the sun.”
d. “You should make sure you use sunscreen that is at least SPF 15.”
ANS: C
The client should stay out of the sun during treatment because the skin can become severely
burned. Sunscreen may or may not help, but an SPF of 15 is low and does not provide adequate
prevention.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
15. The nurse is observing a client performing stoma care for a laryngectomy for the first time.
Which action does the nurse reinforce?
a. Washing the stoma with soap and water
b. Covering the stoma with a gauze pad
c. Irrigating the stoma with half-strength peroxide
d. Making sure any scab around the stoma is removed
ANS: A
The client is taught to wash the stoma gently and to prevent anything from getting into the opening.
The client should never scrape around the opening because this could cause broken skin, irritation,
and infection. Peroxide is not used for irrigation; irrigation of the stoma is not done.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
16. A client has undergone a nasoseptoplasty 2 hours ago. It is a priority for the nurse to assess for
which factor?
a. Nasal drainage
b. Bleeding
c. Pain
d. Airway patency
ANS: D
Assessing and maintaining a patent airway is always the top priority. The other assessments are
important but do not take priority over airway.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Assessment)
17. A client develops posterior nasal bleeding and has packing inserted. What is the nurse’s priority
action?
a. Assess the client’s pain level.
b. Keep the client’s head elevated.
c. Teach the client about the causes of nasal bleeding.
d. Make sure the string is taped to the client’s cheek.
ANS: D
The thread is attached to the client’s cheek that holds the packing in place. The nurse needs to make
sure that this does not move because it can occlude the client’s airway. The other options are good
interventions, but ensuring that the airway is patent is the priority objective.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests, Treatments, Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
18. A client who has sleep apnea is reporting constant daytime sleepiness. The client has multiple
other chronic diseases. What is the nurse’s best action?
a. Refer the client for surgery.
b. Perform a health history.
c. Request an order for a sleeping pill.
d. Move the client to a private room.
ANS: B
The nurse should first assess the client and determine whether he or she has other chronic diseases.
If the client’s other disorders are not contradictory, the client may be eligible for therapy with
modafinil (Attenace) to increase wakefulness during the day. Certain cardiac disorders may prohibit
the use of this drug owing to its simulative effects. A sleeping pill would not be an appropriate
intervention for a client with sleep apnea. A private room will not help to increase the client’s sleep
in sleep apnea.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
MULTIPLE RESPONSE
1. The nurse is assessing a client who is 6 hours post surgery for a nasal fracture. The client has
facial pain (5 out of 10) and nasal packing in place. What actions by the nurse are most appropriate
at this time? (Select all that apply.)
a. Observe for clear drainage.
b. Observe for bleeding.
c. Observe the client for frequent swallowing.
d. Ask the client to open his or her mouth.
e. Administer a nasal steroid to decrease edema.
f.
Change the nasal packing.
g. Administer pain medication.
h. Place the client in Trendelenburg position.
ANS: A, B, C, D, G
The nurse should observe for clear drainage because of the risk for cerebrospinal fluid (CSF)
leakage. The nurse should note whether the client is swallowing frequently because this could
indicate postnasal bleeding. The nurse should also ask the client to open his or her mouth and
should observe the back of the throat for bleeding. Pain medication should also be administered. It
is too soon to change the packing, which should be changed by the surgeon the first time. A nasal
steroid would increase the risk for infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
2. The client with which conditions requires immediate nursing intervention? (Select all that apply.)
a. Shortness of breath
b. Sternal retractions
c. Pulse oximetry reading of 95%
d. Occasional expiratory wheeze
e. Respiratory rate of 8 breaths/min
f.
Arterial blood gas showing a pH of 7.35
g. Stridor
ANS: A, B, E, G
The client with sternal retraction is experiencing serious respiratory difficulty, as is the client with
stridor. The client who reports shortness of breath needs immediate assessment, as does the client
with a respiratory rate of 8. A pulse oximetry of 95% is within normal limits, as is a pH of 7.35.
The client with expiratory wheezes needs to be assessed, but not immediately.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Assessment)
3. A client develops epistaxis. Which conditions in the client’s history could have contributed to this
problem? (Select all that apply.)
a. Diabetes mellitus
b. Hypertension
c. Leukemia
d. Cocaine use
e. Migraine
f.
Elevated platelets
g. High cholesterol
ANS: B, C, D
Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dyscrasias,
inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intranasal procedures.
Diabetes, migraine, and elevated platelets and cholesterol levels do not cause epistaxis.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 582
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
4. The nurse is assessing a client with facial trauma. Which assessment findings require immediate
intervention? (Select all that apply.)
a. Stridor
b. Nasal stuffiness
c. Edema of the cheek
d. Ecchymosis behind the ear
e. Eye pain
f.
Swollen chin
ANS: A, D
Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis or bruising
behind the ear is called “battle sign” and indicates basilar skull fracture.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
Chapter 32: Care of Patients with Noninfectious Lower Respiratory
Problems
Chapter 32: Care of Patients with Noninfectious Lower Respiratory Problems
Test Bank
MULTIPLE CHOICE
1. A client with asthma reports “not being able to take deep breaths.” The nurse auscultates
decreased breath sounds in the bases, and no wheezes. What is the nurse’s best action?
a. Encourage the client to stay calm and take deep breaths.
b. Document the findings and continue to monitor.
c. Have the client cough forcefully.
d. Assess the client’s oxygen saturation.
ANS: D
Decreased wheezing accompanied by decreased breath sounds can mean airway occlusion from
mucus and from inflammation. The nurse should assess the client’s oxygenation and determine
whether additional interventions are needed. Coughing forcefully may cause the smaller airways to
collapse and may not help the client. Encouraging the client to remain calm and to try to take deep
breaths is not helpful. Although providing documentation is important, the nurse needs to do more
than that.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
2. A client with asthma has been having frequent asthma attacks. What is the nurse’s best action?
a. Teach the client to stay away from pets.
b. Assist the client in using an incentive spirometer.
c. Administer aspirin for its anti-inflammatory properties.
d. Administer montelukast (Singulair).
ANS: D
A client who has been having increased attacks can have some chronic inflammation occurring.
This inflammation is probably stimulated by mediators such as histamine and leukotriene and can
be blocked by drugs like diphenhydramine (Benadryl) and montelukast (Singulair).
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes)
MSC: Integrated Process: Nursing Process (Implementation)
3. A client diagnosed with asthma has not responded well to medication. The client is concerned
and asks the nurse, “What is wrong with me, and why am I not getting better?” What is the nurse’s
best response?
a. “You just weren’t used to the medication yet.”
b. “The medication dose has to be increased.”
c. “It is possible that genetic testing may help.”
d. “You should try homeopathic medicine.”
ANS: C
Some genetic variations may cause the activity of beta-adrenergic receptors to change, meaning
that the client would not respond as expected to beta agonists. Genetic testing may help to
determine why the drug therapy is not working and may help the clinician to identify new therapy
that will work.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes)
MSC: Integrated Process: Nursing Process (Implementation)
4. The nurse is caring for four clients with asthma. Which client does the nurse assess first?
a. Client with a barrel chest and clubbed fingernails
b. Client with an SaO2 level of 92% at rest
c. Client whose expiratory phase is longer than the inspiratory phase
d. Client whose heart rate is 120 beats/min
ANS: D
Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A
barrel chest is not an emergency finding. Likewise a pulse oximetry level of 92% is not considered
an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in
someone with airflow limitation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Assessment)
5. The nurse is caring for an older adult who reports experiencing frequent asthma attacks and
severe arthritic pain. What action by the nurse is most appropriate?
a. Review pulmonary function test results.
b. Assess use of medication for arthritis.
c. Assess frequency of bronchodilator use.
d. Review arterial blood gas results.
ANS: B
Aspirin and other NSAIDs can trigger asthma in some people. This results from increased
production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a
high priority given the client’s history. Reviewing pulmonary function test results will not address
the immediate problem of frequent asthma attacks. This is a good intervention for reviewing
response to bronchodilators. Questioning the client about the use of bronchodilators will address
interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be
of use in a client between attacks because many clients are asymptomatic when not having attacks.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Assessment)
6. The nurse is evaluating a client’s response to medication therapy for asthma. The client has a
peak flowmeter reading in the yellow zone. What does the nurse do next?
a. Nothing; this is an acceptable range.
b. Teach the client to take deeper breaths.
c. Assist the client to use a rescue inhaler.
d. Assess the client’s lungs.
ANS: C
The client with a peak flow reading in the yellow zone needs to use a rescue inhaler, then have a
reading taken again within a few minutes. The nurse has no reason to assess the client’s lungs at
this point in time, nor would the nurse take the time to teach at this moment.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes)
MSC: Integrated Process: Nursing Process (Implementation)
7. Which statement indicates that the client understands teaching about the use of long-acting beta 2
agonist medications?
a. “I will not have to take this medication every day.”
b. “I will take this medication when I have an asthma attack.”
c. “I will take this medication daily to prevent an acute attack.”
d. “I will eventually be able to stop using this medication.”
ANS: C
This medication will help prevent an acute asthma attack because it is long acting. The client will
take this medication every day for best effect. This is not the medication the client will use during
an acute asthma attack because it does not have an immediate onset of action. The client will not be
weaned off this medication because this is likely to be one of his or her daily medications.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Nursing Process (Evaluation)
8. Which statement indicates that a client understands teaching about the correct use of a
corticosteroid medication?
a. “This drug can reverse my symptoms during an asthma attack.”
b. “This drug is effective in decreasing the frequency of my asthma
attacks.”
c. “This drug can be used most effectively as a rescue agent.”
d. “This drug can be used safely on a long-term basis for multiple
applications daily.”
ANS: B
Corticosteroids decrease inflammatory and immune responses in many ways, including preventing
the synthesis of mediators. Both inhaled corticosteroids and those taken orally are preventive; they
are not effective in reversing symptoms during an asthma attack and should not be used as rescue
drugs. Systemic corticosteroids, because of severe side effects, are avoided for mild to moderate
intermittent asthma and are used on a short-term basis for moderate asthma.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Nursing Process (Assessment)
9. A client is using omalizumab (Xolair) for the first time. What is the priority nursing action?
a. Make sure the client takes the medication with water.
b. Administer ibuprofen (Motrin) because Xolair often causes headaches.
c. Teach the client how to use a syringe.
d. Remain with the client and assess for anaphylaxis.
ANS: D
Immune modulators are monoclonal antibodies that prevent allergens from binding to receptor sites
on mast cells and basophils. The risk of anaphylaxis is high; the nurse should assess and stay with
the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
10. A client is demonstrating diaphragmatic breathing for the nurse. Which action by the client
shows adequate understanding of this breathing technique?
a. Lying on his or her side with knees bent
b. Having his or her hands on the abdomen
c. Having his or her hands over the head
d. Lying in the prone position
ANS: B
To perform diaphragmatic breathing correctly, the client should put the hands on his or her
abdomen to create resistance. This type of breathing cannot be performed effectively while lying on
the side or with hands over the head. This type of breathing would not be as effective lying prone.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Teaching/Learning
11. A client is undergoing lung reduction surgery. What is the nurse’s highest priority
preoperatively?
a. Administer medications.
b. Discuss the possibility of ventilator dependency.
c. Teach how to cough and deep breathe.
d. Teach about preoperative testing.
ANS: D
In addition to standard preoperative testing, the client who will undergo lung reduction surgery is
tested to determine the location of greatest lung hyperinflation and poorest lung blood flow. These
tests include pulmonary plethysmography, gas dilution, and perfusion scans. The other
interventions are lower priorities.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Nursing Process (Implementation)
12. The nurse assesses a client receiving chemotherapy for lung cancer and notes red swollen
mucous membranes and open sores in the mouth. The client reports mouth pain and difficulty
swallowing. Which action does the nurse perform first?
a. Document the size of the sores.
b. Perform mouth hygiene.
c. Have the client rinse his or her mouth.
d. Call the health care provider and hold chemotherapy.
ANS: D
Although the nurse should perform all interventions for mucositis, the priority is to call the health
care provider and hold the chemotherapy. Mucositis may be a dose-limiting condition in
chemotherapy. The nurse should call the provider, then should assist the client with mouth hygiene,
rinsing the mouth, and obtaining pain relief. Documenting the size and location of ulcers is also
important.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
13. A client is undergoing radiation therapy as treatment for lung cancer and has developed
esophagitis. Which is the best diet selection for this client?
a. Spaghetti with meat sauce, ice cream
b. Scrambled eggs, bacon, toast
c. Omelet, whole wheat bread
d. Pasta salad, custard, orange juice
ANS: C
Side effects of radiation therapy may include inflammation of the esophagus. Clients should be
taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements.
Tomato sauce may prove too spicy for a client with esophagitis. Toast is too difficult to swallow
with this condition, and orange juice and other foods with citric acid are too caustic.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 633
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration)
MSC: Integrated Process: Nursing Process (Assessment)
14. A client with lung cancer refuses pain medications because he or she is “afraid of addiction.”
What is the nurse’s best response?
a. “I can ask the physician to change your medication to a drug that is less
potent.”
b. “I can use other measures such as music therapy to distract you.”
c. “It is unlikely you will become addicted from taking medicine for
pain.”
d. “I can just give you aspirin or acetaminophen (Tylenol) if you like.”
ANS: C
Clients should be encouraged to take their pain medications; addiction usually is not an issue with a
client in pain. The nurse would not request that the pain medication be changed unless it was not
effective. Other methods to decrease pain can be used, in addition to pain medications.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Implementation)
15. What is the best instruction for a client who has step II (mild persistent) asthma?
a. “Avoid participating in aerobic exercise.”
b. “You will need daily inhaled low-dose steroids.”
c. “You need to evaluate your diet for asthma triggers.”
d. “Make sure you use a rescue inhaler three times per day.”
ANS: B
The most important information for clients with step II (mild persistent) asthma is that they need
daily preventive anti-inflammatory medication. Low-dose inhaled steroids are necessary. The client
should exercise as tolerated; however, using a rescue inhaler frequently is not recommended and, if
this is needed, it should be reported to the health care provider because a change in therapy is likely
needed.
DIF: Cognitive Level: Comprehension/Understanding REF: Chart 32-2, p. 603
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Teaching/Learning
16. The nurse assesses a client with asthma and finds wheezing throughout the lung fields and
decreased pulse oxygen saturation. In addition, the nurse notes suprasternal retraction on inhalation.
What is the nurse’s best action?
a. Perform peak expiratory flow readings.
b. Assess for a midline trachea.
c. Administer oxygen and a rescue inhaler.
d. Call a code.
ANS: C
Suprasternal retraction caused by inhalation usually indicates that the client is using accessory
muscles and is having difficulty moving air into the respiratory passages because of airway
narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also
supports this finding. The asthma is not responding to the medication, and intervention is needed.
Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The
nurse would not do a peak flow reading at this time, nor would a code be called. Midline trachea is
a normal and expected finding.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
17. The nurse is teaching a client with asthma about self-management. Which statement by the
nurse is best?
a. “Keep a daily symptom and intervention diary.”
b. “Measure your anterior/posterior diameter weekly.”
c. “Note your symptoms when you don’t take your medications.”
d. “Exercise before and after taking inhalers and compare tolerance.”
ANS: A
The nurse should tell the client to keep a daily symptom diary. This will help identify triggers and
responses to therapy in asthma. Chest circumference is not expected to change in clients with
asthma. The client should not be instructed to discontinue medications. Comparing exercise
tolerance before and after activity will not give the client the most complete information about his
or her asthma.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 606
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
18. Which statement indicates that a client needs additional teaching about using an inhaler?
a. “I will not exhale into the inhaler.”
b. “I will store the inhaler in a drawer in my bedroom.”
c. “I will soak my inhaler in water to clean it.”
d. “I will inhale and hold my breath.”
ANS: C
Submerging an inhaler in water to wash it is not necessary and may cause the medication in the
inhaler to clump together if it is a dry powder inhaler. The other statements are all correct—the
client should not exhale into the inhaler, can store the inhaler in his or her bedroom, and will need
to inhale and hold breath slightly when using the inhaler.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Implementation)
19. The home care nurse observes white patches on the oral mucosa of a client with severe, chronic
airflow limitation. What is the nurse’s best action?
a. Ask the client whether he or she uses a steroid inhaler.
b. Inquire about any recent viral illnesses.
c. Have the client rinse the mouth with salt water.
d. Have the client brush the patches with a soft-bristled brush.
ANS: A
Excessive use of steroid inhalers reduces local immune function and increases the client’s risk for
oral-pharyngeal infection, including candidiasis, which manifests as white patches on the oral
mucosa. The client should not brush the lesions, and salt water will not help the sores. Recent
illnesses would have no effect on these lesions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
20. What statement indicates that a client needs further teaching regarding therapy with salmeterol
(Serevent)?
a. “I will be certain to shake the inhaler well before I use it.”
b. “It may take a while before I notice a change in my asthma.”
c. “I will use the drug when I have an asthma attack.”
d. “I will be careful not to let the drug escape out of my nose and mouth.”
ANS: C
Salmeterol is designed to prevent an asthma attack; it does not relieve or reverse symptoms. The
client does not have to keep this inhaler with him or her always because it is not used as a rescue
medication. Salmeterol (Serevent) has a slow onset of action; therefore it should not be used as a
rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor
technique on the client’s part allows the drug to escape through the nose and mouth.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
21. The nurse is teaching a client about different medications for asthma. Which medication does
the nurse teach the client to administer to control the prolonged inflammatory response?
a. Diphenhydramine (Benadryl)
b. Montelukast (Singulair)
c. Aspirin
d. Bitolterol (Tornalate)
ANS: B
Leukotriene and eotaxin cause later, prolonged inflammatory responses in asthma, which can be
blocked by drugs like montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo). No
evidence suggests that aspirin helps this inflammatory response. Histamine starts an immediate
inflammatory response, which can be blocked by drugs like diphenhydramine (Benadryl).
Bitolterol (Tornalate) is a short-acting beta agonist that will enhance bronchodilation during an
asthma attack, but it will not assist in controlling late inflammation.
DIF: Cognitive Level: Comprehension/Understanding REF: Chart 32-6, p. 606
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Teaching/Learning
22. A client with chronic obstructive pulmonary disease (COPD) reports social isolation. What does
the nurse encourage the client to do?
a. Join a support group for people with COPD.
b. Ask the client’s physician for an antianxiety agent.
c. Verbalize his or her thoughts and feelings.
d. Participate in community activities.
ANS: C
Many clients with moderate to severe COPD become socially isolated because they are
embarrassed by frequent coughing and mucus production. They also can experience fatigue, which
limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so
that appropriate interventions can be selected. Joining a support group would not decrease feelings
of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the
client with social isolation. Encouraging a client to participate in activities without verbalizing
concerns also would not be an effective strategy for decreasing social isolation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)
MSC: Integrated Process: Nursing Process (Implementation)
23. The nurse is teaching a client with cystic fibrosis. What activity does the nurse teach as the
priority?
a. Taking daily antibiotics
b. Having genetic screening
c. Maintaining good nutrition
d. Exercising daily
ANS: C
Clients with cystic fibrosis (CF) often are malnourished owing to vitamin deficiency and pancreatic
malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential
actions. Genetic screening would not help the client manage CF better.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
24. The nurse is assessing a client with lung disease. Which symptom does the nurse intervene for
first?
a. The client’s anterior-posterior chest diameter is 2:2.
b. Clubbing of the finger tips is noted.
c. The client has bilateral dependent leg edema.
d. The client is pale.
ANS: C
The client with bilateral dependent edema may be developing right-sided heart failure in response
to respiratory disease. This symptom should be investigated right away and reported to the health
care provider. Further assessment is needed. The client with chronic lung disease may develop
increased anterior-posterior diameter and clubbing as responses to chronic hypoxia. These
symptoms do not require immediate intervention. The client is often pale or has a dusky
appearance; this also would not warrant immediate intervention.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
25. A client with lung cancer is lying flat in bed and reports shortness of breath. What action does
the nurse take first?
a. Notify the health care provider.
b. Elevate the head of the bed.
c. Assess oxygen saturation.
d. Have the client take deep breaths.
ANS: B
The nurse’s first action should be to elevate the head of the bed. Next, assessing oxygen saturation
will help the nurse determine the client’s status. If the oxygen is low, the nurse would increase
oxygen flow and have the client take deep breaths. The provider could be notified after the nurse
performs the interventions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
26. The nurse observes hematuria in a client receiving IV cyclophosphamide (Cytoxan). After
notifying the health care provider, what intervention is the nurse’s priority?
a. Obtain a urine specimen.
b. Assess laboratory studies.
c. Increase hydration.
d. Stop the medication.
ANS: D
Hemorrhagic cystitis is a frequent side effect of cyclophosphamide therapy. The physician should
be notified to prescribe co-administration of a bladder-protecting agent. The nurse then should stop
the medication. Other actions would be to further assess the client and provide hydration to flush
the medication.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
27. A client with pulmonary fibrosis is being discharged home. What is the highest priority teaching
need?
a. Dietary modifications
b. Determining activity tolerance
c. Avoiding infection
d. Medication therapy
ANS: C
It is extremely important to teach the client with pulmonary fibrosis to avoid infection because the
disease will quickly become worse as a result of decreased lung function. The client may take
longer to recover from an infection, and the ability to recover may be severely limited owing to the
progression of the disease. Teaching the client about modifications in diet, how to determine
response to activity, and treatment medications would be secondary.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
28. The nurse is caring for a client with bronchiolitis obliterans organizing pneumonia (BOOP) and
assesses decreased vital capacity during pulmonary function testing. What is the nurse’s best
action?
a. Administer intermittent positive-pressure breathing treatments.
b. Administer a short-acting beta-adrenergic medication.
c. Prepare to administer IV antibiotics.
d. Document the finding in the client’s chart.
ANS: D
Decreased vital capacity is a common finding with this disorder because the white blood cells
clump and obliterate airways. The nurse should note the finding and should assist the client in
activities that help him or her maintain quality of life.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
29. The nurse is teaching a client with bronchiolitis obliterans organizing pneumonia (BOOP) about
corticosteroid therapy. What statement is accurate for the nurse to teach the client?
a. “You will be on this drug the rest of your life.”
b. “You will be prone to many long-term side effects of this drug.”
c. “A short course of therapy will help with acute episodes.”
d. “This medication cannot be taken with antibiotic therapy.”
ANS: C
Corticosteroids are used for acute episodes and are very effective in decreasing manifestations. The
client may never have another relapse after therapy. The client is not on the drug for “life,” and
therefore is not prone to long-term side effects. Agents can be given with antibiotics.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 630
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Teaching/Learning
30. A client recently diagnosed with lung cancer is being taught by the nurse. What information
does the nurse teach the client?
a. “You will receive 6 weeks of daily radiation therapy.”
b. “Lung cancer has a very good prognosis.”
c. “Further testing is not needed because lung cancer rarely metastasizes.”
d. “It is very likely that surgery will be curative.”
ANS: A
This is the only statement that is accurate. Small doses of radiation given over long periods are an
effective routine treatment. Lung cancer does not have a good prognosis, and it often metastasizes.
Surgery often is only palliative.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 633
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
31. Which nursing intervention is an example of primary prevention for lung cancer?
a. Teaching clients with lung cancer how to cough and deep breathe
b. Teaching clients with lung cancer to avoid infection
c. Teaching clients about prophylactic antibiotics
d. Teaching people about smoking and secondhand smoke
ANS: D
Primary prevention for lung cancer focuses on reducing tobacco smoking. The other examples are
examples of secondary prevention.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 631
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
32. A client’s chest tube is accidentally dislodged. What action by the nurse is best?
a. No action is necessary because the area will reseal itself.
b. Cover the insertion site with a sterile gauze and tape three sides.
c. Obtain a suture kit and prepare for the physician to suture the site.
d. Cover the area with an occlusive dressing.
ANS: B
Immediately covering the insertion site helps prevent air from entering the pleural space and
causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the
chest. The nurse should not leave the client to obtain a suture kit. An occlusive dressing may cause
a tension pneumothorax.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
33. Which is the highest priority problem for a client with late-stage lung cancer?
a. Malnutrition
b. Constipation
c. Weakness and fatigue
d. Pain
ANS: D
Although all of these problems are important issues, effective pain management is the most
important issue for this client and family. The nurse must serve as a client advocate and must
ensure that all appropriate measures for management of intractable, severe pain are implemented.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Illness
Management) MSC: Integrated Process: Nursing Process (Diagnosis)
34. The nurse assesses a client’s chest tube and finds continuous bubbling in the water seal chamber.
When the nurse clamps the chest tube close to the client’s dressing, the bubbling stops. How does
the nurse interpret this finding?
a. An air leak is present at the chest tube insertion site or in the thoracic
cavity.
b. An air leak is present in the drainage system.
c. More water needs to be added to the water seal.
d. The system is functioning appropriately and no intervention is needed.
ANS: A
Bubbling in the water seal chamber indicates air drainage from the client and usually is seen when
the client’s intrathoracic pressure is greater than atmospheric pressure, such as during exhalation,
coughing, or sneezing. When the air in the pleural space has been sufficiently removed, bubbling
stops. Continuous bubbling indicates an air leak. If the air leak is in the thoracic cavity, air and air
pressure increase in the thoracic cavity, forcing more air into the water seal chamber. This air
movement is prevented when the chest tube is clamped close to the insertion site.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Assessment)
35. A client was diagnosed with lung cancer and appears distressed. The client states, “I am so
afraid.” What is the best action for the nurse to take?
a. Provide comfort by holding the client’s hand.
b. Offer to give the client a back rub for relaxation.
c. Offer the client a PRN antianxiety medication.
d. Ask the client what is causing the most fear right now.
ANS: D
A diagnosis of lung cancer often causes fear for many reasons, usually poor prognosis, fear of pain,
and fear of dyspnea. The nurse should assess what is worrying the client most at the moment so
appropriate interventions can be planned. Touch is often a powerful tool, but the nurse should
assess whether this is acceptable to the client. The nurse should assess the client further and provide
assistance with coping before offering to medicate him.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Stress Management)
MSC: Integrated Process: Caring
36. The nurse is assessing a client who has a chest tube. Which assessment finding requires
intervention by the nurse?
a. Pain at the insertion site
b. Bloody drainage in the collection chamber
c. Intermittent bubbling in the water seal chamber
d. Tidaling in the water seal chamber
ANS: A
Pain is the priority for the client. Bloody drainage may be normal, depending on the client’s
condition. Intermittent bubbling in the water seal indicates air escaping as the lung fully expands,
and does not need to be addressed immediately. Tidaling often occurs with inspiration and
expiration.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
37. The nurse assesses a client who is on fluticasone (Flovent) and notes oral lesions. What is the
nurse’s best action?
a. Teach the client to rinse the mouth after Flovent use.
b. Have the client use a mouthwash daily.
c. Start the client on a broad-spectrum antibiotic.
d. Document the finding as a known side effect.
ANS: A
The drug reduces local immunity and increases the risk for local infection, especially Candida
albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this
infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The
nurse should document the finding, but the best action to take is to have the client start rinsing his
or her mouth after using Flovent.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Nursing Process (Implementation)
38. A client has recently been placed on prednisone (Deltasone). What is the highest priority
instruction the nurse will provide?
a. “Expect to experience weight gain.”
b. “Watch your diet while on this medication.”
c. “Take the drug with food or milk.”
d. “Report any abdominal pain or dark-colored vomit.”
ANS: D
All of these directions are appropriate to give the client; however, telling the client to report
abdominal pain and dark-colored vomit is most important because these could signal gastric
ulceration.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Teaching/Learning
39. A client infected with Burkholderia cepacia is admitted to the unit. What is the nurse’s priority
action when caring for this client?
a. Instruct the client to wash his or her hands after contact with other
people.
b. Place the client on strict isolation.
c. Keep the client isolated from other clients with cystic fibrosis.
d. Administer IV vancomycin daily.
ANS: C
The infection is spread through casual contact between cystic fibrosis clients, thus the need for
isolation of these clients from each other. Strict isolation measures will not be necessary. Although
the client should wash his or her hands frequently, the most important measure that can be
implemented on the unit is isolation of the client from other cystic fibrosis clients.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
40. The nurse assesses the following lung sounds in a client. What is the nurse’s best action? (Click
the media button to hear the audio clip.)
a. Administer a rescue inhaler.
b. Administer oxygen.
c. Assess vital signs.
d. Elevate the client’s head.
ANS: A
Stridor is the sound heard. This sound indicates severe airway constriction. The nurse must
administer a bronchodilator to get air into the lungs. Administering oxygen will not help until the
client’s airways are open.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
41. The nurse assesses an older adult after an upper respiratory infection and notes the following
lung sound on auscultation. What is the nurse’s best action? (Click the media button to hear the audio
clip.)
a. Assess the client for the development of asthma.
b. Ask the client if he or she finished all the medication.
c. Administer oxygen immediately.
d. Assess arterial blood gas.
ANS: A
Scattered wheezes is the sound heard. New-onset asthma can occur in older clients after they
recover from an upper respiratory infection or severe cold. The nurse should assess the client for
other symptoms such as sputum production and response to activity. Finishing medication would
not necessarily cause the client to have wheezing. The nurse should assess oxygen saturation before
administering oxygen or assessing arterial blood gas.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC:
Integrated Process: Nursing Process (Assessment)
MULTIPLE RESPONSE
1. A client has a mediastinal chest tube. Which symptoms require the nurse’s immediate
intervention? (Select all that apply.)
a. Production of pink sputum
b. Tracheal deviation
c. Oxygen saturation greater than 95%
d. Sudden onset of shortness of breath
e. Drainage greater than 70 mL/hr
f.
Pain at insertion site
g. Disconnection at Y site
ANS: B, D, E, G
Immediate intervention is warranted if the client has tracheal deviation because this could indicate a
tension pneumothorax; sudden shortness of breath because this could indicate dislodgment of the
tube, occlusion of the tube, or pneumothorax; or drainage greater than 70 mL/hr because this could
indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production
of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not
signs/symptoms that would require immediate intervention.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Assessment)
2. What information about nutrition does the nurse teach a client with chronic obstructive
pulmonary disease (COPD)? (Select all that apply.)
a. “Avoid drinking fluids just before and during meals.”
b. “Rest before meals if you have dyspnea.”
c. “Have about six small meals a day.”
d. “Practice diaphragmatic breathing against resistance four times daily.”
e. “Eat high-fiber foods to promote gastric emptying.”
f.
“Eat dry foods rather than wet foods, which are heavier.”
g. “Increase carbohydrate intake for energy.”
ANS: A, B, C
Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal
will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Dry foods
can cause coughing. Fibrous foods can produce gas, which can cause abdominal bloating and can
increase shortness of breath. Diaphragmatic breathing will not necessarily help nutrition.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
3. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) to determine
activity tolerance. Which questions elicit the most important information? (Select all that apply.)
a. “What color is your sputum?”
b. “Do you have any difficulty sleeping?”
c. “How long does it take to perform your morning routine?”
d. “Do you walk upstairs every day?”
e. “Have you lost any weight lately?”
ANS: B, C, E
Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform
activities of daily living. Weight loss could mean increased dyspnea as the client becomes too
fatigued to eat. The color of the client’s sputum would not assist in determining activity tolerance.
Asking whether the client walks upstairs every day is not as pertinent as determining if the client
becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
4. A client has a chest tube. What assessment findings require immediate intervention from the
nurse? (Select all that apply.)
a. Intermittent bubbling in the water seal chamber in the client with a
pneumothorax
b. “Silent chest” in the client with a pneumothorax
c. Tidaling in the water seal chamber in a client with a pneumothorax
d. Bloody drainage in the tubing of a client with a hemothorax
e. Tracheal deviation in a client after chest trauma
f.
No drainage in the chest tube of a client with a pneumothorax
g. Constant bubbling in the water seal chamber in a client post chest
surgery
ANS: B, E, G
The client with a silent chest could have a mucous plug, the client with tracheal deviation could
have a collapsed lung or tension pneumothorax, and the client with constant bubbling in the water
seal could have an air leak. All of these assessments require intervention. The others are normal for
the condition stated.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Assessment)
5. Which symptoms in chronic lung disease require nursing intervention? (Select all that apply.)
a. Clubbed fingers
b. Increased residual volume
c. Decreased peak flow
d. Increased anterior-posterior diameter
e. Elevated platelets
f.
Expiratory wheezing
g. Stridor
h. Change in sputum color and amount
ANS: C, F, G, H
Decreased peak flow could indicate worsening of symptoms of airflow occlusion. Likewise,
expiratory wheezing and stridor can indicate inflammation and fluid accumulation leading to
airway occlusion. A change in the amount and color of sputum can indicate infection. The other
symptoms normally occur with chronic disease.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
6. The nurse is teaching a client with asthma how to avoid attacks. What information does the nurse
give the client? (Select all that apply.)
a. “You should not dust your furniture.”
b. “Stay inside as much as possible.”
c. “Stay away from people who are sick.”
d. “Do not go out in the fall.”
e. “Stay out of the snow.”
f.
“Do not take aspirin.”
ANS: A, F
Dusting the furniture may increase dust in the air and cause an asthma attack. Aspirin may
stimulate asthma. Staying inside probably will not help. Staying away from snow probably will not
have an effect on the client’s attacks; neither will going outside during the fall.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Planning)
7. The nurse is assessing a client with asthma. Scattered wheezes are noted, and the client’s oxygen
saturation is 88%. What other assessments are essential for the nurse to perform? (Select all that
apply.)
a. Assess for accessory muscle use.
b. Assess anterior-posterior diameter.
c. Assess inspiration/expiration ratios.
d. Assess the suprasternal notch.
e. Perform a stress test.
f.
Assess a chest x-ray.
g. Assess mucous membranes.
ANS: A, C, D, G
Accessory muscle use may help the client breathe during an attack. Muscle retraction may be seen
at the sternum and at the suprasternal notch. Mucous membranes can also tell the nurse about
oxygenation. Inspiration versus expiration can tell the nurse how the client is breathing. The
anterior-posterior diameter gives indication of a chronic condition; assessing this during an attack
will not help the client. Likewise, performing a stress test and a chest x-ray during an attack would
not be beneficial.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
OTHER
1. The nurse is teaching a client to cough productively. Put the actions in proper sequence.
a. Have the client flex the head and hold a pillow to the stomach.
b. Assist the client to a sitting position with feet on the floor.
c. Instruct the client to bend forward and to cough two or three times.
d. Have the client return to an upright position and take a deep breath.
e. Encourage the client to take several deep breaths.
ANS:
b, a, e, c, d
When the client can tolerate it, the best position for effective coughing and secretion removal is
sitting with the shoulders turned inward and the head bent slightly down while hugging a pillow.
The client should take several deep breaths followed by holding the breath slightly before coughing
two or three times in a row. Then the client should cough at the end of exhalation; this should be
followed by taking several deep breaths.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
2. Place the steps for obtaining a peak expiratory flow rate in the order in which they should occur.
a. Take as deep a breath as possible.
b. Stand up (unless you have a physical disability).
c. Place the meter in your mouth, and close your lips around the mouthpiece.
d. Make sure the device reads zero or is at base level.
e. Blow out as hard and as fast as possible for 1 to 2 seconds.
f. Write down the value obtained.
g. Repeat the process two additional times, and record the highest number in your chart.
ANS:
d, b, a, c, e, f, g
The proper order for obtaining a peak expiratory flow rate is as follows: Make sure the device reads zero or is at base level. Stand up
(unless you have a physical disability). Take as deep a breath as possible. Place the meter in your mouth, and close your lips around
the mouthpiece. Blow out as hard and as fast as possible for 1 to 2 seconds. Write down the value obtained. Repeat the process two
more times, and record the highest of the three numbers in your chart.
DIF: Cognitive Level: Comprehension/Understanding REF: Chart 32-4, p. 605
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC:
Integrated Process: Nursing Process (Assessment)
Chapter 33: Care of Patients with Infectious Respiratory Problems
Chapter 33: Care of Patients with Infectious Respiratory Problems
Test Bank
MULTIPLE CHOICE
1. A client has acute rhinitis. What is the most important intervention for the nurse to perform?
a. Assess for symptoms of infection.
b. Ascertain whether the client has allergies.
c. Question the client on the use of nasal sprays.
d. Do blood and urine screenings for drug use.
ANS: A
Bacterial infection often occurs with acute rhinitis. The nurse should assess for symptoms because
treatment may be warranted. It is not essential to assess for allergies or the use of nasal spray, or to
determine whether drug use is occurring. All of these interventions are focused on determining a
cause for repeated acute rhinitis and are primarily the responsibility of the health care provider. The
nurse should focus on client assessment and should determine whether a secondary infection is
present.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
2. A client has pharyngitis. Which symptom helps the nurse determine whether the infection is
bacterial versus viral?
a. Redness in the back of the throat
b. Enlarged lymph glands in the neck
c. Nasal discharge
d. Skin rash
ANS: D
Generally a rash can appear with bacterial pharyngitis, but not with viral. The other symptoms are
characteristic of both.
DIF: Cognitive Level: Comprehension/Understanding REF: Chart 33-2, p. 643
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
3. It is suspected that a client has bacterial pharyngitis. What is the best intervention?
a. Administer a broad-spectrum antibiotic.
b. Have the client produce a sputum specimen.
c. Obtain samples for culture and sensitivity.
d. Assess a rapid antigen test (RAT).
ANS: D
A common cause of bacterial pharyngitis is group A streptococcal virus, which can lead to serious
complications. Both RATs and culture and sensitivity can diagnose this bacterium; however, with
an RAT, the health care provider can obtain results in about 15 minutes, and definitive treatment
can begin much sooner. A broad-spectrum antibiotic would not be administered before it was
determined whether the infection was bacterial. A sputum specimen is needed for lung infection but
not for throat infection.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Nursing Process (Implementation)
4. The nurse is caring for a client with recurrent bacterial pharyngitis. Which is the nurse’s highest
priority intervention?
a. Assess for symptoms of human immune deficiency virus (HIV).
b. Ask about exposure to allergens.
c. Perform nasal cultures.
d. Teach the client about antibiotic therapy.
ANS: D
Management of bacterial pharyngitis involves the use of antibiotics and the same supportive care
provided for viral pharyngitis. Stress the importance of completing the entire antibiotic
prescription, even when symptoms improve or subside. Failure to take all prescribed antibiotics is
often the cause of recurrent infections. Although it is important for overall health that the client
know his or her HIV status, it is not the highest priority intervention in the treatment plan.
Allergens do not cause bacterial infections. Nasal cultures would not be a high priority unless the
client had “failed” treatment with more than one antibiotic and was compliant with treatment.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Teaching/Learning
5. A client who has had acute tonsillitis develops drooling and reports severe throat pain. What is
the nurse’s priority intervention?
a. Assess the throat for deviation of the uvula.
b. Prepare the client for surgery.
c. Teach the client about antibiotic therapy.
d. Prepare the client for percutaneous needle aspiration.
ANS: A
The nurse should first assess the throat for signs of peritonsillar abscess. If present, the nurse should
call the health care provider immediately because aspiration of the abscess may be needed to
maintain the airway.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
6. The nurse has determined that a client has an acute sore throat. What is the nurse’s best action?
a. Assess whether the client can speak.
b. Call an ear-nose-throat specialist.
c. Administer an antibiotic.
d. Give the client ice chips.
ANS: A
A dry cough and difficulty swallowing may indicate that the client is developing laryngitis. The
nurse should assess whether the client can speak or shows any changes in his or her voice. The
other interventions are not appropriate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction in Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
7. A client who is immune compromised develops muscle aches and fever. The client is admitted to
the hospital for several days and is diagnosed with influenza. At discharge, the client asks when he
can go back to work. What is the nurse’s best response?
a. “You should be able to return to work in 5 days.”
b. “You can return to work as soon as you feel ready.”
c. “You cannot return to work for several weeks.”
d. “You will need to have cultures performed before returning to work.”
ANS: C
Immune compromised clients are contagious for several weeks. The client should remain at home
until he is not contagious.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 645
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
8. A client is worried about contracting influenza. What is the nurse’s best response to the client?
a. “Flu is no longer a prevalent problem.”
b. “Did you receive a flu vaccine this year?”
c. “Current flu strains are generally mild.”
d. “If you develop symptoms, antibiotics will cure you.”
ANS: B
Vaccines for influenza are widely available and are recommended to prevent flu. Flu continues to
be a major problem, affecting up to 20% of the U.S. population and causing 36,000 deaths annually.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 645
TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC:
Integrated Process: Nursing Process (Implementation)
9. The nurse assesses a client with pneumonia and notes decreased lung sounds on the left side and
decreased lung expansion. What is the nurse’s best action?
a. Have the client cough and deep breathe.
b. Check oxygen saturation and notify the health care provider.
c. Perform an arterial blood gas analysis.
d. Increase oxygen flow to 10 L/min.
ANS: B
Decreased lung sounds and decreased lung expansion could indicate the development of a
complication such as empyema or pus in the pleural space. The nurse should check the client’s
oxygen saturation and notify the provider. Infection can also move into the bloodstream and result
in sepsis, so quick treatment is needed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
10. An older adult is admitted to the emergency department with respiratory symptoms. Which
client symptom requires the nurse to intervene immediately?
a. Confusion
b. Scattered wheezing
c. Crackles
d. Flushed cheeks
ANS: A
Confusion in an older adult can signify hypoxia. If the nurse waited to intervene until the older
adult showed more traditional symptoms of pneumonia, the client may become critically ill. The
other manifestations also require intervention but not as the priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)
MSC: Integrated Process: Nursing Process (Implementation)
11. Which is the highest priority goal to set for a client with pneumonia?
a. Absence of cyanosis
b. Maintenance of SaO2 of 95%
c. Walking 20 feet three times daily
d. Absence of confusion
ANS: B
Maintenance of an SaO2 of at least 95% is a clear goal that indicates that the client has adequate
oxygenation. Absence of cyanosis and the presence of confusion are assessment factors that
contribute to evaluation of oxygen; however, they are not absolute measures. Likewise, walking
three times a day does not directly address oxygenation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Planning)
12. The nurse is teaching a client with pneumonia ways to clear secretions. Which intervention is
the most effective?
a. Administering an antitussive medication
b. Administering an antiemetic medication
c. Increasing fluids to 2 L/day if tolerated
d. Having the client cough and deep breathe hourly
ANS: C
Increasing fluids has been proven to decrease the thickness of secretions, thus allowing them to be
expectorated quickly. The other interventions would not be as effective.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Teaching/Learning
13. A client who works in a day care facility is admitted to the emergency department. The client is
diagnosed with pneumonia, and a sputum culture is taken. Infection with Streptococcus
pneumoniae is confirmed. What is the nurse’s primary action?
a. Have emergency intubation equipment nearby.
b. Teach the client about the treatment.
c. Isolate the client.
d. Perform chest physiotherapy.
ANS: C
The client who works in a day care facility and is infected with Streptococcus pneumoniae may
have a drug-resistant pneumonia. It is extremely important that this organism does not spread to
other clients; the client should be isolated.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
14. What is the priority nursing intervention when caring for a client with severe acute respiratory
syndrome (SARS)?
a. Maintaining Standard Precautions
b. Administering antibiotics
c. Assessing oxygenation
d. Making sure the client stays hydrated
ANS: C
The client with SARS can rapidly develop hypoxia. Assessing oxygenation is a priority because
intubation and mechanical ventilation may be needed. Maintaining precautions is essential for
preventing the spread of this illness, but oxygenation and client safety are the highest priorities.
Antibiotics are administered if bacterial pneumonia occurs with this disease. Hydration is important
to make sure secretions stay liquefied; this is also secondary to oxygenation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
15. The newly employed nurse received a bacillus Calmette-Guérin (BCG) vaccine before moving
to the United States. The nurse needs to receive a tuberculin (TB) test as part of the preemployment physical. What does the nurse do?
a. The nurse should not receive the tuberculin test.
b. The nurse will need a two-step TB test.
c. The nurse will need a chest x-ray instead.
d. A physician should examine the nurse before the TB test is given.
ANS: C
The bacillus Calmette-Guérin (BCG) vaccine contains attenuated tubercle bacilli and is used in
many countries to produce increased resistance to TB. The nurse will have a positive skin test. The
client should be evaluated for TB with a chest x-ray. A physician examination is not necessary.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
16. The nurse is caring for several clients on a respiratory floor. The nurse should place the client
with which condition in isolation?
a. Fever and weight loss
b. Negative QuantiFERON TB gold test
c. Negative acid-fast bacillus (AFB) stain
d. Positive nucleic acid amplification test (NAAT)
ANS: D
The NAAT is a new rapid test for the diagnosis of tuberculosis (TB). Results are available in less
than 2 hours. A positive test is conclusive for TB, and the client should be placed in isolation per
facility policy. A client with a negative QuantiFERON gold test would not have tuberculosis.
Likewise, a client with a negative AFB would not have tuberculosis. The client with fever and
weight loss could have tuberculosis, but diagnostic tests would be needed because these are
nonspecific manifestations.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Nursing Process (Assessment)
17. A client has multidrug-resistant tuberculosis (TB). What is the most important fact for the nurse
to teach the client?
a. “You will need to take medications longer than clients with other
strains.”
b. “You will need to remain in the hospital until cultures are negative.”
c. “You will need to wear a mask when you go out in public.”
d. “You will need to have drug cultures done weekly.”
ANS: C
The client should wear a mask when out of the home environment and in crowds to prevent spread
of the infection. The other statements are not accurate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Teaching/Learning
18. The nurse is worried that a client who is not entirely reliable is being discharged home on
therapy for multidrug-resistant tuberculosis. What strategy is the best to use for this client?
a. Directly observed therapy
b. IV drug administration
c. Remaining in the hospital
d. Isolation
ANS: A
If a client is “not reliable,” the risk is that the client will not take medications as required, causing
spread of an organism that may become more drug resistant. The other answers are not correct.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
19. A client is admitted with suspected avian influenza. The family asks the nurse what kind of care
the client will get. Which statement by the nurse is correct?
a. “He will be given standard antibiotic agents and will be placed in
contact isolation.”
b. “He will be placed on airborne and contact isolation.”
c. “Oseltamivir (Tamiflu) will reduce complications of this infection.”
d. “All family members should be tested for evidence of the same
disease.”
ANS: B
The client who is experiencing avian influenza should be on both airborne and contact isolation.
Standard antibiotic agents would be ineffective with this disease process, as would most of the
standard antiviral medications commonly used for influenza. Human-to-human contact through
family members is likely only in very close living arrangements, so only specific members of the
client’s family should consider diagnostic testing.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Assessment)
20. Which client does the nurse caution to avoid taking over-the-counter decongestants for
manifestations of a cold or flu?
a. Young man with a latex allergy
b. Middle-aged woman with hypertension
c. Teenage woman who is taking oral contraceptives
d. Older man who has had type 1 diabetes mellitus for 20 years
ANS: B
Most decongestants work by increasing blood vessel constriction. This action increases peripheral
vascular resistance and blood pressure. The client who already has hypertension may develop
dangerously high blood pressure when taking a decongestant. The client who has a latex allergy, is
taking oral contraceptives, or has type 1 diabetes would not be likely to be affected by the
decongestant in such a life-threatening manner as the client who is hypertensive.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Assessment)
21. An older client reports having a cold and a “full bladder.” What does the nurse obtain for or
from the client?
a. Order for a Foley catheter
b. Order for a one-time catheterization
c. Urine specimen
d. History focusing on current medications
ANS: D
The nurse needs to assess more before intervening. Clients often take antihistamines for a “cold.”
Antihistamines are often composed of anticholinergic drugs. In older adult clients, these
medications can cause or worsen urinary retention.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Assessment)
22. A client has a peritonsillar abscess. Which priority instruction does the nurse provide to this
client?
a. “If you notice an enlarged node on the side of your neck where the
abscess is, call your health care provider.”
b. “Stay home from work or school until your temperature has been
normal for 24 hours.”
c. “You may gargle with warm water that has a teaspoon of salt in it as
often as you like.”
d. “Take the antibiotic for the entire time it is prescribed, not just until you
feel better.”
ANS: D
Untreated or ineffectively treated peritonsillar abscesses can extend throughout the pharyngeal area,
causing swelling that may jeopardize the client’s airway. Therefore, the client should take his
antibiotic for the entire time prescribed to maximize the therapeutic effect. Gargling with warm
water and refraining from normal activities may provide symptomatic relief for the client but would
not be considered priority instructions. Also, swelling, pain, and inflammation could be noted by
the client on the same side of the neck as the abscess.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 644
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
23. An older adult client with heart failure asks if she should get a flu shot. Which is the nurse’s best
response?
a. “Yes, because of your heart failure you are at greater risk for
complications.”
b. “Yes, if it has been longer than 5 years since your last flu vaccination.”
c. “No, your heart failure makes you too weak to get the live virus
vaccine.”
d. “No, the vaccine will interact with your heart medications.”
ANS: A
People older than 50 years and those with chronic disease should be vaccinated against the flu each
year early in the fall because they are at higher risk of developing complications if they do get ill.
Flu shots appear to be effective for only one flu season, so the client should get one annually. The
live vaccine is recommended only for healthy people up to age 49. This vaccination should not
have interactions with heart medications.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 645
TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC:
Integrated Process: Teaching/Learning
24. Which person is at greatest risk for developing a community-acquired pneumonia?
a. Middle-aged teacher who typically eats a diet of Asian foods
b. Older adult who smokes and has a substance abuse problem
c. Older adult with exercise-induced wheezing
d. Young adult aerobics instructor who is a vegetarian
ANS: B
Although age is a factor in the development of community-acquired pneumonia, other lifestyle and
exposure factors increase the risk to a greater extent than age. Two conditions that heavily
predispose to the development of pneumonia are cigarette smoking and alcoholism. Dietary choices
typically do not predispose to the development of pneumonia. Cigarette smoking interferes with the
ciliary function of removal of invasive materials. Alcoholism usually results in unbalanced
nutrition, as well as decreased immune function. A middle-aged adult, an older adult with wheezing
induced by exercise, and a young adult vegetarian would not be at risk for community-acquired
pneumonia because they have no predisposing conditions.
DIF: Cognitive Level: Comprehension/Understanding REF: Chart 33-4, p. 648
TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)
MSC: Integrated Process: Nursing Process (Assessment)
25. Which is the nurse’s best response to an older adult client who is hesitant to take the
pneumococcal vaccination and influenza vaccine in the same year?
a. “You need both injections. A risk factor for getting pneumonia is
infection with influenza.”
b. “Take both injections. They will protect you against respiratory
problems for this year.”
c. “The flu shot may protect you against influenza but not against bacteria
that cause pneumonia.”
d. “You should get the pneumococcal vaccination so you won’t infect
other people.”
ANS: C
Although influenza can lead to pneumonia, and preventing influenza with a flu shot reduces the risk
for a secondary pneumonia, bacterial pneumonia can be acquired without influenza as a
precipitating event and can be life threatening. Getting both injections will not protect the client
from respiratory problems, nor will it prevent the client from being infectious to other people.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC:
Integrated Process: Teaching/Learning
26. Which is a priority teaching intervention for the client who is using a nicotine patch?
a. “Abruptly discontinuing this patch can cause high blood pressure.”
b. “Abruptly discontinuing this patch can cause nausea and vomiting.”
c. “Smoking while using this patch increases the risk for pneumonia.”
d. “Smoking while using this patch increases the risk for a heart attack.”
ANS: D
Nicotine constricts blood vessels, increases mean arterial pressure, and increases afterload.
Smoking while using a nicotine patch increases afterload to such an extent that the myocardium
must work harder (with the coronary arteries constricted) and may cause a myocardial infarction.
Abruptly discontinuing the patch will not necessarily cause hypertension or nausea and vomiting.
Smoking while using the patch will not increase the risk for pneumonia.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 652
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse
Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Teaching/Learning
27. A client is admitted with left lower lung pneumonia. Which assessment finding does the nurse
correlate with this condition?
a. Expiratory wheeze on the right side
b. Dullness to percussion on the lower left side
c. Crepitus of the skin around the left lung
d. Crackles heard on expiration bilaterally
ANS: B
The client with pneumonia may have dullness to percussion on the affected side. The other options
are all inconsistent with pneumonia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
28. The nurse auscultates the following lung sound in the client with pneumonia. What is the best
intervention? (Click the media button to hear the audio clip.)
a. Have the client cough and deep breathe.
b. Prepare to administer a bronchodilator.
c. Have the client use an incentive spirometer.
d. Administer IV fluids.
ANS: C
The sound heard is crackles. Crackles often indicate atelectasis, which can be reversed by using an
incentive spirometer. If no spirometer is available, coughing and deep breathing is the next best
option. This client does not have wheezing, so bronchodilators are not indicated. IV fluids would
not help atelectasis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential-Potential for Complications
of Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Intervention)
29. A client has a tuberculin skin test as a pre-employment physical requirement. Which statement
by the nurse is best made to the client who has the test result seen in the photograph below?
a. “Your PPD is negative. No further follow-up is necessary.”
b. “You will need to have a second PPD.”
c. “You will need to have titers drawn.”
d. “You will need further testing.”
ANS: D
The tuberculin test (Mantoux test) result is the most commonly used reliable test of TB infection.
The photo shows a positive reaction. A positive reaction does not mean that active disease is
present but indicates exposure to TB or the presence of inactive (dormant) disease. Conclusive
evidence of TB is not provided through an examination of the chest or a chest x-ray. Only a sputum
specimen will provide definitive evidence of the disease process.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
MULTIPLE RESPONSE
1. What teaching is appropriate for a client with acute rhinitis and sinusitis? (Select all that apply.)
a. Using hot packs over the sinuses
b. Fluid restriction
c. Saline irrigations
d. Staying in a dry climate
e. Taking echinacea
f.
Antifungal medications
ANS: A, C, E
Treatment of sinusitis includes the use of broad-spectrum antibiotics (e.g., amoxicillin), analgesics
for pain and fever, decongestants, steam humidification, hot and wet packs over the sinus area, and
nasal saline irrigations. As complementary therapy, echinacea is recommended for the symptom of
rhinitis. Antifungal medications, fluid restrictions, and staying in a dry climate are not
recommended.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
2. A client enters the clinic with an acute sore throat and a temperature of 101.5° F (38.5° C). What
diagnostic testing does the nurse educate the client about? (Select all that apply.)
a. Complete blood count (CBC)
b. Throat culture
c. Monospot test
d. Arterial blood gas
e. Biopsy
f.
HIV testing
ANS: A, B, C
CBC, throat culture, and monospot testing can help to determine the causes of sore throat and fever.
A biopsy is not needed. Human immune deficiency virus (HIV) testing would not be indicated
unless the symptoms were a recurrent problem. Arterial blood gases would not be performed unless
the client had dyspnea and a low oxygen saturation reading.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Nursing Process (Assessment)
3. What is the best way for the nurse to decrease the risk of ventilator-associated pneumonia (VAP)
in a ventilator-dependent client? (Select all that apply.)
a. Provide prophylactic antibiotics.
b. Provide frequent oral care.
c. Keep the head of the bed elevated.
d. Maintain good hand hygiene.
e. Perform chest percussion frequently.
ANS: B, C, D
Providing frequent oral care, keeping the head of the bed elevated, and maintaining good hand
hygiene are currently stated as the best ways to help prevent VAP. Prophylactic antibiotics are not
recommended; neither is taking the client off the ventilator. Likewise, frequent chest percussion is
not stated as an intervention to decrease VAP.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
4. A client who previously had a bacillus Calmette-Guérin (BCG) vaccine has a positive
tuberculosis (TB) test. What symptoms assist in determining that the client has active disease?
(Select all that apply.)
a. Nausea
b. Weight loss
c. Insomnia
d. Ankle edema
e. Night sweats
f.
Increased urination
ANS: A, B, E
TB symptoms include nausea and weight loss, as well as night sweats. Inability to sleep and ankle
edema are not typical symptoms. Increased urination also is not a typical symptom.
DIF: Cognitive Level: Comprehension/Understanding REF: pp. 654-655
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
5. A client started on therapy for tuberculosis infection is reporting nausea. What does the nurse
teach this client? (Select all that apply.)
a. Eat a diet rich in protein, iron, and vitamins.
b. Do not drink fluids with medications.
c. Take medications at bedtime.
d. Space medications 12 hours apart.
e. Take medications with milk.
f.
Take an antiemetic daily.
ANS: A, C, F
Taking the daily dose of medications at bedtime may help to decrease nausea. A well-balanced diet
with foods rich in iron, protein, and vitamins C and B also helps to decrease nausea. Antiemetics
are often prescribed. Drinking fluids with medications should not influence the nausea; neither
should taking medications with milk. Spacing medications 12 hours apart is not recommended
therapy.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication
Administration)
MSC: Integrated Process: Nursing Process (Implementation)
6. The nurse is caring for a client who is suspected of having severe acute respiratory syndrome
(SARS). What actions by the nurse are most appropriate? (Select all that apply.)
a. Wash hands when entering the client’s room and use Standard
Precautions.
b. Wear a gown and goggles when entering the client’s room.
c. Teach the client to wear a mask at all times when someone is in the
room.
d. Use a disposable particulate mask respirator when the client is
coughing.
e. Keep the door to the client’s room open to allow close monitoring.
f.
Place the client in a negative airflow room, if available in the facility.
ANS: B, D, F
The nurse should follow Airborne Precautions when caring for clients suspected of SARS. Wear a
gown and goggles when in the room and caring for the client. Use a disposable particulate mask
respirator if the client is coughing, or if particles are being aerosolized. Handwashing and Standard
Precautions are not enough. The client does not have to wear a mask while others are in the room
because they should be protecting themselves by using Airborne Precautions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis)
MSC: Integrated Process: Nursing Process (Implementation)
7. The nurse is caring for a client who has inhalation anthrax. What nursing actions are of the
highest priority? (Select all that apply.)
a. Placing the client in an isolation room
b. Teaching the client how to use a mask
c. Teaching the client about long-term antibiotic therapy
d. Using handwashing and other Standard Precautions
e. Reporting suspected cases to the proper authorities
ANS: C, D, E
The client should not stop the drug merely because he or she has no manifestations. The client will
need to be on the drug for longer than 1 month. The nurse should teach the client about long-term
antibiotic therapy to help with compliance. Inhalation anthrax is not spread by person-to-person
contact, so isolation would not be necessary. The client would not need a mask. Health care
providers need only use handwashing and Standard Precautions. Always report inhalation anthrax
to authorities because it is considered an intentional act of terrorism.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Teaching/Learning
Chapter 34: Care of Critically Ill Patients with Respiratory Problems
Chapter 34: Care of Critically Ill Patients with Respiratory Problems
Test Bank
MULTIPLE CHOICE
1. The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus.
The client’s international normalized ratio (INR) is 2.0. What is the nurse’s best action?
a. Increase the heparin dose.
b. Increase the warfarin dose.
c. Continue the current therapy.
d. Discontinue the heparin.
ANS: D
The client who is being treated for pulmonary embolism usually continues on heparin and warfarin
until the INR reaches a therapeutic level between 2 and 3. Heparin can then be discontinued
because warfarin is therapeutic.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—
Pharmacological Agents)
MSC: Integrated Process: Nursing Process (Implementation)
2. The nurse is caring for a postoperative client who suddenly reports difficulty breathing and sharp
chest pain. After notifying the Rapid Response Team, what is the nurse’s priority action?
a. Elevate the head of the bed and apply oxygen.
b. Listen to the client’s lung sounds.
c. Pull the call bell out of the wall socket.
d. Assess the client’s pulse oximetry.
ANS: A
The client’s immediate need is to have oxygen applied. The nurse should then assess the client’s
pulse oximetry.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
3. It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is
initiated. What is the nurse’s priority action?
a. Monitor the client’s oxygenation.
b. Teach the client about potential side effects.
c. Monitor the IV insertion site.
d. Monitor for bleeding.
ANS: A
Airway and breathing are the top priority. The nurse would also need to monitor for bleeding when
administering fibrinolytic therapy, and would monitor the IV site as well. Teaching the client is also
a need, however. Oxygenation is the highest priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
4. A client with a large pulmonary embolism is receiving alteplase (Activase). The nurse notes frank
red blood in the Foley catheter drainage bag. What is the nurse’s first action?
a. Irrigate the Foley.
b. Administer an antibiotic.
c. Clamp the Foley.
d. Notify the health care provider.
ANS: D
Alteplase is a fibrinolytic agent that dissolves formed clots. The drug has an impact on clots outside
the pulmonary embolism, and the client is at great risk for hemorrhage and shock. The nurse should
realize the potential for a severe problem and should call the health care provider immediately for
orders. The other actions would not be appropriate first actions in this situation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Analysis)
5. The nurse is caring for a client with a pulmonary embolus who also has right-sided heart failure.
Which symptom will the nurse need to intervene for immediately?
a. Respiratory rate of 28 breaths/min
b. Urinary output of 10 mL/hr
c. Heart rate of 100 beats/min
d. Dry cough
ANS: B
Urinary output is very low; this could indicate that the client has decreased cardiac output. The
nurse will need to intervene and notify the health care provider. A respiratory rate that is slightly
elevated is expected in this condition. Likewise, a heart rate that is a little higher is expected in this
situation. A dry cough is also commonly found with pulmonary embolus.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Analysis)
6. A client states, “At night, I usually need to sleep propped up on two pillows in the chair, but now
it seems I need three pillows.” What is the nurse’s best response?
a. “You should try to rest more during the day.”
b. “You should try to lie flat for short periods of time.”
c. “You need to stay in the hospital for further evaluation.”
d. “You can take medication at night so you can sleep.”
ANS: C
Orthopnea is the sensation of dyspnea or breathlessness in the supine position. Clients feel that they
cannot catch their breath in the supine position and must rest or sleep in a semi-sitting position by
placing pillows behind their backs or by using a reclining chair. The degree of breathlessness can be
measured roughly by the number of pillows needed to make the client less dyspneic (e.g., onepillow orthopnea, two-pillow orthopnea). With a client who has chronic respiratory problems, a
minor increase in dyspnea may indicate a severe respiratory problem. Respiratory failure is a high
risk. This client needs to stay in the hospital to be evaluated more completely. The client should not
be instructed to try to lie flat, or to take a sleeping pill.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
7. A client is admitted owing to difficulty breathing. The nurse assesses the client’s color, lung
sounds, and pulse oximetry reading. The pulse oximetry is 90%. What is the nurse’s next action?
a. Give an intermittent positive-pressure breathing treatment.
b. Administer a rescue inhaler.
c. Call for a chest x-ray.
d. Assess an arterial blood gas.
ANS: D
When clients with respiratory problems are assessed, an arterial blood gas is needed for the most
accurate assessment of oxygenation. No indications are known for a breathing treatment or an
inhaler, nor does the nurse have enough information to know whether a chest x-ray is warranted.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
8. A client with dyspnea is becoming very anxious. An arterial blood gas (ABG) shows a PaO 2 of
93 mm Hg. How does the nurse best intervene?
a. Increase the oxygen.
b. Administer an antianxiety medication.
c. Administer a bronchodilator.
d. Assist with relaxation techniques.
ANS: D
The nurse should assess the client’s oxygenation; however, this client’s arterial blood gas
documents that the client’s hypoxia has resolved. At this time it is not necessary to increase the
oxygen or administer a bronchodilator; both of these interventions would be appropriate if the
client were hypoxic. The client with respiratory problems should not take an antianxiety medication
as a first-line intervention, because this may decrease the respiratory rate and/or alertness. The best
intervention at this time is to assist with relaxation techniques.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
9. The nurse notes that each time the mechanical ventilator delivers a breath to a client with acute
respiratory distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the
nurse’s best intervention?
a. Suction the client.
b. Perform chest physiotherapy.
c. Administer an inhaler.
d. Assess the airway.
ANS: D
An increase in peak inspiratory pressure (PIP) in the ARDS client is indicative of decreased lung
compliance, making it more difficult to ventilate diseased lungs. The nurse first should assess the
airway to make sure no sputum is present in the airway and that no kinks are noted in the tubing.
The nurse is not able to make changes in the ventilator settings, so an order is needed to increase
inspiratory pressure to oxygenate the client. Suctioning or performing chest physical therapy (PT)
will not help the client’s lung compliance; however, if mucus is impeding the airway, these
interventions would be necessary and would be noticed when the airway is assessed. Administering
a bronchodilator may help the client; however, an inhaler could not be used by a client on a
ventilator.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
10. The nurse is caring for several clients on the respiratory floor. Which client does the nurse
assess most carefully for the development of acute respiratory distress syndrome (ARDS)?
a. Older adult with COPD
b. Middle-aged client receiving a blood transfusion
c. Older adult who has aspirated his tube feeding
d. Young adult with a broken leg from a motorcycle accident
ANS: C
The older adult who has aspirated a tube feeding is at high risk and should be assessed closely for
the possibility of ARDS. A client with COPD and a middle-aged client with no other risk factors are
not at as high a risk for ARDS. The client who has a broken leg from an accident is not at high risk.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Analysis)
11. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is
receiving mechanical ventilation and positive end-expiratory pressure (PEEP). The alarm sounds,
indicating decreased pressure in the system. What is the nurse’s best action?
a. Change the client’s position.
b. Suction the client.
c. Assess lung sounds.
d. Turn off the pressure alarm.
ANS: C
One of the biggest risks in the client with ARDS on mechanical ventilation with PEEP is tension
pneumothorax. The nurse needs to assess lung sounds hourly. The alarms on a ventilator should
never be turned off. If the client needed to be suctioned, the high-pressure alarm would sound.
Changing the client’s position would not change the pressure needed to administer a breath.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of
Equipment) MSC: Integrated Process: Nursing Process (Analysis)
12. The nurse is caring for a client who has been intubated and placed on a ventilator for treatment
of acute respiratory distress syndrome (ARDS). Aside from assessing oxygenation, what is the
nurse’s priority action?
a. Assess hemoglobin.
b. Administer ferrous sulfate.
c. Assess muscle strength.
d. Consult with the registered dietitian.
ANS: D
The client who is intubated needs nutrition delivered via enteral tube feeding. If nutrition is
ignored, the client’s respiratory status can deteriorate, because respiratory muscle function can
deteriorate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
13. The nurse is caring for a client who is intubated with an endotracheal tube and on a mechanical
ventilator. The client is able to make sounds. What is the nurse’s first action?
a. Check cuff inflation on the endotracheal tube.
b. Listen carefully to the client.
c. Call the health care provider.
d. Auscultate the lungs.
ANS: A
If the client has the cuff on the endotracheal tube inflated, the cuff should prevent air from going
around the cuff and through the vocal cords. If the client can talk with the cuff inflated, the cuff
probably has a leak, causing it to become deflated and allowing air to pass through. The risk is that
the client will not receive the prescribed tidal volume.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of
Equipment)
MSC: Integrated Process: Nursing Process (Implementation)
14. Which assessment finding of a client requires the nurse’s immediate action?
a. Being intubated for 4 days
b. Uneven breath sounds
c. Wheezing on auscultation
d. Having the endotracheal (ET) tube taped to the lower jaw
ANS: D
The endotracheal tube can be taped to the upper lip but should never be taped to the lower jaw
because the lower jaw moves too much. The other clients need to be assessed by the nurse, but the
one with the ET tube taped to the jaw requires immediate action.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Evaluation)
15. The pilot balloon on the endotracheal tube of a client being mechanically ventilated is deflated.
What is the nurse’s priority action?
a. Nothing; this is required during ventilation.
b. Inflate the cuff using minimal leak technique.
c. Call the Rapid Response Team.
d. Increase the tidal volume.
ANS: B
The pilot balloon indicates whether the endotracheal tube cuff is inflated or deflated. A deflated
balloon means that the cuff is also deflated and a seal is no longer present around the tube to
prevent air from escaping. Thus, some of the air being moved into the client’s airway by the
ventilator is escaping through the client’s trachea before it reaches the lower airways and alveoli.
The nurse should inflate the cuff. Calling the Rapid Response Team is not necessary, and increasing
tidal volume will not improve oxygenation if the cuff is leaking.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of
Equipment)
MSC: Integrated Process: Nursing Process (Implementation)
16. The nurse is caring for a client with a ventilation/perfusion mismatch who is receiving
mechanical ventilation. Which intervention is a priority for this client?
a. Administering antibiotics every 6 hours
b. Positioning the client with the “good lung dependent”
c. Making sure that the pilot balloon line on the endotracheal tube is
deflated
d. Ensuring that the client is able to speak clearly
ANS: B
Clients who are being mechanically ventilated are experiencing a problem in that their normal
ventilation is not adequate. The recommended position for clients who have one lung more affected
by a problem than the other lung is to place the “good lung down,” keeping the healthier lung
dependent to the less healthy lung. Such positioning allows gravity to keep more blood in the lower
lung (healthier lung) and better ventilation in the upper lung, thus helping a ventilation/perfusion
mismatch. Antibiotics are not prescribed for this disorder. The pilot balloon line should be inflated
to ensure that the cuff is inflated, keeping the endotracheal tube in place and directing ventilated air
into the lungs. The client with an endotracheal tube that is nonfenestrated, with the cuff inflated,
will not be able to speak. Communication is addressed in other ways.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Analysis)
17. The nurse is caring for a client who is receiving mechanical ventilation accompanied by positive
end-expiratory pressure (PEEP). What assessment findings require immediate intervention?
a. Blood pressure drop from 110/90 mm Hg to 80/50 mm/Hg
b. Pulse oximetry value of 96%
c. Arterial blood gas (ABG): pH, 7.40; PaO 2, 80 mm Hg; PaCO2, 45 mm
Hg; HCO3–, 26 mEq/L
d. Urinary output of 30 mL/hr
ANS: A
Increased intrathoracic pressure can inhibit blood return to the heart and cause decreased cardiac
output. This manifests with a drop in blood pressure. The pulse oximetry reading, ABGs, and
urinary output are all normal.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing
Priorities) MSC: Integrated Process: Nursing Process (Analysis)
18. The client receiving mechanical ventilation has become more restless over the course of the
shift. Which is the nurse’s first action?
a. Sedate the client.
b. Call the health care provider.
c. Assess the client for pain.
d. Assess the client’s oxygenation.
ANS: D
Increasing restlessness in a client being mechanically ventilated may mean that the client is not
receiving sufficient oxygen. It can also be a manifestation of pain. When in doubt, determining the
adequacy of ventilation has the highest priority. The nurse would not sedate the client until the
cause of the restlessness has been addressed. The nurse would call the provider if the cause could
not be determined and addressed, or if the client’s status deteriorated.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests, Treatments, and Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
19. The pressure reading during inspiration on the ventilator of a client receiving mechanical
ventilation is fluctuating widely. What is the nurse’s first action?
a. Determine whether an air leak is present in the client’s endotracheal
tube cuff.
b. Have the respiratory therapist check the pressure settings.
c. Assess the client’s oxygenation.
d. Manually ventilate the client with a resuscitation bag.
ANS: C
A widely fluctuating pressure reading is one indication of inadequate airflow and oxygenation. The
nurse’s priority is to check the client’s oxygenation status. If oxygenation is inadequate, the nurse
would assess for a cause while manually ventilating the client and calling for assistance.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests, Treatments, and Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
20. A client is admitted to the emergency department several hours after a motor vehicle crash. The
car’s driver-side airbag was activated during the accident. Which assessment requires the nurse’s
immediate intervention?
a. Disorientation
b. Hemoptysis
c. Pulse oximetry reading of 94%
d. Chest pain with movement
ANS: B
The nurse should be concerned about possible pulmonary contusion. Interstitial hemorrhage
accompanies pulmonary contusion. Bleeding may not be evident at the initial injury, but the client
develops hemoptysis and decreased breath sounds up to several hours after injury as bleeding into
the alveoli or airways occurs. The pulse oximetry reading is within normal limits and chest pain is
expected with movement after chest trauma. Disorientation needs to be investigated, but does not
take priority over a breathing problem.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
21. The nurse assesses a client admitted for chest trauma who reports dyspnea. The nurse finds
tracheal deviation and a pulse oximetry reading of 86%. What is the nurse’s priority intervention?
a. Notify the health care provider and document the symptoms.
b. Intubate the client and prepare for mechanical ventilation.
c. Administer oxygen and prepare for chest tube insertion.
d. Administer an intermittent positive-pressure breathing treatment.
ANS: C
Blunt chest trauma can cause an air leak into the thoracic cavity, collapsing the lung on the side
with the air leak (pneumothorax). More air enters the pleural space with each breath, increasing
intrathoracic pressure on the affected side, moving the trachea to the unaffected side, and leading to
decreased cardiac output. This condition (tension pneumothorax) is life threatening without
intervention. The client will need oxygen administration right away and a chest tube inserted.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Analysis)
22. The nurse assesses a client who has a hemothorax and a chest tube inserted on the right side.
What finding requires immediate attention?
a. Pain at the chest tube insertion site
b. Fluctuation in the water seal chamber with breathing
c. Puffiness of the skin around the chest tube insertion site and a crackling
feeling
d. Dullness to percussion on the affected side
ANS: C
Puffiness of the skin around the chest tube and a crackling feeling indicate subcutaneous
emphysema, or air leaking into the tissue around the insertion site. This must be addressed
immediately. A hemothorax involves bleeding into the thoracic cavity and decreased lung inflation
on the affected side, resulting in duller and less resonant percussion notes. Pain at the insertion site,
fluctuation in the water seal, and dullness to percussion are all expected.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
23. The nurse is caring for a client who is taken off a ventilator and placed on continuous positive
airway pressure (CPAP). What intervention is most appropriate for this client?
a. Administering antianxiety medications PRN
b. Administering a medication to help the client sleep
c. Telling the client to relax and let the ventilator do the work
d. Making sure the client is breathing spontaneously
ANS: D
A requirement for using CPAP is that the client will be able to breathe spontaneously. Antianxiety
and sleep medications should not be administered to the client during weaning. Telling the client to
relax may be helpful in some cases but does not take priority over ensuring the client’s ability to
breathe spontaneously.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Safe Use of
Equipment) MSC: Integrated Process: Nursing Process (Assessment)
24. The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in
during inhalation and out during exhalation. The client’s oxygen saturation has dropped from 94%
to 86%. What is the priority action by the nurse?
a. Encourage the client to take deep, controlled breaths.
b. Document findings and continue to monitor the client.
c. Notify the health care provider and prepare for intubation.
d. Stabilize the chest wall with rib binders.
ANS: C
This client has a flail chest characterized by paradoxical chest wall motion. With the oxygen
saturation dropping, the client is at high risk for respiratory failure and needs to be intubated. Deepbreathing exercises are not enough at this point. Rib binders are not used anymore because they
limit chest wall expansion and were used only for simple rib fractures.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC:
Integrated Process: Nursing Process (Implementation)
25. The nurse auscultates the lungs of a client on mechanical ventilation and hears vesicular breath
sounds throughout the right side but decreased sounds on the left side of the chest. What is the
nurse’s best action?
a. Turn the client to the right side.
b. Elevate the head of the bed.
c. Assess placement of the endotracheal (ET) tube.
d. Suction the client.
ANS: C
The endotracheal tube is more likely to slip into the right mainstem bronchus, leading to the breath
sounds described. The nurse should assess placement of the ET tube by assessing where the
markings are, making sure it is taped, and confirming equal breath sounds bilaterally. If it is
believed that the tube has slipped into the right mainstem bronchus, the health care provider should
order a chest x-ray and reposition the tube.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests, Treatments, and Procedures)
MSC: Integrated Process: Nursing Process (Assessment)
26. What is the best way for the nurse to communicate with a client who is intubated and is
receiving mechanical ventilation?
a. Ask the client to point to words on a board.
b. Ask the client to blink for “yes” and “no.”
c. Have the client mouth words slowly.
d. Teach the client some simple sign language.
ANS: A
The nurse should have the client point to words on a board to communicate needs. The
endotracheal tube is positioned and placement is maintained with tape or some other type of
appliance. Asking the client to move his or her mouth and lips could result in possible extubation.
Communication is limited and could be misunderstood with blinking. Teaching the client sign
language, even simple, would be an involved and unrealistic goal.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Communication and Documentation
27. A client admitted with respiratory difficulty and decreased oxygen saturation keeps pulling off
the oxygen mask. What action does the nurse take?
a. Stays with the client and replaces the oxygen mask
b. Asks the client’s spouse to hold the oxygen mask in place
c. Restrains the client per facility policy
d. Contacts the health care provider and requests sedation
ANS: A
Restlessness and confusion are clinical manifestations of hypoxemia. It is important that the nurse
stay with the client, ensure that the oxygen is maintained, and attempt to calm the client. Because of
the client’s restlessness, the nurse cannot delegate care to the spouse. Requesting a sedative might
adversely affect the client’s respiratory status further. Restraining the client could increase
restlessness and increase oxygen demand.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)
MSC: Integrated Process: Nursing Process (Implementation)
28. A client with severe respiratory insufficiency becomes short of breath during activities of daily
living. Which nursing intervention is best?
a. Call the Rapid Response Team.
b. Decrease involvement in care until the episode is past.
c. Cluster morning activities to provide long rest periods.
d. Space out interventions to provide for periods of rest.
ANS: B
Clients with shortness of breath and decreased oxygen saturation must be monitored closely.
Minimal involvement in activities is required if the client is severely short of breath. The nurse
should continue to assess the client and can increase involvement in activities if shortness of breath
subsides. The Rapid Response Team is not required. Clustering or spacing of activities does nothing
to decrease the client’s involvement, which is the cause of shortness of breath.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC:
Integrated Process: Nursing Process (Implementation)
29. The nurse is assessing arterial blood gases (ABGs). The client with which ABG reading requires
the nurse’s immediate attention?
a. pH, 7.32; PaCO2, 55 mm Hg; PaO2, 70 mm Hg
b. pH, 7.45; PaCO2, 42 mm Hg; PaO2, 70 mm Hg
c. pH, 7.48; PaCO2, 38 mm Hg; PaO2, 60 mm Hg
d. pH, 7.55; PaCO2, 32 mm Hg; PaO2, 50 mm Hg
ANS: D
This client has the most severe hypoxia and respiratory alkalosis, indicated by low partial pressure
of arterial carbon dioxide (PaCO2) values on ABG analysis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Nursing Process (Analysis)
30. The nurse auscultates the following lung sound in a client with a respiratory disorder. What is
the nurse’s best action? (Click the media button to hear the audio clip.)
a. Have the client use an incentive spirometer.
b. Have the client cough and deep breathe.
c. Suction the client after auscultating the lower lobes of the lungs.
d. Call for the Rapid Response Team.
ANS: D
The sound heard is stridor. Stridor on inspiration is caused by laryngospasm or edema and heralds
impending airway occlusion. The client’s airway is in jeopardy and immediate intervention is
necessary. Using the spirometer or coughing and deep breathing will not help the client in this
situation. The nurse needs to call the Rapid Response Team.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Medical Emergencies) MSC:
Integrated Process: Nursing Process (Analysis)
MULTIPLE RESPONSE
1. Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus
(PE)? (Select all that apply.)
a. Wheezes throughout lung fields
b. Hemoptysis
c. Sharp chest pain
d. Flattened neck veins
e. Hypotension
f.
Pitting edema
ANS: B, C, E
Hemoptysis, sharp chest pain, and hypotension all may be caused by pulmonary embolism and the
pulmonary hypertension that results. Rather than wheezes, crackles usually occur along with a dry
cough.
DIF: Cognitive Level: Knowledge/Remembering REF: Chart 34-2, p. 664
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
2. Which clients are at highest risk for pulmonary embolism (PE)? (Select all that apply)
a. Middle-aged client awaiting surgery
b. Older adult with a 20–pack-year history of smoking
c. Client who has been on bedrest for 3 weeks
d. Obese client who has elevated platelets
e. Middle-aged client with diabetes mellitus type 1
f.
Older adult who has just had abdominal surgery
ANS: B, C, D, F
Older adults, especially those with chronic lung problems, are at higher risk for pulmonary
embolism. Prolonged bedrest is also a risk factor, as are abdominal surgery and smoking. Because
platelets are involved in the clotting process, elevated platelets may contribute to increased clotting.
Diabetes and waiting for surgery are not known risk factors.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 663
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
3. A client admitted for difficulty breathing becomes worse. Which assessment findings indicate
that the client has developed acute respiratory distress syndrome (ARDS)? (Select all that apply.)
a. Oxygen administered at 100%, PaO 2 60
b. Increased dyspnea
c. Anxiety
d. Chest pain
e. Pitting pedal edema
f.
Clubbing of fingertips
ANS: A, B, C
A client who is developing ARDS presents with a decrease in oxygen despite an increase in the
fraction of inspired oxygen. Increased dyspnea goes along with the increased hypoxemia, as does
anxiety. Chest pain is not specific to ARDS; although chest pain can occur with ARDS, it occurs
with many other conditions as well. Pitting edema would not be an assessment factor that confirms
ARDS. Clubbing occurs in chronic, not acute, respiratory conditions.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 671
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
4. The nurse is caring for a client on a ventilator when the high-pressure alarm sounds. What actions
are most appropriate? (Select all that apply.)
a. Assess the tubing for kinks.
b. Assess whether the tubing has become disconnected.
c. Determine the need for suctioning.
d. Call the health care provider.
e. Call the Rapid Response Team.
f.
Auscultate the client’s lungs.
ANS: A, C, F
Reasons for a high-pressure alarm include water or a kink impeding airflow or mucus in the airway.
The nurse first should assess the client and determine whether he or she needs to be suctioned; then
the nurse should auscultate the lungs. The nurse also should assess the tubing for kinks. The highpressure alarm sounding would not be a reason to call the health care provider or the Rapid
Response Team. If the tubing became disconnected, the low-pressure alarm would sound.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of
Equipment) MSC: Integrated Process: Nursing Process (Assessment)
5. The nurse is prioritizing care for a client on a ventilator. What are essential nursing interventions
for this client? (Select all that apply.)
a. Change the settings in accordance with provider orders.
b. Modify the settings for weaning the client.
c. Assess the reasons for alarms.
d. Compare the ventilator settings with ordered settings.
e. Assess the water level in the humidifier.
f.
Change the ventilator tubing according to hospital policy.
ANS: C, D, E
The nurse should assess the client when an alarm sounds and should intervene accordingly. The
nurse should also check the settings to make sure they are correct and should evaluate the water
level to make sure the humidifier does not go dry. The nurse would not be responsible for changing
ventilator settings, weaning the client, or changing the ventilator tubing.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of
Equipment) MSC: Integrated Process: Nursing Process (Assessment)
6. The nurse is caring for a client with a high risk for pulmonary embolism (PE). Which prevention
measures does the nurse add to the client’s care plan? (Select all that apply.)
a. Use antiembolism stockings.
b. Massage calf muscles per client request.
c. Maintain supine position with the legs flat.
d. Turn every 2 hours if client is in bed.
e. Refrain from active range-of-motion exercises.
ANS: A, D
Both antiembolism stockings (or sequential pressure devices) and a turning schedule can help
prevent venous thromboembolism, which can lead to PE. Massaging the calves is discouraged
because this can cause a clot to break loose and travel to the lungs. Legs should be elevated when in
bed, and the client should perform active range of motion (ROM) if able. If the client is unable to
perform active ROM, the nurse should provide passive ROM.
DIF: Cognitive Level: Knowledge/Remembering REF: Chart 34-1, p. 663
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Planning)
SHORT ANSWER
1. A nurse is making initial rounds on assigned clients at the beginning of the shift. One client is
receiving a heparin infusion at 5 mL/hr. The nurse notes that 25,000 units of heparin are mixed in
250 mL of solution. How many units per hour is the client receiving? __________ units/hr
ANS:
500
25,000 units/250 mL = X units/hr/(5 mL/hr)
250X = 125,000
X = 500 units/hr
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Dosage
Calculation) MSC: Integrated Process: Nursing Process (Assessment)
2. A client is ordered heparin 5000 units at 7 AM. The heparin is provided in a vial labeled 20,000
units per mL. How much does the nurse administer? ______ mL
ANS:
0.25
5000 units/20,000 units  1 mL = 0.25 mL
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Dosage
Calculation) MSC: Integrated Process: Nursing Process (Assessment)
Chapter 35: Assessment of the Cardiovascular System
Chapter 35: Assessment of the Cardiovascular System
Test Bank
MULTIPLE CHOICE
1. The nurse is caring for a client who has had a recent myocardial infarction involving the left
ventricle. Which assessment finding is expected?
a. Faint S1 and S2 sounds
b. Decreased cardiac output
c. Increased blood pressure
d. Absent peripheral pulses
ANS: B
The myocardium is the layer responsible for the contractile force of the heart. Damage to this layer
can result in decreased cardiac output. This most likely would result in decreased blood pressure
and strength of peripheral pulses. Absent peripheral pulses would be caused by an arterial
occlusion. S1 and S2 most likely would not be affected.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
2. The nurse is caring for a client with coronary artery disease. What assessment finding does the
nurse expect if the client’s mean arterial blood pressure decreases below 60 mm Hg?
a. Increased cardiac output
b. Hypertension
c. Chest pain
d. Decreased heart rate
ANS: C
Coronary artery blood flow occurs primarily during diastole. Mean arterial pressure (MAP) of 60
mg Hg is necessary for adequate blood flow to coronary arteries, and MAP of 60 to 70 mm Hg is
necessary for adequate perfusion to major body organs. If MAP decreases to below 60 mm Hg, the
client with cardiac disease may have chest pain. Cardiac output most likely would decrease, and
blood pressure also would decrease. Heart rate may increase as the body initiates compensatory
mechanisms.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
3. The nurse is assessing a client following a myocardial infarction. The client is hypotensive. What
additional assessment finding does the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease
in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the
sinoatrial (SA) node. This results in an increase in heart rate. This tachycardia is an early response
and is seen even when blood pressure is not critically low.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
4. The nurse administers a beta blocker to a client after a myocardial infarction. What assessment
finding does the nurse expect?
a. Blood pressure increase of 10%
b. Increasing respiratory rate
c. Increased cardiac output
d. Pulse decrease from 100 to 80 beats/min
ANS: D
Beta blockers block the stimulation of beta 1-adrenergic receptors. They block the sympathetic
(fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and
blood pressure, increasing ventricular filling time. It usually does not have effects on beta 2adrenergic receptor sites. Cardiac output will drop because of decreased heart rate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes) MSC: Integrated Process: Nursing Process (Assessment)
5. The nurse is assessing clients at a community health center. Which client does the nurse
determine is at high risk for cardiovascular disease?
a. Older adult man with a history of asthma
b. Asian-American man with colorectal cancer
c. American Indian woman with diabetes mellitus
d. Postmenopausal woman on hormone therapy
ANS: C
The incidence of coronary artery disease and hypertension is higher in American Indians than in
whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary
artery disease in people of any race or ethnicity.
DIF: Cognitive Level: Knowledge/Remembering REF: pp. 692-693
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
MSC: Integrated Process: Nursing Process (Assessment)
6. The nurse is obtaining a client’s health history. Which illness alerts the nurse to the possibility of
abnormal heart valves?
a. Tuberculosis
b. Recurrent viral pneumonia
c. Rheumatic fever
d. Asthma
ANS: C
Rheumatic fever is an inflammatory disease that typically is caused by infection with group A betahemolytic streptococci that can affect the endocardium.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 694
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
MSC: Integrated Process: Nursing Process (Assessment)
7. A nurse is performing an admission assessment on an older adult client with multiple chronic
diseases. The nurse assesses the heart rate to be 48 beats/min. What does the nurse do first?
a. Document the finding in the chart.
b. Evaluate for a pulse deficit.
c. Assess the client’s medications.
d. Administer 1 mg of atropine.
ANS: C
Pacemaker cells in the conduction system decrease in number as a person ages, resulting in
bradycardia. The nurse should check the medication reconciliation for medications that might cause
such a drop in heart rate, then should inform the health care provider. Documentation is important,
but it is not the priority action. The heart rate is not low enough for atropine to be needed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Analysis)
8. The nurse is assessing clients at a clinic. Which activity takes priority?
a. Teaching smoking cessation to a middle-aged woman who smokes
b. Planning an exercise regimen with a woman with a sedentary lifestyle
c. Teaching an older man who is moderately obese to keep a food diary
d. Assessing a man with familial coronary artery disease for specific risk
factors
ANS: A
All of these risk factors contribute to the development of cardiovascular disease, but cigarette
smoking is a major risk factor for both coronary artery disease and peripheral vascular disease.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC:
Integrated Process: Nursing Process (Assessment)
9. The nurse is assessing a client in the emergency department. Which client statement alerts the
nurse to the occurrence of heart failure?
a. “I get short of breath when I climb stairs.”
b. “I see halos floating around my head.”
c. “I have trouble remembering things.”
d. “I have lost weight over the past month.”
ANS: A
Dyspnea on exertion (DOE) is an early manifestation of heart failure and is associated with an
activity such as stair climbing. The other findings are not specific to early occurrence of heart
failure.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
10. The nurse is assessing a client newly admitted to the medical unit. Which statement made by the
client alerts the nurse to the presence of edema?
a. “I wake up to go to the bathroom at night.”
b. “My shoes fit tighter by the end of the day.”
c. “I seem to be feeling more anxious lately.”
d. “I drink at least eight glasses of water a day.”
ANS: B
Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema.
The nurse should note whether the client feels that his or her shoes or rings are tight, and should
observe, when present, an indentation around the leg where the socks end. The other answers do not
describe edema.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
11. When obtaining a client’s vital signs, the nurse assesses a blood pressure of 134/88 mm Hg.
What is the nurse’s best intervention?
a. Call the health care provider and report the finding.
b. Reassess the client’s blood pressure at the next yearly physical.
c. Administer an additional antihypertensive medication to the client.
d. Teach the client lifestyle modifications to decrease blood pressure.
ANS: D
Prehypertension has been designated as 120 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic.
These clients are at higher risk for developing hypertension. The client needs to institute dietary
and activity changes to help decrease blood pressure. The reading is not high enough for the nurse
to call the health care provider. No indications for administering medications are known. Because
the client has prehypertension, the nurse should intervene now to help prevent the development of
frank hypertension.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
MSC: Integrated Process: Nursing Process (Assessment)
12. The nurse is performing a focused cardiac assessment. What assessment finding should be
reported to the health care provider?
a. Bruit heard on the side of the neck
b. Bounding peripheral pulses
c. Pulse rate of 90 beats/min
d. Blood pressure of 140/90 mm Hg
ANS: A
A bruit is a swishing sound that may develop in narrowed arteries. Bruits usually are associated
with atherosclerotic disease. This finding may indicate atherosclerotic disease of the carotid
arteries, and further evaluation is needed. Bounding pulses, a pulse rate of 90 beats/min, and a
blood pressure of 140/90 mm Hg are not assessment findings that require immediate interventions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
13. A client consistently reports feeling dizzy and lightheaded when moving from a supine position
to a sitting position. What nursing assessment takes priority at this time?
a. Pulse oximetry
b. Blood pressure
c. Respiratory rate
d. Neurologic evaluation
ANS: B
Dizziness and lightheadedness on moving from a supine to a sitting or standing position may be
symptoms of postural hypotension. Orthostatic blood pressure measurements (decrease of more
than 20 mm Hg systolic, decrease of more than 10 mm Hg diastolic, and 10% to 20% increase in
heart rate) are used to determine the presence of postural hypotension.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
14. The nurse is assessing an older adult client who is experiencing a myocardial infarction. What
clinical manifestation does the nurse expect in this client?
a. Excruciating pain on inspiration
b. Left lateral chest wall pain
c. Disorientation and confusion
d. Numbness and tingling of the arm
ANS: C
In older adults, disorientation or confusion may be the major manifestation of myocardial infarction
caused by poor cardiac output. Pain manifestations could also be related to the myocardial
infarction. However, the nurse is more concerned about the new onset of disorientation or
confusion caused by decreased perfusion.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
15. A client is newly diagnosed with a heart murmur and asks the nurse to explain what this means.
What is the nurse’s best response?
a. “It is a rushing sound that blood makes moving through narrow places.”
b. “It’s the sound of the heart muscle stretching in an area of weakness.”
c. “It’s a term doctors use to describe the efficiency of blood circulation.”
d. “It is the sound the heart makes when it is has an increased workload.”
ANS: A
Murmurs reflect turbulent blood flow through normal or abnormal valves. The significance of a
murmur depends on its cause. Some murmurs are associated with a healthy heart that ejects blood
quickly and turbulently from the left ventricle. Other murmurs may be indicators of severe valve,
vessel, or heart problems.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 700
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Communication and Documentation
16. A client has returned from a cardiac angiography via the left femoral artery. Two hours after the
procedure, the nurse notes that the left pedal pulse is weak. What is the nurse’s best action?
a. Elevate the leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
c. Assess the color and temperature of the left leg.
d. Document the finding as left pedal pulse of +1/4.
ANS: C
Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial
obstruction. The pulse may be faint because of edema. The left pulse should be compared with the
right, and pulses should be compared with previous assessments, especially before the procedure.
Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation.
Once all peripheral and vascular assessment data are acquired, the primary health care provider
should be notified.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Evaluation)
17. The nurse is recovering a client after a left-sided cardiac catheterization. What assessment
finding requires immediate intervention?
a. Urinary output less than intake
b. Bruising at the insertion site
c. Slurred speech and confusion
d. Discomfort in the left leg
ANS: C
A left-sided cardiac catheterization specifically increases the risk for a cerebrovascular accident
(CVA). A change in neurologic status needs to be acted on immediately. Discomfort and bruising
are expected at the site. If intake decreases, a client can become dehydrated because of dye
excretion. The second intervention would be to increase the client’s fluid status. Neurologic
changes would take priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Assessment)
18. The nurse is preparing a client for a cardiac catheterization. What assessment is a priority before
the procedure?
a. Client’s level of anxiety
b. Ability to turn self in bed
c. Cardiac rhythm and heart rate
d. Allergies to iodine and shellfish
ANS: D
Before the procedure, the nurse should ascertain whether the client has an allergy to iodinecontaining preparations, such as seafood or local anesthetics. The contrast medium used during the
procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority.
Second, it is important for the nurse to assess anxiety, mobility, and knowledge.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Error
Prevention) MSC: Integrated Process: Nursing Process (Assessment)
19. The client is scheduled for a resting electrocardiography. Which statement by the client
indicates a good understanding of the preprocedure teaching?
a. “I cannot eat or drink before the electrocardiography.”
b. “I must lie as still as possible during the procedure.”
c. “I am likely to feel warmth as the dye enters the heart.”
d. “I will increase my fluid intake on the day of the procedure.”
ANS: B
Resting electrocardiography is noninvasive and painless and requires the client to be connected to a
portable electrocardiographic monitor. Movement can cause artifacts and can interfere with the
accuracy of the recording. The client does not have to be NPO before the procedure, and no dye is
used. No reason to increase the client’s fluid intake is known.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Nursing Process (Planning)
20. The nurse is monitoring a client undergoing an exercise electrocardiography (stress test). Which
assessment finding necessitates that the test be stopped?
a. Heart rate increases to 140 beats/min
b. Blood pressure of 100/80 mm Hg
c. Respiratory rate exceeds 36 breaths/min
d. Significant ST-segment depression
ANS: D
This electrocardiographic finding is associated with myocardial ischemia and could signal a
possible myocardial infarction if the physical activity is continued or increased. The other findings
do not indicate emergent assessments.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Evaluation)
21. A client who is scheduled for an echocardiography today asks why this test is being performed.
What is the nurse’s best response?
a. “This procedure is a noninvasive way to assess the structure of the
heart.”
b. “This procedure assesses for abnormal electrical impulses within the
heart.”
c. “This procedure will evaluate the oxygen saturation in your blood.”
d. “This procedure assesses for blockages within the coronary arteries.”
ANS: A
Echocardiography is performed to assess the structure and function of the heart, especially the
valves and wall motion. Coronary arteries are not assessed with echocardiography, and neither is
the electrical conduction system.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 706
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
MSC: Integrated Process: Teaching/Learning
22. The nurse is caring for a client who is scheduled for magnetic resonance imaging (MRI) of the
heart. The client’s history includes a previous myocardial infarction and pacemaker implantation.
Which action by the nurse is most appropriate?
a. Schedule an electrocardiogram just before the MRI.
b. Notify the health care provider before scheduling the MRI.
c. Call the physician and request a laboratory draw for cardiac enzymes.
d. Instruct the client to increase fluid intake the day before the MRI.
ANS: B
The magnetic fields of the magnetic resonance imager can deactivate the pacemaker. The nurse
should call the health care provider and report that the client has a pacemaker so the provider can
order other diagnostic tests. The client does not need cardiac enzymes, an electrocardiogram, or
increased fluids.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—
Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Planning)
23. The nurse obtains a pulmonary artery pressure reading of 25/12 mm Hg in a client recovering
from a myocardial infarction. What is the nurse’s first intervention?
a. Compare the results with previous readings.
b. Increase the IV fluid rate because these readings are low.
c. Immediately notify the physician of the elevated pressures.
d. Document the finding and continue to monitor.
ANS: A
Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15 mm
Hg for diastolic. Although these readings are within normal limits, the nurse needs to assess any
trends that may indicate a need for medical treatment to prevent complications.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in
Body Systems) MSC: Integrated Process: Nursing Process (Evaluation)
24. The nurse is preparing to measure a client’s pulmonary artery wedge pressure (PAWP). In what
position will the nurse place the client for the most accurate results?
a. Supine, with the head elevated to 45 degrees
b. Supine, with the head elevated to 30 degrees
c. Reverse Trendelenburg position at 15 degrees
d. Supine, with the head of the bed flat
ANS: A
To measure PAWP accurately, the client should be placed in supine position, with the head elevated
to 45 degrees.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 709
TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC:
Integrated Process: Nursing Process (Implementation)
25. The nurse is caring for a client with an 80% blockage of the right coronary artery (RCA). While
waiting for bypass surgery, what is essential for the nurse to have available?
a. Furosemide (Lasix)
b. External pacemaker
c. Lidocaine
d. Central venous access
ANS: B
The right coronary artery supplies the right atrium, the right ventricle, the inferior portion of the left
ventricle, and the atrioventricular (AV) node. It also supplies the sinoatrial (SA) node in 50% of
people. If the client totally occludes the RCA, the AV node would not function and the client would
go into heart block, so emergency pacing should be available for the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Planning)
26. The nurse is caring for a client with pericarditis. What assessment finding correlates with this
disorder?
a. Pericardial friction rub
b. Systolic murmur
c. Ventricular gallop
d. Paradoxical splitting
ANS: A
A pericardial friction rub originates from the pericardial sac and is heard in clients with pericarditis.
The other findings are not associated with pericarditis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
27. The nurse is auscultating heart tones on an older client and hears the following sound. What is
the nurse’s best action? (Click the media button to hear the audio clip.)
a. Administer a diuretic.
b. Document the finding.
c. Decrease the IV flow rate.
d. Evaluate the medications.
ANS: B
The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a
stiffened ventricle. The nurse should document the finding, but no other intervention is needed at
this time.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC:
Integrated Process: Nursing Process (Assessment)
28. The nurse is auscultating cardiac tones. Where should the nurse listen to best hear a cardiac
murmur related to aortic regurgitation?
a. Location A
b. Location B
c. Location C
d. Location D
ANS: A
The aortic valve is auscultated in the second intercostal space just to the right of the sternum.
DIF: Cognitive Level: Comprehension/Understanding REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC:
Integrated Process: Nursing Process (Assessment)
MULTIPLE RESPONSE
1. A client with a history of renal insufficiency is scheduled for a cardiac catheterization. What does
the nurse expect to do for this client before the catheterization? (Select all that apply.)
a. Insert a Foley catheter.
b. Administer IV fluids.
c. Assess for allergies to iodine.
d. Assess laboratory results.
e. Assess and mark pulses.
f.
Insert a central venous catheter.
g. Have the client sign the consent.
ANS: B, C, D, E, G
If the client has kidney disease (as indicated by laboratory results), fluids and Mucomyst may be
given 12 to 24 hours before the procedure for renal protection. The client should be assessed for
allergies to iodine, including shellfish. The contrast medium used during the catheterization
contains iodine. Pulses need to be marked for ease in locating them after the procedure. Findings
need to be properly documented, and the primary care provider and other members of the health
care team need to be notified of abnormal findings.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
2. A female client is admitted to the emergency department. Which symptoms cause the nurse to
order an electrocardiogram? (Select all that apply.)
a. Hypertension
b. Fatigue despite adequate rest
c. Indigestion
d. Abdominal fullness
e. Shortness of breath
f.
Feeling of choking
g. Abdominal pain
ANS: B, C, D, E, F
Women may not have chest pain but may feel discomfort or indigestion. They often present with a
triad of symptoms—indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite
adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and
therefore are not treated adequately.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
3. A client is recovering after a coronary catheterization. What assessment findings in the first few
hours after the procedure require immediate action by the nurse? (Select all that apply.)
a. Blood pressure of 140/88 mm Hg
b. Serum potassium of 2.9 mEq/L
c. Warmth and redness at the site
d. Expanding groin hematoma
e. Rhythm changes on the cardiac monitor
ANS: B, D, E
In the first few postprocedure hours, the nurse monitors for complications, such as bleeding from
the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and
dysrhythmias. The client’s blood pressure is slightly elevated but does not need immediate action.
Warmth and redness at the site would indicate an infection, but this would not be present in the first
few hours.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Assessment)
4. When reviewing a client’s laboratory results, which findings alert the nurse to the possibility of
atherosclerosis? (Select all that apply.)
a. Total cholesterol of 280 mg/dL
b. High-density cholesterol of 50 mg/dL
c. Triglycerides of 200 mg/dL
d. Serum albumin of 4 g/dL
e. Low-density cholesterol of 160 mg/dL
ANS: A, C, E
A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and
low-density cholesterol levels are all high, indicating higher risk for cardiovascular disease. Highdensity cholesterol is within the normal range for both males and females. Serum albumin is not
assessed for atherosclerosis.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC:
Integrated Process: Nursing Process (Assessment)
Chapter 36: Care of Patients with Dysrhythmias
Chapter 36: Care of Patients with Dysrhythmias
Test Bank
MULTIPLE CHOICE
1. A client’s cardiac status is being observed by telemetry monitoring. The nurse observes a P wave that changes
shape in lead II. What conclusion does the nurse make about the P wave?
a. It originates from an ectopic focus.
b. The P wave was replaced by U waves.
c. It is from the sinoatrial (SA) node.
d. Multiple P waves are present.
ANS: A
If the P wave is firing consistently from the SA node, the P wave will have a consistent shape in a given lead. If
the impulse is from an ectopic focus, then the P wave will vary in shape in that lead.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 715
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
2. The nurse is assessing the client’s electrocardiography (ECG). What does the P wave on the ECG tracing
represent?
a. Contraction of the atria
b. Contraction of the ventricles
c. Depolarization of the atria
d. Depolarization of the ventricles
ANS: C
The ECG tracing of a P wave represents electrical changes caused by atrial depolarization.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 715
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
3. A nurse notes that the PR interval on a client’s electrocardiograph (ECG) tracing is 0.14 second. What action
does the nurse take?
a. Assess serum cardiac enzymes.
b. Administer 1 mg epinephrine IV.
c. Administer oxygen via nasal cannula.
d. Document the finding in the client’s chart.
ANS: D
The PR interval normally ranges from 0.12 to 0.20 second. This is a normal finding, so the nurse simply
documents this. No further action is required.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity Physiological Integrity (Physiological Adaptation—
Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis)
4. When analyzing a client’s electrocardiograph (ECG) tracing, the nurse observes that not all QRS complexes
are preceded by a P wave. What is the nurse’s interpretation of this observation?
a. The client has hyperkalemia causing irregular QRS complexes.
b. Ventricular tachycardia is overriding the normal atrial rhythm.
c. The client’s chest leads are not making sufficient contact with the skin.
d. Ventricular and atrial depolarizations are initiated from different sites.
ANS: D
Normal rhythm shows one P wave preceding each QRS, indicating that all depolarization is initiated at the
sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 718
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
5. The nurse observes a prominent U wave on the client’s electrocardiograph (ECG) tracing. What is the most
appropriate action for the nurse to take?
a. Document the finding as a normal variant.
b. Review the client’s daily electrolyte results.
c. Move the crash cart closer to the client’s room.
d. Call for an immediate electrocardiogram.
ANS: B
Prominent U waves may be the result of hypokalemia. The nurse should review the client’s daily electrolyte
results. Although documentation is important, this is not a normal variant. Moving the crash cart closer to the
room may or may not be warranted. The client does not need an immediate ECG.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
6. The client’s heart rate increases slightly during inspiration and decreases slightly during expiration. What
action does the nurse take?
a. Evaluate for a respirator disorder.
b. Assess the client for chest pain.
c. Document the finding in the chart.
d. Administer antidysrhythmic drugs.
ANS: C
Sinus dysrhythmia is noted when the heart rate increases slightly during inspiration and decreases slightly
during expiration. Sinus dysrhythmia is a variant of normal sinus rhythm that is frequently observed in healthy
children and adults. No other actions are needed.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 718
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
7. A client with tachycardia is experiencing clinical manifestations. Which manifestation requires immediate
intervention by the nurse?
a. Mid-sternal chest pain
b. Increased urine output
c. Mild orthostatic hypotension
d. P wave touching the T wave
ANS: A
Chest pain, possibly angina, indicates that tachycardia may be increasing the client’s myocardial workload and
oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial
hypoxia and pain.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Analysis)
8. A client is experiencing sinus bradycardia with hypotension and dizziness. What medication does the nurse
administer?
a. Atropine (Atropine)
b. Digoxin (Lanoxin)
c. Lidocaine (Xylocaine)
d. Metoprolol (Lopressor)
ANS: A
Atropine is a cholinergic antagonist that inhibits parasympathetically-induced hyperpolarization of the sinoatrial
node. This inhibition results in an increased heart rate. The other medications are not appropriate.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes)
MSC: Integrated Process: Nursing Process (Implementation)
9. A client experiences occasional premature atrial contractions (PACs) accompanied by palpitations that
resolve spontaneously without treatment. What instruction does the nurse include in the client’s teaching plan?
a. “Minimize or abstain from caffeine.”
b. “Lie on your side until the attack subsides.”
c. “Use your oxygen when you experience PACs.”
d. “Take quinidine (Cardioquin) daily to prevent PACs.”
ANS: A
PACs usually have no hemodynamic consequences. For a client experiencing infrequent bouts of PACs, the
nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side
will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control
symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
10. The nurse identifies a client’s rhythm to be a sustained supraventricular tachycardia. What medication does
the nurse administer?
a. Atropine (Atropine)
b. Epinephrine (Adrenalin)
c. Lidocaine (Xylocaine)
d. Diltiazem (Cardizem)
ANS: D
Diltiazem, a calcium channel blocker, slows depolarization through the conduction system and is commonly
used as an agent to terminate a sustained episode of supraventricular tachycardia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected
Actions/Outcomes)
MSC: Integrated Process: Nursing Process (Implementation)
11. A client has a heart rate averaging 56 beats/min with no adverse symptoms. What activity modifications
does the nurse suggest to avoid further slowing of the heart rate?
a. “Make certain that your bath water is warm (100° F).”
b. “Avoid bearing down or straining while having a bowel movement.”
c. “Avoid strenuous exercise, such as running, during the late afternoon.”
d. “Limit your intake of caffeinated drinks to no more than 2 cups per day.”
ANS: B
Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the
vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has
bradycardia. The other instructions are not appropriate for this condition.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Implementation)
12. The nurse is assessing clients at a community clinic. Which client does the nurse assess most carefully for
atrial fibrillation?
a. Middle-aged client who takes an aspirin daily
b. Client who is dismissed after coronary artery bypass surgery
c. Older adult client after a carotid endarterectomy
d. Client with chronic obstructive pulmonary disease
ANS: B
Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary
artery bypass graft (CABG) surgery. The other conditions do not place a client at higher risk for atrial
fibrillation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
13. The nurse is caring for a client on a cardiac monitor. The monitor shows a rapid rhythm with a “saw tooth”
configuration. What physical assessment findings does the nurse expect?
a. Presence of a split S1 and wheezing
b. Anorexia and gastric distress
c. Shortness of breath and anxiety
d. Hypertension and mental status changes
ANS: C
The rhythm described is atrial flutter with a rapid ventricular response. Rapid atrial flutter may manifest with
palpitations, shortness of breath, and anxiety. Syncope, angina, and evidence of heart failure also may be
present.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
14. The nurse is caring for a client with atrial fibrillation. What manifestation most alerts the nurse to the
possibility of a serious complication from this condition?
a. Sinus tachycardia
b. Speech alterations
c. Fatigue
d. Dyspnea with activity
ANS: B
Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in
mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid
ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have
dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications
from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
15. The nurse is caring for a client with chronic atrial fibrillation. Which drug does the nurse expect to
administer to prevent a common complication of this condition?
a. Sotalol (Betapace)
b. Warfarin (Coumadin)
c. Atropine (Atropine)
d. Lidocaine (Xylocaine)
ANS: B
Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with
anticoagulants, such as heparin, enoxaparin, or warfarin. The other drugs