Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
Chapter 08: Concepts of Care for Patients at End of Life
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse cares for a dying client. Which manifestation of dying does the nurse treat first?
a. Anorexia
b. Pain
c. Nausea
d. Hair loss
ANS: B
Only symptoms that cause distress for a dying client would 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 hair loss, disturb the family, they
would be treated only if the client is distressed by their presence. The nurse would treat the
client’s pain first.
DIF: Applying
TOP: Integrated Process: Caring
MSC: Client Needs Category: Psychosocial Integrity
KEY: End-of-life care, Comfort
2. A nurse plans care for a client who is nearing end of life. Which question will the nurse ask
when developing this client’s plan of care?
a. “Is your advance directive up to date and notarized?”
b. “Do you want to be at home at the end of your life?”
c. “Would you like a physical therapist to assist you with range-of-motion
GRADESLAB.COM
activities?”
d. “Have your children discussed resuscitation with your primary health care
provider?”
ANS: B
When developing a plan of care for a dying client, consideration would be given for where the
client wants to die. Different states have different laws regarding legal requirements for
advance directives, but this would not take priority over establishing client preferences. A
physical therapist would not be involved in end-of-life care. The client would discuss
resuscitation with the primary health care provider and children; do-not-resuscitate status
would be the client’s decision, not the family’s decision.
DIF: Applying
TOP: Integrated Process: Caring
KEY: End-of-life care, Advance directives
MSC: Client Needs Category: Psychosocial Integrity
3. A nurse is caring for a client who has lung cancer and is dying. Which prescription does the
nurse question?
a. Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5
b. Albuterol metered dose inhaler every 4 hours PRN for wheezes
c. Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretions
d. Sodium biphosphate enema once a day PRN for impacted stool
ANS: A
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
Pain medications would be scheduled around the clock to maintain comfort and prevent
reoccurrence of pain. The dying client should not have to request medications for serious pain.
The other medications are appropriate for this client.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: End-of-life care, Pharmacologic pain management
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A nurse is caring for a dying client whose adult child confides frequent crying episodes to the
nurse. How does the nurse respond?
a. “It’s normal. Most people move on within a few months.”
b. “Whenever you start to cry, distract yourself with pleasant thoughts of your
parent.”
c. “You should try not to cry. Your parent will be in a better place soon.”
d. “Your feelings are completely normal and may continue for a long time.”
ANS: D
Everyone grieves and mourns differently. The nurse would offer support to the client and
family during this time. By telling the adult child that the feelings are normal and may
continue, the nurse is providing support to whatever the person is feeling. The other
statements all show lack of compassion and respect to the family member’s feelings.
DIF: Applying
TOP: Integrated Process: Caring
MSC: Client Needs Category: Psychological Integrity
KEY: End-of-life care, Caring
5. After teaching a client about advance directives, a nurse assesses the client’s understanding.
Which statement indicates that the client correctly understands the teaching?
RADmy
ESchildren
LAB.Cfrom
OM selling my home when I’m
a. “An advance directive will G
keep
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 to be 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 or financial matters.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: End-of-life care, Advance directives
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
6. A nurse teaches a client who is considering being admitted to hospice. Which statement does
the nurse include in this client’s teaching?
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 not designed to
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
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 interprofessional 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: Applying
TOP: Integrated Process: Teaching/Learning
KEY: End-of-life care, Palliative, hospice care
MSC: Client Needs Category: Psychosocial Integrity
7. A nurse is caring for a dying client. The client’s spouse states, “I think he is choking to
death.” How would the nurse respond?
a. “Do not worry. The choking sound is normal during the dying process.”
b. “I will administer more morphine to keep your spouse 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 spouse onto the side.”
ANS: D
The choking sound or “death rattle” is common in dying clients. The nurse acknowledges the
spouse’s concerns and provides interventions that will reduce the choking sounds.
Repositioning the client onto one side with a towel under the mouth to collect secretions is the
GRAnot
DEminimize
SLAB.Cthe
OMspouse’s concerns. Morphine will assist
best intervention. The nurse would
with comfort but will not decrease the choking sounds. Nasotracheal suctioning is not
appropriate in a dying client and may cause agitation.
DIF: Applying
TOP: Integrated Process: Caring
MSC: Client Needs Category: Psychosocial Integrity
KEY: End-of-life care, Comfort
8. 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
made by the family member indicates understanding of the nurse’s teaching?
a. “Maybe we should just hire an around-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. Hiring an around-the-clock sitter does not
demonstrate that the client’s family understands complementary therapies. Complementary
therapies are used in conjunction with traditional therapy. Complementary therapy would not
replace pain or anxiety medication but may help decrease the need for these medications.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: End-of-life care, Nonpharmacologic comfort measures
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
9. A nurse is caring for a terminally ill client who has just died in a hospital setting with family
members at the bedside. Which action will the nurse take first?
a. Call for emergency assistance so that resuscitation procedures can begin.
b. Ask family members if they would like to spend time alone with the client.
c. Ensure the primary health care provider completed the death certificate.
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 asks 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 would ask family members if they would like to be alone with
the client. The client’s family would not be expected to prepare the body for the funeral home
but they could be asked if they wish to provide some care such as brushing the hair.
DIF: Applying
TOP: Integrated Process: Caring
KEY: End-of-life care, Postmortem care MSC: Client Needs Category: Psychosocial Integrity
10. A nurse assesses a client who is dying. Which sign or symptoms does 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 0-10 scale
ANS: B
GRA
DESL
B.COM during the dying process, periods of
Although all of these assessments
would
beAperformed
apnea and Cheyne-Stokes respirations indicate that death is near. As peripheral circulation
decreases, the client’s level of consciousness and bowel sounds decrease, and the client would
be unable to provide a numeric number on a pain scale. Even with these other symptoms, the
nurse would continue to assess respiratory rate throughout the dying process. As the rate drops
significantly and breathing becomes agonal, death is near.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: End-of-life care
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
11. A nurse is caring for a client who is terminally ill. The client’s spouse states, “I am concerned
because he does not want to eat.” How does the nurse respond?
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
Anorexia often causes distress in family members. 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 and contributes to client discomfort.
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
DIF: Applying
TOP: Integrated Process: Caring
KEY: End-of-life care, Comfort
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
12. A nurse discusses palliative care with a client and the client’s family. A family member
expresses concern that the loved one will receive only custodial care. How will the nurse
respond?
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. It does not specifically relieve the family’s burden of caring for a client at home. It is
not a place where only pain medications are given. The client is involved in this discussion so
the nurse would not state he or she is unaware of surroundings. The goal of palliative care is
to improve the quality of life for the patient and the family.
DIF: Understanding
TOP: Integrated Process: Caring
KEY: End-of-life care, Palliative, hospice care
MSC: Client Needs Category: Psychosocial Integrity
GRwithdrawal
ADESLABof
.Ccare
OMwith a client’s family. The family
13. An intensive care nurse discusses
expresses concerns related to discontinuation of therapy. How will the nurse respond?
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 primary health care 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 validates the family’s concerns and provides 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 their purpose. If the
client’s family asks for specific information about euthanasia, legal, or religious issues, the
nurse would provide unbiased information about these topics.
DIF: Applying
TOP: Integrated Process: Caring
KEY: End-of-life care, Withdrawal of care
MSC: Client Needs Category: Psychosocial Integrity
14. A hospice nurse is caring for a variety of clients who are dying. Which end-of-life and death
ritual is paired with the correct religion?
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
a. Roman Catholic—autopsies are not allowed except under special circumstances.
b. Christian—upon death, a religious leader should perform rituals of bathing and
wrapping the body in cloth.
c. Judaism—a person who is extremely ill and dying should not be left alone.
d. Islam—an ill or a dying person should receive the Sacrament of the Sick.
ANS: C
According to Jewish law, a person who is extremely ill or dying should not be left alone.
Orthodox Jews do not allow autopsies except under special circumstances. The Islamic faith
requires a religious leader to perform rituals of bathing and wrapping the body in cloth upon
death. A Catholic priest usually performs the Sacrament of the Sick for ill or dying people.
DIF: Remembering
TOP: Integrated Process: Caring
KEY: End-of-life care, Religion, spirituality
MSC: Client Needs Category: Psychosocial Integrity
MULTIPLE RESPONSE
1. A hospice nurse is caring for a dying client and family members. Which interventions does
the nurse implement? (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. Allow the client and familyGto
voice
and
RA
DESconcerns
LAB.CO
M fears.
ANS: A, B, D, F
The nurse would 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 the client’s religion
is the same. The nurse shows presence by allowing the client and family members to voice
their fears and concerns openly.
DIF: Applying
TOP: Integrated Process: Caring
MSC: Client Needs Category: Psychosocial Integrity
KEY: End-of-life care
2. A nurse admits an older adult client to the hospital. Which criteria does the nurse use to
determine if the client can make his or her own medical decisions? (Select all that apply.)
a. Can communicate treatment preferences.
b. Is able to read and write at an eighth-grade level.
c. Is oriented enough to understand information provided.
d. Can evaluate and deliberate information.
e. Has completed an advance directive.
f. The family states the client can make decisions.
ANS: A, C, D
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
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. The family may or may not be
correct in stating the client is capable, but the nurse would listen openly to their statements.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: End-of-life care, Advance directives
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A hospice nurse plans care for a client who is experiencing pain. Which complementary
therapies does the nurse incorporate in this client’s pain management plan? (Select all that
apply.)
a. Play music that the client enjoys.
b. Massage tissue that is tender from radiation therapy.
c. Rub lavender lotion on the client’s feet.
d. Ambulate the client in the hall twice a day.
e. Administer intravenous morphine.
f. Involve the client in guided imagery.
ANS: A, C, F
Complementary therapies for pain management include massage therapy, music therapy,
therapeutic touch, guided imagery, and aromatherapy. Nurses would not massage over sites of
tissue damage from radiation therapy.
GRADEAmbulation
SLAB.COand
M intravenous morphine are not
complementary therapies for pain management.
DIF:
TOP:
KEY:
MSC:
Understanding
Integrated Process: Nursing Process: Implementation
End-of-life care, Complementary therapy
Client Needs Category: Physiological Integrity: Basic Care and Comfort
4. A nurse teaches a client’s family members about signs and symptoms of approaching death.
Which of the following does the nurse include in this teaching? (Select all that apply.)
a. Warm and flushed extremities
b. Long periods of insomnia
c. Increased respiratory rate
d. Decreased appetite
e. Congestion and gurgling
f. Incontinence
ANS: D, E, F
Common physical signs and symptoms of approaching death include coolness of extremities,
increased sleeping, irregular and slowed breathing rate, a decrease in fluid and food intake,
congestion and gurgling, incontinence, disorientation, and restlessness.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: End-of-life care
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
Chapter 21: Concepts of Care for Patients With Infection
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse learning about infection discovers that which factor is the best and most important
barrier to infection?
a. Colonization by host bacteria
b. Gastrointestinal secretions
c. Inflammatory processes
d. Skin and mucous membranes
ANS: D
The skin and mucous membranes are two of the most important barriers against infection. The
other options are also barriers, but are considered secondary to skin and mucous membranes.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Infection
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nursing manager is concerned about the number of infections on the hospital unit. What
action by the manager would best help prevent these infections?
a. Auditing staff members’ hand hygiene practices
b. Ensuring clients are placed in appropriate isolation
c. Establishing a policy to remove urinary catheters quickly
d. Teaching staff members about infection control methods
GRADESLAB.COM
ANS: A
All methods will help prevent infection; however, health care workers’ lack of hand hygiene
is the biggest cause of health care–associated infections. The manager can start with a hand
hygiene audit to see if this is a contributing cause.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Infection, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. An assistive personnel asks why brushing client s’ teeth with a toothbrush in the intensive care
unit is important to infection control. What response by the registered nurse is best?
a. “It mechanically removes biofilm on teeth.”
b. “It’s easier to clean all surfaces with a brush.”
c. “Oral care is important to all our clients.”
d. “Toothbrushes last longer than oral swabs.”
ANS: A
Biofilms are a complex group of bacteria that function within a slimy gel on surfaces such as
teeth. Mechanical disruption (i.e., toothbrushing with friction) is the best way to control them.
The other answers are not accurate.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Infection, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
4. A client is admitted with possible sepsis. Which action will the nurse perform first?
a. Administer antibiotics.
b. Give an antipyretic.
c. Place the client in isolation.
d. Obtain specified cultures.
ANS: D
Prior to administering antibiotics, the nurse obtains the prescribed cultures. Broad-spectrum
antibiotics will be administered until the culture and sensitivity results are known.
Antipyretics are given if the client is uncomfortable; fever is a defense mechanism. Giving
antipyretics does not occur before obtaining cultures. The client may or may not need
isolation.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Medication administration
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
5. A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea.
What action by the nurse is most important?
a. Consult with the primary health care provider about obtaining stool cultures.
b. Delegate frequent perianal care to assistive personnel.
c. Place the client on NPO status until the diarrhea resolves.
d. Request a prescription for an antidiarrheal medication.
ANS: A
Hospitalized clients who have three or more stools a day for 2 or more days are suspected of
having infection with Clostridium
GRAdifficile.
DESLAThe
B.nurse
COM will inform the primary health care
provider and request stool cultures. Frequent perianal care is important and can be delegated
but is not the most important action. The client does not necessarily need to be NPO; if the
client is NPO, the nurse ensures he or she is getting appropriate IV fluids to prevent
dehydration. Antidiarrheal medication may or may not be appropriate as the diarrhea serves as
the portal of exit for the infection.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Infection, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A nurse is observing as an assistive personnel (AP) performs hygiene and provides comfort
measures to a client with an infection. What action by the AP requires intervention by the
nurse?
a. Not using gloves while combing the client’s hair
b. Rinsing the client’s commode pan after use
c. Ordering an oscillating fan for the client
d. Wearing gloves when providing perianal care
ANS: C
Fans in client care areas are discouraged because they can disperse airborne or droplet-borne
pathogens. The other actions are appropriate. If the client has a scalp infection or infestation,
the AP will wear gloves; otherwise, it is not required for grooming the hair.
DIF: Analyzing
TOP: Integrated Process: Communication and Documentation
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
KEY: Infection, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
7. A client is to receive a fecal microbiota transplantation tomorrow (FMT). What action by the
nurse is best?
a. Administer bowel cleansing as prescribed.
b. Educate the client on immunosuppressive drugs.
c. Inform the client he/she will drink a thick liquid.
d. Place a nasogastric tube to intermittent suction.
ANS: A
The usual route of delivering an FMT is via colonoscopy, so the client would have a bowel
cleansing as prescribed for that procedure. The client will not need immunosuppressant drugs,
to drink the material, or have an NG tube inserted.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
8. A nurse manager is preparing an educational session for floor nurses on drug-resistant
organisms. Which statement below indicates the need to review this information?
a. “Methicillin-resistant Staphylococcus aureus can be hospital- or
community-acquired.”
b. “Vancomycin-resistant Enterococcus can live on surfaces and be infectious for
weeks.”
c. Carbapenem-resistant Enterobacteriaceae is hard to treat due to enzymes that
break down antibiotics.”
RADscrubs,
ESLAB
COM home and wash them right
d. “If you leave work wearingGyour
go.directly
away.”
ANS: D
To help prevent the transmission of an MDRO, wear scrubs and change clothes before leaving
work. Keep work clothes separate from personal clothes. The nursing manager would need to
correct his or her knowledge if he or she is letting staff know that wearing scrubs home is
alright. The other statements are correct about multi-drug resistant organisms.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
9. The nurse caring for clients admitted for infectious diseases understands what information
about emerging global diseases and bioterrorism?
a. Many infections are or could be spread by international travel.
b. Safer food preparation practices have decreased foodborne illnesses.
c. The majority of Americans have adequate innate immunity to smallpox.
d. Plague produces a mild illness and generally has a low mortality rate.
ANS: A
Increased global travel has resulted in the spread of many emerging diseases and has the
potential to spread diseases caused by bioterrorism. Foodborne illnesses are on the increase.
Many people in the United States have never been vaccinated against smallpox, and those
who have are not guaranteed life-long protection. Plague can be fatal.
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Infection control
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. A client has been placed on Contact Precautions. The client’s family is very afraid to visit for
fear of being “contaminated” by the client. What action by the nurse is best?
a. Explain to them that these precautions are mandated by law.
b. Show the family how to avoid spreading the disease.
c. Reassure the family that they will not get the infection.
d. Tell the family it is important that they visit the client.
ANS: B
Visitors may be apprehensive about visiting a client in Transmission-Based Precautions. The
nurse would reassure the visitors that taking appropriate precautions will minimize their risks.
The nurse would then demonstrate what precautions were needed. The other options do
nothing to ease the family’s fears.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Infection, Transmission-based precautions
MSC: Client Needs Category: Psychosocial Integrity
11. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA)
infection cultured from the urine. What action by the nurse is most appropriate?
a. Prepare to administer vancomycin.
b. Strictly limit visitors to immediate family only.
c. Wash hands only after taking off gloves after care.
GRADurine
ESLoutput.
AB.COM
d. Wear a respirator when handling
ANS: A
Vancomycin is one of a few drugs approved to treat MRSA. The others include linezolid and
ceftaroline fosamil. Delafloxacin is a new antibiotic approved to treat MRSA. Visitation does
not need to be limited to immediate family only. Hand hygiene is performed before and after
wearing gloves. A respirator is not needed, but if splashing is anticipated, a face shield can be
used.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Antibiotics
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
12. A hospitalized client is placed on Contact Precautions. The client needs to have a computed
tomography (CT) scan. What action by the nurse is most appropriate?
a. Ensure that the radiology department is aware of the Isolation Precautions.
b. Plan to travel with the client to ensure appropriate precautions are used.
c. No special precautions are needed when this client leaves the unit.
d. Notify the primary health care provider that the client cannot leave the room.
ANS: A
Clients in isolation will leave their rooms only when necessary, such as for a CT scan that
cannot be done portably in the room. The nurse will ensure that the receiving department is
aware of the Isolation Precautions needed to care for the client. The other options are not
needed.
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Infection, Transmission-based precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
13. A nurse receives report from the laboratory on a client who was admitted for fever. The
laboratory technician states that the client has “a shift to the left” on the white blood cell
count. What action by the nurse is most important?
a. Document findings and continue monitoring.
b. Notify the primary health care provider and request antibiotics.
c. Place the client in protective isolation.
d. Tell the client this signifies inflammation.
ANS: B
A shift to the left indicates an increase in immature neutrophils and is often seen in infections,
especially those caused by bacteria. The nurse will notify the primary health care provider and
request antibiotics (and cultures). Documentation and teaching need to be done, but the nurse
needs to do more. The client does not need protective isolation.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Infection, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. The nurse caring for clients understands that which factors must be present to transmit
infection? (Select all that apply.)
GRADESLAB.COM
a. Colonization
b. Host
c. Mode of transmission
d. Portal of entry
e. Reservoir
f. Poor hygiene
ANS: B, C, D, E
Factors that must be present in order to transmit an infection include a host with a portal of
entry, a mode of transmission, and a reservoir. Colonization is not one of these factors. Poor
hygiene may or may not contribute to infection.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Infection
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. Which statements are true regarding Standard Precautions? (Select all that apply.)
a. Always wear a gown when performing hygiene on clients.
b. Sneeze into your sleeve or into a tissue that you throw away.
c. Remain 3 feet (1 m) away from any client who has an infection.
d. Use personal protective equipment as needed for client care.
e. Wear gloves when touching clients’ excretions or secretions.
f. Cohorting clients who have infections caused by the same organism.
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
ANS: D, E
Standard Precautions implies that contact with bodily secretions, excretions, and moist
mucous membranes and tissues (excluding perspiration) is potentially infectious. Always wear
gloves when coming into contact with such material. Other personal protective equipment is
used based on the care being given. For example, if face splashing is expected, you will also
wear a mask. Wearing a gown for hygiene is not required. Sneezing into your sleeve or tissue
is part of respiratory etiquette. Remaining 3 feet (1 m) away from client is also not part of
Standard Precautions. Cohorting infectious clients can be used for deciding room/bed
placement, but is not part of Standard Precautions.
DIF:
TOP:
KEY:
MSC:
Remembering
Integrated Process: Nursing Process: Implementation
Infection, Standard precautions
Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. The nurse learns that effective antimicrobial therapy requires which factors to be present?
(Select all that apply.)
a. Appropriate drug
b. Proper route of administration
c. Standardized peak levels
d. Sufficient dose
e. Sufficient length of treatment
f. Appropriate trough levels
ANS: A, B, D, E
In order to be effective, antimicrobial therapy must use the appropriate drug in a sufficient
dose, for a sufficient length of time, and given via the appropriate route. Some antimicrobials
RAtrough
DESLlevels,
AB.Cbut
OM not all.
do require monitoring for peakGand
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Infection, Antibiotics
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are
best? (Select all that apply.)
a. Admit the client to a negative-airflow room.
b. Maintain a distance of 3 feet (1 m) from the client at all times.
c. Obtain specialized respirators for caregiving.
d. Other than wearing gloves, no special actions are needed.
e. Wash hands with chlorhexidine after providing care.
f. Assure client has a respirator for moving between departments.
ANS: A, C
A client with suspected TB is admitted to Airborne Precautions, which includes a
negative-airflow room and special N95 or PAPR masks to be worn when providing care. A
3-foot (1 m) distance without a mask is required for Droplet Precautions (a nurse providing
direct care cannot ensure that he or she will never need to be within 3 feet of the client).
Chlorhexidine is used for clients with a high risk of infection. When moving between
departments, the client wears a surgical mask.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
KEY: Infection, Transmission-based precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. A nurse asks the supervisor why older adults are more prone to infection than other adults.
What reasons does the supervisor give? (Select all that apply.)
a. Age-related decrease in immune function
b. Decreased cough and gag reflexes
c. Diminished acidity of gastric secretions
d. Increased lymphocytes and antibodies
e. Thinning skin that is less protective
f. Higher rates of chronic illness
ANS: A, B, C, E, F
Older adults have several age-related changes making them more susceptible to infection,
including decreased immune function, decreased cough and gag reflex, decreased acidity of
gastric secretions, thinning skin, fewer lymphocytes and antibodies, and higher rates of
chronic illness.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Infection, Older adult
MSC: Client Needs Category: Health Promotion and Maintenance
6. A client with an infection has a fever. What actions by the nurse help increase the client’s
comfort? (Select all that apply.)
a. Administer antipyretics around the clock.
b. Change the client’s gown and linens when damp.
c. Offer cool fluids to the client frequently.
GRand
ADgroin.
ESLAB.COM
d. Place ice bags in the armpits
e. Provide a fan to help cool the client.
f. Sponging the client with tepid water.
ANS: B, C, F
Comfort measures appropriate for this client include offering frequent cool drinks, and
changing linens or the gown when damp. Fever is a defense mechanism, and antipyretics will
be administered only when the client is uncomfortable. Ice bags can help cool the client
quickly but are not comfort measures. Fans are discouraged because they can disperse
microbes. Sponging the client’s body with tepid water is also helpful.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Comfort measures
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
7. A nurse plans care for a client who is at risk for infection. Which interventions will the nurse
implement to prevent infection? (Select all that apply.)
a. Administer prophylactic antibiotics.
b. Monitor white blood cell count and differential.
c. Screen all visitors for infections.
d. Implement Transmission-Based Precautions.
e. Promote sufficient nutritional intake.
ANS: B, C, E
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
Nursing interventions for clients at risk for infection include monitoring white blood cell
count and differential, screening visitors for infections and infectious disease, and promoting
sufficient nutritional intake. Standard Precautions are required but not Transmission-Based
Precautions. Prophylactic antibiotics are not generally used to prevent infections.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Infection control
MSC: Client Needs Category: Health Promotion and Maintenance
8. A nurse cares for several clients on an inpatient unit. Which infection control measures will
the nurse implement? (Select all that apply.)
a. Wear a gown when contact of clothing with body fluids is anticipated.
b. Teach clients and visitors respiratory hygiene techniques.
c. Obtain powered air purifying respirators for all staff members.
d. Do not use alcohol-based hand rub between client contacts.
e. Disinfect frequently touched surfaces in client-care areas.
ANS: A, B, E
Infection control measures appropriate to all clients include hand hygiene with alcohol-based
hand rub or soap between client contact, procedures for routine care, cleaning and disinfection
of frequently contaminated surfaces, and wearing personal protective equipment when
contamination is anticipated. Client and visitors would be instructed on appropriate
respiratory hygiene and cough etiquette. No information in the stem indicates the clients need
anything more than Standard Precautions.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Infection control
GRand
ADEffective
ESLABCare
.COEnvironment:
M
MSC: Client Needs Category: Safe
Safety and Infection Control
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
Chapter 24: Assessment of the Respiratory System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse obtains the health history of a client who is recently diagnosed with lung cancer and
identifies that the client has a 60–pack-year smoking history. Which action is most important
for the nurse to take when interviewing this client?
a. Tell the client that he or she needs 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 assessments and cessation information can be an uncomfortable and sensitive topic
among both clients and health care providers. The nurse would maintain a nonjudgmental
attitude in order to foster trust with the client. Telling the client he or she needs to quit
smoking is paternalistic and threatening. Assessing exposure to smoke includes more than
tobacco and marijuana. The nurse would avoid giving the client false hope but when taking a
history, it is most important to get accurate information.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Respiratory assessment
MSC: Client Needs Category: Psychosocial Integrity
GRADESLAB.COM
2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with
the correct intervention?
a. Client reports being dizzy—nurse calls the Rapid Response Team.
b. Client’s heart rate is 55 beats/min—nurse withholds pain medication.
c. Client has reduced breath sounds—nurse calls primary health care provider
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 primary health care provider needs to be notified
immediately. Dizziness without other data would not lead the nurse to call the RRT. 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: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory assessment, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse assesses a client’s respiratory status. Which information is most important for the
nurse to obtain?
a. Average daily fluid intake.
b. Neck circumference.
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
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. This is part of the I-PREPARE assessment model for particulate
matter exposure. Determining the client’s neck circumference will not be an important part of
a respiratory assessment.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A nurse observes that a client’s anteroposterior (AP) chest diameter is the same as the lateral
chest diameter. Which question would the nurse ask the client in response to this finding?
a. “Are you taking any medications or herbal supplements?”
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 an anteroposterior (AP or front-to-back) diameter ratio with the lateral
(side-to-side) diameter. This ratio normally is about 1:1.5. When the AP diameter approaches
the lateral diameter, and the ratio is 1:1, 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,
RAalso
DESbeLA
B.in
COpeople
M
such as chronic emphysema. ItGcan
seen
who have lived at a high altitude for
many years. Medications, herbal supplements, and aerobic exercise are not associated with a
barrel chest. Although occupation and hobbies may expose a client to irritants that can cause
chronic lung disorders and barrel chest, asking about chronic breathing problems is more
direct and would be asked first.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse is assessing a client who is recovering from a lung biopsy. The client’s breath sounds
are absent. While another nurse calls the Rapid Response Team, what action by the nurse
takes is most important?
a. Take a full set of vital signs.
b. Obtain pulse oximetry reading.
c. Ask the patient about hemoptysis.
d. Inspect the biopsy site.
ANS: B
Absent breath sounds may indicate that the client has a pneumothorax, a serious complication
after a needle biopsy or open lung biopsy. The nurse would first obtain a pulse oximetry
reading and perform other respiratory assessments. Temperature is not a priority. The nurse
can ask about other symptoms while conducting the assessment. The nurse would assess the
biopsy site and/or dressings, but this is not the first action.
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention
would the nurse complete prior to the procedure?
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. Validate that informed consent has been given by the client.
ANS: D
A thoracentesis is an invasive procedure with many potentially serious complications. The
nurse would ensure signed informed consent has been obtained. Verifying that the client
understands complications and explaining the procedure to be performed will be done by the
primary health care provider, not the nurse. Measurement of oxygen saturation before and
after a 12-minute walk is not a procedure unique to a thoracentesis.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Respiratory assessment, Diagnostic testing
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate
action?
a. The client rates pain as a 5/10 at the site of the procedure.
b. A small amount of drainage from the site is noted.
ADoxygen.
ESLAB.COM
c. Pulse oximetry is 93% on 2GLRof
d. The trachea is shifted toward the opposite side of the neck.
ANS: D
A shift of central thoracic structures toward one side is a sign of a tension pneumothorax,
which is a medical emergency. The other findings are normal or near normal. The nurse
would report this finding immediately or call the Rapid Response Team.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory assessment, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
8. A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of
water. What action would the nurse take next?
a. Call the primary health care provider and request food and water for the client.
b. Provide the client with ice chips instead of a drink of water.
c. Assess the client’s gag reflex before giving any food or water.
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: Applying
TOP: Integrated Process: Nursing Process: Assessment
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
KEY: Respiratory assessment, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
9. A nurse plans care for a client who is experiencing dyspnea and must stop multiple times
when climbing a flight of stairs. Which intervention would the nurse include in this client’s
plan of care?
a. Assistance with activities of daily living
b. Physical therapy activities every day
c. Oxygen therapy at 2 L per nasal cannula
d. Complete bedrest with frequent repositioning
ANS: A
A client with dyspnea and the inability to complete activities such as climbing a flight of stairs
without pausing has class IV dyspnea. The nurse would provide assistance with activities of
daily living. These clients would be encouraged to participate in activities as tolerated. They
would not be on complete bedrest, may not be able to tolerate daily physical therapy, and only
need oxygen if hypoxia is present.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory assessment, Functional ability
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
10. A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement
would the nurse include in this client’s teaching?
a. “Make a list of reasons why smoking is a bad habit.”
b. “Rise slowly when getting out of bed in the morning.”
c. “Smoking while taking this medication will increase your risk of a stroke.”
GRADESincreases
LAB.Cyour
OM risk for a heart attack.”
d. “Stopping this medication suddenly
ANS: C
Clients who smoke while using drugs for nicotine replacement therapy increase the risk of
stroke and heart attack. Nurses would teach clients not to smoke while taking these drugs. The
nurse would encourage the client to make a list of reasons for stopping the habit but would not
phrase it so judgmentally. Orthostatic hypotension is not a risk with nicotine replacement
therapy. Stopping suddenly does not increase the risk of heart attack.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory assessment, Smoking cessation
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
11. A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy.
The client presents with continuous cyanosis even with oxygen therapy. What action would
the nurse take next?
a. Administer an albuterol treatment.
b. Notify the Rapid Response Team.
c. Assess the client’s peripheral pulses.
d. Obtain blood and sputum cultures.
ANS: B
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
Cyanosis unresponsive to oxygen therapy is a sign of methemoglobinemia, which is an
adverse effect of benzocaine spray. This condition can lead to death. The nurse would notify
the Rapid Response Team to provide advanced care. An albuterol treatment would not address
the client’s oxygenation problem. Assessment of pulses and cultures will not provide data
necessary to treat the client.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory assessment, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
12. A nurse auscultates a harsh hollow sound over a client’s trachea and larynx. What action
would the nurse take first?
a. Document the findings.
b. Administer oxygen therapy.
c. Position the client in high-Fowler position.
d. Administer prescribed albuterol.
ANS: A
Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal
finding over the trachea and larynx. The nurse would document this finding. There is no need
to implement oxygen therapy, administer albuterol, or change the client’s position because the
finding is normal.
DIF: Understanding
TOP: Integrated Process: Communication and Documentation KEY: Respiratory assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
GRADESLAB.COM
1. A nurse assesses a client who is prescribed varenicline for smoking cessation. Which signs or
symptoms would the nurse identify as adverse effects of this medication? (Select all that
apply.)
a. Visual hallucinations
b. Tachycardia
c. Decreased cravings
d. Manic behavior
e. Increased thirst
f. Orangish urine
ANS: A, D
Varenicline has a black box warning stating that the drug can cause manic behavior and
hallucinations. The nurse would assess for changes in behavior and thought processes,
including manic behaviors and visual hallucinations. Tachycardia, increased thirst, and
orange-colored urine are not adverse effects of this medication. Decreased cravings are a
therapeutic response to this medication.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Medication administration, Medication side effects
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
2. While obtaining a client’s health history, the client states, “I am allergic to avocados, molds,
and grass.” Which responses by the nurse are best? (Select all that apply.)
a. “What happens when you are exposed to those things?
b. “How do you treat these allergies?”
c. “When was the last time you ate foods containing avocados?”
d. “I will document this in your record so all so everyone knows.”
e. “Have you ever been in the hospital after an allergic response?”
f. “How do manage to avoid grass and mold?”
ANS: A, B, D, E
Nurses would assess clients who have allergies for the specific cause, treatment, and response
to treatment. The nurse would also document the allergies in a prominent place in the client’s
medical record. Asking about the last time the client ate avocados does not provide any
pertinent information for the client’s plan of care. Asking how a client manages to avoid
environmental allergies in this fashion also does not provide any pertinent information.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Respiratory assessment, Allergies
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs)
for a client. Which statements would the nurse include in communications with the respiratory
therapist prior to the tests? (Select all that apply.)
a. “I held the client’s morning bronchodilator medication.”
b. “The client is ready to go down to radiology for this examination.”
c. “Physical therapy states the client can run on a treadmill.”
d. “I advised the client not to smoke for 6 hours prior to the test.”
GRADESLAB.COM
e. “The client is alert and can follow your commands.”
ANS: A, D, E
To ensure that the PFTs are accurate, the therapist needs to know that no bronchodilators have
been administered in the past 4 to 6 hours (depending on the suspected cause), the client did
not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands,
including different breathing maneuvers. The respiratory therapist can perform PFTs at the
bedside or the respiratory lab. A treadmill is not used for this test.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Respiratory assessment, Diagnostic testing
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A nurse teaches a client who is interested in smoking cessation. Which statements would the
nurse include in this client’s teaching? (Select all that apply.)
a. “Find an activity that you enjoy and will keep your hands busy.”
b. “Keep snacks like potato chips on hand to nibble on.”
c. “Identify a consequence for yourself in case you backslide.”
d. “Drink at least eight glasses of water each day.”
e. “Make a list of reasons you want to stop smoking.”
f. “Set a quit date and stick to it.”
ANS: A, D, E, F
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
The nurse would teach a client who is interested in smoking cessation to find an activity that
keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least eight
glasses of water each day, to make a list of reasons for quitting smoking, and to set a firm quit
date and stick to it. The nurse would also encourage the client not to be upset if he or she
backslides and has a cigarette but to try to determine what conditions caused him or her to
smoke.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Smoking cessation, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
5. A nurse is assessing a client’s history of particular matter exposure. What questions are
consistent with the I PREPARE tool? (Select all that apply.)
a. Investigate all history of known exposures.
b. Determine if breathing problems are worse at work.
c. Ask the client what type of heating is in the home.
d. Gather details about the geographic location of the client’s home.
e. Have client list all previous jobs and work experiences.
f. Assess what hobbies the client and family enjoy.
ANS: A, B, C, D, E, F
All questions are appropriate for the I PREPARE model of particulate matter exposure. The R
and final E stands for resources/referrals and educate.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory assessment, Smoking cessation
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
GRADESLAB.COM
6. A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings
would alert the nurse to a potential pneumothorax? (Select all that apply.)
a. Bradycardia
b. New-onset cough
c. Purulent sputum
d. Tachypnea
e. Pain with respirations
f. Rapid, shallow respirations
ANS: B, D, E
Symptoms of a pneumothorax include tachycardia, tachypnea, new-onset “nagging” cough,
and pain that is worse at the end of inhalation and the end of exhalation on the affected side.
Additional symptoms include trachea slanted to the unaffected side, cyanosis, and the affected
side of the chest that does not move in and out with respirations. Purulent sputum is a
symptom of infection.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy
procedure at 9:00 AM (0900). What actions would the nurse take? (Select all that apply.)
a. Provide a clear liquid breakfast.
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
b.
c.
d.
e.
f.
Verify that the informed consent was obtained.
Document the client’s allergies.
Review laboratory results.
Hold the client’s bronchodilator.
Monitor the client for at least 24 hours afterwards.
ANS: B, C, D, F
Prior to a bronchoscopy, the nurse would verify that the informed consent was obtained, keep
the client NPO for 4 to 8 hours prior to the procedure or per agency policy to prevent
aspiration, document allergies, and review laboratory results including complete blood count
and bleeding times. There is no reason to hold the client’s bronchodilator prior to this
procedure. The nurse will monitor the client at least every 4 hours for 24 hours.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory assessment, Diagnostic testing
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
GRADESLAB.COM
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
Chapter 29: Critical Care of Patients With Respiratory Emergencies
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain,
and has a blood pressure of 88/52 mm Hg. What action by the nurse takes priority?
a. Assess the client’s lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs.
ANS: B
This client has signs and symptoms of a pulmonary embolism, and the most critical action is
to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are
appropriate also but are not the priority.
DIF:
TOP:
KEY:
MSC:
Remembering
Integrated Process: Communication and Documentation
Pulmonary embolism, Critical rescue
Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active
and has no known risk factors for PE. What action by the nurse is most appropriate?
a. Encourage the client to walk 5 minutes each hour.
b. Refer the client to smoking cessation classes.
GRVALeiden
DESLtesting.
AB.COM
c. Teach the client about factor
d. Tell the client that sometimes no cause for disease is found.
ANS: C
Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events,
including PE. A client with no known risk factors for this disorder would be asked about
family history and referred for testing. Encouraging the client to walk is healthy, but is not
related to the development of a PE in this case, nor is smoking. Although there are cases of
disease where no cause is ever found, this assumption is premature.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Pulmonary embolism, Genetic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge
nurse why the client’s oxygen saturation has not significantly improved. What response by the
nurse is best?
a. “Breathing so rapidly interferes with oxygenation.”
b. “Maybe the client has respiratory distress syndrome.”
c. “The blood clot interferes with perfusion in the lungs.”
d. “The client needs immediate intubation and mechanical ventilation.”
ANS: C
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless
the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with
oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating,
and this is also not the most precise physiologic answer. Acute respiratory distress syndrome
can occur, but this is not as likely soon after the client starts on oxygen plus there is no
indication of how much oxygen the client is on. The client may need to be mechanically
ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Pulmonary embolism, Respiratory system
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A client is on intravenous heparin to treat a pulmonary embolism. The client’s most recent
partial thromboplastin time (PTT) was 25 seconds. What order would the nurse anticipate?
a. Decrease the heparin rate.
b. Increase the heparin rate.
c. No change to the heparin rate.
d. Stop heparin; start warfarin.
ANS: B
For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate
that the heparin is working. A normal PTT is 25 to 35 seconds, so this client’s PTT value is
too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.
DIF: Applying
TOP: Integrated Process: Nursing Process: Analysis
KEY: Pulmonary embolism, Anticoagulants, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
GRADESLAB.COM
5. A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic
testing reveals that the client has an alteration in the gene CYP2C19. What action by the nurse
is best?
a. Instruct the client to eliminate all vitamin K from the diet.
b. Prepare preoperative teaching for an inferior vena cava (IVC) filter.
c. Refer the client to a chronic illness support group.
d. Teach the client to use a soft-bristled toothbrush.
ANS: B
Often clients are discharged from the hospital on warfarin after a PE. However, clients with a
variation in the CYP2C19 gene do not metabolize warfarin well and have much higher blood
levels and more side effects. This client is a poor candidate for warfarin therapy, and the
prescriber will most likely order an IVC filter device to be implanted. The other option is to
lower the dose of warfarin. The nurse would prepare to do preoperative teaching on this
procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness
support group may be needed, but this is not the best intervention as it is not as specific to the
client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on
anticoagulation therapy.
DIF: Applying
TOP: Integrated Process: Nursing Process: Analysis
KEY: Pulmonary embolism, Genetic alterations
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
6. A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value
possibly indicates that a serious side effect has occurred?
a. Hemoglobin: 14.2 g/dL (142 g/L)
b. Platelet count: 82,000/L (82  109/L)
c. Red blood cell count: 4.8/mm3 (4.8  1012/L)
d. White blood cell count: 8700/mm3 (8.7  109/L)
ANS: B
This platelet count is low and could indicate heparin-induced thrombocytopenia. The other
values are normal for either gender.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Anticoagulants, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
7. A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
a. Assess for other signs of hypoxia.
b. Change the sensor on the pulse oximeter.
c. Obtain a new oximeter from central supply.
d. Tell the client to take slow, deep breaths.
ANS: A
Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors
can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse
would conduct a more thorough assessment. The other actions are not appropriate for a
hypoxic client.
GRADProcess:
ESLABNursing
.COMProcess: Assessment
DIF: Applying
TOP: Integrated
KEY: Respiratory assessment, Hypoxia
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. A nurse is assisting the primary health care provider (PHCP) who is intubating a client. The
PHCP has been attempting to intubate for 40 seconds. What action by the nurse is best?
a. Ensure that the client has adequate sedation.
b. Find another qualified provider to intubate.
c. Interrupt the procedure to give oxygen.
d. Monitor the client’s oxygen saturation.
ANS: C
Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia.
The nurse would interrupt the intubation attempt and give the client oxygen. The nurse would
also have adequate sedation during the procedure and monitor the client’s oxygen saturation,
but these do not take priority. Finding another qualified provider to intubate the client is not
appropriate at this time.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory system, Intubation
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. An intubated client’s oxygen saturation has dropped to 88%. What action by the nurse takes
priority?
a. Determine if the tube is kinked.
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
b. Ensure that all connections are patent.
c. Listen to the client’s lung sounds.
d. Suction the endotracheal tube.
ANS: C
When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most
common cause), obstruction (often by secretions), pneumothorax, and equipment problems.
The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube
is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic
and perform suction if needed, assess for pneumothorax, and finally check the equipment.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Mechanical ventilation, Respiratory assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
10. A client with acute respiratory failure is on a ventilator and is sedated. What care may the
nurse delegate to the assistive personnel AP)?
a. Assess the client for sedation needs.
b. Get family permission for restraints.
c. Provide frequent oral care per protocol.
d. Use nonverbal pain assessment tools.
ANS: C
The client on mechanical ventilation needs frequent oral care, which can be delegated to the
AP. The other actions fall within the scope of practice of the nurse.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Mechanical ventilation, Oral
GRcare,
ADEDelegation
SLAB.COM
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
11. A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator
settings with the respiratory therapist, what would the nurse ensure?
a. The client is able to initiate spontaneous breaths.
b. The inspired oxygen has adequate humidification.
c. The upper peak airway pressure limit alarm is off.
d. The upper peak airway pressure limit alarm is on.
ANS: D
The upper peak airway pressure limit alarm will sound when the airway pressure reaches a
preset maximum. This is critical to prevent barotrauma to the lungs. Alarms are never be
turned off. Initiating spontaneous breathing is important for some modes of ventilation but not
others. Adequate humidification is important but does not take priority over preventing injury.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Mechanical ventilation, Equipment safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
12. A nurse is caring for a client on mechanical ventilation and finds the client agitated and
thrashing about. What action by the nurse is most appropriate?
a. Assess the cause of the agitation.
b. Reassure the client that he or she is safe.
c. Restrain the client’s hands.
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
d. Sedate the client immediately.
ANS: A
The nurse needs to determine the cause of the agitation. The inability to communicate often
makes clients anxious, even to the point of panic. Pain, confusion, and hypoxia can also cause
agitation. Once the nurse determines the cause of the agitation, he or she can implement
measures to relieve the underlying cause. Reassurance is also important but may not address
the etiology of the agitation. Restraints and more sedation may be necessary but not as a first
step. Ensuring the client is adequately oxygenated is the priority.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Mechanical ventilation, Anxiety
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
13. A nurse is preparing to admit a client on mechanical ventilation for acute respiratory failure
from the emergency department. What action does the nurse take first?
a. Assessing that the ventilator settings are correct
b. Ensuring that there is a bag-valve-mask in the room
c. Obtaining personal protective equipment
d. Planning to suction the client upon arrival to the room
ANS: B
Having a bag-valve-mask device is critical in case the client needs manual breathing. The
respiratory therapist is usually primarily responsible for setting up the ventilator, although the
nurse would know and check the settings. Personal protective equipment is important, but
ensuring client safety is the most important action. The client may or may not need suctioning
on arrival.
GRADESLAB.COM
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Mechanical ventilation, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
14. A client is on mechanical ventilation and the client’s spouse wonders why ranitidine is needed
since the client “only has lung problems.” What response by the nurse is best?
a. “It will increase the motility of the gastrointestinal tract.”
b. “It will keep the gastrointestinal tract functioning normally.”
c. “It will prepare the gastrointestinal tract for enteral feedings.”
d. “It will prevent ulcers from the stress of mechanical ventilation.”
ANS: D
Stress ulcers can occur in many clients who are receiving mechanical ventilation, and often
prophylactic medications are used to prevent them and possible subsequent aspiration.
Frequently used medications include antacids, histamine blockers, and proton pump
inhibitors. Ranitidine is a histamine-blocking agent.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Mechanical ventilation, Histamine blocker
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
15. A client has been brought to the emergency department with a life-threatening chest injury.
What action by the nurse takes priority?
a. Apply oxygen at 100%.
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
b. Assess the respiratory rate.
c. Ensure a patent airway.
d. Start two large-bore IV lines.
ANS: C
The priority for any chest trauma client is airway, breathing, and circulation. The nurse first
ensures that the client has a patent airway. Assessing respiratory rate and applying oxygen are
next, followed by inserting IVs.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Emergency nursing, Primary survey, Trauma
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
16. A client with ARDS is receiving minimal amounts of IV fluids. The new nurse notes the client
is scheduled to receive a diuretic at this time. The nurse consults the Staff Development Nurse
to determine the best course of action. What will the new nurse do?
a. Contact the primary health care provider.
b. Give the ordered diuretic as scheduled.
c. Request an increase in the IV rate.
d. Calculate the client’s 24-hour fluid balance.
ANS: B
Research has shown that clients with ARDS may benefit from conservative fluid therapy
along with diuretics to maintain fluid balance. The nurse will give the ordered diuretic as
scheduled. There is no reason to contact the provider or request an increased IV rate. The
nurse can calculate the 24-hour fluid balance, but this will not influence the administration of
the medication.
GRADESLAB.COM
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: ARDS, Medication
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
17. A nurse is assessing a client who is suspected of having ARDS. The nurse is confused that
although the client appears dyspneic and the oxygen saturation is 88% on 6 L/min of oxygen,
the client’s lungs are clear. What explanation does the more senior nurse provide?
a. “The client is too dehydrated for moist-sounding lungs.”
b. “The client hasn’t started having any bronchospasm yet.”
c. “Lung edema is in the interstitial tissues, not the airways.”
d. “Clients with ARDS usually have clear lung sounds.”
ANS: C
The clear lung sounds are due to the fact that the edema is found in the lung interstitial tissues,
where it can’t be auscultated, instead of in the airways. It is not related to the client being
dehydrated or having bronchospasm. The statement about all clients with ARDS having clear
lung sounds does not provide any information.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: ARDS, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
18. A client in the emergency department has several broken ribs and reports severe pain. What
care measure will best promote comfort?
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
a.
b.
c.
d.
Prepare to assist with intercostal nerve block.
Humidify the supplemental oxygen.
Splint the chest with a large ACE wrap.
Provide warmed blankets and warmed IV fluids.
ANS: A
Uncomplicated rib fractures generally are simple to manage; however, opioids may be needed
for pain. For severe pain, an intercostal nerve block is beneficial. The client needs to be able
to breathe deeply and cough so as not to get atelectasis and/or pneumonia. Humidifying the
oxygen will not help with the pain. Rib fractures are not wrapped or splinted in any way
because this inhibits chest movement. Warmed blankets and warm IV fluids are nice comfort
measures, but do not help with severe pain.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory system, Pharmacological pain management
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
19. A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping
blood pressure. What medication would the nurse being most beneficial?
a. Alteplase
b. Enoxaparin
c. Unfractionated heparin
d. Warfarin sodium
ANS: A
Alteplase is a “clot-busting” agent indicated in large PEs in the setting of hemodynamic
instability. The nurse knows that this drug is the priority, although heparin may be started
GRAare
DEnot
SLindicated
AB.COM
initially. Enoxaparin and warfarin
in this setting.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Analysis
KEY: Pulmonary embolism, Anticoagulants
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
20. A client is brought to the emergency department after sustaining injuries in a severe car crash.
The client’s chest wall does not appear to be moving normally with respirations, oxygen
saturation is 82%, and the client is cyanotic. What action does the nurse take first?
a. Administer oxygen and reassess.
b. Auscultate the client’s lung sounds.
c. Facilitate a portable chest x-ray.
d. Prepare to assist with intubation.
ANS: D
This client has signs and symptoms of flail chest and, with the other signs, needs to be
intubated and mechanically ventilated immediately. The nurse does not have time to
administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken
after the client is intubated.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Trauma, Respiratory system
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
21. A new nurse asks for an explanation of “refractory hypoxemia.” What answer by the staff
development nurse is best?
a. “It is chronic hypoxemia that accompanies restrictive airway disease.”
b. “It is hypoxemia from lung damage due to mechanical ventilation.”
c. “It is hypoxemia that continues even after the client is weaned from oxygen.”
d. “It is hypoxemia that persists even with 100% oxygen administration.”
ANS: D
Refractory hypoxemia is hypoxemia that persists even with the administration of 100%
oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany
restrictive airway disease and is not caused by the use of mechanical ventilation or by being
weaned from oxygen.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory disorders, Pathophysiology
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
22. A nurse is caring for a client on the medical stepdown unit. The following data are related to
this client:
Subjective Information
Shortness of breath for 20
minutes
Reports feeling frightened
“Can’t catch my breath”
Laboratory Analysis
pH: 7.32
PaCO2: 28 mm Hg
PaO2: 78 mm Hg
SaO2: 88%
Physical Assessment
Pulse: 120 beats/min
Respiratory rate: 34
breaths/min
Blood pressure 158/92 mm
Hg
Lungs have crackles
What action by the nurse is most
GRappropriate?
ADESLAB.COM
a. Call respiratory therapy for a breathing treatment.
b. Facilitate a STAT pulmonary angiography.
c. Prepare for immediate endotracheal intubation.
d. Prepare to administer intravenous anticoagulants.
ANS: B
This client has signs and symptoms of pulmonary embolism (PE); however, many conditions
can cause the client’s presentation. The gold standard for diagnosing a PE is pulmonary
angiography. The nurse would facilitate this test as soon as possible. The client does not have
wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need
intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of
PE.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Pulmonary embolism
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. A nurse is caring for five clients. For which clients would the nurse assess a high risk for
developing a pulmonary embolism (PE)? (Select all that apply.)
a. Client who had a reaction to contrast dye yesterday
b. Client with a new spinal cord injury on a rotating bed
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
c.
d.
e.
f.
Middle-age client with an exacerbation of asthma
Older client who is 1 day post-hip replacement surgery
Young obese client with a fractured femur
Middle-age adult with a history of deep vein thrombosis
ANS: B, D, E
Conditions that place clients at higher risk of developing PE include prolonged immobility,
central venous catheters, surgery, obesity, advancing age, conditions that increase blood
clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure,
stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma
pose no risk for PE.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Pulmonary embolism, Risk factors
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. When working with women who are taking hormonal birth control, what health promotion
measures does the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that
apply.)
a. Avoid drinking alcohol.
b. Eat more omega-3 fatty acids.
c. Exercise on a regular basis.
d. Maintain a healthy weight.
e. Stop smoking cigarettes.
ANS: C, D, E
Health promotion measures for clients to prevent thromboembolic events such as PE include
GRADESL
.COM basis, and not smoking. Avoiding
maintaining a healthy weight, exercising
onAaBregular
alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do
not relate to the prevention of PE.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Pulmonary embolism, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
3. A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most
appropriate? (Select all that apply.)
a. Acknowledge the frightening nature of the illness.
b. Delegate a back rub to the assistive personnel (AP).
c. Give simple explanations of what is happening.
d. Request a prescription for antianxiety medication.
e. Stay with the client and speak in a quiet, calm voice.
ANS: A, B, C, E
Clients with PEs are often anxious. The nurse can acknowledge the client’s fears, delegate
comfort measures, give simple explanations the client will understand, and stay with the
client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are
not used routinely because they can contribute to hypoxia. If the client’s anxiety is interfering
with diagnostic testing or treatment, they can be used, but there is no evidence that this is the
case.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
KEY: Pulmonary embolism, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
4. The nurse caring for mechanically ventilated clients uses best practices to prevent
ventilator-associated pneumonia. What actions are included in this practice? (Select all that
apply.)
a. Adherence to proper hand hygiene
b. Administering antiulcer medication
c. Elevating the head of the bed
d. Providing oral care per protocol
e. Suctioning the client on a regular schedule
f. Turning and positioning the client at least every 2 hours
ANS: A, B, C, D, F
The “ventilator bundle” is a group of care measures to prevent ventilator-associated
pneumonia. Actions in the bundle include using proper hand hygiene, giving antiulcer
medications, elevating the head of the bed, providing frequent oral care per policy, preventing
aspiration, turning and positioning, and providing pulmonary hygiene measures. Suctioning is
done as needed.
DIF:
TOP:
KEY:
MSC:
Remembering
Integrated Process: Nursing Process: Implementation
Mechanical ventilation, Infection control
Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. A nurse is caring for a client in acute respiratory failure who is on mechanical ventilation.
What actions will promote comfort in this client? (Select all that apply.)
GRbedside.
ADESLAB.COM
a. Allow visitors at the client’s
b. Ensure that the client can communicate if awake.
c. Keep the television tuned to a favorite channel.
d. Provide back and hand massages when turning.
e. Turn the client every 2 hours or more.
ANS: A, B, D, E
There are many basic care measures that can be employed for the client who is on a ventilator.
Allowing visitation, providing a means of communication, massaging the client’s skin, and
routinely turning and repositioning the client are some of them. Keeping the TV on will
interfere with sleep and rest.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Mechanical ventilation, Comfort measures
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
6. The nurse caring for mechanically ventilated clients knows that older adults are at higher risk
for weaning failure. What age-related changes contribute to this? (Select all that apply.)
a. Chest wall stiffness
b. Decreased muscle strength
c. Inability to cooperate
d. Less lung elasticity
e. Poor vision and hearing
f. Chronic anemia
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
ANS: A, B, D
Age-related changes that increase the difficulty of weaning older adults from mechanical
ventilation include increased stiffness of the chest wall, decreased muscle strength, and less
elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory
acuity. Anemia can make it difficult to wean a client, but this is not a normal age-related
change.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Analysis
KEY: Mechanical ventilation, Older adult
MSC: Client Needs Category: Health Promotion and Maintenance
7. A 100-kg client has developed ARDS and needs mechanical ventilation. Which of the
following are potentially correct ventilator management choices? (Select all that apply.)
a. Tidal volume: 600 mL
b. Volume-controlled ventilation
c. PEEP based on oxygen saturation
d. Suctioning every hour
e. High-frequency oscillatory ventilation
f. Limited turning for ventilator pressures
ANS: A, C, E
The client with ARDS who needs mechanical ventilation benefits from “open lung” and lung
protective strategies, such as using low tidal volumes (6 mL/kg body weight).
Pressure-controlled ventilation is preferred due to the high pressures often required in these
clients. PEEP usually starts at 5 cm H2O and adjusted to keep oxygen saturations in an
acceptable range. Suctioning may need to be frequent due to secretions, but is not scheduled
hourly. High-frequency oscillatory ventilation is an alternative to traditional modes of
GRADESLAB.COM
ventilation. Early mobility is encouraged as is turning and positioning the client.
DIF:
TOP:
KEY:
MSC:
Understanding
Integrated Process: Nursing Process: Implementation
Mechanical ventilation, ARDS
Client Needs Category: Physiological Integrity: Physiological Adaptation
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
Chapter 34: Critical Care of Patients With Shock
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is caring for a client who suffered massive blood loss after trauma. How does the
nurse correlate the blood loss with the client’s mean arterial pressure (MAP)?
a. It causes vasoconstriction and increased MAP.
b. Lower blood volume lowers MAP.
c. There is no direct correlation to MAP.
d. It raises cardiac output and MAP.
ANS: B
Lower blood volume will decrease MAP. The other answers are not accurate.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Mean arterial blood pressure, Shock
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse is caring for a client after surgery. The client’s respiratory rate has increased from 12
to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since the client was last
assessed 4 hours ago. What action by the nurse is best?
a. Ask if the client needs pain medication.
b. Assess using the MEWS score.
c. Document the findings in the client’s chart.
d. Increase the rate of the client’s IV infusion.
GRADESLAB.COM
ANS: B
Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart
rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal
range, the nurse would conduct a thorough assessment of the patient, focusing on indicators of
perfusion. The MEWS score (Modified Early Warning Score) was developed to identify
clients at risk for deterioration. The client may need pain medication, but this is not the
priority at this time. Documentation would be done thoroughly but would be done after the
assessment. The nurse would not increase the rate of the IV infusion without an order.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Shock, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. The nurse gets the hand-off report on four clients. Which client would the nurse assess first?
a. Client with a blood pressure change of 128/74 to 110/88 mm Hg
b. Client with oxygen saturation unchanged at 94%
c. Client with a pulse change of 100 to 88 beats/min
d. Client with urine output of 40 mL/hr for the last 2 hours
ANS: A
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing
pulse pressure, all of which may be indications of worsening perfusion status and possible
shock. The nurse would assess this client first. The client with the unchanged oxygen
saturation is stable at this point. Although the client with a change in pulse has a slower rate, it
is not an indicator of shock since the pulse is still within the normal range; it may indicate that
the client’s pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine
output of 40 mL/hr is above the normal range, which is 30 mL/hr.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Shock, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A nurse is caring for a client after surgery who is restless and apprehensive. The assistive
personnel (AP) reports the vital signs and the nurse sees that they are only slightly different
from previous readings. What action does the nurse delegate next to the AP?
a. Assess the client for pain or discomfort.
b. Measure urine output from the catheter.
c. Reposition the client to the side.
d. Stay with the client and reassure him or her.
ANS: B
Urine output changes are a sensitive early indicator of shock. The nurse would delegate
emptying the urinary catheter and measuring output to the AP as a baseline for hourly urine
output measurements. The AP cannot assess for pain. Repositioning may or may not be
effective for decreasing restlessness, but does not take priority over physical assessments.
Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.
GRADProcess:
ESLABNursing
.COMProcess: Assessment
DIF: Applying
TOP: Integrated
KEY: Shock, Delegation
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of
208 mg/dL (11.6 mmol/L). The spouse asks why the client needs insulin as the client is not a
diabetic. What response by the nurse is best?
a. “High glucose is common in shock and needs to be treated.”
b. “Some of the medications we are giving are to raise blood sugar.”
c. “The IV solution has lots of glucose, which raises blood sugar.”
d. “The stress of this illness has made your spouse a diabetic.”
ANS: A
High glucose readings are common in shock, and best outcomes are the result of treating them
and maintaining glucose readings in the range of 140 to 180 mg/dL (7.7 to 10 mmol/L.
Medications and IV solutions may raise blood glucose levels, but this is not the most accurate
answer. The stress of the illness has not “made” the client diabetic.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Shock, Insulin
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
6. A nurse caring for a client notes the following assessments: white blood cell count 3800/mm 3
(3.8  109/L), blood glucose level 198 mg/dL (11 mmol/L), and temperature 96.2° F (35.6°
C). What action by the nurse takes priority?
a. Document the findings in the client’s chart.
b. Give the client warmed blankets for comfort.
c. Notify the primary health care provider immediately.
d. Prepare to administer insulin per sliding scale.
ANS: C
This client has several indicators of sepsis with systemic inflammatory response. The nurse
would notify the primary health care provider immediately. Documentation needs to be
thorough but does not take priority. The client may appreciate warm blankets, but comfort
measures do not take priority. The client may need insulin if blood glucose is being regulated
tightly.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Shock, Critical rescue
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A nurse works at a community center for older adults. What self-management measure can the
nurse teach the clients to prevent shock?
a. Do not get dehydrated in warm weather.
b. Drink fluids on a regular schedule.
c. Seek attention for any lacerations.
d. Take medications as prescribed.
ANS: B
RADEisSL
AB.CObecause
M
Preventing dehydration in olderGadults
important
the age-related decrease in the
thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a
regular schedule will help keep them hydrated without the influence of thirst (or lack of
thirst). Telling clients not to get dehydrated is important, but not the best answer because it
doesn’t give them the tools to prevent it from occurring. Older adults should seek attention for
lacerations, but this is not as important an issue as staying hydrated. Taking medications as
prescribed may or may not be related to hydration.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Older adult, Fluid and electrolyte imbalance
MSC: Client Needs Category: Health Promotion and Maintenance
8. A client arrives in the emergency department after being in a car crash with fatalities. The
client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes
priority?
a. Apply direct pressure to the bleeding.
b. Ensure the client has a patent airway.
c. Obtain a pulse oximetry reading
d. Start two large-bore IV catheters.
ANS: B
Airway is the priority, followed by breathing (pulse oximetry) and circulation (IVs and direct
pressure).
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Critical rescue, Shock
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. A client is receiving norepinephrine for shock. What assessment finding best indicates a
therapeutic effect from this drug?
a. Alert and oriented, answering questions
b. Client denies chest pain or chest pressure
c. IV site without redness or swelling
d. Urine output of 30 mL/hr for 2 hours
ANS: A
Normal cognitive function is a good indicator that the client is receiving the benefits of
norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion.
Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain is
good but does not indicate therapeutic effect. The IV site is normal. The urine output is
normal, but only minimally so.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Shock, Vasoconstrictors
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
10. A nurse is caring for a client who has a diagnosis of multiple organ dysfunction syndrome
(MODS) who will be receiving sodium nitroprusside via IV infusion. What action by the
nurse causes the charge nurse to intervene?
a. Assessing the IV site before giving the drug
b. Obtaining a programmable (“smart”) IV pump
RAbrown
DESLplastic
AB.Ccover
OM
c. Removing the IV bag fromGthe
d. Taking and recording a baseline set of vital signs
ANS: C
Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the
original brown plastic bag when infusing. The other actions are correct
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Shock, Vasoconstrictors
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
11. A nurse on the general medical-surgical unit is caring for a client in shock and assesses the
following:
Respiratory rate: 10 breaths/min
Pulse: 136 beats/min
Blood pressure: 92/78 mm Hg
Level of consciousness: responds to voice
Temperature: 101.5° F (38.5° C)
Urine output for the last 2 hours: 40 mL/hr.
What action by the nurse is best?
a. Transfer the client to the Intensive Care Unit.
b. Continue monitoring every 30 minutes.
c. Notify the unit charge nurse immediately.
d. Call the Rapid Response Team.
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
ANS: D
This client has a MEWS score of 7 (RR: 0, P: 3, SBP: 1, LOC: 1, Temperature: 1, UO: 1).
Scores above 5 are associated with a high risk of death and ICU admission. The most
important action for the nurse is to notify the Rapid Response Team so that timely
interventions can be initiated. The client most likely will be transferred to the ICU, but an
order is required. Monitoring the client every 30 minutes is appropriate, but the nurse needs to
obtain care for the client. The charge nurse is a valuable resource, but the best action is to
notify the Rapid Response Team.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Sepsis, Critical rescue
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
12. A nurse is caring for several clients at risk for shock. Which laboratory value requires the
nurse to communicate with the primary health care provider?
a. Creatinine: 0.9 mg/dL (68.6 mcmol/L)
b. Lactate: 5.4 mg/dL (6 mmol/L)
c. Sodium: 150 mEq/L (150 mmol/L)
d. White blood cell count: 11,000/mm3 (11  109/L)
ANS: B
A lactate level of 5.4 mg/dL (6 mmol/L) is high and is indicative of possible shock. A
creatinine level of 0.9 mg/dL (68.6 mcmol/L) is normal. A sodium level of 150 mEq/L (150
mmol/L) is slightly high but does not need to be communicated. A white blood cell count of
11,000/mm3 (11  109/L) is slightly high but is not as critical as the lactate level.
DIF: Analyzing
TOP: Integrated Process: Communication and Documentation
KEY: Shock, Laboratory values GRADESLAB.COM
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
13. A nurse receives hand-off report from the emergency department on a new admission
suspected of having septic shock. The client’s qSOFA score is 3. What action by the nurse is
best?
a. Plan to calculate a full SOFA score on arrival.
b. Contact respiratory therapy about ventilator setup.
c. Arrange protective precautions to be implemented.
d. Call the hospital chaplain to support the family.
ANS: A
The qSOFA score is an abbreviated Sequential Organ Failure Assessment (or “quick”). A
score of 3 is high and requires the nurse to assess the client further for organ impairment. The
client may or may not need a ventilator, but that in not specified in the score. The client does
not need protective precautions. The client’s family may well need support, but the nurse
would assess their needs and wishes prior to calling the chaplain.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Shock, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
14. A client is being discharged home after a large myocardial infarction and subsequent coronary
artery bypass grafting surgery. The client’s sternal wound has not yet healed. What statement
by the client most indicates a higher risk of developing sepsis after discharge?
a. “All my friends and neighbors are planning a party for me.”
b. “I hope I can get my water turned back on when I get home.”
c. “I am going to have my daughter scoop the cat litter box.”
d. “My grandkids are so excited to have me coming home!”
ANS: B
All these statements indicate a potential for leading to infection once the client gets back
home. A large party might include individuals who are themselves ill and contagious. Having
litter boxes in the home can expose the client to microbes that can lead to infection. Small
children often have upper respiratory infections and poor hand hygiene that spread germs.
However, the most worrisome statement is the lack of running water for handwashing and
general hygiene and cleaning purposes.
DIF: Analyzing
TOP: Integrated Process: Communication and Documentation
KEY: Shock, Infection control
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
15. A client with MODS has been started on dobutamine. What assessment finding requires the
nurse to communicate with the primary health care provider immediately?
a. Blood pressure of 98/68 mm Hg
b. Pedal pulses 1+/4+ bilaterally
c. Report of chest heaviness
d. Urine output of 32 mL/hr
ANS: C
GRADESLAB.COM
Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of
dobutamine. While taking dobutamine, the oxygen requirements of the heart are increased due
to increased myocardial workload, and may cause ischemia. Without knowing the client’s
previous blood pressure or pedal pulses, there is not enough information to determine if these
are an improvement or not. A urine output of 32 mL/hr is acceptable.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Shock, Vasoconstrictors
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
MULTIPLE RESPONSE
1. The nurse studying shock understands that the common signs and symptoms of this condition
are directly related to which problems? (Select all that apply.)
a. Anaerobic metabolism
b. Hyperglycemia
c. Hypotension
d. Impaired renal perfusion
e. Increased systemic perfusion
ANS: A, C
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
The common signs and symptoms of shock, no matter the cause, are directly related to the
effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function,
and increased perfusion are not the cause of common signs and symptoms of shock.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Shock, Pathophysiology
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. The nurse caring for hospitalized clients includes which actions on their care plans to reduce
the possibility of the clients developing shock? (Select all that apply.)
a. Assessing and identifying clients at risk
b. Monitoring the daily white blood cell count
c. Performing proper hand hygiene
d. Removing invasive lines as soon as possible
e. Using aseptic technique during procedures
f. Limiting the client’s visitors until more stable
ANS: A, C, D, E
Assessing and identifying clients at risk for shock is probably the most critical action the
nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique,
and removing IV lines and catheters are also important actions to prevent shock. Monitoring
laboratory values does not prevent shock but can indicate a change. Limiting the client’s
visitors is not a caring action. The nurse would ensure they perform proper hand hygiene on
entering and leaving the room and that visitors are not ill themselves.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Shock, Infection control
GRand
ADEffective
ESLABCare
.COEnvironment:
M
MSC: Client Needs Category: Safe
Safety and Infection Control
3. The nurse caring frequently for older adults in the hospital is aware of risk factors that place
them at a higher risk for shock. For what factors would the nurse assess? (Select all that
apply.)
a. Altered mobility/immobility
b. Decreased thirst response
c. Diminished immune response
d. Malnutrition
e. Overhydration
f. Use of diuretics
ANS: A, B, C, D, F
Immobility, decreased thirst response, diminished immune response, malnutrition, and use of
diuretics can place the older adult at higher risk of developing shock. Overhydration is not a
common risk factor for shock.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Shock, Older adult
MSC: Client Needs Category: Health Promotion and Maintenance
4. A client is in the early stages of shock and is restless. What comfort measures does the nurse
delegate to the assistive personnel (AP)? (Select all that apply.)
a. Bringing the client warm blankets
GARDESLAB.COM
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
b.
c.
d.
e.
Giving the client hot tea to drink
Massaging the client’s painful legs
Reorienting the client as needed
Sitting with the client for reassurance
ANS: A, B, D, E
The AP can bring the client warm blankets, reorient the client as needed to decrease anxiety,
and sit with the client for reassurance. If the nurse assesses the client is safely able to swallow,
small amounts of fluids would be allowed. Massaging the legs is not recommended as this can
dislodge any clots present, which may lead to pulmonary embolism.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Shock, Nonpharmacologic comfort interventions
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
5. The nurse is caring for a client with suspected septic shock. What does the nurse prepare to do
within 1 hour of the client being identified as possibly having sepsis? (Select all that apply.)
a. Administer antibiotics.
b. Draw serum lactate levels.
c. Infuse vasopressors.
d. Measure central venous pressure.
e. Obtain blood cultures.
f. Administer rapid bolus of IV crystalloids.
ANS: A, B, C, E, F
Within the first hour of suspecting severe sepsis, the nurse would draw (or facilitate) serum
lactate levels, obtain blood cultures (or other cultures), administer antibiotics (after the
GRAD
ESLadministration
AB.COM of 30 mL/kg crystalloid for
cultures have been obtained), begin
rapid
hypotension or lactate 4 mmol/L. and administer vasopressors if hypotensive during or after
fluid resuscitation to maintain a mean arterial pressure 65 mm Hg. Initiating hemodynamic
monitoring would be done after these “bundle” measures have been accomplished.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Shock, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
GARDESLAB.COM