TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 1: Foundations for Medical-Surgical Nursing
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. The medical-surgical nurse identifies a clinical practice issue and wants to determine if there is sufficient
evidence to support a change in practice. Which type of study provides the strongest evidence to support a
practice change?
1) Randomized control study
2) Quasi-experimental study
3) Case-control study
4) Cohort study
____
2. The medical-surgical unit recently implemented a patient-centered care model. Which action implemented by
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the nurse supports this model?
1) Evaluating care
2) Assessing needs
3) Diagnosing problems
4) Providing compassion
____
3. Which action should the nurse implement when providing patient care in order to support The Joint
1)
2)
3)
4)
Silencing a cardiorespiratory monitor
Identifying each patient using one source
Determining patient safety issues upon admission
Decreasing the amount of pain medication administered
____
4. Which interprofessional role does the nurse often assume when providing patient care in an acute care
setting?
1) Social worker
2) Client advocate
3) Care coordinator
4) Massage therapist
____
5. The medical-surgical nurse wants to determine if a policy change is needed for an identified clinical problem.
Which is the first action the nurse should implement?
1) Developing a question
2) Disseminating the findings
3) Conducting a review of the literature
4) Evaluating outcomes of practice change
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
____
6. The nurse is evaluating the level of evidence found during a recent review of the literature. Which evidence
carries the lowest level of support for a practice change?
1) Level IV
2) Level V
3) Level VI
4) Level VII
____
7. The nurse is reviewing evidence from a quasi-experimental research study. Which level of evidence should
the nurse identify for this research study?
1) Level I
2) Level II
3) Level III
4) Level IV
____
8. Which level of evidence should the nurse identify when reviewing evidence from a single descriptive research
study?
1) Level IV
2) Level V
3) Level VI
4) Level VII
____
9.
communication?
1)
2)
3)
4)
abdominal
-
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____ 10. The staff nurse is communicating with the change nurse about the change of status of the patient. The nurse
would begin her communication with which statement if correctly using the SBAR format?
1)
2)
3)
-year4)
____ 11. Which nursing action exemplifies the Quality and Safety Education for Nursing (QSEN) competency of
safety?
1) Advocating for a patient who is experiencing pain
2)
3) Evaluating patient learning style prior to implementing discharge instructions
4) Assessing the right drug prior to administering a prescribed patient medication
____ 12. Which type of nursing is the root of all other nursing practice areas?
1) Pediatric nursing
2) Geriatric nursing
3) Medical-surgical nursing
4) Mental health-psychiatric nursing
____ 13. Which did the Nursing Executive Center of The Advisory Board identify as an academic-practice gap for new
graduate nurses?
1) Patient advocacy
2) Patient education
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3) Disease pathophysiology
4) Therapeutic communication
____ 14. Which statement regarding the use of the nursing process in clinical practice is accurate?
1)
2)
3)
nursing process has 4 basic steps: assessment, planning, implementation,
4)
-
____ 15. Which is the basis of nursing care practices and protocols?
1) Assessment
2) Evaluation
3) Diagnosis
4) Research
____ 16. Which is a common theme regarding patient dissatisfaction related to care provided in the hospital setting?
1) Space in hospital rooms
2) Medications received to treat pain
3) Time spent with the health-care team
4) Poor quality food received from dietary
____ 17. The nurse manager is preparing a medical-surgical unit for The Joint Commission (TJC) visit With the nurse
manager presenting staff education focusing on TJC benchmarks, which of the following topics would be
most appropriate?
1) Implementation of evidence-based practice
2) Implementation of patient-centered
care
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INGKING.COM
3) Implementation of medical asepsis practices
4) Implementation of interprofessional care
____ 18. Which aspect of patient-centered care should the nurse manager evaluate prior to The Joint Commission site
visit for accreditation?
1) Visitation rights
2) Education level of staff
3) Fall prevention protocol
4) Infection control practices
____ 19. The medical-surgical nurse is providing patient care. Which circumstance would necessitate the nurse
1)
2)
3)
4)
Prior to delivering a meal tray
Prior to passive range of motion
Prior to medication administration
Prior to documenting in the medical record
____ 20. The nurse is providing care to several patients on a medical-surgical unit. Which situation would necessitate
the nurse to use SBAR during the hand-off process?
1) Wound care
2) Discharge to home
3) Transfer to radiology
4) Medication education
Multiple Response
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Identify one or more choices that best complete the statement or answer the question.
____ 21. The staff nurse is teaching a group of student nurses the situations that necessitate hand-off communication.
Which student responses indicate the need for further education related to this procedure? Select all that
apply.
1)
-off is required prior
2)
3)
4)
5)
hand____ 22. Which actions by the nurse enhance patient safety during medication administration? Select all that apply.
1) Answering the call bell while transporting medications for a different patient
2) Identifying the patient using two sources prior to administering the medication
3)
4) Administering the medication two hours after the scheduled time
5) Having another nurse verify the prescribed dose of insulin the patient is to receive
____ 23. The medical-surgical nurse assumes care for a patient who is receiving continuous cardiopulmonary
monitoring. Which actions by the nurse enhance safety for this patient? Select all that apply.
1) Silencing the alarm during family visitation
2) Assessing the alarm parameters at the start of the shift
3) Responding to the alarm in a timely fashion
4) Decreasing the alarm volume to enhance restful sleep
5) Adjusting alarm parameters based on specified practitioner prescription
NURSI
NGconference
KING.Cfor
OMa patient who is approaching discharge from
____ 24. The nurse is planning an interprofessional
care
the hospital. Which members of the interprofessional team should the nurse invite to attend? Select all that
apply.
1) Physician
2) Pharmacist
3) Unit secretary
4) Social worker
5) Home care aide
____ 25. The nurse manager wants to designate a member of the nursing team as the care coordinator for a patient who
will require significant care during the hospitalization. Which skills should this nurse possess in order to
assume this role? Select all that apply.
1) Effective clinical reasoning
2) Effective communication skills
3) Effective infection control procedures
4) Effective documentation
5) Effective intravenous skills
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter 1: Foundations for Medical-Surgical Nursing
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 1, Foundations for Medical Surgical Practice
Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical
nursing
Chapter page reference: 003-004
Heading: Evidence-Based Nursing Care
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Evidence-Based Practice
Difficulty: Easy
1
2
3
4
Feedback
Systematic reviews of randomized control studies (Level I) are the highest level of
evidence because they include data from selected studies that randomly assigned
participants to control and experimental groups. The lower the numerical rating of the
level of evidence indicates the highest level of evidence; therefore, this type of study
provides the strongest evidence to support a practice change.
Quasi-experimental studies are considered Level III; therefore, this study does not
NUtoRsupport
SINGKa I
NG.Cchange.
OM
provide the strongest evidence
practice
Case-control studies are considered Level IV; therefore, this study does not provide the
strongest evidence to support a practice change.
Cohort studies are considered Level IV; therefore, this study does not provide the
strongest evidence to support a practice change.
PTS: 1
CON: Evidence-Based Practice
2. ANS: 4
Chapter number and title: 1, Foundations of Medical-Surgical Practice
Chapter learning objective: Explaining the importance of patient-centered care in the management of medicalsurgical patients
Chapter page reference: 004-005
Heading: Patient-Centered Care in the Medical-Surgical Setting
Integrated Processes: Caring
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Nursing Roles
Difficulty: Moderate
1
2
Feedback
Evaluation is a step in the nursing process; however, this is not an action that supports
the patient-centered care model.
Assessment is a step in the nursing process; however, this is not an action that supports
the patient-centered care model.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3
4
Diagnosis is a step in the nursing process; however, this is not an action that supports
the patient-centered care model.
Compassion is a competency closely associated with patient-centered care; therefore,
this action supports the patient-centered model of care.
PTS: 1
CON: Nursing Roles
3. ANS: 3
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Discussing implications to medical-surgical nurses of Quality and Safety
Education for Nurses (QSEN) competencies
Chapter page reference: 005-006
Heading: Patient Safety Outcomes
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Application [Applying]
Concept: Safety
Difficulty: Moderate
1
2
3
4
Feedback
Safely using alarms is a NPSG identified by TJC. Silencing a cardiorespiratory monitor
is not nursing action that supports this NPSG.
Patient identification using two separate resources is a NPSG identified by TJC.
Identifying a patient using only one source does not support this NPSG.
Identification of patient safety risks is a NPSG identified by the TJC. Determining
patient safety issues upon admission supports this NPSG.
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Safe use of medication is a NPSG identified by the TJC. Decreasing the amount of pain
medication administered does not support this NPSG.
PTS: 1
CON: Safety
4. ANS: 3
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Describing the role and competencies of medical-surgical nursing
Chapter page reference: 006-007
Heading: Interprofessional Collaboration and Communication
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Nursing Roles
Difficulty: Easy
1
2
3
4
Feedback
The nurse does not often assume the interprofessional role of social worker when
providing patient care in an acute care setting.
The nurse does not often assume the interprofessional role of client advocate role when
providing patient care in an acute care setting.
The nurse often assumes the interprofessional role of care coordinator when providing
patient care in an acute care setting.
The nurse does not often assume the interprofessional role of massage therapist when
providing patient care in an acute care setting.
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PTS: 1
CON: Nursing Roles
5. ANS: 1
Chapter number and title: 1, Foundations of Medical-Surgical Practice
Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical
nursing
Chapter page reference: 003
Heading: Box 1.3 Steps of Evidence-Based Practice
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Evidence-Based Practice
Difficulty: Difficult
1
2
3
4
Feedback
The first step of evidence-based practice is to develop a question based on the clinical
issue.
The last step of evidence-based practice is to disseminate findings.
The second step of evidence-based practice is to conduct a review of the literature, or
current evidence, available.
The fifth step of evidence-based practice is to evaluate the outcomes associated with the
practice change.
PTS: 1
CON: Evidence-Based Practice
6. ANS: 4
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Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical
nursing
Chapter page reference: 004
Heading: Box 1.4 Evaluating Levels of Evidence
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Evidence-Based Practice
Difficulty: Easy
1
2
3
4
Feedback
The lower the numeric value of the evidence the greater the support for a change in
practice. Level IV evidence does not carry the lowest level of support for a practice
change.
The lower the numeric value of the evidence the greater the support for a change in
practice. Level V evidence does not carry the lowest level of support for a practice
change.
The lower the numeric value of the evidence the greater the support for a change in
practice. Level VI evidence does not carry the lowest level of support for a practice
change.
The lower the numeric value of the evidence the greater the support for a change in
practice. Level VII evidence carries the lowest level of support for a practice change.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1
CON: Evidence-Based Practice
7. ANS: 3
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical
nursing
Chapter page reference: 004
Heading: Box 1.4 Evaluating Levels of Evidence
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Application [Applying]
Concept: Evidence-Based Practice
Difficulty: Moderate
1
2
3
4
Feedback
A systemic review of randomized controlled studies, not a quasi-experimental research
study, is identified as Level I.
Evidence from at least one study randomized control study, not a quasi-experimental
research study, is identified as Level II.
A quasi-experimental research study is identified as a Level III.
Evidence from case-control or cohort studies, not a quasi-experimental research study,
is identified as a Level IV.
PTS: 1
CON: Evidence-Based Practice
8. ANS: 3
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
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Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical
nursing
Chapter page reference: 004
Heading: Box 1.4 Evaluating Levels of Evidence
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Application [Applying]
Concept: Evidence-Based Practice
Difficulty: Moderate
1
2
3
4
Feedback
Evidence from case-control or cohort studies, not a single descriptive research study, is
identified as a Level IV.
Evidence from systemic reviews of descriptive or qualitative studies, not a single
descriptive research study, is identified as Level V.
Evidence from a single descriptive research study is identified as Level VI.
Evidence from expert individual authorities or committees, not a single descriptive
research study, is identified as Level VII.
PTS: 1
CON: Evidence-Based Practice
9. ANS: 1
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Describing the role of interprofessional collaboration and teamwork in the
provision of safe, quality patient care
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Chapter page reference: 005
Heading: Box 1.6 The SBAR Approach for Effective Communication
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1
rrent situation which is communicated by providing a
brief statement of the issue. This statement by the nurse exemplifies the current
situation.
2
3
the current problem.
4
nurse exemplifies the actions implemented to address current level of pain.
PTS: 1
CON: Communication
10. ANS: 4
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Describing the role of interprofessional collaboration and teamwork in the
provision of safe, quality patient care
Chapter page reference: 005
NURfor
SIEffective
NGKINCommunication
G.COM
Heading: Box 1.6 The SBAR Approach
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Communication
Difficulty: Moderate
Feedback
1
by the staff nurse.
2
the staff nurse.
3
the SBAR communication. This is the background
information.
4
information.
PTS: 1
CON: Communication
11. ANS: 4
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Discussing implications to medical-surgical nurses of Quality and Safety
Education for Nurses (QSEN) competencies
Chapter page reference: 006
Heading: Box 1.8 Quality and Safety Education for Nursing (QSEN) Competencies
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Application [Applying]
Concept: Safety
Difficulty: Moderate
1
Feedback
Advocating for a patient who is in pain exemplifies the QSEN competency of patientcentered care, not safety.
2
patient-centered care, not safety.
3
4
exemplifies the QSEN competency of patient-centered care, not safety.
Assessing the right drug prior to administering a prescribed medication exemplifies the
QSEN competency of safety.
PTS: 1
CON: Safety
12. ANS: 3
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Describing the role and competencies of medical-surgical nursing
Chapter page reference: 002
Heading: Introduction
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Knowledge [Remembering]
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Concept: Nursing
Difficulty: Easy
1
2
3
4
Feedback
Pediatric nursing is not the root of all nursing practice areas.
Geriatric nursing is not the root of all nursing practice areas.
Medical-surgical nursing is the root of all nursing practice as care provided here can be
implemented in all other areas of nursing practice.
Mental health-psychiatric nursing is not the root of all nursing practice areas.
PTS: 1
CON: Nursing
13. ANS: 3
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Describing the role and competencies of medical-surgical nursing
Chapter page reference: 002-003
Heading: Competencies in Medical-Surgical Nursing
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity/Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Critical Thinking
Difficulty: Easy
1
Feedback
Patient advocacy is not identified as an academic-practice gap for new graduate nurses.
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2
3
4
Patient education is not identified as an academic-practice gap for new graduate nurses.
Knowledge of pathophysiology of patient conditions is identified as an academicpractice gap for new graduate nurses.
Therapeutic communication is not identified as an academic-practice gap for new
graduate nurses.
PTS: 1
CON: Critical Thinking
14. ANS: 1
Chapter number and title: 1, Foundations of Medical-Surgical
Chapter learning objective: Describing the role and competencies of medical-surgical nursing
Chapter page reference: 003
Heading: Competencies Related to the Nursing Process
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Critical Thinking
Difficulty: Easy
Feedback
1
2
3
4
-making in the clinical
environment. This statement is accurate.
The nursing process is not used by all members of the interprofessional team to plan
care.
The nursing process has 5, not 4, basic steps: assessment, diagnosis, planning,
implementation, and evaluation.
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The nursing process is not being replaced by the implementation of evidence-based
practice.
PTS: 1
CON: Critical Thinking
15. ANS: 4
Chapter number and title: 1, Foundations for Medical-Surgical Nursing Practice
Chapter learning objective: Discussing the incorporation of evidence-based practices into medical-surgical
nursing
Chapter page reference: 003-004
Heading: Evidence-Based Nursing Care
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Knowledge [Remembering]
Concept: Evidence-Based Practice
Difficulty: Easy
1
2
3
Feedback
Assessment is a step in the nursing process; however, this is not the basis for nursing
care practices and protocols.
Evaluation is a step in the nursing process; however, this is not the basis for nursing
care practices and protocols.
Diagnosis is a step in the nursing process; however, this is not the basis for nursing care
practices and protocols.
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4
Evidence that is obtained through research is the basis for nursing care practices and
protocols.
PTS: 1
CON: Evidence-Based Practice
16. ANS: 3
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Explaining the importance of patient-centered care in the management of medicalsurgical patients
Chapter page reference: 004-005
Heading: Patient-Centered Care in the Medical-Surgical Setting
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Knowledge [Remembering]
Concept: Communication
Difficulty: Easy
1
2
3
4
Feedback
Space in each hospital room is not a common theme of patient dissatisfaction.
Medications received for pain management is not a common theme of patient
dissatisfaction.
A lack of time with members of the health care team is a common theme of patient
dissatisfaction.
Poor food quality is not a common theme of patient dissatisfaction.
PTS: 1
CON: Communication
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17. ANS: 2
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Explaining the importance of patient-centered care in the management of medicalsurgical patients
Chapter page reference: 004-005
Heading: Patient-Centered Care in the Medical-Surgical Setting
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Application [Applying]
Concept: Quality Improvement
Difficulty: Moderate
1
2
3
4
Feedback
Implementation of evidence-based practice is not the benchmark in which acute care
facilities are evaluated against.
Implementation of patient-centered care is the benchmark in which acute care facilities
are evaluated against.
Implementation of medical asepsis practices is not the benchmark in which acute care
facilities are evaluated against.
Implementation of interprofessional care is not the benchmark in which acute care
facilities are evaluated against.
PTS: 1
18. ANS: 1
CON: Quality Improvement
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Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Explaining the importance of patient-centered care in the management of medicalsurgical patients
Chapter page reference: 004-005
Heading: Patient-Centered Care in the Medical-Surgical Setting
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Application [Applying]
Concept: Quality Improvement
Difficulty: Moderate
1
2
3
4
Feedback
Visitation rights should be evaluated prior to a TJC accreditation site visit as this aspect
of patient-centered care is incorporated into the site evaluation.
The education level of staff is not evaluated prior to a TJC accreditation visit. This
information should be evaluated for a hospital that is attempting to earn Magnet status.
While the fall prevention program will be reviewed during a TJC accreditation site visit
this is not an aspect of patient-centered care.
While infection control practices will be reviewed during a TJC accreditation site visit
this is not an aspect of patient-centered care.
PTS: 1
CON: Quality Improvement
19. ANS: 3
Chapter number and title: 1, Foundations of Medical-Surgical Practice
Chapter learning objective: Discussing implications to medical-surgical nurses of Quality and Safety
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Education for Nurses (QSEN) competencies
Chapter page reference: 005-006
Heading: Patient Safety Outcomes
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment/Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Safety
Difficulty: Moderate
1
2
3
4
Feedback
While the nurse should take care to deliver the meal tray to the correct patient this
circumstance does not require verification of patient identity through two sources.
While the nurse should take care to implement passive range of motion on the correct
patient this circumstance does not require verification of patient identity through two
sources.
The nurse should identify a patient using two sources prior to medication
administration.
While the nurse should take care to document patient care in the correct medical record
this circumstance does not require verification of patient identity through two sources.
PTS: 1
CON: Safety
20. ANS: 3
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Describing the role of interprofessional collaboration and teamwork in the
provision of safe, quality patient care
Chapter page reference: 005-006
Heading: Patient Safety Outcomes
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Application [Applying]
Concept: Communication, Safety
Difficulty: Moderate
1
2
3
4
Feedback
Effective staff communication is essential to safe patient care, especially during handoffs. Implementation of wound care is not an example of a hand-off situation.
Effective staff communication is essential to safe patient care, especially during handoffs. Discharge to home is not an example of a hand-off situation.
Effective staff communication is essential to safe patient care, especially during handoffs. Patient transfer to another unit of the hospital necessitate a change in who is
responsible for direct patient care; therefore, this situation would necessitate the need
for SBAR during the hand-off process.
Effective staff communication is essential to safe patient care, especially during handoffs. Medication education is not an example of a hand-off situation.
PTS: 1
CON: Communication | Safety
MULTIPLE RESPONSE
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21. ANS: 2, 3, 4
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Describing the role of interprofessional collaboration and teamwork in the
provision of safe, quality patient care
Chapter page reference: 005-006
Heading: Patient Safety Outcomes
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Communication
Difficulty: Difficult
1.
2.
3.
4.
5.
Feedback
This is incorrect. Hand-off communication is not required prior to the administration of
This is correct. Hand-off communication is required when patient care is transferred from one
provider to another, such as during the change of shift.
This is correct. Hand-off communication is required when patient care is transferred from one
provider to another, such as when a patient is transferred to the surgical suite.
This is correct. Hand-off communication is required when patient care is transferred from one
provider to another, such as anytime the nurse receives a new patient assignment.
This is incorrect. Hand-off communication is not required prior to family visitation.
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PTS: 1
CON: Communication
22. ANS: 2, 3, 5
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Discussing implications to medical-surgical nurses of Quality and Safety
Education for Nurses (QSEN) competencies
Chapter page reference: 005-006
Heading: Patient Safety Outcomes
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment/Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Safety
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is incorrect. Interruptions should be minimized during the medication administration
process; therefore, the nurse should not answer the call bell for another patient while
transporting medications for administration.
This is correct. Verification of the right patient is one of the rights of medication
administration; therefore, the nurse would identify the patient using two sources prior to the
administration of medication.
This is correct. The nurse should ensure that the rationale for all medications are associated
with the patient condition; therefore, this action enhances patient safety during medication
administration.
This is incorrect. One of the rights of medication administration is the right time, which
NUbefore
RSIN
KI
NG.Cafter
OM the scheduled time. This nursing action
correlates to 30 minutes
orG30
minutes
would not enhance patient safety during medication administration.
This is correct. Verifying the dose of a high-risk medication, such as insulin, enhances patient
safety during medication administration.
PTS: 1
CON: Safety
23. ANS: 2, 3, 5
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Discussing implications to medical-surgical nurses of Quality and Safety
Education for Nurses (QSEN) competencies
Chapter page reference: 005-006
Heading: Patient Safety Outcomes
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment/Safety and Infection Control
Cognitive level: Analysis [Analyzing]
Concept: Safety
Difficulty: Difficult
1.
2.
Feedback
This is incorrect. Monitor alarms should be audible even during family visitation. Inaudible
alarms may impede patient safety.
This is correct. The nurse should assess the alarm parameters, comparing to the prescribed
settings, at the start of each shift. This action enhanced patient safety.
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3.
4.
5.
This is correct. The nurse should respond to all alarms in a timely fashion, which enhances
patient safety.
This is incorrect. Monitor alarms should be audible at all times, even when the patient is
asleep to enhance patient safety.
This is correct. The nurse should adjust alarm parameters based on specific practitioner
prescriptions. This action enhances safety.
PTS: 1
CON: Safety
24. ANS: 1, 2, 4
Chapter number and title: 1, Foundations of Medical-Surgical Nursing Practice
Chapter learning objective: Describing the role of interprofessional collaboration and teamwork in the
provision of safe, quality patient care
Chapter page reference: 006-007
Heading: Interprofessional Collaboration and Communication
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Application [Applying]
Concept: Collaboration
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. The physician is a member of the interprofessional team and should be invited
to participate in the care conference.
This is correct. The pharmacist is a member of the interprofessional team and should be
invited to participate in the care conference.
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This is incorrect. The unit secretary is not a member of the interprofssional team; therefore,
would not require an invitation to attend the care conference.
This is correct. The social worker is a member of the interprofessional team; therefore, should
be invited to participate in the care conference.
This is incorrect. The home care aide, while a member of the interprofessional team, would
not benefit from attending a care conference while the patient is hospitalized.
PTS: 1
CON: Collaboration
25. ANS: 1, 2, 4
Chapter number and title: 1, Foundation of Medical-Surgical Nursing Practice
Chapter learning objective: Describing the role of interprofessional collaboration and teamwork in the
provision of safe, quality patient care
Chapter page reference: 006-007
Heading: Interprofessional Collaboration and Communication
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Collaboration
Difficulty: Difficult
1.
Feedback
This is correct. Effective clinical reasoning is a skill required for the nurse to assume the role
of care coordinator.
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2.
This is correct. Effective communication is a skill required for the nurse to assume the role of
care coordinator.
This is incorrect. Effective infection control procedures are expected to meet the standard of
care; however, this skill is not required for the nurse to assume the role of care coordinator.
This is correct. Effective documentation, a form of communication, is a skill required for the
nurse to assume the role of care coordinator.
This is incorrect. Effective intravenous skills are not required for the nurse to assume the role
of care coordinator.
3.
4.
5.
PTS: 1
CON: Collaboration
Chapter 2: Interprofessional Collaboration and Care Coordination
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. The home care nurse is planning care for a diabetic patient requiring an extensive dressing change twice a
day, assistance with activities of daily living (ADLs), and comprehensive education. Which role is the nurse
assuming by coordinating the care this patient requires?
1) Collaborator
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2) Case manager
3) Health educator
4) Health promoter
____
2. The nurse is discussing follow-up care with a patient who is being discharged. The patient and family cross
their arms and state angrily that the team's suggestions are not acceptable. Which response by the nurse is
appropriate?
1)
2)
3)
4)
____
3. The nurse is preparing a patient for discharge who will be requiring physical therapy (PT) to rehabilitate after
a total knee replacement. After reading the healthinitial action?
1) Teach the family the exercises needed for the patient.
2) Call home health and schedule a therapist to visit the home for therapy.
3) Set up appointments according to the order with the hospital PT department.
4) Discuss the various types of settings for therapy and have the patient choose the venue.
____
4. The nurse is caring for a patient with rheumatoid arthritis who expresses the desire to remain active as long as
possible. In order for the patient to meet this goal, what should the nurse prepare to do?
1) Tell the patient there is no hope.
2) Ask the patient the reason for the decision.
3) Teach the patient nutrition and joint exercises.
4) Refer the patient to the appropriate professionals.
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____
5. A nurse is working as the designated leader of a group of health-care providers in a community clinic setting.
The team members are working to decrease the number of adolescent pregnancies in the community. They
have defined the problem and are now focusing on objectives and considering various viewpoints presented
by the group. The nurse is tasked with helping the team to stay focused in order to address the defined
problem. Which competency of collaboration does this describe?
1) Trust
2) Mutual respect
3) Communication
4) Decision making
____
6. The nurse managers in a community hospital have been charged with reviewing job descriptions of unlicensed
assistive personnel (UAPs) and have questions about the delegation of certain patient care activities to UAPs
by nurses. To which group, organization, or individual would committee members direct their questions to
obtain definitive answers about the parameters of nurse delegation to UAPs?
1) The state board of nursing
2) The American Nurses Association
3) The hospital's Chief Nursing Officer
4) The hospital's Chief Executive Officer
____
7. Which statement is a primary and historical barrier to effective nurse-physician collaboration that has
persisted over time?
1)
important to their health and well-being compared to the contribution of physicians
2)
subservient role and physicians assuming leadership and superior role in health-care
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settings
3) A general lack of education provided in schools for health professionals about the benefits
on health-care quality linked
4) A lack of published evidence about the effectiveness of collaborative efforts among and
between nurses and physicians to nurse-physician collaboration
____
8. A patient with Type 1 diabetes mellitus has developed an open sore on the shin and is having trouble meeting
daily goals for exercising. The patient is scheduled for discharge in a couple of days. When planning for this
p
1) The pharmacy
2) The case manager
3) The physical therapist
4) The occupational therapist
____
9. A patient who is recovering from coronary bypass surgery is placed on a critical pathway for extended care.
Which patient statement indicates appropriate understanding of the plan of care?
1)
2)
3)
4)
____ 10. The case manager interviews an older adult patient hospitalized after hip replacement surgery. The patient
requires in-patient rehabilitation prior to being discharged home. The case manager works with the hospital
smooth transition. Which is the primary goal of the care management model described here?
1) To provide greater peace of mind for the patient and his or her family members
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2)
3) To manage concerns that are
only
4) To provide a continuum of clinical services in order to help contain costs and improve
patient outcomes
____ 11.
-
the
team, the dynamic has shifted between which two types of teams?
1) Intradisciplinary to interdisciplinary team
2) Multidisciplinary to intradisciplinary team
3) Interprofessional to interdisciplinary team
4) Interdisciplinary to multidisciplinary team
____ 12. A school-age patient is admitted to the pediatric intensive care unit (PICU), unconscious and with multiple
traumatic injuries, after a skateboard accident that included a closed head injury. Many health professionals
are involved in the p
know what is happening. The case manager asks for an interdisciplinary team meeting to speak with the
1) To allow for each specialty to practice independently
2) To share and evaluate information for care planning and implementation, and prevent
priority conflicts, redundancy, and omissions in care
3) To all the primary health-care provider to make all the dec
care
4) To prevent the parents from trying to change the plan of care
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____ 13. The Chief Nursing Officer and Chief Medical Officer in an urban teaching hospital are leading a series of
meetings with nurses, physicians, hospital lawyers, and risk managers to review and update hospital
privileging procedures and requirements for advanced practice RNs and physicians new to the hospital. This
is an example of which type of collaborative team?
1) Intradisciplinary
2) Interdisciplinary
3) Multidisciplinary
4) Complementary
____ 14. A local hospital formed a neurotrauma (NT) team with the following members: acute care nurses, physicians,
other care partners (e.g., physical therapists, social workers, case managers, dieticians), and representatives
from the NT outpatient clinic. This team is led by a physician who makes treatment decisions based on the
treatment plans developed by individual team members who each communicate with the patients, asking the
same or similar questions to obtain data needed for their treatment plan. Which type of communication and
action is represented in the scenario described?
1) Parallel communication
2) Parallel functioning
3) Information exchange
4) Coordination and consultation
____ 15. The nurse is caring for a patient who is reporting pain of 8/10 on a 1 to 10 numeric pain scale. The nurse
administers the prescribed pain medication. When the nurse re-evaluates the patient one hour later, the patient
is still reporting pain of 8/10. Which action by the nurse is appropriate at this time?
1) Wait for the health-care provider to make rounds to report the problem.
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2) Report to the health-care provider by telephone.
3) Increase the dosage of the medication.
4) Include in the nursing report that the medication is ineffective.
____ 16. Handoff communication, the transfer of information during transitions in care such as during change-of-shift
report, includes an opportunity to ask questions, clarify, and confirm the information between sender and
receiver. Which is the main objective for ensuring effective communication during a patient handoff?
1) To avoid lawsuits
2) To ensure patient safety
3) To facilitate quality improvement
4) To make sure all documentation is done
____ 17. The nurse is providing care to a patient diagnosed with end-stage renal disease. When planning a care plan
conference for this patient, who does the nurse invite to participate?
1) The oncologist
2) The psychiatrist
3) The hospital CEO
4) The family members
____ 18. Which should be the focus of an educational session for nurses and other members of the interdisciplinary
team when addressing high rates of patient readmission to the health system?
1) Medication errors
2) Coordination of care
3) Adverse clinical events
4) Roles of each member providing care
____ 19. Which patient population should the
nurse
toGincrease
NU
RSIfocus
NGKonIN
.COM access to care that is coordinated, safe, and
1)
2)
3)
4)
Pediatric patients
Older adult patients
Young adult patients
Acute needs patients
____ 20. Which is a basic principle of the Patient Protection and Affordable Care Act of 2010 that the nurse should
include in a teaching session for members of the health-care team?
1) Decreased access
2) Decreased cost of care
3) Decreased quality of care
4) Decreased safety
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21.
emergency department (ED) to the intensive care unit (ICU), and then onto the medical-surgical unit. After
three weeks of hospitalization, the case manager is helping to prepare the patient for discharge to a
rehabilitation center where treatment will continue. Which outcomes have been documented in the literature
as benefits of such collaboration? Select all that apply.
1) Improved patient outcomes
2) Decreased duplication of health-care services
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3) Increased overall cost of health-care services
4) Decreased patient morbidity and mortality
5) Decreased level of job satisfaction
____ 22. The case manager assembles a team of health-care
provider, physical therapist, and social worker, for the purpose of collaborative discharge planning and
decision making. Which type of team did the case manager assemble? Select all that apply.
1) Management
2) Intradisciplinary
3) Interdisciplinary
4) Interprofessional
5) Primary nursing care
____ 23. The nurse is preparing to document care provided to the patient during the day shift. The nurse documents
that the patient experienced an increased pain level while ambulating which required an extra dose of pain
medication; took a shower; visited with family; and ate a small lunch. Which information is important to
include during the oral end-of-shift reporting? Select all that apply.
1) The last antibiotics given
2)
3)
4) The extra dose of pain medication
5)
____ 24. When the nurse receives a telephone order from the health-care provider's office, which guidelines are used to
ensure the order is correct? Select all that apply.
1) Ask the prescriber to speak slowly.
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2) Read the order back to the prescriber.
3) Know agency policy for telephone orders.
4)
5) Ask the prescriber to repeat or spell out medication.
____ 25. When discussing the importance of interprofessional collaboration, which advantages should the nurse
include? Select all that apply.
1) Improved team member satisfaction
2) Increased division among team members
3) Increased safety with medication administration
4) Enhanced communication among team members
5) Increased patient satisfaction with discharge transition process
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Chapter 2: Interprofessional Collaboration and Care Coordination
Answer Section
MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Exploring the role of the registered nurse in patient-centered transitional care
programs
Chapter page reference: 017
Heading: Case Manager
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Collaboration
Difficulty: Easy
Feedback
1
Collaboration means a collegial working relationship with other health-care providers
to supply patient care. Collaborative practice requires the discussion of diagnoses and
management in the delivery of care.
2
Case management involves one or more individuals overseeing the needs and
requirements of a particular individual's health.
3
Health promotion activities include disease prevention and healthy lifestyle
interventions. Health education would be included in this particular situation, but
NURdefinition
SINGKI
G.CisOoccurring
M
collaboration is a more inclusive
ofNwhat
with these individuals
and the care they require.
4
Health promotion activities include disease prevention and healthy lifestyle
interventions. Health education would be included in this particular situation, but
collaboration is a more inclusive definition of what is occurring with these individuals
and the care they require.
PTS: 1
CON: Collaboration
2. ANS: 4
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Defining interprofessional collaboration in the health-care setting
Chapter page reference: 010-011
Heading: The Care Transitions Program
Integrated Processes: Communication and Documentation
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1
Telling the patient that the doctor only wants what is best sends the message that the
patient does not know what is best, when, in fact, a well-informed patient does know
what is best and should be able to make the correct choice.
2
By leaving the room, the nurse and doctor have turned their backs on the patient.
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3
4
The patient may not understand the recommendations, but pointing that out can be seen
as demeaning.
The patient is the center of the team, and the goal is to facilitate healing. There are
always other options to consider to reach that goal. The nurse would discuss other
options with the patient, which will most likely increase cooperation by the patient,
who will feel in control as the decision is made.
PTS: 1
CON: Communication
3. ANS: 4
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Exploring the role of the registered nurse in patient-centered transitional care
programs
Chapter page reference: 011
Heading: The Care Transitions Program
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Collaboration
Difficulty: Moderate
Feedback
1
The therapy that the patient requires must be performed by a professional physical
therapist. To teach the family exercises encroaches upon the expertise of the
professional who will be performing the service.
2
Scheduling home PT is leaving the patient out of the decision-making process.
3
The nurse would not refer the patient for outpatient therapy unless the patient requests
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that form of therapy.
4
The nurse best exhibits the characteristic that the patient has a right to selfdetermination by presenting the methods available for PT and answering the patient's
questions about each so the patient can make an informed decision.
PTS: 1
CON: Collaboration
4. ANS: 4
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Identifying the roles of health-care professionals coordinating care for patients
Chapter page reference: 015-019
Heading: Providers
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Collaboration
Difficulty: Hard
Feedback
1
The patient with a chronic disease should not be told there is no hope but should be
helped toward reaching desired goals.
2
Asking the patient the reason for the decision is irrelevant to the situation.
3
The nurse can teach some nutrition and exercise but cannot go into the depth that this
patient would need.
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4
The number of patients with chronic diseases with health-care needs is increasing
rapidly, and nurses and primary healthneeds. When a patient expresses the desire to live as normally as possible, the nurse
should refer the patient to professionals who can help the patient meet that goal.
PTS: 1
CON: Collaboration
5. ANS: 4
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Defining interprofessional collaboration in the health-care setting
Chapter page reference: 013-015
Heading: Interprofessional Collaboration
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Collaboration
Difficulty: Easy
Feedback
1
Trust occurs when an individual is confident in the actions of another individual. Both
mutual respect and trust imply mutual process and outcome and may be expressed
verbally or nonverbally.
2
Mutual respect occurs when two or more people show or feel honor or esteem toward
one another.
3
Communication is necessary in effective collaboration; it occurs only if the involved
parties are committed to understanding each other's professional roles and appreciating
each other as individuals.
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4
Decision making involves shared responsibility for the outcome. The team must follow
specific steps of the decision-making process, beginning with a clear definition of the
problem. Team decision making must be directed at the objectives of the effort and
requires full consideration and respect for various and diverse viewpoints, and often
requires guidance and direction from a group leader.
PTS: 1
CON: Collaboration
6. ANS: 1
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Identifying the roles of health-care professionals coordinating care for patients
Chapter page reference: 014-015
Heading: Interprofessional Education
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Legal
Difficulty: Easy
Feedback
1
Parameters for the delegation of patient care tasks by nurses to UAPs are established by
each state's board of nursing.
2
This organization does not provide definitive answers regarding tasks that nurses can
delegate to UAPs.
3
This individual does not provide definitive answers regarding tasks that nurses can
delegate to UAPs.
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4
This individual does not provide definitive answers regarding tasks that nurses can
delegate to UAPs.
PTS: 1
CON: Legal
7. ANS: 2
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Defining interprofessional collaboration in the health-care setting
Chapter page reference: 013-015
Heading: Interprofessional Collaboration
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Collaboration
Difficulty: Easy
Feedback
1
2
3
4
care of patients as less important, thus this is not considered a primary barrier to nursephysician collaboration.
A primary and historical barrier to effective nurse-physician collaboration has been
subservient role and medical providers perceiving their role to be superior in the
provision of health-care services.
Likewise, because health professional students are in fact educated about the benefits of
collaborative practice and published evidence has documented the effectiveness of
collaboration in improving patient outcomes, these are not barriers to collaboration.
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In addition, the federal government, as evidenced in particular by the Healthy People
initiative, has promoted collaborative efforts among patients, nurses, physicians, other
health-care providers, and the larger community to improve the health of the U.S.
population.
PTS: 1
CON: Collaboration
8. ANS: 2
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Identifying the roles of health-care professionals coordinating care for patients
Chapter page reference: 017-018
Heading: Case Manager
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Collaboration
Difficulty: Moderate
Feedback
1
The pharmacy is not needed as part of the team at this time.
2
3
coordinate changes in care needed
needs to be revamped, and the case manager is the individual to coordinate this change.
A physical therapist may be needed, but the nurse would coordinate care best by
notifying the case manager.
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4
The occupational therapist mainly deals with the upper body areas needing
rehabilitation.
PTS: 1
CON: Collaboration
9. ANS: 4
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Exploring unique patient situations requiring or enhanced by interprofessional
collaboration
Chapter page reference: 019-020
Heading: Unique Patient Situations Requiring or Enhanced by Interprofessional Collaboration
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Management
Difficulty: Difficult
Feedback
1
The patient is included in the discussion of meeting goals.
2
The case manager monitors and works with the patient to alter the pathway as needed
during the recovery process.
3
It is possible to have variances in a critical pathway that, if documented properly,
should be paid for by insurance.
4
Care maps, or critical pathways, are flexible enough to be adjusted and tailored to the
patient's needs and wishes.
PTS: 1
CON: Management
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10. ANS: 4
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Describing models of transitional care
Chapter page reference: 010-012
Heading: Evidence-Based Models of Transitional Care
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehensive [Understanding]
Concept: Management
Difficulty: Easy
Feedback
1
Although the involvement of case managers in care typically provides greater peace of
mind for patients and family members, this is not the primary goal of this service.
2
Toward this end, case managers not only with help to coordinate care and treatment
during hospitalization, but also assist with planning for care following discharge.
3
Their focus includes not only medical care, but issues related to health promotion and
disease prevention, the cost of health care received, and planning for the efficient use of
resources.
4
Case managers coordinate patient care to help ensure that a continuum of clinical
services is provided. The goal of case management is to improve patient outcomes and
to help contain costs.
PTS: 1
11. ANS: 4
CON: Management
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Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Describing models of transitional care
Chapter page reference: 010-011
Heading: The Transitional Care Model
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Collaboration
Difficulty: Easy
1
2
3
4
Feedback
Intradisciplinary teams include members of the same profession. Interdisciplinary teams
include professionals of varied backgrounds who share in decision making.
Multidisciplinary teams include members of varied backgrounds, but treatment
decisions are made by one member usually the primary health-care provider.
Intradisciplinary teams include members of the same profession.
The term interprofessional team is synonymous with interdisciplinary team.
Interdisciplinary teams include professionals of varied backgrounds who share in
decision making. Multidisciplinary teams include members of varied backgrounds, but
treatment decisions are made by one member usually the primary health-care provider.
PTS: 1
CON: Collaboration
12. ANS: 2
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Exploring unique patient situations requiring or enhanced by interprofessional
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collaboration
Chapter page reference: 019-020
Heading: Unique Patient Situations Requiring or Enhanced by Interprofessional Collaboration
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Collaboration
Difficulty: Easy
Feedback
1
planning, implementation, and accomplishment of patient goals, with possibly less
redundancy, more efficiency, and fewer care omissions. The parents of a minor child
should be involved in all aspects of care and decision making.
2
planning, implementation, and accomplishment of patient goals, with possibly less
redundancy, more efficiency, and fewer care omissions. The parents of a minor child
should be involved in all aspects of care and decision making.
3
planning, implementation, and accomplishment of patient goals, with possibly less
redundancy, more efficiency, and fewer care omissions. The parents of a minor child
should be involved in all aspects of care and decision making.
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4
Interdisciplinary collaboration engages each profe
planning, implementation, and accomplishment of patient goals, with possibly less
redundancy, more efficiency, and fewer care omissions. The parents of a minor child
should be involved in all aspects of care and decision making.
PTS: 1
CON: Collaboration
13. ANS: 2
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Describing models of transitional care
Chapter page reference: 010-011
Heading: The Transitional Care Model
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Collaboration
Difficulty: Easy
1
2
3
4
Feedback
Intradisciplinary teams comprise members of the same profession working to achieve a
common goal.
A team comprising members from different disciplines that is focused on achieving a
common goal is an interdisciplinary team. Their varying professional backgrounds
helps to ensure that other perspectives are represented as the issue is considered.
Multidisciplinary teams are more commonly teams whose members work more
autonomously toward the common goal.
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Complementary is not a type of team, although t
complementary and provide a broader perspective of issues.
PTS: 1
CON: Collaboration
14. ANS: 1
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Defining interprofessional collaboration in the health-care setting
Chapter page reference: 013-014
Heading: Interprofessional Communication
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Communication
Difficulty: Easy
Feedback
1
The type of communication and action used by this health-care team is parallel
communication. It is at the lowest level along the continuum of communication and
collaboration among health team members and is characterized by each professional
communicating with the patient independently, asking the same or similar questions
needed to develop their plan of care.
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2
3
4
The next level up on the continuum of communication and collaboration, but not
described in this scenario, is parallel functioning. Here, communication is more
coordinated, but each professional still develops separate interventions and care plans.
In parallel functioning, the exchange of information among team members is more
structured and planned, but decision making is unilateral and does not involve much
collegiality.
While there is an information exchange occurring, this is not the best description of the
scenario.
The actions of this NT team do not demonstrate coordination and consultation or comanagement and referral, the two highest levels of communication and collaborative
action.
PTS: 1
CON: Communication
15. ANS: 2
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Defining interprofessional collaboration in the health-care setting
Chapter page reference: 013-014
Heading: Interprofessional Communication
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1
Waiting for the physician to arrive could cause the patient to experience a great deal of
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pain in the interim.
2
In this case reporting to the physician by telephone is appropriate.
3
The nurse cannot alter the dose of medication.
4
The nurse would address the patient's distress immediately and later include the event
in the end-of-shift report to the oncoming nurse.
PTS: 1
CON: Communication
16. ANS: 2
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Defining interprofessional collaboration in the health-care setting
Chapter page reference: 013-014
Heading: Interprofessional Communication
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Comprehension [Understanding]
Concept: Communication; Safety
Difficulty: Easy
Feedback
1
Handoff communication may be scrutinized during a lawsuit, but avoiding litigation is
not a primary objective.
2
Ineffective communication is the primary cause of sentinel events, making patient
safety the primary objective of the handoff communication process.
3
Analysis of handoff communication may be a quality improvement criterion, not a
primary objective.
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4
Handoff communication may be verbal or written.
PTS: 1
CON: Communication | Safety
17. ANS: 4
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Defining interprofessional collaboration in the health-care setting
Chapter page reference: 013-014
Heading: Interprofessional Communication
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Management
Difficulty: Moderate
Feedback
1
The choice of health-care professionals who are invited to attend the conference is
based on the needs of the patient.
2
The choice of health-care professionals who are invited to attend the conference is
based on the needs of the patient.
3
The choice of health-care professionals who are invited to attend the conference is
based on the needs of the patient.
4
The choice of health-care professionals who are invited to attend the conference is
based on the needs of the patient. Family members are an important part of the care
plan conference, especially for patients who are unable to advocate for themselves.
PTS: 1
CON: Management
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18. ANS: 2
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Discussing the importance of successful transitions for medical-surgical patients
Chapter page reference: 009-010
Heading: Overview of Transitional Care
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Management
Difficulty: Easy
Feedback
1
The safety of the patient is at risk during transitions between care settings, particularly
2
3
4
risk for medication errors and adverse clinical events; however, these are not the focus
of an education session regarding readmission rates.
Hospital readmission rates are often attributed to a lack of coordination of care as
patients are discharged to rehabilitation facilities, long-term care agencies, or back to
their homes; therefore, this should be the focus of the educational session.
The safety of the patient is at risk during transitions between care settings, particularly
risk for medication errors and adverse clinical events; however, these are not the focus
of an education session regarding readmission rates.
The role of each member of the interdisciplinary team should not be the focus of an
educational session to decrease hospital readmission rates.
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PTS: 1
CON: Management
19. ANS: 2
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Discussing the importance of successful transitions for medical-surgical patient
Chapter page reference: 009
Heading: Introduction
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Management
Difficulty: Moderate
Feedback
1
The pediatric patient population is not identified as a group where access to
coordinated, safe, and focused care is lacking across care settings.
2
3
4
across all care settings has eluded many patients, particularly the elderly and
chronically ill.
The young adult patient population is not identified as a group where access to
coordinated, safe, and focused care is lacking across care settings.
Patients requiring acute care is not identified as a group where access to coordinated,
safe, and focused care is lacking across care settings.
PTS: 1
CON: Management
20. ANS: 2
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Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Describing changes in the health-care landscape
Chapter page reference: 009-010
Heading: Overview of Transitional Care
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Healthcare System
Difficulty: Moderate
1
2
3
4
Feedback
Increased, not decreased, access is a basic principle of the Patient Protection and
Affordable Care Act of 2010.
Decreased cost of care is a basic principle of the Patient Protection and Affordable Care
Act of 2010.
Increased, not decreased, quality of care is a basic principle of the Patient Protection
and Affordable Care Act of 2010.
Increased, not decreased, safety is a basic principle of the Patient Protection and
Affordable Care Act of 2010.
PTS: 1
CON: Healthcare System
MULTIPLE RESPONSE
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21. ANS: 1, 2, 4
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Describing models of transitional care
Chapter page reference: 009-010
Heading: Overview of Transitional Care
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Management
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is correct. Research findings suggest that collaboration in health care among patients,
family members, caregivers, and communities leads to improved patient outcomes, a reduction
in duplicated health-care services, and a decrease in patient morbidity and mortality.
This is correct. Research findings suggest that collaboration in health care among patients,
family members, caregivers, and communities leads to improved patient outcomes, a reduction
in duplicated health-care services, and a decrease in patient morbidity and mortality.
This is incorrect. Research findings suggest that collaboration in health care among patients,
family members, caregivers, and communities leads to a decreased, not increased, cost of care.
This is in correct. Research findings suggest that collaboration in health care among patients,
family members, caregivers, and communities leads to improved patient outcomes, a reduction
in duplicated health-care services, and a decrease in patient morbidity and mortality.
This is incorrect. Collaborative efforts have also been found to contribute to an enhanced
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satisfaction.
PTS: 1
CON: Management
22. ANS: 3, 4
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Describing models of transitional care
Chapter page reference: 010-011
Heading: The Transitional Care Model
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Collaboration
Difficulty: Easy
1.
2.
3.
Feedback
This is incorrect. Management teams are executive-level teams that run the day-to-day
operations of a corporation.
This is incorrect. Intradisciplinary teams include members of the same profession.
This is correct. Interdisciplinary teams include professionals of varied backgrounds who share
decision making. The terms interprofessional team and interdisciplinary team are
synonymous.
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4.
5.
This is correct. Interdisciplinary teams include professionals of varied backgrounds who share
decision making. The terms interprofessional team and interdisciplinary team are
synonymous.
This is incorrect. A primary nursing care team includes a primary nurse and associate nurses
who will provide care to a patient during a hospital stay.
PTS: 1
CON: Collaboration
23. ANS: 4, 5
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Defining interprofessional collaboration in the health-care setting
Chapter page reference: 013-014
Heading: Interprofessional Communication
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Communication
Difficulty: Difficult
1.
2.
3.
4.
5.
Feedback
This is incorrect. Antibiotics are reflected on the medication administration record (MAR).
This is incorrect. Taking a shower does not need to be reported, only documented.
This is incorrect. Visiting with the family need not be mentioned at change of shift but should
be documented.
This is correct. The nurse would also report any as-needed medications given and when they
were last given.
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PTS: 1
CON: Communication
24. ANS: 1, 2, 3, 5
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Defining interprofessional collaboration in the health-care setting
Chapter page reference: 013-014
Heading: Interprofessional Communication
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Communication
Difficulty: Moderate
1.
2.
3.
Feedback
This is correct. When receiving a telephone order from a provider, the nurse should ask the
prescriber to repeat or spell out the medication, to speak slowly, and read the order back to the
prescriber once the prescription is complete.
This is correct. When receiving a telephone order from a provider, the nurse should ask the
prescriber to repeat or spell out the medication, to speak slowly, and read the order back to the
prescriber once the prescription is complete.
This is c
telephone orders.
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4.
transcribed the prescription and the prescriber countersigns it within a time period prescribed
5.
This is correct. When receiving a telephone order from a provider, the nurse should ask the
prescriber to repeat or spell out the medication, to speak slowly, and read the order back to the
prescriber once the prescription is complete.
PTS: 1
CON: Communication
25. ANS: 1, 4, 5
Chapter number and title: 2, Interprofessional Collaboration and Care Coordination
Chapter learning objective: Exploring unique patient situations requiring or enhanced by interprofessional
collaboration
Chapter page reference: 019-020
Heading: Unique Patient Situations Requiring or Enhanced By Interprofessional Collaboration
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Collaboration
Difficulty: Moderate
Feedback
This is correct. Improved team member satisfaction is an advantage of interprofessional
collaboration.
This is incorrect. There is a decreased, not increased, division among team members with
interprofessional collaboration.
NU
SINGKsafety
INGwith
.COthe
M discharge transition process, not
This is incorrect. There
is R
increased
medication administration, with interprofessional collaboration.
This is correct. Enhanced communication among team members is an advantage of
interprofessional collaboration.
This is correct. Increased patient satisfaction with the discharge transition process is an
advantage of interprofessional collaboration.
1.
2.
3.
4.
5.
PTS: 1
CON: Collaboration
Chapter 3: Cultural Considerations
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. The nurse is providing care to a Muslim patient who presents to the emergency department (ED) with
Which is the most culturally appropriate statement by the nurse in response to this request?
1)
2)
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3)
4)
____
2.
nonverbal cues indicate pain, but the patient denies the need for pain medication. Which action by the nurse is
appropriate?
1) Seeking out a family member to convince the patient to take the medication
2) Consulting the healthknowledge
3) Offering the medication again stating that providing comfort is a priority
4) Allowing the patient to suffer in silence
____
3.
United States six months ago. The mother explains that she believes that an herbal remedy, prepared by the
1)
2)
3)
4)
Ask the mother what the ingredients are in the remedy.
Give the mother an alternate remedy for colic.
Explain how herbal ingredients may be harmful to the infant.
Tell the mother not to use the remedy because there is no way to know what the
____
4. During a sexual history the pa
conclusion about the patient is potentially accurate?
1) Bisexuality
2) Heterosexuality
3) Homosexuality
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4) Transgender
____
5. The nurse is working with a number of patients at a free clinic. Which population is at the highest risk for low
levels of health care?
1) Immigrants
2) Adolescents
3) Older adults
4) Newborns
____
6. Which treatment program should the nurse include in the plan of care for a homeless client whose Type 1
diabetes mellitus (DM) requires daily insulin injections?
1) Home health care
2) Outpatient clinic
3) Partial hospitalization
4) Inpatient hospital-based care
____
7. The novice nurse working in an inner-city hospital that serves
1)
2)
3)
4)
____
8. Which acculturation behavior will the nurse observe in a patient who has emigrated from Mexico to the
United States?
1) The client buys all needed products from the local store owned by people from Mexico.
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2) The client lives in a neighborhood that is populated predominantly with people from
Mexico.
3) The client speaks Spanish only.
4) The client attends a church service in the neighboring community to meet new people.
____
9.
appears uncomfortable with the nurse and moves closer to the patient. Which action by the nurse is most
appropriate?
1)
2)
3) Perform the intervention without discussion with the patient or spouse.
4) Explain the procedure to both the patient and the spouse.
____ 10. The nurse is providing care to an adult patient from another country and notices that the patient consults with
her mother on all health-care decisions. Which action by the nurse is the most appropriate?
1) Ask the patient why the parent is being consulted for every decision.
2) Accept the behavior of the patient and family member.
3) Ask the patient's mother to leave the room to provide the patient with more privacy.
4)
decisions.
____ 11. When preparing an in-service for staff nurses regarding health disparity, which definition should the nurse
include in the presentation?
1) Factors that help explain why some people experience poorer health than others.
2) Describes the health of a person or community along with the many measures that
contribute to this health.
NUthe
RSopportunity
INGKINGto.attain
COMhis or her health potential and
3) Achieved when every person has
no one is disadvantaged.
4) Differences in the incidence, prevalence, mortality rate, and burden of diseases that exist
among specific populations.
____ 12. Which of these should the nurse focus on to decrease health disparities among Hispanic patients?
1) Translation services
2) Nutritional education
3) Pediatric immunizations
4) Hypertension prevention
____ 13. Which traditional Chinese medical treatment includes the insertion of needles into precise points along the
channel system of flow of the qi?
1) Cupping
2) Moxibustion
3) Acupuncture
4) Skin pinching
____ 14. Which traditional Chinese medical treatment involves the use of a heated cup used to treat joint pain?
1) Cupping
2) Moxibustion
3) Acupuncture
4) Skin pinching
____ 15. Which traditional Chinese medical treatment includes the application of heat from different sources to various
points which allows medicine to be absorbed through the skin?
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1)
2)
3)
4)
Cupping
Moxibustion
Acupuncture
Skin pinching
____ 16. Which traditional Vietnamese medical treatment is used to treat a headache or sore throat?
1) Cupping
2) Moxibustion
3) Acupuncture
4) Skin pinching
____ 17. A Vietnamese patient with a history of joint and muscle pain presents with large ecchymosis on the hips and
legs. Which traditional Vietnamese medical treatment should the nurse inquire about when conducing the
assessment?
1) Cao gio
2) Be bao or bar gio
3) Giac
4) Xong
____ 18. Which patient population should the nurse plan care based on individualistic cultural attributes?
1) Canadian
2) Latino
3) Filipino
4) Hindu
____ 19. Which patient population should the nurse plan care based on collectivistic cultural attributes?
1) British
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2) Swedish
3) Norwegian
4) Vietnamese
____ 20. When communicating with a patient who is of Vietnamese descent, which action by the nurse is appropriate?
1) Using the
2) Being straightforward with the patient
3) Maintaining direct eye contact with the patient
4) Sharing intimate life details with the patient
____ 21. Which nursing action is appropriate when conducting a cultural assessment for a patient?
1)
2) Evaluating the concepts in isolation from one another
3)
4) Assuming that the patient believes all aspects of information related to the identified
culture
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 22. Which should the nurse consider when assessing for health disparities within the community? Select all that
apply.
1) Age
2) Gender
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3) Ethnicity
4) Disability
5) Education
____ 23. The nurse is caring for several pediatric patients with numerous cultural backgrounds. Which patients would
the nurse anticipate will be encouraged to express themselves? Select all that apply.
1) An Appalachian adolescent
2) A British school-age child
3) An Arab school-age child
4) An Asian-Indian adolescent
5) A Japanese pre-adolescent
____ 24. The nurse is caring for several pediatric patients with numerous cultural backgrounds. Which patients would
the nurse anticipate will be discouraged to express themselves? Select all that apply.
1) An Appalachian adolescent
2) A British school-age child
3) An Arab school-age child
4) An Asian-Indian adolescent
5) A Japanese pre-adolescent
____ 25. Which health-care practices are anticipated when providing care to a patient of German descent? Select all
that apply.
1) Traditional practices as the first line of defense
2) Self-medicating with over-the-counter drugs
3) Use of liberal pain medication
4) Use of medications ordered from other countries
NURand
SIare
NGhidden
KING.COM
5) Mental health issues hold a stigma
____ 26. Which health-care practices are anticipated when providing care to an Alaskan Native patient? Select all that
apply.
1) Traditional practices as the first line of defense
2) Self-medicating with over-the-counter drugs
3) Use of liberal pain medication
4) Use of medications ordered from other countries
5) Mental health issues hold a stigma and are hidden
____ 27. Which questions should the nurse ask when conducting an assessment to determine if the patient has any
high-risk cultural behaviors? Select all that apply.
1)
2)
3)
4)
5)
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Chapter 3: Cultural Considerations
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
Integrated Processes: Communication and Documentation
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Diversity
Difficulty: Moderate
1
Feedback
The response of covering the client or stating the request is unreasonable shows
2
Although both male and female staff have professional and ethical responsibilities to
3
4
client.
The response of covering the patient or stating the request is unreasonable shows
insensitivity to
URSIthat
NGK
ING.examination
COM
Many cultures have religiousNbeliefs
prohibit
by men of the
reproductive areas of a female. To provide culturally appropriate care, the nurse must
recognize this as a legitimate request and make every attempt to honor this request.
PTS: 1
CON: Diversity
2. ANS: 3
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity - Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort; Diversity
Difficulty: Moderate
Feedback
1
Members of the Chinese culture will typically not complain of pain or physical
problems because they are taught self-restraint and the priority of the group over
individual needs. Due to this belief, seeking out a family member to convince the
patient to take the medication is inappropriate.
2
It is unethical to administer a medication to a patient without his or her consent.
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3
4
Members of the Chinese culture will typically not complain of pain or physical
problems because they are taught self-restraint and the priority of the group over
individual needs. Many people of this culture will consider refusal of something offered
as a gesture of courtesy. The nurse should take these into account and offer the pain
medication to the client.
The nurse should make every effort to offer the patient pain medication but respect his
or her decision.
PTS: 1
CON: Comfort | Diversity
3. ANS: 1
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Discussing elements of cultural assessment
Chapter page reference: 026-028
Heading: Overview of Cultural Domains and Their Concepts
Integrated Processes: Communication and Documentation
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Diversity
Difficulty: Moderate
Feedback
1
To recognize cultural practices, the nurse must acknowledge that use of old and home
remedies is part of caregiving practices. Asking the mother what ingredients are in the
herbal remedy allows the nurse to best evaluate what the mother is using, and then a
determination of the benefit or detriment to the infant can be made in a nonjudgmental
manner.
URremedy,
SINGKgiving
ING.
OM
2
Telling the mother not to useNthe
anCalternative,
or making a judgment
that any herbal ingredient is harmful does not recognize this cultural practice and shows
insensitivity on the part of the nurse.
3
Telling the mother not to use the remedy, giving an alternative, or making a judgment
that any herbal ingredient is harmful does not recognize this cultural practice and shows
insensitivity on the part of the nurse.
4
Telling the mother not to use the remedy, giving an alternative, or making a judgment
that any herbal ingredient is harmful does not recognize this cultural practice and shows
insensitivity on the part of the nurse.
PTS: 1
CON: Diversity
4. ANS: 4
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Discussing elements of cultural assessment
Chapter page reference: 026-028
Heading: Overview of Cultural Domains and Their Concepts
Integrated Processes: Nursing Process Assessment
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Diversity
Difficulty: Easy
Feedback
1
A bisexual individual prefers sexual relationships with both men and women.
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2
3
4
A homosexual individual prefers sexual relationships with individuals of the same
gender.
A heterosexual individual prefer sexual relationships with individuals of the opposite
gender.
A transgender individual is someone who identifies with a different gender than one
assigned.
PTS: 1
CON: Diversity
5. ANS: 1
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Describing how health disparities impact the health and welfare of society
Chapter page reference: 023-025
Heading: Health Disparities and the Need for Cultural Competence
Integrated Processes: Nursing Process Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Diversity
Difficulty: Easy
Feedback
1
greater risk for diseases and reduced life span due to lack of resources and exposure to
more risk factors. People may be made vulnerable by immigration status.
2
3
the greatest risk.
While older adults are often at risk for low
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the greatest risk.
4
the greatest risk.
PTS: 1
CON: Diversity
6. ANS: 2
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Describing how health disparities impact the health and welfare of society
Chapter page reference: 023-025
Heading: Health Disparities and the Need for Cultural Competence
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Health Care System
Difficulty: Moderate
Feedback
1
Because the patient is homeless, home health care would not be the best option in this
situation.
2
The outpatient clinic would provide the care the patient requires in the most costeffective manner.
3
There is no indication for inpatient or partial hospitalization at this time.
4
There is no indication for inpatient or partial hospitalization at this time.
PTS: 1
CON: Health Care System
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7. ANS: 4
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Identifying domains, concepts, and terminology essential to cultural assessment
Chapter page reference: 025-026
Heading: Culture and Essential Terminology
Integrated Processes: Culture and Spirituality
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Diversity
Difficulty: Moderate
Feedback
1
Reading about culture and remaining nonjudgmental are strategies that can be
incorporated after engaging in a self-awareness inventory.
2
Reading about culture and remaining nonjudgmental are strategies that can be
incorporated after engaging in a self-awareness inventory.
3
Although experience working with diverse clients will help, it will be more meaningful
after engaging in a self-awareness inventory.
4
It is a priority for the nurse to develop an awareness of his or her own perceptions,
prejudices, and stereotypes regarding the client populations that are served.
PTS: 1
CON: Diversity
8. ANS: 4
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Identifying domains, concepts, and terminology essential to cultural assessment
Chapter page reference: 025-026
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Heading: Culture and Essential Terminology
Integrated Processes: Nursing Process Assessment
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Diversity
Difficulty: Easy
Feedback
1
This behavior is an example of a patient who may feel comfortable only in the Mexican
culture.
2
This behavior is an example of a patient who may feel comfortable only in the Mexican
culture.
3
This behavior is an example of a patient who may feel comfortable only in the Mexican
culture.
4
Individuals experience acculturation when they begin to adapt or borrow habits of the
new culture. The client who attends church in the neighboring community to meet new
people is displaying acculturation.
PTS: 1
CON: Diversity
9. ANS: 4
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Describing the importance of culturally competent skills
Chapter page reference: 026-028
Heading: Overview of Cultural Domains and Their Concepts
Integrated Processes: Nursing Process Implementation
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Client Need: Safe and Effective Care Environment
Cognitive level: Application [Applying]
Concept: Diversity
Difficulty: Moderate
Feedback
Management of Care
1
2
3
4
this procedure to be done with privacy.
Performing an intervention without first discussing it and asking for permission may be
interpreted as assault.
The nurse should explain the procedure to both the patient and the spouse prior to
touching the patient.
PTS: 1
CON: Diversity
10. ANS: 2
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Describing the importance of culturally competent skills
Chapter page reference: 026-028
Heading: Overview of Cultural Domains and Their Concepts
Integrated Processes: Nursing Process - Implementation
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Diversity
Difficulty: Moderate
Feedback
1
2
3
4
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The nurse should accept this behavior as a cultural norm.
This action is inappropriate and do not consider the
PTS: 1
CON: Diversity
11. ANS: 4
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Describing how health disparities impact the health and welfare of society
Chapter page reference: 023-025
Heading: Health Disparities and the Need for Cultural Competence
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Diversity
Difficulty: Moderate
Feedback
1
Determinants of health is defined as factors that help explain why some people
experience poorer health than others.
2
Health status is described the health of a person or community along with the many
measures that contribute to this health.
3
Health equity is achieved when every person has the opportunity to attain his or her
health potential and no one is disadvantaged.
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4
Health disparity is defined as the differences in the incidence, prevalence, mortality
rate, and burden of disease that exist among specific populations.
PTS: 1
CON: Diversity
12. ANS: 1
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Describing how health disparities impact the health and welfare of society
Chapter page reference: 023-025
Heading: Health Disparities and the Need for Cultural Competence
Integrated Processes: Nursing Process Planning
Client Need: Psychosocial Integrity
Cognitive level: Analysis [Analyzing]
Concept: Diversity
Difficulty: Difficult
1
2
3
4
Feedback
Health-care providers and policymakers need to target vulnerable subgroups of
Hispanic seniors and identify areas of linguistic isolation to minimize these disparities;
therefore, the nurse should focus on translation services to decrease noted health
disparities for Hispanic patients.
Nutritional education, pediatric immunizations, and hypertension prevention may all be
population.
Nutritional education, pediatric immunizations, and hypertension prevention may all be
appropriate;
NURSINGKING.COM
population.
Nutritional education, pediatric immunizations, and hypertension prevention may all be
arities for this
population.
PTS: 1
CON: Diversity
13. ANS: 3
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
Integrated Processes: Culture and Spirituality
Client Need: Psychosocial Integrity
Cognitive level: Knowledge [Remembering]
Concept: Diversity
Difficulty: Easy
Feedback
1
Cupping is a traditional Chinese medical treatment where a heated cup or glass jar is
put on the skin creating a vacuum, which causes the skin to be drawn into the cup. The
heat that is generated is used to treat joint pain.
2
Moxibustion is the application of heat from different sources to various points. The
localized erythema occurs with the heat from the burning substance and the medicine is
absorbed through the skin.
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3
4
Acupuncture includes the insertion of needles into precise points along the channel
system of flow of the qi.
Skin pinching is traditional Vietnamese, not Chinese, medicine.
PTS: 1
CON: Diversity
14. ANS: 1
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
Integrated Processes: Culture and Spirituality
Client Need: Psychosocial Integrity
Cognitive level: Knowledge [Remembering]
Concept: Diversity
Difficulty: Easy
Feedback
1
Cupping is a traditional Chinese medical treatment where a heated cup or glass jar is
put on the skin creating a vacuum, which causes the skin to be drawn into the cup. The
heat that is generated is used to treat joint pain.
2
Moxibustion is the application of heat from different sources to various points. The
localized erythema occurs with the heat from the burning substance and the medicine is
absorbed through the skin.
3
Acupuncture includes the insertion of needles into precise points along the channel
system of flow of the qi.
4
Skin pinching is traditional Vietnamese, not Chinese, medicine.
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PTS: 1
CON: Diversity
15. ANS: 2
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
Integrated Processes: Culture and Spirituality
Client Need: Psychosocial Integrity
Cognitive level: Knowledge [Remembering]
Concept: Diversity
Difficulty: Easy
Feedback
1
Cupping is a traditional Chinese medical treatment where a heated cup or glass jar is
put on the skin creating a vacuum, which causes the skin to be drawn into the cup. The
heat that is generated is used to treat joint pain.
2
Moxibustion is the application of heat from different sources to various points. The
localized erythema occurs with the heat from the burning substance and the medicine is
absorbed through the skin.
3
Acupuncture includes the insertion of needles into precise points along the channel
system of flow of the qi.
4
Skin pinching is traditional Vietnamese, not Chinese, medicine.
PTS: 1
CON: Diversity
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16. ANS: 4
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
Integrated Processes: Culture and Spirituality
Client Need: Psychosocial Integrity
Cognitive level: Knowledge [Remembering]
Concept: Diversity
Difficulty: Easy
Feedback
1
Cupping is a traditional Chinese, not Vietnamese, medical treatment where a heated cup
or glass jar is put on the skin creating a vacuum, which causes the skin to be drawn into
the cup. The heat that is generated is used to treat joint pain.
2
Moxibustion is the application of heat from different sources to various points. The
localized erythema occurs with the heat from the burning substance and the medicine is
absorbed through the skin. This is a traditional Chinese, not Vietnamese, medical
practice.
3
Acupuncture includes the insertion of needles into precise points along the channel
system of flow of the qi. This is a traditional Chinese, not Vietnamese, medical
practice.
4
Skin pinching is traditional Vietnamese medical practice used to treat headache or sore
throat.
PTS: 1
CON: Diversity
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17. ANS: 3
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
Integrated Processes: Nursing Process Assessment
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Diversity
Difficulty: Easy
Feedback
1
Cao gio
sinusitis, and similar ailments.
2
Be bao or bar gio (skin pinching) is a treatment for headache or sore throat.
3
Giac (cup suctioning), another dermabrasive procedure, is used to relieve stress,
headaches, and joint and muscle pain.
4
Xong (an herbal preparation) relieves motion sickness or cold-related problems.
PTS: 1
CON: Diversity
18. ANS: 1
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
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Integrated Processes: Nursing Process Planning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Diversity
Difficulty: Moderate
Feedback
1
Patients of Canadian descent are likely to have individualistic cultural attributes.
2
Patients of Latino descent are likely to have collectivistic, not individualistic, cultural
attributes.
3
Patients of Filipino descent are likely to have collectivistic, not individualistic, cultural
attributes.
4
Patients of Hindu descent are likely to have collectivistic, not individualistic, cultural
attributes.
PTS: 1
CON: Diversity
19. ANS: 4
Chapter number and title: 3, Cultural Attributes
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
Integrated Processes: Nursing Process Planning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Diversity
Difficulty: Moderate
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Feedback
1
Patients of British descent are likely to have individualistic, not collectivistic, cultural
attributes.
2
Patients of Swedish descent are likely to have individualistic, not collectivistic, cultural
attributes.
3
Patients of Norwegian descent are likely to have individualistic, not collectivistic,
cultural attributes.
4
Patients of Vietnamese descent are likely to have collectivistic cultural attributes.
PTS: 1
CON: Diversity
20. ANS: 1
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
Integrated Processes: Communication and Documentation
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Communication; Diversity
Difficulty: Moderate
Feedback
1
Individuals of Vietnamese descent tend to have collectivistic cultural attributes;
of gaining trust.
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2
3
4
This is an individualistic, not collectivistic, cultural attribute related to communication.
This is an individualistic, not collectivistic, cultural attribute related to communication.
This is an individualistic, not collectivistic, cultural attribute related to communication.
PTS: 1
CON: Communication | Diversity
21. ANS: 3
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Discussing elements of cultural assessment
Chapter page reference: 026-028
Heading: Overview of Cultural Domains and Their Concepts
Integrated Processes: Nursing Process Assessment
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Diversity; Assessment
Difficulty: Moderate
Feedback
1
2
3
4
stereotyping based on culture should be avoided.
Concepts monitored during a cultural assessment should not be evaluated in isolation.
Concepts should be assessed together because they affect one another.
Assumptions should not be made regarding patient care based on the identified culture.
PTS: 1
CON: Diversity | Assessment
MULTIPLE RESPONSE
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22. ANS: 1, 2, 3, 4
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Describing how health disparities impact the health and welfare of society
Chapter page reference: 023-025
Heading: Health Disparities and the Need for Cultural Competence
Integrated Processes: Nursing Process Assessment
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Diversity
Difficulty: Moderate
1.
2.
3.
Feedback
This is correct. Health disparities can affect population groups based on gender, age, ethnicity,
socioeconomic status, geography, sexual orientation, disability, or special needs health-care
needs.
This is correct. Health disparities can affect population groups based on gender, age, ethnicity,
socioeconomic status, geography, sexual orientation, disability, or special needs health-care
needs.
This is correct. Health disparities can affect population groups based on gender, age, ethnicity,
socioeconomic status, geography, sexual orientation, disability, or special needs health-care
needs.
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4.
5.
This is correct. Health disparities can affect population groups based on gender, age, ethnicity,
socioeconomic status, geography, sexual orientation, disability, or special needs health-care
needs.
This is incorrect. Education is not a specific consideration when assessing the RN to assess for
health disparities within the community.
PTS: 1
CON: Diversity
23. ANS: 1, 2
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
Integrated Processes: Communication and Documentation
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Communication; Diversity
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is correct. The Appalachian culture is considered individualistic; therefore, the nurse
would anticipate that this patient will be encourage to express him- or herself.
This is correct. The British culture is considered individualistic; therefore, the nurse would
anticipate that this patient will be encourage to express him- or herself.
This is incorrect. The Arab culture is considered collectivistic; therefore, the nurse would not
anticipate this patient to be encourage to express him- or herself.
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This is incorrect. The Asian-Indian culture is considered collectivistic; therefore, the nurse
would not anticipate this patient to be encourage to express him- or herself.
This is incorrect. The Japanese culture is considered collectivistic; therefore, the nurse would
not anticipate this patient to be encourage to express him- or herself.
PTS: 1
CON: Communication | Diversity
24. ANS: 3, 4, 5
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
Integrated Processes: Communication and Documentation
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Communication; Diversity
Difficulty: Easy
1.
2.
3.
Feedback
This is incorrect. The Appalachian culture is considered individualistic; therefore, the nurse
would anticipate that this patient will be encouraged to express him- or herself.
This is incorrect. The British culture is considered individualistic; therefore, the nurse would
anticipate that this patient will be encouraged to express him- or herself.
This is correct. The Arab culture is considered collectivistic; therefore, the nurse would
anticipate this patient to be discouraged from expressing him- or herself.
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4.
This is correct. The Asian-Indian culture is considered collectivistic; therefore, the nurse
would anticipate this patient to be discouraged from expressing him- or herself.
This is correct. The Japanese culture is considered collectivistic; therefore, the nurse would
anticipate this patient to be discouraged from expressing him- or herself.
5.
PTS: 1
CON: Communication | Diversity
25. ANS: 1, 2, 3
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
Integrated Processes: Nursing Process Planning
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Diversity
Difficulty: Easy
Feedback
This is correct. A patient of German descent is likely to have individualistic cultural attributes;
therefore, this practice is anticipated.
This is correct. A patient of German descent is likely to have individualistic cultural attributes;
therefore, this practice is anticipated.
This is correct. A patient of German descent is likely to have individualistic cultural attributes;
therefore, this practice is anticipated.
This is incorrect. This would be anticipated for a patient with collectivistic cultural attributes.
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This is incorrect. This would be anticipated for a patient with collectivistic cultural attributes.
1.
2.
3.
4.
5.
PTS: 1
CON: Diversity
26. ANS: 4, 5
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Distinguishing the cultural attributes of collectivistic and individualistic cultures
Chapter page reference: 030-034
Heading: Individualism versus Collectivism
Integrated Processes: Nursing Process Planning
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Diversity
Difficulty: Easy
Feedback
This is incorrect. This would be anticipated for a patient with individualistic cultural attributes.
This is incorrect. This would be anticipated for a patient with individualistic cultural attributes.
This is incorrect. This would be anticipated for a patient with individualistic cultural attributes.
This is correct. An Alaskan Native patient is likely to have collectivistic cultural attributes;
therefore, this practice should be anticipated by the nurse.
This is correct. An Alaskan Native patient is likely to have collectivistic cultural attributes;
therefore, this practice should be anticipated by the nurse.
1.
2.
3.
4.
5.
PTS: 1
CON: Diversity
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27. ANS: 1, 2
Chapter number and title: 3, Cultural Considerations
Chapter learning objective: Identifying domains, concepts, and terminology essential to cultural assessment
Chapter page reference: 026-028
Heading: Overview of Cultural Domains and Their Concepts
Integrated Processes: Nursing Process Assessment
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Diversity; Assessment
Difficulty: Moderate
Feedback
This is correct. Use of tobacco is considered a high-risk behavior that is monitored during the
cultural assessment process.
This is correct. Use of alcoholic beverages may be a high-risk behavior; therefore, this
question is appropriate to include in the domain of the cultural assessment which monitors
high-risk behaviors.
This is incorrect. This question assesses family roles and organization, not high-risk
behaviors.
This is incorrect. This question assesses health-care practices, not high-risk behaviors.
This is incorrect. This question assesses nutrition, not high-risk behaviors.
1.
2.
3.
4.
5.
PTS: 1
CON: Diversity | Assessment
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Chapter 4: Ethical Concepts
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. The nurse is providing care to a client who is considered brain dead. The family has opted to end care and the
health-care provider asks the nurse to pull the endotracheal (ET) tube. The nurse is uncomfortable with this
request. Which is the reason the nurse is experiencing difficulty with this task?
1) An ethical conflict
2) Personal values
3) Legal issues
4) A cultural conflict
____
2. The nurse is providing care to an older adult patient with terminal cancer who has opted to discontinue
present while the patient tells the family. Which ethical patient principle is the nurse supporting?
1) Beneficence
2) Autonomy
3) Nonmaleficence
4) Justice
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____
3. Which statement best describes the American Nurses Association (ANA) Code of Ethics for professional
nurses?
1)
2)
3)
4)
____
4. Which statement regarding the American Nurses Association (ANA) Code of Ethics for professional nurses is
accurate?
1)
2)
3)
4)
for nurses."
____
5. Which professional value is the nurse demonstrating by volunteering time to work in a local free clinic?
1) Human dignity
2) Integrity
3) Altruism
4) Social justice
____
6. Which action is appropriate when dealing with an ethical dilemma in practice?
1) Relying on nursing judgment
2) Examining all conflicts in the situation
3) Investigating all aspects of the situation
4) Making a decision based on the policy of the agency
____
7. The hospice nurse is providing careNto
aS
terminal
UR
INGKpatient
ING.who
COMhas asked about guidance and support in ending
life. Which should the nurse recognize in regards to making an ethical and moral decision in this
circumstance?
1) Euthanasia has legal implications along with moral and ethical ones.
2) Passive euthanasia is an easy decision to arrive at.
3) Active euthanasia is supported in the Code for Nurses.
4) Assisted suicide is illegal in all states.
____
8. The nurse is providing care to a 3-year-old child whose parents decide to decline further treatment for cancer,
should the nurse consider when determining the appropriate action for this patient?
1) The age of the child
2) The beliefs of the child
3) The values of the parents
4) The values of the rest of the family
____
9.
action should the nurse take, when considering the Health
Insurance Portability and Accountability Act (HIPAA) of 1996?
1)
2)
3) Communicate only necessary information.
4) Not disclosing any information to anyone.
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____ 10. The nurse is providing care to an older adult patient who has decided to discontinue the prescribed
of
principles-based reasoning, which statement from the nurse is appropriate?
1)
2)
3)
4)
health is so deteriorated that the treatment is not saving the patient's life. It
____ 11. The nurse is providing care to an older adult patient who is scheduled for surgery. During the preoperative
assessment, the nurse discovers that the patient does not have an adequate understanding of the procedure.
Which is the reason for the nurse to take action in this situation?
1) The patient is very old and has multiple health problems.
2) The family needs to agree to the surgery.
3) The nurse witnessed the consent.
4) The patient has a right to informed consent.
____ 12.
noncompliant with his recommenda
1) Have the patient contact a consumer agency.
2) Advise the patient to sue the health-care provider.
3)
4) Notify the health-care
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____ 13. A patient diagnosed with acquired immune deficiency syndrome (AIDS) is admitted to the acute care floor.
Which stance regarding the care for this patient is supported by the American Nurses Association (ANA)
Code of Ethics?
1) The nurse is morally obligated to care for the patient unless the risk exceeds responsibility.
2) The nurse has the responsibility to ensure the patient gets adequate medical care.
3) The patient has the right to choose not to disclose his or her condition to staff.
4) The patient is morally bound to disclose every aspect of his or her condition to staff.
____ 14.
parents, however, want the health-care team to continue all treatments. Which action by the nurse is
appropriate when providing care to this patient and family?
1) Helping the family by providing information and allowing them to voice their concerns
2) Confronting
3) Calling the authorities immediately
4) Obtaining a court order to determine the patient is legally able to make his or her own
decisions
____ 15. A patient tells the nur
the nurse is appropriate in order to advocate for this patient?
1) Call the agency patient advocacy department.
2) Confront the nurse when she comes to work.
3) Tell the patient he or she has the right to switch nurses.
4) Call the local authorities.
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____ 16.
propriate?
1)
2)
3)
4)
____ 17. Which is the priority nursing action for the ethical decision-making process?
1) Determine exactly what needs to be decided.
2) Formulate alternatives to solve the issue.
3) Implement an action to achieve the greatest benefit with the least amount of risk.
4) Ascertain if new information is available regarding the issue.
____ 18. Which number of alternative solutions should be included when conducting ethical decision-making?
1) One
2) Two
3) Three
4) Four
____ 19. Which ethical principle is the nurse assessing when asking who benefits from the actions of others?
1) Beneficence
2) Autonomy
3) Justice
4) Fidelity
____ 20. Which ethical principle requires theNnurse
toNbeGaccountable
URSI
KING.COfor
M commitments made to self or others?
1) Beneficence
2) Autonomy
3) Justice
4) Fidelity
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. Which should the nurse be aware of when preparing to act as a patient advocate in the hospital setting? Select
all that apply.
1) The rights of a patient in a long-term care facility
2) The health department's patient rights statement
3) The hospital's patient rights statement
4) State and federal patient rights legislation
5) The unit policy manual
____ 22. According to Provision 2 of the American Nurses Association (ANA) Code of Ethics, which member of the
healthSelect all that apply.
1) Patient
2) Family
3) Physician
4) Community
5) Surgeon
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____ 23. Which are ethical issues for the nurse to consider prior to deciding whether or not to honor the picket line
during a strike situation? Select all that apply.
1) The need to support coworkers in their efforts to improve working conditions
2) The need to ensure that clients receive care and are not abandoned
3) The desire to take some time off
4)
5) The need for higher pay
____ 24. The nurse is providing care to a pregnant patient with a history of drug use. The patient refuses testing for
human immunodeficiency virus (HIV) despite the recommendation of her nurse-midwife. Which actions by
the nurse are appropriate in this situation? Select all that apply.
1) Refusing to treat the patient unless she is tested
2)
3) Emphasizing the importance of the test to the patient
4) Offering counseling regarding the testing
5) Encouraging the patient to reconsider the decision to be tested throughout the pregnancy
____ 25. A hospice nurse is providing care to a patient diagnosed with ovarian cancer. The patient is concerned that her
two daughters are at an increased risk for cancer and asks the nurse for help. Which actions by the nurse are
appropriate? Select all that apply.
1) Provide the family with information on hereditary cancer risks.
2) Assure the client that ovarian cancer is not hereditary.
3) Offer to refer the daughters to a genetic counselor.
4) Arrange for the client to have genetic testing.
5) Tell the client that her additional worrying is too stressful.
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Chapter 4: Ethical Concepts
Answer Section
MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Addressing ethical dilemmas associated with the care of the acutely ill adult
Chapter page reference: 042
Heading: Experimental Therapies
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Ethics
Difficulty: Easy
Feedback
1
The decision is within ethical principles.
2
The nurse is distressed because of personal values, which are in conflict with causing
the client's death.
3
Extubating this patient would not be a legal decision.
4
Cultural values are not evidenced in this instance.
PTS: 1
CON: Ethics
2. ANS: 2
URSINGKING.COM
Chapter number and title: 4, EthicalNConcepts
Chapter learning objective: Defining ethical principles
Chapter page reference: 037-039
Heading: Ethical Theories Relevant to Nursing
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Ethics
Difficulty: Easy
Feedback
1
2
principle by supporting the client in his decision.
3
4
Justice is often referred to as fairness.
PTS: 1
CON: Ethics
3. ANS: 2
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Identifying professional standards that guide ethical nursing practice
Chapter page reference: 035-037
Heading: Professional Standards for Ethical Practice
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment Management of Care
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Cognitive level: Comprehension [Understanding]
Concept: Ethics
Difficulty: Easy
Feedback
1
Codes of ethics provide the atmosphere in which the nurse is able to alleviate suffering.
2
3
4
set of ethical principles that serves as a standard for professional actions.
Codes of ethics do not necessarily reflect legal judgments.
Codes of ethics usually have higher requirements than legal standards, and they are
never lower than the legal standards of the profession.
PTS: 1
CON: Ethics
4. ANS: 2
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Identifying professional standards that guide ethical nursing practice
Chapter page reference: 035-037
Heading: Professional Standards for Ethical Practice
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Ethics
Difficulty: Easy
Feedback
1
Each profession has its own code of ethics.
2
The ANA Code of Ethics is N
aU
guide
nurses
RSIfor
NG
KINin
G.their
COwork
M with clients and other
professionals.
3
State laws regarding nursing are the basis of lawsuits, not the Code of Ethics.
4
There is also an International Code of Ethics promulgated by the International Council
of Nurses.
PTS: 1
CON: Ethics
5. ANS: 4
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Defining ethical principles
Chapter page reference: 035-037
Heading: Professional Standards for Ethical Practice
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Ethics
Difficulty: Easy
Feedback
1
Human dignity is respect for the worth and uniqueness of individuals and populations.
2
Integrity is acting in accordance with an appropriate code of ethics and accepted
standards of practice.
3
Altruism is concern for the welfare and well-being of others.
4
Social justice is upholding fairness on a social scale. This value is demonstrated in
professional practice when the nurse works to ensure equal treatment under the law and
equal access to quality health care.
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PTS: 1
CON: Ethics
6. ANS: 3
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse
Chapter page reference: 039-043
Heading: Ethical Dilemmas
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Ethics
Difficulty: Moderate
Feedback
1
Overconfidence can lead to poor decision making.
2
Examining the conflicts surrounding the issue is only one aspect of the situation to
consider.
3
To avoid making a premature decision, the nurse plans to investigate all aspects of the
dilemma before deciding.
4
Reading the agency policy regarding the matter addresses only one aspect of the
situation.
PTS: 1
CON: Ethics
7. ANS: 1
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Addressing
with the care of the acutely ill adult
NURethical
SINGdilemmas
KING.associated
COM
Chapter page reference: 039-043
Heading: Ethical Dilemmas
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Ethics; Legal
Difficulty: Easy
Feedback
1
Determining whether an action is legal is only one aspect of deciding whether it is
ethical. Legality and morality are not one and the same. The nurse must know and
follow the legal statutes of the profession and boundaries within the state before making
any decision.
2
Passive euthanasia involves the withdrawal of extraordinary means of life support and
is never an easy decision.
3
Active euthanasia and assisted suicide are in violation of the Code for Nurses.
4
Some states and countries have laws permitting assisted suicide for clients who are
severely ill, are near death, and wish to commit suicide.
PTS: 1
CON: Ethics | Legal
8. ANS: 3
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse
Chapter page reference: 039-043
Heading: Ethical Dilemmas
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Integrated Processes: Caring
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Ethics
Difficulty: Easy
Feedback
1
The age of the child is not a relevant factor in the decision making if the child is under
18 years.
2
The child is too young to have values and beliefs.
3
When confronted with a conflict regarding care, one of the first actions by the nurse is
to consider the values and beliefs of the parents who are making the decision.
4
decision only.
PTS: 1
CON: Ethics
9. ANS: 3
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Identifying professional standards that guide ethical nursing practice
Chapter page reference: 037-039
Heading: Ethical Theories Relevant to Nursing
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Ethics
Difficulty: Moderate
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1
2
3
4
Feedback
Clients must be able to trust that their information is secure and will only be shared
with appropriate entities. In this case, the nurse may be required to report information to
the state health department.
Clients must be able to trust that their information is secure and will only be shared
with appropriate entities. In this case, the nurse may be required to report information to
the state health department.
HIPAA includes standards that protect the confidentiality, integrity, and availability of
data as well as standards that define appropriate disclosures of identifiable health
information and client rights protection. Nurses are entrusted with sensitive
information, which at times must be revealed to other health-care personnel in order to
provide appropriate health care. In this case, the nurse may be required to report
information to the state health department.
Nurses should not make promises to keep necessary information private.
PTS: 1
CON: Ethics
10. ANS: 3
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Describing ethical theories
Chapter page reference: 037-039
Heading: Ethical Theories Relevant to Nursing
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
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Cognitive level: Application [Applying]
Concept: Ethics
Difficulty: Moderate
Feedback
1
2
3
Caring theories, or relationship theories, stress courage, generosity, commitment, and
the need to nurture and maintain relationships. Caring theories promote the common
decision is an example of a caring-based theory in practice.
Principles-based theories stress individual rights, such as autonomy. The patient has the
ability to make the decision, and it is his right to autonomy to do that.
4
consequence-based reasoning, in which the nurse l
decision.
PTS: 1
CON: Ethics
11. ANS: 4
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Addressing ethical dilemmas associated with the care of the acutely ill adult
Chapter page reference: 040
Heading: Informed Consent
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
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Concept: Ethics
Difficulty: Easy
Feedback
1
2
3
4
The family does not make the decision regarding surgery unless the patient has been
declared incompetent by the court.
The nurse would want to have
the nurse signed the form.
The nurse should notify the surgeon because the patient has the right to informed
consent.
PTS: 1
CON: Ethics
12. ANS: 3
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse
Chapter page reference: 043-044
Heading: Ethics Committees
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Ethics
Difficulty: Hard
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1
2
Feedback
A consumer agency is not appropriate because this is an ethical matter.
The nurse never advises a patient to sue but assists the patient to find help resolving the
issue.
3
4
the help of the hospital ethics committee.
The nurse should act on behalf of the patient, and the best way to do that is by taking
the issue to the hospital ethics committee, not to the health-care provider.
PTS: 1
CON: Ethics
13. ANS: 1
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Identifying professional standards that guide ethical nursing practice
Chapter page reference: 035-037
Heading: Professional Standards for Ethical Practice
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Ethics
Difficulty: Easy
Feedback
1
According to the ANA Code of Ethics, the nurse cannot set aside the moral obligation
to care for the patient infected with human immunodeficiency virus (HIV) unless the
risk exceeds the responsibility.
2
This does not reflect the stance
Ethics.
NUby
RSthe
INANA
GKICode
NG.ofCO
M
3
This does not reflect the stance by the ANA Code of Ethics.
4
This does not reflect the stance by the ANA Code of Ethics.
PTS: 1
CON: Ethics
14. ANS: 1
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse
Chapter page reference: 039-043
Heading: Ethical Dilemmas
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Ethics
Difficulty: Moderate
Feedback
1
Parents have the authority to make health-care decisions for their children. Dilemmas
arise when parents and children do not agree on whether or not to go forward with a
recommended treatment. In most cases, the nurse and other members of the health-care
team who have developed a therapeutic alliance with the child and family may be able
to help the family come to a joint decision by providing additional information and
opportunity to discuss their concerns with each other calmly and openly. In some cases,
however, the health-care team may n
committee.
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2
Confronting the parents is likely to do more harm than good especially in the context of
3
4
There is no need to contact the authorities.
It is not appropriate to obtain a court order to determine if the patient is legally able to
make his or her own decision in this circumstance.
PTS: 1
CON: Ethics
15. ANS: 1
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse
Chapter page reference: 035-037
Heading: Professional Standards for Ethical Practice
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Ethics
Difficulty: Moderate
Feedback
1
Individual patients who feel their rights have been violated or are endangered have a
number of options. Many hospitals and large provider agencies have patient advocates
who can help patients navigate the system and intervene to ensure that their rights are
maintained.
2
Confronting the nurse is likely to cause a confrontation and is not the best action for the
nurse to take at this time.
3
While the patient does have the right to refuse care, this is not always a realistic
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solution.
4
There is no need to contact the authorities as there is no evidence that the nurse has
been abusive to this patient.
PTS: 1
CON: Ethics
16. ANS: 1
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse
Chapter page reference: 035-037
Heading: Professional Standards for Ethical Practice
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Communication; Ethics
Difficulty: Moderate
Feedback
1
Most hospitals now publish lists of patient responsibilities, emphasizing that health care
is a partnership between the patient and caregivers, that other patients have a right to be
comfortable too, and that there are consequences if patients don't comply with treatment
plans, cooperate with the health-care team, or be considerate of the staff and other
patients.
2
This is not an appropriate response by the nurse.
3
This is not an appropriate response by the nurse.
4
This is not an appropriate response by the nurse.
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PTS: 1
CON: Communication | Ethics
17. ANS: 1
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse
Chapter page reference: 039-043
Heading: Ethical Dilemmas
Integrated Processes: Nursing Process Assessment
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Ethics
Difficulty: Hard
Feedback
1
The priority action for the ethical decision-making process is assessment. During this
step, the nurse determines exactly what needs to be decided.
2
During the planning stage of ethical decision-making, the nurse formulates alternatives
to solve the issue.
3
During the implementation stage of ethical decision-making, the nurse implements an
action to achieve the greatest benefit with the least amount of risk.
4
During the evaluation stage of ethical decision-making, the nurse ascertains if new
information is available regarding the issue to determine if new actions should be
implemented.
PTS: 1
CON: Ethics
18. ANS: 3
NURSINGKING.COM
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse
Chapter page reference: 039-043
Heading: Ethical Dilemmas
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Knowledge [Remembering]
Concept: Ethics
Difficulty: Easy
Feedback
1
One alternative solution is not the recommended number when implementing ethical
decision-making.
2
Two alternative solutions are not the recommended number when implementing ethical
decision-making.
3
The nurse should ensure that three alternative solutions are available when
implementing ethical decision-making.
4
Four alternative solutions are not the recommended number when implementing ethical
decision-making.
PTS: 1
CON: Ethics
19. ANS: 1
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Defining ethical principles
Chapter page reference: 037-039
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Heading: Ethical Theories Relevant to Nursing
Integrated Processes: Nursing Process Assessment
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Ethics
Difficulty: Easy
Feedback
1
Beneficence asks the question who benefits from the actions taken by others.
2
3
4
Justice examines who will be vulnerable from any actions taken.
Fidelity requires the nurse to be accountable for commitments made to others and self.
PTS: 1
CON: Ethics
20. ANS: 4
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Defining ethical principles
Chapter page reference: 037-039
Heading: Ethical Theories Relevant to Nursing
Integrated Processes: Nursing Process Assessment
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Ethics
Difficulty: Easy
Feedback
NURSINGKING.COM
1
Beneficence asks the question who benefits from the actions taken by others.
2
3
4
Justice examines who will be vulnerable to any actions taken.
Fidelity requires the nurse to be accountable for commitments made to others and self.
PTS: 1
CON: Ethics
MULTIPLE RESPONSE
21. ANS: 3, 4
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Identifying professional standards that guide ethical nursing practice
Chapter page reference: 039-043
Heading: Ethical Dilemmas
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Ethics; Nursing Roles
Difficulty: Easy
Feedback
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1.
2.
This is incorrect. The rights of a patient in a long-term care facility are not applicable when
providing care in the hospital setting.
This is incorrect. The rights of a patient in the health department setting are not applicable
when providing care in the hospital setting.
3.
4.
advocate in the hospital setting.
This is correct. The state and federal patient rights legislation is applicable to patients in the
hospital setting; therefore, the nurse should have knowledge of this information when acting
as a patient advocate.
5.
PTS: 1
CON: Ethics | Nursing Roles
22. ANS: 1, 2, 4
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Identifying professional standards that guide ethical nursing practice
Chapter page reference: 035-037
Heading: Professional Standards for Ethical Practice
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Ethics
Difficulty: Easy
Feedback
1.
2.
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Ethics.
This is correct. The family is t
Ethics.
3.
Code of Ethics.
4.
Code of Ethics.
5.
Code of Ethics.
PTS: 1
CON: Ethics
23. ANS: 1, 2, 4
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse
Chapter page reference: 035-037
Heading: Professional Standards for Ethical Practice
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Ethics
Difficulty: Easy
Feedback
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1.
2.
3.
4.
5.
This is correct. Strikers may be concerned about patient care as it is related to adequate
staffing.
This is correct. Strikes may adversely affect patient care and outcomes.
This is incorrect. The desire to take time off and the need for higher pay are not ethical issues.
This is correct. Nurses may feel allegiance to a hospital where they have worked for years.
This is incorrect. The desire to take time off and the need for higher pay are not ethical issues.
PTS: 1
CON: Ethics
24. ANS: 3, 4, 5
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse
Chapter page reference: 039-043
Heading: Ethical Dilemmas
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Ethics
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is incorrect. Testing for HIV status is not mandatory; therefore, it is unethical to refuse to
treat the patient unless she is tested.
This is incorrect. It is unethical to test the patient for HIV without her knowledge; patients
have the right to refuse treatment.
This is correct. Suggesting
encouraging testing are recommended.
NURcounseling
SINGKIand
NGconsistently
.COM
This is correct. Suggesting counseling and consistently encouraging testing are recommended.
This is correct. Suggesting counseling and consistently encouraging testing are recommended.
PTS: 1
CON: Ethics
25. ANS: 1, 3, 4
Chapter number and title: 4, Ethical Concepts
Chapter learning objective: Discussing how ethical principles guide decision making for the registered nurse
Chapter page reference: 039-043
Heading: Ethical Dilemmas
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Ethics
Difficulty: Moderate
Feedback
1.
2.
3.
4.
5.
This is correct. Providing appropriate alternatives and options for the patient and the family
are correct responses to the patient's concerns.
This is correct. Providing appropriate alternatives and options for the patient and the family
are correct responses to the patient's concerns.
This is i
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PTS: 1
CON: Ethics
Chapter 5: Palliative Care and End-of-Life Issues
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1.
contest the living will. Which nursing action is appropriate based on the current situation?
1) Notify the hospital attorney.
2) Contact the Social Services department.
3)
4) Explain to the patient that the conflict could invalidate the document.
____
2. The nurse is providing care for a Catholic patient who has suffered a massive cerebral hemorrhage and is not
expected to survive. Which intervention by the nurse is most appropriate?
1) Contact a priest to deliver the Sacrament of the Sick.
2) Make plans for the family to wash the body after death.
3) Contact a rabbi so that the patient can participate in prayer.
4) Discuss the need to cremate the patient, as burial is not accepted in this faith.
____
3. The nurse is caring for a terminally ill patient and family members. The family has been tearful and sad since
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1)
2)
3)
4)
Hopelessness
Caregiver role strain
Anticipatory grieving
Complicated grieving
____
4. The nurse is providing care to a patient who is diagnosed with terminal lung cancer. The patient is lying in the
supine position with noisy wet respirations noted and is not breathing well. The patient has a living will which
designates the implementation of comfort measures. Which action by the nurse is appropriate?
1) Withhold all care until the patient dies.
2) Provide the patient with pain medication as ordered.
3) Ask the family what they want to be done for the patient.
4) Reposition the patient to a lateral position, with the head elevated as tolerated.
____
5. The nurse is caring for a dying child who is being treated with comfort measures only. Which nursing action
supports the primary goal for this patient?
1) Assess and medicate, as ordered, for any signs and symptoms of distress.
2) Maintain a busy schedule for child and family members.
3) Keep the child entertained so she does not think about dying.
4) Ensure that a good relationship is maintained with the family.
____
6. The parents of a child with terminal cancer ask the nurse that the child not be told that he will not recover.
The child asks the nurse if he is dying. What should the nurse do at this time?
1)
ange the subject.
2) Tell the child he is dying and offer to stay with him.
3) Suggest a meeting with the health-care team and the parents.
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4) Offer to bring in the child life therapist to help explain the situation.
____
7. An older school-age child is brought to the emergency department (ED) after a car accident. The parents
witness and stare at the resuscitation scene unfolding before them. The child is not responding to the
resuscitative efforts after 30 minutes. Which is the best communication strategy for the nurse to use in this
situation?
1) Ask the parents to leave until the child has stabilized.
2) Ask the parents to stand at the foot of the cart to watch.
3) Discuss with the parents whether they would like resuscitative efforts to be continued at
this point.
4) Inform the parents that resuscitative efforts have not been effective and are not beneficial
to the child.
____
8. An adolescent patient with terminal cancer tells the nurse that she does not want to continue treatment, even
though her parents are planning for her to participate in a study trial that involves aggressive chemotherapy.
Which action by the nurse is the most appropriate?
1) Tell her not to worry, that she knows her parents want the best for her.
2)
3) Notify the adolescent that she can make her own decisions no matter what her parents
want.
4) Request that the parents and daughter meet together with the health-care team to discuss
options and the implications of various choices.
____
9. The nurse is providing care for a patient receiving curative care who is experiencing chronic pain due to
cancer. Which type of care should the nurse plan for upon discharge for this patient?
1) Home health care
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2) Palliative care
3) Hospice care
4) Rehabilitative care
____ 10. The nurse is assessing the patient for palliative care. When assessing the social domain, which should the
nurse include?
1) Financial concerns
2) Pain
3) Depression
4) Spiritual concerns
____ 11. The nurse is assessing the patient for palliative care. When assessing the physical domain, which should the
nurse include?
1) Financial concerns
2) Pain
3) Depression
4) Spiritual concerns
____ 12. The nurse is assessing the patient for palliative care. When assessing the psychosocial and psychiatric domain,
which should the nurse include?
1) Financial concerns
2) Pain
3) Depression
4) Spiritual concerns
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____ 13. The nurse is assessing the patient for palliative care. When assessing the cultural domain, which question
should the nurse include?
1)
2)
3)
4)
____ 14. The nurse is educating the family of a patient who is receiving hospice care due to a terminal illness. Which
medication should the nurse tell the family to administer for this patient if delirium occurs?
1) Morphine
2) Haloperidol
3) Diphenhydramine
4) Docusate
____ 15. The nurse is educating the family of a patient who is receiving hospice care due to a terminal illness. Which
medication should the
1) Morphine
2) Haloperidol
3) Diphenhydramine
4) Docusate
____ 16. The nurse is educating the family of a patient who is receiving hospice care due to a terminal illness. Which
benzodiazepine medication should the nurse tell the family to administer to treat the patient if hyperactive
delirium occurs?
1) Morphine
2) Haloperidol
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3) Diphenhydramine
4) Lorazepam
____ 17. The nurse is providing care to a patient who is approaching death. Which family member statement regarding
the physical and psychological changes associated with death is reflective of the late stage?
1)
2)
3)
4)
____ 18. The nurse is providing care to a patient who is approaching death. Which family member statement regarding
the physical and psychological changes associated with death is reflective of the middle stage?
1)
2)
3)
4)
____ 19. Which response by the nurse indicates the use of reflective reasoning when communicating with the family of
a patient who is in the process of dying?
1)
2)
3)
4)
____ 20. Which concept exemplifies a well-managed death experience for a terminal patient and family members?
1) Allowing the patient to die alone
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2) Withholding pain medication to decrease addiction
3) Encouraging a lengthy dying process to allow for goodbyes
4) Preparing the patient and the family for the process of dying
____ 21. Which is a team action that nurses can employ as a stress-reducing strategy?
1) Practicing yoga on a daily basis
2) Journaling feelings related to patient care
3) Engaging in aerobic exercise several times per week
4) Sending a bereavement card to the family of a patient who recently passed
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 22. Which factors can create moral distress for nurses? Select all that apply.
1) Supportive management staff
2) Low stress patient environment
3) High technology patient care situations
4) Cultural differences with the patient population
5) Resource pressures when providing patient care
____ 23. The nurse is providing care to a patient who is diagnosed with terminal lung cancer. Which clinical
manifestations indicate imminent death? Select all that apply.
1) Diaphoresis
2) Increased cardiac output
3) Decreased blood pressure
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4) Tachycardia followed by bradycardia
5) An increase in the volume of Korotkoff's sounds
____ 24. The wife of a patient with end-stage chronic obstructive pulmonary disease (COPD) tells the nurse that she
wishes her husband were eligible for hospice care but she thinks that hospice is only available for cancer
patients and would require a change in health-care providers. Which responses by the nurse are appropriate?
Select all that apply.
1) Inform her that hospice care is very expensive.
2) Inform her that a diagnosis of cancer is not required for hospice care.
3) Inform her that all hospice programs provide care 24 hours per day, 7 days per week
4) Inform her that her husband can retain his provider when transitioning to hospice care.
5) Inform her that her husband is not eligible for hospice care with the current diagnosis of
COPD.
____ 25. The nurse is providing care to a terminal patient who is experiencing delirium. Which should the nurse assess
prior to administering haloperidol to this patient? Select all that apply.
1) Last stool
2) Blood pressure
3) Respiratory rate
4) Bladder distention
5) Medication regimen
____ 26. Which statement from the nurse to family members is appropriate to encourage the participation of providing
physical care to the patient during the dying process? Select all that apply.
1)
2)
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3)
4)
5)
____ 27. A terminal patient has opted to stop treatment. The family, however, believes the patient is no longer
competent to make this decision. Which data supports that the patient is capable of making this treatment
decision? Select all that apply.
1) The patient is aware of the current date and location.
2) The patient does not want to be a burden on the family.
3) The patient communicates the decision with the health-care team.
4) The patient understands the nature and consequences of treatment.
5) The patient states the benefits and risks associated with the treatment.
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Chapter 5: Palliative Care and End-of-Life Issues
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life
Chapter page reference: 051
Heading: Domain 8: Ethical and Legal Aspects of Care
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Critical Thinking; Legal
Difficulty: Moderate
1
2
3
4
Feedback
There is no need to notify the hospital attorney at this time.
If there are concerns about the authenticity of the document, the Social Services
department or the unit supervisor will need to be contacted.
This patient is competent; therefore, the wishes of the client take priority. The
-care provider
notified.
A lack of support by the family, or a plan to contest, does not invalidate the document
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legally.
PTS: 1
CON: Critical Thinking | Legal
2. ANS: 1
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Listing the domains of palliative care
Chapter page reference: 048
Heading: Domain 5: Spiritual, Religious, and Existential Aspects of Care
Integrated Processes: Nursing Process Implementation
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Spirituality
Difficulty: Moderate
Feedback
1
In the Catholic faith, it is common to receive the Sacrament of the Sick from a priest in
order to receive spiritual strength and prepare for death.
2
Making plans for the family to wash the body after death is appropriate for a patient
who is Muslim, not Catholic.
3
Contacting a rabbi would be appropriate for a Jewish, not Catholic, patient.
4
Cremation is not preferred over burial in the Catholic faith.
PTS: 1
CON: Spirituality
3. ANS: 3
Chapter number and title: 5, Palliative Care and End-of-Life Issues
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Chapter learning objective: Developing communication and support strategies for family members
Chapter page reference: 050-051
Heading: Family Support
Integrated Processes: Nursing Process Planning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
Feedback
1
There are no assessment findings that indicate complicated grieving or hopelessness.
2
This reaction is typical of family members, so there is no indication that the family is
exhibiting caregiver role strain.
3
Grieving prior to the actual loss is termed anticipatory grieving.
4
There are no assessment findings that indicate complicated grieving or hopelessness.
PTS: 1
CON: Grief and Loss
4. ANS: 1
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Listing the domains of palliative care
Chapter page reference: 048-050
Heading: Symptom Management
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Grief and Loss
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Difficulty: Moderate
Feedback
1
measures to sustain life. This does not mean that nursing care ceases but that nursing
care to provide patient comfort is intensified and maintained through the end stages of
2
3
4
The nurse did not note the patient had any verbal or nonverbal signs or symptoms of
pain, so medicating the patient for pain is not appropriate.
Asking the family what they want to be done is inappropriate when a patient has written
a living will.
Repositioning the patient from the supine position to a lateral position with the head
nurse may need to medicate the patient with an anticholinergic agent to dry the
secretions if ordered. If not ordered, the patient may need to contact the health-care
provider to get an order for this type of medication for comfort measures.
PTS: 1
CON: Grief and Loss
5. ANS: 1
Ans: 1
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Listing the domains of palliative care
Chapter page reference: 048-050
Heading: Symptom Management
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Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
Feedback
1
2
3
4
The major goal for the dying child is to promote comfort and keep the child symptomfree.
A dying child does not have the energy to maintain a busy schedule.
Keeping the child entertained is good, but the pediatric patient needs to voice her
feelings about death and dying.
Maintaining a good relationship is important but not a major goal f
PTS: 1
CON: Grief and Loss
6. ANS: 3
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Developing communication and support strategies for family members
Chapter page reference: 050-051
Heading: Family Support
Integrated Processes: Nursing Process Implementation
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
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Feedback
1
Avoiding the subject is not an option. Changing the subject or ignoring the child is not
appropriate.
2
3
4
Offering to set up a meeting with the healthconcerns about telling their child the truth is the best action by the nurse.
The nurse should explain that the parents will talk to the child about this. The child has
asked the nurse, but because the child is a minor, the nurse must consult with the
parents first. Legally they cannot talk to the child.
PTS: 1
CON: Grief and Loss
7. ANS: 4
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Developing communication and support strategies for family members
Chapter page reference: 050-051
Heading: Family Support
Integrated Processes: Communication and Documentation
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
Feedback
1
This is not an effective communication strategy in this situation.
2
This is not an effective communication strategy in this situation.
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3
4
When asking to withhold therapy such as cardiopulmonary resuscitation, it is helpful to
indicate that the therapy is not effective in reversing overwhelming illness or brain
damage.
Care must be used in how the parents are asked to withdraw therapies. An effective
communication strategy is to inform the parents that an intervention was initiated to
give the child the best chance of recovery, but it has not been effective and is not
beneficial to the child.
PTS: 1
CON: Grief and Loss
8. ANS: 4
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Developing communication and support strategies for family members
Chapter page reference: 050-051
Heading: Family Support
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Grief and Loss; Legal
Difficulty: Moderate
Feedback
1
Telling her not to worry does not address the problem.
2
This is not an accurate statement from the nurse.
3
This is not an accurate statement from the nurse.
4
Adolescents with a serious medical condition are more capable of making treatment
decisions than most teenagers. However, the Patient Self- Determination Act of 1990
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limits the legal rights of individuals younger than 18 to make their own health-care
decisions. If the adolescent states a desire to withdraw from or refuse treatment, her
parents and health-care team should discuss the reasons for her decision and help her
understand the implications of her decision and any treatment alternatives that may
influence her choice.
PTS: 1
CON: Grief and Loss | Legal
9. ANS: 2
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Discussing the meaning of palliative care and hospice care
Chapter page reference: 047-052
Heading: Palliative Care
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
Feedback
1
Home health care provides skilled care to patients who are home bound. This is not the
best choice for the patient.
2
Palliative care is a specialized form of care that focuses on relief of pain and other
symptoms and stress associated with a severe illness.
3
Hospice care focuses on the care of a terminally patient with less than 6 months to live.
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4
Rehabilitative care provides rehab services for patients who require strengthening after
hospitalization.
PTS: 1
CON: Comfort
10. ANS: 1
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Listing the domains of palliative care
Chapter page reference: 048
Heading: Domain 4: Social Aspects of Care
Integrated Processes: Nursing Process Assessment
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Assessment
Difficulty: Moderate
Feedback
1
for the social aspects related to palliative care.
2
3
4
aspects of palliative care.
Assessing the patient for depression is included when conducting an assessment for the
psychosocial and psychiatric aspects of palliative care.
Assessing the patient for spiritual concerns is included when conducting an assessment
for the spiritual, religious, and existential aspects of palliative care.
PTS: 1
CON: Assessment
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11. ANS: 2
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Listing the domains of palliative care
Chapter page reference: 048
Heading: Domain 2: Physical Aspects of Care
Integrated Processes: Nursing Process Assessment
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Assessment
Difficulty: Moderate
Feedback
1
for the social aspects related to palliative care.
2
3
4
aspects of palliative care.
Assessing the patient for depression is included when conducting an assessment for the
psychosocial and psychiatric aspects of palliative care.
Assessing the patient for spiritual concerns is included when conducting an assessment
for the spiritual, religious, and existential aspects of palliative care.
PTS: 1
CON: Assessment
12. ANS: 3
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Listing the domains of palliative care
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Chapter page reference: 048
Heading: Domain 3: Psychological and Psychiatric Aspects of Care
Integrated Processes: Nursing Process Assessment
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Assessment
Difficulty: Moderate
Feedback
1
for the social aspects related to palliative care.
2
3
4
aspects of palliative care.
Assessing the patient for depression is included when conducting an assessment for the
psychosocial and psychiatric aspects of palliative care.
Assessing the patient for spiritual concerns is included when conducting an assessment
for the spiritual, religious, and existential aspects of palliative care.
PTS: 1
CON: Assessment
13. ANS: 4
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Listing the domains of palliative care
Chapter page reference: 048
Heading: Domain 6: Cultural Aspects of Care
Integrated Processes: Nursing Process Assessment
Client Need: Psychosocial Integrity
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Cognitive level: Application [Applying]
Concept: Assessment; Diversity
Difficulty: Moderate
Feedback
1
for the social aspects related to palliative care.
2
3
4
aspects of palliative care.
Assessing the patient for depression or anxiety is included when conducting an
assessment for the psychosocial and psychiatric aspects of palliative care.
Assessing the patient for dietary preferences that may affect care is included when
conducting an assessment for the cultural aspects of palliative care.
PTS: 1
CON: Assessment | Diversity
14. ANS: 2
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life
Chapter page reference: 048-050
Heading: Symptom Management
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
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Feedback
1
2
Haloperidol is a drug that is administered to treat delirium that can occur at the end of
life.
3
4
secretions, not to treat delirium.
Docusate is a stool softener used to treat constipation, not delirium.
PTS: 1
CON: Grief and Loss
15. ANS: 1
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life
Chapter page reference: 048-050
Heading: Symptom Management
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
Feedback
1
Morphine is an opiate administered to treat the pain that patients may experience at the
end of life.
2
Haloperidol is a drug that is administered to treat delirium, not pain, that can occur at
the end of life.
3
4
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secretions, not to treat pain.
Docusate is a stool softener used to treat constipation, not pain.
PTS: 1
CON: Grief and Loss
16. ANS: 4
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life
Chapter page reference: 048-050
Heading: Symptom Management
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
1
2
3
4
Feedback
Morphine is an opiate administered to treat the pain that patients may experience at the
end of life.
Docusate is a stool softener used to treat constipation, not delirium.
s
secretions, not to treat delirium.
Lorazepam, a benzodiazepine, is administered for a patient who is experiencing
hyperactive delirium at the end of life.
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PTS: 1
CON: Grief and Loss
17. ANS: 2
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life
Chapter page reference: 048-050
Heading: Domain 7: Care of the Imminently Dying
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Grief and Loss
Difficulty: Hard
Feedback
1
A loss of appetite often occurs during the early stage of the physical and psychological
changes that occur prior to death.
2
Respirations often sound loud and wet during the late stage of the physical and
psychological changes that occur prior to death.
3
Sleeping more often occurs during the early stage of the physical and psychological
changes that occur prior to death.
4
Confusion or disorientation often occurs during the middle stage of the physical and
psychological changes that occur prior to death.
PTS: 1
CON: Grief and Loss
18. ANS: 4
Chapter number and title: 5, Palliative Care and End-of-Life Issues
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Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life
Chapter page reference: 048-050
Heading: Domain 7: Care of the Imminently Dying
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Grief and Loss
Difficulty: Hard
Feedback
1
A loss of appetite often occurs during the early stage of the physical and psychological
changes that occur prior to death.
2
Respirations often sound loud and wet during the late stage of the physical and
psychological changes that occur prior to death.
3
Sleeping more often occurs during the early stage of the physical and psychological
changes that occur prior to death.
4
Confusion or disorientation often occurs during the middle stage of the physical and
psychological changes that occur prior to death.
PTS: 1
CON: Grief and Loss
19. ANS: 1
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Developing communication and support strategies for family members
Chapter page reference: 050-051
Heading: Family Support
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Integrated Processes: Communication and Documentation
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Communication; Grief and Loss
Difficulty: Moderate
Feedback
1
The use of reflective listening often helps the family process the dying experience.
Making a statement such as acknowledging that the experience is difficult is a response
by the nurse that exemplified reflective listening.
2
This is not an example of reflective listening.
3
This is not an example of reflective listening.
4
This is not an example of reflective listening.
PTS: 1
CON: Communication | Grief and Loss
20. ANS: 4
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Developing communication and support strategies for family members
Chapter page reference: 050-051
Heading: Domain 8: Ethical and Legal Aspects of Care
Integrated Processes: Caring
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Grief and Loss
Difficulty: Easy
Feedback
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1
A well-managed death experience includes a patient who does not die alone but in the
presence of loved ones or caretakers.
2
Appropriate symptom management, including pain management, is included in a wellmanaged death experience. The risk for addiction is not an issue.
3
A prolonged dying experience should be avoided even if the patient is unable to say
goodbye to loved ones.
4
A well-managed death experience includes preparing the patient, and family members,
for what to expect during the process of dying.
PTS: 1
CON: Grief and Loss
21. ANS: 4
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Identifying nursing self-care strategies
Chapter page reference: 052-053
Heading: Nurse Self-Care
Integrated Processes: Caring
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Nursing Roles
Difficulty: Easy
Feedback
1
Yoga is an individual, not team, self-care activity.
2
Journaling feelings is an individual, not team, self-care activity.
3
Engaging in aerobic exercise is an individual, not team, self-care activity.
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4
Sending a bereavement card to the family of a patient who has recently passed is a team
action nurses can employ as a stress-reducing strategy.
PTS: 1
CON: Nursing Roles
MULTIPLE RESPONSE
22. ANS: 3, 4, 5
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Explaining moral distress in end-of-life issues
Chapter page reference: 052-053
Heading: Ethical Implications and Moral Distress
Integrated Processes: Caring
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Grief and Loss
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is incorrect. An unsupportive, not supportive, management staff leads to moral distress
for nurses.
This is incorrect. A high, not low, stress environment leads to moral distress for nurses.
This is correct. High technology patient care situations often lead to moral distress for nurses.
This is correct. Cultural differences between the nurse and the patient population often lead to
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moral distress for nurses.
This is correct. Resource pressures when providing patient care often lead to moral distress for
nurses.
PTS: 1
CON: Grief and Loss
23. ANS: 1, 3, 4
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Developing communication and support strategies for family members
Chapter page reference: 048-051
Heading: Domain 7: Care of the Imminently Dying
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Grief and Loss
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is correct. Peripheral circulation decreases, leading to diaphoresis; clammy, cool skin;
and changes in skin coloring.
This is incorrect. Decreased cardiac output results from bradycardia and hypotension.
This is correct. The heart rate and blood pressure decrease, resulting in decreased cardiac
output, which is a sign of imminent death.
This is correct. The heart rate might initially increase as hypoxia develops; then the heart rate
and blood pressure decrease, resulting in decreased cardiac output.
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5.
This is incorrect. A change in pulse pressure and a decrease in the volume of Korotkoff's
sounds indicate imminent death.
PTS: 1
CON: Grief and Loss
24. ANS: 2, 4
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Discussing the meaning of palliative care and hospice care
Chapter page reference: 047
Heading: Domain 1: Structure and Process of Care
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is incorrect. Hospice care is often less expensive than conventional care in the last six
months of life.
This is correct. In addition to clients who are diagnosed with cancer, a variety of clients
qualify for hospice care.
This is incorrect. Hospice teams visit clients intermittently, although they are available 24/7
for support and care.
This is correct. Hospice reinforces the client-primary physician relationship by advocating
office or home visits.
This is incorrect. In addition to clients who are diagnosed with cancer, a variety of clients
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qualify for hospice care. A diagnosis of end-stage COPD is often a qualifier for hospice care.
PTS: 1
CON: Grief and Loss
25. ANS: 1, 4, 5
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life
Chapter page reference: 048-050
Heading: Symptom Management
Integrated Processes: Nursing Process Assessment
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Grief and Loss; Assessment
Difficulty: Moderate
1.
2.
Feedback
This is correct. The last noted stool should be assessed to determine if constipation may be
causing the delirium prior to medicating with the prescribed drug.
e
cause of delirium.
3.
4.
cause of the delirium.
This is correct. Bladder distention is often a cause for delirium; therefore, the nurse should
assess for this prior to administering the prescribed drug.
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5.
This is correct. Certain medications are known to cause delirium; therefore, the nurse should
PTS: 1
CON: Grief and Loss | Assessment
26. ANS: 2, 3
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Developing communication and support strategies for family members
Chapter page reference: 050-051
Heading: Family Support
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Analysis [Analyzing]
Concept: Grief and Loss
Difficulty: Hard
1.
2.
3.
4.
5.
Feedback
This is incorrect. While bringing pictures is an appropriate suggestion, this does not allow the
family to participate in the physical care of the patient during the dying process.
This is correct. The lips of a patient who is experiencing the process of dying often become
dry; therefore, the application of lip balm is an appropriate suggestion to allow the family to
participate in the physical care of this patient.
This is correct. A patient who is dying often experiences pain that can be remedied by
massage; therefore, suggesting this to the family allows them to participate in the physical care
of this patient.
This is incorrect. While bringing music for the patient to listen to is appropriate, this addresses
NURnot
SIphysical,
NGKINneeds.
G.COM
This is incorrect. Suggesting that a child call the dying patient is appropriate; however, this
addresses the psychosocial, and not physical, needs of the patient and family.
PTS: 1
CON: Grief and Loss
27. ANS: 3, 4, 5
Chapter number and title: 5, Palliative Care and End-of-Life Issues
Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life
Chapter page reference: 051-052
Heading: Domain 8: Ethical and Legal Aspects of Care
Integrated Processes: Nursing Process Assessment
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Grief and Loss
Difficulty: Easy
1.
2.
3.
Feedback
This is incorrect. While this data supports that the patient is alert and oriented it does not
This is incorrect. The patient stating that he or she does not want to be a burden on the family
is not data th
This is correct. Being able to communicate a decision with the health-care team supports the
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4.
This is correct. Understanding the nature and the consequences of treatment supports the
5.
This is correct. Stating the benefits and risks associated with the treatment supports the
PTS: 1
CON: Grief and Loss
Chapter 6: Geriatric Implications for Medical-Surgical Nursing
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. The nurse is providing care to an older adult patient who is experiencing bradycardia. When educating the
patient about this disorder, which age-related cardiovascular change should the nurse include?
1) Stiffened artery walls
2) Increased size of the left atrium
3) Reduced number of pacemaker cells in the SA node
4) Decreased cardiac responsiveness to beta-adrenergic stimuli
____
2. The nurse is providing care to an older
with congestive heart failure (CHF).
NURadult
SINpatient
GKINwho
G.isCdiagnosed
OM
When educating the patient about this disorder, which age-related cardiovascular change should the nurse
include?
1) Stiffened artery walls
2) Increased size of the left atrium
3) Reduced number of pacemaker cells in the SA node
4) Decreased cardiac responsiveness to beta-adrenergic stimuli
____
3. The nurse is providing care to an older adult patient who is diagnosed with atrial fibrillation. When educating
the patient about this disorder, which age-related cardiovascular change should the nurse include?
1) Stiffened artery walls
2) Increased size of the left atrium
3) Reduced number of pacemaker cells in the SA node
4) Decreased cardiac responsiveness to beta-adrenergic stimuli
____
4. Which statement should the nurse include when educating older adult patients about dementia?
1)
2)
3)
4)
____
5. The nurse is providing care to an older adult patient who is diagnosed with an ulcer. Which age-related
gastrointestinal change is often the cause for this diagnosis?
1) Slowed gastric emptying
2) Atrophied gastric mucosa
3) Increased secretion of gastrin
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4) Reduced secretion of intrinsic factor
____
6. The nurse is providing care to an older adult patient who is diagnosed with osteoporosis. Which age-related
cause should the nurse include in the teaching session?
1) Decreased speed of foot movements
2) Decreased absorption of vitamin D
3) Increased intramuscular fat
4) Increased subcutaneous fat
____
7. The nurse is assessing the older adult patient using the Get-Up-and-Go test. The patient is unable to stand
without assistance. Which score should the nurse document?
1) 0
2) 1
3) 3
4) 4
____
8. Which nursing action is appropriate when conducting an hourly rounding when providing care to older adult
patients?
1) Obtaining patient vital signs
2) Assisting the patient to the bathroom
3)
4) Documenting the amount of intake for the last meal eaten by the patient
____
9. Which classification should the nurse use when providing care to an adult patient who is 70 years of age?
1) Old
2) Old-old
3) Oldest old
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4) Young-old
____ 10. Which senescence term should the nurse use to describe the hardening of tissue due to fibrous tissue
overgrowth that occurs with the aging process?
1) Atrophy
2) Stenosis
3) Sclerosis
4) Calcification
____ 11. Which senescence term should the nurse for a patient who is diagnosed with narrowing of the coronary
arteries?
1) Atrophy
2) Stenosis
3) Sclerosis
4) Calcification
____ 12. Which senescence term should the nurse use to describe the wasting away of muscle mass that occurs with the
aging process?
1) Atrophy
2) Stenosis
3) Sclerosis
4) Calcification
____ 13. Which senescence term should the nurse use to describe deposits of calcium salt in the blood vessels that
often occurs with aging?
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1)
2)
3)
4)
Atrophy
Stenosis
Sclerosis
Calcification
____ 14. Which data collected by the nurse during the health history of an older adult patient increases the risk for
heart disease?
1) Dependent edema
2) Diabetes insipidus
3) Cigarette smoking
4) Diminished hearing
____ 15. Which nursing action supports The Joint Commission (TJCs) safety goals for providing home care to an older
adult patient?
1)
2) Administering all prescribed medications to the patient during scheduled visits
3) Recommending the use of throw rugs on hard wood floors to prevent patient falls
4) Asking family members to smoke in another room when oxygen is in use by the patient
____ 16. Which clinical manifestation should the nurse anticipate when providing care to an older adult patient who is
diagnosed with Parkinson disease?
1) Tremors
2) Paralysis
3) Vision impairment
4) Right-sided weakness
____ 17. Which electrolyte imbalance shouldNthe
monitor
older
URnurse
SING
KINGan.C
OM adult patient for due to impaired renal diluting
capacity and concentrating ability?
1) Hypokalemia
2) Hyponatremia
3) Hypocalcemia
4) Hypomagnesemia
____ 18. Which electrolyte imbalance should the nurse monitor an older adult patient for when a diuretic is prescribed?
1) Hypokalemia
2) Hyponatremia
3) Hypocalcemia
4) Hypomagnesemia
____ 19. The nurse is providing care to an older adult patient who is diagnosed with a vitamin B deficiency. The
should the nurse suspect?
1) Anemia
2) Osteoporosis
3) Atrophic gastritis
4) Gastroesophageal reflux disease (GERD)
____ 20. The nurse educates the older adult patient to increase activity, lose weight, and limit dietary intake of fats and
calories. Which disease process is the patient at risk for based on the teaching?
1) Fecal impaction
2) Diabetes insipidus
3) Type 2 diabetes mellitus (DM)
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4) Gastroesophageal reflux disorder (GERD)
____ 21. Which clinical manifestation does the nurse anticipate when providing care to an older adult patient diagnosed
with failure to thrive (FTT)?
1) An increased appetite
2) A high cholesterol level
3) A weight loss of five pounds
4) Skin that loses elasticity with poor turgor
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 22. Which older adult patient diagnoses should the nurse include information regarding cachexia into the plan of
care? Select all that apply.
1) Lung cancer
2) Osteoporosis
3) Gastroesophageal reflux disorder (GERD)
4) Acquired immune deficiency syndrome (AIDS)
5) Chronic obstructive pulmonary disease (COPD)
____ 23. Which priority safety concerns should the nurse assess when providing care to older adult patients? Select all
that apply.
1) Falls
2) Neglect
3) Depression
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4) Polypharmacy
5) Poor dietary intake
____ 24.
safety issues? Select all that apply.
1) Rugs
2) Electrical cords
3) Nonskid appliance in bathtub
4) Medications stored in a weekly divider
5) Telephone with emergency numbers listed
____ 25. Which changes associated with aging should the nurse identify as possible inhibitors to medication adherence
and safety? Select all that apply.
1) Decreased memory
2) Decreased visual acuity
3) Decreased hearing acuity
4) Decreased sense of smell
5) Decreased physical strength
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Chapter 6: Geriatric Implications for Medical-Surgical Nursing
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Discussing age-related physiological changes
Chapter page reference: 057-058
Heading: Common Cardiovascular Health Issues
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
1
2
3
4
Feedback
The stiffening of artery walls causes the systolic blood pressure to rise.
Left atrial enlargement causes a fourth heart sound to be auscultated and is also
responsible for an increased risk for hypertension and congestive heart failure (CHF).
A reduced number of pacemaker cells in the SA node causes the maximum heart rate to
decrease with age, leading to bradycardia.
Decreased cardiac responsiveness to beta-adrenergic stimuli increases the risk for
arrhythmias, atrial fibrillation, and reduced heart rate control when exposed to stressors.
NURSINGKING.COM
PTS: 1
CON: Perfusion
2. ANS: 2
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Discussing age-related physiological changes
Chapter page reference: 057-058
Heading: Common Cardiovascular Health Issues
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
1
2
3
4
Feedback
The stiffening of artery walls causes the systolic blood pressure to rise.
Left atrial enlargement causes a fourth heart sound to be auscultated and is also
responsible for an increased risk for hypertension and congestive heart failure (CHF).
A reduced number of pacemaker cells in the SA node causes the maximum heart rate to
decrease with age, leading to bradycardia.
Decreased cardiac responsiveness to beta-adrenergic stimuli increases the risk for
arrhythmias, atrial fibrillation, and reduced heart rate control when exposed to stressors.
PTS: 1
3. ANS: 4
CON: Perfusion
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Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Discussing age-related physiological changes
Chapter page reference: 057-058
Heading: Common Cardiovascular Health Issues
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
1
2
3
4
Feedback
The stiffening of artery walls causes the systolic blood pressure to rise.
Left atrial enlargement causes a fourth heart sound to be auscultated and is also
responsible for an increased risk for hypertension and congestive heart failure (CHF).
A reduced number of pacemaker cells in the SA node causes the maximum heart rate to
decrease with age, leading to bradycardia.
Decreased cardiac responsiveness to beta-adrenergic stimuli increases the risk for
arrhythmias, atrial fibrillation, and reduced heart rate control when exposed to stressors.
PTS: 1
CON: Perfusion
4. ANS: 1
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Identifying common health-care issues of the elderly
Chapter page reference: 059-060
Heading: Dementia
URSINGKING.COM
Integrated Processes: Teaching andNLearning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback
1
Dementia causes impaired judgment; therefore, the nurse should include this statement
in the educational session.
2
Delirium, not dementia, caused fluctuation in alertness.
3
Delirium, not dementia, causes day-night reversal.
4
Delirium, not dementia, lasts for no more than one month.
PTS: 1
CON: Cognition
5. ANS: 3
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Discussing age-related physiological changes
Chapter page reference: 062-064
Heading: Common Gastrointestinal Changes
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Digestion
Difficulty: Easy
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1
2
3
4
Feedback
Slowed gastric emptying causes gastric distention and anorexia.
Atrophied gastric mucosa causes gastric distention and anorexia.
Increased secretion of gastrin causes an increase in gastric acid which often leads to
ulceration.
Reduced secretion of intrinsic factor causes impaired vitamin B12 absorption.
PTS: 1
CON: Digestion
6. ANS: 2
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Discussing age-related physiological changes
Chapter page reference: 064-065
Heading: Common Musculoskeletal Changes
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
2
3
4
Decreased vitamin D absorption caused the development of osteoporosis.
Increased intramuscular fat causes a loss of muscle mass.
Increased subcutaneous fat causes a loss of muscle mass.
PTS: 1
CON: FluidN
and
URElectrolyte
SINGKIBalance
NG.COM
7. ANS: 4
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Identifying common health-care issues of the elderly
Chapter page reference: 064-065
Heading: Common Musculoskeletal Changes
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Mobility
Difficulty: Easy
Feedback
1
A score of 0 is assigned for a patient who can rise unassisted or hands free.
2
A score of 1 is assigned for a patient who can rise using arms to push up in one attempt.
3
A score of 3 is assigned for a patient who makes several attempts to push up and
succeeds in standing. This score indicates a higher risk for falls.
4
A score of 4 is assigned for a patient who is unable to stand without assistance. This
score indicates a higher risk for falls.
PTS: 1
CON: Mobility
8. ANS: 2
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Analyzing care priorities for geriatric patients
Chapter page reference: 067-069
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Heading: Safety Issues
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Evidence-Based Practice
Difficulty: Moderate
Feedback
1
Hourly rounding is evidence-based practice that increases patient safety and decreases
2
and possessions. Obtaining vital signs is not an action included
rounding.
Hourly rounding is evidence-based practice that increases patient safety and decreases
3
and possessions. Assisting the patient
hourly rounding.
Hourly rounding is evidence-based practice that increases patient safety and decreases
and possessions. Accounting for essential, not all, personal items is an action included
4
glasses, etc.
Hourly rounding is evidence-based practice that increases patient safety and decreases
and possessions. Documenting the amount of intake at the last meal is not an action
NURSING
KING.COM
PTS: 1
CON: Evidence-Based
Practice
9. ANS: 4
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Defining the demographics of the aging population
Chapter page reference: 056
Heading: Demographics
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Knowledge [Remembering]
Concept: Communication
Difficulty: Easy
Feedback
1
A patient age 75 to 85 is classified as old.
2
A patient 85 years of age and older is classified as oldest old or old-old.
3
A patient 85 years of age and older is classified as oldest old or old-old.
4
A patient age 65 to 75 is classified as young-old.
PTS: 1
CON: Communication
10. ANS: 3
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Discussing age-related physiological changes
Chapter page reference: 056-057
Heading: Age-Related Changes and Common Health Problems
Integrated Processes: Communication and Documentation
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Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1
Atrophy is the term used to describe a wasting away or decrease in the size of an organ.
2
Stenosis is the term used to describe the narrowing or constricting of a passage of
orifice.
3
Sclerosis is the term used to describe the hardening of tissue due to fibrous tissue
overgrowth.
4
Calcification is the term used to describe abnormal deposits of calcium salts on organs.
PTS: 1
CON: Communication
11. ANS: 2
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Discussing age-related physiological changes
Chapter page reference: 056-057
Heading: Age-Related Changes and Common Health Problems
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1
Atrophy is the term used to describe a wasting away or decrease in the size of an organ.
NURSINGKING.COM
2
Stenosis is the term used to describe the narrowing or constricting of a passage of
orifice.
3
Sclerosis is the term used to describe the hardening of tissue due to fibrous tissue
overgrowth.
4
Calcification is the term used to describe abnormal deposits of calcium salts on organs.
PTS: 1
CON: Communication
12. ANS: 1
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Discussing age-related physiological changes
Chapter page reference: 056-057
Heading: Age-Related Changes and Common Health Problems
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1
Atrophy is the term used to describe a wasting away or decrease in the size of an organ.
2
Stenosis is the term used to describe the narrowing or constricting of a passage of
orifice.
3
Sclerosis is the term used to describe the hardening of tissue due to fibrous tissue
overgrowth.
4
Calcification is the term used to describe abnormal deposits of calcium salts on organs.
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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PTS: 1
CON: Communication
13. ANS: 4
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Discussing age-related physiological changes
Chapter page reference: 056-057
Heading: Age-Related Changes and Common Health Problems
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1
Atrophy is the term used to describe a wasting away or decrease in the size of an organ.
2
Stenosis is the term used to describe the narrowing or constricting of a passage of
orifice.
3
Sclerosis is the term used to describe the hardening of tissue due to fibrous tissue
overgrowth.
4
Calcification is the term used to describe abnormal deposits of calcium salts on organs.
PTS: 1
CON: Communication
14. ANS: 3
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Identifying common health-care issues of the elderly
Chapter page reference: 056-057 NURSINGKING.COM
Heading: Age-Related Changes and Common Health Problems
Integrated Processes:
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Perfusion
Difficulty: Easy
Feedback
1
Dependent edema is often a clinical manifestation of, not risk factor for, heart disease.
2
Diabetes mellitus, not insipidus, is a risk factor for heart disease.
3
Cigarette smoking is a risk factor for heart disease.
4
Diminished hearing is an age-related change; however, this is not a risk factor for heart
disease.
PTS: 1
CON: Perfusion
15. ANS: 1
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Analyzing care priorities for geriatric patients
Chapter page reference: 058
Heading: Safety Alert
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Safety
Difficulty: Moderate
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1
2
3
4
Feedback
Correctly identifying the patient is a TJC safety goal when providing home care. The
nurse verifies the patient using the first and last name in order to meet this safety goal.
Using medications safety is a TJC safety goal when providing home care. The nurse
must use communication, teaching, and organizational skills to educate the patient
about his or her medications. This includes indications, side effects, and dosing
intervals. The nurse helps the patient develop a system for organizing the medications,
Throw rugs are discouraged as these increase the risk for patient falls, according to the
TJC safety goals when providing home care.
Smoking is prohibited in the home of any patient who is receiving oxygen per the TJC
safety goals when providing home care.
PTS: 1
CON: Safety
16. ANS: 1
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Identifying common health-care issues of the elderly
Chapter page reference: 061
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Neurologic Regulation
Difficulty: Easy
Feedback
NURSINGKING.COM
1
Tremors, rigidity, and gait disturbances are all anticipated when providing care to an
older adult patient diagnosed with Parkinson disease.
2
Paralysis is not a clinical manifestation anticipated when providing care to a patient
diagnosed with Parkinson disease.
3
Vision impairment is not a clinical manifestation anticipated when providing care to a
patient diagnosed with Parkinson disease.
4
Right-sided weakness is not a clinical manifestation anticipated when providing care to
a patient diagnosed with Parkinson disease.
PTS: 1
CON: Neurologic Regulation
17. ANS: 2
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Identifying common health-care issues of the elderly
Chapter page reference: 061-062
Heading: Common Renal Issues
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
Feedback
1
Potassium imbalances occur from gastrointestinal losses and diuretics.
2
Sodium imbalances occur due to impaired renal diluting capacity and concentrating
ability.
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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3
4
Calcium imbalances are not associated with impaired renal diluting capacity and
concentrating ability.
Magnesium imbalances are not associated with impaired renal diluting capacity and
concentrating ability.
PTS: 1
CON: Fluid and Electrolyte Balance
18. ANS: 1
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Identifying common health-care issues of the elderly
Chapter page reference: 061-062
Heading: Common Renal Issues
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
Feedback
1
Potassium imbalances occur from gastrointestinal losses and diuretics.
2
Sodium imbalances occur due to impaired renal diluting capacity and concentrating
ability.
3
Calcium imbalances are not caused by diuretics.
4
Magnesium imbalances are not caused by diuretics.
PTS: 1
CON: Fluid and Electrolyte Balance
19. ANS: 1
NURSINGKING.COM
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Identifying common health-care issues of the elderly
Chapter page reference: 062-064
Heading: Common Gastrointestinal Changes
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Hematologic Regulation
Difficulty: Easy
Feedback
1
A vitamin B12 deficiency often leads to anemia, which manifests with fatigue and pale
skin.
2
Osteoporosis is not a consequence of a vitamin B12 deficiency nor does it manifest with
fatigue and pale skin.
3
Atrophic gastritis is a common gastrointestinal issue that can occur with aging;
however, it is not a consequence of a vitamin B12 deficiency nor does it manifest with
fatigue and pale skin.
4
GERD is a common gastrointestinal issue that occurs with aging; however, it is not a
consequence of a vitamin B12 deficiency nor does it manifest with fatigue and pale skin.
PTS: 1
CON: Hematologic Regulation
20. ANS: 3
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Identifying common health-care issues of the elderly
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Chapter page reference: 062-064
Heading: Common Gastrointestinal Changes
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Metabolism
Difficulty: Easy
Feedback
1
This patient is not at risk for fecal impaction based on the current teaching.
2
This patient is not at risk for diabetes insipidus based on the current teaching.
3
This patient is at risk for type 2 DM based on the current teaching.
4
This patient is not at risk for GERD based on the current teaching.
PTS: 1
CON: Metabolism
21. ANS: 4
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Identifying common health-care issues of the elderly
Chapter page reference: 063-064
Heading: Nutritional Issues
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback
NURSINGKING.COM
1
A decreased, not increased, appetite is anticipated when providing care to an older adult
patient diagnosed with FTT.
2
A low, not elevated, cholesterol level is anticipated when providing care to an older
adult patient diagnosed with FTT.
3
Weight los
a patient diagnosed with FTT.
4
Dehydration, manifested with decreased elasticity and turgor of the skin, supports the
diagnosis of FTT.
PTS: 1
CON: Nutrition
MULTIPLE RESPONSE
22. ANS: 1, 4, 5
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Identifying common health-care issues of the elderly
Chapter page reference: 063-064
Heading: Nutritional Issues
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
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1.
2.
3.
4.
5.
Feedback
This is correct. Cachexia is the loss of weight and muscle mass and cannot be reversed
nutritionally. It is associated with the diagnosis of cancer.
This is incorrect. A diagnosis of osteoporosis is not associated with cachexia.
This is incorrect. A diagnosis of GERD is not associated with cachexia.
This is correct. Cachexia is the loss of weight and muscle mass and cannot be reversed
nutritionally. It is associated with the diagnosis of AIDS.
This is correct. Cachexia is the loss of weight and muscle mass and cannot be reversed
nutritionally. It is associated with the diagnosis of COPD.
PTS: 1
CON: Nutrition
23. ANS: 1, 2, 4
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Analyzing care priorities for geriatric patients
Chapter page reference: 067-069
Heading: Safety Issues
Integrated Processes: Nursing Process Assessment
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Safety
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. Falls are
concern
NUaRpriority
SINGsafety
KING
.COMthe nurse should assess for when providing
care to any older adult patient.
This is correct. Neglect is a priority safety concern the nurse should assess for when providing
care to any older adult patient.
This is incorrect. Depression is not a priority safety concern for older adult patients.
This is correct. Polypharmacy is a priority safety concern the nurse should assess for when
providing care for any older adult patient.
This is incorrect. Poor dietary intake is not a priority safety concern for older adult patients.
PTS: 1
CON: Safety
24. ANS: 1, 2
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Developing support strategies for the elderly
Chapter page reference: 067
Heading: Physical Safety
Integrated Processes: Nursing Process Assessment
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Safety
Difficulty: Moderate
1.
Feedback
This is correct. Rugs increase the risk for falls for older adult patients; therefore, this is a
physical safety risk.
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2.
This is correct. Electrical cords increase the risk for falls for older adult patients; therefore,
this is a physical safety risk.
3.
falls.
This is
physical injury.
4.
5.
physical injury.
PTS: 1
CON: Safety
25. ANS: 1, 2, 5
Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing
Chapter learning objective: Analyzing care priorities for geriatric patients
Chapter page reference: 067-068
Heading: Medication Safety
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Safety
Difficulty: Moderate
Feedback
1.
medication has been taken, which is a safety risk.
2.
NURSINGKING.COM
medication label for administration purposes, which is a safety risk.
This is incorrect. While older adult patients do experience a decrease in hearing, this is not a
factor in medication adherence and safety.
This is incorrect. While older adult patients do experience a decrease in the sense of smell, this
is not a factor in medication adherence and safety.
3.
4.
5.
prescribed medications.
PTS: 1
CON: Safety
Chapter 7: Oxygen Therapy Management
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. The nurse is providing care to a patient who has a tracheostomy. The loss of which protective mechanism
does the nurse plan to monitor this patient for during the respiratory assessment process?
1) The ability to cough
2) The filtration and humidification of inspired air
3) A decrease in the oxygen-carrying capacity of the trachea
4) The sneeze reflex initiated by irritants in the nasal passages
____
2. When conducting a respiratory assessment, the nurse notes a low-pitched sound that is continuous throughout
inspiration. Which does this lung sound indicate to the nurse?
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1)
2)
3)
4)
Narrow bronchi
Narrow trachea passages
Inflamed pleural surfaces
Blocked large airway passages
____
3. The nurse is providing care to a patient admitted with a respiratory disorder. Which laboratory finding would
be most significant?
1) Blood pH 7.32
2) Oxygen saturation 96%
3) Serum sodium 140 mg/dL
4) Hemoglobin level 12 mg/dL
____
4. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) who is
prescribed 24% oxygen at 2 L/min. Which is the best method for the nurse to use in order to administer
oxygen to this patient?
1) Face mask
2) Venturi mask
3) Nasal cannula
4) Nonrebreather mask
____
5. The nurse is providing care for a patient admitted with smoke inhalation injury who is developing acute
respiratory distress syndrome (ARDS). Which course of action regarding oxygen therapy does the nurse
anticipate for this patient?
1) Oxygen via a facial mask
2) Oxygen via a Venturi mask
3) Oxygen via a nasal cannula
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4) Oxygen via mechanical ventilation
____
6. The nurse is providing care to a patient, diagnosed with asthma, with a respiratory rate of 28 at rest who is
experiencing audible wheezing during inspiration. Which nursing diagnosis should the nurse use when
planning care for this patient?
1) Activity Intolerance
2) Impaired Tissue Perfusion
3) Ineffective Airway Clearance
4) Ineffective Breathing Pattern
____
7. The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease
experiencing hypertension and fatigue. Which nursing diagnosis is a priority when planning care for this
patient?
1) Anxiety
2) Ineffective Coping
3) Ineffective Breathing Pattern
4) Ineffective Airway Clearance
____
8. The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease
minute. The most recent chest x-ray indicates a flattened diaphragm with infiltrates. The patient is currently
febrile with an increased number of white blood cells (WBCs) noted on the latest complete blood count
(CBC). Which prescription does the nurse question for this patient based on the current data?
1) Antibiotic therapy
2) Nonsteroidal anti-inflammatory therapy
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3) Oxygen therapy via nasal cannula at 3-4 L/min
4) Bronchodilators therapy with adrenergic stimulating drugs
____
9. The nurse is providing care to an infant diagnosed with respiratory syncytial virus (RSV). The infant is
grunting with expiration. Which action by the nurse is appropriate?
1) Limit fluid intake
2) Place the infant in a supine position
3) Perform chest physiotherapy to clear the nasal passages
4) Suction the airway to relieve the current obstruction that is noted
____ 10. Which nursing action determines
saturation via oximetry?
1) Using a site with adequate perfusion
2) Ensuring the any nail polish is removed
3) Leaving the sensor in place for a minimum of ten seconds
4) Assessing the heart rate and comparing it with the displayed pulse
____ 11.
documented?
1) Snoring sounds
2) Gurgling sounds
3) Low-pitched bubbling
4) High-pitched squeaking
____ 12.
1)
2)
3)
4)
Snoring sounds
Gurgling sounds
Low-pitched bubbling
High-pitched squeaking
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____ 13. Which position should the nurse place a patient prior to performing in-line suctioning?
1) Prone
2) Supine
3)
4) Semi____ 14. When conducting in-line suctioning, which is the maximum amount of time for each suctioning event?
1) 10 seconds
2) 30 seconds
3) 45 seconds
4) 60 seconds
____ 15. When conducting in-line suctioning on a patient, which amount of time should the nurse allow as a rest period
between suction procedures?
1) 5 to 15 seconds
2) 10 to 20 seconds
3) 15 to 25 seconds
4) 20 to 30 seconds
____ 16. The nurse is performing in-line suctioning when the patient experiences a drop in oxygen saturation and
bradycardia. Which nursing action is appropriate?
1) Continue suctioning and administer 50% oxygen
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2) Discontinue suctioning and prepare for resuscitation
3) Discontinue suctioning and administer 100% oxygen
4) Continue suctioning and administer prescribed epinephrine
____ 17. The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm beeps and
the nurse notes a mucous plug in the endotracheal (ET) tube. Which action by the nurse is appropriate?
1) Suction, as needed
2) Insert an oral airway
3) Assess for asymmetric chest rise
4) Empty water from the ventilator tubing
____ 18. The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm beeps and
the nurse notes the patient is biting down on the endotracheal (ET) tube. Which action by the nurse is
appropriate?
1) Suction, as needed
2) Insert an oral airway
3) Assess for asymmetric chest rise
4) Empty water from the ventilator tubing
____ 19. The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm beeps and
the nurse notes a collection of moisture in the ventilator tubing. Which action by the nurse is appropriate?
1) Empty the water
2) Suction, as needed
3) Insert an oral airway
4) Assess for asymmetric chest rise
____ 20. The nurse is providing education toNaUpatient
is N
prescribed
RSINwho
GKI
G.COMoxygen in the home environment. Which
statement made by the patient indicates the need for further education?
1)
2)
3)
4)
____ 21. The nurse is providing education to a patient regarding the use of an incentive spirometer. Which patient
statement indicates the need for further education?
1)
2)
3)
4)
____ 22. The nurse is providing care to a patient who is mechanically ventilated. In order to decrease the risk for
aspiration, which action by the nurse is appropriate?
1) Elevate the head of the bed between 30 to 45 degrees
2) Limit each suctioning event to no more than 10 seconds
3) Perform chest physiotherapy as prescribed by the practitioner
4) Ensure an NPO status is maintained for the length of the prescribed treatment
____ 23. The nurse is providing care to a patient who is being weaned from mechanical ventilation. Which finding
would necessitate the continuation of mechanical ventilation if noted during the assessment process?
1) An FIO2 less than or equal to 0.4 0.5
2) A PEEP less than or equal to 5 8 cm H2O
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3) A pH greater than 7.25 during spontaneous ventilation
4) A drop in blood pressure indicating a hypotensive state
____ 24. The nurse is providing care to a patient who is recovering from facial trauma who requires high-flow oxygen
therapy. Which method of oxygen delivery should the nurse plan for when providing care?
1) Face tent
2) Nasal cannula
3) Venturi mask
4) Nonrebreather mask
____ 25. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) who
requires supplemental oxygen. Which is the anticipated flow rate range by nasal cannula (NC) when
providing care for this patient?
1) 1-2 L/min
2) 2-3 L/min
3) 3-4 L/min
4) 4-5 L/min
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. Which independent nursing actions are appropriate to include in the plan of care for a patient who is
experiencing an alteration in oxygenation? Select all that apply.
1) Providing suctioning
2) Assisting with positioning
3) Prescribing bronchodilators NURSINGKING.COM
4) Monitoring activity tolerance
5) Encouraging deep breathing exercises
____ 27. Which should the nurse include in the plan of care for a mechanically ventilated patient who is receiving care
based on a ventilator bundle? Select all that apply.
1) Elevating the head of the bed
2) Ensuring a sedation vacation each day
3) Conducting a readiness to wean assessment
4) Administering a prescribed peptic ulcer prophylactic regimen
5) Avoiding the use of compression stockings during immobility
____ 28.
Select all that apply.
1) The SpO2 result
2) The current vital signs
3)
4) The type and amount of oxygen therapy in use
5) The education provided to the patient and family
____ 29. The nurse suctions a mechanically ventilated patient using in-line suctioning. Which information should the
nurse document in the medical record after the procedure is completed? Select all that apply.
1) The amount of secretions
2) The color of the secretions
3) The consistency of the secretions
4)
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5) The amount of oxygen the patient received during the procedure
____ 30. Which actions by the nurse are considered best practice when providing tracheostomy care? Select all that
apply.
1) Asking the family to leave the bedside
2) Suctioning at the start and finish of the procedure
3) Applying appropriate personal protective equipment
4) Inspecting the site of infection, irritation, and skin breakdown
5) Rinsing a disposable inner cannula with sterile water and drying
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Chapter 7: Oxygen Therapy Management
Answer Section
MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Explaining indications, management, and complications of artificial airways
Chapter page reference: 085-092
Heading: Tracheostomy
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
The client can still cough and sneeze, and there is no decrease in the oxygen-carrying
capacity of the trachea.
2
When the nasal passages are bypassed, as they would be in the case of a client with a
tracheostomy, the filtration, humidification, and warming of the nasal passages are also
bypassed.
3
The client can still cough and sneeze, and there is no decrease in the oxygen-carrying
capacity of the trachea.
4
The client can still cough and sneeze, and there is no decrease in the oxygen-carrying
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capacity of the trachea.
PTS: 1
CON: Oxygenation
2. ANS: 4
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Reviewing concepts of oxygenation
Chapter page reference: 084-085
Heading: ETT Management
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Wheezing is created by narrow bronchi.
2
Stridor is the sound created by narrow tracheal passages.
3
A low-pitched grating sound is created by inflamed pleural surfaces.
4
The nurse auscultated rhonchi, which are low-pitched sounds that are continuous
throughout inspiration. Rhonchi suggests blockage of large airway passages, which may
be cleared with coughing.
PTS: 1
CON: Oxygenation
3. ANS: 1
Chapter number and title: 7, Oxygen Therapy Management
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Chapter learning objective: Reviewing concepts of oxygenation
Chapter page reference: 076
Heading: Oxygen Monitoring and Measurement
Integrated Processes: Nursing Process Evaluation
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
Normal blood pH is 7.35 7.45. A decreased pH indicates that the client is experiencing
acidosis, which indicates an alteration in oxygenation.
2
Oxygen saturation of 96% is within normal limits.
3
The serum sodium does not impact the oxygen capacity of the body.
4
The hemoglobin level affects the amount of oxygen that can be carried in the blood;
however, the value is within normal limits.
PTS: 1
CON: Oxygenation
4. ANS: 3
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Describing methods of oxygen delivery
Chapter page reference: 077
Heading: Nasal Cannula
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
NURSINGKING.COM
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
A face mask is better suited to deliver oxygen at higher percentages and flow rates.
2
A Venturi mask is better suited to deliver oxygen at higher percentages and flow rates.
3
The oxygen delivery device that would safely administer 24% oxygen at the flow rate
of 2 liters per minute is through nasal cannula.
4
A nonrebreather mask is better suited to deliver oxygen at higher percentages and flow
rates.
PTS: 1
CON: Oxygenation
5. ANS: 4
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation
Chapter page reference: 095-101
Heading: Overview of Mechanical Ventilation
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
therapy alone; therefore, oxygen via face mask is not anticipated.
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2
3
4
With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
therapy alone; therefore, oxygen via a Venturi mask is not anticipated.
With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
therapy alone; therefore, oxygen via nasal cannula is not anticipated.
With mechanical ventilation, the FiO2 (fraction of inspired oxygen the percentage of
oxygen administered) is set at the lowest possible level to maintain a PaO2 higher than
60 mmHg and oxygen saturation of approximately 90%. It is important to remember
that mechanical ventilation does not cure ARDS; it simply supports respiratory function
while the underlying problem is identified and treated.
PTS: 1
CON: Oxygenation
6. ANS: 4
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Reviewing concepts of oxygenation
Chapter page reference: 099
Heading: Nursing Diagnoses
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
There is not enough information to determine if this nursing diagnosis is appropriate.
2
There is not enough information to determine if this nursing diagnosis is appropriate.
3
There is not enough information to determine if this nursing diagnosis is appropriate.
NURSINGKING.COM
4
The patient is experiencing tachypnea and wheezing; therefore, the patient is
experiencing an ineffective breathing pattern necessitating the use of this nursing
diagnosis when planning care.
PTS: 1
CON: Oxygenation
7. ANS: 3
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Reviewing concepts of oxygenation
Chapter page reference: 099
Heading: Nursing Diagnoses
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Hard
Feedback
1
There is no information to support Anxiety or Ineffective Coping.
2
There is no information to support Anxiety or Ineffective Coping.
3
The patient's respiratory rate of 32 per minute is an indication of an ineffective
breathing pattern. The elevated blood pressure and fatigue are indications of a
compromised respiratory status. The diagnosis of Ineffective Breathing Pattern would
be the priority for the patient at this time.
4
There is no information to support Ineffective Airway Clearance, as there is no mention
that the client is coughing.
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PTS: 1
CON: Oxygenation
8. ANS: 3
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Describing methods of oxygen delivery
Chapter page reference: 076
Heading: Contraindications to Oxygen Administration
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
This is an appropriate prescription for this patient.
2
This is an appropriate prescription for this patient.
3
The nurse should be concerned about the order for oxygen to be provided at 3-4
liters/minute. This amount of oxygen is too much for a patient with COPD because the
patient's breaths are stimulated by a hypoxic drive and this disease process causes the
body to retain carbon dioxide. Providing this much oxygen can result in an increase in
carbon dioxide levels, leading to respiratory failure. Oxygen for this patient should be
at a lower rate, such as 1-2 liters/minute, with close assessments of the patient's
breathing status.
4
This is an appropriate prescription for this patient.
PTS: 1
CON: Oxygenation
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9. ANS: 4
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Reviewing concepts of oxygenation
Chapter page reference: 084-085
Heading: ETT Management
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Fluids should be increased to thin secretions.
2
Laying the child on his back will not improve the child's ability to breathe.
3
Performing chest physiotherapy is not an appropriate action to assist the child to clear
the nasal passages.
4
Grunting is seen with partial airway obstruction caused by increased secretions and
edema. The nurse should suction the airway to relieve the obstruction.
PTS: 1
CON: Oxygenation
10. ANS: 4
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Reviewing concepts of oxygenation
Chapter page reference: 076-077
Heading: Oxygen Monitoring and Measurement
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Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
1
Feedback
While using a site with adequate perfusion is important, this action does not determine
2
via oximetry.
While ensuring that any nail polish is removed is important, this action does not
3
4
saturation via oximetry.
While leaving the sensor in place for a minimum of ten seconds is important, this action
does not determine the accuracy of the d
oxygen saturation via oximetry.
Assessing the heart rate and comparing it with the displayed pulse is the nursing action
saturation via oximetry.
PTS: 1
CON: Oxygenation
11. ANS: 4
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Reviewing concepts of oxygenation
Chapter page reference: 084-085
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Heading: ETT Management
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Snoring sounds indicate rhonchi, caused by airflow obstruction from thick secretions or
fluid in the large airways.
2
Gurgling sounds indicate crackles. On inhalation, air comes in contact with secretions
in the trachea and large bronchi.
3
Loud, low-pitched bubbling sounds indicate crackles. On inhalation, air comes in
contact with secretions in the trachea and large bronchi.
4
Wheezing is characterized as musical, high-pitched squeaking that indicates narrowed
passages caused by secretions, bronchospasm, edema, and inflammation.
PTS: 1
CON: Oxygenation
12. ANS: 1
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Reviewing concepts of oxygenation
Chapter page reference: 084-085
Heading: ETT Management
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
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Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Snoring sounds indicate rhonchi, caused by airflow obstruction from thick secretions or
fluid in the large airways.
2
Gurgling sounds indicate crackles. On inhalation, air comes in contact with secretions
in the trachea and large bronchi.
3
Loud, low-pitched bubbling sounds indicate crackles. On inhalation, air comes in
contact with secretions in the trachea and large bronchi.
4
Wheezing is characterized as musical, high-pitched squeaking that indicates narrowed
passages caused by secretions, bronchospasm, edema, and inflammation.
PTS: 1
CON: Oxygenation
13. ANS: 4
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Explaining indications, management, and complications of artificial airways
Chapter page reference: 084-085
Heading: ETT Management
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
NURSINGKING.COM
1
A prone position is not appropriate for a patient who requires in-line suctioning.
2
A supine position is not appropriate for a patient who requires in-line suctioning.
3
-line suctioning.
4
A high-line suctioning.
Elevating the head of bed will allow for easier ventilation for the patient.
PTS: 1
CON: Oxygenation
14. ANS: 1
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Explaining indications, management, and complications of artificial airways
Chapter page reference: 084-085
Heading: ETT Management
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
Each suctioning event should last no longer than 10 seconds. Suctioning lasting longer
than 10 seconds causes hypoxia, cardiopulmonary compromise, and a vagal response.
2
Each suctioning event should not last 30 seconds as this can cause hypoxia,
cardiopulmonary compromise, and a vagal response.
3
Each suctioning event should not last 45 seconds as this can cause hypoxia,
cardiopulmonary compromise, and a vagal response.
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4
Each suctioning event should not last 60 seconds as this can cause hypoxia,
cardiopulmonary compromise, and a vagal response.
PTS: 1
CON: Oxygenation
15. ANS: 2
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Explaining indications, management, and complications of artificial airways
Chapter page reference: 084-085
Heading: ETT Management
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
A rest period of 5 to 15 seconds is not adequate between suction procedures.
2
A rest period of 10 to 20 seconds is an appropriate time frame between suction
procedures. This time frame decreases the risk for hypoxia, dysrhythmia, and
bronchospasm.
3
A rest period of 15 to 25 seconds is not appropriate between suction procedures.
4
A rest period of 20 to 30 seconds is not appropriate between suction procedures.
PTS: 1
CON: Oxygenation
16. ANS: 3
Chapter number and title: 7, Oxygen
NUTherapy
RSINManagement
GKING.COM
Chapter learning objective: Explaining indications, management, and complications of artificial airways
Chapter page reference: 084-085
Heading: ETT Management
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
1
2
3
4
Feedback
The nurse should not continue suctioning and administer 50% oxygen if in-lining
suctioning causes a drop in oxygen saturation and bradycardia.
While the nurse should discontinue suctioning, it is not necessary to prepare for
resuscitation.
When in-line suctioning causes a drop in oxygen saturation and bradycardia, the nurse
discontinues suctioning and administers 100% oxygen.
The nurse should not continue suctioning and administer prescribed epinephrine if inlining suctioning causes a drop in oxygen saturation and bradycardia.
PTS: 1
CON: Oxygenation
17. ANS: 1
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation
Chapter page reference: 097
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Heading: Pressure Support Ventilation
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
A mucous plug often causes a high-pressure alarm when a patient is being mechanically
ventilated. The appropriate action by the nurse is to suction the ET tube in order to
remove the mucous plug.
2
An oral airway is inserted if the patient is biting on the ET tube, which can cause a
high-pressure alarm for a patient who is being mechanically ventilated.
3
Assessing for asymmetric chest rise is an appropriate action if the high-pressure alarm
is caused by a pneumothorax, not a mucous plug.
4
Emptying water in the ventilator tubing is an appropriate action if the high-pressure
alarm is caused by water collection, not a mucous plug.
PTS: 1
CON: Oxygenation
18. ANS: 2
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation
Chapter page reference: 097
Heading: Pressure Support Ventilation
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
NURSINGKING.COM
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
A mucous plug often causes a high-pressure alarm when a patient is being mechanically
ventilated. The appropriate action by the nurse is to suction the ET tube in order to
remove the mucous plug.
2
An oral airway is inserted if the patient is biting on the ET tube, which can cause a
high-pressure alarm for a patient who is being mechanically ventilated.
3
Assessing for asymmetric chest rise is an appropriate action if the high-pressure alarm
is caused by a pneumothorax, not when the patient is biting down on the ET tube.
4
Emptying water in the ventilator tubing is an appropriate action if the high-pressure
alarm is caused by water collection, not when the patient is biting down on the ET tube.
PTS: 1
CON: Oxygenation
19. ANS: 1
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation
Chapter page reference: 097
Heading: Pressure Support Ventilation
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
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Difficulty: Moderate
Feedback
1
Emptying water in the ventilator tubing is an appropriate action if the high-pressure
alarm is caused by moisture collection.
2
A mucous plug often causes a high-pressure alarm when a patient is being mechanically
ventilated. The appropriate action by the nurse is to suction the ET tube in order to
remove the mucous plug.
3
An oral airway is inserted if the patient is biting on the ET tube, which can cause a
high-pressure alarm for a patient who is being mechanically ventilated.
4
Assessing for asymmetric chest rise is an appropriate action if the high-pressure alarm
is caused by a pneumothorax, not a collection of moisture in the ventilator tubing.
PTS: 1
CON: Oxygenation
20. ANS: 3
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Describing methods of oxygen delivery
Chapter page reference: 081-082
Heading: Oxygen Delivery
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Analysis [Analyzing]
Concept: Safety
Difficulty: Hard
Feedback
1
Oxygen should be kept at least 6 feet from sources of heat, such as the stove. This
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statement indicates correct understanding of the information presented.
2
3
4
statement indicates correct understanding of the information presented.
Oxygen should be stored upright, not on its side. This statement indicates the need for
further education.
A fire extinguisher should be maintained in the home and stored close to where the
oxygen is stored. This statement indicates correct understanding of the information
presented.
PTS: 1
CON: Safety
21. ANS: 2
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Clarifying indications and nursing implications for the following respiratory care
modalities: Incentive Spirometry.
Chapter page reference: 093
Heading: Nursing Implications
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Hard
Feedback
1
A sitting, or highspirometer. This statement indicates correct understanding of the information presented.
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2
3
4
The device should be used 5 to 10 times each hour while awake. This statement
indicates the need for further education.
The patient exhales completely prior to placing the mouth on the device. This statement
indicates correct understanding of the information presented.
The patient should hold the breath for three seconds and then exhale completely. This
statement indicates correct understanding of the information presented.
PTS: 1
CON: Oxygenation
22. ANS: 1
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation
Chapter page reference: 099
Heading: Ventilator-Associated Pneumonia
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Unless contraindicated, any patient who is mechanically ventilated should have the
head of the bed elevated at 30 to 45 degrees to decrease the risk for aspiration.
2
While it is important to limit each suctioning event to 10 seconds in length, this is not
an action to decrease the risk for aspiration.
3
While chest physiotherapy is often prescribed, this action is not intended to decrease the
risk for aspiration.
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4
While many patients who are mechanically ventilated will receive parenteral or enteral
nutrition, an NPO status is unnecessary to decrease the risk for aspiration.
PTS: 1
CON: Oxygenation
23. ANS: 4
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation
Chapter page reference: 100-101
Heading: Patient Criteria for Weaning
Integrated Processes: Nursing Process Evaluation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
1
2
3
4
Feedback
An FIO2 less than or equal to 0.4 0.5 indicates the patient is able to be weaned from
mechanical ventilation.
A PEEP less than or equal to 5 8 cm H2O indicates the patient is able to be weaned
from mechanical ventilation.
A pH greater than 7.25 during spontaneous ventilation indicates the patient is able to be
weaned from mechanical ventilation.
Hemodynamic instability, such as a drop in blood pressure to a hypotensive state,
indicates the patient is not a candidate for being weaned from mechanical ventilation.
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PTS: 1
CON: Oxygenation
24. ANS: 1
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Describing methods of oxygen delivery
Chapter page reference: 079-080
Heading: High-Flow Delivery Devices
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
1
2
3
4
Feedback
A face-tent is a high-flow delivery device of oxygen that is appropriate for the patient
who requires supplemental oxygen if facial trauma is experienced.
While a nasal cannula might be appropriate for a patient who needs a low-flow delivery
device, this is not appropriate for the patient who requires a high-flow delivery device.
A Venturi mask delivers a high-flow of oxygen; however, facial trauma makes this an
unrealistic choice.
A nonrebreather mask is not an appropriate for the high-flow delivery of oxygen.
PTS: 1
CON: Oxygenation
25. ANS: 1
Chapter number and title: 7, Oxygen Therapy Management
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Chapter learning objective: Describing methods of oxygen delivery
Chapter page reference: 077
Heading: Nasal Cannula
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Oxygenation
Difficulty: Easy
1
2
3
4
Feedback
A low flow rate of 1-2 L/min via NC is anticipated for a patient with COPD. The
patient who retains CO2, such as the patient with COPD, will use the lower amount of
oxygen (1 2 L/min) so the patient does not lose his or her hypoxic drive to breathe.
This flow rate is higher than anticipated when providing care for a patient with COPD
who requires supplement oxygen via NC.
This flow rate is higher than anticipated when providing care for a patient with COPD
who requires supplement oxygen via NC.
This flow rate is higher than anticipated when providing care for a patient with COPD
who requires supplement oxygen via NC.
PTS: 1
CON: Oxygenation
MULTIPLE RESPONSE
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26. ANS: 1, 2, 4, 5
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Reviewing concepts of oxygenation
Chapter page reference: 074-076
Heading: Overview of Oxygen Therapy
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. Suctioning is an independent nursing action.
This is correct. Repositioning is an independent nursing action.
This is incorrect. Prescribing bronchodilators is outside the scope of nursing practice.
This is correct. Monitoring activity tolerance is an independent nursing action.
This is correct. Encouraging deep breathing exercises is an independent nursing action.
PTS: 1
CON: Oxygenation
27. ANS: 1, 2, 3, 4
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation
Chapter page reference: 099-100
Heading: Nursing Management for a Mechanically Ventilated Patient
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Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Evidence-Based Practice
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. Elevation of the head of the bed is included in the plan of care for a patient
who is receiving care based on a ventilator bundle.
This is correct. A sedation vacation each day is included in the plan of care for a patient who
is receiving care based on a ventilator bundle.
This is correct. Assessing for readiness to be weaned is included in the plan of care for a
patient who is receiving care based on a ventilator bundle.
This is correct. Administering the prescribed peptic ulcer prophylactic regimen is included in
the plan of care for a patient who is receiving care based on a ventilator bundle.
This is incorrect. The patient is placed on deep vein thrombosis prophylaxis, which should
include the use of compression stockings during immobility.
PTS: 1
CON: Evidence-Based Practice
28. ANS: 1, 2, 4, 5
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Describing methods of oxygen delivery
Chapter page reference: 076-077
Heading: Oxygen Monitoring and Measurement
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Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Communication; Oxygenation
Difficulty: Moderate
1.
Feedback
This is correct. The SpO2 result is documented in the medical record when monitoring a
2.
This is correct. The current vital signs are documented in the medical record when monitoring
3.
4.
that is documented in the medical record when monitoring oxygenation saturation via
oximetry.
This is correct. The type, and amount, of oxygen therapy in use is documented in the medical
5.
This is correct. The education provided to the patient and family is documented in the medical
PTS: 1
CON: Communication | Oxygenation
29. ANS: 1, 2, 3, 4
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation
Chapter page reference: 084-085
Heading: ETT Management
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Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Communication; Oxygenation
Difficulty: Moderate
1.
Feedback
This is correct. The amount of secretions collected during in-line suctioning is documented in
2.
This is correct. The color of secretions collected during in-line suctioning is documented in the
3.
This is correct. The consistency of secretions collected during in-line suctioning is
4.
5.
This is incorrect. The amount of oxygen the patient received during the suctioning procedure
is documented on a separate flow sheet, not the medical record.
PTS: 1
CON: Communication | Oxygenation
30. ANS: 3, 4
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Explaining indications, management, and complications of artificial airways
Chapter page reference: 090-091
Heading: Tracheostomy Care
Integrated Processes: Nursing Process Implementation
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Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
This is incorrect. The family should be educated about the procedure but there is no need to
ask the family to leave the bedside.
This is incorrect. The tracheostomy should be suctioned at the start of the procedure and as
needed.
This is correct. Personal protective equipment is applied to decrease the risk for infection.
This is correct. The tracheostomy site is assessed for infection, irritation, and skin breakdown.
This is incorrect. A reusable, not disposable, inner cannula is rinsed with sterile water and
dried prior to reinsertion.
1.
2.
3.
4.
5.
PTS: 1
CON: Oxygenation
Chapter 8: Fluid and Electrolyte Management
Multiple Choice
Identify the choice that best completes the statement or answers the question.
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____
1. The nurse is providing care to a patient who is diagnosed with multisystem fluid volume deficit. The patient is
currently experiencing tachycardia and decreased urine output along with skin that is pale and cool to the
touch. The patient has a decreased urine output. W
nurse include when educating the family?
1) Congestive heart failure
2) Rapidly infused intravenous fluids
3) Natural compensatory mechanisms
4) Pharmacological effects of a diuretic
____
2. The nurse is providing care to a patient whose serum calcium levels have increased since a surgical procedure
performed three days prior. Which intervention should the nurse implement to decrease the risk for the
development of hypercalcemia?
1) Monitor vital signs every eight hours
2) Encourage ambulation three times a day
3) Irrigate the Foley catheter one time a day
4) Recommend turning, coughing, and deep breathing every two hours
____
3. Which intervention should the nurse implement for a patient whose serum phosphorus level is 2.0 mg/dL?
1) Enforce contact precautions
2) Strain all urine for kidney stones
3) Encourage consumption of milk and yogurt
4) Discourage the consumption of a high-calorie diet
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____
4. The nurse is providing care to a patient who is prescribed furosemide as part of the treatment for congestive
encourage the patient to eat based on this data?
1) Peas
2) Iced tea
3) Bananas
4) Baked fish
____
5. A patient is admitted to the emergency department (ED) for dehydration. The patient is 154 lbs. Which urine
output indicate the rehydration efforts for this patient have been effective?
1) 20 mL/hr
2) 25 mL/hr
3) 30 mL/hr
4) 35 mL/hr
____
6. An older adult patient, who appears intermittently confused, is admitted to the hospital after a fall. Based on
the current data, which is the patient at an increased risk for developing?
1) Brain attack
2) Dehydration
3) Hemorrhage
4) Kidney damage
____
7. The nurse is providing care to an older adult patient who is receiving intravenous (IV) fluids at 150 mL/hr.
The patient is currently exhibiting crackles in the lungs, shortness of breath, and jugular vein distention.
Which complication of IV fluid therapy does the nurse suspect the patient is experiencing?
1) Speed shock
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2) Fluid volume excess
3) Anaphylactic reaction
4) Pulmonary embolism
____
8. A patient is prescribed 20 mEq of potassium chloride due to excessive vomiting. Which is the rationale for
this drug the nurse should provide to the patient?
1) It controls and regulates water balance in the body.
2) It is used in the body to synthesize ingested protein.
3) It is vital in regulating muscle contraction and relaxation.
4) It is needed to maintain skeletal, cardiac, and neuromuscular activity.
____
9. Which data collected by the nurse during the assessment process places the older adult patient at risk for
dehydration?
1) Poor skin turgor
2) Body mass index of 20.5
3) Blood pressure of 140/98 mmHg
4) Water intake of 2 glasses per day
____ 10. The nurse is reviewing laboratory values for a female patient suspected of having a fluid imbalance. Which
laboratory value evaluated by the nurse supports the diagnosis of dehydration?
1) Hematocrit 30%
2) Hematocrit 53%
3) Serum potassium 3.8 mEq/L
4) Serum osmolality 230 mOsm/kg
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____ 11. The nurse is analyzing the intake and output record for a patient being treated for dehydration. The patient
weighs 176 lbs. and had a 24-hour intake of 2,000 mL and urine output of 1,200 mL. Based on this data,
which conclusion by the nurse is the most appropriate?
1) Treatment has not been effective.
2) Treatment needs to include a diuretic.
3) Treatment is effective and should continue.
4) Treatment has been effective and should end.
____ 12. The nurse is providing care to a patient who seeks emergency treatment for headache and nausea. The patient
this patient?
1)
2)
3)
4)
Drink juices and carbonated sodas.
Eat something salty when drinking water.
Eat something sweet when drinking water.
Double the amount of water being ingested.
____ 13. An older adult patient, who lives in a long-term care facility, presents in the emergency department (ED) due
to fever, nausea, and vomiting over the past two days. The patient denies thirst. The urine dipstick indicates a
decreased urine specific gravity. Which medical diagnosis should the nurse anticipate when planning care for
this patient?
1) Dehydration
2) Hypertension
3) Fluid overload
4) Congestive heart failure
____ 14. The nurse receives shift report on a pediatric medical-surgical unit. The nurse has been assigned four patients
NURS
INtoGK
INGfirst
.CO
M on the increased risk for dehydration?
for the shift. Which child does the nurse
plan
assess
based
1) A 4-year-old child with a broken leg
2) A 15-month-old child with tachypnea
3) A 16-year-old child with migraine headaches
4) A 10-year-old child with cellulitis of the left leg
____ 15. The nurse is teaching a group of children and their parents about the prevention of heat-related illness during
exercise. Which statement by a parent indicates an appropriate understanding of the preventive techniques
taught during the teaching session?
1)
2)
3)
-20 minutes during the
4)
____ 16. The nurse is providing care to an adult patient admitted with dehydration and hyponatremia. Which medical
condition supports the current nursing diagnosis of Electrolyte Imbalance?
1) Osmotic pressure
2) Hydrostatic pressure
3) Isotonic dehydration
4) Hypotonic dehydration
____ 17. The nurse is caring for a patient who is receiving intravenous fluids postoperatively following cardiac
surgery. The nurse is aware that this patient is at risk for fluid volume excess. The family asks why the patient
is at risk for this condition. Which response by the nurse is the most appropriate?
1)
2)
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3)
4)
response to the stres
____ 18. The nurse is providing care to a patient following hemodialysis. The patient is experiencing tachycardia and
decreased urine output along with skin that is pale and cool to the touch. Which goal of hemodialysis does the
nurse determine the patient has not met based on the current data?
1) Cardiac decompensation
2) A reduction of extracellular fluid
3) The effects of rapidly infused intravenous fluids
4) The pharmacological effects of a diuretic infused in the dialysate
____ 19. The nurse is caring for a patient with congestive heart failure who is admitted to the medical-surgical unit
hypokalemic state?
1) Cortisol
2) Demerol
3) Skelaxin
4) Nonsteroidal anti-inflammatory drugs (NSAIDs)
____ 20. The nurse is caring for a patient with a potassium level of 5.9 mEq/L. The health-care provider prescribes
by the nurse is the most appropriate?
1)
2)
3)
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4)
____ 21. A patient is admitted to the emergency department (ED) for fluid volume deficit. Which body system should
the nurse focus to determine the cause of this imbalance when assessing this patient?
1) Genitourinary
2) Cardiovascular
3) Gastrointestinal
4) Musculoskeletal
____ 22. The nurse is instructing a patient with heart failure about a prescribed sodium-restricted diet. Which patient
statement indicates that additional teaching is required?
1)
2)
3)
4)
____ 23.
s care based on
the nursing diagnosis of Excess Fluid Volume. Which assessment data supports this nursing diagnosis?
1) Wheezing in the lungs
2) Generalized weakness
3) Bowel sounds positive in four quadrants
4) Pitting edema in the lower extremities
____ 24. A patient with acute renal failure has jugular vein distention, lower extremity edema, and elevated blood
pressure. Based on this data, which nursing diagnosis is the most appropriate?
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1)
2)
3)
4)
Risk for Infection
Excess Fluid Volume
Ineffective Renal Tissue Perfusion
Risk for Altered Cardiac Perfusion
____ 25. The nurse is caring for a patient admitted with hypertension and chronic renal failure who receives
hemodialysis three times per week. The nurse is assessing the patient's diet and notes the use of salt
substitutes. When teaching the patient to avoid salt substitute, which rationale supports this teaching point?
1) They can potentiate hyperkalemia.
2) They will cause the client to retain fluid.
3) They will increase the risk of AV fistula infection.
4) They will interact with the client's antihypertensive medications.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. The nurse is providing care to a patient who is exhibiting clinical manifestations of a fluid and electrolyte
deficit. Based on this data, which health-care provider prescriptions does the nurse prepare to implement?
Select all that apply.
1) Administer diuretics
2) Administer antibiotics
3) Initiate hypodermoclysis
4)
5) Initiate intravenous therapy
NUmg/dL.
RSINBased
GKINonG.
COdata,
M which interventions should the nurse plan
____ 27. A patient's serum sodium level is 150
this
for this patient? Select all that apply.
1) Elevate the head of the bed.
2) Instruct on a low-sodium diet.
3) Monitor heart rate and rhythm.
4) Administer diuretics as prescribed.
5) Administer potassium supplement as prescribed.
____ 28. The school nurse is preparing a class session for high school students on ways to maintain fluid balance
during the summer months. Which interventions should the nurse recommend Select all that apply.
1) Drink diet soda.
2) Reduce the intake of coffee and tea.
3) Drink more fluids during hot weather.
4) Drink flat cola or ginger ale if vomiting.
5) Exercise during the hours of 10 am and 2 pm.
____ 29. The nurse is concerned that an older adult patient is at risk for developing acute renal failure. Which
Select all that apply.
1) Diagnosed with hypotension
2) Recent aortic valve replacement surgery
3) Total hip replacement surgery five years ago
4) Taking medication for type 2 diabetes mellitus
5) Prescribed high doses of intravenous antibiotics
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____ 30. The community nurse visits the home of a young child who is home from school because of sudden onset of
nausea, vomiting, and lethargy. The nurse suspects acute renal failure. Which clinical manifestations support
Select all that apply.
1) Edema
2) Wheezing
3) Hematuria
4) Postural hypotension
5) Elevated blood pressure
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Chapter 8: Fluid and Electrolyte Management
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Reviewing basic concepts related to fluid and electrolyte balance
Chapter page reference: 104-105
Heading: Basic Concepts of Fluids
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
1
2
3
4
Feedback
The manifestations reported are not indicative of cardiac failure in this client.
Rapidly infused intravenous fluids would not cause a decrease in urine output.
The internal vasoconstrictive compensatory reactions within the body are responsible
for the symptoms exhibited. The body naturally attempts to conserve fluid internally
specifically for the brain and heart.
A diuretic would cause further fluid loss, and is contraindicated.
URElectrolyte
SINGKIBalance
NG.COM
PTS: 1
CON: FluidN
and
2. ANS: 2
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte
disorders
Chapter page reference: 128-129
Heading: Hypercalcemia
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
This intervention is not appropriate to decrease the risk for the development of
hypercalcemia.
2
Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent
leaching of calcium from the bones into the serum.
3
This intervention is not appropriate to decrease the risk for the development of
hypercalcemia.
4
This intervention is not appropriate to decrease the risk for the development of
hypercalcemia.
PTS: 1
3. ANS: 3
CON: Fluid and Electrolyte Balance
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Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte
disorders
Chapter page reference: 129-130
Heading: Hypophosphatemia
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
There is no indication that contact precautions are needed.
2
This intervention is not appropriate for a patient who is experiencing low serum
phosphorus levels.
3
A phosphorus level of 2.0 is low, and the client will need additional dietary phosphorus.
Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that
additional phosphorus.
4
There is no indication that the patient requires a high-calorie diet.
PTS: 1
CON: Fluid and Electrolyte Balance
4. ANS: 3
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte
disorders
Chapter page reference: 120-124
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Heading: Potassium
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
Peas are not a potassiumserum potassium level.
2
Iced tea is not a potassiumserum potassium level.
3
A potassium level of 3.4 is low, so the client should be encouraged to consume
potassium-rich foods. Of the foods listed, the highest in potassium is banana.
4
Baked fish is not a potassium-rich food, which is currently needed based on the
PTS: 1
CON: Fluid and Electrolyte Balance
5. ANS: 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Explaining the significance of osmolality, osmolarity, blood urea nitrogen (BUN),
creatinine, and urine specific gravity related to fluid and electrolyte status
Chapter page reference: 105-109
Heading: Fluid and Electrolyte Regulation
Integrated Processes: Nursing Process Assessment
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Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
2
3
4
Expected urine output for an adult patient is 0.5 mL/kg/hr. The patient currently weighs
70 kg; therefore, adequate urine output would be at least 35 mL/hr.
PTS: 1
CON: Fluid and Electrolyte Balance
6. ANS: 2
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of
dehydration, hypovolemia, and hypervolemia
Chapter page reference: 106-108
Heading: Regulatory Mechanisms
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
Feedback
1
The risks for kidney damage, brain attack, and bleeding are not specifically related to
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aging or fluid and electrolyte issues.
2
During the aging process, the thirst mechanism declines. In a patient with an altered
level of consciousness, this can increase the risk of dehydration and high serum
osmolality.
3
The risks for kidney damage, brain attack, and bleeding are not specifically related to
aging or fluid and electrolyte issues.
4
The risks for kidney damage, brain attack, and bleeding are not specifically related to
aging or fluid and electrolyte issues.
PTS: 1
CON: Fluid and Electrolyte Balance
7. ANS: 2
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of
dehydration, hypovolemia, and hypervolemia
Chapter page reference: 112-114
Heading: Hypervolemia: Fluid Volume Excess
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
Feedback
1
The data does not support this complication.
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2
3
4
Fluid volume excess may occur when older adult patients receive intravenous fluids
rapidly.
The data does not support this complication.
The data does not support this complication.
PTS: 1
CON: Fluid and Electrolyte Balance
8. ANS: 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte
disorders
Chapter page reference: 120
Heading: Hypokalemia Nursing Management
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parental Therapies
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
Sodium controls and regulates water balance in the body.
2
Magnesium is used in the body to synthesize ingested protein.
3
Calcium is vital in regulating muscle contraction and relaxation.
4
Potassium is the major cation in intracellular fluids, with only a small amount found in
plasma and interstitial fluid. Potassium is a vital electrolyte for skeletal, cardiac, and
smooth muscle activity.
NURSINGKING.COM
PTS: 1
CON: Fluid and Electrolyte Balance
9. ANS: 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Discussing changes in fluid and electrolyte balance associated with aging
Chapter page reference: 105-109
Heading: Fluid and Electrolyte Regulation
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
Skin turgor is a poor indicator of fluid balance in an older adult patient.
2
A body mass index within normal limits would not contribute to dehydration. A body
mass index associated with overweight or obesity could be associated with dehydration,
as fat cells contain little or no water.
3
An elevated blood pressure could indicate fluid volume overload or sodium sensitivity.
4
A poor intake of water could indicate a loss of the thirst response, which occurs as a
normal age-related change. Since the patient only ingests two glasses of water each day,
this could indicate a reduction in the normal thirst response.
PTS: 1
CON: Fluid and Electrolyte Balance
10. ANS: 2
Chapter number and title: 8, Fluid and Electrolyte Management
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of
dehydration, hypovolemia, and hypervolemia
Chapter page reference: 110
Heading: Laboratory Values
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
1
2
3
4
Feedback
A normal hematocrit value for a female is 37% to 47%. The hematocrit level will
decrease in overhydration.
The hematocrit measures the volume of whole blood that is composed of RBCs.
Because the hematocrit is a measure of the volume of cells in relation to plasma, it is
affected by changes in plasma volume. The hematocrit increases with severe
dehydration.
Serum potassium is not an electrolyte used to determine an alteration in fluid balance.
Serum sodium values would be more appropriate.
Serum osmolality is a measure of the solute concentration of the blood and is used to
evaluate fluid balance. Normal values are 280-300 mOsm/kg. An increase in serum
osmolality indicates a fluid volume deficit; a decrease reflects fluid volume excess.
PTS: 1
CON: Fluid and Electrolyte Balance
11. ANS: 3
NUR
SINGKIManagement
NG.COM
Chapter number and title: 8, Fluid and
Electrolyte
Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte
disorders
Chapter page reference: 105-109
Heading: Fluid and Electrolyte Regulation
Integrated Processes: Nursing Process Evaluation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Fluid and Electrolyte Balance
Difficulty: Difficult
Feedback
1
Treatment has been effective.
2
A diuretic is not needed because the patient is being treated for dehydration.
3
Urinary output is normally equivalent to the amount of fluids ingested; the usual range
is 1,500-2,000 mL in 24 hours, or 40-80 mL in 1 hour (0.5 mL/kg per hour). Patients
whose intake substantially exceeds output are at risk for fluid volume excess; however,
the patient is dehydrated. The extra fluid intake is being used to improve body fluid
balance. The patient's output is 40 mL/hr, which is within the normal range.
4
Treatment has been effective; however, it should continue until the intake and output
are more balanced. Ending treatment now could further jeopardize this client's fluid
balance.
PTS: 1
12. ANS: 2
CON: Fluid and Electrolyte Balance
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Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of
dehydration, hypovolemia, and hypervolemia
Chapter page reference: 114-119
Heading: Sodium
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
Juices and carbonated sodas will not help to replace the loss of sodium.
2
Both salt and water are lost through sweating. When only water is replaced, the
individual is at risk for salt depletion. Symptoms include fatigue, weakness, headache,
and gastrointestinal symptoms such as loss of appetite and nausea. The client should be
instructed to eat something salty when drinking water to help replace the loss of
sodium.
3
Eating something sweet will not help replace the loss of sodium.
4
Doubling the amount of water being ingested could lead to hyponatremia and further
manifestations.
PTS: 1
CON: Fluid and Electrolyte Balance
13. ANS: 1
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Explaining the significance of osmolality, osmolarity, blood urea nitrogen (BUN),
NUrelated
RSIN
KINand
G.electrolyte
COM status
creatinine, and urine specific gravity
toGfluid
Chapter page reference: 108-109
Heading: Indicators of Fluid Status
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
1
2
3
4
Feedback
Older adult patients are less able to concentrate their urine, making them susceptible to
dehydration. In addition, there is a deficit of the thirst response. However, fever,
nausea, and vomiting resulting from these changes are not considered normal. The
patient's symptoms of nausea and vomiting suggest decreased intake and increased
output through vomiting, placing the client at risk for dehydration.
Hypertension does not manifest with the current clinical indicators.
Congestive heart failure and fluid overload would present with respiratory difficulty
and peripheral edema.
Congestive heart failure and fluid overload would present with respiratory difficulty
and peripheral edema.
PTS: 1
CON: Fluid and Electrolyte Balance
14. ANS: 2
Chapter number and title: 8, Fluid and Electrolyte Management
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of
dehydration, hypovolemia, and hypervolemia
Chapter page reference: 108
Heading: Insensible Losses
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Fluid and Electrolyte Balance
Difficulty: Difficult
Feedback
1
The pediatric patient with a chronic or acute condition that does not directly affect the
GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at a lower risk
than is a toddler with a condition that increases insensible water loss.
2
The pediatric patient with the greatest risk for dehydration is the child who is under 2
years of age experiencing tachypnea which increases insensible fluid loss.
3
The pediatric patient with a chronic or acute condition that does not directly affect the
GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at a lower risk
than is a toddler with a condition that increases insensible water loss.
4
The pediatric patient with a chronic or acute condition that does not directly affect the
GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at a lower risk
than is a toddler with a condition that increases insensible water loss.
PTS: 1
CON: Fluid and Electrolyte Balance
15. ANS: 3
Chapter number and title: 8, Fluid and Electrolyte Management
NURthe
SIpathophysiology,
NGKING.COclinical
M
Chapter learning objective: Describing
presentations, and management of
dehydration, hypovolemia, and hypervolemia
Chapter page reference: 109-112
Heading: Fluid Imbalances
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Analysis [Analyzing]
Concept: Fluid and Electrolyte Balance
Difficulty: Difficult
Feedback
1
Hydration should occur before and during the activity, not just at the end.
2
A combination of water and sports drinks is best to replace fluids during exercise.
3
During activity, stopping for fluids every 15-20 minutes is recommended.
4
Light-colored, light-weight clothing is best to wear during exercise activities; wearing
of dark colors can increase sweating.
PTS: 1
CON: Fluid and Electrolyte Balance
16. ANS: 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte
disorders
Chapter page reference: 116-117
Heading: Hyponatremia
Integrated Processes: Nursing Process Diagnosis
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Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
Feedback
1
Osmotic pressure pulls fluid into the capillaries, usually in response to the presence of
albumin and other plasma proteins made by the liver.
2
Hydrostatic pressure occurs when extracellular fluid volume excess occurs; the
increased fluid volume in the vascular compartment congests the veins.
3
Isotonic dehydration occurs when fluid loss is not balanced by intake, and the losses of
water and sodium are in proportion.
4
Hypotonic dehydration occurs when fluid loss is characterized by a proportionately
greater loss of sodium than water, causing serum sodium to fall below normal levels.
PTS: 1
CON: Fluid and Electrolyte Balance
17. ANS: 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of
dehydration, hypovolemia, and hypervolemia
Chapter page reference: 112-113
Heading: Hypervolemia: Fluid Volume Excess
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
NURSINGKING.COM
Difficulty: Moderate
Feedback
1
Fluid volume excess is not caused by inactivity.
2
It is unlikely that the fluid volume excess experienced by the patient is caused by
intravenous fluids.
3
Liver failure is not caused by the surgery.
4
Antidiuretic hormone (ADH) and aldosterone levels are commonly increased following
the stress response before, during, and immediately after surgery. This increase leads to
sodium and water retention. Adding more fluids intravenously can cause a fluid volume
excess and stress upon the heart and circulatory system.
PTS: 1
CON: Fluid and Electrolyte Balance
18. ANS: 2
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Describing the role of endocrine, renal, and respiratory systems in the regulation
of fluid and electrolyte balance
Chapter page reference: 112-113
Heading: Hypervolemia: Fluid Volume Excess
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
Feedback
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1
2
3
4
Cardiac decompensation would not be an expected outcome of treatment.
The patient receiving hemodialysis is expected to have a reduction of extracellular
fluid, not a fluid deficit that puts the patient at risk.
Diuretics and IV fluids are not administered during hemodialysis.
Diuretics and IV fluids are not administered during hemodialysis.
PTS: 1
CON: Fluid and Electrolyte Balance
19. ANS: 1
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Correlating laboratory data and clinical manifestations related to disorders in:
Potassium balance
Chapter page reference: 121-122
Heading: Hypokalemia
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
1
2
3
4
Feedback
Excess potassium loss through the kidneys is often caused by such medications as
corticosteroids, potassium-wasting (loop) diuretics, amphotericin B, and large doses of
some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia.
NSAIDs, narcotics, and muscle relaxers would not bring about potassium loss to cause
hypokalemia.
NURSINGKING.COM
NSAIDs, narcotics, and muscle relaxers would not bring about potassium loss to cause
hypokalemia.
NSAIDs, narcotics, and muscle relaxers would not bring about potassium loss to cause
hypokalemia.
PTS: 1
CON: Fluid and Electrolyte Balance
20. ANS: 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte
disorders
Chapter page reference: 122-124
Heading: Hyperkalemia
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
Insulin does not promote renal excretion of potassium.
2
Giving insulin to decrease serum potassium levels is not considered a safer method than
other medications that can be used.
3
Serum potassium is lowered by entering the cells; this is not controlled by serum
glucose.
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4
Serum potassium levels may be temporarily lowered by administering glucose and
insulin, which cause potassium to leave the extracellular fluid and enter cells.
PTS: 1
CON: Fluid and Electrolyte Balance
21. ANS: 3
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of
dehydration, hypovolemia, and hypervolemia
Chapter page reference: 110-112
Heading: Hypovolemia: Fluid Volume Deficit
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
The patient may demonstrate genitourinary system changes because of the fluid volume
deficit; however, this body system does not cause the deficit.
2
The patient may demonstrate cardiovascular system changes because of the fluid
volume deficit; however, this body system does not cause the deficit.
3
The most common cause of fluid volume deficit is excessive loss of gastrointestinal
fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or
intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives
and/or enemas.
4
The patient may demonstrate musculoskeletal system changes because of the fluid
NURSINGKING.COM
volume deficit; however, this body system does not cause the deficit.
PTS: 1
CON: Fluid and Electrolyte Balance
22. ANS: 1
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte
disorders
Chapter page reference: 114-119
Heading: Sodium
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Analysis [Analyzing]
Concept: Fluid and Electrolyte Balance
Difficulty: Difficult
Feedback
1
Low-sodium salt substitutes are not really sodium-free. They may contain half as much
sodium as regular salt. The patient should be instructed to use salt substitutes sparingly
because larger amounts often taste bitter instead of salty.
2
Patients should be instructed to read food labels for the amount of sodium in the food
item.
3
Baking soda and baking powder contain sodium and should be restricted on a sodiumrestricted diet.
4
In place of salt or salt substitutes, the patient should be instructed to use herbs, spices,
lemon juice, vinegar, and wine as flavoring when cooking.
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PTS: 1
CON: Fluid and Electrolyte Balance
23. ANS: 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Describing the role of endocrine, renal, and respiratory systems in the regulation
of fluid and electrolyte balance
Chapter page reference: 112-114
Heading: Hypervolemia: Fluid Volume Excess
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
Feedback
1
Wheezing in the lungs is an assessment consistent with asthma.
2
Generalized weakness may be due to whatever disease process precipitated the renal
failure.
3
Bowel sounds in four quadrants is a normal assessment finding.
4
The patient in acute renal failure will likely be edematous, as the kidneys are not
producing urine.
PTS: 1
CON: Fluid and Electrolyte Balance
24. ANS: 2
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte
NURSINGKING.COM
disorders
Chapter page reference: 112-114
Heading: Hypervolemia: Fluid Volume Excess
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
The patient is not demonstrating any manifestations that indicate a Risk for Infection.
2
Jugular vein distention, edema, and elevated blood pressure are indications of excessive
fluid. The diagnosis Excess Fluid Volume should be selected to guide this patient's
care.
3
Oliguria or reduced urine output would be a symptom associated with Ineffective Renal
Tissue Perfusion.
4
Alterations in heart rate and rhythm would be symptoms associated with Risk for
Altered Cardiac Perfusion.
PTS: 1
CON: Fluid and Electrolyte Balance
25. ANS: 1
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte
disorders
Chapter page reference: 120-124
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Heading: Potassium
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
Many salt substitutes use potassium chloride. Potassium intake is carefully regulated in
patients with renal failure, and the use of salt substitutes will worsen hyperkalemia.
2
Increases in weight do need to be reported to the health-care provider as a possible
indication of fluid volume excess, but this is not the reason why salt substitute is to be
avoided.
3
An AV fistula does need to be protected from injury and infection could be caused by
constricting clothing, venipunctures, and other items.
4
The control of hypertension is essential in the management of a client with kidney
disease, but salt substitute is not known to interact with antihypertensive medications.
PTS: 1
CON: Fluid and Electrolyte Balance
MULTIPLE RESPONSE
26. ANS: 3, 4, 5
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of
dehydration, hypovolemia, and hypervolemia
NURSINGKING.COM
Chapter page reference: 105-109
Heading: Fluid and Electrolyte Regulation
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
1.
2.
3.
Feedback
This is incorrect. Diuretics may be ordered to reduce fluid volume excess.
This is incorrect. Antibiotics are not used for fluid and electrolyte imbalance.
This is correct. Hypodermoclysis, fluid administered subcutaneously, may be employed as a
fluid delivery method, especially among older adults.
4.
5.
tatus.
This is correct. Intravenous fluids may be ordered for the patient with a fluid volume deficit if
replacement oral fluids cannot be taken in sufficient quantity.
PTS: 1
CON: Fluid and Electrolyte Balance
27. ANS: 2, 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Correlating laboratory data and clinical manifestations related to disorders in:
Sodium balance
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Chapter page reference: 114-119
Heading: Sodium
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
This is incorrect. Elevating the head of the bed would be appropriate if the patient were
demonstrating signs of fluid volume overload. This is not known at this time and would not be
a routine intervention with an elevated sodium level.
This is correct. For an elevated sodium level, the electrolyte will need to be restricted, in the
form of a low-sodium diet.
This is incorrect. Monitoring of heart rate and rhythm would be more appropriate with a
potassium imbalance.
This is correct. Diuretics will remove excess fluid being held in the body because of the extra
sodium.
This is incorrect. A potassium imbalance is not associated with a sodium imbalance. More
information is needed before this intervention would be planned or implemented.
1.
2.
3.
4.
5.
PTS: 1
CON: Fluid and Electrolyte Balance
28. ANS: 2, 3, 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Explaining nursing considerations related to patients with fluid and electrolyte
NURSINGKING.COM
disorders
Chapter page reference: 105-109
Heading: Fluid and Electrolyte Regulation
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
This is incorrect. Diet soda often contains caffeine.
This is correct. Actions to prevent fluid volume deficit during the summer months include
increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of
coffee and tea.
This is correct. Actions to prevent fluid volume deficit during the summer months include
increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of
coffee and tea.
This is correct. Actions to prevent fluid volume deficit during the summer months include
increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of
coffee and tea.
This is incorrect. Exercising between the hours of 10 am and 2 pm, considered the hottest time
of the day, should be avoided.
1.
2.
3.
4.
5.
PTS: 1
CON: Fluid and Electrolyte Balance
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29. ANS: 1, 2, 5
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Describing the role of endocrine, renal, and respiratory systems in the regulation
of fluid and electrolyte balance
Chapter page reference: 105-109
Heading: Fluid and Electrolyte Regulation
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is correct. Older adults develop acute renal failure more frequently because of the higher
incidence of serious illnesses, hypotension, major surgeries, diagnostic procedures, and
treatment with nephrotoxic drugs. Decreased kidney function associated with aging also puts
the older patient at risk for kidney failure. Hypotension, scheduled for aortic valve
risk for developing acute renal failure.
This is correct. Older adults develop acute renal failure more frequently because of the higher
incidence of serious illnesses, hypotension, major surgeries, diagnostic procedures, and
treatment with nephrotoxic drugs. Decreased kidney function associated with aging also puts
the older patient at risk for kidney failure. Hypotension, scheduled for aortic valve
risk for developing acute renal failure.
NURShistory
INGKofIN
G.Csurgery
OM and current treatment for type 2 diabetes
This is incorrect. A previous
major
mellitus are not identified risk factors for the development of acute renal failure.
This is incorrect. A previous history of major surgery and current treatment for type 2 diabetes
mellitus are not identified risk factors for the development of acute renal failure.
This is correct. Older adults develop acute renal failure more frequently because of the higher
incidence of serious illnesses, hypotension, major surgeries, diagnostic procedures, and
treatment with nephrotoxic drugs. Decreased kidney function associated with aging also puts
the older patient at risk for kidney failure. Hypotension, scheduled for aortic valve
replacement surgery, and receiving high doses of intravenous antibiotics increase this patien
risk for developing acute renal failure.
PTS: 1
CON: Fluid and Electrolyte Balance
30. ANS: 1, 3, 5
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Describing the pathophysiology, clinical presentations, and management of
dehydration, hypovolemia, and hypervolemia
Chapter page reference: 112-114
Heading: Hypervolemia: Fluid Volume Excess
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
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Feedback
This is correct. Pediatric manifestations of acute renal failure characteristically begin with a
healthy child who suddenly becomes ill with nonspecific symptoms that indicate a significant
illness or injury. These symptoms may include any combination of the following: nausea,
vomiting, lethargy, edema, gross hematuria, oliguria, and hypertension.
This is incorrect. Wheezing is not a manifestation of acute renal failure.
This is correct. Pediatric manifestations of acute renal failure characteristically begin with a
healthy child who suddenly becomes ill with nonspecific symptoms that indicate a significant
illness or injury. These symptoms may include any combination of the following: nausea,
vomiting, lethargy, edema, gross hematuria, oliguria, and hypertension.
This is incorrect. Postural hypotension is a manifestation of acute renal failure in an older
person.
This is correct. Pediatric manifestations of acute renal failure characteristically begin with a
healthy child who suddenly becomes ill with nonspecific symptoms that indicate a significant
illness or injury. These symptoms may include any combination of the following: nausea,
vomiting, lethargy, edema, gross hematuria, oliguria, and hypertension.
1.
2.
3.
4.
5.
PTS: 1
CON: Fluid and Electrolyte Balance
Chapter 9: Acid-Base Balance
Multiple Choice
Identify the choice that best completes the statement or answers the question.
NURSINGKING.COM
____
1. The nurse is providing care for an adult patient who is admitted to the emergency department (ED) after
passing out. The patient has been fasting and currently has ketones in the urine. Which acid-based imbalance
should the nurse monitor the patient for based on the current data?
1) Metabolic acidosis
2) Metabolic alkalosis
3) Respiratory acidosis
4) Respiratory alkalosis
____
2. The nurse is providing care to patient with the following laboratory values: pH 7.31; PaCO2 48 mmHg;
and a normal HCO3. Which condition should the nurse plan care for based on the current data?
1) Metabolic acidosis
2) Metabolic alkalosis
3) Respiratory acidosis
4) Respiratory alkalosis
____
3. The nurse is reviewing the latest arterial blood gas results for a patient with metabolic alkalosis. Which result
indicates that the metabolic alkalosis is compensated?
1) pH 7.32
2) HCO3 8 mEq/L
3) PaCO2 48 mmHg
4) PaCO2 18 mmHg
____
4. Which diagnostic test should the nurse anticipate when providing care to a patient diagnosed with chronic
obstructive pulmonary disease (COPD) to monitor acid-base balance?
1) Pulse oximetry
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2) Bronchoscopy
3) Sputum studies
4) Arterial blood gases
____
5. Which patient statement indicates the need for additional education regarding the use of sodium bicarbonate
to treat acidosis?
1)
2)
3)
4)
____
6. The patient is receiving sodium bicarbonate intravenously (IV) for correction of acidosis secondary to
diabetic coma. The nurse assesses the patient to be lethargic, confused, and breathing rapidly. Which is the
nurse's priority response to the current situation?
1) Stop the infusion and notify the provider because the patient is in alkalosis.
2) Increase the rate of the infusion and continue to assess the patient for symptoms of
acidosis.
3) Decrease the rate of the infusion and continue to assess the patient for symptoms of
alkalosis.
4) Continue the infusion, because the patient is still in acidosis, and notify the provider.
____
7. The nurse is planning care for an older adult patient with respiratory acidosis. Which intervention should the
1)
2)
3)
4)
____
Maintain adequate hydration.
Reduce environmental stimuli.
Administer intravenous sodium bicarbonate.
NURfluids
SING
KING.COM
Administer prescribed intravenous
carefully.
8.
nurse closely assess when providing care to this patient?
1) Perfusion
2) Cognition
3) Communication
4) Fluid and electrolytes
____
9. The nurse is caring for a comatose patient with respiratory acidosis. For which intervention will the nurse
need to collaborate when caring for this patient?
1) Monitoring vital signs
2) Measuring intake and output
3) Determining recent eating behaviors
4) Identifying current oxygen saturation level
____ 10. The nurse is analyzing the patient's arterial blood gas report, which reveals a pH of 7.15. The patient has just
suffered a cardiac arrest. Which consequences of this pH value does the nurse consider for this patient?
1) Decreased cardiac output
2) Decreased potassium levels
3) Increased magnesium levels
4) Decreased free calcium in the ECF
____ 11. The nurse is caring for a patient admitted with renal failure and metabolic acidosis. Which clinical
manifestation would indicate to the nurse that planned interventions to relieve the metabolic acidosis have
been effective?
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1)
2)
3)
4)
Tachypnea
Palpitations
Increased deep tendon reflexes
Decreased depth of respirations
____ 12. A patient with metabolic acidosis has been admitted to the unit from the emergency department (ED). The
patient is experiencing confusion and weakness. Which independent nursing intervention is the priority?
1) Protecting the patient from injury
2) Placing the patient in a high-Fowler's position
3) Administering sodium bicarbonate to the patient
4) Providing the patient with appropriate skin care
____ 13. The nurse is reviewing new orders provided by the health-care provider for a critical care patient with
metabolic acidosis. Which prescription should the nurse question?
1) Draw serum potassium levels every two hours.
2) Draw arterial blood gas samples every two hours.
3) Administer one ampule of sodium bicarbonate now.
4) Begin intravenous infusion of 0.9% normal saline.
____ 14. The nurse is providing care to a patient who has been vomiting for several days. The nurse knows that the
patient is at risk for metabolic alkalosis because gastric secretions have which characteristic?
1) Gastric secretions are acidic.
2) Gastric secretions are alkaline.
3) Gastric secretions have a foul smell.
4) Gastric secretions are green in color.
____ 15. Which is the priority nursing actionNwhen
patient who is admitted with metabolic
URSproviding
INGKINcare
G.to
COa M
alkalosis?
1) Monitoring oxygen saturation
2) Setting goals for the plan of care
3) Administering prescribed medications
4) Teaching the family about risk factors
____ 16. The nurse is providing care to a patient who is admitted after a morphine overdose. Which acid-base
1)
2)
3)
4)
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
____ 17. The nurse is providing care for a patient admitted to the unit with respiratory failure and respiratory acidosis.
1)
2)
3)
4)
Aspiration pneumonia
A recent trip to South America
Recent recovery from a cold virus
Use of ibuprofen for the control of pain
____ 18.
respiratory acidosis?
1) Aspiration
2) Pneumonia
3) Cystic fibrosis
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4) Hyperthyroidism
____ 19. A patient is admitted to the emergency department for the treatment of a drug overdose causing acute
respiratory acidosis. Which substance noted on the toxicology report is the most likely cause for the current
diagnosis?
1) PCP
2) Cocaine
3) Marijuana
4) Oxycodone
____ 20.
1)
2)
3)
4)
Irritability
Blurred vision
Daytime sleepiness
Warm, flushed skin
____ 21. The nurse is providing care to a patient who is admitted to the hospital with sudden, severe abdominal pain.
lkalosis?
1) pH is 7.35 and PaO2 is 88.
2) pH is 7.30 and HCO3 is 30.
3) pH is 7.47 and PaCO2 is 25.
4) pH is 7.33 and PaCO2 is 36.
____ 22. The client is admitted to the emergency department (ED) with symptoms of a panic attack. Based on this data,
the nurse plans care for which health problem?
1) Emesis
2) Memory loss
NURSINGKING.COM
3) Hypoventilation
4) Respiratory alkalosis
____ 23. The nurse completes discharge teaching for a patient with an anxiety disorder. Which patient statement
indicates correct understanding of information related to respiratory alkalosis?
1)
2)
3)
4)
____ 24. The nurse is reviewing the health-care provider orders for a patient who is diagnosed with respiratory
1)
2)
3)
4)
Draw arterial blood gas analysis.
Administer oxygen via face mask.
Restrict fluids to two liters per day.
Infuse one ampule of sodium bicarbonate.
____ 25. The nurse is providing care to a patient who is intubated and receiving mechanical ventilation after a motor
vehicle crash. The patient is fighting the ventilator and attempting to remove the endotracheal tube. Which
1)
2)
3)
4)
Apply wrist restraints.
Administer a prescribed sedative.
Teach the patient to take slow, deep breaths.
Discuss removing the endotracheal tube with the health-care provider.
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. Which risk factors exhibited by the patient presenting in the emergency department (ED) would place the
patient at risk for metabolic acidosis? Select all that apply.
1) Pneumonia
2) Abdominal fistulas
3) Acute renal failure
4) Hypovolemic shock
5) Chronic obstructive pulmonary disease
____ 27. A patient recently diagnosed with diabetes mellitus (DM) is hospitalized in diabetic ketoacidosis (DKA) after
The nurse is not knowledgeable about this particular religion. Which
nursing actions would be appropriate? Select all that apply.
1) Request a consult from a diabetes educator.
2) Assess the meaning and context of fasting for this religion.
3) Tell the patient that things are different now because of the new diagnosis.
4) Ask family members of the same religion to discuss fasting with the patient.
5) Encourage the patient to seek medical care if signs of ketoacidosis occur in the future.
____ 28. The nurse is caring for the patient experiencing hypovolemic shock and metabolic acidosis. Which nursing
actions are appropriate for this patient? Select all that apply.
1) Limit the intake of fluids.
2) Administer sodium bicarbonate.
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3) Monitor ECG for conduction problems.
4) Keep the bed in the locked and low position.
5) Monitor weight on admission and discharge.
____ 29. The nurse is providing care to a patient who is admitted with manifestations of metabolic alkalosis. Which
diagnostic test findings support the admitting diagnosis? Select all that apply.
1) Serum glucose level 142 mg/dL
2) Blood pH 7.47 and bicarbonate 34 mEq/L
3) Intravenous pyelogram shows kidney stones
4) Bilateral lower lobe infiltrates noted on chest x-ray
5) Electrocardiogram changes consistent with hypokalemia
____ 30. Which nursing actions are appropriate when conducting an Allen test? Select all that apply.
1)
2)
3) Tell the patient to relax the hand and then clench a fist.
4) Ensure that a second nurse is available to assist with the procedure.
5)
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Chapter 9: Acid-Base Balance
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Comparing and contrasting major acid-base disorders
Chapter page reference: 141-143
Heading: Metabolic Acidosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: pH Regulation
Difficulty: Easy
Feedback
1
The patient who is fasting is at risk for metabolic acidosis. The body recognized fasting
as starvation and begins to metabolize its own proteins into ketones, which are
metabolic acid.
2
The nurse would not monitor this patient for metabolic alkalosis.
3
The nurse would not monitor this patient for respiratory acidosis.
4
The nurse would not monitor this patient for respiratory alkalosis.
PTS: 1
CON: pH Regulation
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2. ANS: 3
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Comparing and contrasting major acid-base disorders
Chapter page reference: 140
Heading: Respiratory Acidosis
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: pH Regulation
Difficulty: Easy
Feedback
1
Uncompensated metabolic acidosis has a decreased pH, normal PaCO2, and normal
HCO3.
2
Uncompensated metabolic alkalosis has an increased pH, normal PaCO2, and increased
HCO3.
3
If the pH is decreased and the PaCO2 is increased with a normal HCO3, it is
uncompensated respiratory acidosis.
4
Uncompensated respiratory alkalosis has an increased pH, decreased PaCO2, and
normal HCO3.
PTS: 1
CON: pH Regulation
3. ANS: 3
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Describing the role of the respiratory and renal systems in acid-base balance
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Chapter page reference: 143-145
Heading: Metabolic Alkalosis
Integrated Processes: Nursing Process Evaluation
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: pH Regulation
Difficulty: Moderate
Feedback
1
A normal pH level is 7.35-7.45. A pH of less than 7.35 is acidosis
2
A HCO3 level of 8 mEq/L is low and is most likely associated with metabolic acidosis.
In metabolic alkalosis, there is an excess of bicarbonate.
3
To compensate for this imbalance, the rate and depth of respirations decrease, leading
to retention of carbon dioxide. The PaCO2 will be elevated.
4
A PaCO2 level of 18 mmHg is low and is seen in respiratory alkalosis.
PTS: 1
CON: pH Regulation
4. ANS: 4
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Stating the steps for arterial blood gas interpretation
Chapter page reference: 140
Heading: Arterial Blood Gas Results
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: pH Regulation
NURSINGKING.COM
Difficulty: Moderate
Feedback
1
Pulse oximetry is a noninvasive test that evaluates the oxygen saturation level of blood.
2
A bronchoscopy provides visualization of internal respiratory structures.
3
Sputum studies can provide specific information about bacterial organisms.
4
Arterial blood gas analysis is done to assess alterations in acid-base balance caused by
respiratory disorders, metabolic disorders, or both.
PTS: 1
CON: pH Regulation
5. ANS: 2
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders
Chapter page reference: 141-143
Heading: Metabolic Acidosis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Analysis [Analyzing]
Concept: pH Regulation
Difficulty: Difficult
1
Feedback
The patient should be instructed to use non-sodium antacids to prevent the absorption
of excess sodium.
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2
3
4
Bicarbonate antacid should not be used for longer than two weeks. This statement
indicates the need for additional teaching.
The patient should be instructed to immediately contact the primary health-care
provider if gastric discomfort occurs with chest pain or if dyspnea or diaphoresis
occurs.
The patient should be instructed to immediately contact the primary health-care
provider if gastric discomfort occurs with chest pain or if dyspnea or diaphoresis
occurs.
PTS: 1
CON: pH Regulation
6. ANS: 4
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders
Chapter page reference: 141-143
Heading: Metabolic Acidosis
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: pH Regulation
Difficulty: Difficult
Feedback
1
The client receiving sodium bicarbonate is prone to alkalosis; monitor for cyanosis,
2
3
4
so infusion should not be stopped.
The infusion should not be increased or decreased without a practitioner order.
NURSINGKING.COM
The infusion should not be increased or decreased without a practitioner order.
The client continues to exhibit signs of acidosis; symptoms of acidosis include lethargy,
confusion, CNS depression leading to coma, and a deep, rapid respiration rate that
indicates an attempt by the lungs to rid the body of excess acid, and the provider should
be notified.
PTS: 1
CON: pH Regulation
7. ANS: 1
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders
Chapter page reference: 140
Heading: Respiratory Acidosis
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: pH Regulation
Difficulty: Moderate
Feedback
1
In respiratory acidosis, there are a drop in the blood pH, reduced level of oxygen, and
retaining of carbon dioxide. The body needs to be well-hydrated so that pulmonary
secretions can be removed to improve oxygenation.
2
Reducing environmental stimuli would be appropriate for the patient with respiratory
alkalosis.
3
Sodium bicarbonate is indicated in the treatment of metabolic acidosis.
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4
Careful administration of intravenous fluids is important in the older patient with
metabolic alkalosis because this population is at risk because of their fragile fluid and
electrolyte status.
PTS: 1
CON: pH Regulation
8. ANS: 2
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders
Chapter page reference: 133-135
Heading: Acid-Base Balance Overview
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Analysis [Analyzing]
Concept: pH Regulation
Difficulty: Difficult
Feedback
1
Perfusion is affected by a reduction in circulating fluids.
2
An oxygen level of less than 75 mmHg can be due to hypoventilation. This drop in
oxygen will change the patient's level of responsiveness.
3
Although acid-base imbalances can alter communication, there is no direct link between
a low oxygen level and changes in communication.
4
With a fluid and electrolyte imbalance, there is another disorder affecting acid-base
balance. This might not be affected by oxygen level.
PTS: 1
CON: pH Regulation
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9. ANS: 3
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders
Chapter page reference: 140
Heading: Respiratory Acidosis
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: pH Regulation
Difficulty: Difficult
Feedback
1
Monitoring vital signs is an independent nursing action.
2
Measuring intake and output is an independent nursing action.
3
For patients in severe distress, family members may need to be consulted for critical
information such as recent eating habits and history of vomiting.
4
Identifying current oxygen saturation level is an independent nursing action.
PTS: 1
CON: pH Regulation
10. ANS: 1
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Describing the significance of acid-base balance for normal function
Chapter page reference: 133-135
Heading: Acid-Base Balance Overview
Integrated Processes: Nursing Process Planning
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Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: pH Regulation
Difficulty: Moderate
1
2
3
4
Feedback
The nurse knows that severe acidosis depresses myocardial contractility, which leads to
decreased cardiac output.
Acid-base imbalances also affect electrolyte balance. In acidosis, potassium is retained
as the kidney excretes excess hydrogen ion. Excess hydrogen ions also enter the cells,
displacing potassium from the intracellular space to maintain the balance of cations and
anions within the cells. The effect of both processes is to increase serum potassium
levels.
Magnesium levels may fall in acidosis.
In acidosis, calcium is released from its bonds with plasma proteins, increasing the
amount of ionized (free) calcium in the blood.
PTS: 1
CON: pH Regulation
11. ANS: 4
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Describing the role of the respiratory and renal systems in acid-base balance
Chapter page reference: 141-143
Heading: Metabolic Acidosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
NURSINGKING.COM
Cognitive level: Comprehension [Understanding]
Concept: pH Regulation
Difficulty: Easy
Feedback
1
This finding indicates the patient continues to experience metabolic acidosis.
2
Increased deep tendon reflexes and palpitations are not associated with metabolic
acidosis.
3
Increased deep tendon reflexes and palpitations are not associated with metabolic
acidosis.
4
The patient with metabolic acidosis will have an increased respiratory rate and depth.
Signs that care has been effective would include a decrease in the rate and depth of
respirations.
PTS: 1
CON: pH Regulation
12. ANS: 1
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders
Chapter page reference: 141-143
Heading: Metabolic Acidosis
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: pH Regulation
Difficulty: Difficult
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1
2
3
4
Feedback
The patient with metabolic acidosis may have symptoms of drowsiness, lethargy,
confusion, and weakness. A priority of care would be preventing injury.
The high-Fowler's position would not be the safest position for the confused patient.
Medication administration requires a practitioner prescription.
Skin care would not be a priority on admission.
PTS: 1
CON: pH Regulation
13. ANS: 3
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders
Chapter page reference: 141-143
Heading: Metabolic Acidosis
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: pH Regulation
Difficulty: Easy
1
2
3
4
Feedback
As metabolic acidosis is corrected, potassium shifts back into the intracellular space.
This shift can lead to hypokalemia and cardiac dysrhythmias. Serum potassium levels
should be carefully monitored during treatment
Arterial blood gases are used to evaluate treatment and guide additional therapies.
Administering bicarbonate to
correct
NU
RSIacidosis
NGKINincreases
G.COMthe risk for hypernatremia,
hyperosmolality, and fluid volume excess. This is the order that the nurse should
question before providing.
Treatment of metabolic acidosis includes correction of fluid balance. An infusion of
normal saline would be appropriate.
PTS: 1
CON: pH Regulation
14. ANS: 1
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Comparing and contrasting major acid-base disorders
Chapter page reference: 143-145
Heading: Metabolic Alkalosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: pH Regulation
Difficulty: Easy
Feedback
1
Metabolic alkalosis due to loss of hydrogen ions usually occurs because of vomiting or
gastric suction. Gastric secretions are highly acidic (pH 1-3). When these are lost
through vomiting or gastric suction, the alkalinity of body fluids increases. This
increased alkalinity results from the loss of acid and from selective retention of
bicarbonate by the kidneys as chloride is depleted.
2
Gastric secretions are not alkaline.
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3
4
The color and odor of gastric secretions have no influence on the development of
metabolic acidosis.
The color and odor of gastric secretions have no influence on the development of
metabolic acidosis.
PTS: 1
CON: pH Regulation
15. ANS: 1
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders
Chapter page reference: 143-145
Heading: Metabolic Alkalosis
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: pH Regulation
Difficulty: Difficult
Feedback
1
The priority for this patient is monitoring oxygen saturation. The depressed respiratory
drive that often accompanies metabolic alkalosis can lead to hypoxemia and impaired
oxygenation of the tissues.
2
Teaching and goal setting are important aspects of nursing care but are not the priority.
3
Administering medications will be needed as a treatment, but the priority is to discover
the cause.
4
Teaching and goal setting are important aspects of nursing care but are not the priority.
NURSINGKING.COM
PTS: 1
CON: pH Regulation
16. ANS: 3
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Comparing and contrasting major acid-base disorders
Chapter page reference: 140
Heading: Respiratory Acidosis
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: pH Regulation
Difficulty: Easy
Feedback
1
Respiratory alkalosis, metabolic acidosis, and metabolic alkalosis are caused by many
conditions, none of which are related to this patient's morphine overdose.
2
Respiratory alkalosis, metabolic acidosis, and metabolic alkalosis are caused by many
3
4
Morphine is a narcotic and generally acts to decrease or suppress respirations;
therefore, this patient is probably hypoventilating. The expected acid-base imbalance
would be respiratory acidosis.
Respiratory alkalosis, metabolic acidosis, and metabolic alkalosis are caused by many
PTS: 1
17. ANS: 1
CON: pH Regulation
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Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Comparing and contrasting major acid-base disorders
Chapter page reference: 140
Heading: Respiratory Acidosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: pH Regulation
Difficulty: Easy
Feedback
1
Aspiration of a foreign body and acute pneumonia would put the patient at risk for
respiratory acidosis.
2
A recent trip to South America would not constitute a respiratory risk factor for
acidosis.
3
Recent recovery from a cold would not likely put the patient at risk for respiratory
acidosis.
4
Ibuprofen does not pose a threat to the respiratory health of the patient.
PTS: 1
CON: pH Regulation
18. ANS: 3
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Describing the role of the respiratory and renal systems in acid-base balance
Chapter page reference: 140
Heading: Respiratory Acidosis
Integrated Processes: Nursing Process Assessment
NUR
SINGKINAdaptation
G.COM
Client Need: Physiological Integrity
Physiological
Cognitive level: Analysis [Analyzing]
Concept: pH Regulation
Difficulty: Difficult
Feedback
1
Pneumonia and aspiration are both acute lung conditions.
2
Pneumonia and aspiration are both acute lung conditions.
3
Chronic lung disease such as asthma and cystic fibrosis puts the patient at risk for
respiratory acidosis.
4
Hyperthyroidism is a disorder that results in metabolic acidosis.
PTS: 1
CON: pH Regulation
19. ANS: 4
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Describing the role of the respiratory and renal systems in acid-base balance
Chapter page reference: 140
Heading: Respiratory Acidosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: pH Regulation
Difficulty: Easy
Feedback
1
PCP is a hallucinogenic agent.
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2
3
4
Cocaine is a stimulant.
Marijuana is not considered as a drug that depresses the central nervous system or
respiratory center.
Oxycodone is an opiate narcotic. Excessive use or overdose of narcotic substances can
lead to respiratory depression and respiratory acidosis.
PTS: 1
CON: pH Regulation
20. ANS: 3
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Comparing and contrasting major acid-base disorders
Chapter page reference: 140
Heading: Respiratory Acidosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: pH Regulation
Difficulty: Easy
Feedback
1
The patient with acute respiratory acidosis may demonstrate warm, flushed skin,
irritability, and blurred vision from the acute decline in oxygenation.
2
The patient with acute respiratory acidosis may demonstrate warm, flushed skin,
irritability, and blurred vision from the acute decline in oxygenation.
3
The manifestations of acute and chronic respiratory acidosis differ. The patient with
chronic respiratory acidosis will demonstrate daytime sleepiness.
4
The patient with acute respiratory
NURSacidosis
INGKmay
INGdemonstrate
.COM warm, flushed skin,
irritability, and blurred vision from the acute decline in oxygenation.
PTS: 1
CON: pH Regulation
21. ANS: 3
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Comparing and contrasting major acid-base disorders
Chapter page reference: 140-141
Heading: Respiratory Alkalosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: pH Regulation
Difficulty: Moderate
1
2
3
4
Feedback
This data does not support the current diagnosis.
This data does not support the current diagnosis.
Acute pain usually causes hyperventilation, which causes the CO2 to drop and the client
to experience respiratory alkalosis. The pH would denote alkalosis and would be higher
than 7.45. HCO3 would trend downward as the kidneys begin to compensate for the
alkalosis by excreting HCO3. The PaO2 is likely to be normal unless the client has been
hyperventilating for a long time and is beginning to tire.
This data does not support the current diagnosis.
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PTS: 1
CON: pH Regulation
22. ANS: 4
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Comparing and contrasting major acid-base disorders
Chapter page reference: 140-141
Heading: Respiratory Alkalosis
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: pH Regulation
Difficulty: Easy
Feedback
1
The patient with anxiety does not necessarily have vomiting or memory loss as risk
factors.
2
The patient with anxiety does not necessarily have vomiting or memory loss as risk
factors.
3
Anxiety and panic attacks will lead to hyperventilation, not hypoventilation.
4
Anxiety disorders increase the risk for the acid-base imbalance respiratory alkalosis,
due to hyperventilation that accompanies anxiety and panic attacks.
PTS: 1
CON: pH Regulation
23. ANS: 2
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders
Chapter page reference: 140-141
NURSINGKING.COM
Heading: Respiratory Alkalosis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: pH Regulation
Difficulty: Difficult
Feedback
1
Eating bananas is more appropriate for the patient at risk for metabolic alkalosis who is
on diuretics.
2
The patient understands that reducing anxiety can reduce hyperventilation and
respiratory alkalosis. Seeing a counselor can help the patient develop alternative
strategies for dealing with anxiety.
3
Taking too many antacids is associated with metabolic alkalosis.
4
Breathing faster will increase hyperventilation.
PTS: 1
CON: pH Regulation
24. ANS: 1
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders
Chapter page reference: 140-141
Heading: Respiratory Alkalosis
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
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Concept: pH Regulation
Difficulty: Easy
Feedback
1
Management of respiratory alkalosis focuses on correcting the imbalance and treating
the underlying cause. Arterial blood gases must be ordered prior to beginning
medication or oxygen therapy.
2
Oxygen is not anticipated when providing care to a patient experiencing respiratory
alkalosis.
3
A fluid restriction is not required in the treatment of respiratory alkalosis.
4
Sodium bicarbonate is used in the treatment of respiratory and metabolic acidosis.
PTS: 1
CON: pH Regulation
25. ANS: 2
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders
Chapter page reference: 140-141
Heading: Respiratory Alkalosis
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: pH Regulation
Difficulty: Moderate
1
2
3
4
Feedback
Applying wrist restraints to a patient who is demonstrating anxiety with an endotracheal
NURSINGKING.COM
For a patient being mechanically ventilated, the only way to reduce rapid respirations
might be to provide a sedative.
The patient is being mechanically ventilated, which means there is a problem with
maintaining the airway. The patient will not be able to take slow, deep breaths at this
time.
The reason for the endotracheal tube is to maintain the patient's airway after chest
trauma. Removing the tube could lead to a collapse of the airway and a life-threatening
situation.
PTS: 1
CON: pH Regulation
MULTIPLE RESPONSE
26. ANS: 2, 3, 4
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Comparing and contrasting major acid-base disorders
Chapter page reference: 141-143
Heading: Metabolic Acidosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: pH Regulation
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Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is incorrect. Chronic obstructive pulmonary disease and pneumonia place the patient at
risk for respiratory acidosis with the increased retention of carbon dioxide in the blood.
This is correct. Metabolic acidosis is rarely a primary disorder. It usually develops during the
course of another disease; presence of abdominal fistulas; which can cause excess bicarbonate
loss; acute renal failure; and hypovolemic shock.
This is correct. Metabolic acidosis is rarely a primary disorder. It usually develops during the
course of another disease; presence of abdominal fistulas; which can cause excess bicarbonate
loss; acute renal failure; and hypovolemic shock.
This is correct. Metabolic acidosis is rarely a primary disorder. It usually develops during the
course of another disease; presence of abdominal fistulas; which can cause excess bicarbonate
loss; acute renal failure; and hypovolemic shock.
This is incorrect. Chronic obstructive pulmonary disease and pneumonia place the patient at
risk for respiratory acidosis with the increased retention of carbon dioxide in the blood.
PTS: 1
CON: pH Regulation
27. ANS: 1, 2, 5
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders
Chapter page reference: 141-143
Heading: Metabolic Acidosis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
NURSINGKING.COM
Cognitive level: Application [Applying]
Concept: pH Regulation
Difficulty: Moderate
1.
Feedback
This is correct. The diabetes educator should be contacted to work with the patient on
strategies that might allow the fasting to occur in a safe manner.
2.
3.
4.
5.
educative for the nurse and an appropriate action.
This is incorrect. Telling the patient that life is different now does not support religious
beliefs.
This is incorrect. Asking the family to talk to the patient might help, but the diabetes educator
would be able to provide more direct and helpful information for the patient.
This is correct. Stressing the importance of promptly seeking care when signs of ketoacidosis
occur helps to promote the patient's health and is appropriate.
PTS: 1
CON: pH Regulation
28. ANS: 2, 3, 4
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Explaining nursing considerations related to patients with acid-base disorders
Chapter page reference: 141-143
Heading: Metabolic Acidosis
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
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Cognitive level: Application [Applying]
Concept: pH Regulation
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is incorrect. The treatment for hypovolemic shock would include the administration of
fluids, not limiting fluids.
This is correct. Administering sodium bicarbonate and monitoring ECGs are appropriate for
the patient with shock.
This is correct. Administering sodium bicarbonate and monitoring ECGs are appropriate for
the patient with shock.
This is correct. The patient recovering from hypovolemic shock is at risk for injury, so the bed
should be kept in the locked and low position.
This is incorrect. Patients being treated for hypovolemia will require daily weights, not a
weight on admission and then discharge.
PTS: 1
CON: pH Regulation
29. ANS: 2, 5
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Comparing and contrasting major acid-base disorders
Chapter page reference: 143-145
Heading: Metabolic Alkalosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
NURSINGKING.COM
Concept: pH Regulation
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is incorrect. Serum glucose level is not used to confirm the diagnosis of metabolic
alkalosis.
This is correct. In metabolic alkalosis, the blood pH will be greater than 7.45 and the
bicarbonate level greater than 28 mEq/L.
This is incorrect. The presence of kidney stones is not associated with the development of
metabolic alkalosis.
This is incorrect. The presence of bilateral lower lobe infiltrates on chest x-ray would not
contribute to the development of metabolic alkalosis. This finding might be the result of
metabolic alkalosis if the client's respiratory status is compromised.
This is correct. The ECG pattern shows changes similar to those seen with hypokalemia.
PTS: 1
CON: pH Regulation
30. ANS: 1, 2, 5
Chapter number and title: 9, Acid-Base Balance
Chapter learning objective: Stating the steps for arterial blood gas interpretation
Chapter page reference: 138
Heading: Arterial Blood Gas Assessment
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
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Concept: pH Regulation
Difficulty: Moderate
Feedback
1.
wrist
with a rolled towel.
2.
with a rolled towel.
This is incorrect. The nurse will tell the patient to first clench the fist, hold the position for a
few seconds and then hold the hand in a relaxed position.
This is incorrect. A second nurse is not required to perform this test.
3.
4.
5.
ulnar arteries.
PTS: 1
CON: pH Regulation
Chapter 10: Overview of Infusion Therapies
Multiple Choice
Identify the choice that best completes the statement or answers the question.
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____
1. The nurse is providing care to a patient who is receiving a blood transfusion. Ten minutes after the infusion is
initiated, the patient reports a headache. Upon further assessment the nurse notes that the patient is
experiencing dyspnea and feels warm to the touch. Which is the priority nursing action by the nurse?
1) Stop the transfusion.
2) Prepare for a full resuscitation.
3) Notify the health-care provider.
4) Decrease the rate of the transfusion.
____
2. Which intravenous (IV) fluid should the nurse prepare when a patient requires an isotonic solution?
1) 0.9% normal saline
2) 2.5% dextrose in water
3) 0.33% sodium chloride
4) 5% dextrose in Lactated ringers
____
3.
line. Which is the first action the nurse takes after adding the medication to the container?
1) Connect the bag to the tubing.
2) Rotate the bag to distribute the medication.
3) Place a completed medication-added label to the bag.
4) Connect the bag to new tubing and flush the air from the tubing.
____
4. The nurse is initiating intravenous (IV) therapy for an adult patient who requires IV fluid infusion for 2 3
days and might require blood administration. Which would the nurse choose as the best option for IV
catheterization?
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1)
2)
3)
4)
Butterfly
Huber needle
Angiocatheter
Implantable venous access device
____
5. The nurse is assessing an intravenous (IV) insertion site noting redness, warmth, and mild swelling. The
patient reports a burning pain along the course of the vein during medication administration. Which term
should the nurse use when documenting these findings in the medical record?
1) Phlebitis
2) Infiltration
3) Extravasation
4) Inflammation
____
6. The nurse is caring for a patient with a medical diagnosis of increased intracranial pressure (ICP). Which
intravenous (IV) fluid order would the nurse accept without questioning?
1) Run normal saline at 125 mL/hour.
2) Run half-normal saline at 200 mL/hour.
3) Run 5% dextrose in water at 80 mL/hour.
4) Run 5% dextrose in 0.45% NaCl at 75 mL/hour.
____
7. The nurse working in the emergency department (ED) is caring for a patient who experienced deep-thickness
burns over 40% of the body and is in shock. Which intravenous (IV) prescription does the nurse anticipate for
this patient?
1) Nutrient solutions
2) Volume expanders
3) Electrolyte solutions
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4) Total parenteral nutrition
____
8. Which aspect of intravenous (IV) therapy could the nurse safely delegate to the unlicensed assistive personnel
(UAP)?
1) Changing the IV site dressing on the patient's left hand
2) Watching the IV insertion site of the patient who complained of pain at the site
3)
patient
4)
5W, without medications
added
____
9. The nurse is setting up an intravenous (IV) infusion on an electronic infusion pump for a patient recently
admitted to the unit. After leaving the room, the pump alarms and reads high pressure. Which is the priority
action by the nurse?
1) Resetting the pump to resume infusion
2) Asking the patient if the pump has been tampered with in any way
3) Assessing the IV site and the tubing for kinks or closed roller clamps
4)
____ 10. The nurse is administering a blood transfusion to an adult patient. The patient reports feeling cold and is
shivering 15 minutes after the initiat
the last assessment. Which is the nurse's priority action?
1) Notify the health-care provider.
2) Monitor the blood pressure every five minutes.
3) Stop the blood infusion, and run the normal saline on the other side of the Y tubing.
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4) Stop the blood infusion, and remove the tubing from the IV catheter, replacing it with
normal saline.
____ 11. The nurse is caring for a patient with a central venous catheter used for intermittent medication
administration. When flushing the catheter prior to administering the next dose of medication, which initial
action by the nurse is the most appropriate?
1)
2) Positioning the patient in reverse Trendelenburg position
3) Flushing the catheter, using as much force as required in order to clear the line
4) Obtaining a 3 mL syringe and filling it with normal saline for flushing the line
____ 12.
1)
2)
3)
4)
hich action by the nurse is the priority?
Applying sterile gloves
Inspecting the insertion site for signs of infection
Pulling the tape off in the direction of the catheter
Pressing the catheter into the skin while removing the tape
____ 13. The nurse is caring for a patient who is to have a peripherally inserted central catheter (PICC) line inserted
Which site would the nurse avoid using?
1) Radial vein
2) Cephalic vein
3) Median cubital vein
4) Dorsal metacarpal veins
____ 14. Which intravenous (IV) fluid should the nurse prepare when a patient requires a hypertonic solution?
1) 0.9% normal saline
NURSINGKING.COM
2) 2.5% dextrose in water
3) 0.33% sodium chloride
4) 5% dextrose in Lactated ringers
____ 15. Which intravenous (IV) fluid should the nurse prepare when a patient requires a hypotonic solution?
1) 0.9% normal saline
2) 5% dextrose in water
3) 0.33% sodium chloride
4) 5% dextrose in Lactated ringers
____ 16. The nurse is providing care to a trauma patient who will require the rapid administration of large volumes of
fluid in addition to a blood transfusion. Which gauge should the nurse use when initiating intravenous (IV)
access for this patient?
1) 18
2) 20
3) 22
4) 24
____ 17. Which component should the nurse anticipate will be prescribed for a patient with acute blood loss?
1) Platelets
2) Albumin
3) Fresh frozen plasma
4) Packed red blood cells
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____ 18. Which component should the nurse anticipate will be prescribed for a patient with an elevated prothrombin
time (PT) and international normalized ratio (INR) who is at an increased risk for bleeding?
1) Platelets
2) Albumin
3) Fresh frozen plasma
4) Packed red blood cells
____ 19. Which component should the nurse anticipate will be prescribed for a patient is not responding to crystalloids
for volume expansion?
1) Platelets
2) Albumin
3) Fresh frozen plasma
4) Packed red blood cells
____ 20. Which component should the nurse anticipate will be prescribed for a patient with severe thrombocytopenia?
1) Platelets
2) Albumin
3) Fresh frozen plasma
4) Packed red blood cells
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. The nurse is caring for a patient receiving intravenous (IV) medications. After infusing an IV antibiotic, the
nurse assesses the IV site and finds it to be red and edematous, and the patient is reporting pain at the site.
NU
RS
INGKnotes
INGregarding
.COM the infiltration? Select all that apply.
Which would the nurse document in
the
nursing
1) Incident report
2) Actions taken to correct the problem
3) Size and location of erythematous area
4) Health-care provider notification and any orders received
5) Amount of fluid infused per shift on the intake and output record
____ 22. Which patients may benefit from central intravenous (IV) access? Select all that apply.
1) The patient receiving caustic IV therapy.
2) The patient requiring long-term IV therapy.
3) The patient who is afraid of needles and does not want a catheter in the peripheral
extremity.
4) The patient requiring numerous IV infusions that are not compatible and cannot be infused
together.
5) The unstable patient requiring reliable IV access for administration of medications
required. immediately.
____ 23. The nurse is performing venipuncture to initiate intravenous (IV) therapy. Which indicators should the nurse
use when choosing the site for IV therapy? Select all that apply.
1) Choosing a straight vein
2) Avoiding a sclerotic vein
3) Looking for sites distal to joints
4) Using the dominant arm, whenever possible
5) Choosing a vein that is visible in addition to palpable
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____ 24. The nurse is providing care to patient who is receiving total parenteral nutrition (TPN). During the shift
assessment, the nurse notes that the patient is lethargic and has an elevated temperature and white blood cell
count. The nurse suspects the patient is septic. Which actions by the nurse are appropriate in this situation?
Select all that apply.
1) Changing the IV tubing
2) Saving the remaining TPN
3) Notifying the health-care provider
4) Recording the lot number of the TPN
5) Replacing the TPN with a normal saline solution
____ 25. The nurse is caring for a patient with a central venous catheter (CVC). Which nursing actions should the nurse
implement to prevent an air embolism? Select all that apply.
1) Using Luer-locked connections
2) Frequently checking connections
3) Wearing sterile gloves when accessing any connections
4) Clamping catheters and injection sites when not in use
5) Placing the patient in low-Fowler position to remove the CVC
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Chapter 10: Overview of Infusion Therapies
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Explaining the procedure for safely administering blood products
Chapter page reference: 161
Heading: Types of Infusion Reactions
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Analysis [Analyzing]
Concept: Medication
Difficulty: Moderate
1
2
3
4
Feedback
The priority nursing action is to stop the transfusion. If the patient is experiencing a
transfusion reaction, this will limit the amount of blood administered.
There is no need for resuscitation based on the current data.
While the nurse would contact the health-care provider, this is not the priority.
Slowing the rate of the transfusion allows for the blood to continue to be administered;
therefore, this is not an appropriate nursing action.
NURSINGKING.COM
PTS: 1
CON: Medication
2. ANS: 1
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Describing the characteristics of common IV solutions
Chapter page reference: 147-149
Heading: Solutions Used in Infusion Therapy
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1
An example of an isotonic solution is 0.9% normal saline.
2
An example of a hypotonic solution is 2.5% dextrose in water.
3
An example of a hypotonic solution is 0.33% sodium chloride.
4
An example of a hypertonic solution is 5% dextrose in Lactated ringers.
PTS: 1
CON: Medication
3. ANS: 2
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Describing the equipment used to provide infusion therapy
Chapter page reference: 156-162
Heading: Nursing Management of Infusion Therapy
Integrated Processes: Nursing Process Implementation
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Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Analysis [Analyzing]
Concept: Medication
Difficulty: Difficult
Feedback
1
This is not the first action by the nurse after adding the medication to the IV solution.
2
The bag should be rotated to distribute the medication throughout the fluid, and then a
medication label added to the bag. Only after the bag is properly labeled can it be hung.
3
This is not the first action by the nurse after adding the medication to the IV solution.
4
This is not the first action by the nurse after adding the medication to the IV solution.
PTS: 1
CON: Medication
4. ANS: 3
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Describing the equipment used to provide infusion therapy
Chapter page reference: 155-156
Heading: Equipment Used in Infusion Therapy
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1
A butterfly can be used, if necessary, for IV catheterization, but is best when used for
short-term IV infusion, as the needle remains in place within the vein, and is more
NURSINGKING.COM
likely to infiltrate sooner than is an angiocatheter.
2
A Huber needle is used to access an implantable venous access device, and would not
be used for short-term use of a few days.
3
An angiocatheter would be the best choice because the needle is removed and only the
catheter remains in place, so it is more likely to last for 2 days without infiltrating.
4
Implantable venous access devices are used when IV fluid needs are anticipated for
several months.
PTS: 1
CON: Medication
5. ANS: 1
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Describing the potential complications of infusion therapy and strategies to
prevent these complications
Chapter page reference: 156-162
Heading: Nursing Management of Infusion Therapy
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Medication
Difficulty: Easy
1
Feedback
Redness, warmth, edema, and pain that runs along the course of the vein characterize
phlebitis.
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2
3
4
An infiltrate is defined as fluid entering the tissues, resulting in swelling, coolness,
so it is not an infiltrate.
Extravasation includes a vesicant drug (one that causes blistering when in the tissues
but not in the vascular system), so this is not an extravasation.
Inflammation is not a term used for IV therapy.
PTS: 1
CON: Medication
6. ANS: 4
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Describing the characteristics of common IV solutions
Chapter page reference: 147-149
Heading: Solutions Used in Infusion Therapy
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapy
Cognitive level: Analysis [Analyzing]
Concept: Medication
Difficulty: Difficult
Feedback
1
Normal saline and D5W are isotonic solutions, and so would need to be questioned.
2
Half-normal saline is hypotonic, and so would not be advisable for this patient.
3
Normal saline and D5W are isotonic solutions, and so would need to be questioned.
4
Isotonic and hypotonic fluids should not be administered to clients with increased
intracranial pressure, because they increase the risk of cerebral edema. D5 in one-half
normal saline is hypertonic, N
and
beKan
acceptable
URwould
SING
IN
G.COMIV solution for this patient.
PTS: 1
CON: Medication
7. ANS: 2
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Discussing reasons patients require infusion therapy
Chapter page reference: 147-149
Heading: Solutions Used in Intravenous Therapy
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1
Long term, this patient might require total parenteral nutrition if he is unable to
maintain adequate calorie intake orally, but nutritional solutions would not be a priority
concern this early in the patient's course of treatment.
2
Initially, the patient who is in shock will require volume expanders.
3
Once vital signs are stabilized, the primary care provider may order electrolyte
solutions.
4
Long term, this patient might require total parenteral nutrition if he is unable to
maintain adequate calorie intake orally, but nutritional solutions would not be a priority
concern this early in the patient's course of treatment.
PTS: 1
CON: Medication
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8. ANS: 3
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Describing the potential complications of infusion therapy and strategies to
prevent these complications
Chapter page reference: 156-162
Heading: Nursing Management of Infusion Therapy
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Medication; Legal
Difficulty: Moderate
Feedback
1
The IV dressing should be changed using sterile technique, and should not be delegated
to the UAP.
2
3
4
The UAP is not responsible for assessing the site, because the nurse is responsible for
all assessments.
The UAP can safely be taught to report complaints of pain or leakage from an IV site if
it is noted during routine care.
Whether medications are added to the IV fluid or not, only the nurse can change the
bag, because sterile technique is required, and even a plain solution is considered a
medication.
PTS: 1
CON: Medication | Legal
9. ANS: 3
NURof
SIInfusion
NGKIN
G.COM
Chapter number and title: 10, Overview
Therapies
Chapter learning objective: Describing the potential complications of infusion therapy and strategies to
prevent these complications
Chapter page reference: 156-162
Heading: Nursing Management of Infusion Therapy
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1
Resetting the pump without performing a thorough assessment could increase the tissue
damage if the site is infiltrated.
2
Accusing the patient of tampering with the pump would not be justified.
3
The nurse should assess the IV site because an infiltrated IV, or a site that is proximal
to a joint, can impede infusion. If the IV site appears to be within normal limits, the
tubing should be checked for any kinks, closed roller clamps, or any other impediment
to infusion.
4
The IV site should not be discontinued if it is intact, so it should be assessed before
considering moving the site.
PTS: 1
CON: Medication
10. ANS: 4
Chapter number and title: 10, Overview of Infusion Therapies
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Chapter learning objective: Explaining the procedure for safely administering blood products
Chapter page reference: 159-161
Heading: Administration of Blood Products
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1
Only after the blood infusion is discontinued would the nurse notify the health-care
2
Only after the blood infusion is discontinued would the nurse notify the health-care
3
Stopping the blood infusion and running saline through the blood tubing will administer
the blood found in the tubing, and could make the transfusion reaction worse.
The nurse should completely discontinue the blood infusion, disconnecting the tubing
from the IV catheter and placing normal saline or the ordered solution infusing prior to
beginning the blood infusion with new tubing.
4
PTS: 1
CON: Medication
11. ANS: 1
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Comparing peripheral and central venous access including indications, access
devices, and potential complications
Chapter page reference: 156-162
URSITherapy
NGKING.COM
Heading: Nursing Management of N
Infusion
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapy
Cognitive level: Analysis [Analyzing]
Concept: Medication
Difficulty: Difficult
Feedback
1
The catheter should be aspirated for blood prior to flushing the tubing.
2
There would be no need to place the patient in reverse Trendelenburg position, although
a left Trendelenburg position may be used if an air embolism is suspected.
3
Excessive pressure should not be used when flushing the catheter, because it can
dislodge a clot or cause the catheter to rupture.
4
The tubing would be flushed with a 10 mL syringe or larger because small syringes
exert too much pressure, which can damage the catheter.
PTS: 1
CON: Medication
12. ANS: 3
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Comparing peripheral and central venous access including indications, access
devices, and potential complications
Chapter page reference: 152-155
Heading: Central Venous Access
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
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Cognitive level: Analysis [Analyzing]
Concept: Medication
Difficulty: Difficult
Feedback
1
Sterile gloves are not used when removing the old dressing.
2
The site is inspected after the old dressing is removed, not while removing the dressing.
3
The tape should be removed in the direction of the catheter to avoid displacing the
catheter.
4
the tape is removed, not pressed
PTS: 1
CON: Medication
13. ANS: 3
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Comparing peripheral and central venous access including indications, access
devices, and potential complications
Chapter page reference: 152-155
Heading: Central Venous Access
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Medication
Difficulty: Easy
Feedback
1
There is no need to avoid this site when restarting the peripheral access line.
NURSINGKING.COM
2
There is no need to avoid this site when restarting the peripheral access line.
3
The median cubital vein is often used for PICC lines, so the nurse should attempt to
avoid this site in order to maintain it for the central line.
4
There is no need to avoid this site when restarting the peripheral access line.
PTS: 1
CON: Medication
14. ANS: 4
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Describing the characteristics of common IV solutions
Chapter page reference: 147-149
Heading: Solutions Used in Infusion Therapy
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1
An example of an isotonic solution is 0.9% normal saline.
2
An example of a hypotonic solution is 2.5% dextrose in water.
3
An example of a hypotonic solution is 0.33% sodium chloride.
4
An example of a hypertonic solution is 5% dextrose in Lactated ringers.
PTS: 1
CON: Medication
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15. ANS: 3
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Describing the characteristics of common IV solutions
Chapter page reference: 147-149
Heading: Solutions Used in Infusion Therapy
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1
An example of an isotonic solution is 0.9% normal saline.
2
An example of an isotonic solution is 5% dextrose in water.
3
An example of a hypotonic solution is 0.33% sodium chloride.
4
An example of a hypertonic solution is 5% dextrose in Lactated ringers.
PTS: 1
CON: Medication
16. ANS: 1
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Describing the equipment used to provide infusion therapy
Chapter page reference: 150-152
Heading: Peripheral Venous Access
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
NURSINGKING.COM
Concept: Medication
Difficulty: Easy
Feedback
1
An 18 gauge is appropriate to initiate IV access for a patient who requires both rapid
administration of large volumes of fluid and a blood transfusion.
2
While a 20-gauge catheter is appropriate for blood transfusion, this is not appropriate
for the rapid administration of large volumes.
3
This catheter is not appropriate for this patient.
4
This catheter is not appropriate for this patient.
PTS: 1
CON: Medication
17. ANS: 4
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Explaining the procedure for safely administering blood products
Chapter page reference: 159-161
Heading: Administration of Blood Products
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Medication
Difficulty: Easy
Feedback
1
Platelets are administered for patients who are bleeding due to thrombocytopenia or
platelet abnormalities.
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2
3
4
Albumin is administered for volume expansion when crystalloid solutions are not
adequate.
Fresh frozen plasma is anticipated for a patient with a deficiency of plasma coagulation
factors.
Packed red blood cells are anticipated for a patient with acute or chronic blood loss and
for patients diagnosed with anemia.
PTS: 1
CON: Medication
18. ANS: 3
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Explaining the procedure for safely administering blood products
Chapter page reference: 159-161
Heading: Administration of Blood Products
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Medication
Difficulty: Easy
Feedback
1
Platelets are administered for patients who are bleeding due to thrombocytopenia or
platelet abnormalities.
2
Albumin is administered for volume expansion when crystalloid solutions are not
adequate.
3
Fresh frozen plasma is anticipated for a patient with a deficiency of plasma coagulation
factors.
NURSINGKING.COM
4
Packed red blood cells are anticipated for a patient with acute or chronic blood loss and
for patients diagnosed with anemia.
PTS: 1
CON: Medication
19. ANS: 2
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Explaining the procedure for safely administering blood products
Chapter page reference: 159-161
Heading: Administration of Blood Products
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Medication
Difficulty: Easy
Feedback
1
Platelets are administered for patients who are bleeding due to thrombocytopenia or
platelet abnormalities.
2
Albumin is administered for volume expansion when crystalloid solutions are not
adequate.
3
Fresh frozen plasma is anticipated for a patient with a deficiency of plasma coagulation
factors.
4
Packed red blood cells are anticipated for a patient with acute or chronic blood loss and
for patients diagnosed with anemia.
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PTS: 1
CON: Medication
20. ANS: 1
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Explaining the procedure for safely administering blood products
Chapter page reference: 159-161
Heading: Administration of Blood Products
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Medication
Difficulty: Easy
Feedback
1
Platelets are administered for patients who are bleeding due to thrombocytopenia or
platelet abnormalities.
2
Albumin is administered for volume expansion when crystalloid solutions are not
adequate.
3
Fresh frozen plasma is anticipated for a patient with a deficiency of plasma coagulation
factors.
4
Packed red blood cells are anticipated for a patient with acute or chronic blood loss and
for patients diagnosed with anemia.
PTS: 1
CON: Medication
MULTIPLE RESPONSE
NURSINGKING.COM
21. ANS: 2, 3
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Describing the potential complications of infusion therapy and strategies to
prevent these complications
Chapter page reference: 156-157
Heading: Phlebitis and Infiltration
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Communication; Medication
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is incorrect. The nurse would complete an incident report any time an IV infiltrates;
however, this should not be included in the nursing notes.
This is correct. Actions taken, such as discontinuation of the IV, should also be documented in
the nursing notes.
This is correct. The size of the erythematous area should be measured, marked, and
documented in the nursing notes for continuity of care.
This is incorrect. Although the health-care provider might be notified, orders received would
be written on the health-care provider order sheet and not documented in the nursing record.
This is incorrect. Intake from IV fluid would be documented on the intake and output record,
not in the nursing notes.
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PTS: 1
CON: Communication | Medication
22. ANS: 1, 2, 4, 5
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Comparing peripheral and central venous access including indications, access
devices, and potential complications
Chapter page reference: 152-155
Heading: Central Venous Access
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Medication
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is correct. Central venous access can be very useful for patients requiring long-term IV
therapy because the catheter can remain in place for extended periods, and IV sites do not
have to be changed every few days.
This is correct. Caustic medications are less likely to cause phlebitis when administered into
the large central veins as opposed to the smaller peripheral veins.
This is incorrect. Because of the potential complications from central venous access, it would
not be an option considered because of patient preference if short-term IV therapy is required.
This is correct. In the critical care areas where patients may receive numerous continuous IV
medication drips that might not all be compatible infusing through the same site, a multipleport central venous access device can provide the best option.
NU
RSare
INunstable
GKINGand
.Crequire
OM rapid administration of medications
This is correct. Patients
who
require reliable IV access that might not be available with peripheral IV lines, and central
venous access may be the best option.
PTS: 1
CON: Medication
23. ANS: 1, 2, 3
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Comparing peripheral and central venous access including indications, access
devices, and potential complications
Chapter page reference: 150-152
Heading: Peripheral Venous Access
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Medication
Difficulty: Moderate
1.
2.
3.
Feedback
This is correct. Straight veins provide space for the catheter to be inserted easily.
This is correct. Sclerotic veins make it difficult to obtain and maintain IV therapy.
This is correct. The site should be sufficiently distal to the wrist or elbow joint to avoid
bending or kinking of the IV catheter.
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4.
5.
-dominant arm, because
movement might be somewhat limited, so the patient should be allowed to use the dominant
arm.
This is incorrect. Some patients, especially dark-skinned people, might not have easily visible
veins, so the veins should be palpable even if not visible.
PTS: 1
CON: Medication
24. ANS: 1, 2, 3, 4
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Describing the special precautions required to safely administer parenteral
nutrition
Chapter page reference: 161-162
Heading: Administration of Total Parenteral Nutrition
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Medication
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. This is an appropriate action by the nurse.
This is correct. This is an appropriate action by the nurse.
This is correct. This is an appropriate action by the nurse.
This is correct. This is an appropriate action by the nurse.
This is incorrect. The N
fluid
URshould
SINGbe
KIreplaced
NG.Cwith
OM a 5% or 10% dextrose solution, not normal
saline, because the patient has adjusted to a high sugar intake via the TPN, and eliminating all
sugar infused could result in hypoglycemia.
PTS: 1
CON: Medication
25. ANS: 1, 2, 4
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: Describing the potential complications of infusion therapy and strategies to
prevent these complications
Chapter page reference: 157
Heading: Central Line Complications
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Analysis [Analyzing]
Concept: Medication
Difficulty: Difficult
1.
2.
3.
4.
5.
Feedback
This is correct. The nurse should use Luer-lock connections to prevent an air embolism.
This is correct. The nurse should frequently check all connections.
This is incorrect. Wearing sterile gloves when accessing any connections will not prevent an
air embolism.
This is correct. Clamping catheters and injection sites when not in use will help to prevent an
air embolism.
This is incorrect. The patient should be placed in the supine position for removal of the CVC.
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PTS: 1
CON: Medication
Chapter 11: Pain Management
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. Which action by the nurse is the most appropriate when initiating guided imagery with a patient as a method
to control pain?
1) Suggesting a place where the patient will find peace
2) Guiding the patient toward a most beautiful or peaceful place
3) Asking the patient to use progressive muscle relaxation exercises
4) Asking the patient to take slow, full diaphragmatic/abdominal breaths
____
2. A patient, who rates abdominal pain as a 10 on a 1 to 10 numeric scale is experiencing nausea, vomiting, and
restlessness. Which conclusion is appropriate by the nurse based on the current data?
1) Acute pain
2) Chronic pain
3) End-of-life pain
4) Fibromyalgia pain
____
3. The nurse is caring for a patient who is experiencing acute chest pain that is rated as a 9 on a 0 to 10 pain
scale. Based on this data, which medication does the nurse plan to administer?
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1) Morphine
2) Ibuprofen
3) Naproxen
4) Acetaminophen
____
4. The nurse is teaching a class on the perception of pain. What will the nurse teach as being the second step in
processing pain stimuli?
1) Thalamus
2) Limbic system
3) Cerebral cortex
4) Reticular system
____
5. Which nursing action will provide the patient with the most pain relief after abdominal surgery?
1) Offer pain relief before the patient complains of pain.
2) Assess the pain level every 4 hours around the clock.
3) Wait until the patient can describe the pain specifically.
4) Allow the
____
6. The patient with a sprained ankle is complaining of pain in the injured area. Which term will the nurse use
1)
2)
3)
4)
____
Somatic pain
Visceral pain
Neuropathic pain
Physiological pain
7. Which term should the nurse use to document the maximum amount of pain is able to tolerate?
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1)
2)
3)
4)
Allodynia
Hyperalgesia
Pain tolerance
Pain threshold
____
8. The nurse is using a
voltage electrical stimulation directly over the pain area. When documenting this intervention, which term is
the most appropriate for the nurse to use?
1) TENS unit
2) Nerve block
3) Functional restoration
4) Cutaneous stimulation
____
9. The patient has pain in the lower back that radiates down the leg as the result of a herniated disk compressing
the sciatic nerve that began 4 months ago. When documenting this
use?
1) Acute somatic pain
2) Acute visceral pain
3) Acute neuropathic pain
4) Chronic neuropathic pain
____ 10. Which type of pain syndrome should the nurse assess when providing care to a female patient?
1) Back pain
2) Interstitial cystitis
3) Cluster headaches
4) Visceral pain from the heart
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____ 11. The nurse is providing care to a postoperative patient who is getting out of bed for the first time since surgery.
When conducting the pain assessment,
1)
2)
3)
4)
ics if you can
____ 12. The nurse is providing care to a patient who had an abdominal nevus removed who is reporting intense pain.
Which action by the nurse is appropriate?
1) Administer the stronger analgesic ordered by the primary care provider.
2) Administer a nonnarcotic analgesic because the patient had minor surgery.
3) Notify the health-care provider that the patient's pain is excessive for the minor surgery
performed.
4) Attempt to divert the patient without administering an analgesic because the surgery was
so minor.
____ 13.
the call bell, always reporting how severe his pain is, and I think he is just drug-seeking. I am going to make
appropriate in this situation?
1) Informing the charge nurse of what was overheard
2) Reprimanding the nurse and completing an incident or variance report
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3)
4) Reminding the nurse, in private, that the sensation of pain is whatever the patient says it is
____ 14. The hospice nurse is making a home visit to a patient with terminal cancer. The patient reports poor pain
appropriate?
1)
2)
3)
4)
____ 15. The nurse finds a postoperative patient perspiring with fist clenched upon entering the room. The nurse
administers routine medication and provides care. The patient is pleasant and cooperative. Which action by
the nurse is appropriate?
1) Asking the patient if pain is being experienced
2) Instructing the patient to use the call bell if he experiences pain
3) Informing the patient that he looks uncomfortable and asking him to describe his pain
4)
____ 16. The nurse is caring for a patient who is experiencing acute pain. Which action by the patient, noted by the
nurse during the assessment, is considered an associated symptom of pain?
1) Crying
2) Vomiting
3) Grimacing
4) Changing position
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____ 17. The nurse is obtaining a pain history. The patient reports pain in the right ear. Which response by the nurse is
the most appropriate?
1)
2)
3)
4)
____ 18. Which data collected by the nurse is nonessential when conducting a patient pain history?
1) Intensity, quality, and patterns
2)
3) Precipitating factors, alleviating factors, and associated symptoms
4) Effects on activities of daily living, coping resources, and affective responses
____ 19. When caring for an older adult patient who does not speak English, which assessment tool is the most
appropriate for the nurse
1) An interpreter.
2)
3)
4) The FACES rating scale.
____ 20. The pain management team individualizes the analgesic regimen by guiding the adjustment of medication,
dose, time intervals, and route of administration. When discussing this method of treating pain, which term is
the most appropriate for the nurse to use?
1) Analgesia
2) Equianalgesia
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3) Polypharmacy
4) Dose-reduction pharmacology
____ 21. Which is the reason for the nurse to administer ibuprofen, over acetaminophen, when providing patient pain
management?
1) Analgesic effects
2) Antipyretic effects
3) Anti-inflammatory effects
4) Antipyretic and anti-inflammatory effects
____ 22. The patient reports difficulty sleeping related to anxiety. Which nonpharmacologic pain management
intervention might the nurse consider performing in order to relax the patient?
1) Massage
2) Distraction
3) Acupressure
4) Acupuncture
____ 23. The nurse administered an oral analgesic to a patient complaining of a mild-to-moderate headache. Which
1)
2)
3)
4)
Crossword puzzles
Slow rhythmic breathing
Reading or watching TV
Video or computer games
Multiple Response
Identify one or more choices that best completeNthe
URstatement
SINGKor
INanswer
G.COthe
M question.
____ 24. The nurse is creating a pain management plan using the three-step approach for a patient with intractable pain.
Which interventions should the nurse include in this plan? Select all that apply.
1) Administer an opioid analgesic first.
2) Administer a nonopioid analgesic first.
3) Administer a mild opioid analgesic last.
4) Administer analgesics upon patient request.
5) Administer a combination nonopioid-opioid second.
____ 25. The nurse is working on the orthopedic unit, and is caring for a patient who reports back pain. Which
responses by the nurse would be appropriate when caring for this patient? Select all that apply.
1)
2)
3)
4)
5)
experience very different symptoms. Tell me more about your
____ 26. According to the World Health Organization Three-Step Approach, if the nurse is caring for a patient
reporting mild pain that persists after using full doses of step 1 medications, which medications can the nurse
administer? Select all that apply.
1) Codeine
2) Fentanyl
3) Morphine
4) Hydrocodone with ibuprofen
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5) Oxycodone with acetaminophen
____ 27. The nurse administers a nonsteroidal anti-inflammatory drug (NSAID) to a patient who is experiencing
chronic pain. When teaching the patient about this medication, which effects will the nurse include in the
session? Select all that apply.
1) Sedating effects
2) Analgesic effects
3) Anesthetic effects
4) Antipyretic effects
5) Anti-inflammatory effects
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Chapter 11: Pain Management
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 11, Pain Management
Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based
interventions into a plan of care for patients with pain
Chapter page reference: 179-196
Heading: Pain Management Options
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
Feedback
1
The nurse should never suggest a peaceful place, but should allow the patient to choose
the place where he finds peace.
2
The nurse should never suggest a peaceful place, but should allow the patient to choose
the place where he finds peace.
3
After deep breathing, the patient may be asked to use progressive muscle relaxation
exercises, and then the nurse will guide the patient toward a peaceful place.
4
The nurse begins by helping the patient to relax using slow breaths.
NURSINGKING.COM
PTS: 1
CON: Comfort
2. ANS: 1
Chapter number and title: 11, Pain Management
Chapter learning objective: Defining types of pain
Chapter page reference: 174-177
Heading: Comprehensive Assessment Strategies for Acute and Chronic Pain
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Comprehension [Understanding]
Concept: Comfort
Difficulty: Easy
1
2
3
4
Feedback
Acute pain is pain of varying severity, location, and etiology that lasts fewer than 6
months. Acute pain is often manifested by nausea, vomiting, and restlessness.
Chronic pain lasts longer than 6 months and persists beyond the expected period of
healing.
End-of-life pain is pain that is associated with the process of dying.
Fibromyalgia pain is widespread muscular and joint pain.
PTS: 1
CON: Comfort
3. ANS: 1
Chapter number and title: 11, Pain Management
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Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based
interventions into a plan of care for patients with pain
Chapter page reference: 179-196
Heading: Pain Management Options
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
Feedback
1
Acute pain is often treated with an opioid such as morphine. Morphine is often used to
treat chest pain that is associated with a myocardial infarction.
2
Acetaminophen, ibuprofen, and naproxen are more appropriate for other types of pain,
not acute chest pain.
3
Acetaminophen, ibuprofen, and naproxen are more appropriate for other types of pain,
not acute chest pain.
4
Acetaminophen, ibuprofen, and naproxen are more appropriate for other types of pain,
not acute chest pain.
PTS: 1
CON: Comfort
4. ANS: 3
Chapter number and title: 11, Pain Management
Chapter learning objective: Explaining the pathophysiologic processes that underlie the pain process
Chapter page reference: 169-172
Heading: Processing Pain Messages
URSINGKING.COM
Integrated Processes: Teaching andNLearning
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
Feedback
1
The thalamus is the main relay station for sensory information.
2
The transmission of pain moves through the limbic system after the thalamus.
3
The cerebral cortex is the second step in processing pain stimuli.
4
Transmission of pain impulses occurs in the reticular system after traveling though the
thalamus as the main relay station.
PTS: 1
CON: Comfort
5. ANS: 1
Chapter number and title: 11, Pain Management
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with pain
Chapter page reference: 177-179
Heading: Nursing Management of Pain
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
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3
Feedback
Anticipating
waiting until the patient complains of pain.
If the patient is asleep, she should not be awakened simply to assess the pain every 4
hours unless there are other significant nonverbal signs during sleep that indicate that
the patient is in pain. These can include grimacing, moaning, thrashing, or guarding of a
surgical site.
Pain management needs to be implemented prior to the patient's describing specific
4
Pain management needs to be implemented prior to the patient's describing specific
1
2
PTS: 1
CON: Comfort
6. ANS: 1
Chapter number and title: 11, Pain Management
Chapter learning objective: Defining types of pain
Chapter page reference: 166-169
Heading: Definitions of Pain
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
1
2
3
4
Feedback
NURSINGKING.COM
Somatic pain originates in the skin, muscles, bone, or connective tissue, and would best
Visceral pain tends to be poorly located, resulting from activation of pain receptors in
the organs and/or hollow viscera.
Neuropathic pain results from damaged or malfunctioning nerves.
Somatic pain is a subclassification of physiological pain, so it would be less specific to
call it physiological as opposed to somatic.
PTS: 1
CON: Comfort
7. ANS: 3
Chapter number and title: 11, Pain Management
Chapter learning objective: Defining types of pain
Chapter page reference: 172-174
Heading: Factors Shaping the Pain Experience
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
Feedback
1
Allodynia is pain produced by nonpainful stimuli, such as the touch of wind to the area.
2
Hyperalgesia, or hyperpathia, denotes a heightened response to painful stimuli.
3
Pain tolerance is the maximum amount of pain a client can tolerate.
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4
Pain threshold is the lowest amount of stimuli needed for a person to label a sensation
as pain.
PTS: 1
CON: Comfort
8. ANS: 1
Chapter number and title: 11, Pain Management
Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based
interventions into a plan of care for patients with pain
Chapter page reference: 179-196
Heading: Pain Management Options
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
Feedback
1
The unit described is a TENS unit, or transcutaneous electrical nerve stimulator, which
is a form of cutaneous stimulation.
2
Nerve block is a pharmacologic treatment injecting an analgesic or steroid into the site
of pain.
3
Functional restoration is a form of social therapy.
4
TENS would be the specific name of this treatment, whereas cutaneous stimulation
would be a more general term.
PTS: 1
CON: Comfort
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9. ANS: 3
Chapter number and title: 11, Pain Management
Chapter learning objective: Defining types of pain
Chapter page reference: 166-169
Heading: Definitions of Pain
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
Feedback
1
2
3
The terminology is not used to
The pain is considered acute because it has lasted less than 6 months. It is neuropathic
pain because it is caused by damage to the sciatic nerve.
4
PTS: 1
CON: Comfort
10. ANS: 2
Chapter number and title: 11, Pain Management
Chapter learning objective: Describing components that comprise a comprehensive pain assessment
Chapter page reference: 174-177
Heading: Comprehensive Assessment Strategies for Acute and Chronic Pain
Integrated Processes: Nursing Process Assessment
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Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
Feedback
1
Back pain syndrome is more common in male, not female, patients.
2
Interstitial cystitis is more common in female patients; therefore, the nurse should
assess for this.
3
Cluster headache syndrome is more common in male, not female, patients.
4
Visceral pain syndrome is more common in male, not female, patients.
PTS: 1
CON: Comfort
11. ANS: 3
Chapter number and title: 11, Pain Management
Chapter learning objective: Developing patient educational strategies to promote self-care and improved
patient outcomes
Chapter page reference: 177-179
Heading: Nursing Management of Pain
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
1
2
3
4
Feedback
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This statement is inappropriate.
This statement is inappropriate.
Many patients worry about becoming addicted to narcotic analgesics if they are
required for more than a few days. It is important for the nurse to reassure the patient by
providing truthful information.
This statement is inappropriate.
PTS: 1
CON: Comfort
12. ANS: 1
Chapter number and title: 11, Pain Management
Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based
interventions into a plan of care for patients with pain
Chapter page reference: 177-179
Heading: Nursing Management of Pain
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
1
Feedback
Pain perception is what the patient says it is, and the nurse should medicate the patient
patient reports severe pain, the nurse should administer strong analgesics.
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2
3
4
Patients who have minor surgery can still experience severe pain, and administering
weaker analgesics when the patient reports severe pain would not be responsible
practice.
There is no need to notify the health-care provider unless the
indicates there is something unusual occurring.
Diverting the patient most likely will not be effective alone, although diversion might
be possible after administering the analgesic.
PTS: 1
CON: Comfort
13. ANS: 4
Chapter number and title: 11, Pain Management
Chapter learning objective: Developing patient educational strategies to promote self-care and improved
patient outcomes
Chapter page reference: 177-179
Heading: Nursing Management of Pain
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Communication
Difficulty: Moderate
1
2
3
Feedback
Informing the charge nurse would only be necessary if the nurse who was overheard did
This is not an appropriate response by the nurse.
NURSINGKING.COM
arise that place the client at risk of incorrect treatment.
4
station.
PTS: 1
CON: Communication
14. ANS: 3
Chapter number and title: 11, Pain Management
Chapter learning objective: Developing patient educational strategies to promote self-care and improved
patient outcomes
Chapter page reference: 177-179
Heading: Nursing Management of Pain
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort; Communication
Difficulty: Moderate
1
Feedback
This response is likely to make the spouse feel guilty and does not provide information
to provide the best care possible.
2
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3
4
It is not unusual for a family caregiver to withhold medication out of fear of overdosing
the cancer patient. It is important for the nurse to inform the caregiver that his feelings
are not unusual, and then provide him with the information he needs to make an
informed and appropriate decision that will make the client more comfortable.
This response is likely to make the spouse feel guilty and does not provide information
to provide the best care possible.
PTS: 1
CON: Comfort | Communication
15. ANS: 3
Chapter number and title: 11, Pain Management
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with pain
Chapter page reference: 177-179
Heading: Nursing Management of Pain
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
1
2
Feedback
Some patients might feel that admitting to pain is a sign of weakness, and might not
asks him to describe his pain and indicates the patient's apparent discomfort.
Instructing the patient to use the call bell puts the responsibility for pain assessment on
the patient instead of on the nurse.
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3
it.
4
PTS: 1
CON: Comfort
16. ANS: 2
Chapter number and title: 11, Pain Management
Chapter learning objective: Describing components that comprise a comprehensive pain assessment
Chapter page reference: 166-169
Heading: Definitions of Pain
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Comprehension [Understanding]
Concept: Comfort
Difficulty: Easy
Feedback
1
Changing position, crying, and grimacing are manners of expressing pain.
2
Symptoms that are often associated with pain include nausea, vomiting, and dizziness.
3
Changing position, crying, and grimacing are manners of expressing pain.
4
Changing position, crying, and grimacing are manners of expressing pain.
PTS: 1
CON: Comfort
17. ANS: 4
Chapter number and title: 11, Pain Management
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Chapter learning objective: Describing components that comprise a comprehensive pain assessment
Chapter page reference: 174-177
Heading: Comprehensive Assessment Strategies for Acute and Chronic Pain
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
1
2
3
4
Feedback
This is a closed question and will not allow the nurse to gather the information needed
This is a closed question and will not allow the nurse to gather the information needed
regarding the
This is a closed question and will not allow the nurse to gather the information needed
When the patient reports pain, the nurse should seek more information. When assessing
pain, the nurse should assess all aspects of the pain, including character, onset, location,
duration, exacerbation, relief, and radiation.
PTS: 1
CON: Comfort
18. ANS: 2
Chapter number and title: 11, Pain Management
Chapter learning objective: Describing components that comprise a comprehensive pain assessment
Chapter page reference: 174-177
NUStrategies
RSINGKfor
INAcute
G.Cand
OMChronic Pain
Heading: Comprehensive Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Comprehension [Understanding]
Concept: Assessment; Comfort
Difficulty: Easy
1
Feedback
The nurse should determine all of the other factors in order to put a plan of care in place
that will help the patient address and treat the pain effectively.
2
3
4
The nurse should determine all of the other factors in order to put a plan of care in place
that will help the patient address and treat the pain effectively.
The nurse should determine all of the other factors in order to put a plan of care in place
that will help the patient address and treat the pain effectively.
PTS: 1
CON: Assessment | Comfort
19. ANS: 4
Chapter number and title: 11, Pain Management
Chapter learning objective: Describing components that comprise a comprehensive pain assessment
Chapter page reference: 196-199
Heading: Managing Pain in Special Populations
Integrated Processes: Nursing Process Assessment
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Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Comprehension [Understanding]
Concept: Comfort
Difficulty: Easy
1
Feedback
If an interpreter is available the nurse can ask the interpreter to discuss the pain in more
appropriately and quickly without waiting for an interpreter.
2
3
4
mfort.
An interpreter might not always be readily available, so the FACES rating scale can be
used because it is not necessary to use language.
PTS: 1
CON: Comfort
20. ANS: 2
Chapter number and title: 11, Pain Management
Chapter learning objective: Defining types of pain
Chapter page reference: 166-169
Heading: Definitions of Pain
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Comprehension [Understanding]
Concept: Comfort
Difficulty: Easy
NURSINGKING.COM
Feedback
1
Analgesia is a classification of medication used for pain control.
2
The term equianalgesia refers to the relative potency of various opioid analgesics
compared to a standard dose of parenteral morphine (gold standard opioid). This tool
helps professionals individualize the analgesic regimen by guiding the adjustment of
medication, dose, time interval, and route of administration.
3
Polypharmacy is a generic term for multiple medication administration, often used with
elders who are on many medications.
4
Dose-reduction pharmacology is not terminology associated with pain management.
PTS: 1
CON: Comfort
21. ANS: 3
Chapter number and title: 11, Pain Management
Chapter learning objective: Examining pain management strategies
Chapter page reference: 179-196
Heading: Pain Management Options
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Comfort
Difficulty: Easy
Feedback
1
Both ibuprofen and acetaminophen provide analgesic effects.
2
Both ibuprofen and acetaminophen provide antipyretic effects.
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3
4
Ibuprofen is administered over acetaminophen when anti-inflammatory properties are
desired for pain management.
While ibuprofen is administered for its anti-inflammatory properties both
acetaminophen and ibuprofen have antipyretic properties.
PTS: 1
CON: Comfort
22. ANS: 1
Chapter number and title: 11, Pain Management
Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based
interventions into a plan of care for patients with pain
Chapter page reference: 179-196
Heading: Pain Management Options
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Comprehension [Understanding]
Concept: Comfort
Difficulty: Easy
Feedback
1
Massage is used for relaxation, and can be effective in helping the client who is
anxious.
2
Distraction, acupressure, and acupuncture are not used for relaxation, although they can
be effective in helping the patient cope with pain.
3
Distraction, acupressure, and acupuncture are not used for relaxation, although they can
be effective in helping the patient cope with pain.
4
Distraction, acupressure, and acupuncture are not used for relaxation, although they can
NURSINGKING.COM
be effective in helping the patient cope with pain.
PTS: 1
CON: Comfort
23. ANS: 2
Chapter number and title: 11, Pain Management
Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based
interventions into a plan of care for patients with pain
Chapter page reference: 179-196
Heading: Pain Management Options
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
Feedback
1
Reading, watching TV, video games, and crossword puzzles might exacerbate the
symptoms because the patient with a headache is often more comfortable in a dark,
low-stimuli environment.
2
Slow rhythmic breathing would be an effective distraction technique for a patient with a
headache.
3
Reading, watching TV, video games, and crossword puzzles might exacerbate the
symptoms because the patient with a headache is often more comfortable in a dark,
low-stimuli environment.
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4
Reading, watching TV, video games, and crossword puzzles might exacerbate the
symptoms because the patient with a headache is often more comfortable in a dark,
low-stimuli environment.
PTS: 1
CON: Comfort
MULTIPLE RESPONSE
24. ANS: 2, 3, 5
Chapter number and title: 11, Pain Management
Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based
interventions into a plan of care for patients with pain
Chapter page reference: 179-196
Heading: Pain Management Options
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parental Therapies
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is incorrect. An opioid analgesic is not the first choice when using the three-step
approach in pain management.
This is correct. The first step in the three-step approach to pain management involves
administering a nonopioid
NURdrug
SINfirst.
GKING.COM
This is correct. If the patient is still experiencing pain, the mild opioid should be replaced with
a stronger opioid in step 3.
This is incorrect. Pain-6 hours) rather
than on demand to maintain freedom from pain.
This is correct. If pain is not adequately controlled with this mild intervention, patients should
advance to step 2 and receive a mild opioid in combination with the same or a new nonopioid
drugs.
PTS: 1
CON: Comfort
25. ANS: 1, 2, 5
Chapter number and title: 11, Pain Management
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with pain
Chapter page reference: 177-179
Heading: Nursing Management of Pain
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
Feedback
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1.
2.
3.
4.
5.
This is correct. The nurse should inform the patient that it is the job of the nurse to work to
make the patient feel better, seek more information about the type of pain the patient is
experiencing, and question any other discomforts the patient may be experiencing.
This is correct. The nurse should inform the patient that it is the job of the nurse to work to
make the patient feel better, seek more information about the type of pain the patient is
experiencing, and question any other discomforts the patient may be experiencing.
This is incorrect. Allowing the patient to remain in pain would not be prudent practice, and
would be lacking in caring.
This is incorrect. Allowing the patient to remain in pain would not be prudent practice, and
would be lacking in caring.
This is correct. The nurse should inform the patient that it is the job of the nurse to work to
make the patient feel better, seek more information about the type of pain the patient is
experiencing, and question any other discomforts the patient may be experiencing.
PTS: 1
CON: Comfort
26. ANS: 1, 4, 5
Chapter number and title: 11, Pain Management
Chapter learning objective: Incorporating both pharmacologic and nonpharmacologic evidence-based
interventions into a plan of care for patients with pain
Chapter page reference: 179-196
Heading: Pain Management Options
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Comfort
NURSINGKING.COM
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. If the pain persists or the pain is moderate, the second step is a weak opioid, or
a combination of opioid and nonopioid medicine can be used. Codeine is a weak opioid.
This is incorrect. Fentanyl is a strong opioid that is not administered until step 3.
This is incorrect. Morphine is a strong opioid that is not administered until step 3.
This is correct. If the pain persists or the pain is moderate, the second step is a weak opioid, or
a combination of opioid and nonopioid medicine can be used. Hydrocodone with ibuprofen is
an opioid/nonopioid medicine.
This is correct. If the pain persists or the pain is moderate, the second step is a weak opioid, or
a combination of opioid and nonopioid medicine can be used. Oxycodone with acetaminophen
is an opioid/nonopioid medicine.
PTS: 1
CON: Comfort
27. ANS: 2, 4, 5
Chapter number and title: 11, Pain Management
Chapter learning objective: Developing patient educational strategies to promote self-care and improved
patient outcomes
Chapter page reference: 179-196
Heading: Pain Management Options
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
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Concept: Comfort
Difficulty: Moderate
Feedback
This is incorrect. These medications do not have sedating or anesthetic effects in most
patients, although some patients might report being able to fall asleep more easily once pain is
reduced.
This is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) have anti-inflammatory,
analgesic, and antipyretic effects.
This is incorrect. These medications do not have sedating or anesthetic effects in most
patients, although some patients might report being able to fall asleep more easily once pain is
reduced.
This is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) have anti-inflammatory,
analgesic, and antipyretic effects.
This is correct. Nonsteroidal anti-inflammatory drugs (NSAIDs) have anti-inflammatory,
analgesic, and antipyretic effects.
1.
2.
3.
4.
5.
PTS: 1
CON: Comfort
Chapter 12: Complementary and Alternative Care Initiatives
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
URSthe
INRecipient/Practitioner
GKING.COM Partnership in the delivery of
1. Which is a guiding principle when N
using
complementary and alternative medicine to a patient?
1) Defining health as harmonious and balanced
2) Believing that qi permeates and bonds all living things
3) Establishing a relationship because building trust instills hope
4) Emphasizing a healthy lifestyle for a proactive approach to wellness
____
2. Which is a guiding principle when using the Wellness Model of Care in the delivery of complementary and
alternative medicine to a patient?
1) Defining health as harmonious and balanced
2) Believing that qi permeates and bonds all living things
3) Establishing a relationship because building trust instills hope
4) Emphasizing a healthy lifestyle for a proactive approach to wellness
____
3. Which is a guiding principle when using the Energy Paradigm in the delivery of complementary and
alternative medicine to a patient?
1) Defining health as harmonious and balanced
2) Encouraging self-awareness regarding body changes
3) Establishing a relationship because building trust instills hope
4) Emphasizing a healthy lifestyle for a proactive approach to wellness
____
4. The nurse should offer the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan
of care for patients with which emotional or psychological disorder?
1) Neuropathy
2) Fibromyalgia
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3) Chronic fatigue
4) Carpal tunnel syndrome
____
5. The nurse should offer the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan
of care for patients with which pain disorder?
1) Insomnia
2) Menopause
3) Fibromyalgia
4) Chronic fatigue
____
6. Which patient statement indicates the need for further education regarding the benefits of using Energy
Healing Therapies in the plan of care?
1)
2)
3)
4)
____
7. Which gastrointestinal (GI) issue might benefit from the nurse educating the patient about the use of herbal
medicine?
1) Reflux
2) Flatulence
3) Constipation
4) Hemorrhoids
____
8. A patient is interested in exploring the use of a complementary and alternative medicine (CAM) health-care
provider. Which patient statement indicates the need for further education regarding questions that should be
asked of any CAM provider?
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1)
2)
3)
4)
____
9. A nurse is interested in implementing complementary and alternative medicine (CAM) into practice. Which
research barrier may inhibit this from occurring?
1) Detailed standardization for interpretation of systematic reviews
2) Large number of patients involved in clinical trials
3) Generic treatment plans
4) Reluctant funding
____ 10. A patient asks for reliable information from the Internet regarding complementary and alternative medicine
(CAM). Which URL should the nurse provide to this patient?
1) www.google.com
2) www.webmd.com
3) www.cdc.gov
4) www.fda.gov
____ 11. Which term should the nurse use when referring to the dominant health-care system within the United States
during a training session with other health-care providers regarding complementary and alternative medicine
(CAM)?
1) Eastern medicine
2) Conventional medicine
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3) Folklore medicine practices
4) Old-world traditional medicine
____ 12. When teaching about the use of complementary and alternative medicine (CAM), which patient statement
indicates to the nurse the need for additional education?
1)
2)
alternative
3)
4)
gs such as pain, anxiety, depression, and
____ 13. Which nursing action indicates a holistic approach to patient care?
1) Refusing a patient assignment because of differing religious beliefs
2)
beliefs should be kept to themselves
3)
4)
____ 14. Which therapy should the nurse document as a specific category for complementary and alternative medicine
(CAM)?
1) Naturopathy
2) Acupuncture
3) Therapeutic touch
4) Dietary supplements
____ 15. Which patient diagnosis would contraindicate the use of massage at a complementary and alternative
medicine (CAM) therapy?
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1) Depression
2) Osteoporosis
3) Fibromyalgia
4) Tumor sites
____ 16. Which patient prescription would contraindicate the use of massage therapy in the nursing plan of care?
1) Insulin
2) Warfarin
3) Propranolol
4) Acetaminophen
____ 17. Which patient condition would cause the nurse to assess for physical limitations and mobility restrictions
prior to including mind/body therapies in the plan of care?
1) Cataracts
2) Pregnancy
3) Previous back surgery
4) Controlled hypertension
____ 18. Which patient condition supports the use of an energy healing therapy with anecdotal evidence?
1) Asthma
2) Depression
3) Bipolar disorder
4) Anorexia nervosa
____ 19. Which term should the nurse use to describe the healing properties associated with botanicals?
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1)
2)
3)
4)
Natural
Artificial
Alternative
Complementary
____ 20. The nurse is preparing to administer a prescribed herbal product with a traditional antibiotic. Which should
the nurse consult prior to administering these prescribed therapies?
1) The charge nurse for the shift.
2) The pharmacologist for the unit.
3)
4) A reputable Internet site regarding complementary and alternative medicine (CAM).
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. Which top ten diagnoses for adult patients should the nurse include complementary and alternative therapies
when planning care? Select all that apply.
1) Cancer
2) Anxiety
3) Arthritis
4) Insomnia
5) Dyspepsia
____ 22. Which are the benefits for a patient diagnosed with heart disease, when the nurse includes Mind/Body
therapies in the plan of care? Select all that apply.
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1) Decreased fatigue
2) Decreased headache
3) Decreased heart rate
4) Decreased blood pressure
5) Decreased body temperature
____ 23. The nurse plans to include the use of Mind/Body therapies for patients with which diagnoses in order to
facilitate communication and social interaction? Select all that apply.
1) Autism
2) Anxiety
3) Depression
4) Sleep disorders
5) Alzheimer disease
____ 24. The nurse plans to include the use of Mind/Body therapies for patients with which diagnoses in order to
facilitate relaxation? Select all that apply.
1) Autism
2) Anxiety
3) Depression
4) Sleep disorders
5) Alzheimer disease
____ 25. Which are general benefits the nurse would include in a teaching session for a patient who is considering the
use of Manipulative and Body-Based therapies? Select all that apply.
1) Alleviates pain
2) Relieves insomnia
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3) Decreases heart rate
4) Facilitates mental clarity
5) Increases range of motion
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Chapter 12: Complementary and Alternative Care Initiatives
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Defining complementary and alternative medicine
Chapter page reference: 202-203
Heading: Introduction
Integrated Processes: Nursing Process Planning
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Promoting Health
Difficulty: Easy
Feedback
1
This is a guiding principle when using the Energy Paradigm for the implementation of
complementary and alternative medicine.
2
This is a guiding principle when using the Energy Paradigm for the implementation of
complementary and alternative medicine.
3
This is a guiding principle when using the Recipient/Practitioner Partnership for the
implementation of complementary and alternative medicine.
4
This is the guiding principle when using the Wellness Model of Care for the
implementation of the complementary and alternative medicine.
NURSINGKING.COM
PTS: 1
CON: Promoting Health
2. ANS: 4
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Defining complementary and alternative medicine
Chapter page reference: 202-203
Heading: Introduction
Integrated Processes: Nursing Process Planning
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Promoting Health
Difficulty: Easy
1
2
3
4
Feedback
This is a guiding principle when using the Energy Paradigm for the implementation of
complementary and alternative medicine.
This is a guiding principle when using the Energy Paradigm for the implementation of
complementary and alternative medicine.
This is a guiding principle when using the Recipient/Practitioner Partnership for the
implementation of complementary and alternative medicine.
This is the guiding principle when using the Wellness Model of Care for the
implementation of complementary and alternative medicine.
PTS: 1
CON: Promoting Health
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3. ANS: 1
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Defining complementary and alternative medicine
Chapter page reference: 202-203
Heading: Introduction
Integrated Processes: Nursing Process Planning
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Promoting Health
Difficulty: Easy
1
2
3
4
Feedback
This is a guiding principle when using the Energy Paradigm for the implementation of
complementary and alternative medicine.
This is the guiding principle when using the Wellness Model of Care for the
implementation of complementary and alternative medicine.
This is a guiding principle when using the Recipient/Practitioner Partnership for the
implementation of complementary and alternative medicine.
This is the guiding principle when using the Wellness Model of Care for the
implementation of complementary and alternative medicine.
PTS: 1
CON: Promoting Health
4. ANS: 3
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
Chapter page reference: 203-209 NURSINGKING.COM
Heading: Classification of CAM
Integrated Processes: Nursing Process Planning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
Feedback
1
Neuropathy is a pain, not emotional or psychological, disorder that might be treated
with the inclusion of the Whole Medical Systems/Alternative Medical Systems in the
plan of care.
2
Fibromyalgia is a pain, not emotional or psychological, disorder that might be treated
with the inclusion of the Whole Medical Systems/Alternative Medical Systems in the
plan of care.
3
Chronic fatigue is an emotional or psychological disorder that might be treated with the
inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan of
care.
4
Carpal tunnel syndrome is a pain, not emotional or psychological, disorder that might
be treated with the inclusion of the Whole Medical Systems/Alternative Medical
Systems in the plan of care.
PTS: 1
CON: Nursing
5. ANS: 3
Chapter number and title: 12, Complementary and Alternative Care Initiatives
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
Chapter page reference: 203-209
Heading: Classification of CAM
Integrated Processes: Nursing Process Planning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
Feedback
1
Insomnia is an emotional or psychological, not pain, disorder that might be treated with
the inclusion of the Whole Medical Systems/Alternative Medical Systems in the plan of
care.
2
Menopause is an emotional or psychological, not pain, disorder that might be treated
with the inclusion of the Whole Medical Systems/Alternative Medical Systems in the
plan of care.
3
Fibromyalgia is a pain disorder that might be treated with the inclusion of the Whole
Medical Systems/Alternative Medical Systems in the plan of care.
4
Chronic fatigue is an emotional or psychological, not pain, disorder that might be
treated with the inclusion of the Whole Medical Systems/Alternative Medical Systems
in the plan of care.
PTS: 1
CON: Nursing
6. ANS: 3
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
NURSINGKING.COM
Chapter page reference: 208
Heading: Box 12.6 Benefits of Energy Healing Therapies
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Analysis [Analyzing]
Concept: Promoting Health
Difficulty: Difficult
Feedback
1
Energy Healing Therapies are known to promote relaxation. This statement indicates
correct understanding of the information presented.
2
Energy Healing Therapies are known to reduce stress. This statement indicates correct
understanding of the information presented.
3
Energy Healing Therapies are known to increase, not decrease, stamina. This statement
indicates the need for further education.
4
Energy Healing Therapies are known to relieve musculoskeletal discomfort. This
statement indicates correct understanding of the information presented.
PTS: 1
CON: Promoting Health
7. ANS: 3
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
Chapter page reference: 208-209
Heading: Herbal Medicine and Botanicals
Integrated Processes: Nursing Process Planning
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Comprehension [Understanding]
Concept: Bowel Elimination
Difficulty: Easy
Feedback
1
The treatment of reflux is not a GI issue that is supported by evidence to benefit from
herbal medicines.
2
The treatment of flatulence is not a GI issue that is supported by evidence to benefit
from herbal medicines.
3
Evidence supports the use of herbal medicines in the treatment of constipation.
4
The treatment of hemorrhoids is not a GI issue that is supported by evidence to benefit
from herbal medicines.
PTS: 1
CON: Bowel Elimination
8. ANS: 2
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Discussing the nursing implications of complementary and alternative medicine
Chapter page reference: 209-211
Heading: Nursing Implications: Assessment, Education, and Research
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Analysis [Analyzing]
Concept: Promoting Health
Difficulty: Difficult
Feedback
1
2
3
4
NURSINGKING.COM
health insurance plan.
Many CAM providers are licensed; therefore, this statement indicates the need for
further education by the nurse.
The patient should be sure that he or she is educated regarding any possible side effects
associated with the CAM treatment.
Many CAM treatments require follow-up visits; therefore, this statement indicates
appropriate understanding of the information presented.
PTS: 1
CON: Promoting Health
9. ANS: 4
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Discussing the nursing implications of complementary and alternative medicine
Chapter page reference: 209-211
Heading: Nursing Implications: Assessment, Education, and Research
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Evidence-Based Practice
Difficulty: Easy
Feedback
1
Inadequate, not detailed, standardization for interpretation of systematic reviews is a
research barrier for the implementation of CAM into practice.
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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2
3
4
A limited, not large, number of patients involved in clinical trials is a research barrier
for the implementation of CAM into practice.
Personalized, not generic, treatment plans is a research barrier for the implementation
of CAM into practice.
Funding for research is an issue for the implementation of CAM into practice.
PTS: 1
CON: Evidence-Based Practice
10. ANS: 4
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Discussing the nursing implications of complementary and alternative medicine
Chapter page reference: 209-211
Heading: Nursing Implications: Assessment, Education, and Research
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Promoting Health
Difficulty: Moderate
Feedback
1
A google search will not yield reliable information from the Internet regarding CAM.
2
WebMD is not a reliable source for information on the Internet regarding CAM.
3
While the CDC is a reputable Internet resource, it is not known as a reliable resource
regarding CAM.
4
The FDA is a reputable Internet resource regarding CAM. This is the URL the nurse
should provide to this patient.
NURSINGKING.COM
PTS: 1
CON: Promoting Health
11. ANS: 2
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Defining complementary and alternative medicine
Chapter page reference: 202-203
Heading: Introduction
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Health Care System
Difficulty: Moderate
1
2
3
4
Feedback
Western, not eastern, medicine is another term for the traditional health-care system
within the United States.
Conventional medicine is another term for the traditional health-care system within the
United States.
Folklore medicine practices refers to CAM, not the traditional health-care system
within the United States.
Old-world traditional medicine refers to CAM, not the traditional health-care system
within the United States.
PTS: 1
12. ANS: 1
CON: Health Care System
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Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Defining complementary and alternative medicine
Chapter page reference: 202-203
Heading: Introduction
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Health Care System
Difficulty: Difficult
Feedback
1
The goals of care for CAM and conventional medicine are quite similar. This statement
indicates the need for further education.
2
The term alternative in CAM refers to treatment that is outside of the conventional
methods.
3
The term complementary in CAM refers to practices that are paired with conventional
medicine.
4
Pain, anxiety, depression, and headaches are included in the top 10 reasons adult
patients seeks CAM.
PTS: 1
CON: Health Care System
13. ANS: 4
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Defining complementary and alternative medicine
Chapter page reference: 202-203
Heading: Introduction
NURS
INGKING.COM
Integrated Processes: Nursing Process
Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
1
Feedback
Refusing a patient assignment due to differing religious beliefs does not indicate a
holistic approach to patient care.
2
not indicates a holistic approach to patient care.
3
does not indicates a holistic approach to patient care.
4
ear infection indicates a holistic approach to patient care.
PTS: 1
CON: Nursing
14. ANS: 4
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
Chapter page reference: 203-209
Heading: Classification of CAM
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
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Cognitive level: Application [Applying]
Concept: Critical Thinking
Difficulty: Moderate
Feedback
1
Naturopathy is a type of Whole medical systems/Alternative medical systems therapy
but not a category of CAM.
2
Acupuncture is a type of Whole medical systems/Alternative medical systems therapy
but not a category of CAM.
3
Therapeutic touch is a type of healing energy touch therapy but not a category of CAM.
4
Dietary supplements a specific therapy that is also a category of CAM.
PTS: 1
CON: Critical Thinking
15. ANS: 4
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
Chapter page reference: 206
Heading: Massage Therapy
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Critical Thinking
Difficulty: Moderate
Feedback
1
Depression is not a patient diagnosis that contraindicates the use of massage therapy.
2
Osteoporosis is not a patientNdiagnosis
contraindicates
URSINthat
GKI
NG.COM the use of massage therapy.
3
Fibromyalgia is not a patient diagnosis that contraindicates the use of massage therapy.
4
The use of massage therapy over tumor sites is contraindicated.
PTS: 1
CON: Critical Thinking
16. ANS: 2
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Discussing the nursing implications of complementary and alternative medicine
Chapter page reference: 207
Heading: Safety Alert
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1
The use of insulin by the patient does not contraindicate the use of massage therapy in
the nursing plan of care.
2
The use of warfarin, an anticoagulant agent, contraindicates the use of massage therapy
in the nursing plan of care due to the increased risk for bleeding.
3
The use of propranolol by the patient does not contraindicate the use of massage
therapy in the nursing plan of care.
4
The use of acetaminophen by the patient does not contraindicate the use of massage
therapy in the nursing plan of care.
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PTS: 1
CON: Medication
17. ANS: 2
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Discussing the nursing implications of complementary and alternative medicine
Chapter page reference: 207
Heading: Safety Alert
Integrated Processes: Nursing Process Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Assessment
Difficulty: Moderate
Feedback
1
Glaucoma, not cataracts, is a patient diagnosis which would necessitate the need for the
nurse to assess for physical limitations and mobility restrictions prior to the
implementation of mind/body therapies.
2
Pregnancy is a patient diagnosis which would necessitate the need for the nurse to
assess for physical limitations and mobility restrictions prior to the implementation of
mind/body therapies.
3
Recent back surgery, not previous back surgery, is a patient diagnosis which would
necessitate the need for the nurse to assess for physical limitations and mobility
restrictions prior to the implementation of mind/body therapies.
4
Uncontrolled, not controlled, hypertension is a patient diagnosis which would
necessitate the need for the nurse to assess for physical limitations and mobility
restrictions prior to the implementation of mind/body therapies.
NURSINGKING.COM
PTS: 1
CON: Assessment
18. ANS: 1
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
Chapter page reference: 207-208
Heading: Energy Healing Therapy
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Knowledge [Remembering]
Concept: Evidence-Based Practice
Difficulty: Easy
1
2
3
4
Feedback
The use of energy healing therapies is supported by anecdotal evidence for patients
diagnosed with asthma.
This condition does not support the use of energy healing therapies by anecdotal
evidence.
This condition does not support the use of energy healing therapies by anecdotal
evidence.
This condition does not support the use of energy healing therapies by anecdotal
evidence.
PTS: 1
CON: Evidence-Based Practice
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19. ANS: 1
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
Chapter page reference: 208-209
Heading: Herbal Medicine and Botanicals
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Communication
Difficulty: Easy
Feedback
1
Natural is a term that is often used to describe the healing properties associated with
botanicals.
2
This is not the term that is used to describe the healing properties associated with
botanicals.
3
This is not the term that is used to describe the healing properties associated with
botanicals.
4
This is not the term that is used to describe the healing properties associated with
botanicals.
PTS: 1
CON: Communication
20. ANS: 2
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Discussing the nursing implications of complementary and alternative medicine
Chapter page reference: 209
NURSINGKING.COM
Heading: Safety Alert
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Analysis [Analyzing]
Concept: Medication; Safety
Difficulty: Difficult
Feedback
1
The charge nurse for the shift may not be the best resource for the nurse to consult prior
to administering this combination of prescribed therapies.
2
The nurse should consult with the provider, pharmacist, or herbalist prior to
administering any herbal product with a prescribed drug.
3
While a PDR is an appropriate reference for prescribed drugs, this resource many not
have information regarding the prescribed herbal product.
4
A reputable Internet site for CAM may not have the specific information needed
regarding the prescribed drug the nurse needs to administer with the herbal product.
PTS: 1
CON: Medication | Safety
MULTIPLE RESPONSE
21. ANS: 2, 3, 4, 5
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Defining complementary and alternative medicine
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Chapter page reference: 202-203
Heading: Introduction
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Knowledge [Remembering]
Concept: Nursing
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is incorrect. Cancer is not a top ten diagnosis for adult patients regarding the use of
complementary and alternative therapies.
This is correct. Anxiety is a top ten diagnosis for adult patients for the use of complementary
and alternative medicine.
This is correct. Arthritis is a top ten diagnosis for adult patients for the use of complementary
and alternative medicine.
This is correct. Insomnia is a top ten diagnosis for adult patients for the use of complementary
and alternative medicine.
This is correct. Dyspepsia, or stomach upset, is a top ten diagnosis for adult patients for the
use of complementary and alternative medicine.
PTS: 1
CON: Nursing
22. ANS: 3, 4, 5
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
Chapter page reference: 203-209
NURSINGKING.COM
Heading: Classification of CAM
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is incorrect. Decreased fatigue is a benefit when including Mind/Body therapies in the
plan of care for a patient diagnosed with an emotional or psychological disorder, not heart
disease.
This is incorrect. Decreased incidence of headache is a benefit when including Mind/Body
therapies in the plan of care for a patient diagnosed with an emotional or psychological
disorder, not heart disease.
This is correct. A decrease in the heart rate is a benefit of including Mind/Body therapies in
the plan of care for a patient who is diagnosed with heart disease.
This is correct. A decrease in the blood pressure is a benefit of including Mind/Body therapies
in the plan of care for a patient who is diagnosed with heart disease.
This is correct. A decrease in body temperature is a benefit of including Mind/Body therapies
in the plan of care for a patient who is diagnosed with heart disease.
PTS: 1
CON: Perfusion
23. ANS: 1, 5
Chapter number and title: 12, Complementary and Alternative Care Initiatives
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
Chapter page reference: 203-209
Heading: Classifications of CAM
Integrated Processes: Nursing Process Planning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Communication
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. Mind/Body therapies are helpful to facilitate communication and social
interaction for patients diagnosed with autism.
This is incorrect. While Mind/Body therapies are helpful to patients with anxiety, they do not
facilitate communication and social interaction for these patients.
This is incorrect. While Mind/Body therapies are helpful to patients with depression, they do
not facilitate communication and social interaction for these patients.
This is incorrect. While Mind/Body therapies are helpful to patients with sleep disorders, they
do not facilitate communication and social interaction for these patients.
This is correct. Mind/Body therapies are helpful to facilitate communication and social
interaction for patients diagnosed with Alzheimer disease.
PTS: 1
CON: Communication
24. ANS: 2, 3, 4
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
NURSINGKING.COM
Chapter page reference: 203-209
Heading: Classifications of CAM
Integrated Processes: Nursing Process Planning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Communication
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is incorrect. Mind/Body therapies are helpful to facilitate communication and social
interaction, not relaxation, for patients diagnosed with autism.
This is correct. Mind/Body therapies are helpful to facilitate relaxation for patients diagnosed
with anxiety.
This is correct. Mind/Body therapies are helpful to facilitate relaxation for patients diagnosed
with depression.
This is correct. Mind/Body therapies are helpful to facilitate relaxation for patients diagnosed
with sleep disorders.
This is incorrect. Mind/Body therapies are helpful to facilitate communication and social
interaction, not relaxation, for patients diagnosed with Alzheimer disease.
PTS: 1
CON: Communication
25. ANS: 2, 4, 5
Chapter number and title: 12, Complementary and Alternative Care Initiatives
Chapter learning objective: Differentiating the classifications of complementary and alternative medicine
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Chapter page reference: 205-206
Heading: Mind/Body Therapies
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Promoting Health
Difficulty: Moderate
Feedback
This is incorrect. Pain reduction is not a general benefit for the use of Manipulative and BodyBased therapies.
This is correct. Relief of insomnia is a general benefit for the use of Manipulative and BodyBased therapies.
This is incorrect. A reduction in heart rate is not a general benefit for the use of Manipulative
and Body-Based therapies. This is a cardiovascular benefit.
This is correct. The facilitation of mental clarity is a general benefit for the use of
Manipulative and Body-Based therapies.
This is correct. An increase in range of motion is a general benefit for the use of Manipulative
and Body-Based therapies.
1.
2.
3.
4.
5.
PTS: 1
CON: Promoting Health
Chapter 13: Overview of Cancer Care
NURSINGKING.COM
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. The nurse is caring for a patient with leukemia. Which treatment should the nurse expect to be prescribed?
1) Chemotherapy
2) IV fluid therapy
3) Diuretic therapy
4) Electrolyte replacement therapy
____
2. The nurse is caring for an adolescent Asian patient with a strong family history of breast cancer. What should
the nurse teach the patient regarding cancer prevention?
1) Perform monthly breast self-examination.
2) Teach the side effects of cancer treatment.
3) Talk to family members who have the disease.
4) Discuss cancer fears with the health-care provider.
____
3. A patient with anemia caused by chemotherapy is prescribed synthetic erythropoietin. When teaching the
patient about the therapeutic effect of this treatment, which is appropriate for the nurse to include?
1) Increase in platelets
2) Decrease in lymph fluid
3) Increase in red blood cells
4) Decrease in white blood cells
____
4. A nurse is caring for a patient with cancer. The nurse teaches the patient about which potentially undesirable
cellular alterations that can occur during the cell cycle?
1) Dysphagia
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2) Adaptation
3) Hyperplasia
4) Differentiation
____
5. During a treatment meeting on an oncology unit, the nurse learns that a patient is scheduled for chemotherapy
before surgery. What are the purposes for this patient to receive chemotherapy at this specific time?
1) Shrink the tumor
2) Improve wound healing
3) Eradicate all cancer cells
4) Allow the immune system to kill cancer cells
____
6. The nurse has completed a seminar teaching a group in the community about ways to reduce cancer risks. The
nurse returns a month later to evaluate the effectiveness of the seminar. Which statements made by members
of the group indicate retention and application of the material presented by the nurse to reduce the risk of
developing cancer?
1)
2)
3)
4)
____
7. The nurse is preparing a seminar that discusses the risk and incidence of cancer and culture. What information
is considered culturally correct when teaching about the risk of developing cancer?
1) Hispanics have an increased risk of cervical, stomach, and liver cancer.
2) African-Americans are more likely to develop cancer than any other ethnic group.
3) The incidence and mortality rate of all type of cancers are lowest in the Caucasian
population.
NURtoSdevelop
INGKI
NG.than
COMany other ethnic or racial group
4) African-Americans are less likely
cancer
in the United States.
____
8. A patient being treated with chemotherapy for cancer complains of fatigue, pallor, progressive weakness,
exertional dyspnea, headache, and tachycardia. Which diagnosis should the nurse use as the priority when
1)
2)
3)
4)
____
Powerlessness
Ineffective Coping
Activity Intolerance
Imbalanced Nutrition, Less than Body Requirements
9. The nurse accompanies the healthis shared with the patient and family. Once the health-care provider leaves the room, the nurse notes that the
patient and family are tearythis time?
1) Provide emotional support in coping with the diagnosis.
2) Help the patient and family remain realistic about prognosis.
3) Provide teaching about the treatment options for this form of cancer.
4) Arrange for the patient to complete a medical power of attorney form.
____ 10. A patient being treated for cancer has a tumor designation of Stage IV, T4, N3, M1. What does this staging
indicate to the nurse?
1) The tumor is small in size.
2) There is one single tumor to treat.
3) The tumor will respond to chemotherapy.
4) The tumor has metastasized with lymph node involvement.
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____ 11. During an assessment, the nurse notes that a patient receiving radiation treatments for breast cancer has
excoriated skin. What is the priority nursing diagnosis?
1) Risk for Infection
2) Activity Intolerance
3) Excess Fluid Volume
4) Ineffective Breathing Pattern
____ 12. A patient has just been told that a colectomy and ileostomy are needed to treat a new diagnosis of colon
1)
2)
3)
4)
Knowledge Deficit
Anticipatory Grieving
Risk for Disuse Syndrome
Risk for Perioperative Positioning Injury
____ 13. The nurse is teaching a patient scheduled for a colonoscopy on pre- and postprocedure care. Which statement
by the patient indicates the need for further teaching?
1)
2)
3)
4)
____ 14. A patient receiving radiation therapy as treatment for colorectal cancer is experiencing nausea and vomiting.
What should the nurse encourage the patient to do?
1) Use a commercial mouthwash before eating a meal.
2) Eat spicy or well-seasoned foods instead of bland foods.
3) Delay the intake of a meal until
three
toNfour
NU
RSI
GKhours
ING.after
COtreatment.
M
4) Avoid all food and liquid until nausea and vomiting stop.
____ 15. A patient with terminal colon cancer is refusing all food and fluids. The patient has a living will that states no
artificial nutrition is to be provided; however, the family is asking for a gastrostomy tube. What should the
nurse do?
1)
2)
3) Honor the
4)
____ 16. A patient is receiving chemotherapy for the treatment of leukemia. While providing care for this patient,
which clinical manifestations would indicate tumor lysis syndrome?
1) Thrombocytopenia
2) Respiratory distress
3) Upper-extremity edema
4) Altered levels of consciousness
____ 17. The nurse is caring for a patient who had a bone marrow transplant for the treatment of leukemia several
understanding of this type of isolation?
1)
2)
3)
4)
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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____ 18. The nurse is assisting the health-care provider with a bone marrow aspiration and biopsy on a patient who has
leukemia. The patient also has thrombocytopenia. Upon completing of the test, which intervention is a
priority for the nurse?
1) Make certain the patient understands the purpose of the test.
2) Hold pressure on the wound for approximately five minutes.
3) Label and refrigerate the specimen obtained by the physician.
4) Dispose of the equipment used, and clean the area properly.
____ 19. The nurse is caring for a patient with leukemia who is experiencing neutropenia as a result of chemotherapy.
Which action should the nurse include in the plan of care for this patient?
1) Restrict fluid intake
2) Replace hand hygiene with gloves
3) Restrict visitors with communicable illnesses.
4) Insert an indwelling urinary catheter to prevent skin breakdown
____ 20. A nurse is caring for a patient with leukemia who is neutropenic. Which intervention will the nurse implement
1)
2)
3)
4)
Place patient in reverse isolation
Place patient in standard precaution isolation
Administer a prophylactic gram-negative antibiotic
Administer neutrophil colony-stimulating factor (N-CSF) as ordered
____ 21.
diagnosis. Which interventions support this nursing diagnosis?
1) Educate patient in use of soft toothbrush for oral care
2) Use non-electric razor when providing grooming for patient
NURsites
SINfor
GK5Iminutes
NG.COM
3) Apply pressure to arterial puncture
4) Encourage patient to breathe deeply and huff cough frequently
____ 22. The nurse is caring for a patient who is undergoing diagnostic tests to rule out lung cancer. The patient asks
the nurse why a computed tomography (CT) scan was ordered. What is the best response by the nurse?
1)
2)
3)
4)
____ 23. A patient is scheduled to undergo a prostate biopsy. The patient asks the nurse what is expected immediately
following the procedure. Which response by the nurse is the most appropriate?
1)
2)
3)
4)
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 24. The nurse is caring for a thin, older adult patient who is diagnosed with cancer and is receiving aggressive
chemotherapy. The patient is experiencing severe side effects from the therapy and has lost 10 pounds in the
past week. What should the nurse teach the patient to do? Select all that apply.
1) Keep a food diary and record intake.
2) Purchase fast foods and prepared foods.
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3) Eat small frequent meals high in calories.
4) Drink liquid supplements to increase intake of nutrients.
5) Eat cold foods rather than hot foods, because they are better tolerated.
____ 25. A nurse is caring for a patient who is diagnosed with skin cancer. Which nursing interventions will reduce the
growth of cancer cells and support normal cell function? Select all that apply.
1) Increasing calorie intake
2) Encouraging mobility and exercise
3) Encouraging increased rest and sleep
4) Assessing normal functioning of organ systems
5) Reducing oxygen supply to retard growth of cancer cells
____ 26. The nurse instructs a group of community members on the difference between benign and malignant
neoplasms. Which participant statements indicate that teaching has been effective? Select all that apply.
1)
2)
3)
4)
5)
____ 27. The nurse is preparing to perform a health assessment on an adult patient who has a family history of cancer.
Which questions should the nurse ask the patient to assess for the early warning signs of cancer? Select all
that apply.
1)
2)
3)
NURSINGKING.COM
4)
5)
____ 28. The nurse is caring for a patient who is diagnosed with cancer. Which diagnostic tests may be helpful to assist
with treatment options? Select all that apply.
1) MRI
2) Urinalysis
3) Stool analysis
4) Tumor markers
5) Physical assessment
____ 29. The nurse instructs a group of community members about ways to reduce the development of cancer. Which
participant statements indicate that teaching has been effective? Select all that apply.
1)
2)
3)
4)
5)
____ 30. The nurse is providing discharge instructions to a patient being treated for cancer. For which symptoms
should the patient be instructed to call for help at home? Select all that apply.
1) Desire to end life
2) Difficulty breathing
3) New onset of bleeding
4) Improved sense of well-being
5) Significant increase in vomiting
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Chapter 13: Overview of Cancer Care
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Identifying treatment options for oncology patients
Chapter page reference: 231-239
Heading: Treatment
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Cellular Regulation
Difficulty: Easy
Feedback
1
The patient with an alteration in cell growth has cancer and will most likely be treated
with chemotherapy and antibiotics.
2
Diuretic therapy, IV fluids, and electrolyte replacement are not typically used to treat
cancer, although they may be used if complications develop.
3
Diuretic therapy, IV fluids, and electrolyte replacement are not typically used to treat
cancer, although they may be used if complications develop.
4
Diuretic therapy, IV fluids, and electrolyte replacement are not typically used to treat
cancer, although they may be used if complications develop.
NURSINGKING.COM
PTS: 1
CON: Cellular Regulation
2. ANS: 1
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient
Chapter page reference: 226-229
Heading: Prevention
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Promoting Health
Difficulty: Moderate
Feedback
1
In families with a disease, the nurse should inform patients about breast selfexamination.
2
Teaching the side effects of cancer treatment would be appropriate if the patient was
diagnosed with breast cancer.
3
Talking to family members who have the disease will not help with early detection or
prevention.
4
The patient can discuss cancer fears with the nurse; however, this action will not help
prevent the development of the disease.
PTS: 1
3. ANS: 3
CON: Promoting Health
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Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Developing teaching and support strategies for the oncology patient and family
Chapter page reference: 231-239
Heading: Treatment
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1
Erythropoietin will not stimulate or decrease the production of platelets, white blood
cells, or lymph fluid.
2
Erythropoietin will not stimulate or decrease the production of platelets, white blood
cells, or lymph fluid.
3
Erythropoietin is a hormone produced in the body to stimulate production of red blood
cells; synthetic forms are available for administration to cancer patients or others with
significantly low red blood cell counts.
4
Erythropoietin will not stimulate or decrease the production of platelets, white blood
cells, or lymph fluid.
PTS: 1
CON: Medication
4. ANS: 3
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Explaining the pathophysiology of cancer cells
Chapter page reference: 215-217
NURSINGKING.COM
Heading: Pathophysiology
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Cellular Regulation
Difficulty: Moderate
Feedback
1
Dysphagia and adaptation are not a part of the cell cycle.
2
Dysphagia and adaptation are not a part of the cell cycle.
3
Potentially undesirable cellular alterations that can occur during the cell cycle include
hyperplasia and anaplasia. Hyperplasia is an increase in the number or density of
normal cells.
4
Differentiation is a normal process occurring over many cell cycles that allows cells to
specialize in certain tasks.
PTS: 1
CON: Cellular Regulation
5. ANS: 1
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Identifying treatment options for oncology patients
Chapter page reference: 231-239
Heading: Treatment
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
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Concept: Cellular Regulation
Difficulty: Easy
Feedback
1
Chemotherapy before surgery is used to shrink the tumor.
2
Chemotherapy is not used to improve wound healing.
3
It is impossible to eradicate all cancer cells with chemotherapy.
4
The use of chemotherapy before surgery will not allow the immune system to kill the
cancer cells.
PTS: 1
CON: Cellular Regulation
6. ANS: 1
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient
Chapter page reference: 226-229
Heading: Prevention
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Analysis [Analyzing]
Concept: Promoting Health
Difficulty: Difficult
Feedback
1
Use of tanning booths increases the risk of skin cancer, so discontinuing use would
indicate understanding.
2
Increased fiber intake reduces the risk of colon cancer.
3
Increasing the amount of lean
and
two
NUred
RSmeat
ING
KIdrinking
NG.CO
M glasses of red wine daily are
not actions that reduce cancer risk.
4
Increasing the amount of lean red meat and drinking two glasses of red wine daily are
not actions that reduce cancer risk.
PTS: 1
CON: Promoting Health
7. ANS: 2
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Discussing the epidemiology of cancer
Chapter page reference: 214-215
Heading: Epidemiology
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Cellular Regulation; Diversity
Difficulty: Easy
Feedback
1
There is no specific information about the Hispanic population.
2
African-American clients are more likely to develop cancer than any other ethnic group.
3
Mortality rates for cancer are the lowest in the Asian/Pacific Islander population.
4
African-Americans are more likely to develop cancer than any other ethnic or racial
group in the United States.
PTS: 1
CON: Cellular Regulation | Diversity
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8. ANS: 3
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Analyzing nursing care for the oncology patient
Chapter page reference: 239-245
Heading: Nursing Management
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Cellular Regulation
Difficulty: Moderate
Feedback
1
must be met prior to emotional needs. Although the patient might be having coping
issues, the physical symptoms are her greatest complaints; therefore, coping is not the
top priority in planning her care. Again, physiological needs must be met prior to selfactualization needs.
2
3
4
must be met prior to emotional needs. Although the patient might be having coping
issues, the physical symptoms are her greatest complaints; therefore, coping is not the
top priority in planning her care. Again, physiological needs must be met prior to selfactualization needs.
The symptoms (fatigue, pallor, progressive weakness, exertional dyspnea, headache,
and tachycardia) are caused by aplastic anemia from bone marrow suppression, which
NURSIdrugs.
NGKDecreased
ING.COred
M blood cells cause less oxygen
is a side effect of the chemotherapy
to be delivered to body tissues, resulting in tissue hypoxia. Tachycardia is a
compensation mechanism to speed up the delivery of oxygen that is available in the
fewer number of cells that are present. Tissue hypoxia will result in muscle fatigue, and
the symptoms that are related to aplastic anemia will decrease endurance and ability to
perform activities.
Nutrition is not the cause of the symptoms, which are related to tissue hypoxia.
PTS: 1
CON: Cellular Regulation
9. ANS: 1
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Developing teaching and support strategies for the oncology patient and family
Chapter page reference: 239-245
Heading: Nursing Management
Integrated Processes: Nursing Process Implementation
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Cellular Regulation
Difficulty: Moderate
Feedback
1
When a patient and family receive a new diagnosis of cancer, it tends to evoke many
emotions, including fear, grief, and anger. The patient and family require emotional
support at this time, and other actions can be initiated when they have time to learn to
accept and cope with the diagnosis.
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2
3
4
This is not an opportune time to teach, set goals, or make decisions regarding power of
attorney.
This is not an opportune time to teach, set goals, or make decisions regarding power of
attorney.
This is not an opportune time to teach, set goals, or make decisions regarding power of
attorney.
PTS: 1
CON: Cellular Regulation
10. ANS: 4
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Explaining the pathophysiology of cancer cells
Chapter page reference: 217
Heading: Staging
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Cellular Regulation
Difficulty: Easy
Feedback
1
T refers to the depth of invasion. A 4 indicates a large, not small, tumor.
2
There is no way to determine the number of tumors based on this designation.
3
The staging system is not used to determine tumor response to chemotherapy.
4
Stage IV indicates metastasis. N refers to the absence or presence and extent of lymph
node involvement. A 3 indicates a significant number of lymph nodes are involved.
NURSINGKING.COM
PTS: 1
CON: Cellular Regulation
11. ANS: 1
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Analyzing nursing care for the oncology patient
Chapter page reference: 239-245
Heading: Nursing Management
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Cellular Regulation
Difficulty: Moderate
Feedback
1
Radiation causes skin excoriation. With the excoriation, the patient is at risk for
infection due to skin breakdown.
2
Depending on the assessment, the patient may or may not have activity intolerance.
3
The patient who receives radiation is more at risk for fluid volume deficit.
4
There is no evidence of respiratory difficulties in this patient.
PTS: 1
CON: Cellular Regulation
12. ANS: 2
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Developing teaching and support strategies for the oncology patient and family
Chapter page reference: 239-245
Heading: Nursing Management
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Integrated Processes: Nursing Process Diagnosis
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Cellular Regulation
Difficulty: Moderate
Feedback
1
Now is not the time to begin instructions, because the patient will most likely be unable
to learn or concentrate on what the nurse is teaching.
2
The patient and family will require support to deal with their emotional response to
learning the patient has cancer and will undergo body image-changing surgery.
3
Disuse syndrome and injury from positioning may be factors after surgery.
4
Disuse syndrome and injury from positioning may be factors after surgery.
PTS: 1
CON: Cellular Regulation
13. ANS: 1
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient
Chapter page reference: 229-231
Heading: Diagnosing Cancer
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Reduction in Risk Potential
Cognitive level: Analysis [Analyzing]
Concept: Cellular Regulation
Difficulty: Difficult
Feedback
NURSINGKING.COM
1
The colonoscopy is not a painful examination.
2
It usually takes about an hour.
3
Tissue samples are often taken during colonoscopies.
4
The client will be given conscious sedation, which causes drowsiness.
PTS: 1
CON: Cellular Regulation
14. ANS: 3
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Developing teaching and support strategies for the oncology patient and family
Chapter page reference: 239-245
Heading: Nursing Management
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Cellular Regulation
Difficulty: Moderate
Feedback
1
Using a mouthwash and eating spicy foods are not recommended interventions for
nausea and vomiting.
2
Using a mouthwash and eating spicy foods are not recommended interventions for
nausea and vomiting.
3
Nausea and vomiting are not uncommon in a client receiving radiation, and the patient
may benefit from delaying meals for a few hours after treatment, allowing the primary
effects to subside somewhat.
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4
Avoiding all food and liquid could put the patient at risk for dehydration.
PTS: 1
CON: Cellular Regulation
15. ANS: 3
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Developing teaching and support strategies for the oncology patient and family
Chapter page reference: 239-245
Heading: Nursing Management
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Legal; Cellular Regulation
Difficulty: Moderate
Feedback
1
An ethics committee is usually considered when there is an ethical dilemma and more
input is needed to make a decision. In this case, the patient has made a decision and it
should be honored.
2
Patients, not their families, should make decisions about their own health care and
treatment.
3
A nurse is morally obligated to withhold food and fluids if it is determined to be more
harmful to administer them than to withhold them. The nurse must also honor
ate and through
the moral principle of autonomy.
4
refusal.
NURSINGKING.COM
PTS: 1
CON: Legal | Cellular Regulation
16. ANS: 4
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Identifying treatment options for oncology patients
Chapter page reference: 217-226
Heading: Clinical Presentation
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Cellular Regulation
Difficulty: Moderate
Feedback
1
Thrombocytopenia occurs with a hematological emergency.
2
Space-occupying lesions can cause respiratory distress and upper-extremity edema.
3
Space-occupying lesions can cause respiratory distress and upper-extremity edema.
4
Tumor lysis causes a metabolic emergency. Because of electrolyte imbalance, the signs
can be oliguria and altered levels of consciousness.
PTS: 1
CON: Cellular Regulation
17. ANS: 4
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Identifying treatment options for oncology patients
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Chapter page reference: 231-239
Heading: Treatment
Integrated Processes: Nursing Process Evaluation
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Analysis [Analyzing]
Concept: Cellular Regulation; Infection
Difficulty: Difficult
Feedback
1
Restrict only visitors with colds, flu, or infection.
2
Oral hygiene should be encouraged after every meal.
3
Medications by injection should be avoided.
4
A patient on protective isolation will be at an increased risk for infection. It will be
important to encourage meticulous hand washing among all people who come in
contact with the patient.
PTS: 1
CON: Cellular Regulation | Infection
18. ANS: 2
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Analyzing nursing care for the oncology patient
Chapter page reference: 231-239
Heading: Treatment
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Safety
NURSINGKING.COM
Difficulty: Moderate
Feedback
1
An explanation of the test is performed before the procedure is begun.
2
The most important task for the nurse is to prevent bleeding after the biopsy. Holding
pressure on the wound for five minutes is effective.
3
Dealing with the specimen is accomplished by a third party or after the nurse stabilizes
the patient.
4
Cleaning the area is completed after the patient is stable and the specimen is sent to the
laboratory.
PTS: 1
CON: Safety
19. ANS: 3
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Analyzing nursing care for the oncology patient
Chapter page reference: 231-239
Heading: Treatment
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Safety
Difficulty: Moderate
1
Feedback
Fluid intake should be encouraged.
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2
3
4
Gloves may be appropriate but should never replace hand hygiene.
In the neutropenic patient, visitors with communicable infections should be restricted.
Invasive procedures such as indwelling catheters should be avoided.
PTS: 1
CON: Safety
20. ANS: 1
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Analyzing nursing care for the oncology patient
Chapter page reference: 231-239
Heading: Treatment
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Safety
Difficulty: Moderate
Feedback
1
A patient who is neutropenic has a decrease in the level of white blood cells (WBCs)
and is susceptible to infection and/or disease. To ensure the safety of the patient with
neutropenia, the nurse will place the patient in reverse isolation.
2
Standard precautions should be used for all patients and this does not ensure safety of
the neutropenic patient.
3
Administer a broad-spectrum antibiotic as ordered.
4
Administer granulocyte colony-stimulating factor (G-CSF) as ordered.
PTS: 1
CON: SafetyNURSINGKING.COM
21. ANS: 1
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Analyzing nursing care for the oncology patient
Chapter page reference: 239-245
Heading: Nursing Management
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Safety
Difficulty: Moderate
1
2
3
4
Feedback
The patient at risk for bleeding has specific interventions to which the nurse should
adhere. The nurse should educate the patient in the use of a soft toothbrush.
An electric razor is preferred when providing grooming for a patient who is at risk for
bleeding.
The nurse should also limit the use of parenteral injections and apply 15 20 minutes of
pressure to any arterial puncture sites.
The nurse should discourage the patient to forcefully cough to prevent further bleeding.
PTS: 1
CON: Safety
22. ANS: 3
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient
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Chapter page reference: 229-231
Heading: Diagnosing Cancer
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Cellular Regulation
Difficulty: Moderate
Feedback
1
Health-care provider preference is not a factor for why the CT was ordered.
2
3
4
is having concerns about the test.
Computed tomography (CT) is used to evaluate and localize tumors, particularly tumors
in the lung parenchyma and pleura.
A chest x-ray can be used to diagnose pneumonia.
PTS: 1
CON: Cellular Regulation
23. ANS: 4
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient
Chapter page reference: 229-231
Heading: Diagnosing Cancer
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Cellular Regulation
NURSINGKING.COM
Difficulty: Moderate
Feedback
1
There is no need to notify sexual partners following the procedure.
2
Strenuous activity is avoided only for about four hours.
3
The patient must restrict activity for only a short period after the procedure.
4
The patient may experience discomfort for one to two days after the procedure.
PTS: 1
CON: Cellular Regulation
MULTIPLE RESPONSE
24. ANS: 1, 3, 4, 5
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Developing teaching and support strategies for the oncology patient and family
Chapter page reference: 239-245
Heading: Nursing Management
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback
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1.
2.
3.
4.
5.
This is correct. The goal of nutritional teaching is to help the patient increase caloric and
nutrient intake through the use of liquid supplements, small frequent meals, and a food diary
that will help the nurse evaluate strengths and weaknesses of the current plan.
This is incorrect. Fast foods and prepared foods tend to be high in fat and sodium and are not
the best choice because they do not contain adequate healthy nutrients. Instead, involving the
family in preparing meals or in enrolling in Meals on Wheels may be better options for easy
ways of obtaining meals.
This is correct. The goal of nutritional teaching is to help the patient increase caloric and
nutrient intake through the use of liquid supplements, small frequent meals, and a food diary
that will help the nurse evaluate strengths and weaknesses of the current plan.
This is correct. The goal of nutritional teaching is to help the patient increase caloric and
nutrient intake through the use of liquid supplements, small frequent meals, and a food diary
that will help the nurse evaluate strengths and weaknesses of the current plan.
This is correct. The patient receiving chemotherapy may tolerate cold foods better than hot
foods.
PTS: 1
CON: Nutrition
25. ANS: 1, 3, 4
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Analyzing nursing care for the oncology patient
Chapter page reference: 239-245
Heading: Nursing Management
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
NURSINGKING.COM
Concept: Cellular Regulation
Difficulty: Easy
1.
2.
Feedback
This is correct. Cancer cells grow faster than normal cells, so they use more nutrients for
growth, resulting in wasting, which can only be counteracted by increasing the caloric intake
of the patient.
This is incorrect. While patients should not be inactive, they should be taught to reduce
activity to reduce weight loss and provide more energy to the healthy cells.
3.
4.
5.
cells.
This is correct. Because cancer cells can grow in any area of the body, it is important for the
nurse to assess normal functioning of all organ systems.
This is incorrect. Decreasing oxygen supply will retard cancer cell growth but it will also
retard normal cell health.
PTS: 1
CON: Cellular Regulation
26. ANS: 1, 2, 3, 4
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Developing teaching and support strategies for the oncology patient and family
Chapter page reference: 217
Heading: Types of Cancer
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
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Cognitive level: Analysis [Analyzing]
Concept: Cellular Regulation
Difficulty: Difficult
Feedback
This is correct. Malignant tumors are more difficult to remove. They invade neighboring tissue
and can return once removed.
This is correct. Benign tumors are slow-growing and stay in one area.
This is correct. Benign tumors are slow-growing and stay in one area.
This is incorrect. Benign, not malignant, tumors are easy to remove.
This is incorrect. Benign, not malignant, tumors push other tissue out of the way.
1.
2.
3.
4.
5.
PTS: 1
CON: Cellular Regulation
27. ANS: 2, 3, 4, 5
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient
Chapter page reference: 217-266
Heading: Clinical Presentation
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Application]
Concept: Cellular Regulation
Difficulty: Moderate
Feedback
NURSINGKING.COM
This is incorrect. Changes in appetite or cough that is associated with seasonal allergies are
not associated with the early warning signs of cancer.
This is correct. Nurses should assess all patients, especially those with a history of cancer, for
early warning signs of cancer. The early warning signs include change in bowel or bladder
habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the
breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a
nagging cough or hoarseness.
This is correct. Nurses should assess all patients, especially those with a history of cancer, for
early warning signs of cancer. The early warning signs include change in bowel or bladder
habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the
breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a
nagging cough or hoarseness.
This is correct. Nurses should assess all patients, especially those with a history of cancer, for
early warning signs of cancer. The early warning signs include change in bowel or bladder
habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the
breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a
nagging cough or hoarseness.
This is correct. Nurses should assess all patients, especially those with a history of cancer, for
early warning signs of cancer. The early warning signs include change in bowel or bladder
habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the
breast or elsewhere, indigestion or difficulty swallowing, obvious change in wart or mole, or a
nagging cough or hoarseness.
1.
2.
3.
4.
5.
PTS: 1
CON: Cellular Regulation
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28. ANS: 1, 2, 4
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient
Chapter page reference: 229-231
Heading: Diagnosing Cancer
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Cellular Regulation
Difficulty: Easy
Feedback
This is correct. Many diagnostic tests are helpful in determining treatment for cancer. An
MRI, urinalysis, and tumor markers are all diagnostic tests that may be used to determine
treatment for cancer.
This is correct. Many diagnostic tests are helpful in determining treatment for cancer. An
MRI, urinalysis, and tumor markers are all diagnostic tests that may be used to determine
treatment for cancer.
This is incorrect. A stool analysis is not a diagnostic test listed to determine treatment for
cancer.
This is correct. Many diagnostic tests are helpful in determining treatment for cancer. An
MRI, urinalysis, and tumor markers are all diagnostic tests that may be used to determine
treatment for cancer.
This is incorrect. A physical assessment may be useful to determine how a patient is
responding to treatment, but it is not considered a diagnostic test.
1.
2.
3.
4.
5.
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PTS: 1
CON: Cellular Regulation
29. ANS: 2, 3, 4
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Describing vital diagnostic and preventive measures for the oncology patient
Chapter page reference: 226-229
Heading: Prevention
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Cellular Regulation
Difficulty: Difficult
Feedback
This is incorrect. All smoking should be discouraged.
This is correct. The home should be tested for radon, which is a known cancer-causing
substance.
This is correct. Children should be protected from exposure to tobacco smoke.
This is correct. Sunscreen should be used by those who spend time outside regularly for work
or recreation.
This is incorrect. Efforts to reduce the development of cancer include eating five servings of
fruits and vegetables each day.
1.
2.
3.
4.
5.
PTS: 1
CON: Cellular Regulation
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30. ANS: 1, 2, 3, 5
Chapter number and title: 13, Overview of Cancer Care
Chapter learning objective: Developing teaching and support strategies for the oncology patient and family
Chapter page reference: 239-245
Heading: Nursing Management
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Cellular Regulation
Difficulty: Moderate
Feedback
This is correct. The patient should be instructed to call for help with any difficulty breathing,
significant increase in vomiting, a desire to end life, or a new onset of bleeding.
This is correct. The patient should be instructed to call for help with any difficulty breathing,
significant increase in vomiting, a desire to end life, or a new onset of bleeding.
This is correct. The patient should be instructed to call for help with any difficulty breathing,
significant increase in vomiting, a desire to end life, or a new onset of bleeding.
This is incorrect. An increased sense of well-being would be a desired effect of treatment for
cancer.
This is correct. The patient should be instructed to call for help with any difficulty breathing,
significant increase in vomiting, a desire to end life, or a new onset of bleeding.
1.
2.
3.
4.
5.
PTS: 1
CON: Cellular Regulation
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Chapter 14: Overview of Shock and Sepsis
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. The nurse is preparing an educational session on sepsis. Which should the nurse include as a major risk factor
for the development of this health problem?
1) Immunosuppression
2) Elevated temperature
3) Pneumococcal bacteria
4) Leukocytosis on the complete blood count
____
2. The nurse identifies the nursing diagnosis of Ineffective Peripheral Tissue Perfusion as being appropriate for a
1)
2)
3)
4)
____
Monitor for cyanosis.
Monitor heart rate every hour.
Assess temperature every four hours.
Monitor pupil reactions every eight hours.
3. An older adult patient is recovering in the intensive care unit (ICU) from septicemia. Which intervention will
help prevent further infection for this patient?
1) Provide oral and skin care
2) Implement sterile wound care
3) Encourage turn, cough, and deep breathe every shift.
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4)
____
4.
1)
nervous system damage, and
2)
3)
4)
____
5. An older adult patient is experiencing hypovolemic shock. Which is the priority intervention for this patient?
1) Assessing the cause of bleeding
2) Providing replacement of volume
3) Establishing invasive cardiac monitoring
4) Administering analgesics for control of pain
____
6. The nurse has just completed the assessment of a patient admitted with a gunshot wound to the femoral artery.
Which is the priority nursing diagnosis for this patient?
1) Ineffective Coping
2) Deficient Fluid Volume
3) Decreased Cardiac Output
4) Ineffective Airway Clearance
____
7. The nurse is administering albuminN5%
a patient
nursing action is appropriate when
URtoSI
NGKIin
NGshock.
.COWhich
M
assessing this patient?
1) Auscultate breath sounds for crackles
2) Auscultate breath sounds for hyperresonance
3) Auscultate breath sounds for inspiratory stridor
4) Auscultate for an absence of breath sounds in the lower lobes
____
8. The nurse explains the purpose of an infusion of albumin 5% to a patient recovering from hypovolemic shock.
Which statement indicates that the patient understands the instructions?
1)
2)
3)
4)
____
9. A patient being treated for hypovolemic shock is prescribed a low dose of dopamine. Which outcome does the
nurse anticipate for this patient?
1) Increased cardiac output
2) Stabilization of fluid loss
3) Urinary output of at least 30 mL/hour
4) Vasoconstriction and increased blood pressure
____ 10. A nurse is caring for a patient who was involved in a motor vehicle accident who has lost approximately
1,500 mL of blood. Based on this data, which type of shock is the patient experiencing?
1) Hypovolemic
2) Cardiogenic
3) Distributive
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4) Obstructive
____ 11. A nurse working in the intensive care unit (ICU) is caring for a patient in refractory stage of shock. When
planning care, which does the nurse anticipate?
1) A subtle change in heart rate
2) A change from aerobic to anaerobic metabolism
3) The development of hyperglycemia
4) The development of cardiac dysrhythmias
____ 12. The nurse is preparing to administer diphenhydramine to a patient who is experiencing a severe allergic
reaction to peanuts. Which information about the drug should the nurse provide to the patient?
1)
2)
3)
4)
____ 13. The nurse is conducting medication teaching for a patient who is prescribed an epi-pen. Which statements
made by the patient indicates the need for additional instruction?
1)
2)
3)
epi4)
____ 14. The nurse is providing care to a patient who is admitted to the emergency department with symptoms of a
myocardial infarction (MI). Which is the primary purpose of the interventions administered to this patient?
1) Providing pain relief
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2) Preventing extension of damage
3) Preventing cardiogenic shock
4) Reducing blood pressure
____ 15. The nurse is providing care for a patient receiving treatment for cardiogenic shock. Which assessment finding
indicates that the compensatory mechanism of vasoconstriction has occurred in this patient?
1) Increased heart rate
2) Increased injection fraction
3) Decreased urine output
4) Decreased temperature
____ 16. The nurse is providing care to a patient who is admitted with cardiogenic shock. The nurse administers the
prescribed atropine with no results. Which prescription does the nurse anticipate from the health-care provider
based on this data?
1) A beta blocker
2) Transcutaneous pacing
3) Cardiac defibrillation
4) A preload reducer
____ 17. The nurse is providing care to a patient diagnosed with hypovolemic shock. Which nursing action is
appropriate for this patient during the initial compensatory phase?
1) Placing a cool blanket over the patient
2)
-degree angle
3) Positioning the patient in the left-lateral recumbent position
4)
injury is suspected
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____ 18. During the initial stage of shock, which clinical manifestation should the nurse monitor for when assessing
the patient?
1) Lethargy
2) Hypotension
3) Respiratory alkalosis
4) Subtle changes in heart rate
____ 19. The nurse is providing care to a patient admitted to the emergency department (ED) with a gunshot wound
and profound blood loss. Which order does the nurse anticipate for this patient?
1) Normal saline
2) Dextrose in water
3) Packed red blood cells
4) Albumin
____ 20. A patient develops hypovolemic shock secondary to pancreatitis. Which action by the nurse is most
appropriate?
1) Starting an 182) Ordering a type and cross-match of packed red blood cells
3) Preparing to assist with central line placement
4) Inserting a nasogastric tube
____ 21. The nurse is providing care to a patient admitted with a spinal cord injury. The patient is bradycardic,
hypotensive, and has cold and clammy skin. Which is the priority nursing action for this patient?
1) Starting two large intravenous catheters
2) Notifying the Rapid Response Team
3)
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4) Placing oxygen on the patient
____ 22. A patient in neurogenic shock is receiving rapid intravenous fluids. Which assessment finding indicates the
need for additional nursing interventions?
1)
2) The patient is unconscious.
3) The patient has received two liters of infused fluid.
4) The patient is perspiring heavily.
____ 23. Which is the highest priority nursing action when providing care to a patient with shock?
1) Starting two large intravenous catheters
2) Recognizing early clinical manifestations
3) Administering high-flow oxygen
4) Calling for help immediately
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 24. Which will the nurse closely monitor due to the pathophysiology associated with early shock? Select all that
apply.
1) Bowel sounds
2) Level of consciousness
3) Urine output
4) Peripheral pulses
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5) Heart rate
____ 25. Which assessment findings would indicate to the nurse that a patient is exhibiting early symptoms of shock?
Select all that apply.
1) Pallor
2) Increased bowel sounds
3) Restlessness
4) Decreased blood glucose
5) Increased respiratory rate
____ 26. A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with early septic shock from
the emergency department (ED). The nurse will recognize which symptoms associated with this condition?
Select all that apply.
1) Shallow respirations
2) Normal blood pressure
3) Warm and flushed skin
4) Lethargic mental status
5) Decreased urine output
6) Rapid and deep respirations
____ 27. A patient is admitted to the intensive care unit with a systemic infection. Which manifestations will the nurse
most likely assess in this patient? Select all that apply.
1) Pain
2) Fever
3) Edema
4) Anorexia
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5) Tachycardia
____ 28. A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with late septic shock from
the emergency department (ED). The nurse will recognize which symptoms associated with this condition?
Select all that apply.
1) Shallow respirations
2) Lethargic mental status
3) Decreased urine output
4) Normal blood pressure
5) Warm and flushed skin
6) Rapid and deep respirations
____ 29. The nurse is concerned that a patient is demonstrating early signs of hypovolemic shock. Which assessment
Select all that apply.
1) Rapid weak pulse
2) Normal respirations
3) Normal blood pressure
4) Slight increase in pulse
5) Prolonged capillary refill time
____ 30. A patient is receiving intravenous nitroprusside (Nipride) for shock. Which adverse reactions will the nurse
assess this patient for when administering the infusion? Select all that apply.
1) Confusion
2) Tachycardia
3) Disorientation
4) Muscle spasms
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5) Gastrointestinal bleeding
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Chapter 14: Overview of Shock and Sepsis
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Discussing the pathophysiology of shock
Chapter page reference: 266-271
Heading: Sepsis/Septic Shock
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
1
2
3
4
Feedback
Immunosuppression is a risk factor for the development of sepsis.
An elevated temperature is a manifestation of sepsis.
Sepsis is most often the result of gram-positive infections from Staphylococcus and
Streptococcus bacteria but may also follow gram-negative bacterial infections such as
Pseudomonas, Escherichia coli, and Klebsiella.
Leukocytosis occurs with sepsis if the patient is able to mount an immune response.
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PTS: 1
CON: Infection
2. ANS: 1
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Analyzing the nursing management of selected shock states
Chapter page reference: 266-271
Heading: Sepsis/Septic Shock
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Infection; Perfusion
Difficulty: Difficult
Feedback
1
A change in skin color will alert the nurse immediately of decreased tissue perfusion.
2
Assessing temperature and monitoring heart rate and pupil reaction are important when
assessing a patient with septicemia; however, these interventions do not address the
identified nursing diagnosis.
3
Assessing temperature and monitoring heart rate and pupil reaction are important when
assessing a patient with septicemia; however, these interventions do not address the
identified nursing diagnosis.
4
Assessing temperature and monitoring heart rate and pupil reaction are important when
assessing a patient with septicemia; however, these interventions do not address the
identified nursing diagnosis.
PTS: 1
CON: Infection | Perfusion
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3. ANS: 1
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Analyzing the nursing management of selected shock states
Chapter page reference: 266-271
Heading: Sepsis/Septic Shock
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
Good oral and skin care will prevent breakdown and prevent entry by bacteria.
2
There is no evidence that this patient has a wound.
3
In order to prevent skin breakdown and promote respiratory function, the patient is
turned at least every two hours.
4
prevent reflux.
PTS: 1
CON: Infection
4. ANS: 1
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Identifying hypovolemic, cardiogenic, and obstructive, and distributive shock
Chapter page reference: 264-266
Heading: Anaphylactic Shock
Integrated Processes: Communication and Documentation
NUR
SINGKINAdaptation
G.COM
Client Need: Physiological Integrity
Physiological
Cognitive level: Application [Applying]
Concept: Inflammation; Perfusion
Difficulty: Moderate
Feedback
1
Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord
suggests neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a
recent infection may indicate septic shock; and a history of allergies with a sudden
onset of symptoms may suggest anaphylactic shock.
2
Kidney failure is not a type of shock.
3
Respiratory failure is not a type of shock.
4
Liver failure is not a type of shock.
PTS: 1
CON: Inflammation | Perfusion
5. ANS: 3
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Describing the medical management of selected shock states
Chapter page reference: 253-257
Heading: Hypovolemic Shock
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Perfusion
Difficulty: Difficult
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1
2
3
4
Feedback
Assessing the cause of bleeding would also occur after establishing invasive cardiac
monitoring.
Replacement of volume would occur after invasive cardiac monitoring is established.
With aging, there is a decrease in cardiac sympathetic activity. Older patients can have
secondary volume depletion because of diuretics or malnutrition, and if prescribed a
beta blocker, tachycardia may not occur as an early sign of hypovolemic shock. The
older patient will require early invasive monitoring in order to avoid excessive or
inadequate volume restoration. This should be done early in the treatment phase.
Pain would be a consideration but would not be attended to as a first priority.
PTS: 1
CON: Perfusion
6. ANS: 3
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Analyzing the nursing management of selected shock states
Chapter page reference: 253-257
Heading: Hypovolemic Shock
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Perfusion
Difficulty: Difficult
Feedback
1
There is not enough information to determine whether the patient is experiencing
ineffective coping.
NURSINGKING.COM
2
The patient will most likely have deficient fluid volume; however, cardiac output is the
first priority at this time.
3
The patient sustained a gunshot wound to the femoral artery, which would lead to
significant bleeding and the risk of hypovolemic shock. The nursing diagnosis that
would be a priority for the patient is Decreased Cardiac Output because of low blood
volume.
4
There is not enough information to determine whether the patient has ineffective airway
clearance.
PTS: 1
CON: Perfusion
7. ANS: 1
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Analyzing the nursing management of selected shock states
Chapter page reference: 253-257
Heading: Hypovolemic Shock
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
Because albumin 5% is a volume expander and pulls fluid into the vascular space,
circulatory overload is a serious complication. The nurse must monitor breath sounds;
crackles will be heard with pulmonary congestion
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2
3
4
Hyperresonance is assessed by percussion, not auscultation.
Stridor is auscultated with airway obstruction, not pulmonary edema.
An absence of breath sounds is heard with a pneumothorax, not with pulmonary edema.
PTS: 1
CON: Fluid and Electrolyte Balance
8. ANS: 1
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Analyzing the nursing management of selected shock states
Chapter page reference: 253-257
Heading: Hypovolemic Shock
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Analysis [Analyzing]
Concept: Fluid and Electrolyte Balance
Difficulty: Difficult
Feedback
1
Colloids are proteins or other large molecules that stay suspended in the blood for long
periods because they are too large to easily cross membranes. They draw water
molecules from the cells and tissues into the blood vessels through their ability to
increase plasma oncotic pressure.
2
Albumin 5% does not act on the kidneys.
3
Albumin 5% is not a concentrated saline solution.
4
Crystalloids are intravenous (IV) solutions that contain electrolytes, not proteins, in
concentrations resembling those of plasma. They are used to replace lost fluids and
promote urine output.
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PTS: 1
CON: Fluid and Electrolyte Balance
9. ANS: 3
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Describing the medical management of selected shock states
Chapter page reference: 253-257
Heading: Hypovolemic Shock
Integrated Processes: Nursing Process Evaluation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Perfusion
Difficulty: Easy
Feedback
1
Increased cardiac output occurs with high, not low, doses of dopamine when beta1adrenergic receptors are stimulated.
2
Dopamine does not prevent or stabilize fluid loss.
3
At low doses, dopamine stimulates dopaminergic receptors, especially in the kidneys,
leading to vasodilation and an increased blood flow through the kidneys.
4
Vasoconstriction and increased blood pressure occur with high, not low, doses of
dopamine when alpha-adrenergic receptors are stimulated.
PTS: 1
CON: Perfusion
10. ANS: 1
Chapter number and title: 14, Overview of Shock and Sepsis
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Chapter learning objective:
Chapter page reference: 247-248
Heading: Classifications of Shock
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Perfusion
Difficulty: Easy
Feedback
1
Blood loss causes hypovolemic shock.
2
Blood loss does not cause cardiogenic shock.
3
Blood loss does not cause distributive shock.
4
Blood loss does not cause obstructive shock.
PTS: 1
CON: Perfusion
11. ANS: 2
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Describing the stages of shock
Chapter page reference: 248-250
Heading: Stages of Shock
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Perfusion
Difficulty: Easy
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Feedback
1
A subtle change in heart rate is anticipated during the initial stage of shock.
2
In the refractory stage of shock, there is a change from aerobic to anaerobic metabolism
due to cellular hypoxia from decreased perfusion.
3
Hyperglycemia develops during the compensatory stage of shock.
4
Cardiac dysrhythmias develop during the progressive stage of shock.
PTS: 1
CON: Perfusion
12. ANS: 2
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Describing the medical management of selected shock states
Chapter page reference: 264-266
Heading: Anaphylactic Shock
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Inflammation
Difficulty: Moderate
Feedback
1
While antihistamines may help to prevent airway obstruction if administered quickly
after exposure to an allergen this classification is not the medication of choice for
treating airway obstruction.
2
Antihistamines help to relieve histamine-related symptoms such as itching, flushing,
hives, and rhinorrhea.
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3
4
Antihistamines do not prevent anaphylactic shock; they are used to relieve the
histamine-related symptoms associated with an allergic reaction.
This description is more applicable to the action of corticosteroids.
PTS: 1
CON: Inflammation
13. ANS: 4
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Describing the medical management of selected shock states
Chapter page reference: 264-266
Heading: Anaphylactic Shock
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Analysis [Analyzing]
Concept: Medication
Difficulty: Difficult
Feedback
1
Epi-pens do expire, so the patient should have a plan for checking the date regularly.
This statement indicates appropriate understanding of the information presented.
2
Epi-pens do expire, so the patient should have a plan for checking the date regularly.
This statement indicates appropriate understanding of the information presented.
3
The pen is held firmly in place for 10 seconds after injection. This statement indicates
appropriate understanding of the information presented.
4
The pen is placed against the thigh, not the abdomen, for injection. This statement
indicates the need for additional instruction.
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PTS: 1
CON: Medication
14. ANS: 3
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Describing the medical management of selected shock states
Chapter page reference: 257-261
Heading: Cardiogenic Shock
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Perfusion
Difficulty: Easy
Feedback
1
Pain relief is important for this patient, but that is not the primary purpose of the
interventions used when treating a patient experiencing an MI.
2
Interventions are performed to prevent further damage, but this is not the primary
rationale for their use when treating a patient experiencing an MI.
3
Cardiogenic shock is the cause of death for many persons who have a myocardial
infarction. Interventions are designed to reduce the risk of cardiogenic shock when
treating a patient experiencing an MI.
4
Interventions would be implemented to reduce elevated blood pressure, but this is not
the primary concern in myocardial infarction when treating a patient experiencing an
MI.
PTS: 1
CON: Perfusion
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15. ANS: 3
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Cardiogenic shock
Chapter page reference: 257-261
Heading: Cardiogenic Shock
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Perfusion
Difficulty: Easy
Feedback
1
Tachycardia is the result of compensation for decreased cardiac output due to decreased
stroke volume.
2
Vasoconstriction does not result in an increase of ejection fraction.
3
Vasoconstriction results in diminished renal blood flow and urine production.
4
Vasoconstriction does not
vasoconstriction results in shunting of blood away from the skin, causing the skin to be
cold and clammy.
PTS: 1
CON: Perfusion
16. ANS: 2
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Describing the medical management of selected shock states
Chapter page reference: 257-261
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Heading: Cardiogenic Shock
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Perfusion
Difficulty: Easy
Feedback
1
A beta blocker would not increase the heart rate for a patient who is experiencing
cardiogenic shock.
2
Atropine is administered as treatment for bradycardia that can occur as a result of
cardiogenic shock. If the patient is not responsive to atropine, pacing is likely
necessary.
3
Defibrillation is not performed for the bradycardia associated with cardiogenic shock.
4
A preload reducer is not indicated in the treatment of bradycardia.
PTS: 1
CON: Perfusion
17. ANS: 4
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Analyzing the nursing management of selected shock states
Chapter page reference: 253-257
Heading: Hypovolemic Shock
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
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Concept: Safety
Difficulty: Moderate
Feedback
1
The patient should be kept warm and comfortable.
2
The head should lie flat.
3
The patient should be supine.
4
PTS: 1
CON: Safety
18. ANS: 4
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Describing the assessment of and monitoring techniques indicated for shock
Chapter page reference: 248-250
Heading: Stages of Shock
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
Feedback
1
Lethargy is anticipated during the progressive, not initial, stage of shock.
2
Hypotension is anticipated during the progressive, not initial, stage of shock.
3
Respiratory alkalosis is anticipated during the compensatory, not initial, stage of shock.
4
Subtle or no clinical manifestations are anticipated when providing care to a patient in
the initial stage of shock. NURSINGKING.COM
PTS: 1
CON: Perfusion
19. ANS: 3
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Describing the medical management of selected shock states
Chapter page reference: 253-257
Heading: Hypovolemic Shock
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Perfusion
Difficulty: Easy
Feedback
1
Crystalloids such as normal saline can be given for volume expansion, but are not of the
greatest benefit to the patient.
2
Dextrose in water is seldom administered as a volume expander.
3
Replacement of lost fluid with packed red blood cells increases oxygen-carrying
capacity. This is the best choice for blood loss from trauma such as gunshot wounds.
4
Albumin is a volume expander but is not the best choice for this situation.
PTS: 1
CON: Perfusion
20. ANS: 3
Chapter number and title: 14, Overview of Shock and Sepsis
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Chapter learning objective: Describing the medical management of selected shock states
Chapter page reference: 253-257
Heading: Hypovolemic Shock
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
Feedback
1
A single medium-gauge IV catheter is not sufficient for volume expansion required for
a patient experiencing hypovolemic shock.
2
The hypovolemia associated with pancreatitis is not a blood loss hypovolemia. It is also
outside of the scope of nursing practice to order laboratory and diagnostic testing.
3
Rapid volume expansion requires the use of large veins, preferably a central line.
4
While a nasogastric tube may be indicated for this patient, it will not be used to increase
fluid intake.
PTS: 1
CON: Perfusion
21. ANS: 2
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Analyzing the nursing management of selected shock states
Chapter page reference: 263-264
Heading: Neurogenic Shock
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
NURSINGKING.COM
Cognitive level: Analysis [Analyzing]
Concept: Perfusion
Difficulty: Difficult
Feedback
1
This is an appropriate action but is not the priority action.
2
The nurse should call for help from the Rapid Response Team.
3
The nurse should eventually notify the physician, but this is not the priority action.
4
Oxygen therapy is indicated but is not the primary intervention.
PTS: 1
CON: Perfusion
22. ANS: 1
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Analyzing the nursing management of selected shock states
Chapter page reference: 263-264
Heading: Neurogenic Shock
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Perfusion
Difficulty: Easy
Feedback
1
The MAP should be at least 65 mmHg. This finding indicates the need for further
intervention.
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2
3
4
Unconsciousness may result from the mechanism of injury and is not indicative of the
need for further intervention.
Large amounts of fluid may be required.
The presence of perspiration is not related to the adequacy of fluid resuscitation.
PTS: 1
CON: Perfusion
23. ANS: 2
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Analyzing the nursing management of selected shock states
Chapter page reference: 247-250
Heading: Overview of Shock
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Perfusion
Difficulty: Difficult
Feedback
1
While starting two large intravenous catheters is an important nursing action this is not
the priority action.
2
3
4
is the priority action.
While oxygen is often administered in the treatment of shock this is not the priority
nursing action.
While the nurse may need additional help this is not the priority nursing action.
NURSINGKING.COM
PTS: 1
CON: Perfusion
MULTIPLE RESPONSE
24. ANS: 1, 3, 4
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Describing the stages of shock
Chapter page reference: 247-250
Heading: Overview of Shock
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Perfusion
Difficulty: Difficult
1.
2.
3.
Feedback
This is correct. Compensatory changes in early shock can result in hypoperfusion of the gut;
therefore, the nurse must closely assess bowel sounds.
This is incorrect. While the nurse will assess mental status, the brain is usually protected by
compensatory mechanisms in early shock; therefore, this is not an area of priority assessment.
This is correct. The shunting that occurs in early shock may cause hypoperfusion of the
kidneys leading to decreased urine output; therefore, the nurse must closely monitor intake
versus output.
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4.
5.
This is correct. The body shunts blood away from the peripheral tissues in an effort to keep
vital organs perfused; therefore, the nurse will monitor for decreased peripheral pulses when
assessing for early clinical manifestations of shock.
This is incorrect. The body tries to protect the heart and does so in early shock by shunting
blood to it; therefore, this is not an area of priority assessment.
PTS: 1
CON: Perfusion
25. ANS: 1, 3, 5
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Describing the stages of shock
Chapter page reference: 247-250
Heading: Overview of Shock
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Perfusion
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is correct. Pallor of the skin, lips, oral mucosa, nail beds, and conjunctiva may occur in
early shock.
This is incorrect. Bowel motility decreases, resulting in a decrease in bowel sounds.
This is correct. Slight decreases in perfusion of the brain may result in restlessness.
This is incorrect. Blood glucose typically rises slightly as a response to the stress of shock.
This is correct. A compensatory
tissue oxygenation is the attempt to
NURSINmechanism
GKING.for
COdecreased
M
obtain additional oxygen through more rapid respirations.
PTS: 1
CON: Perfusion
26. ANS: 2, 3, 6
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Distributive Shock Sepsis/Septic Shock
Chapter page reference: 266-271
Heading: Sepsis/Septic Shock
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection; Perfusion
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is incorrect. Shallow respirations, a lethargic mental status, and decreased urine output
are late-phase manifestations of septic shock.
This is correct. Early-phase manifestations include normal blood pressure, rapid and deep
respirations, and warm or flushed skin.
This is correct. Early-phase manifestations include normal blood pressure, rapid and deep
respirations, and warm or flushed skin.
This is incorrect. Shallow respirations, a lethargic mental status, and decreased urine output
are late-phase manifestations of septic shock.
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5.
6.
This is incorrect. Shallow respirations, a lethargic mental status, and decreased urine output
are late-phase manifestations of septic shock.
This is correct. Early-phase manifestations include normal blood pressure, rapid and deep
respirations, and warm or flushed skin.
PTS: 1
CON: Infection | Perfusion
27. ANS: 2, 4, 5
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Describing the assessment of and monitoring techniques indicated for shock
Chapter page reference: 266-271
Heading: Sepsis/Septic Shock
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is incorrect. Edema and pain are symptoms of a local infection.
This is correct. Fever, tachycardia, and anorexia are the most common symptoms of a
systemic infection.
This is incorrect. Edema and pain are symptoms of a local infection.
This is correct. Fever, tachycardia, and anorexia are the most common symptoms of a
systemic infection.
This is correct. Fever, N
tachycardia,
URSINGand
KINanorexia
G.COare
M the most common symptoms of a
systemic infection.
PTS: 1
CON: Infection
28. ANS: 1, 2, 3
Feedback
1.
This is correct. Late-phase manifestations include shallow respirations, lethargic mental status,
and decreased urine output.
2.
This is correct. Late-phase manifestations include shallow respirations, lethargic mental status,
and decreased urine output.
3.
This is correct. Late-phase manifestations include shallow respirations, lethargic mental status,
and decreased urine output.
4.
This is incorrect. Early-phase manifestations include normal blood pressure, rapid and deep
respirations, and warm or flushed skin.
5.
This is incorrect. Early-phase manifestations include normal blood pressure, rapid and deep
respirations, and warm or flushed skin.
6.
This is incorrect. Early-phase manifestations include normal blood pressure, rapid and deep
respirations, and warm or flushed skin.
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Distributive shock Sepsis/Septic Shock
Chapter page reference: 266-271
Heading: Sepsis/Septic Shock
Integrated Processes: Nursing Process Assessment
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Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection; Perfusion
Difficulty: Easy
PTS: 1
CON: Infection | Perfusion
29. ANS: 3, 4, 5
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Hypovolemic shock
Chapter page reference: 253-257
Heading: Hypovolemic Shock
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Perfusion
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is incorrect. A weak rapid pulse is a characteristic of the irreversible stage of
hypovolemic shock.
This is incorrect. Normal respirations are not anticipated for a patient demonstrating early
signs of hypovolemic shock.
This is correct. Manifestations of early hypovolemic shock include a slight increase in pulse,
normal respirations, prolonged capillary refill time, and normal blood pressure.
NURSIofNG
KIN
G.COM shock include a slight increase in pulse,
This is correct. Manifestations
early
hypovolemic
normal respirations, prolonged capillary refill time, and normal blood pressure.
This is correct. Manifestations of early hypovolemic shock include a slight increase in pulse,
normal respirations, prolonged capillary refill time, and normal blood pressure.
PTS: 1
CON: Perfusion
30. ANS: 1, 2, 3, 4
Chapter number and title: 14, Overview of Shock and Sepsis
Chapter learning objective: Describing the medical management of selected shock states
Chapter page reference: 257-261
Heading: Cardiogenic Shock
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
1.
2.
Feedback
This is correct. Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning,
which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia
are adverse reactions that the nurse should report immediately to the health-care provider.
This is correct. Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning,
which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia
are adverse reactions that the nurse should report immediately to the health-care provider.
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3.
This is correct. Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning,
which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia
are adverse reactions that the nurse should report immediately to the health-care provider.
This is correct. Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning,
which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia
are adverse reactions that the nurse should report immediately to the health-care provider.
This is incorrect. Gastrointestinal bleeding is not an adverse effect of this medication.
4.
5.
PTS: 1
CON: Perfusion
Chapter 15: Priorities for the Preoperative Patient
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. The nurse administers the preoperative medication to the patient one hour before elective surgery, and then
discovers the preoperative consent is not signed. Which action by the nurse is the most appropriate?
1) Have the patient sign the consent quickly, before the medication begins taking effect.
2) Have a family member or medical power of attorney sign the consent.
3) Send the patient to the holding area without a signed consent.
4) Notify the health-care provider that surgery will need to be canceled.
____
2.
NURSINGKING.COM
scheduled for 0800. Which tasks could the nurse complete at this time?
1) Documenting the time of last voiding
2) Checking the medical record for the history, physical, and signed informed consent
3) Administering preoperative medication
4) Removing the prosthesis
____
3. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is
appropriate for the patient who is prescribed amiodarone?
1) Obtaining a baseline ECG
2) Monitoring blood pressure
3) Assessing for hyperglycemia
4) Tapering the drug two days prior to surgery
____
4. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is
appropriate for the patient who is prescribed warfarin?
1) Obtaining a baseline ECG
2) Monitoring blood pressure
3) Assessing for hyperglycemia
4) Tapering the drug two days prior to surgery
____
5. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is
appropriate for the patient who is prescribed metoprolol?
1) Obtaining a baseline ECG
2) Monitoring blood pressure
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3) Assessing for hyperglycemia
4) Tapering the drug two days prior to surgery
____
6. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is
appropriate for the patient who is prescribed dexamethoasone?
1) Obtaining a baseline ECG
2) Monitoring blood pressure
3) Assessing for hyperglycemia
4) Tapering the drug two days prior to surgery
____
7. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is
appropriate for the patient who is prescribed phenobarbital?
1) Obtaining a baseline ECG
2) Monitoring blood pressure
3) Maintaining the drug during the perioperative period
4) Assessing blood glucose levels closely during the perioperative period
____
8. The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is
appropriate for the patient who is prescribed insulin?
1) Obtaining a baseline ECG
2) Monitoring blood pressure
3) Holding the drug during the perioperative period
4) Assessing blood glucose levels closely during the perioperative period
____
9. Which should the nurse teach the patient regarding NPO status prior to a surgical procedure?
1) Nothing by mouth for 12 hours prior to surgery
2) Nothing solid by mouth for sixNhours
prior
URSI
NGto
KIsurgery
NG.COM
3) No clear liquids by mouth for four hours prior to the surgery
4) No clear liquids by mouth for two hours prior to the surgery
____ 10. Which is the priority nursing action when providing patient care during the preoperative phase of care?
1) Ensuring NPO status
2) Monitoring vital signs
3) Obtaining informed consent
4) Completing a preoperative checklist
____ 11. The nurse is reviewing the medical records for patients who are scheduled for surgery the next day. Which
patient may not provide consent to receive blood products?
1) A Hispanic Catholic patient.
2) An African-American Baptist patient.
3)
4) A Native American patient with no religious affiliation.
____ 12. Which identifier should the nurse use during the initial time-out to determine the right patient?
1) Date of birth
2) Maiden name
3) Medical record number
4) Photo placed in the medical record
____ 13. Which information should the nurse collect during the health history that is conducted during the preoperative
period?
1) Caretaker after discharge
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2) Oral intake over the last day
3) Date of last sexual encounter
4) Previous response to anesthesia
____ 14. The nurse is preparing a patient, diagnosed with asthma, for surgery. Which should the nurse include in the
plan of care for this patient?
1) Monitoring blood pressure every hour
2) Assessing bowel sounds twice per shift
3) Monitoring pulse oximetry continuously
4) Assessing deep tendon reflexes every hour
____ 15. Which is the priority action by the nurse when a patient discloses a medication allergy during the health
history prior to a surgical procedure?
1) Asking the patient to describe the reaction that occurs
2)
3) Placing an alert bracelet on the patient prior to leaving the unit
4)
____ 16. Which parameter for NPO status is appropriate when providing care to a pediatric patient in the preoperative
period?
1) Ensuring nothing by mouth for six hours prior to the surgical procedure
2) Ensuring no solid foods by mouth for six hours prior to the surgical procedure
3)
surgical procedure
4)
surgical procedure
NURSINGKING.COM
____ 17. Which risk factor should the nurse include in the preoperative plan of care for a patient who smokes?
1) Angina pain
2) Gastrointestinal upset
3) Cognitive impairment
4) Respiratory depression
____ 18. Which laboratory test should the nurse include in the plan of care for a patient who may require a blood
transfusion during the surgical procedure?
1) Urinalysis
2) Type and crossmatch
3) Basic metabolic panel
4) Arterial blood gas analysis
____ 19. Which gauge catheter should the nurse use when initiating intravenous (IV) access for a preoperative patient?
1) 18
2) 20
3) 22
4) 24
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 20. Which should the nurse ask the patient to verify during the initial time1)
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2)
3)
4)
5)
____ 21. A patient is informed that a surgical procedure is to be scheduled in two weeks. Which teaching points should
the nurse focus to prepare the patient for the surgery? Select all that apply.
1) Maintaining a patent airway
2) Deep breathing and coughing
3) Caring for the surgical incision
4) Managing constipation
5) Managing pain
____ 22. The nurse is preparing a patient for emergency surgery to repair liver and colon lacerations caused by a motor
vehicle crash. Which information about this type of surgery will the nurse use to guide the patient's care?
Select all that apply.
1) An organ is going to be removed.
2) This is an emergency surgery.
3) The patient will be hospitalized longer.
4) The patient is at risk for blood loss.
5) The patient is at risk for hypothermia.
____ 23. The nurse is preparing an older adult patient for surgery. Which topics should the nurse focus on when
Select all that apply.
1) Level of hearing
2) Transportation needs of the patient after discharge
NUcoughing
RSINGKING.COM
3) Teaching on deep breathing and
4) Plans for discharge care
5) Actions to prevent pressure ulcers
____ 24. When providing preoperative teaching for the patient who is scheduled for coronary artery bypass surgery in
the morning, the nurse would include which topics? Select all that apply.
1) Location of incisions
2) Discharge information
3) Postoperative drains to expect
4) Postoperative pain management
5) Coughing and deep breathing exercises
____ 25. The nurse performs preoperative teaching for a patient requiring a surgical intervention. Which actions by the
patient indicate appropriate understanding of the information provided? Select all that apply.
1) Demonstrating how to turn and get out of bed
2) Having no anxiety about the impending surgery
3) Demonstrating proper performance of leg exercises
4) Demonstrating proper coughing and deep breathing
5) Asking questions about and voicing understanding of information provided
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Chapter 15: Priorities for the Preoperative Patient
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Discussing the essentials of the surgical experience
Chapter page reference: 274-279
Heading: Informed Consent
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Legal; Perioperative
Difficulty: Moderate
Feedback
1
2
3
4
The nurse cannot have the patient sign the consent once the preoperative medication
Emergency surgery, in some facilities, may be performed if a family member or
medical power of attorney signs the consent when the patient is unable to do so, but
decision.
The nurse cannot send the patient to the holding area without a signed consent form.
The nurse will notify the health-care
NURSIprovider,
NGKINwho
G.Cwill
OMneed to cancel surgery until the
lity to make
informed decisions, at which time the consent can be signed.
PTS: 1
CON: Legal | Perioperative
2. ANS: 2
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Discussing the essentials of the surgical experience
Chapter page reference: 274
Heading: Introduction
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
The nurse on day shift preparing to send the patient to surgery would document time of
last voiding and administration of preoperative medication.
2
The nurse on night shift could check the medical record to ensure that a history and
physical have been completed, and that the consent for surgery is signed.
3
The nurse on day shift preparing to send the patient to surgery would document time of
last voiding and administration of preoperative medication.
4
Many patients prefer to wait until just before going to surgery before removing
dentures, contact lenses, and other prostheses.
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PTS: 1
CON: Perioperative
3. ANS: 1
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Explaining the priority assessments for the surgical patient
Chapter page reference: 280-284
Heading: Patient Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
The prescribed drug is an antiarrhythmic; therefore, the most appropriate nursing action
is to obtain a baseline ECG.
2
This nursing action is appropriate for a patient who is prescribed an antihypertensive
drug.
3
This nursing action is appropriate for a patient who is prescribed a corticosteroid drug.
4
The nursing action is appropriate for a patient who is prescribed an anticoagulant drug.
PTS: 1
CON: Perioperative
4. ANS: 4
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Explaining the priority assessments for the surgical patient
Chapter page reference: 280-284
NURSINGKING.COM
Heading: Patient Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
This nursing action is appropriate for a patient who is prescribed an antiarrhythmic.
2
This nursing action is appropriate for a patient who is prescribed an antihypertensive
drug.
3
This nursing action is appropriate for a patient who is prescribed a corticosteroid drug.
4
The prescribed drug is an anticoagulant; therefore, the most appropriate nursing action
is to teach the patient to taper the drug for 48 hours prior to the surgical procedure.
PTS: 1
CON: Perioperative
5. ANS: 2
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Explaining the priority assessments for the surgical patient
Chapter page reference: 280-284
Heading: Patient Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Difficulty: Moderate
Feedback
1
This nursing action is appropriate for a patient who is prescribed an antiarrhythmic.
2
The prescribed drug is an antihypertensive; therefore, the most appropriate nursing
3
4
This nursing action is appropriate for a patient who is prescribed a corticosteroid drug.
The nursing action is appropriate for a patient who is prescribed an anticoagulant drug.
PTS: 1
CON: Perioperative
6. ANS: 3
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Explaining the priority assessments for the surgical patient
Chapter page reference: 280-284
Heading: Patient Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
This nursing action is appropriate for a patient who is prescribed an antiarrhythmic.
2
This nursing action is appropriate for a patient who is prescribed an antihypertensive
drug.
3
The prescribed drug is a corticosteroid; therefore, the most appropriate nursing action is
to assess the patient for hyperglycemia.
NURSINGKING.COM
4
The nursing action is appropriate for a patient who is prescribed an anticoagulant drug.
PTS: 1
CON: Perioperative
7. ANS: 3
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Explaining the priority assessments for the surgical patient
Chapter page reference: 280-284
Heading: Patient Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
This nursing action is appropriate for a patient who is prescribed an antiarrhythmic.
2
This nursing action is appropriate for a patient who is prescribed an antihypertensive
drug.
3
The prescribed drug is a medication used to control seizures; therefore, this drug should
be maintained during the perioperative period.
4
The nursing action is appropriate for a patient who is prescribed insulin for diabetes
management.
PTS: 1
CON: Perioperative
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8. ANS: 4
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Explaining the priority assessments for the surgical patient
Chapter page reference: 280-284
Heading: Patient Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
This nursing action is appropriate for a patient who is prescribed an antiarrhythmic.
2
This nursing action is appropriate for a patient who is prescribed an antihypertensive
drug.
3
This nursing action is inappropriate as insulin should be administered throughout the
perioperative period.
4
perioperative period.
PTS: 1
CON: Perioperative
9. ANS: 4
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Identifying the vital preoperative preparation for the patient
Chapter page reference: 280-284
NURSINGKING.COM
Heading: Patient Assessment
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
This is not the guideline regarding NPO status prior to a surgical procedure.
2
This is not the guideline regarding NPO status prior to a surgical procedure.
3
This is not the guideline regarding NPO status prior to a surgical procedure.
4
The guidelines for NPO status prior to a surgical procedure is nothing solid by mouth
for eight hours prior to the procedure and no clear liquids by mouth for two hours prior
PTS: 1
CON: Perioperative
10. ANS: 4
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Identifying the vital preoperative preparation for the patient
Chapter page reference: 274
Heading: Introduction
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Perioperative
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Difficulty: Difficult
Feedback
1
While ensuring NPO status is important, this is not the priority nursing action.
2
While monitoring vital signs is important, this is not the priority nursing action.
3
The health-care provider, not the nurse, is responsible for obtaining informed consent.
4
The priority nursing action during the preoperative period is to complete the
preoperative checklist prior to the patient being transferred to the surgical suite.
PTS: 1
CON: Perioperative
11. ANS: 3
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Analyzing the nursing role in the preoperative process
Chapter page reference: 274-279
Heading: Informed Consent
Integrated Processes: Nursing Process Assessment
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Perioperative; Diversity
Difficulty: Easy
Feedback
1
This patient is likely to provide consent to receive blood products.
2
This patient is likely to provide consent to receive blood products.
3
4
products during the perioperative period.
This patient is likely to provide
consent
NUR
SINGtoKreceive
ING.blood
COM products.
PTS: 1
CON: Perioperative | Diversity
12. ANS: 1
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Identifying the vital preoperative preparation for the patient
Chapter page reference: 279-280
Heading: Time Outs/Cause for Pause
Integrated Processes: Nursing Process Assessment
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Legal; Perioperative
Difficulty: Moderate
Feedback
1
Date of birth is an identifier the nurse should use to determine the right patient during
the initial time-out conducted during the preoperative period.
2
3
to determine the right patient during the initial time-out conducted during the
preoperative period.
r, is an identifier the
nurse should use to determine the right patient during the initial time-out conducted
during the preoperative period.
4
the nurse should use to determine the right patient during the initial time-out conducted
during the preoperative period.
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PTS: 1
CON: Legal | Perioperative
13. ANS: 4
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Explaining the priority assessments for the surgical patient
Chapter page reference: 280-284
Heading: Patient Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Perioperative; Assessment
Difficulty: Easy
Feedback
1
While the support system and living conditions should be assessed it is unnecessary to
determine a specific caregiver after discharge.
2
Last oral intake, not intake over the previous day, is information collected.
3
4
PTS: 1
CON: Perioperative | Assessment
14. ANS: 3
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Identifying the vital preoperative preparation for the patient
Chapter page reference: 280-284
Heading: Patient Assessment
NURSINGKING.COM
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative; Oxygenation
Difficulty: Moderate
Feedback
1
2
3
4
A patient diagnosed with asthma, who is scheduled for surgery, may have difficulty
being weaned from the mechanical ventilator. This patient would require continuous
pulse oximetry and arterial blood gas analysis in the plan of care.
This parameter is
PTS: 1
CON: Perioperative | Oxygenation
15. ANS: 3
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Identifying the vital preoperative preparation for the patient
Chapter page reference: 280-284
Heading: Patient Assessment
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Perioperative
Difficulty: Difficult
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1
Feedback
While it is important to determine the type of reaction the patient experiences, this is
not the priority nursing action.
2
3
not the priority nursing action.
The nurse should immediately place an alert bracelet on the patient and communicate
this information with the surgical team.
4
bedside.
PTS: 1
CON: Perioperative
16. ANS: 3
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Identifying the vital preoperative preparation for the patient
Chapter page reference: 280-284
Heading: Patient Assessment
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Perioperative; Nutrition
Difficulty: Easy
Feedback
1
This parameter is not appropriate for the pediatric patient.
2
This parameter is not appropriate for the pediatric patient. Solid foods are allowed up to
up eight hours prior to surgery.
NURSINGKING.COM
3
The pediatric patient can have formula for up to six hours prior to surgery.
4
This parameter is not appropriate for the pediatric patient. Breast milk is allowed for up
to four hours prior to surgery.
PTS: 1
CON: Perioperative | Nutrition
17. ANS: 4
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Analyzing the nursing role in the preoperative process
Chapter page reference: 280-284
Heading: Patient Assessment
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative; Oxygenation
Difficulty: Moderate
Feedback
1
A patient who smokes is not at a greater risk for angina pain during the perioperative
period.
2
A patient who smokes is not at a greater risk for gastrointestinal upset during the
perioperative period.
3
A patient who smokes is not at a greater risk for cognitive impairment during the
perioperative period.
4
A patient who smokes is at a greater risk for respiratory depression during the
perioperative period.
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PTS: 1
CON: Perioperative | Oxygenation
18. ANS: 2
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Identifying the vital preoperative preparation for the patient
Chapter page reference: 284-286
Heading: Patient Preparation for Surgical Experience
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
A urinalysis is not anticipated for a patient who may require a blood transfusion during
a surgical procedure.
2
A type and crossmatch is anticipated for a patient who may require a blood transfusion
during a surgical procedure. This will allow for type specific blood to be available for
the patient if a transfusion is required.
3
A basic metabolic panel is not anticipated for a patient who may require a blood
transfusion during a surgical procedure.
4
An arterial blood gas analysis is not anticipated for a patient who may require a blood
transfusion during a surgical procedure.
PTS: 1
CON: Perioperative
19. ANS: 1
NURSINGKING.COM
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Identifying the vital preoperative preparation for the patient
Chapter page reference: 284-286
Heading: Patient Preparation for Surgical Experience
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Knowledge [Remembering]
Concept: Perioperative; Fluid and Electrolyte Maintenance
Difficulty: Easy
Feedback
1
An 18-gauge catheter is used when initiating IV access for a perioperative patient as
this is the gauge preferred for the administration of blood products.
2
This is not an appropriate gauge for the nurse to use when initiating IV access for a
perioperative patient.
3
This is not an appropriate gauge for the nurse to use when initiating IV access for a
perioperative patient.
4
This is not an appropriate gauge for the nurse to use when initiating IV access for a
perioperative patient.
PTS: 1
CON: Perioperative | Fluid and Electrolyte Balance
MULTIPLE RESPONSE
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20. ANS: 1, 2, 3, 4
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Explaining the priority assessments for the surgical patient
Chapter page reference: 279-280
Heading: Time-Outs/Pause for Cause
Integrated Processes: Nursing Process Assessment
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
This is correct. This question is included in the initial timeThis is correct. This question is included in the initial timeThis is correct. This question is included in the initial timeThis is correct. This question is included in the initial timeThis is incorrect. This question is not included in the initial time-out. This information is
included in the preoperative checklist.
1.
2.
3.
4.
5.
PTS: 1
CON: Perioperative
21. ANS: 2, 3, 4, 5
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Developing teaching and support strategies for the surgical patient and his or her
family
Chapter page reference: 284-286
NURSINGKING.COM
Heading: Patient Preparation for the Surgical Experience
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
This is incorrect. Maintaining a patent airway is a nursing action that is performed during the
postoperative phase of surgical care.
This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse
should focus teaching on deep breathing and coughing exercises, care of the surgical incision,
managing constipation, and managing pain.
This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse
should focus teaching on deep breathing and coughing exercises, care of the surgical incision,
managing constipation, and managing pain.
This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse
should focus teaching on deep breathing and coughing exercises, care of the surgical incision,
managing constipation, and managing pain.
This is correct. In the preoperative phase, when the patient is alert and oriented, the nurse
should focus teaching on deep breathing and coughing exercises, care of the surgical incision,
managing constipation, and managing pain.
1.
2.
3.
4.
5.
PTS: 1
CON: Perioperative
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22. ANS: 2, 3, 4, 5
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Developing teaching and support strategies for the surgical patient and his or her
family
Chapter page reference: 284-286
Heading: Patient Preparation for the Surgical Experience
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
This is incorrect. The suffix -ectomy indicates removal of an organ. The patient is having
surgery to repair lacerations. No organ is identified for removal.
This is correct. Emergency surgery is performed when a condition is life-threatening.
This is correct. Surgery to control internal hemorrhage from lacerations is an example of
emergency surgery. An open procedure usually requires a longer hospital stay.
This is correct. Open procedures place the patient at a higher risk for blood loss.
This is correct. If there is a large surgical opening, the patient cannot be adequately covered
and will be exposed to cold surgical suite air, and can develop hypothermia.
1.
2.
3.
4.
5.
PTS: 1
CON: Perioperative
23. ANS: 1, 3, 4, 5
Chapter number and title: 15, Priorities for the Preoperative Patient
NURSINGKING.COM
Chapter learning objective: Developing teaching and support strategies for the surgical patient and his or her
family
Chapter page reference: 284-286
Heading: Patient Preparation for the Surgical Experience
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
This is correct. For the older patient, make sure the patient can hear the information to be
presented or provide information through alternative means.
This is incorrect. Transportation needs of the patient after discharge would not be part of the
preoperative teaching plan.
This is correct. Older adults are at greater risk for pneumonia and other postoperative
complications and should have teaching related to deep breathing and coughing.
This is correct. The older patient is going to need assistance once discharged and should have
the necessary medical equipment such as walkers and raised toilet seats, assistance with
transportation, or extended care.
This is correct. The older patient is at risk for pressure ulcer formation because of poor
nutritional status, diabetes, cardiovascular illness, or history of steroid use.
1.
2.
3.
4.
5.
PTS: 1
CON: Perioperative
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24. ANS: 1, 3, 4, 5
Feedback
1.
This is correct. The location of incisions is included in the preoperative teaching session.
2.
This is incorrect. Discharge information is not included in the preoperative teaching session.
3.
This is correct. Drains to expect after the surgical procedure is information included in the
preoperative teaching session.
4.
This is correct. Postoperative pain management is information included in the preoperative
teaching session.
5.
This is correct. Coughing and deep breathing exercises is information included in the
preoperative teaching session.
Chapter number and title: 15, Priorities for the Preoperative Patient
Chapter learning objective: Developing teaching and support strategies for the surgical patient and his or her
family
Chapter page reference: 284-286
Heading: Patient Preparation for the Surgical Experience
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
PTS: 1
CON: Perioperative
25. ANS: 1, 3, 4, 5
Chapter number and title: 15, Priorities for the Preoperative Patient
NURteaching
SINGKand
INsupport
G.COM
Chapter learning objective: Developing
strategies for the surgical patient and his or her
family
Chapter page reference: 284-286
Heading: Patient Preparation for the Surgical Experience
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Perioperative
Difficulty: Difficult
Feedback
1.
and the return demonstration of skills performed.
This is incorrect. Although preoperative teaching can help to reduce anxiety, it is unlikely to
completely eliminate fear.
2.
3.
and the return demonstration of skills performed.
4.
s asked
and the return demonstration of skills performed.
5.
and the return demonstration of skills performed.
PTS: 1
CON: Perioperative
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Chapter 16: Priorities for the Intraoperative Patient
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. The patient is transferred to the operating table. Which dimension of the operative period is the patient
currently experiencing?
1) Postoperative period
2) Preoperative period
3) Perioperative period
4) Intraoperative period
____
2. The nurse is performing a surgical hand scrub, and holds the hands in which position when rinsing?
1) Straight out from the elbows
2) Lower than the elbows
3) Higher than the elbows
4) Irrelevant as long as the hands are well scrubbed
____
3. Which personal protective equipment should the scrub nurse don to decrease the likelihood of a splash injury
during a surgical procedure?
1) Gloves
NURSINGKING.COM
2) Gown
3) Mask
4) Eyewear
____
4. Which classification should the nurse document, according to the American Society of Anesthesiologists, for
a patient who is diagnosed with a mild systemic disease?
1) 2
2) 3
3) 4
4) 5
____
5. Which classification should the nurse document, according to the American Society of Anesthesiologists, for
a patient who is diagnosed with a severe systemic disease?
1) 2
2) 3
3) 4
4) 5
____
6. Which classification should the nurse document, according to the American Society of Anesthesiologists, for
a patient who is diagnosed with a severe systemic disease that is a threat to life?
1) 2
2) 3
3) 4
4) 5
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____
7. Which classification should the nurse document, according to the American Society of Anesthesiologists, for
a patient who is not expected to survive without the planned surgical procedure?
1) 2
2) 3
3) 4
4) 5
____
8.
patient who is brain-dead and having organs procured for donation?
1) 3
2) 4
3) 5
4) 6
____
9. Which term should the nurse document for a patient who is having surgery for the removal of female
reproductive organs?
1) Episiotomy
2) Hysterectomy
3) Amniocentesis
4) Cholecystectomy
____ 10. Which term should the nurse document for a patient who is having surgery for the removal of the gallbladder?
1) Episiotomy
2) Hysterectomy
3) Amniocentesis
4) Cholecystectomy
NURSINGKING.COM
____ 11. The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure.
When documenting the administration of propofol, which terminology should the nurse use?
1) A narcotic analgesic
2) An intravenous anesthetic
3) A depolarizing muscle relaxant
4) A nondepolarizing muscle relaxant
____ 12. The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure.
When documenting the administration of morphine sulfate, which terminology should the nurse use?
1) A narcotic analgesic
2) An intravenous anesthetic
3) A depolarizing muscle relaxant
4) A nondepolarizing muscle relaxant
____ 13. The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure.
When documenting the administration of cisatracurium, which terminology should the nurse use?
1) A narcotic analgesic
2) An intravenous anesthetic
3) A depolarizing muscle relaxant
4) A nondepolarizing muscle relaxant
____ 14. The circulating nurse is assisting the anesthesiologist with patient monitoring during a surgical procedure.
When documenting the administration of succinylcholine, which terminology should the nurse use?
1) A narcotic analgesic
2) An intravenous anesthetic
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3) A depolarizing muscle relaxant
4) A nondepolarizing muscle relaxant
____ 15. Which drug should the nurse prepare for the anesthesiologist to reverse the effects of cisatracurium during a
surgical procedure?
1) Fentanyl
2) Atropine
3) Neostigmine
4) Glycopyrrolate
____ 16. Which action should the circulating nurse anticipate during the induction of general anesthesia?
1)
2) Administering oxygen to the patient by face mask
3) Maintaining the patient using balanced anesthesia
4) Suctioning the patient to decrease incidence of aspiration
____ 17. Which action should the circulating nurse anticipate when the patient is intubated with the administration of
general anesthesia?
1)
2) Administering oxygen to the patient by face mask
3) Maintaining the patient using balanced anesthesia
4) Suctioning the patient to decrease incidence of aspiration
____ 18. Which action by the circulating nurse is appropriate when providing care to a patient during the maintenance
phase of general anesthesia?
1)
airway
2) Administering oxygen to the patient
NURSby
INface
GKmask
ING.COM
3) Suctioning the patient to decrease incidence of aspiration
4) Documenting drugs for administered for balanced anesthesia
____ 19. Which action should the circulating nurse anticipate during the emergence phase of general anesthesia?
1)
2) Administering oxygen to the patient by face mask
3) Maintaining the patient using balanced anesthesia
4) Suctioning the patient to decrease incidence of aspiration
Completion
Complete each statement.
20. Place the steps the nurse will take to don sterile gloves using the close procedure. (Enter the number of each
step in the proper sequence; do not use punctuation or spaces. Example: 1234)
1. With the dominant hand, pick up the opposite glove with the thumb and index finger, handling it through
the sleeve.
2. Open the sterile glove wrapper while the hands are still covered by the sleeves.
3. Use the nondominant hand to grasp the cuff of the glove through the gown cuff, and firmly anchor it.
4. Extend the fingers into the glove as you pull the glove up over the cuff.
5. Place the fingers of the gloved hand under the cuff of the remaining glove.
Multiple Response
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Identify one or more choices that best complete the statement or answer the question.
____ 21. Which individuals should the nurse emphasize when discussing providers who take part in providing patient
care during the intraoperative period of the surgical process? Select all that apply.
1) Surgeon
2) Postoperative nurse
3) Circulating nurse
4) Anesthesiologist
5) Social worker
____ 22. Which of these items would the perioperative nurse identify as part of the intraoperative documentation?
Select all that apply.
1) Pain assessment
2) Start and stop times of anesthesia
3) Medication review
4) Antibiotic infusion times
5) Start and stop times of the procedure
____ 23. Which is included in the scope of practice for the circulating registered nurse (RN)? Select all that apply.
1) Obtaining informed consent
2) Conducting the initial assessment
3) Assisting the CRNA with patient monitoring
4) Labeling patient samples and sending for analysis
5) Documenting information pertinent the surgical procedure
____ 24. The nurse works in a facility whose policy requires an antiseptic hand rub instead of a surgical scrub when
NURSare
INknown
GKINadvantages
G.COM of the hand rub over the scrub? Select all that
performing surgical hand asepsis. Which
apply.
1) Less harmful to the skin
2) Does not require the use of a brush
3) Contains ingredients that help to protect the skin
4) Takes longer to perform
5) Contains alcohol, which could dry the skin
____ 25. Which members of the surgical team are considered sterile? Select all that apply.
1) Surgeon
2) Scrub nurse
3) Anesthesiologist
4) Circulating nurse
5) Surgical assistant
____ 26. Which actions by the nurse are appropriate when preparing a patient for a surgical procedure that requires
supine positioning? Select all that apply.
1) Placing the patient on his or her back
2)
3)
4)
5) Lowering the foot of the bed flexing the
____ 27. Which actions by the nurse are appropriate when preparing a patient for a surgical procedure that requires
Select all that apply.
1) Placing the patient in a lateral position
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2)
3)
4)
5)
head in a headrest
____ 28. Which patient populations are at risk for complications due to positioning that is required during surgical
procedures? Select all that apply.
1) Pediatric patients
2) Older adult patients
3) Young adult patients
4) Patients diagnosed with bipolar disorder
5) Patients diagnosed with diabetes mellitus
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Chapter 16: Priorities for the Intraoperative Patient
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Explaining priority assessments and procedures in the OR
Chapter page reference: 290-291
Heading: Overview of the Surgical Experience
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Knowledge [Remembering]
Concept: Perioperative
Difficulty: Easy
Feedback
1
The postoperative phase begins with the admission of the patient to the postanesthesia
care unit, and ends when healing is complete.
2
The preoperative phase begins when surgery is planned, and ends when the patient is
transferred to the operating table.
3
The perioperative period covers all three time periods, from planning surgery until
healing is complete.
4
The intraoperative phase begins when the patient is transferred to the operating table,
and ends when the patient is admitted to the recovery room.
NURSINGKING.COM
PTS: 1
CON: Perioperative
2. ANS: 3
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Explaining priority assessments and procedures in the OR
Chapter page reference: 293-295
Heading: Priority Assessments and Procedures
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
1
2
3
4
Feedback
This is not an appropriate nursing action during the surgical scrub.
This is not an appropriate nursing action during the surgical scrub.
The hands should be held higher than the elbows so the water drains down to the
elbows and prevents contamination of the clean hands by water running from above the
scrubbed area.
This is not an appropriate nursing action during the surgical scrub.
PTS: 1
CON: Perioperative
3. ANS: 4
Chapter number and title: 16, Priorities for the Intraoperative Patient
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Chapter learning objective: Explaining priority assessments and procedures in the OR
Chapter page reference: 293-295
Heading: Priority Assessments and Procedures
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Perioperative; Infection
Difficulty: Moderate
Feedback
1
Gloves do not decrease the risk for a splash injury during a surgical procedure.
2
Gowns do not decrease the risk for a splash injury during a surgical procedure.
3
Masks do not decrease the risk for a splash injury during a surgical procedure.
4
Eyewear is worn by the scrub nurse to decrease the risk for a splash injury during a
surgical procedure.
PTS: 1
CON: Perioperative | Infection
4. ANS: 1
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Discussing types of anesthesia utilized in the OR
Chapter page reference: 295-301
Heading: Anesthesia
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Communication; Perioperative
NURSINGKING.COM
Difficulty: Moderate
Feedback
1
This is the appropriate classification for a patient with mild systemic disease.
2
This is the appropriate classification for a patient with severe systemic disease.
3
This is the appropriate classification for a patient with severe systemic disease that is a
constant threat to life.
4
This is the appropriate classification for a moribund patient who is not expected to
survive without the operation.
PTS: 1
CON: Communication | Perioperative
5. ANS: 2
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Discussing types of anesthesia utilized in the OR
Chapter page reference: 295-301
Heading: Anesthesia
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Communication; Perioperative
Difficulty: Moderate
Feedback
1
This is the appropriate classification for a patient with mild systemic disease.
2
This is the appropriate classification for a patient with severe systemic disease.
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
3
4
This is the appropriate classification for a patient with severe systemic disease that is a
constant threat to life.
This is the appropriate classification for a moribund patient who is not expected to
survive without the operation.
PTS: 1
CON: Communication | Perioperative
6. ANS: 3
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Discussing types of anesthesia utilized in the OR
Chapter page reference: 295-301
Heading: Anesthesia
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Communication; Perioperative
Difficulty: Moderate
Feedback
1
This is the appropriate classification for a patient with mild systemic disease.
2
This is the appropriate classification for a patient with severe systemic disease.
3
This is the appropriate classification for a patient with severe systemic disease that is a
constant threat to life.
4
This is the appropriate classification for a moribund patient who is not expected to
survive without the operation.
PTS: 1
CON: Communication
NURSIN|GPerioperative
KING.COM
7. ANS: 4
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Discussing types of anesthesia utilized in the OR
Chapter page reference: 295-301
Heading: Anesthesia
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Communication; Perioperative
Difficulty: Moderate
Feedback
1
This is the appropriate classification for a patient with mild systemic disease.
2
This is the appropriate classification for a patient with severe systemic disease.
3
This is the appropriate classification for a patient with severe systemic disease that is a
constant threat to life.
4
This is the appropriate classification for a moribund patient who is not expected to
survive without the operation.
PTS: 1
CON: Communication | Perioperative
8. ANS: 4
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Discussing types of anesthesia utilized in the OR
Chapter page reference: 295-301
Heading: Anesthesia
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Communication; Perioperative
Difficulty: Moderate
Feedback
1
This is the appropriate classification for a patient with severe systemic disease.
2
This is the appropriate classification for a patient with severe systemic disease that is a
constant threat to life.
3
This is the appropriate classification for a moribund patient who is not expected to
survive without the operation.
4
This is an appropriate classification for a patient who is brain-dead whose organs are
being removed for donation.
PTS: 1
CON: Communication | Perioperative
9. ANS: 2
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Explaining priority assessments and procedures in the OR
Chapter page reference: 290-291
Heading: Overview of the Surgical Experience
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Communication; Perioperative
Difficulty: Moderate
NURSINGKING.COM
1
2
3
4
Feedback
An episiotomy is an incision made to the vagina during childbirth; -otomy is the suffix
that indicates an incision.
A hysterectomy is the removal of the female reproductive organs; -ectomy is the suffix
that indicates the removal of organs.
An amniocentesis is the removal of amniotic fluid during pregnancy for analysis; centesis is the suffix that indicates puncture.
A cholecystectomy is the removal of the gallbladder; -ectomy is the suffix that indicates
the removal of organs.
PTS: 1
CON: Communication | Perioperative
10. ANS: 4
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Explaining priority assessments and procedures in the OR
Chapter page reference: 290-291
Heading: Overview of the Surgical Experience
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Communication; Perioperative
Difficulty: Moderate
Feedback
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1
2
3
4
An episiotomy is an incision made to the vagina during childbirth; -otomy is the suffix
that indicates an incision.
A hysterectomy is the removal of the female reproductive organs; -ectomy is the suffix
that indicates the removal of organs.
An amniocentesis is the removal of amniotic fluid during pregnancy for analysis; centesis is the suffix that indicates puncture.
A cholecystectomy is the removal of the gallbladder; -ectomy is the suffix that indicates
the removal of organs.
PTS: 1
CON: Communication | Perioperative
11. ANS: 2
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Discussing types of anesthesia utilized in the OR
Chapter page reference: 295-301
Heading: Anesthesia
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Perioperative; Medication
Difficulty: Moderate
Feedback
1
Morphine sulfate is a narcotic analgesic.
2
Propofol is an intravenous anesthetic.
3
Succinylcholine is a depolarizing muscle relaxant.
4
Cisatracurium is a nondepolarizing
muscle
relaxant.
NURSI
NGKI
NG.COM
PTS: 1
CON: Perioperative | Medication
12. ANS: 1
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Discussing types of anesthesia utilized in the OR
Chapter page reference: 295-301
Heading: Anesthesia
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Perioperative; Medication
Difficulty: Moderate
Feedback
1
Morphine sulfate is a narcotic analgesic.
2
Propofol is an intravenous anesthetic.
3
Succinylcholine is a depolarizing muscle relaxant.
4
Cisatracurium is a nondepolarizing muscle relaxant.
PTS: 1
CON: Perioperative | Medication
13. ANS: 4
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Discussing types of anesthesia utilized in the OR
Chapter page reference: 295-301
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Heading: Anesthesia
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Perioperative; Medication
Difficulty: Moderate
Feedback
1
Morphine sulfate is a narcotic analgesic.
2
Propofol is an intravenous anesthetic.
3
Succinylcholine is a depolarizing muscle relaxant.
4
Cisatracurium is a nondepolarizing muscle relaxant.
PTS: 1
CON: Perioperative | Medication
14. ANS: 3
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Discussing types of anesthesia utilized in the OR
Chapter page reference: 295-301
Heading: Anesthesia
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Perioperative; Medication
Difficulty: Moderate
Feedback
1
Morphine sulfate is a narcotic analgesic.
NURSINGKING.COM
2
Propofol is an intravenous anesthetic.
3
Succinylcholine is a depolarizing muscle relaxant.
4
Cisatracurium is a nondepolarizing muscle relaxant.
PTS: 1
CON: Perioperative | Medication
15. ANS: 3
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Discussing types of anesthesia utilized in the OR
Chapter page reference: 295-301
Heading: Anesthesia
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Perioperative; Medication
Difficulty: Moderate
1
2
3
4
Feedback
Fentanyl is a narcotic analgesic administered for pain.
Atropine is an anticholinergic agent that reverses muscle relaxants, not depolarizing
neuromuscular agents.
Neostigmine is a cholinergic agent that reverses the effects of cisatracurium, a
depolarizing neuromuscular agent.
Glycopyrrolate is an anticholinergic agent that reverses muscle relaxants, not
depolarizing neuromuscular agents.
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PTS: 1
CON: Perioperative | Medication
16. ANS: 2
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Analyzing the importance of airway management in the OR
Chapter page reference: 301-303
Heading: Airway Management
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
2
3
4
Oxygen is administered to the patient by face mask during the induction of general
anesthesia.
The patient is maintained with balanced anesthesia during maintenance phase of
general anesthesia.
The patient is suctioned to decrease the incidence of aspiration during emergence phase
of general anesthesia.
PTS: 1
CON: Perioperative
17. ANS: 1
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Analyzing
the
importance
NUR
SI
NGKINGof.airway
COM management in the OR
Chapter page reference: 301-303
Heading: Airway Management
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
2
3
4
Oxygen is administered to the patient by face mask during the induction of general
anesthesia.
The patient is maintained with balanced anesthesia during maintenance of general
anesthesia.
The patient is suctioned to decrease the incidence of aspiration during emergence phase
of general anesthesia.
PTS: 1
CON: Perioperative
18. ANS: 4
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Analyzing the importance of airway management in the OR
Chapter page reference: 301-303
Heading: Airway Management
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
2
3
4
Oxygen is administered to the patient by face mask during the induction of general
anesthesia.
The patient is suctioned to decrease the incidence of aspiration during emergence phase
of general anesthesia.
The circulating nurse will document the drugs that are administered to maintain
balanced anesthesia during the maintenance phase of general anesthesia.
PTS: 1
CON: Perioperative
19. ANS: 4
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Analyzing the importance of airway management in the OR
Chapter page reference: 301-303
Heading: Airway Management
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
2
3
4
NURSINGKING.COM
Oxygen is administered to the patient by face mask during the induction of general
anesthesia.
The patient is given drugs for balanced anesthesia during maintenance of general
anesthesia.
The patient is suctioned to decrease the incidence of aspiration during emergence phase
of general anesthesia.
PTS: 1
CON: Perioperative
COMPLETION
20. ANS:
21354
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Explaining priority assessments and procedures in the OR
Chapter page reference: 290-291
Heading: Overview of the Surgical Experience
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
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Feedback: The first step of the process is to open the sterile glove wrapper while the hands are covered by the
sleeves of the gown. Next, with the dominant hand, pick up the opposite glove with the thumb and index
finger, handling it through the sleeve. The third step is to use the nondominant hand to grasp the cuff of the
glove through the gown cuff, and firmly anchor it. The fourth step is to place the fingers of the gloved hand
under the cuff of the remaining glove. Finally, the nurse will extend the fingers into the glove and pull the
glove up over the cuff.
PTS: 1
CON: Perioperative
MULTIPLE RESPONSE
21. ANS: 1, 3, 4
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Identifying the roles and responsibilities of operating room (OR) team members
Chapter page reference: 291-293
Heading: Overview of the Surgical Team Members
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Knowledge [Remembering]
Concept: Perioperative
Difficulty: Easy
4.
Feedback
This is correct. The surgeon
NURSperforms
INGKIthe
NGprocedure.
.COM
This is incorrect. The postoperative nurse will provide care to the patient after the surgery is
completed.
This is correct. The circulating nurse is a perioperative registered nurse who cares for the
patient during the surgical procedure.
This is correct. The anesthesiologist provides the anesthesia during the surgery and continually
5.
This is incorrect. The social worker will not be in attendance during the procedure but may
1.
2.
3.
PTS: 1
CON: Perioperative
22. ANS: 2, 4, 5
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Explaining priority assessments and procedures in the OR
Chapter page reference: 293-295
Heading: Priority Assessments and Procedures
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Communication; Perioperative
Difficulty: Easy
1.
Feedback
This is incorrect. The pain assessment and medication review are documented during both the
preoperative and postoperative assessments.
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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2.
3.
4.
5.
This is correct. Intraoperative documentation is to include documentation about specific times,
such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop
times of the procedure.
This is incorrect. The pain assessment and medication review are documented during both the
preoperative and postoperative assessments.
This is correct. Intraoperative documentation is to include documentation about specific times,
such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop
times of the procedure.
This is correct. Intraoperative documentation is to include documentation about specific times,
such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop
times of the procedure.
PTS: 1
CON: Communication | Perioperative
23. ANS: 2, 3, 4, 5
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Identifying the roles and responsibilities of operating room (OR) team members
Chapter page reference: 291-293
Heading: Overview of Surgical Team Members
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Perioperative
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
NURSINGKING.COM
This is incorrect. The surgical provider obtained the informed consent during the preoperative
period.
This is correct. The circulating RN conducts the initial assessment when the patient is received
to the surgical suite.
This is correct. The circulating RN assists the anesthesia provider with patient monitoring.
This is correct. The circulating RN labels patient samples and sends them for analysis.
This is correct. The circulating RN documents information pertinent to the surgical procedure.
PTS: 1
CON: Perioperative
24. ANS: 1, 2, 3
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Explaining priority assessments and procedures in the OR
Chapter page reference: 293-295
Heading: Priority Assessments and Procedures
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Comprehension [Understanding]
Concept: Perioperative
Difficulty: Easy
Feedback
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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1.
This is correct. The antiseptic rub was implemented because it is less harmful to the skin, does
not require the use of a brush, and contains ingredients that actually protect the skin. As a
result, the nurse is less likely to develop abrasions or dermatitis when using a hand rub instead
of the older method of scrubbing the hands using a brush and caustic soaps.
2.
This is correct. The antiseptic rub was implemented because it is less harmful to the skin, does
not require the use of a brush, and contains ingredients that actually protect the skin. As a
result, the nurse is less likely to develop abrasions or dermatitis when using a hand rub instead
of the older method of scrubbing the hands using a brush and caustic soaps.
This is correct. The antiseptic rub was implemented because it is less harmful to the skin, does
not require the use of a brush, and contains ingredients that actually protect the skin. As a
result, the nurse is less likely to develop abrasions or dermatitis when using a hand rub instead
of the older method of scrubbing the hands using a brush and caustic soaps.
This is incorrect. The antiseptic hand rub is faster, not longer, to perform.
This is incorrect. The antiseptic hand rub does not contain any drying agents, such as alcohol.
3.
4.
5.
PTS: 1
CON: Perioperative
25. ANS: 1, 2, 5
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Identifying the roles and responsibilities of operating room (OR) team members
Chapter page reference: 291-293
Heading: Overview of Surgical Team Members
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Comprehension [Understanding]
NURSINGKING.COM
Concept: Perioperative
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is correct. The surgeon is considered sterile during a surgical procedure.
This is correct. The scrub nurse is considered sterile during a surgical procedure.
This is incorrect. The anesthesiologist is not considered sterile during the surgical procedure.
This is incorrect. The circulating nurse is not considered sterile during the surgical procedure.
This is correct. The surgical assistant is considered sterile during a surgical procedure.
PTS: 1
CON: Perioperative
26. ANS: 1, 4
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Developing support strategies for the surgical patient and his or her family
Chapter page reference: 303-307
Heading: Positioning the Patient in the OR
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
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1.
This is correct. This is an appropriate nursing action when using the supine position during a
surgical procedure.
2.
3.
4.
5.
procedure.
This is incorrect.
procedure.
This is correct. This is an appropriate nursing action when using the supine position during a
surgical procedure.
This is incorrect. This nursing action is ap
procedure.
PTS: 1
CON: Perioperative
27. ANS: 2, 3, 5
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Developing support strategies for the surgical patient and his or her family
Chapter page reference: 303-307
Heading: Positioning the Patient in the OR
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
1.
Feedback
This is incorrect. The lateral position is side-lying and would not be used if the surgical
NURSINGKING.COM
2.
procedure.
3.
4.
procedure.
This is incorrect. This is an appropriate nursing action when using the supine position during a
surgical procedure.
5.
procedure.
PTS: 1
CON: Perioperative
28. ANS: 1, 2, 5
Chapter number and title: 16, Priorities for the Intraoperative Patient
Chapter learning objective: Examining risks and complications for the surgical patient
Chapter page reference: 303-307
Heading: Positioning the Patient in the OR
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Perioperative
Difficulty: Easy
Feedback
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1.
This is correct. Pediatric patients are at an increased risk for complications during surgical
procedures due to required positioning.
This is correct. Older adult patients are at an increased risk for complications during surgical
procedures due to required positioning.
This is incorrect. A young adult patient is not at risk for complications due to positioning
during surgical procedures.
This is incorrect. A patient diagnosed with bipolar disorder is not at risk for complications due
to positioning during surgical procedures.
This is correct. Any patient diagnosed with a disease process affecting circulation, such as
diabetes mellitus, is at an increased risk for complications during surgical procedures due to
required positioning.
2.
3.
4.
5.
PTS: 1
CON: Perioperative
Chapter 17: Priorities for the Postoperative Patient
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. Which laboratory test should the postanesthesia care nurse monitor closely for a patient who is prescribed
warfarin in the treatment of atrial fibrillation?
1) Serum glucose
NURSINGKING.COM
2) Serum potassium
3) Prothrombin (PT) time
4) Blood urea nitrogen (BUN)
____
2.
____
3. The nurse is caring for a patient with a drain connected to a portable drainage suction device shaped like a
grenade made of plastic. Which term will the nurse use when describing this system during end-of-shift
report?
1) Closed wound drainage system
2) Hemovac
3) Jackson-Pratt
4) Reinfusion drain
____
4.
postoperative wound and finds it has separated from the suture line with
extrusion of the bowel through the opening. When documenting this finding, which term will the nurse use?
1) Wound infection
2) Wound dehiscence
3) Wound evisceration
4) Wound tunneling
classification would the nurse use when documenting care for this patient?
1) Preoperative
2) Postoperative
3) Perioperative
4) Intraoperative
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____
5. Upon receiving the patient from the postanesthesia care unit, which nursing action is the priority?
1) Apply clean linens to the bed
2) Assemble required equipment, such as suction, IV pole, or oxygen equipment
3) Assess the patient
4)
____
6. In the ongoing postoperative period, the nurse independently determines, within the protocols of the hospital,
the need for which provision of care?
1) Type of diet
2) Activity level
3) Assessment intervals
4) Intravenous solutions
____
7. The postoperative patient displays sudden chest pain, shortness of breath, cyanosis, tachycardia, and low
blood pressure. The nurse suspects which postoperative complication?
1) Pneumonia
2) Atelectasis
3) Hypovolemia
4) Pulmonary embolism
____
8. Which laboratory test should the postanesthesia care nurse monitor for a patient who is having difficulty
regaining consciousness after a surgical procedure?
1) Serum glucose
2) Serum potassium
3) Prothrombin (PT) time
4) Blood urea nitrogen (BUN) NURSINGKING.COM
____
9. Which is the priority laboratory test that the postanesthesia care nurse should monitor closely for an older
adult patient with renal disease who retained fluid during a surgical procedure?
1) Serum glucose
2) Serum potassium
3) Prothrombin (PT) time
4) Blood urea nitrogen (BUN)
____ 10. The postanesthesia care nurse is providing care to a patient with fluid volume overload who is experiencing
cardiac dysrhythmias. Which laboratory test should the nurse monitor for this patient?
1) Serum glucose
2) Serum potassium
3) Prothrombin (PT) time
4) Blood urea nitrogen (BUN)
____ 11. The medical-surgical nurse is providing care to a postoperative patient who is experiencing an elevated
temperature. Which laboratory value should the nurse monitor to gather more information?
1) Platelet count
2) Serum glucose
3) Red blood cell (RBC) count
4) White blood cell (WBC) count
____ 12. Which nursing action is appropriate when providing care to a patient who is difficult to arouse in the
postanesthesia care unit (PACU)?
1) Monitor breath sounds
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2) Administer prescribed heparin
3) Hold prescribed opioid analgesics
4) Assess for malignant hyperthermia
____ 13. Which nursing action is appropriate when providing care to a patient who is exhibiting low oxygen saturation
levels in the postanesthesia care unit (PACU).
1) Monitor breath sounds
2) Administer prescribed heparin
3) Hold prescribed opioid analgesics
4) Assess for malignant hyperthermia
____ 14. Which nursing action is appropriate when providing care to a patient who is exhibiting symptoms of a venous
thromboembolism (VTE)?
1) Monitor breath sounds
2) Administer prescribed heparin
3) Hold prescribed opioid analgesics
4) Assess for malignant hyperthermia
____ 15. The postanesthesia care unit (PACU) nurse is providing care for a patient who is exhibiting hypothermia.
Which nursing action is appropriate?
1) Monitor breath sounds
2) Check serum glucose level
3) Hold prescribed opioid analgesics
4) Provide warm blankets or warming devices
____ 16. The nurse is providing care to a postoperative patient who is experiencing pain. The patient rates the pain at a
4 on a 1 to 10 numeric pain assessment
NURscale.
SINWhich
GKINprescribed
G.COM medication should the nurse administer to
this patient?
1) Fentanyl
2) Morphine
3) Ibuprofen
4) Hydromorphone
____ 17. Which patient finding would indicate the need for further monitoring rather than discharge home after an
outpatient surgical procedure?
1) Pain management with opioid analgesics
2) Lethargy that resolves after several hours
3) Inability to void without fluid retention
4) Persistent nausea without vomiting
____ 18. Which is the priority initial assessment for a patient who is admitted to the postanesthesia care unit (PACU)?
1) Heart rate
2) Temperature
3) Respirations
4) Blood pressure
____ 19. How many providers from the operating room (OR) should participate in the hand-off communication that
occurs with the postanesthesia care (PACU) nurse prior to patient transfer?
1) One
2) Two
3) Three
4) Four
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____ 20. The nurse is providing care to a patient in the postanesthesia care unit (PACU) who lost a large amount of
blood during a surgical procedure. Which assessment finding should the nurse monitor this patient for based
on the current data?
1) Bradypnea
2) Tachycardia
3) Hypothermia
4) Hypertension
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. The postoperative nurse is planning care for a patient recovering from major thoracic surgery. Which nursing
Select all that apply.
1) Risk for Impaired Gas Exchange
2) Risk for Decreased Cardiac Output
3) Risk for Ineffective Airway Clearance
4) Risk for Imbalanced Nutrition: Less than Body Requirements
5) Risk for Imbalanced Fluid Volume
____ 22. Which tasks can the nurse assign to the unlicensed assistive personnel (UAP) who is assisting with providing
care to postoperative patients on a medical surgical unit? Select all that apply.
1) Documenting the assessment completed by the nurse
2) Giving the patient pain medication as ordered by the health-care provider
3) Assisting with patient exercises
4) Reporting when a patient cannot
NUcomplete
RSINGexercises
KING.COM
5) Conducting discharge teaching
____ 23. Which information should the postanesthesia care unit (PACU) nurse include in the hand-off that occurs with
the medical-surgical nurse who will assume care? Select all that apply.
1) Fluid intake and blood loss
2) Placement of intravenous (IV) lines
3) Patient identification using one identifier
4) Information regarding the surgical procedure
5) Over-the-counter (OTC) medications taken at home
____ 24. Which nursing actions are appropriate during Phase I of the postoperative period? Select all that apply.
1) Providing discharge instructions
2) Assessing vital signs per protocol
3) Monitoring electrocardiogram continuously
4) Providing ongoing care until a bed is available
5) Preparing for transfer to the medical-surgical unit
____ 25. Which are appropriate nurse-to-patient ratios in the postanesthesia care unit (PACU)? Select all that apply.
1) 1:1
2) 1:2
3) 1:3
4) 1:4
5) 1:5
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Chapter 17: Priorities for the Postoperative Patient
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 312-314
Heading: Patient Care in the Post-Anesthesia Care Unit (PACU)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
Serum glucose is monitored for a patient who is having difficulty regaining
consciousness in the postoperative period.
2
Serum potassium is monitored for patients who experienced abnormal fluid or blood
losses and for patients who may have been overhydrated.
3
A PT time is monitored closely for any patient who is prescribed warfarin. Warfarin is
often stopped for several days prior to a surgical procedure. However, this patient will
continue to be at an increased risk for bleeding.
4
A BUN is monitored for any patient who may have experienced abnormal fluid or
RSIshould
NGKIalso
NG.
OM
blood losses during surgery.NAUBUN
beCmonitored
for older adult patients
and for those with renal disease.
PTS: 1
CON: Perioperative
2. ANS: 3
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 315
Heading: Potential Complications
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
Wound infection is inflammation, redness, and/or drainage from the wound.
2
Wound dehiscence is separation of the suture line without visible organs or tissues.
3
Wound evisceration is separation of the wound with internal organs and tissues visible
through the opening.
4
Wound tunneling is small channels within the wound.
PTS: 1
CON: Perioperative
3. ANS: 3
Chapter number and title: 17, Priorities for the Postoperative Patient
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Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 312-314
Heading: Patient Care in the Post-Anesthesia Care Unit (PACU)
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative; Communication
Difficulty: Moderate
1
2
3
4
Feedback
All of these drains are nonspecifically known as closed wound drainage systems.
A Hemovac is a flat disk.
The drain described, shaped like a grenade, is a Jackson-Pratt.
A reinfusion drain allows collection of blood from the wound for readministration.
PTS: 1
CON: Perioperative | Communication
4. ANS: 2
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Discussing the significance of the postoperative period
Chapter page reference: 310-312
Heading: Introduction
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative; Communication
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Difficulty: Moderate
Feedback
1
The preoperative phase begins when surgery is planned, and ends when the patient is
transferred to the operating table.
2
The patient is in the postoperative phase. The postoperative phase begins with the
admission of the patient to the postanesthesia care unit, and ends when healing is
complete.
3
The perioperative period covers all three time periods, from planning surgery until
healing is complete.
4
The intraoperative phase begins when the patient is transferred to the operating table,
and ends when the patient is admitted to the recovery room.
PTS: 1
CON: Perioperative | Communication
5. ANS: 3
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 312-314
Heading: Patient Care in the Post-Anesthesia Care Unit (PACU)
Integrated Processes: Nursing Process Assessment
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Perioperative
Difficulty: Difficult
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1
2
3
4
Feedback
Clean linens should be applied to the bed as soon as the patient leaves for surgery or
upon notification that the patient will be coming to the unit.
Equipment should be gathered in advance and set up to be ready when the patient
returns.
The priority action for the nurse is
condition.
Only after assessing the patient would the nurse notify family members.
PTS: 1
CON: Perioperative
6. ANS: 3
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 315-317
Heading: Nursing Interventions
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative; Nursing
Difficulty: Moderate
Feedback
1
Activity level, intravenous solutions, and type of diet are ordered by the health-care
provider.
2
Activity level, intravenous solutions, and type of diet are ordered by the health-care
provider.
NURSINGKING.COM
3
The nurse will determine the frequency of patient assessments required, within the
protocols established by the facility. The minimum frequency is determined by the
facilit
and is the decision of the nurse.
4
Activity level, intravenous solutions, and type of diet are ordered by the health-care
provider.
PTS: 1
CON: Perioperative | Nursing
7. ANS: 4
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 315
Heading: Potential Complications
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Perioperative; Oxygenation
Difficulty: Easy
Feedback
1
The patient with pneumonia is likely to have a fever, but usually will not display sharp
chest pain.
2
Atelectasis can cause respiratory distress, but will not cause chest pain.
3
Hypovolemia does not produce chest pain either, and will usually be displayed by
tachycardia, decreased urine output, and drop in blood pressure.
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4
The patient is displaying signs of pulmonary emboli, which will cause sudden chest
pain and difficulty breathing.
PTS: 1
CON: Perioperative | Oxygenation
8. ANS: 1
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 312-314
Heading: Patient Care in the Post-Anesthesia Care Unit (PACU)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
Serum glucose is monitored for a patient who is having difficult regaining
consciousness in the postoperative period.
2
Serum potassium is monitored for patients who experienced abnormal fluid or blood
losses and for patients who may have been overhydrated.
3
A PT time is monitored closely for any patient who is prescribed warfarin. Warfarin is
often stopped for several days prior to a surgical procedure. However, this patient will
continue to be at an increased risk for bleeding.
4
A BUN is monitored for any patient who may have experienced abnormal fluid or
blood losses during surgery. A BUN should also be monitored for older adult patients
and for those with renal disease.
NURSINGKING.COM
PTS: 1
CON: Perioperative
9. ANS: 4
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 312-314
Heading: Patient Care in the Post-Anesthesia Care Unit (PACU)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Analysis [Analyzing]
Concept: Perioperative
Difficulty: Difficult
Feedback
1
Serum glucose is monitored for a patient who is having difficult regaining
consciousness in the postoperative period.
2
Serum potassium is monitored for patients who experienced abnormal fluid or blood
losses and for patients who may have been overhydrated.
3
A PT time is monitored closely for any patient who is prescribed warfarin. Warfarin is
often stopped for several days prior to a surgical procedure. However, this patient will
continue to be at an increased risk for bleeding.
4
A BUN is monitored for any patient who may have experienced abnormal fluid or
blood losses during surgery. A BUN should also be monitored for older adult patients
and for those with renal disease.
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PTS: 1
CON: Perioperative
10. ANS: 2
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 312-314
Heading: Patient Care in the Post-Anesthesia Care Unit (PACU)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Difficult
Feedback
1
Serum glucose is monitored for a patient who is having difficult regaining
consciousness in the postoperative period.
2
Serum potassium is monitored for patients who experienced abnormal fluid or blood
losses and for patients who may have been overhydrated. Patients who experience
either hyperkalemia, or hypokalemia, may exhibit cardiac dysrhythmias.
3
A PT time is monitored closely for any patient who is prescribed warfarin. Warfarin is
often stopped for several days prior to a surgical procedure. However, this patient will
continue to be at an increased risk for bleeding.
4
A BUN is monitored for any patient who may have experienced abnormal fluid or
blood losses during surgery. A BUN should also be monitored for older adult patients
and for those with renal disease.
PTS: 1
CON: Perioperative
NURSINGKING.COM
11. ANS: 4
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 312-314
Heading: Patient Care in the Post-Anesthesia Care Unit (PACU)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Perioperative; Infection
Difficulty: Moderate
Feedback
1
The nurse would monitor a platelet count for a patient who is experiencing bleeding in
the postoperative period.
2
A serum glucose level is monitored for a patient with diabetes mellitus.
3
An RBC count is monitored for a patient who experienced significant blood loss during
a surgical procedure in order to determine if anemia has occurred.
4
An elevated temperature often indicates the patient is experiencing an infection. An
increased WBC count would support this diagnosis.
PTS: 1
CON: Perioperative | Infection
12. ANS: 3
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate
postoperative period
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Chapter page reference: 315
Heading: Potential Complications
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
The nurse would monitor breath sounds for a patient experiencing inadequate
oxygenation.
2
The nurse would administer a prescribed anticoagulant, such as heparin, for a patient
who is experiencing venous thromboembolism (VTE).
3
A patient who is difficult to arouse should have prescribed analgesics held until the
patient stabilizes.
4
The nurse would assess a patient for malignant hyperthermia for a patient who is
experiencing an increased temperature in the PACU.
PTS: 1
CON: Perioperative
13. ANS: 1
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 315-317
Heading: Nursing Interventions
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
NURSINGKING.COM
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
The nurse would monitor breath sounds for a patient experiencing inadequate
oxygenation.
2
The nurse would administer a prescribed anticoagulant, such as heparin, for a patient
who is experiencing venous thromboembolism (VTE).
3
A patient who is difficult to arouse should have prescribed analgesics held until the
patient stabilizes.
4
The nurse would assess a patient for malignant hyperthermia for a patient who is
experiencing an increased temperature in the PACU.
PTS: 1
CON: Perioperative
14. ANS: 2
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate
postoperative period
Chapter page reference: 315
Heading: Potential Complications
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative
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Difficulty: Moderate
Feedback
1
The nurse would monitor breath sounds for a patient experiencing inadequate
oxygenation.
2
The nurse would administer a prescribed anticoagulant, such as heparin, for a patient
who is experiencing venous thromboembolism (VTE).
3
A patient who is difficult to arouse should have prescribed analgesics held until the
patient stabilizes.
4
The nurse would assess a patient for malignant hyperthermia for a patient who is
experiencing an increased temperature in the PACU.
PTS: 1
CON: Perioperative
15. ANS: 4
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 315
Heading: Potential Complications
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
The nurse would monitor breath sounds for a patient experiencing inadequate
oxygenation.
NURSINGKING.COM
2
The nurse would monitor serum glucose levels for a patient who exhibited confusion.
3
A patient who is difficult to arouse should have prescribed analgesics held until the
patient stabilizes.
4
The nurse would provide warm blankets or warming devices for a patient with
hypothermia.
PTS: 1
CON: Perioperative
16. ANS: 3
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate
postoperative period
Chapter page reference: 314-315
Heading: Pain Management
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Perioperative; Comfort
Difficulty: Moderate
Feedback
1
Fentanyl is an opioid analgesic that is reserved for severe pain in the postoperative
period.
2
Morphine is an opioid analgesic that is reserved for severe pain in the postoperative
period.
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3
4
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is appropriate for
mild pain in the postoperative period.
Hydromorphone is an opioid analgesic that is reserved for severe pain in the
postoperative period.
PTS: 1
CON: Perioperative | Comfort
17. ANS: 4
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 312-314
Heading: Patient Care in the Post-Anesthesia Care Unit (PACU)
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
Effective pain management with opioid analgesics does not indicate the need for further
monitoring. This patient can be discharged home.
2
Lethargy that resolves does not indicate the need for further monitoring. This patient
can be discharged home.
3
An inability to void postsurgery, without a history of urinary retention, does not require
further monitoring. This patient can be discharged home.
4
Persistent nausea, without vomiting, would indicate the need for further monitoring.
This patient is not stable enough for discharge home.
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PTS: 1
CON: Perioperative
18. ANS: 3
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 315-317
Heading: Nursing Interventions
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Perioperative; Assessment
Difficulty: Difficult
Feedback
1
While heart rate is an important parameter in the nursing assessment, this is not the
priority. The ABCs should guide priority during the initial nursing assessment for the
patient admitted to the PACU.
2
While temperature is an important parameter in the nursing assessment, this is not the
priority. The ABCs should guide priority during the initial nursing assessment for the
patient admitted to the PACU.
3
Respirations is the priority initial assessment for a patient who is admitted to the
PACU. The ABCs should guide priority during the initial nursing assessment for the
patient admitted to the PACU.
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4
While blood pressure is an important parameter in the nursing assessment, this is not
the priority. The ABCs should guide priority during the initial nursing assessment for
the patient admitted to the PACU.
PTS: 1
CON: Perioperative | Assessment
19. ANS: 3
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Discussing the significance of the postoperative period
Chapter page reference: 312-314
Heading: Patient Care in the Post-Anesthesia Care Unit (PACU)
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Knowledge [Remembering]
Concept: Communication; Perioperative
Difficulty: Easy
Feedback
1
This is not the appropriate number of OR providers who should participate in the handoff communication with the PACU nurse.
2
This is not the appropriate number of OR providers who should participate in the handoff communication with the PACU nurse.
3
Three members of the OR team (anesthesia, surgical provider, and OR nurse) should
participate in the hand-off communication with the PACU nurse.
4
This is not the appropriate number of OR providers who should participate in the handoff communication with the PACU nurse.
NURSINGKING.COM
PTS: 1
CON: Communication | Perioperative
20. ANS: 2
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Explaining the priority assessments for the postsurgical patient
Chapter page reference: 315-317
Heading: Nursing Interventions
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehensive [Understanding]
Concept: Perioperative; Perfusion
Difficulty: Easy
Feedback
1
Bradypnea is not an assessment finding that occurs with blood loss.
2
Tachycardia is an anticipated assessment finding for a patient who loses a significant
amount of blood during a surgical procedure.
3
Hypothermia is not an assessment finding that occurs with blood loss.
4
Hypotension, not hypertension, is an assessment finding that occurs with blood loss.
PTS: 1
CON: Perioperative | Perfusion
MULTIPLE RESPONSE
21. ANS: 1, 2, 5
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Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate
postoperative period
Chapter page reference: 315-317
Heading: Nursing Interventions
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Perioperative
Difficulty: Difficult
1.
2.
3.
4.
5.
Feedback
This is correct. Nursing diagnoses appropriate for the immediate postoperative phase include
the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the
Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid
Volume because of blood loss and nothing by mouth status.
This is correct. Nursing diagnoses appropriate for the immediate postoperative phase include
the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the
Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid
Volume because of blood loss and nothing by mouth status.
This is incorrect. The Risk for Ineffective Airway Clearance might be appropriate later as the
patient recovers from surgery.
This is incorrect. There is no Risk for Imbalanced Nutrition: Less than Body Requirements
during the immediate postoperative phase.
This is correct. Nursing diagnoses appropriate for the immediate postoperative phase include
URExchange
SINGKbecause
ING.CofOanesthesia
M
the Risk for Impaired N
Gas
medications and hypothermia, the
Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid
Volume because of blood loss and nothing by mouth status.
PTS: 1
CON: Perioperative
22. ANS: 2, 3, 4
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate
postoperative period
Chapter page reference: 315-317
Heading: Nursing Interventions
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. The nurse performs and documents the patient assessment, not the UAP.
This is incorrect. The UAP cannot pass medications.
This is correct. The UAP can assist the patient with exercises and report any problems the
patient has when performing exercises.
This is correct. The UAP can assist the patient with exercises and report any problems the
patient has when performing exercises.
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5.
This is incorrect. The UAP cannot conduct discharge teaching.
PTS: 1
CON: Perioperative
23. ANS: 1, 2, 4
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate
postoperative period
Chapter page reference: 312-314
Heading: Patient Care in the Post-Anesthesia Care Unit (PACU)
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Communication; Perioperative
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. Fluid intake and blood loss is included in the hand-off communication process
between the PACU and medical-surgical nurses.
This is correct. Information regarding the placement of IV lines is included in the hand-off
communication process between the PACU and medical-surgical nurses.
This is incorrect. Patient identification during the hand-off process should include two patient
identifiers, not one.
This is correct. Information regarding the surgical procedure is included in the hand-off
communication process between the PACU and medical-surgical nurses.
This is incorrect. Important medications taken by the patient at home, not OTC medications,
NURSINGKING.COM
should be included in the hand-off process.
PTS: 1
CON: Communication | Perioperative
24. ANS: 2, 3
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Applying the vital postoperative interventions for the patient in the immediate
postoperative period
Chapter page reference: 312-314
Heading: Patient Care in the Post-Anesthesia Care Unit (PACU)
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. This is not an appropriate nursing action during Phase I of the postoperative
period.
This is correct. Assessing vital signs per protocol is an appropriate nursing action during
Phase I of the postoperative period.
This is correct. Monitoring the electrocardiogram continuously is an appropriate nursing
action during Phase I of the postoperative period.
This is incorrect. Providing ongoing care until a bed is available is not an appropriate nursing
action during Phase I of the postoperative period.
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5.
This is incorrect. Preparing for transfer to the medical-surgical unit is not an appropriate
nursing action during Phase I of the postoperative period.
PTS: 1
CON: Perioperative
25. ANS: 1, 2, 3
Chapter number and title: 17, Priorities for the Postoperative Patient
Chapter learning objective: Discussing the significance of the postoperative period
Chapter page reference: 312-314
Heading: Patient Care in the Post-Anesthesia Care Unit (PACU)
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Knowledge [Remembering]
Concept: Perioperative
Difficulty: Easy
Feedback
This is correct. This is an appropriate nurse to patient ratio in the PACU.
This is correct. This is an appropriate nurse to patient ratio in the PACU.
This is correct. This is an appropriate nurse to patient ratio in the PACU if one patient is
awaiting transfer to another unit or awaiting discharge home.
This is incorrect. This is not an appropriate nurse to patient ratio in the PACU.
This is incorrect. This is not an appropriate nurse to patient ratio in the PACU.
1.
2.
3.
4.
5.
PTS: 1
CON: Perioperative
NURSINGKING.COM
Chapter 18: Assessment of Immune Function
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1.
1)
2)
3)
4)
____
A surgical incision
Occasional smoking
Alcoholic beverages
Adequate urinary output
2. A nurse working in the emergency department (ED) is providing care for a group of patients. Which patient
demonstrates a decline in immune response that typically occurs with the aging process?
1) An 88-year-old with pneumonia who has a temperature of 99.5°F.
2) A 56-year-old who has 8 mm induration at the site of a PPD skin test 72 hours earlier.
3) A 58-year-old who reports redness and itching due to a rash from contact with poison ivy.
4) A 70-year-old who has swelling and redness at the incision from an open appendectomy.
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____
3. The nurse is providing care to a patient who has an increased number of lymphocytes. Which explanation
should the nurse provide to the patient regarding this abnormality?
1)
2)
3)
4)
r
____
4. Which scenario should the nurse provide as one in which active immunity is acquired when educating a group
within the community?
1) Having measles as a child
2) Receiving an injection of gamma globulin
3) Becoming ill with tetanus and receiving tetanus toxoid
4) Receiving a rabies shot after being bitten by a rabid dog
____
5. The nurse is providing care to a patient with a compromised immune system. Which independent nursing
intervention is appropriate for the nurse to include
1) Recommending gene transfer therapy
2) Administering corticosteroids, per order
3) Prescribing prophylactic antibiotic therapy
4) Educating on the importance of a nutritious diet
____
6. A nurse is caring for a patient with who is experiencing leukocytosis. When providing care to this patient,
which action by the nurse is the most appropriate?
1) Assess for source of infection
2) Assess for bleeding and bruising
NURSprecautions
INGKING.COM
3) Place the patient in reverse isolation
4) Instruct the patient on the use of an electric razor and soft toothbrush
____
7. Which question should the nurse to ask during a health history with an adolescent patient, accompanied by a
parent, to determine immune status?
1)
2)
3)
4)
-to-
____
8.
physical examination?
1) Asking the patient to cough several times
2)
3)
4)
____
9. Which type of immunoglobulin (Ig) is produced during an allergic reaction?
1) IgA
2) IgD
3) IgE
4) IgM
____ 10.
1) Proteins
2) Calcium
3) Potassium
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4) Carbohydrates
____ 11. The nurse is providing care to a patient who experienced an allergic reaction. Which leukocyte does the nurse
anticipate will be elevated?
1) Basophils
2) Monocytes
3) Eosinophils
4) Neutrophils
____ 12. The nurse is teaching a new mother the immune benefits of breastfeeding her newborn. Which
immunoglobulin (Ig) should the nurse include as one that is passed from mother to newborn by breast milk?
1) IgA
2) IgD
3) IgE
4) IgG
____ 13. The nurse is providing care to a patient who has a decreased neutrophil count and elevated hepatic enzymes.
infection?
1) Anorexia nervosa
2) Acute renal failure
3) Pulmonary disease
4) Cirrhosis of the liver
____ 14. The nurse is providing care to patient who is at an increased risk for infection due to poor dietary intake, a
decreased white blood cell count, and diminished neutrophil activity. Which information in the pat
health history supports the current data?
NURSINGKING.COM
1) Anorexia nervosa
2) Acute renal failure
3) Pulmonary disease
4) Cirrhosis of the liver
____ 15. The nurse is providing care to a patient who had the spleen removed after a car accident. Which type of
infection is this patient at an increased risk for experiencing?
1) Viral
2) Fungal
3) Parasitic
4) Bacterial
____ 16. Which laboratory test should the nurse anticipate for a patient who reports chronic inflammation?
1) Varicella titer
2) Type and crossmatch
3) Erythrocyte sedimentation rate (ESR)
4) Complete blood count (CBC), with differential
____ 17. The nurse is teaching a group of patients about first-line defense against infection. Which patient statement
indicates the need for further education?
1)
2)
3)
4)
first-
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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____ 18. The nurse is conducting a health history for a patient who is at risk for infection. Which question is
appropriate when collecting data related to the current problem?
1)
2)
-to3)
4)
____ 19. The nurse is conducting a health history for a patient who is at risk for infection. Which question is
1)
2)
3)
4)
-to-
____ 20. The nurse is conducting a health history for a patient who is at risk for infection. Which question is
l history?
1)
2)
-to3)
4)
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. A patient receives the yellow fever vaccine before traveling to the Amazon Basin and asks the nurse how the
URSING
INnurse
G.CisOM
vaccine provides protection. WhichNresponses
byKthe
the most appropriate? Select all that apply.
1)
2)
-specific T cells is activated. B cells secrete yellow fever
3)
antigens to
4)
5)
nd antigens
____ 22. The nurse is conducting a physical assessment for a patient with a compromised immune system. Which
actions by the nurse are appropriate? Select all that apply.
1) Assessing general appearance
2) Recommending increased fluid intake
3) Checking joint range of motion (ROM), including that of the spine
4) Inspecting the mucous membranes of the nose and mouth for color and condition
5) Palpating the cervical lymph nodes for evidence of lymphadenopathy or tenderness
____ 23. Which locations should the nurse include when discussing the storage and production of lymphocytes during
an education session for novice nurses? Select all that apply.
1) Liver
2) Spleen
3) Thymus
4) Lymph nodes
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5) Bone marrow
____ 24.
to alterations in biochemical barriers? Select all that apply.
1) Dysphagia
2) Dry mouth
3) Nonintact skin
4) Urinary retention
5) Clogged tear duct
____ 25.
to alterations in mechanical barriers? Select all that apply.
1) Dysphagia
2) Dry mouth
3) Nonintact skin
4) Urinary retention
5) Clogged tear duct
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Chapter 18: Assessment of Immune Function
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Identifying key anatomical components of the immune system
Chapter page reference: 321-330
Heading: Overview of Anatomy and Physiology
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Immunity
Difficulty: Easy
Feedback
1
A surgical incision can both allow microorganisms to enter the body.
2
The consumption of alcoholic beverages has been known to increase the risk for
infection.
3
Occasional smoking does not defend the body from microorganisms; it destroys the
cilia in the nose that helps to filter organisms.
4
A physiological barrier protecting patients against microorganism is adequate urinary
output. The act of voiding flushes organisms that might try to enter the body through
the urinary meatus.
NURSINGKING.COM
PTS: 1
CON: Immunity
2. ANS: 1
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Discussing changes in immune function associated with aging
Chapter page reference: 335-336
Heading: Age-Related Changes
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
1
The patient who has only a slight elevation in temperature in response to pneumonia is
an example of a decline in the expected immune response.
2
This patient is demonstrating an expected immune response as evidenced by redness,
swelling, and induration.
3
This patient is demonstrating an expected immune response as evidenced by redness,
swelling, and induration.
4
This patient is demonstrating an expected immune response as evidenced by redness,
swelling, and induration.
PTS: 1
3. ANS: 2
CON: Immunity
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Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Correlating relevant diagnostic examinations to immune function
Chapter page reference: 332-334
Heading: Diagnostic Studies
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying}
Concept: Immunity
Difficulty: Moderate
Feedback
1
An elevated eosinophil, not neutrophil, count indicates the body is battling a parasitic
infection.
2
A bacterial infection is often indicated by an elevated neutrophil count.
3
An elevated basophil, not neutrophil, count indicates the body is experiencing an
allergic reaction.
4
An elevated lymphocyte, not neutrophil, count indicates an adaptive immune response.
PTS: 1
CON: Immunity
4. ANS: 1
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Discussing the function of the immune system
Chapter page reference: 321-330
Heading: Overview of Anatomy and Physiology
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
NURSINGKING.COM
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty:
Feedback
1
When the patient has the disease, the body stimulates the process of acquired active
immunity.
2
Receiving injections for rabies, tetanus, and gamma globulin are examples of
artificially acquired passive immunity.
3
Receiving injections for rabies, tetanus, and gamma globulin are examples of
artificially acquired passive immunity.
4
Receiving injections for rabies, tetanus, and gamma globulin are examples of
artificially acquired passive immunity.
PTS: 1
CON: Immunity
5. ANS: 4
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Discussing the function of the immune system
Chapter page reference: 320-321
Heading: Introduction
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
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1
2
3
4
Feedback
It is outside the scope of nursing practice to prescribe medication and to recommend
therapies. The nurse can administer antibiotics and educate the patient on gene transfer
therapy, if prescribed by the health-care provider.
Administering corticosteroids, per order, is a collaborative intervention.
It is outside the scope of nursing practice to prescribe medication and to recommend
therapies. The nurse can administer antibiotics and educate the patient on gene transfer
therapy, if prescribed by the health-care provider.
While these may be appropriate treatments for a patient who is experiencing a
compromised immune system, the only independent nursing intervention is educating
the patient on the importance of a nutritious diet.
PTS: 1
CON: Immunity
6. ANS: 1
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of a
patient with impaired immune function
Chapter page reference: 330-334
Heading: Assessment of the Immune System
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
NURSINGKING.COM
Feedback
1
A patient with leukocytosis has a white blood cell (WBC) count that is elevated above
normal (>10,000 mm3), which is an indication of infection. The appropriate action by
the nurse is to assess the patient for a source of the infection.
2
Instructing the patient on the use of an electric razor and soft toothbrush and assessing
for bleeding and bruising would be appropriate actions for a patient with decreased
platelet levels, or thrombocytopenia.
3
Placing the patient in reverse isolation precautions would be appropriate for the patient
with neutropenia, a decrease in the number of neutrophils.
4
Instructing the patient on the use of an electric razor and soft toothbrush and assessing
for bleeding and bruising would be appropriate actions for a patient with decreased
platelet levels, or thrombocytopenia.
PTS: 1
CON: Immunity
7. ANS: 4
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of a
patient with impaired immune function
Chapter page reference: 330-334
Heading: Assessment of the Immune System
Integrated Processes: Nursing Process Assessment
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Immunity
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Difficulty: Moderate
Feedback
1
While sexual activity places the adolescent at risk for sexual transmitted infections, this
is not the most appropriate question for the nurse to ask to determine immune status.
2
3
4
While smoking can increase the risk for infection, this is not an appropriate question for
the nurse to ask an adolescent patient when a parent is in the room.
Inquiring about the c
interview to determine immune status.
PTS: 1
CON: Immunity
8. ANS: 2
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of a
patient with impaired immune function
Chapter page reference: 330-334
Heading: Assessment of the Immune System
Integrated Processes: Nursing Process Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
The tonsils are located between
the
palatine
NUR
SI
NGKIarches
NG.ConOeither
M side of the pharynx;
assessment process.
3
4
PTS: 1
CON: Immunity
9. ANS: 3
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Correlating relevant diagnostic examinations to immune function
Chapter page reference: 321-330
Heading: Overview of Anatomy and Physiology
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Knowledge [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
1
IgA is not produced during an allergic reaction.
2
IgD is not produced during an allergic reaction.
3
IgE is produced during an allergic reaction.
4
IgM is not produced during an allergic reaction.
PTS: 1
CON: Immunity
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10. ANS: 1
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Identifying key anatomical components of the immune system
Chapter page reference: 321-330
Heading: Overview of Anatomy and Physiology
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
1
Nutritional status is a critical component of immunocompetence. Cellular immunity,
phagocyte activity, and complement ability are greatly impacted by protein
deficiencies.
2
A calcium deficiency is more likely to impact bone health.
3
A potassium deficiency is more likely to impact cardiovascular health.
4
response.
PTS: 1
CON: Immunity
11. ANS: 1
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Correlating relevant diagnostic examinations to immune function
Chapter page reference: 332-334
Heading: Diagnostic Studies
NUR
SINGKING.COM
Integrated Processes: Nursing Process
- Planning
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
1
An elevated basophil count indicates an allergic reaction.
2
Monocytes are produced for phagocytosis in order to ingest engulfed microorganisms.
3
An elevated eosinophil count indicates a parasitic infection.
4
An elevated neutrophil count indicates bacterial infection.
PTS: 1
CON: Immunity
12. ANS: 1
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Discussing the function of the immune system
Chapter page reference: 321-330
Heading: Overview of Anatomy and Physiology
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
1
2
3
4
IgA is passed from mother to newborn in breast milk and provides immunity to the
newborn.
IgD is not secreted in breast milk.
IgE is not secreted in breast milk.
IgG is passed through the placenta during pregnancy and provides the newborn with
some immunity during the first few months of life.
PTS: 1
CON: Immunity
13. ANS: 4
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to immune
function
Chapter page reference: 330-334
Heading: Assessment of the Immune System
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
1
Anorexia nervosa causes malnutrition causing a decreased white blood cell (WBC)
count and diminished neutrophil activity leading to a risk for infection.
2
Acute renal failure leads to decreased neutrophil action and immunoglobulin activity
causing an increased risk for infection.
3
Pulmonary disease leads to decrease
NURSIneutrophil
NGKINGactivity
.COMcausing an increased risk for
infection.
4
Cirrhosis of the liver is an example of hepatic disease. This leads to a decreased
neutrophil count which increases the risk for infection.
PTS: 1
CON: Immunity
14. ANS: 1
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to immune
function
Chapter page reference: 330-334
Heading: Assessment of the Immune System
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
1
Anorexia nervosa causes malnutrition causing a decreased white blood cell (WBC)
count and diminished neutrophil activity leading to a risk for infection.
2
Acute renal failure leads to decreased neutrophil action and immunoglobulin activity
causing an increased risk for infection.
3
Pulmonary disease leads to decrease neutrophil activity causing an increased risk for
infection.
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4
Cirrhosis of the liver is an example of hepatic disease. This leads to a decreased
neutrophil count which increases the risk for infection.
PTS: 1
CON: Immunity
15. ANS: 4
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Identifying key anatomical components of the immune system
Chapter page reference: 321-330
Heading: Overview of Anatomy and Physiology
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
1
A splenectomy does not increase the risk for viral infection.
2
A splenectomy does not increase the risk for fungal infection.
3
A splenectomy does not increase the risk for parasitic infection.
4
The impact of a splenectomy is a loss of recognition and encapsulation of bacteria;
therefore, this patient is at an increased risk for bacterial infection.
PTS: 1
CON: Immunity
16. ANS: 3
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Correlating
to immune function
NURrelevant
SINGKdiagnostic
ING.Cexaminations
OM
Chapter page reference: 332-334
Heading: Diagnostic Studies
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
1
A varicella titer is anticipated for a patient who is uncertain of his or her chicken pox
status.
2
A type and crossmatch is anticipated for a patient who has lost blood and requires a
transfusion.
3
An ESR screens for the presence of the inflammatory process.
4
A CBC, with differential measures total leukocytes with a breakdown of leukocyte
types and percentage present.
PTS: 1
CON: Immunity
17. ANS: 4
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Identifying key anatomical components of the immune system
Chapter page reference: 321-330
Heading: Overview of Anatomy and Physiology
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Cognitive level: Analysis [Analyzing]
Concept: Immunity
Difficulty: Difficult
Feedback
1
This statement indicates correct understanding of first-line defenses against infection.
2
This statement indicates correct understanding of first-line defenses against infection.
3
This statement indicates correct understanding of first-line defenses against infection.
4
Pus or exudate indicates cellular infiltration which is a second line of defense against
infection. This second line of defense is an inflammatory response to acute cellular
injury.
PTS: 1
CON: Immunity
18. ANS: 3
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of a
patient with impaired immune function
Chapter page reference: 330-334
Heading: Assessment of the Immune System
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
3
4
NURSINGKING.COM
PTS: 1
CON: Immunity
19. ANS: 1
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of a
patient with impaired immune function
Chapter page reference: 330-334
Heading: Assessment of the Immune System
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
3
4
This question is appropriate
PTS: 1
CON: Immunity
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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20. ANS: 4
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of a
patient with impaired immune function
Chapter page reference: 330-334
Heading: Assessment of the Immune System
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
3
4
PTS: 1
CON: Immunity
MULTIPLE RESPONSE
21. ANS: 2, 3, 4, 5
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to immune
function
NURSINGKING.COM
Chapter page reference: 321-330
Heading: Overview of Anatomy and Physiology
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is incorrect. The immune system damaging the myelin is the autoimmune response that
occurs with multiple sclerosis (MS).
This is correct. Antibodies directly attack and destroy antigens either before or after antigens
invade body cells.
This is correct. Lymph nodes filter foreign products or antigens from the lymph system and
house and support proliferation of lymphocytes and macrophages.
This is correct. Memory B cells and T cells remember how to identify the antigen and will
reactivate at a future time if the same type of antigen is present.
This is correct. Macrophages ingest antigens and signal helper T cells that antigens are
present.
PTS: 1
CON: Immunity
22. ANS: 1, 3, 4, 5
Chapter number and title: 18, Assessment of Immune Function
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Chapter learning objective: Describing the procedure for completing a history and physical assessment of a
patient with impaired immune function
Chapter page reference: 330-334
Heading: Assessment of the Immune System
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
3.
Feedback
This is correct. The techniques of inspection and palpation are especially important in
assessing
inspect the mucous membranes of the nose and mouth for color and condition, palpate the
ing that
of the spine.
This is incorrect. While recommending that the patient increase fluid intake may be an
appropriate intervention, this is not an action that is conducted during the physical assessment
for this patient.
This is correct. The techniques of inspection and palpation are especially important in
4.
inspect the mucous membranes of the nose and mouth for color and condition, palpate the
cervical
of the spine.
This is correct. The techniques of inspection and palpation are especially important in
1.
2.
NURSINGKING.COM
inspect the mucous membranes of the nose and mouth for color and condition, palpate the
5.
of the spine.
This is correct. The techniques of inspection and palpation are especially important in
inspect the mucous membranes of the nose and mouth for color and condition, palpate the
cervical lymph
of the spine.
PTS: 1
CON: Immunity
23. ANS: 2, 3, 4, 5
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Identifying key anatomical components of the immune system
Chapter page reference: 321-330
Heading: Overview of Anatomy and Physiology
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
1.
Feedback
This is incorrect. The liver does not store or produce lymphocytes.
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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2.
3.
4.
5.
This is correct. Lymphocytes are found in the spleen.
This is correct. Lymphocytes are found in the thymus.
This is correct. Lymphocytes are found in the lymph nodes.
This is incorrect. Lymphocytes are found in the bone marrow.
PTS: 1
CON: Immunity
24. ANS: 2, 5
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Identifying key anatomical components of the immune system
Chapter page reference: 321-330
Heading: Overview of Anatomy and Physiology
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is incorrect. Swallowing is a mechanical, not biochemical, barrier to infection.
risk for infection.
This is incorrect. Intact skin is a physical, not biochemical, barrier to infection.
This is incorrect. Urination is a mechanical, not biochemical, barrier to infection.
This is correct. Tears are a biochemical barrier to infection. A clogged tear duct increases this
NURSINGKING.COM
PTS: 1
CON: Immunity
25. ANS: 1, 4
Chapter number and title: 18, Assessment of Immune Function
Chapter learning objective: Identifying key anatomical components of the immune system
Chapter page reference: 321-330
Heading: Overview of Anatomy and Physiology
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is incorrect. Swallowing is a mechanical barrier to infection. Dysphagia, or impaired
This is correct. Saliva is a biochemical, not mechanical, barrier to infection. A dry mouth
increases t
This is incorrect. Intact skin is a physical, not mechanical, barrier to infection. Nonintact skin
This is incorrect. Urination is a mechanical barrier to infection. Urinary retention increases the
risk for bacterial growth and infection.
This is correct. Tears are a biochemical, not mechanical, barrier to infection. A clogged tear
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PTS: 1
CON: Immunity
Chapter 19: Coordinating Care for Patients With Connective Tissue Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. A patient recently diagnosed with rheumatoid arthritis (RA) asks the nurse if the disease is caused by
ethnicity. Which response by the nurse is the most appropriate?
1)
2)
3)
4)
____
2. The nurse is collecting a health history for a patient in an outpatient clinic who reports joint pain and swelling
for the last two months. The patient is diagnosed with rheumatoid arthritis (RA). When planning care for this
patient, which statement supports the nursing diagnosis of Activity Intolerance?
1)
2)
3)
4)
____
3. The nurse is completing a health screening for a school-age child with rheumatoid arthritis (RA). The parents
NUthat
RSI
NGpromote
KING.exercise
COM for their child. Which recommendation by
ask the nurse to recommend activities
will
the nurse is the most appropriate?
1) Running
2) Softball
3) Football
4) Swimming
____
4. A patient with rheumatoid arthritis (RA) is being seen in the outpatient clinic for a progress check-up. The
the patient makes which statement?
1)
2)
3)
4)
____
5. The nurse is caring for a patient who was diagnosed with rheumatoid arthritis (RA) last year. The patient has
recently been placed on prednisone for treatment. Which patient statement indicates that the medication
teaching was successful?
1)
2)
3)
4)
____
6. A nurse is caring for a pregnant patient who has rheumatoid arthritis (RA). Based on this data, which does the
nurse anticipate when providing care to this patient?
1) A higher risk for preterm delivery
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2) An increased need for medication
3) An acute exacerbation of symptoms
4) A continued risk for anemia
____
7. A nurse is caring for a patient who is newly diagnosed with rheumatoid arthritis (RA). The patient asks the
nurse what the difference is between RA and osteoarthritis (OA). Which response by the nurse is most
appropriate?
1)
2)
3)
4)
____
8.
no appetite, and
bridge of nose and on the cheeks. Based on this data, which diagnosis does the nurse anticipate?
1) Gout
2) Lyme disease
3) Fibromyalgia
4) Systemic lupus erythematosus
____
9. A patient asks the nurse if there are any conditions that can exacerbate systemic lupus erythematosus (SLE).
Which response by the nurse is the most appropriate?
1)
2)
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3)
4)
____ 10. The nurse is providing health education to a diverse group at a neighborhood community center. Why does
the nurse plan to include signs and symptoms of systemic lupus erythematosus (SLE)?
1) The neighborhood is composed of many young female children.
2) The audience has asked the nurse to include the information.
3) The audience is mainly composed of Caucasian women.
4) The audience is mainly females of Asian-American descent.
____ 11. The nurse is caring for a patient who is hospitalized due to an exacerbation of systemic lupus erythematosus
(SLE). The nurse is revie
the left. Based on this information, which is a priority nursing diagnosis for this patient?
1) Risk for Infection
2) Ineffective Individual Coping
3) Risk for Impaired Skin Integrity
4) Ineffective Health Maintenance
____ 12. A patient with systemic lupus erythematosus (SLE) is being treated with immunosuppressant drugs and
corticosteroids. Which patient statement indicates the need for further education after teaching?
1)
2)
3)
4)
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____ 13. A nurse is caring for a patient with
this patient to minimize skin infections associated with SLE?
1) Use sunscreen with an SPF of 15 or greater
2) Remain indoors on sunny days
3) Avoid swimming in a pool or the ocean
4) Decrease sun exposure between 3:00 p.m. and 5:00 p.m.
____ 14. The nurse is caring for a patient diagnosed with discoid lupus erythematosus. The nurse is collaborating with
the patient to set goals for the nursing plan of care. Which is an appropriate goal for this patient?
1) Work through the stages of death and dying
2) Compliance with a sun protection plan
3) Gain weight to within 10 pounds of normal for height
4) Report pain no higher than 4 on a scale of 1-10
____ 15. The nurse is planning care for an adolescent patient who has systemic lupus erythematosus (SLE). Which
action by the patient indicates the implemented plan of care is appropriate?
1) Refusing to attend school
2) Discussing skin changes with a good friend
3) Refraining from attending any social functions
4) Discussing skin changes with the health-care provider
____ 16. The nurse is providing care for a newly married woman with systemic lupus erythematosus (SLE). Which
patient statement indicates an appropriate understanding of the plan of care?
1)
2)
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3)
4)
____ 17. A nurse is caring for a patient with systemic lupus erythematous (SLE) who is taking hydroxychloroquine
(Plaquenil). When providing care for this patient, the nurse monitors for which adverse effect associated with
the prescribed medication?
1) Renal toxicity
2) Retinal toxicity
3) Cushingoid effects
4) Pulmonary fibrosis
____ 18.
most appropriate for the nurse to include in a plan of care for this family?
1) Medications used to treat fibromyalgia
2) An exercise program to increase energy
3) Information and literature on fibromyalgia
4) Suggested dietary changes to help with the pain
____ 19. The nurse identifies the nursing diagnosis of chronic pain as being appropriate for a patient with fibromyalgia.
Which manifestation did the patient most likely report that caused the nurse to select this diagnosis?
1) Acute chest pain
2) Pain from eyestrain
3) Tender points in the knees
4) Pain from a severe skin rash
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____ 20. An adult patient is diagnosed with fibromyalgia. The patient asks the nurse whether a recent of infection with
the Coxsackie B virus could have caused fibromyalgia. Which response by the nurse is the most appropriate?
1)
2)
3)
4)
____ 21. The nurse is counseling an adult patient with fibromyalgia. What are some elements of counseling that can
help this patient develop effective coping skills?
1) Remind the patient that the patient has a progressive disease.
2) Suggest to the patient that some symptoms may be psychosomatic.
3) Inform the patient that the patient does not need to see a specialist.
4) Teach the patient strategies including distractions, relaxation techniques, or journaling.
____ 22. The mother of three teenagers is diagnosed with fibromyalgia and asks the nurse how to keep up with all of
the children's activities. Which suggestion by the nurse is the most appropriate?
1) Ask the children to limit their activities.
2) Attempt to attend the all the functions of the children.
3) Avoid attending any afterschool functions for the children.
4) Negotiate with the children to alternate attending their functions.
____ 23. The nurse is discussing goals to relieve pain and fatigue with a patient newly diagnosed with fibromyalgia.
Which goal statement would be realistic for this patient to achieve within 30 days?
1) Join an exercise group
2) Get a job outside the home
3) Walk her son to school daily
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4) Cook dinner five nights a week
____ 24. During a home visit, the family of a patient with fibromyalgia asks the nurse what they can do to help the
patient with painful episodes. What should the nurse suggest to the patient and family?
1) Plan a family reunion
2) Keep the patient in bed
3) Protect the patient from injury
4) Divide household chores among each member of the family
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 25. The nurse is caring for a patient who has recently been diagnosed with fibromyalgia. Which medications does
Select all that apply.
1) Ibuprofen
2) Aerobic exercise
3) Pregabalin (Lyrica)
4) Zolpidem (Ambien)
5) Tenormin (Atenolol)
____ 26. The nurse is providing care to a patient who is receiving nonsteroidal anti-inflammatory drugs (NSAIDs) in
the treatment of rheumatoid arthritis. When providing care to this patient, which actions by the nurse are
appropriate? Select all that apply.
1) Assessing for an allergic reaction
2) Monitoring for signs of renal problems
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3) Advising against abrupt discontinuation of drugs
4) Assuring the patient that there is no relationship between NSAIDs and heart disease
5) Encouraging the patient to take with water, milk, or small snack to help avoid stomach
distress
____ 27. A patient, recently diagnosed with rheumatoid arthritis (RA), asks the nurse whether RA will affect her in
other ways. When responding to the patient, which systems will the nurse include as possibly being affected
by the diagnosis? Select all that apply.
1) Exocrine
2) Respiratory
3) Hematologic
4) Reproductive
5) Cardiovascular
____ 28. A patient recently diagnosed with rheumatoid arthritis (RA) asks the nurse if RA always causes crippling
deformities. Which teaching topics will the nurse include as ways to decrease the likelihood of crippling
deformities? Select all that apply.
1) Ignore pain as a warning signal
2) Use stronger joints for most activity
3) Avoid stress to any current area of deformity
4) Type instead of handwriting items if possible
5) Stop an activity if it is beyond your ability to perform
____ 29. Which information should the nurse include when teaching a patient information regarding limited systemic
scleroderma? Select all that apply.
1) A rapid onset is anticipated.
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2) An insidious onset is anticipated.
3) Affects internal organs several years prior to onset
4)
5) Skin of extremities distal to the elbows and knees are affected
____ 30. Which subjective findings should the nurse anticipate when assessing a patient diagnosed with gout? Select
all that apply.
1) Presence of tophi
2) Tenderness on palpation
3) Reports of severe pain in the great toe
4)
5) Soft tissue swelling accompanied by warmth
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Chapter 19: Coordinating Care for Patients With Connective Tissue Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Describing the epidemiology of connective tissue disorders
Chapter page reference: 344-351
Heading: Rheumatoid Arthritis
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
RA affects 12% of the total population across all races.
2
RA is not more prevalent in Caucasian females.
3
RA does not affect those of German descent most often.
4
It affects women three times more than men, and the onset is usually between the ages
of 20 and 40 years.
PTS: 1
CON: Immunity
2. ANS: 1
NURSICare
NGKfor
INPatients
G.COWith
M Connective Tissue Disorders
Chapter number and title: 19, Coordinating
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with connective
tissue disorders
Chapter page reference: 344-351
Heading: Rheumatoid Arthritis
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
1
2
3
4
need for a nap supports the inclusion of Activity Intolerance in the plan of care. The
nurse would teach the patient about frequent rest periods during the day to conserve
energy.
Joints of the RA patient are stiffest in the morning.
The patient with RA will be stiff early in the morning, but that would not interfere with
activities later in the day.
Taking ibuprofen for pain does not affect the ability for activity.
PTS: 1
CON: Immunity
3. ANS: 4
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
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Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with connective tissue disorders
Chapter page reference: 344-351
Heading: Rheumatoid Arthritis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
Running, softball or football could exacerbate joint discomfort.
2
Running, softball or football could exacerbate joint discomfort.
3
Running, softball or football could exacerbate joint discomfort.
4
Swimming exercises all the extremities without putting undue stress on joints.
PTS: 1
CON: Immunity
4. ANS: 3
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with connective
tissue disorders
Chapter page reference: 344-351
Heading: Rheumatoid Arthritis
Integrated Processes: Nursing Process Evaluation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
NURSINGKING.COM
Concept: Immunity
Difficulty: Difficult
Feedback
1
Sleeping for 10 hours at night will not alleviate the need for frequent rest periods during
the day.
2
Increased joint pain would indicate that goals have not been met.
3
One technique for reducing stress on the joints is to delegate household tasks to family
members.
4
The patient does not need to refrain from all household chores.
PTS: 1
CON: Immunity
5. ANS: 4
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Discussing the medical management of: Rheumatoid arthritis
Chapter page reference: 344-351
Heading: Rheumatoid Arthritis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Analysis [Analyzing]
Concept: Immunity
Difficulty: Difficult
Feedback
1
Steroids can cause fluid retention, so sodium intake should be limited. A hidden source
of sodium is canned vegetables.
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2
3
4
Steroids are taken with food to minimize GI distress, not to enhance absorption.
Steroids also increase blood sugar, so blood sugar may need to be monitored more
frequently while on the medication regimen.
Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important
to take the medication at the same time each day.
PTS: 1
CON: Immunity
6. ANS: 4
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with connective
tissue disorders
Chapter page reference: 344-351
Heading: Rheumatoid Arthritis
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity; Pregnancy
Difficulty: Easy
Feedback
1
Many pregnant patients with RA may have prolonged gestations and often experience a
remission during pregnancy and relapse after delivery.
2
Due to remission, a decrease in medication is often necessitated.
3
Many pregnant patients with RA may have prolonged gestations and often experience a
remission during pregnancy and relapse after delivery.
4
The pregnant patient with RA
risk
NUisRatSaIcontinued
NGKING
.Cfor
OManemia.
PTS: 1
CON: Immunity | Pregnancy
7. ANS: 1
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Osteoarthritis
Chapter page reference: 339-344
Heading: Osteoarthritis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
The onset of OA is gradual while the onset of RA may be rapid.
2
RA affects multiple joints symmetrically while OA affects one joint at a time.
3
The affected joints in OA feel cold to the touch while the joints affected by RA are
warm or hot to the touch.
4
Pain associated with RA is predominant upon arising versus the pain in OA, which is
with activity.
PTS: 1
CON: Immunity
8. ANS: 4
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
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Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Lupus
erythematosus
Chapter page reference: 354-359
Heading: Lupus
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
1
While fibromyalgia, Lyme's disease, and gout share some symptoms of SLE, they do
not cause a rash over the nose and cheeks.
2
While fibromyalgia, Lyme's disease, and gout share some symptoms of SLE, they do
not cause a rash over the nose and cheeks.
3
While fibromyalgia, Lyme's disease, and gout share some symptoms of SLE, they do
not cause a rash over the nose and cheeks.
4
The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for
the diagnosis of systemic lupus erythematosus (SLE).
PTS: 1
CON: Immunity
9. ANS: 3
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Lupus
erythematosus
Chapter page reference: 354-359
NURSINGKING.COM
Heading: Lupus
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE.
2
Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE.
3
Pregnancy can be associated with an exacerbation of SLE due to the rise of estrogen
levels.
4
Hypotension, fever, and GI upset are not factors that risk exacerbation of SLE.
PTS: 1
CON: Immunity
10. ANS: 4
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Lupus
erythematosus
Chapter page reference: 354-359
Heading: Lupus
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity; Diversity
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Difficulty: Easy
Feedback
1
SLE affects individuals of child-bearing age.
2
There is no evidence that the audience asked for the information.
3
Among women who are of child-bearing age, SLE is seen in more African-Americans,
Hispanics, and Asian-Americans than Caucasians.
4
Among women who are of child-bearing age, SLE is seen in more African-Americans,
Hispanics, and Asian-Americans than Caucasians.
PTS: 1
CON: Immunity | Diversity
11. ANS: 1
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of connective
tissue disorders
Chapter page reference: 354-359
Heading: Lupus
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Analysis [Analyzing]
Concept: Immunity
Difficulty: Difficult
Feedback
1
All identified diagnoses are appropriate for a patient with SLE. However, the shift to
the left in the WBC count indicates an increased risk for infection. A shift to the left in
a WBC differential is indicative of a large number of immature cells, suggesting
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infection. Therefore, the priority diagnosis is Risk for Infection.
2
While this is an appropriate nursing diagnosis for this patient, this is not the priority
based on the current WBC count.
3
While this is an appropriate nursing diagnosis for this patient, this is not the priority
based on the current WBC count.
4
While this is an appropriate nursing diagnosis for this patient, this is not the priority
based on the current WBC count.
PTS: 1
CON: Immunity
12. ANS: 1
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Discussing the medical management of: Lupus erythematosus
Chapter page reference: 354-359
Heading: Lupus
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Immunity
Difficulty: Difficult
Feedback
1
Crowds may increase exposure to infection.
2
Annual influenza vaccination is recommended but patients with significant
immunosuppression should not receive live vaccines.
3
Immunosuppressive drugs may increase the risk of birth defects.
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4
Chills, fever, sore throat, fatigue, or malaise should be reported.
PTS: 1
CON: Immunity
13. ANS: 1
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with connective tissue disorders
Chapter page reference: 354-359
Heading: Lupus
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
The nurse teaches the patient to live a normal life with a few extra precautions. There is
a relationship between sun exposure and infection, so the patient is taught to use
sunscreen with an SPF of at least 15.
2
The patient does not need to stay indoors on sunny days or to decrease sun exposure
between 3:00 p.m. and 5:00 p.m.
3
The patient may swim but should reapply sunscreen after swimming.
4
The patient does not need to stay indoors on sunny days or to decrease sun exposure
between 3:00 p.m. and 5:00 p.m.
PTS: 1
CON: Immunity
NURSINGKING.COM
14. ANS: 2
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with connective
tissue disorders
Chapter page reference: 354-359
Heading: Lupus
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
It is not fatal, is not related to weight, and is rarely painful unless complications arise.
2
Discoid lupus erythematosus is an autoimmune disorder of the skin, so the patient must
protect against the sun to avoid skin cancers and other complications.
3
It is not fatal, is not related to weight, and is rarely painful unless complications arise.
4
It is not fatal, is not related to weight, and is rarely painful unless complications arise.
PTS: 1
CON: Immunity
15. ANS: 2
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with connective
tissue disorders
Chapter page reference: 354-359
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Heading: Lupus
Integrated Processes: Nursing Process Evaluation
Client Need: Psychosocial Integrity
Cognitive level: Analysis [Analyzing]
Concept: Immunity
Difficulty: Difficult
Feedback
1
Refusing to go to school or attend social functions indicates nonacceptance of the
changes to body image.
2
Peer interaction is important to teens. Being able to discuss the physical changes related
to SLE with a friend indicates acceptance of the change in body image.
3
Refusing to go to school or attend social functions indicates nonacceptance of the
changes to body image.
4
Discussing changes only with health-care personnel does not indicate the teen has
adjusted to the body image changes.
PTS: 1
CON: Immunity
16. ANS: 1
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Discussing the medical management of: Lupus erythematosus
Chapter page reference: 354-359
Heading: Lupus
Integrated Processes: Nursing Process Evaluation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
NURSINGKING.COM
Concept: Immunity
Difficulty: Difficult
Feedback
1
Treatment for SLE can include cytotoxic drugs. The patient is taught to avoid
pregnancy by using contraceptives, as these drugs can cause birth defects.
2
Patients with SLE should contact their primary care providers should manifestations of
infection occur, as the immune system is compromised.
3
The patient is taught to avoid crowds, as they are potential sources of infection.
4
Aspirin can cause bleeding and should be taken with extreme care.
PTS: 1
CON: Immunity
17. ANS: 2
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Discussing the medical management of: Lupus erythematosus
Chapter page reference: 354-359
Heading: Lupus
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
Renal toxicity is not the primary concern with Plaquenil.
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2
3
4
Hydroxychloroquine (Plaquenil) is an antimalarial drug used in SLE to reduce the
frequency of acute episodes of SLE. The primary concern with Plaquenil is retinal
toxicity and possible irreversible blindness.
Cushingoid effects are a concern with corticosteroid therapy.
Pulmonary fibrosis is a potential adverse effect of cyclophosphamide, not Plaquenil.
PTS: 1
CON: Immunity
18. ANS: 3
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with connective tissue disorders
Chapter page reference: 362-364
Heading: Fibromyalgia
Integrated Processes: Nursing Process Planning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Immunity; Diversity
Difficulty: Moderate
1
2
3
4
Feedback
The physician orders medication and diets.
There is no proof that exercise, or lack thereof, causes fibromyalgia.
In many cultures, accepting a disease like fibromyalgia may be difficult due to the
vagueness of the disease. Information and written literature may help the family
understand that the disease is real.
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The physician orders medication and diets.
PTS: 1
CON: Immunity | Diversity
19. ANS: 3
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with connective
tissue disorders
Chapter page reference: 362-364
Heading: Fibromyalgia
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
1
Acute chest pain, pain from a rash, and muscle strain of the eye are not reported
symptoms.
2
Acute chest pain, pain from a rash, and muscle strain of the eye are not reported
symptoms.
3
Patients with fibromyalgia typically complain of multiple tender points generally
including the neck, spine, and knees.
4
Acute chest pain, pain from a rash, and muscle strain of the eye are not reported
symptoms.
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PTS: 1
CON: Immunity
20. ANS: 2
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Describing the epidemiology of connective tissue disorders
Chapter page reference: 362-364
Heading: Fibromyalgia
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
1
The exact cause of fibromyalgia is unknown. Infections such as hepatitis C virus
(HCV), HIV, Coxsackie B, and parvovirus may trigger fibromyalgia.
2
The exact cause of fibromyalgia is unknown. Infections such as hepatitis C virus
(HCV), HIV, Coxsackie B, and parvovirus may trigger fibromyalgia.
3
The exact cause of fibromyalgia is unknown. Infections such as hepatitis C virus
(HCV), HIV, Coxsackie B, and parvovirus may trigger fibromyalgia.
4
Having a psychiatric disorder such as attention deficit/hyperactivity disorder (ADHD)
or depression may be a risk factor for fibromyalgia, but the condition is not a
psychiatric disorder.
PTS: 1
CON: Immunity
21. ANS: 4
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
NURSINGKING.COM
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with connective tissue disorders
Chapter page reference: 362-364
Heading: Fibromyalgia
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
Fibromyalgia is not a progressive disease.
2
It is important to validate the
3
Getting appropriate help is important in managing fibromyalgia. Patients should be
encouraged to see a fibromyalgia specialist.
4
It helps to identify stressors that make pain and fatigue worse, and then develop
strategies to avoid those stressors or to minimize symptoms when those stressors occur.
PTS: 1
CON: Immunity
22. ANS: 4
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with connective tissue disorders
Chapter page reference: 362-364
Heading: Fibromyalgia
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Integrated Processes: Nursing Process Implementation
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
It is not reasonable for a patient with fibromyalgia to try to run the home and attend all
of the functions of each child.
3
symptoms.
4
ions, the nurse suggests
meeting the needs of each child.
PTS: 1
CON: Immunity
23. ANS: 4
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with connective
tissue disorders
Chapter page reference: 362-364
Heading: Fibromyalgia
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
NURSINGKING.COM
Concept: Immunity
Difficulty: Moderate
1
2
3
Feedback
Walking her son to school daily is a bit ambitious to start, as are joining an exercise
group and getting a job outside the home.
Walking her son to school daily is a bit ambitious to start, as are joining an exercise
group and getting a job outside the home.
Walking her son to school daily is a bit ambitious to start, as are joining an exercise
group and getting a job outside the home.
4
able to perform daily tasks for the family such as cooking and doing the laundry.
PTS: 1
CON: Immunity
24. ANS: 4
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with connective tissue disorders
Chapter page reference: 362-364
Heading: Fibromyalgia
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
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Difficulty: Moderate
Feedback
1
A family vacation might cause more stress to the patient, who would more than likely
be planning and packing.
2
Keeping the patient in bed would not be therapeutic.
3
There is no reason to believe that this patient is at higher risk for injury than another
member of the family.
4
Although the causes and treatments are not all known, there is general agreement that
reducing stress may help lessen the effects of fibromyalgia. The nurse could help the
family by suggesting ways to decrease stress on the patient by having the family pitch
in on responsibilities.
PTS: 1
CON: Immunity
MULTIPLE RESPONSE
25. ANS: 1, 2, 3
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Discussing the medical management of: Fibromyalgia
Chapter page reference: 362-364
Heading: Fibromyalgia
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
NURSINGKING.COM
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. Treatment for fibromyalgia may include NSAIDs such as ibuprofen for pain,
pregabalin (Lyrica), and aerobic exercise.
This is correct. Treatment for fibromyalgia may include NSAIDs such as ibuprofen for pain,
pregabalin (Lyrica), and aerobic exercise.
This is correct. Treatment for fibromyalgia may include NSAIDs such as ibuprofen for pain,
pregabalin (Lyrica), and aerobic exercise.
This is incorrect. Zolpidem (Ambien) is for producing sleep.
This is incorrect. Tenormin (Atenolol) is an antihypertensive drug.
PTS: 1
CON: Immunity
26. ANS: 1, 2, 3, 5
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Discussing the medical management of: Rheumatoid Arthritis
Chapter page reference: 344-351
Heading: Rheumatoid Arthritis
Integrated Processes: Nursing Process -Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
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1.
2.
3.
4.
5.
Feedback
This is correct. When providing care to a patient who is receiving any medication, it is
important to monitor the patient for signs of an allergic reaction.
This is correct. If you take NSAIDs in high doses, the reduced blood flow can permanently
damage the kidneys, and it can eventually lead to kidney failure and require dialysis.
This is correct. Abrupt discontinuation can have serious side effects.
This is incorrect. NSAIDs have been linked to heart failure; therefore, this action by the nurse
is not appropriate when providing care to this patient.
This is correct. Taking NSAIDs with food may help reduce irritation of the stomach and
prevent an ulcer.
PTS: 1
CON: Immunity
27. ANS: 1, 2, 3, 5
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Rheumatoid arthritis
Chapter page reference: 344-351
Heading: Rheumatoid Arthritis
Integrated Processes: Nursing Process - Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
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1.
2.
3.
4.
5.
Feedback
This is correct. RA can affect the respiratory system with pleural effusion (collection of fluid
in the pleural space); the cardiovascular system with coronary heart disease; the exocrine
glands, resulting in dry eyes and mouth; and the hematologic system with a variety of
disorders, particularly anemia.
This is correct. RA can affect the respiratory system with pleural effusion (collection of fluid
in the pleural space); the cardiovascular system with coronary heart disease; the exocrine
glands, resulting in dry eyes and mouth; and the hematologic system with a variety of
disorders, particularly anemia.
This is correct. RA can affect the respiratory system with pleural effusion (collection of fluid
in the pleural space); the cardiovascular system with coronary heart disease; the exocrine
glands, resulting in dry eyes and mouth; and the hematologic system with a variety of
disorders, particularly anemia.
This is incorrect. If properly managed, RA is not considered to be a danger for pregnant
women or their babies.
This is correct. RA can affect the respiratory system with pleural effusion (collection of fluid
in the pleural space); the cardiovascular system with coronary heart disease; the exocrine
glands, resulting in dry eyes and mouth; and the hematologic system with a variety of
disorders, particularly anemia.
PTS: 1
CON: Immunity
28. ANS: 2, 3, 4, 5
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
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Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with connective tissue disorders
Chapter page reference: 344-351
Heading: Rheumatoid Arthritis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is incorrect. Pain is a warning signal, and the patient with RA should stop any activity
that causes pain.
This is correct. Using a stronger joint or part of the body, such as the palm, to carry items is
preferable to grasping.
This is correct. When performing a task, the patient should avoid stress in the area of the
deformity to help prevent further deformities.
This is correct. Writing requires using a strong grip, so typing is preferable.
This is correct. The patient with RA should never attempt to push a joint beyond its ability.
PTS: 1
CON: Immunity
29. ANS: 2, 4, 5
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Scleroderma
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Chapter page reference: 351-354
Heading: Scleroderma
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
1.
2.
3.
Feedback
This is incorrect. Diffuse, not limited, systemic scleroderma has rapid onset.
This is correct. Limited systemic scleroderma often has an insidious onset.
This is incorrect. Internal organ involvement is more likely with diffuse, not limited, systemic
scleroderma.
4.
5.
phenomenon.
This is correct. These are clinical manifestations associated with limited systemic scleroderma.
PTS: 1
CON: Immunity
30. ANS: 3, 4
Chapter number and title: 19, Coordinating Care for Patients With Connective Tissue Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Gout
Chapter page reference: 359-361
Heading: Gout
Integrated Processes: Nursing Process Assessment
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Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Easy
Feedback
This is incorrect. This is an objective, not subjective, assessment finding for a patient
diagnosed with gout.
This is incorrect. This is an objective, not subjective, assessment finding for a patient
diagnosed with gout.
This is correct. This is a subjective assessment finding for a patient diagnosed with gout.
This is correct. This is a subjective assessment finding for a patient diagnosed with gout.
This is incorrect. This is an objective, not subjective, assessment finding for a patient
diagnosed with gout.
1.
2.
3.
4.
5.
PTS: 1
CON: Immunity
Chapter 20: Coordinating Care for Patients With Immune Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
NURSINGKING.COM
____
1. A nurse is caring for a pediatric patient who is receiving an infusion of intravenous antibiotic at the
ambulatory clinic. Which clinical manifestation indicates that the patient is experiencing a type I
hypersensitivity reaction?
1) Erythema
2) Fever
3) Joint pain
4) Hypotension
____
2.
health history increases the risk for experiencing a hypersensitivity reaction?
1) 26 years of age
2) Caucasian race
3) Previous antibiotic therapy
4) Concurrent chronic illness
____
3. The nurse is admitting a pediatric patient to the hospital with a ventroperitoneal (VP) shunt malfunction. The
history from the parents and learns that the patient received the shunt at birth after a menigocele repair. Based
on this data, which product should be avoided when providing care to this patient?
1) Synthetic rubber gloves
2) Polyethylene gloves
3) Nonpowdered nitrile gloves
4) Latex gloves
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____
4. The nurse is caring for a patient in an allergy clinic. After completing the patient history, the nurse selects the
diagnosis?
1) A history of an anaphylactic reaction to shellfish.
2) A drug reaction to penicillin causing a rash.
3) A history of glomerulonephritis.
4) A history of dermatitis resulting from a response to changing laundry detergent.
____
5.
begins showing
symptoms of a latex sensitivity. Which action by the nurse is the most appropriate?
1) Ask the family member to leave the unit
2) Transfer the patient to a department that does not use latex products
3) Wait until Monday to report the problem to the supervisor of the unit
4) Obtain latex-
____
6. The nurse is caring for a patient who is experiencing anaphylactic shock following the administration of a
medication. Which position is the most appropriate for the nurse to place the patient based on this data?
1) Trendelenburg position
2) Flat, with legs slightly elevated
3) Supine position
4) High Fowler position
____
7. The nurse is caring for a patient with a history of latex allergies. The patient develops audible wheezing,
pruritus, urticaria, and signs of angioedema. Which is the priority intervention for this patient?
1) Teach the patient regarding using a kit that contains treatment for allergic reactions.
2) Administer diphenhydramine (Benadryl) by mouth every four hours per the health-care
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provider's orders.
3) Administer epinephrine 1:1,000 by subcutaneous injection per the health-care provider's
orders.
4) Collect a detailed history from the patient regarding the history of latex allergies.
____
8. A nurse has been providing a young adult patient with a history of hypersensitivity reactions. The nurse is
preparing instructions on the correct methods for using an EpiPen. Which patient statement indicates
understanding of the proper technique?
1)
2)
3)
4)
____
9. A pediatric patient with a history of anaphylactic hypersensitivity reactions will be discharged with a
prescription for an EpiPen. Which statement is appropriate for the nurse to include in the discharge
instructions for this patient and family?
1)
2)
3)
4)
____ 10. A nurse is caring for a patient with seasonal hypersensitivity reactions. What teaching would the nurse
1) Keep doors and windows open on high-allergen days to circulate air.
2) Maintain a clean, dust-free environment.
3) Take antihistamine and leukotriene medication as ordered
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4) Stop taking oral corticosteroids immediately once symptoms disappear.
____ 11. The nurse suspects that the patient is experiencing a reaction to a specific antigen. Which laboratory result
supports the conclusion made by the nurse?
1)
2) Patch test with a 1-inch area of erythema
3) 2% eosinophils in the WBC count
4) Rh antigen with negative results
____ 12. The nurse is providing care to a patient with psoriasis. Which medication should the nurse prepare to teach
this patient about based on the diagnosis?
1) Epinephrine
2) Azathioprine
3) Cyclosporine
4) Mycophenolate mofetil
____ 13. The nurse is providing care to a patient with autoimmune hepatitis. Which medication should the nurse
prepare to teach this patient about based on the diagnosis?
1) Epinephrine
2) Azathioprine
3) Cyclosporine
4) Mycophenolate mofetil
____ 14. The nurse is providing care to a patient with lupus. Which medication should the nurse prepare to teach this
patient about based on the diagnosis?
1) Epinephrine
2) Azathioprine
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3) Cyclosporine
4) Mycophenolate mofetil
____ 15. Which is the priority nursing action to decrease the risk of a transfusion reaction?
1) Assessing the
2) Documenting the procedure in the medical record
3)
4) Checking the bag to ensure it is the correct blood type
____ 16. The nurse is providing care for a patient diagnosed with agammaglobulinemia. Which is the anticipated
treatment for this patient?
1) Oral diphenhydramine
2) Topical corticosteroids
3) Subcutaneous epinephrine
4) Intravenous immunoglobulin (IVIG)
____ 17. The nurse is providing care to a patient diagnosed with X-linked agammaglobulinemia (XLA). Which should
1)
2)
3)
4)
Immunization with inactivated polio vaccine (IPV)
Administration of intravenous immunoglobulin every six months
Education regarding the use of high dose prophylactic antibiotics
Periodic magnetic resonance imagery (MRI) to monitor for respiratory complications
____ 18. Which respiratory data should the nurse anticipate when assessing a patient diagnosed with X-linked
agammaglobulinemia (XLA)?
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1)
2)
3)
4)
Wheezes
Rhonchi
Tachypnea
Eupnea
____ 19. Which is the priority nursing diagnosis for a patient diagnosed with X-linked agammaglobulinemia (XLA)?
1) Risk for infection
2) Decreased cardiac output
3) Anticipatory grieving
4) Fatigue
____ 20. Which general manifestation should the nurse anticipate when providing care to a patient diagnosed with
1)
2)
3)
4)
Poor muscle tone
Failure to thrive
Shortness of breath
Delayed development
____ 21. Which respiratory manifestation should the nurse anticipate when providing care to a patient diagnosed with
1)
2)
3)
4)
Poor muscle tone
Failure to thrive
Shortness of breath
Delayed development
____ 22. Which should the
syndrome?
1) Sodium
2) Calcium
3) Potassium
4) Magnesium
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____ 23. Which is the priority nursing action to decrease the risk for infection for a patient diagnosed
syndrome?
1) Hand hygiene
2) Reverse isolation
3) Prokinetic agents
4) Droplet precautions
____ 24.
gastrointestinal reflux disorder (GERD)?
1) Hand hygiene
2) Reverse isolation
3) Prokinetic agents
4) Droplet precautions
____ 25. Which immune disorder should the nurse include in the plan of care for a patient who is receiving
chemotherapeutic agents in the treatment of cancer?
1) B-cell deficiency
2) T-cell deficiency
3) Excessive immune response
4) Secondary immune deficiency
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. A nurse is working in a summer camp for children. One of the children comes to the clinic with several bee
stings. Which clinical manifestations would necessitate the need to inject the child with epinephrine (EpiPen)?
Select all that apply.
1) Skin that is cold and clammy to the touch
2) Skin that is warm and dry to the touch
3) The child is hyperactive and hyperverbal.
4) Complaints of thirst
5) Restlessness and confusion
____ 27. The nurse is providing care to a patient who is suspected of having an immune deficiency. Which information
Select all that apply.
1) Persistent oral thrush
2) Tinea infection of the feet
3) One occurrence of pneumonia last year
4) Four or more infections in a one-year period
5) Two serious sinus infections in a one-year period
____ 28.
indicates a cardiovascular abnormality? Select all that apply.
1) Murmur
2) Cyanosis
3) Polycythemia
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4) Failure to thrive
5) Cleft lip and palate
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Chapter 20: Coordinating Care for Patients With Immune Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Excessive
immune response
Chapter page reference: 378-385
Heading: Type I Hypersensitivity Reaction
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Inflammation
Difficulty: Easy
Feedback
1
Erythema and fever are associated with type IV hypersensitivity reactions.
2
Fever and joint pain are associated with a type III hypersensitivity reactions.
3
Fever and joint pain are associated with a type III hypersensitivity reactions.
4
Clinical manifestations associated with a type I hypersensitivity reaction include
hypotension, wheezing, gastrointestinal or uterine spasm, stridor, and urticaria.
PTS: 1
CON: Inflammation
NURSINGKING.COM
2. ANS: 3
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Explaining the pathophysiological processes of immune dysfunction
Chapter page reference: 377-390
Heading: Excessive Immune Response
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Inflammation
Difficulty: Moderate
Feedback
1
Age, sex, concurrent illnesses, and previous reactions to related substances have been
identified as having a role in risk for hypersensitivity; however, these pose a lower risk
than previous exposure.
2
Age, sex, concurrent illnesses, and previous reactions to related substances have been
identified as having a role in risk for hypersensitivity; however, these pose a lower risk
than previous exposure.
3
Anyone can have a hypersensitivity reaction. However, risk generally increases with
previous exposure, because antigens must be formed with the first exposure before
hypersensitivity is likely to occur.
4
Age, sex, concurrent illnesses, and previous reactions to related substances have been
identified as having a role in risk for hypersensitivity; however, these pose a lower risk
than previous exposure.
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PTS: 1
CON: Inflammation
3. ANS: 4
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune
dysfunction
Chapter page reference: 377-390
Heading: Excessive Immune Response
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Inflammation
Difficulty: Easy
Feedback
1
This product is appropriate for this patient.
2
This product is appropriate for this patient.
3
This product is appropriate for this patient.
4
Patients with a history of meningocele typically experience severe latex allergies. It is
important for the nurse, and other health-care providers, to use latex alternative
products on this patient.
PTS: 1
CON: Inflammation
4. ANS: 1
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune
dysfunction
NURSINGKING.COM
Chapter page reference: 377-390
Heading: Excessive Immune Response
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Inflammation
Difficulty: Moderate
Feedback
1
Type I hypersensitivities, such as anaphylactic reactions, occur immediately and may
be life-threatening. Because the patient has a history of this type of reaction, Risk for
Shock is an appropriate nursing diagnosis.
2
The other items would not necessitate the need for this nursing diagnosis.
3
The other items would not necessitate the need for this nursing diagnosis.
4
The other items would not necessitate the need for this nursing diagnosis.
PTS: 1
CON: Inflammation
5. ANS: 4
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune
dysfunction
Chapter page reference: 377-390
Heading: Excessive Immune Response
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
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Cognitive level: Application [Applying]
Concept: Inflammation
Difficulty: Moderate
Feedback
1
Asking the family member to
2
Transferring the patient to a department that does not use latex products is not realistic
because the family member might experience exposure on another unit. (No hospital
unit can be latex-free.)
3
Waiting until Monday does not solve the problem.
4
When symptoms of sensitivity to latex occur on exposure, latex-free products should be
supplied.
PTS: 1
CON: Inflammation
6. ANS: 4
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune
dysfunction
Chapter page reference: 377-390
Heading: Excessive Immune Response
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Inflammation
Difficulty: Moderate
Feedback
NURSINGKING.COM
1
The Trendelenburg position elevates the foot of the bed and is no longer recommended
for the treatment of shock, as it causes abdominal organs to press against the
diaphragm, which impedes respirations and decreases coronary artery filling.
2
Lying flat is not recommended.
3
A person in a supine position may not be able to maintain an open airway.
4
Placing the patient in Fowler or high Fowler position allows optimal lung expansion
and ease of breathing.
PTS: 1
CON: Inflammation
7. ANS: 3
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Discussing the medical management of: Excessive immune response
Chapter page reference: 377-390
Heading: Excessive Immune Response
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Inflammation
Difficulty: Difficult
Feedback
1
Patients who have experienced an anaphylactic reaction to insect venom or another
potentially unavoidable allergen should carry a bee sting kit.
2
Diphenhydramine is often given as well but by injection, not by mouth.
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3
4
For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous
injection of 0.3-0.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should
give the epinephrine first due to the symptoms.
The nurse does not have time to collect a detailed history, because of the severity of the
signs and symptoms.
PTS: 1
CON: Inflammation
8. ANS: 1
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a teaching plan for a patient with immune dysfunction
Chapter page reference: 377-390
Heading: Excessive Immune Response
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Analysis [Analyzing]
Concept: Inflammation; Medication
Difficulty: Difficult
Feedback
1
The patient and family should frequently check the expiration date of the EpiPen. A kit
should be readily available in all settings where the patient studies, works, or plays.
2
Proper storage of the kit is important, avoiding exposure to sun or high temperature.
3
In addition to the patient, someone else should always know how to use the kit as well.
4
The patient should be encouraged to wear a medical alert bracelet or tag.
PTS: 1
CON: Inflammation
NURSI| NMedication
GKING.COM
9. ANS: 3
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a teaching plan for a patient with immune dysfunction
Chapter page reference: 377-390
Heading: Excessive Immune Response
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Inflammation; Medication
Difficulty: Moderate
Feedback
1
An EpiPen is a syringe-and-needle medication system used to treat an anaphylactic
reaction. Because an anaphylactic reaction is a medical emergency, it is essential that
the nurse provides thorough teaching regarding the use of the EpiPen. The EpiPen
comes prefilled to ensure a quick delivery when necessary.
2
The medication should not be kept in the car at all times, as the EpiPen needs to be
stored away from high heat and direct sunlight.
3
The expiration date should be checked frequently to ensure accurate strength.
4
The patient should have multiple EpiPens and they should be kept in multiple areas, not
one location.
PTS: 1
CON: Inflammation | Medication
10. ANS: 2
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Chapter learning objective: Developing a teaching plan for a patient with immune dysfunction
Chapter page reference: 377-390
Heading: Excessive Immune Response
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Inflammation; Medication
Difficulty: Moderate
Feedback
1
The nurse should instruct the patient to keep doors and windows closed on highallergen days and to remain indoors if possible.
2
A patient with seasonal hypersensitivity should be educated regarding prevention and
comfort measures. The nurse should also include teaching on maintaining a clean, dustfree environment.
3
Medication instruction should include instruction on taking antihistamine and antileukotriene medication, not leukotriene.
4
The patient should also be instructed to taper oral corticosteroids as ordered, not to
immediately stop taking them.
PTS: 1
CON: Inflammation | Medication
11. ANS: 2
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected
immune dysfunctions
Chapter page reference: 377-390
NURSINGKING.COM
Heading: Excessive Immune Response
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Inflammation
Difficulty: Easy
Feedback
1
2
3
4
agglutination is considered a normal finding.
An area of erythema after a patch test indicates a positive response to a specific antigen.
An eosinophil count of 2% is within the normal range.
An Rh antigen with a negative result indicates that the patient does not carry the antigen
and is not an indicator of a reaction to a specific antigen.
PTS: 1
CON: Inflammation
12. ANS: 3
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Discussing the medical management of: Excessive immune response
Chapter page reference: 377-390
Heading: Excessive Immune Response
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Inflammation; Medication
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Difficulty: Moderate
Feedback
1
Epinephrine is not used in the treatment of psoriasis.
2
Azathioprine is used to treat autoimmune hepatitis and rheumatoid arthritis.
3
Cyclosporine is used to treat psoriasis, rheumatoid arthritis, multiple sclerosis,
myasthenia gravis, scleroderma, and is used to prevent organ transplant rejection.
4
Mycophenolate mofetil is used to treat scleroderma, lupus, and to prevent organ
transplant rejection.
PTS: 1
CON: Inflammation | Medication
13. ANS: 2
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Discussing the medical management of: Excessive immune response
Chapter page reference: 377-390
Heading: Excessive Immune Response
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Inflammation; Medication
Difficulty: Moderate
Feedback
1
Epinephrine is not used in the treatment of automimmune hepatitis.
2
Azathioprine is used to treat autoimmune hepatitis and rheumatoid arthritis.
3
Cyclosporine is used to treat psoriasis, rheumatoid arthritis, multiple sclerosis,
myasthenia gravis, scleroderma,
prevent
NURand
SIisNused
GKItoNG
.COMorgan transplant rejection.
4
Mycophenolate mofetil is used to treat scleroderma, lupus, and to prevent organ
transplant rejection.
PTS: 1
CON: Inflammation | Medication
14. ANS: 4
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Discussing the medical management of: Excessive immune response
Chapter page reference: 377-390
Heading: Excessive Immune Response
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Inflammation; Medication
Difficulty: Moderate
Feedback
1
Epinephrine is not used in the treatment of lupus.
2
Azathioprine is used to treat autoimmune hepatitis and rheumatoid arthritis.
3
Cyclosporine is used to treat psoriasis, rheumatoid arthritis, multiple sclerosis,
myasthenia gravis, scleroderma, and is used to prevent organ transplant rejection.
4
Mycophenolate mofetil is used to treat scleroderma, lupus, and to prevent organ
transplant rejection.
PTS: 1
CON: Inflammation | Medication
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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15. ANS: 4
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune
dysfunction
Chapter page reference: 377-390
Heading: Excessive Immune Response
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Nursing
Difficulty: Difficult
Feedback
1
2
nursing action to decrease the risk of a transfusion reaction.
While documenting the procedure in the medical record is important, this is not the
priority nursing action to decrease the risk of a transfusion reaction.
3
4
priority nursing action to decrease the risk of a transfusion reaction.
The priority nursing action to decrease the risk of a transfusion reaction is to ensure the
bag contains the correct blood type for the patient.
PTS: 1
CON: Nursing
16. ANS: 4
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Discussing the medical management of: B-cell deficiencies
NURSINGKING.COM
Chapter page reference: 373
Heading: Primary Immune Dysfunction
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Infection; Medication
Difficulty: Moderate
Feedback
1
Diphenhydramine is not the anticipated pharmacological treatment for this patient.
2
Corticosteroids are not the anticipated pharmacological treatment for this patient.
3
Epinephrine is not the anticipated pharmacological treatment for this patient.
4
IVIG is the anticipated pharmacological treatment for this patient.
PTS: 1
CON: Infection | Medication
17. ANS: 1
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune
dysfunction
Chapter page reference: 374-375
Heading: Primary Immune Dysfunction
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Infection
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Difficulty: Moderate
1
2
3
4
Feedback
Patients diagnosed with XLA should be immunized with IPV versus oral polio vaccine
due to the risk of developing vaccine-acquired polio.
IVIG should be administered every three to four weeks, not every six months.
Education regarding low, not high, dose prophylactic antibiotics is required.
Periodic chest x-rays, not MRIs, to monitor for respiratory complications are included
in the plan of care.
PTS: 1
CON: Infection
18. ANS: 3
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Describing complications associated with selected immune dysfunctions
Chapter page reference: 374
Heading: Primary Immune Dysfunction
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1
Wheezing is not anticipated for this patient.
2
Rhonchi is not anticipated for this patient.
3
Tachypnea, or increased respiratory
is I
anticipated
NURSIrate,
NGK
NG.COMfor this patient.
4
Absent or decreased breath sounds, not eupnea, is anticipated for this patient.
PTS: 1
CON: Infection
19. ANS: 1
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune
dysfunction
Chapter page reference: 373
Heading: Primary Immune Dysfunction
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1
The priority nursing diagnosis for a patient diagnosed with XLA is an increased risk for
infection.
2
This is not the priority nursing diagnosis for this patient.
3
This is not the priority nursing diagnosis for this patient.
4
This is not the priority nursing diagnosis for this patient.
PTS: 1
20. ANS: 2
CON: Infection
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: B-cell
deficiencies
Chapter page reference: 368-371
Heading: Primary Immune Dysfunction
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
2
3
4
syndrome.
PTS: 1
CON: Infection
21. ANS: 3
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: B-cell
deficiencies
Chapter page reference: 368-371
Heading: Primary Immune Dysfunction
Integrated Processes: Nursing Process Assessment
NUR
SINGKINAdaptation
G.COM
Client Need: Physiological Integrity
Physiological
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
2
3
4
Delayed developme
syndrome.
PTS: 1
CON: Infection
22. ANS: 2
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune
dysfunction
Chapter page reference: 371-375
Heading: Primary Immune Dysfunction
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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1
Sodium is not an electrolyte the nurse should plan to monitor when providing care to
this patient.
2
3
4
calcium.
Potassium is not an electrolyte the nurse should plan to monitor when providing care to
this patient.
Magnesium is not anticipated to be affected by this diagnosis.
PTS: 1
CON: Infection
23. ANS: 1
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune
dysfunction
Chapter page reference: 371-375
Heading: Primary Immune Dysfunction
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1
2
3
4
Reverse isolation decreases the risk for infection for a patient who is neutropenic.
Prokinetic agents are administered
this
gastrointestinal
symptoms.
NURStoIN
GKpatient
ING.forCO
M
Droplet precautions are implemented for a patient with a communicable disease.
PTS: 1
CON: Infection
24. ANS: 3
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune
dysfunction
Chapter page reference: 371-375
Heading: Primary Immune Dysfunction
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection; Medication
Difficulty: Moderate
Feedback
1
2
3
4
This is not appropriate to treat GERD.
Reverse isolation decreases the risk for infection for a patient who is neutropenic.
Prokinetic agents are administered to treat GERD for this patient.
Droplet precautions are implemented for a patient with a communicable disease.
PTS: 1
25. ANS: 4
CON: Infection
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune
dysfunction
Chapter page reference: 375-377
Heading: Secondary Immune Dysfunction
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1
Chemotherapy does not cause B-cell deficiency.
2
Chemotherapy does not cause T-cell deficiency.
3
Chemotherapy does not cause an excessive immune response.
4
Chemotherapy often results in a secondary immune deficiency.
PTS: 1
CON: Infection
MULTIPLE RESPONSE
26. ANS: 1, 4, 5
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Excessive
immune response
Chapter page reference: 383
NURSINGKING.COM
Heading: Excessive Immune Response
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Inflammation
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is correct. General symptoms of shock that would necessitate an epinephrine injection
include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy.
The skin may feel cold and clammy in shock.
This is incorrect. The skin will not be warm and dry to the touch.
This is incorrect. In shock, the patient will not be hyperactive or hyperverbal.
This is correct. Thirst is a common complaint in shock.
This is correct. General symptoms of shock that would necessitate an epinephrine injection
include behavioral changes such as restlessness, anxiety, confusion, depression, and apathy.
The skin may feel cold and clammy in shock.
PTS: 1
CON: Inflammation
27. ANS: 1, 5
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with immune
dysfunction
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Chapter page reference: 370
Heading: Primary Immune Dysfunction
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
This is correct. Persistent oral thrush is an indication of immune deficiency.
This is incorrect. A tinea infection of the feet does not support suspected immune deficiency.
This is incorrect. Two, not one, occurrence of pneumonia within in one-year period indicates
immune deficiency.
This is incorrect. Six, not four, or more infections in a one-year period supports the diagnosis
of immune deficiency.
This is correct. Two or more serious sinus infections in a one-year period supports the
diagnosis of immune deficiency.
1.
2.
3.
4.
5.
PTS: 1
CON: Infection
28. ANS: 1, 2, 3, 4
Chapter number and title: 20, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: B-cell
deficiencies
Chapter page reference: 371-375
Heading: Primary Immune Dysfunction
NURSINGKING.COM
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
This is correct. A heart murmur indicates a cardiovascular abnormality.
This is correct. Cyanosis indicates a cardiovascular abnormality.
This is correct. Polycythemia indicates a cardiovascular abnormality.
This is correct. Failure to thrive indicates a cardiovascular abnormality.
This is incorrect. While cleft lip and palate often occurs with this syndrome, this data does not
indicate a cardiovascular abnormality.
1.
2.
3.
4.
5.
PTS: 1
CON: Infection
Chapter 21 Coordinating Care for Patients With Multidrug-Resistant Organism Infectious Disorders
Chapter 21: Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
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Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. The nurse is planning care for several patients in the hospital environment. Which is a risk factor for a patient
developing hospital-acquired MRSA?
1) Recent use of antibiotics
2) Recent surgical procedure
3) Current intensive care unit stay
4) Prolonged rehabilitation unit stay
____
2. The nurse is planning care for several patients in the hospital environment. Which is a risk factor for a patient
developing Clostridium difficile?
1) Recent use of antibiotics
2) Recent surgical procedure
3) Current intensive care unit stay
4) Prolonged rehabilitation unit stay
____
3. The nurse is planning care for several patients in the hospital environment. Which is a risk factor for a patient
developing Acinetobacter baumannii?
1) Recent use of antibiotics
2) Recent surgical procedure
3) Current intensive care unit stay
4) Prolonged rehabilitation unit stay
____
4. The nurse is planning care for several
Which is a risk factor for a patient
NUpatients
RSINGinKthe
INhospital
G.COenvironment.
M
developing VRE?
1) Recent use of antibiotics
2) Recent surgical procedure
3) Current intensive care unit stay
4) Prolonged rehabilitation unit stay
____
5. The nurse is planning care for several patients. Which is a risk factor for a patient developing communityacquired MRSA?
1) Recent use of antibiotics
2) Recent surgical procedure
3) Being younger than 2 years of age
4) Being older than 65 years of age
____
6. The nurse is providing care to a several patients in the hospital environment. Which patient should the nurse
include education regarding the need for increased fluid intake in the plan of care?
1) The patient diagnosed with VRE
2) The patient diagnosed with MRSA
3) The patient diagnosed with Acinetobacter
4) The patient diagnosed with Clostridium difficile
____
7. The nurse is providing care to a several patients in the hospital environment. Which patient requires the nurse
to closely monitor respiratory status?
1) The patient diagnosed with VRE
2) The patient diagnosed with MRSA
3) The patient diagnosed with Acinetobacter
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4) The patient diagnosed with Clostridium difficile
____
8. Which is the priority nursing action to decrease the risk of spreading infection among patients diagnosed with
Multidrug-Resistant Organisms?
1) Performing hand hygiene before and after care
2) Donning appropriate personal protective equipment (PPE)
3) Administering prescribed doses of antibiotics as scheduled
4) Monitoring for clinical manifestations of bacterial illnesses
____
9. Which antibiotic prescription should the nurse anticipate when providing care to a patient who is diagnosed
with multi-drug resistant (MDR) MRSA?
1) Vancomycin
2) Metronidazole
3) Ampicillin-sulbactam
4) Quinupristin-dalfopristin
____ 10. Which antibiotic prescription should the nurse anticipate when providing care to a patient who is diagnosed
with multi-drug resistant (MDR) VRE?
1) Vancomycin
2) Metronidazole
3) Ampicillin-sulbactam
4) Quinupristin-dalfopristin
____ 11. Which antibiotic prescription should the nurse anticipate when providing care to a patient who is diagnosed
with multi-drug resistant (MDR) Clostridium difficile?
1) Vancomycin
2) Metronidazole
NURSINGKING.COM
3) Ampicillin-sulbactam
4) Quinupristin-dalfopristin
____ 12. Which antibiotic prescription should the nurse anticipate when providing care to a patient who is diagnosed
with multi-drug resistant (MDR) Acinetobacter?
1) Vancomycin
2) Metronidazole
3) Ampicillin-sulbactam
4) Quinupristin-dalfopristin
____ 13. The nurse is providing education to a patient who is diagnosed with Clostridium difficile. Which patient
statement indicates correct understanding regarding the cause of inflammation?
1)
2)
3)
4)
____ 14. The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates
correct understanding of contact transmission?
1)
2)
3)
4)
-
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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____ 15. The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates
correct understanding of vector-borne transmission?
1)
2)
3)
4)
containing a disease____ 16. The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates
correct understanding of airborne transmission?
1)
2)
3)
4)
____ 17. The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates
correct understanding of vehicle transmission?
1)
2)
3)
4)
____ 18. The nurse is conducting an in-service on the spread of infection in the hospital environment. Which statement
should the nurse include regarding the most common mode of pathogen transmission?
1)
2)
3)
NURSINGKING.COM
4)
____ 19. The infection prevention and control nurse is providing an in-service regarding multi-drug resistant (MDR)
infection. Which is the most common site of MDR MRSA colonization the nurse should include in the
presentation?
1) Throat
2) Axillae
3) Perineum
4) Anterior nares
____ 20. Which nursing action is appropriate when providing care to a patient who is diagnosed with multi-drug
resistant (MDR) MRSA?
1) Implementing isolation precautions
2) Implementing standard precautions only
3) Washing hands with soap and water only
4) Wearing a gown that is tied at the neck but not at the waist
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21. Which is being studied when a nurse participates in the BUGG (benefits of universal gown and gloving)
research initiative? Select all that apply.
1) Decreasing the length of the hospital stay
2) Decreasing the frequency of adverse events
3) Increasing the risk for antibiotic resistance
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4) Decreasing the risk for hospital-acquired infection
5) Decreasing the risk for being diagnosed with a bacterial infection during hospitalization
____ 22. The nurse is providing care to a patient diagnosed with a MRSA skin infection. Which clinical manifestations
should the nurse anticipate during the patient assessment? Select all that apply.
1) Pus
2) Edema
3) Tachypnea
4) Discomfort
5) Bradycardia
____ 23. Which clinical manifestations should the nurse anticipate when assessing any patient diagnosed with a multidrug resistant (MDR) infection? Select all that apply.
1) Fever
2) Tachypnea
3) Tachycardia
4) Hypertension
5) Hypervolemia
____ 24. Which assessment data supports the nursing diagnosis of deficient fluid volume for a patient diagnosed with
Clostridium difficile? Select all that apply.
1) Decreased skin turgor
2) Increased urine output
3) Dry mucous membranes
4) Increased serum creatinine
5) Decreased white blood cells
NURSINGKING.COM
____ 25. Which should the nurse include in the plan of care for a patient who is diagnosed with a multi-drug resistant
(MDR) pneumonia? Select all that apply.
1) Encourage ambulation
2) Administer prescribed oxygen
3) Implement chest physiotherapy
4) Perform wound care as prescribed
5) Educate that alcohol-based hand gels are ineffective
____ 26. Which nursing actions are appropriate when collecting a stool sample to determine if a patient is experiencing
a C. diff. infection? Select all that apply.
1) Holding the sample for twenty-four hours
2) Keeping the sample at room temperature
3) Sending the sample to the laboratory immediately
4) Preparing a requisition for a culture and sensitivity
5) Using an alcohol-based hand gel before and after care
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Chapter 21: Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders
Chapter page reference: 393-394
Heading: Multidrug-Resistant Organisms
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1
Recent use of antibiotics is a risk factor for Clostridium difficile.
2
Recent surgical procedure is a risk factor for Acinetobacter baumannii.
3
Current or recent hospitalization increases the risk for hospital-acquired MRSA.
4
A prolonged rehabilitation stay increases the risk for VRE.
PTS: 1
CON: Infection
NURSINGKING.COM
2. ANS: 1
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders
Chapter page reference: 397-398
Heading: Multidrug-Resistant Organisms
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1
Recent use of antibiotics is a risk factor for Clostridium difficile.
2
Recent surgical procedure is a risk factor for Acinetobacter baumannii.
3
Current or recent hospitalization increases the risk for hospital-acquired MRSA.
4
A prolonged rehabilitation stay increases the risk for VRE.
PTS: 1
CON: Infection
3. ANS: 2
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders
Chapter page reference: 399
Heading: Multidrug-Resistant Organisms
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1
Recent use of antibiotics is a risk factor for Clostridium difficile.
2
Recent surgical procedure is a risk factor for Acinetobacter baumannii.
3
Current or recent hospitalization increases the risk for hospital-acquired MRSA.
4
A prolonged rehabilitation stay increases the risk for VRE.
PTS: 1
CON: Infection
4. ANS: 4
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders
Chapter page reference: 395-396
Heading: Multidrug-Resistant Organisms
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1
Recent use of antibiotics is a risk factor for Clostridium difficile.
NURSINGKING.COM
2
Recent surgical procedure is a risk factor for Acinetobacter baumannii.
3
Current or recent hospitalization increases the risk for hospital-acquired MRSA.
4
A prolonged rehabilitation stay increases the risk for VRE.
PTS: 1
CON: Infection
5. ANS: 3
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders
Chapter page reference: 393-394
Heading: Multidrug-Resistant Organisms
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
1
2
3
4
Feedback
Recent use of antibiotics is a risk factor for Clostridium difficile.
Recent surgical procedure is a risk factor for Acinetobacter baumannii.
A patient who is younger than 2 years of age is at an increased risk for communityacquired MRSA.
A patient who is older than 65 years of age is not at an increased risk for communityacquired MRSA.
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PTS: 1
CON: Infection
6. ANS: 4
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with multidrug-resistant organism infectious disorders
Chapter page reference: 404-406
Heading: Nursing Management
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
This patient is not an increased risk for alterations in fluid and electrolytes.
2
This patient is not an increased risk for alterations in fluid and electrolytes.
3
This patient is not an increased risk for alterations in fluid and electrolytes.
4
This patient is at risk for both fluid and electrolyte imbalances; therefore, the nurse
PTS: 1
CON: Infection
7. ANS: 3
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
NURSINGKING.COM
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with multidrugresistant organism infectious disorders
Chapter page reference: 404-406
Heading: Nursing Management
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection; Oxygenation
Difficulty: Moderate
Feedback
1
This patient is not an increased risk for respiratory issues.
2
This patient is not an increased risk for respiratory issues.
3
This patient is at an increased risk for requiring mechanical ventilation; therefore, the
4
This patient is at risk for both fluid and electrolyte imbalances, not respiratory issues.
PTS: 1
CON: Infection | Oxygenation
8. ANS: 1
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with multidrugresistant organism infectious disorders
Chapter page reference: 404-406
Heading: Nursing Management
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Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1
Hand hygiene, or hand washing, is the most important intervention to decrease the risk
for infection.
2
While donning appropriate PPE decreases the risk for spreading infection, this is not the
priority.
3
Administering prescribed doses of antibiotics as scheduled decreases the risk for
antibiotic resistance, not infection.
4
While early diagnosis may decrease the risk for spreading infection, this is not the
priority.
PTS: 1
CON: Infection
9. ANS: 1
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Discussing the medical management of: Methicillin-resistant Staphylococcus
aureus
Chapter page reference: 401-404
Heading: Management of Multidrug-Resistant Organisms
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
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Cognitive level: Application [Applying]
Concept: Infection; Medication
Difficulty: Moderate
Feedback
1
Vancomycin is a drug that the nurse anticipates administering when providing care to a
patient who is diagnosed with MDR MRSA.
2
Metronidazole is a drug that the nurse anticipates administering when providing care to
a patient who is diagnosed with MDR Clostridium difficile.
3
Ampicillin-sulbactam is a drug that the nurse anticipates administering when providing
care to a patient who is diagnosed with MDR Acinetobacter.
4
Quinupristin-dalfopristin is a drug that the nurse anticipates administering when
providing care to a patient who is diagnosed with MDR VRE.
PTS: 1
CON: Infection | Medication
10. ANS: 4
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Discussing the medical management of: Vancomycin-resistant enterococci
Chapter page reference: 401-404
Heading: Management of Multidrug-Resistant Organisms
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Infection; Medication
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Difficulty: Moderate
Feedback
1
Vancomycin is a drug that the nurse anticipates administering when providing care to a
patient who is diagnosed with MDR MRSA.
2
Metronidazole is a drug that the nurse anticipates administering when providing care to
a patient who is diagnosed with MDR Clostridium difficile.
3
Ampicillin-sulbactam is a drug that the nurse anticipates administering when providing
care to a patient who is diagnosed with MDR Acinetobacter.
4
Quinupristin-dalfopristin is a drug that the nurse anticipates administering when
providing care to a patient who is diagnosed with MDR VRE.
PTS: 1
CON: Infection | Medication
11. ANS: 2
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Discussing the medical management of: Clostridium difficile
Chapter page reference: 401-404
Heading: Management of Multidrug-Resistant Organisms
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Infection; Medication
Difficulty: Moderate
Feedback
1
Vancomycin is a drug that the nurse anticipates administering when providing care to a
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patient who is diagnosed with MDR MRSA.
2
Metronidazole is a drug that the nurse anticipates administering when providing care to
a patient who is diagnosed with MDR Clostridium difficile.
3
Ampicillin-sulbactam is a drug that the nurse anticipates administering when providing
care to a patient who is diagnosed with MDR Acinetobacter.
4
Quinupristin-dalfopristin is a drug that the nurse anticipates administering when
providing care to a patient who is diagnosed with MDR VRE.
PTS: 1
CON: Infection | Medication
12. ANS: 3
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Discussing the medical management of: Acinetobacter baumannii
Chapter page reference: 401-404
Heading: Management of Multidrug-Resistant Organisms
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Infection; Medication
Difficulty: Moderate
Feedback
1
Vancomycin is a drug that the nurse anticipates administering when providing care to a
patient who is diagnosed with MDR MRSA.
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2
3
4
Metronidazole is a drug that the nurse anticipates administering when providing care to
a patient who is diagnosed with MDR Clostridium difficile.
Ampicillin-sulbactam is a drug that the nurse anticipates administering when providing
care to a patient who is diagnosed with MDR Acinetobacter.
Quinupristin-dalfopristin is a drug that the nurse anticipates administering when
providing care to a patient who is diagnosed with MDR VRE.
PTS: 1
CON: Infection | Medication
13. ANS: 2
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Clostridium difficile
Chapter page reference: 398
Heading: Multidrug-Resistant Organisms
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
1
2
3
4
Feedback
This statement does not indicate correct understanding regarding the cause of
inflammation for a patient diagnosed with Clostridium difficile.
The bacteria release toxins which are responsible for the inflammation that occurs with
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a Clostridium difficile infection. This patient statement indicates correct understanding.
This statement does not indicate correct understanding regarding the cause of
inflammation for a patient diagnosed with Clostridium difficile.
This statement does not indicate correct understanding regarding the cause of
inflammation for a patient diagnosed with Clostridium difficile.
PTS: 1
CON: Infection
14. ANS: 2
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders
Chapter page reference: 393
Heading: Introduction
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1
This statement indicates correct understanding of vector-borne transmission.
2
This statement indicates correct understanding of contact transmission.
3
This statement indicates correct understanding of airborne transmission.
4
This statement indicates correct understanding of vehicle transmission.
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PTS: 1
CON: Infection
15. ANS: 1
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders
Chapter page reference: 393
Heading: Introduction
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1
This statement indicates correct understanding of vector-borne transmission.
2
This statement indicates correct understanding of contact transmission.
3
This statement indicates correct understanding of airborne transmission.
4
This statement indicates correct understanding of vehicle transmission.
PTS: 1
CON: Infection
16. ANS: 3
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders
Chapter page reference: 393
Heading: Introduction
NURSINGKING.COM
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1
This statement indicates correct understanding of vector-borne transmission.
2
This statement indicates correct understanding of contact transmission.
3
This statement indicates correct understanding of airborne transmission.
4
This statement indicates correct understanding of vehicle transmission.
PTS: 1
CON: Infection
17. ANS: 4
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders
Chapter page reference: 393
Heading: Introduction
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
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1
2
3
4
This statement indicates correct understanding of vector-borne transmission.
This statement indicates correct understanding of contact transmission.
This statement indicates correct understanding of airborne transmission.
This statement indicates correct understanding of vehicle transmission.
PTS: 1
CON: Infection
18. ANS: 1
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Describing the epidemiology of multidrug-resistant organism infectious disorders
Chapter page reference: 393
Heading: Introduction
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Knowledge [Remembering]
Concept: Infection
Difficulty: Easy
Feedback
1
Contact transmission is the most common mode of pathogen transmission.
2
Vehicle transmission is not the most common mode of pathogen transmission.
3
Airborne transmission is not the most common mode of pathogen transmission.
4
Vector-borne transmission is not the most common mode of pathogen transmission.
PTS: 1
CON: Infection
19. ANS: 4
NURSINGKING.COM
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Methicillin-resistant Staphylococcus auerus
Chapter page reference: 393
Heading: Multidrug-Resistant Organisms
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1
While MRSA colonization often occurs in the throat, this is not the most common site
of colonization.
2
While MRSA colonization often occurs in the axillae, this is not the most common site
of colonization.
3
While MRSA colonization often occurs in the perineum, this is not the most common
site of colonization.
4
The most common site of MRSA colonization is the anterior nares.
PTS: 1
20. ANS: 1
CON: Infection
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Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Discussing the medical management of: Methicillin-resistant Staphylococcus
aureus
Chapter page reference: 401
Heading: Management of Multidrug-Resistant Organisms
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
A patient diagnosed with MDR MRSA requires isolation precautions, specifically
contact precautions.
2
This patient would require isolation, not standard, precautions.
3
The patient diagnosed with MDR MRSA does not require the implementation of hand
hygiene with soap and water only. This intervention is appropriate for the patient
diagnosed with Clostridium difficile.
4
Gowns should be tied at the neck and waist in order to decrease the risk for disease
transmission.
PTS: 1
CON: Infection
MULTIPLE RESPONSE
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21. ANS: 1, 2, 4, 5
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with multidrugresistant organism infectious disorders
Chapter page reference: 406
Heading: Nursing Management
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Comprehension [Understanding]
Concept: Evidence-Based Practice
Difficulty: Easy
1.
2.
3.
Feedback
This is correct. The BUGG study will test if doctors, nurses, and others wearing gloves and a
gown while caring for all patients in an intensive care unit (ICU) will decrease the length of
the hospital stay.
This is correct. The BUGG study will test if doctors, nurses, and others wearing gloves and a
gown while caring for all patients in an intensive care unit (ICU) will decrease the frequency
of adverse events.
This is incorrect. The BUGG study does not test for an increase in the risk for antibiotic
resistance.
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4.
5.
This is correct. The BUGG study will test if doctors, nurses, and others wearing gloves and a
gown while caring for all patients in an intensive care unit (ICU) will decrease the risk for
hospital-acquired infection.
This is correct. The BUGG study will test if doctors, nurses, and others wearing gloves and a
gown while caring for all patients in an intensive care unit (ICU) will decrease the risk for
hospital-acquired infection.
PTS: 1
CON: Evidence-Based Practice
22. ANS: 1, 2, 4
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Methicillin-resistant Staphylococcus auerus
Chapter page reference: 405
Heading: Multidrug-Resistant Organisms
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is correct. Pus is a clinical manifestation associated with a MRSA skin infection.
This is correct. Edema, or swelling, is a clinical manifestation associated with a MRSA skin
infection.
NURSINGKING.COM
This is incorrect. Tachypnea may occur with a systemic, not localized, MRSA skin infection.
This is correct. Discomfort, or pain, is a clinical manifestation associated with a MRSA skin
infection.
This is incorrect. Bradycardia may occur with a systemic, not localized, MRSA skin infection.
PTS: 1
CON: Infection
23. ANS: 1, 2, 3
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with multidrugresistant organism infectious disorders
Chapter page reference: 405
Heading: Multidrug-Resistant Organisms
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
1.
2.
Feedback
This is correct. Hyperthermia, or fever, is an anticipated clinical manifestation when providing
care to any patient diagnosed with a MDR infection.
This is correct. Tachypnea, or an increased rate of respirations, is an anticipated clinical
manifestation when providing care to any patient diagnosed with a MDR infection.
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3.
4.
5.
This is correct. Tachycardia, or an increased heart rate, is an anticipated clinical manifestation
when providing care to any patient diagnosed with a MDR infection.
This is incorrect. Hypertension is not an anticipated clinical manifestation for a patient
diagnosed with an MDR infection.
This is incorrect. Hypovolemia is an anticipated clinical manifestation for a patient diagnosed
with an MDR infection.
PTS: 1
CON: Infection
24. ANS: 1, 3, 4
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with multidrugresistant organism infectious disorders
Chapter page reference: 404-406
Heading: Nursing Management
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is correct. Decreased skin turgor often occurs due to dehydration; therefore, this supports
the current nursing diagnosis.
This is incorrect. A decreased, not increased, urine output supports the current nursing
NURSINGKING.COM
diagnosis.
This is correct. Dry mucous membranes often occur due to dehydration; therefore, this
supports the current nursing diagnosis.
This is correct. An increased serum creatinine level often occurs due to dehydration; therefore,
this supports the current nursing diagnosis.
This is incorrect. Increased white blood cell count is anticipated due to infection; however,
this does not support the current nursing diagnosis.
PTS: 1
CON: Infection
25. ANS: 1, 2, 3
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with multidrugresistant organism infectious disorders
Chapter page reference: 404-406
Heading: Nursing Management
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection; Oxygenation
Difficulty: Moderate
Feedback
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1.
the risk for atelectasis.
2.
plan of care to increase oxygen saturation.
3.
mobilize secretions and increase oxygen saturation.
This is incorrect. Wound care is included in the plan of care for a patient with an MDR MRSA
skin infection, not pneumonia.
This is incorrect. Alcohol-based hand gels are effective to decrease the risk for infection with
all MDR infections with the exception of Clostridium difficile, not pneumonia.
4.
5.
PTS: 1
CON: Infection | Oxygenation
26. ANS: 3, 4
Chapter number and title: 21, Coordinating Care for Patients with Multidrug-Resistant Organism Infectious
Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of infectious
disorders
Chapter page reference: 400-401
Heading: Management of Multidrug-Resistant Organisms
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
NURSINGKING.COM
Feedback
This is incorrect. The sample should be sent to the laboratory immediately as a false-negative
may occur if the sample is not tested within two hours of collection.
This is incorrect. The C diff toxins are unstable at room temperature, and false-negative results
may occur in samples that are not tested within two hours of collection.
This is correct. The sample is sent to the laboratory immediately as C diff toxins are unstable
at room temperature, and false-negative results may occur in samples that are not tested within
two hours of collection.
This is correct. A laboratory requisition for a culture and sensitivity is required when sending
a stool sample to the laboratory to determine the presence of C diff.
This is incorrect. Any patient who is suspected of having C diff will require hand hygiene with
soap and water as alcohol-based hand gel displaces this organism but does not kill it.
1.
2.
3.
4.
5.
PTS: 1
CON: Infection
Chapter 22: Coordinating Care for Patients With HIV
Multiple Choice
Identify the choice that best completes the statement or answers the question.
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____
1. The nurse is caring for a patient with acquired immunodeficiency syndrome (AIDS) who is in antiretroviral
therapy. The patient reports nausea, fever, severe diarrhea, and anorexia. Which prescribed medication does
1)
2)
3)
4)
Dronabinol (Marinol)
Abacavir (Ziagen)
Ciprofloxacin (Cipro)
Zidovudine (Retrovir, AZT)
____
2. A nurse is performing an admission assessment on a patient with symptoms that indicate human
immunodeficiency virus (HIV). Which question from the nurse addresses a major risk factor for contracting
HIV?
1)
2)
3)
4)
____
3. The nurse is discharging a pediatric patient who was recently diagnosed with acquired immunodeficiency
syndrome (AIDS). When discussing appropriate health promotion activities for this child, which
immunization is contraindicated?
1) Varicella vaccine
2) Haemophilus influenzae type B (HIB conjugate vaccine)
3) Hepatitis B vaccine (hep B)
4) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)
____
4. A nurse is developing a plan of care for a patient diagnosed with human immunodeficiency virus (HIV). The
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priority nursing diagnosis for this patient?
1) Risk for Infection
2) Death Anxiety
3) Deficient Knowledge
4) Social Isolation
____
5. The nurse is caring for a patient who is newly diagnosed with human immunodeficiency virus (HIV). The
educating the patient, which statement indicates the need for further education?
1)
2)
3)
4)
____
6. A home health nurse is conducting home visits for several patients who are diagnosed with acquired
immunodeficiency syndrome (AIDS). Which patient would the nurse see first?
1) A patient who is receiving lamivudine (Epivir) because of a diagnosis of a low CD4 cell
count
2) A patient with Pneumocystis carinii pneumonia (PCP) who called the office this morning
to report a new onset of fever, cough, and shortness of breath
3) A patient with wasting syndrome who needs modifications and education regarding
dietary changes
4) A patient who is receiving IV antibiotics daily for toxoplasmosis
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____
7. The nurse is providing care to a pediatric patient who is HIVmay
require further intervention?
1)
2)
3)
4)
____
8. A nurse working in an intensive care unit (ICU) is assigned a patient diagnosed with acquired
immunodeficiency syndrome (AIDS). Based on this data, which type of precaution does the nurse implement
when providing direct care?
1) Droplet
2) Reverse
3) Standard
4) Contact
____
9. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+
count of 500 cells/ L. Which classification of HIV should the nurse document for this patient?
1) Stage 0
2) Stage 1
3) Stage 2
4) Stage 3
____ 10. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+
count of 300 cells/ L. Which classification of HIV should the nurse document for this patient?
1) Stage 0
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2) Stage 1
3) Stage 2
4) Stage 3
____ 11. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV), with a CD4+
count of less than 200 cells/ L. Which classification of HIV should the nurse document for this patient?
1) Stage 0
2) Stage 1
3) Stage 2
4) Stage 3
____ 12. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The
patient has lost 15% of body weight since the last appointment. Which reason should the nurse include in a
teaching session for this patient regarding this occurrence?
1) Infection
2) Disease progression
3) Mycobacterial infection
4) Pneumocystis carinii pneumonia
____ 13. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The
patient presents with a fever without other notable symptoms. Which is the most likely cause of this data?
1) Infection
2) Disease progression
3) Mycobacterial infection
4) Pneumocystis carinii pneumonia
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____ 14. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The
patient reports night sweats. Which is the most likely reason for this clinical manifestation?
1) Infection
2) Disease progression
3) Mycobacterial infection
4) Pneumocystis carinii pneumonia
____ 15. The nurse is providing care to a patient who is diagnosed with human immunodeficiency virus (HIV). The
patient has shortness of breath when walking, but no problems breathing at rest. Which is the most likely
cause for this clinical manifestation?
1) Infection
2) Disease progression
3) Mycobacterial infection
4) Pneumocystis carinii pneumonia
____ 16. The nurse is assessing a patient who is diagnosed with human immunodeficiency virus (HIV) who presents
with a rash. Which assessment question is most appropriate?
1)
2)
3)
4)
____ 17. Which immunization should the nurse encourage for a patient who is diagnosed with Stage 2 human
immunodeficiency virus?
1) Measles, mumps, and rubella (MMR) vaccine
2) Oral polio vaccine (OPV)
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3) Influenza vaccine
4) Varicella vaccine
____ 18. Which is the priority action for a nurse who is exposed to a needle-stick injury while providing patient care?
1) Washing the injury under running water
2)
3) Taking two or three drugs for 28 days
4) Consenting to a human immunodeficiency virus (HIV) test
____ 19. Which patient should the nurse offer the opportunity for human immunodeficiency virus (HIV) testing during
an annual physical examination?
1) A 66-year-old male patient
2) A 75-year-old female patient
3) An 8-year-old school-age child
4) An 18-year-old young adult patient
____ 20.
CD4+ count is currently 480 cells/ L. Which complication is this patient at risk for developing?
1) Toxoplasmosis
2) Herpes zoster virus
3) Vaginal candidiasis
4) Severe bacterial infection
____ 21. The nurse is providing care to a patient diagnosed with human
CD4+ count is less than 200 cells/ L. Which complication is this patient at risk for developing?
1) Toxoplasmosis
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2) Herpes zoster virus
3) Vaginal candidiasis
4) Severe bacterial infection
____ 22. The
CD4+ count is greater than 500 cells/ L. Which complication is this patient at risk for developing?
1) Toxoplasmosis
2) Herpes zoster virus
3) Vaginal candidiasis
4) Severe bacterial infection
____ 23.
CD4+ count is currently 250 cells/ L. Which complication is this patient at risk for developing?
1) Toxoplasmosis
2) Herpes zoster virus
3) Vaginal candidiasis
4) Severe bacterial infection
____ 24. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). Which patient
statement indicates the need for further education regarding HIV management?
1)
2)
3)
4)
clean the cat litter to decrease my risk for developing
Completion
Complete each statement.
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25. Place the progression of human immunodeficiency virus (HIV) in sequential order. (Enter the number of each
step in the proper sequence; do not use punctuation or spaces. Example: 1234)
1) AIDS
2) Death
3) Seroconversion
4) Viral transmission
5) Acute viral infection
6) Asymptomatic chronic infection
26. Human immunodeficiency virus (HIV) infects and destroys CD4 cells. List the following events in the order
in which they occur for a patient who is HIV-positive. (Enter the number of each step in the proper sequence;
do not use punctuation or spaces. Example: 1234)
1) Virus invades helper T cell
2) Viral RNA converts with reverse transcriptase to viral DNA
3) Viral DNA integrates with host cell DNA.
4) Virus remains latent, or actively replicates
5) Virus sheds protein coat
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 27. The nurse is planning care for a pediatric patient diagnosed with human immunodeficiency virus (HIV). The
nurse selects Risk for Infection as a priority nursing diagnosis for this pediatric patient. Based on this nursing
diagnosis, which actions by the nurse are appropriate? Select all that apply.
1) Administering tuberculosis skin tests every six months
2) Teaching proper food-handling techniques to the family
3) Instructing on the importance of consuming ample fresh fruits and vegetables
4) Assessing the health status of all visitors
5) Monitoring hand-washing techniques used by the family
____ 28. The nurse is reviewing the laboratory values of a patient who is newly diagnosed with acquired
-care provider?
Select all that apply.
1) CD4 cell count 1,100/mm3
2) T4 cell count 150
3) CD4 lymphocytes 12%
4) Viral load 11,500 copies/mL
5) WBC 6,500
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Chapter 22: Coordinating Care for Patients With HIV
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological,
dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 415
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Infection; Medication
Difficulty: Moderate
Feedback
1
Megestrol (Megace) and dronabinol (Marinol) are often ordered to increase patient
appetite and promote weight gain.
2
Abacavir (Ziagen) is a potent inhibitor of reverse transcriptase.
3
Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine (Retrovir, AZT)
is an antiretroviral agent.
4
Ciprofloxacin (Cipro) is an anti-infective medication, and zidovudine (Retrovir, AZT)
is an antiretroviral agent.
NURSINGKING.COM
PTS: 1
CON: Infection | Medication
2. ANS: 4
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Describing the etiology of HIV disorders
Chapter page reference: 409-410
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
2
HIV.
3
4
One risk factor for contracting HIV is the use of intravenous recreational drugs. This
PTS: 1
3. ANS: 1
CON: Infection
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Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological,
dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 415
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Planning
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
A child with an immune disorder such as HIV/AIDS should not be immunized with a
live varicella vaccine, because of the risk of contracting the disease.
2
DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on
schedule.
3
DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on
schedule.
4
DTaP, HIB, and hepatitis B vaccinations are not live vaccines, and should be given on
schedule.
PTS: 1
CON: Infection
4. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological,
dietary, and lifestyle considerations for patients with HIV disease
NURSINGKING.COM
Chapter page reference: 417
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1
While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient
ust because I
2
decrease the risk of transmission to potential sexual partners.
While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient
3
decrease the risk of transmission to potential sexual partners.
While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient
4
decrease the risk of transmission to potential sexual partners.
While all options are appropriate nursing diagnosis, the priority diagnosis is Deficient
ires education regarding safer sex practices to
decrease the risk of transmission to potential sexual partners.
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PTS: 1
CON: Infection
5. ANS: 1
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological,
dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 416
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1
The nurse should educate the patient on methods that will decrease the risk of
transmitting the HIV. The patient statement regarding the use of an oil-based lubricant
requires further education. The patient should use only water-based lubricants, not oilbased, such as petroleum jelly, which can result in condom damage.
2
This patient statement indicates appropriate understanding of the information presented
by the nurse.
3
This patient statement indicates appropriate understanding of the information presented
by the nurse.
4
This patient statement indicates appropriate understanding of the information presented
by the nurse.
NURSINGKING.COM
PTS: 1
CON: Infection
6. ANS: 2
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV
Chapter page reference: 417
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1
The home health nurse should see the patient with PCP because of the complaint of
shortness of breath with the new onset of fever. All of the patients need to be seen by
the nurse, but based on the ABCs (airway, breathing, and circulation), the nurse should
visit this patient first to obtain vital signs and perform a respiratory assessment.
2
This patient needs to be seen by the nurse; however, based on the ABCs (airway,
breathing, and circulation) this patient is not the priority.
3
This patient needs to be seen by the nurse; however, based on the ABCs (airway,
breathing, and circulation) this patient is not the priority.
4
This patient needs to be seen by the nurse; however, based on the ABCs (airway,
breathing, and circulation) this patient is not the priority.
PTS: 1
CON: Infection
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7. ANS: 1
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological,
dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 417-419
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Assessment
Client Need: Psychosocial Integrity
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1
This statement indicates that the patient is not adequately coping with the current
situation and requires further assessment and/or intervention by the nurse.
2
Positive outcomes for an HIV patient would include remaining free from secondary
infection, displaying normal nutritional patterns, demonstrating adequate coping with
the stress of chronic disease, and attending school.
3
Positive outcomes for an HIV patient would include remaining free from secondary
infection, displaying normal nutritional patterns, demonstrating adequate coping with
the stress of chronic disease, and attending school.
4
Positive outcomes for an HIV patient would include remaining free from secondary
infection, displaying normal nutritional patterns, demonstrating adequate coping with
the stress of chronic disease, and attending school.
PTS: 1
CON: Infection
NURSINGKING.COM
8. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological,
dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 418
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
Droplet precautions are not necessary as HIV is not transmitted via the route.
2
Reverse precautions are needed for a patient who is experiencing neutropenia.
3
Health-care workers can prevent most exposures to HIV by using standard precautions.
With standard precautions, the health-care professionals treat all patients alike,
eliminating the need to know their HIV status. Treat all high-risk body fluids as if they
are infectious, and use barrier precautions to prevent skin, mucous membrane, or
percutaneous exposure to these fluids.
4
Contact precautions are not necessary as HIV does not require additional precautions
aside from standard precautions.
PTS: 1
9. ANS: 2
CON: Infection
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Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV
Chapter page reference: 409
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Infection; Communication
Difficulty: Moderate
1
2
3
4
Feedback
This is not a stage for the classification of HIV.
Stage 1 is documented for a patient with a CD4+ count of at least 500 cells/ L.
Stage 2 is documented for a patient with a CD4+ count of 200 499 cells/ L.
Stage 3 is documented for a patient with a CD4+ count of less than 200 cells/ L.
PTS: 1
CON: Infection | Communication
10. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV
Chapter page reference: 409
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
NURSINGKING.COM
Concept: Infection; Communication
Difficulty: Moderate
1
2
3
4
Feedback
This is not a stage for the classification of HIV.
Stage 1 is documented for a patient with a CD4+ count of at least 500 cells/ L.
Stage 2 is documented for a patient with a CD4+ count of 200 499 cells/ L.
Stage 3 is documented for a patient with a CD4+ count of less than 200 cells/ L.
PTS: 1
CON: Infection | Communication
11. ANS: 4
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV
Chapter page reference: 409
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Infection; Communication
Difficulty: Moderate
1
Feedback
This is not a stage for the classification of HIV.
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2
3
4
Stage 1 is documented for a patient with a CD4+ count of at least 500 cells/ L.
Stage 2 is documented for a patient with a CD4+ count of 200 499 cells/ L.
Stage 3 is documented for a patient with a CD4+ count of less than 200 cells/ L.
PTS: 1
CON: Infection | Communication
12. ANS: 2
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV
Chapter page reference: 410
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
A fever is caused by infection.
2
Weight loss is generally caused by worsening of the disease or disease progression.
3
Night sweats are caused by a mycobacterial infection.
4
Dyspnea on exertion, but not at rest, is caused by Pneumocystis carinii pneumonia.
PTS: 1
CON: Infection
13. ANS: 1
Chapter number and title: 22, Coordinating Care for Patients With HIV
NURand
SIcontrasting
NGKINGclinical
.COM presentations of the disease spectrum of HIV
Chapter learning objective: Comparing
Chapter page reference: 410
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1
A fever is caused by infection.
2
Weight loss is generally caused by worsening of the disease or disease progression.
3
Night sweats are caused by a mycobacterial infection.
4
Dyspnea on exertion, but not at rest, is caused by Pneumocystis carinii pneumonia.
PTS: 1
CON: Infection
14. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV
Chapter page reference: 410
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
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Difficulty: Easy
Feedback
1
A fever is caused by infection.
2
Weight loss is generally caused by worsening of the disease or disease progression.
3
Night sweats are caused by a mycobacterial infection.
4
Dyspnea on exertion, but not at rest, is caused by Pneumocystis carinii pneumonia.
PTS: 1
CON: Infection
15. ANS: 4
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV
Chapter page reference: 411
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1
A fever is caused by infection.
2
Weight loss is generally caused by worsening of the disease or disease progression.
3
Night sweats are caused by a mycobacterial infection.
4
Dyspnea on exertion, but not at rest, is caused by Pneumocystis carinii pneumonia.
PTS: 1
CON: Infection
NURSINGKING.COM
16. ANS: 1
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV
Chapter page reference: 413
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Infection; Assessment
Difficulty: Moderate
Feedback
1
A new onset rash for a patient diagnosed with HIV is often a delayed reaction to a
prophylactic antibiotic, such as Bactrim. This question is the most appropriate.
2
While new soaps can cause a rash, this is not the most appropriate question for a patient
diagnosed with HIV who presents with a rash.
3
While new soaps can cause a rash, this is not the most appropriate question for a patient
diagnosed with HIV who presents with a rash.
4
Unprotected sex is unlikely to be the cause of a rash.
PTS: 1
CON: Infection | Assessment
17. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients With HIV
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Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological,
dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 415
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Planning
Client Need: Heath Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Promoting Health
Difficulty: Moderate
Feedback
1
This is a live virus vaccine and is contraindicated for a patient diagnosed with HIV.
2
This is a live virus vaccine and is contraindicated for a patient diagnosed with HIV.
3
The influenza vaccine is not a live virus vaccine and is recommended annually, early in
the flu season, for patients with HIV.
4
This is a live virus vaccine and is contraindicated for a patient diagnosed with HIV.
PTS: 1
CON: Promoting Health
18. ANS: 1
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological,
dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 415
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Safety and Infection Control
NURSINGKING.COM
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1
The priority nursing action in this situation is to wash the injury under running water.
2
The nurse should avoid squeezing the injury as this is likely to increase the risk for
infection.
3
The nurse may be prescribed several drugs for 28 days; however, this is not the priority
action.
4
The nurse is likely to consent to an HIV test; however, this is not the priority action.
PTS: 1
CON: Infection
19. ANS: 4
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Discussing the epidemiology of HIV
Chapter page reference: 416
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
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1
2
3
4
This patient is not within the suggested age range for HIV testing during an annual
physical examination.
This patient is not within the suggested age range for HIV testing during an annual
physical examination.
This patient is not within the suggested age range for HIV testing during an annual
physical examination.
The nurse offers HIV testing to all patients between the ages of 15 years and 65 years
of age.
PTS: 1
CON: Infection
20. ANS: 2
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV
Chapter page reference: 417
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
1
2
Feedback
Toxoplasmosis is a complication that occurs when
below 200 cells/ L. This complication typically indicates the patient has progressed
from HIV to acquired immunodeficiency syndrome (AIDS).
NURSINGKING.COM
between
500 and 350 cells/ L.
3
greater than 500 cells/ L.
4
and 200 cells/ L.
PTS: 1
CON: Infection
21. ANS: 1
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV
Chapter page reference: 417
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
below 200 cells/ L. This complication typically indicates the patient has progressed
from HIV to acquired immunodeficiency syndrome (AIDS).
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2
Herpes zoster virus is a complic
500 and 350 cells/ L.
3
4
greater than 500 cells/ L.
Severe bacterial infection is a complication that occurs when th
and 200 cells/ L.
PTS: 1
CON: Infection
22. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV
Chapter page reference: 417
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
below 200 cells/ L. This complication typically indicates the patient has progressed
from HIV to acquired immunodeficiency syndrome (AIDS).
2
500 and 350 cells/ L.
3
4
NURSINGKING.COM
greater than 500 cells/ L.
Severe bacterial infection is
and 200 cells/ L.
PTS: 1
CON: Infection
23. ANS: 4
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV
Chapter page reference: 417
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
below 200 cells/ L. This complication typically indicates the patient has progressed
from HIV to acquired immunodeficiency syndrome (AIDS).
2
500 and 350 cells/ L.
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3
Vaginal candidiasi
greater than 500 cells/ L.
4
and 200 cells/ L.
PTS: 1
CON: Infection
24. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological,
dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 419
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1
This patient statement indicates correct understanding regarding HIV management.
2
This patient statement indicates correct understanding regarding HIV management.
3
Adherence is essential in managing the progression of the disease. Taking medications
as ordered and at the same time each day (plan administration times around activities of
daily living) helps maintain therapeutic drug levels and decreases the risk of viral
resistance developing.
4
This patient statement indicates
understanding
HIV management.
NURcorrect
SING
KING.COregarding
M
PTS: 1
CON: Infection
COMPLETION
25. ANS:
435612
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Comparing and contrasting clinical presentations of the disease spectrum of HIV
Chapter page reference: 411
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback: The progression of HIV is as follows: first, viral transmission occurs; second, seroconversion
occurs; next, the patient has symptoms of an acute viral infection; fourth, the patient has an asymptomatic
chronic infection; fifth, the patient becomes symptomatic and is diagnosed with AIDS; lastly, the patient dies.
PTS: 1
26. ANS:
CON: Infection
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13452
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Describing diagnostic results used to confirm the diagnosis of HIV
Chapter page reference: 411
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback: The HIV virus gains entry into helper T cells, uses the cell DNA to replicate, interferes with
normal function of the T cells, and destroys the normal cells.
PTS: 1
CON: Infection
MULTIPLE RESPONSE
27. ANS: 2, 4, 5
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Developing a comprehensive plan of nursing care including pharmacological,
dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 417-419
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Implementation
NURSINGKING.COM
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. Tuberculosis skin tests should be administered annually, not every six
months.
This is correct. A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and
opportunistic infections because of the effect of the virus on the immune system. The nurse
teaches the family to keep those who have symptoms of illness away from the child and also
instructs them in proper hand-washing technique and proper food handling to prevent
infection.
This is incorrect. Fresh fruits and vegetables are not recommended for a patient with a
depressed immune system.
This is correct. A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and
opportunistic infections because of the effect of the virus on the immune system. The nurse
teaches the family to keep those who have symptoms of illness away from the child and also
instructs them in proper hand-washing technique and proper food handling to prevent
infection.
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5.
This is correct. A patient with HIV is at risk for a myriad of bacterial, viral, fungal, and
opportunistic infections because of the effect of the virus on the immune system. The nurse
teaches the family to keep those who have symptoms of illness away from the child and also
instructs them in proper hand-washing technique and proper food handling to prevent
infection.
PTS: 1
CON: Infection
28. ANS: 2, 3, 4
Chapter number and title: 22, Coordinating Care for Patients With HIV
Chapter learning objective: Describing diagnostic results used to confirm the diagnosis of HIV
Chapter page reference: 417-419
Heading: Human Immunodeficiency Virus (HIV)
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
This is incorrect. The risk of opportunistic infection is the most common manifestation of
AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The
normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the
CD4 cell count and the WBC, which was within normal range.
This is correct. The risk of opportunistic infection is the most common manifestation of AIDS.
The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal
NUthan
RSI1,000/mm
NGKIN3G. All
.Cof
OMthe labs are abnormal except for the CD4 cell
CD4 cell count is greater
count and the WBC, which was within normal range.
This is correct. The risk of opportunistic infection is the most common manifestation of AIDS.
The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal
CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell
count and the WBC, which was within normal range.
This is correct. The risk of opportunistic infection is the most common manifestation of AIDS.
The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The normal
CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the CD4 cell
count and the WBC, which was within normal range.
This is incorrect. The risk of opportunistic infection is the most common manifestation of
AIDS. The risk of opportunistic infection is predictable by the T4 and CD4 cell count. The
normal CD4 cell count is greater than 1,000/mm3. All of the labs are abnormal except for the
CD4 cell count and the WBC, which was within normal range.
1.
2.
3.
4.
5.
PTS: 1
CON: Infection
Chapter 23: Assessment of Respiratory Function
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. The nurse educator is teaching a student nurse how to auscultate the lungs. Which action by the student nurse
indicates the need for further education?
1) Listening to sound over the bony structures
2) Asking the client to sit in an upright position
3) Instructing the client to breathe slowly through mouth
4) Beginning auscultation from lung apices and moving toward intercostal spaces
____
2. The nurse is providing care to a patient who will need a bronchoscopy. Which patient statement indicates
appropriate understanding of the information presented?
1)
2)
3)
4)
____
3. The nurse is conducting a respiratory assessment for a patient who is diagnosed with asthma. Which
assessment finding indicates the patient is experiencing airway irritation?
1) Hemoptysis
2) Dry, hacking cough
3) Harsh, barky cough
4) Loose-sounding cough
____
4. The nurse is assessing a patient who is admitted with a persistent cough and is diagnosed with pulmonary
1)
2)
3)
4)
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Foul smelling sputum
Clear, whitish, or yellow sputum
Large amounts of frothy, pink tinged sputum
Clear to gray with occasional specks of brown sputum
____
5. The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding supports this
diagnosis?
1) Wheezing
2) Hemoptysis
3) Grey sputum
4) Slightly whitish sputum
____
6.
-pitched sound over the chest.
Which term does the nurse use to describe these sounds?
1) Dull
2) Tympany
3) Resonance
4) Hyperresonance
____
7. Which diagnostic procedure is used to remove pleural fluid for analysis?
1) Lung biopsy
2) Bronchoscopy
3) Thoracentesis
4) Sputum studies
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____
8. The nurse is providing care to a patient who undergoes a sputum study. Which will the sputum study help to
diagnose?
1) Asthma
2) Lung cancer
3) Bacterial lung infection
4) Chronic obstructive pulmonary disease
____
9.
nurse anticipate?
1) Bronchiectasis
2) Pleural effusion
3) Pulmonary edema
4) Chronic obstructive pulmonary disease
____ 10. The nurse is conducting a health history interview for a patient who is diagnosed with chronic obstructive
pulmonary disease (COPD). Which questio
-metabolic
pattern?
1)
2)
3)
4)
____ 11. The nurse assesses a patient who presents with tachypnea and clubbing of the fingers. Based on this data,
which diagnosis does the nurse anticipate for this patient?
1) Asthma
2) Chest trauma
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3) Chronic hypoxemia
4) Chronic pulmonary obstructive disease
____ 12. A patient is admitted to the emergency department (ED) with dyspnea. Upon assessment, the nurse notes a
lung fields. Based on this data, which diagnosis does the nurse anticipate?
1) Asthma
2) Pleural effusion
3) Pulmonary edema
4) Pulmonary fibrosis
____ 13. Which is the term used to describe abnormal breath sounds?
1) Vesicular
2) Bronchial
3) Adventitious
4) Bronchovesicular
____ 14. Which would the nurse assess when using palpation during the respiratory assessment?
1) Tracheal position
2) Bronchovesicular sounds
3) Lung density
4) Adventitious sounds
____ 15. The nurse is performing pulmonary function testing on a patient. Which nursing action is beneficial to the
patient?
1) Assessing for respiratory distress
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2) Scheduling the test after a meal
3) Providing rest before the procedure
4) Administering an inhaled bronchodilator six hours before procedure
____ 16. The nurse is caring for a patient with a suspected pulmonary embolism. Which radiology study does the nurse
anticipate to be beneficial for the patient?
1) Chest x-ray
2) Pulmonary angiogram
3) Computed tomography
4) Magnetic resonance imaging
____ 17. The nurse is caring for a patient with shortness of breath and respiratory rate of 28 breaths per minute. Which
is the most preferred method to auscultate the chest of the patient with this condition?
1) Listening at the apices
2) Listening at the lung bases
3) Listening by comparing opposite areas of the chest
4) Listening to each cycle of inspiratory and expiratory cycle
____ 18. What is the function of the epiglottis?
1) To aid in the sensation of smell
2) To conduct gases to the alveoli
3) To filter small particles before air enters the lungs
4) To prevent the entry of solids and liquids into the lungs
____ 19. Which interconnected structure allows the movement of air between the alveoli?
1) Bronchioles
2) Pores of Kohn
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3) Visceral pleura
4) Parietal pleura
____ 20. The nurse is providing care to a patient who is diagnosed with asthma. Which noninvasive method will the
1)
2)
3)
4)
Pulse oximetry
Arterial blood gas
Venous blood gas
Cardiopulmonary monitor
____ 21. The nurse is conducting a respiratory assessment. Which respiratory manifestation indicates inadequate
oxygenation?
1) Mild hypertension
2) Cool, clammy skin
3) Dyspnea on exertion
4) Unexplained apprehension
____ 22. The nurse is providing care to a patient who is diagnosed with pneumonia. The patient admits to smoking one
pack of cigarettes per day. Which respiratory defense mechanism may have failed to cause the patie
diagnosis?
1) Cough reflex
2) Filtration of air
3) Alveolar macrophages
4) Mucociliary clearance system
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____ 23. What is the location of central chemoreceptors?
1) Lungs
2) Pores of Kohn
3) Roof of the nose
4) Medulla oblongata
____ 24. Which structure is located in the lower respiratory tract?
1) Alveoli
2) Larynx
3) Trachea
4) Pharynx
____ 25. Which is the major muscle of respiration?
1) Accessory muscle
2) Intercostal muscle
3) Diaphragm muscle
4) Abdominal muscle
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease
(COPD). Which laboratory values will the nurse monitor when planning care for this client? Select all that
apply.
1) Elevated eosinophils count
2) Decreased neutrophils count NURSINGKING.COM
3) Elevated red blood cells count
4) Decreased partial pressure of arterial oxygen
5) Decreased partial pressure of arterial carbon dioxide
____ 27.
exercise patterns? Select all that apply.
1)
2)
3)
4)
5)
____ 28. During the respiratory assessment, the nurse notes coarse crackles upon auscultation of the lung fields. Which
diagnoses presents with this assessment finding? Select all that apply.
1) Pneumonia
2) Heart failure
3) Cystic fibrosis
4) Bronchospasm
5) Interstitial edema
____ 29. Which are age1) Decreased cilia function
2) Decreased chest wall compliance
3) Decreased response to hypoxemia
4) Decreased cell-mediated immunity
Select all that apply.
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5) Decreased respiratory muscle strength
____ 30. Which are age-related changes to respiratory control that may be observed when assessing the older adult
patient? Select all that apply.
1) Less forceful cough
2) Calcification of costal cartilage
3) Decreased response to hypoxemia
4) Decrease in number of functional alveoli
5) Decreased response to hypercapnia
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Chapter 23: Assessment of Respiratory Function
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
Heading: Assessment
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation; Assessment
Difficulty: Easy
Feedback
1
Auscultation is performed to identify fluid, mucus, or obstruction in the respiratory
system. The nurse should avoid auscultating sound over bony structures as it interferes
with the sound quality.
2
Upright position optimizes airflow and allows chest expansion which facilitates clear
respiratory sounds during auscultation.
3
Breathing slowly through an open mouth prevents transmission of turbulent sound and
helps to hear clear sound.
URSapices
INGand
KIN
G.COtoward
M intercostal spaces to the
4
Beginning auscultation fromNlung
moving
lung bases helps to compare one lung with the other at the same level.
PTS: 1
CON: Oxygenation | Assessment
2. ANS: 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to respiratory
function
Chapter page reference: 431-438
Heading: Diagnostic Studies
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1
The patient will be sedated during the procedure.
2
The patient will not require mechanical ventilation after this procedure.
3
The patient will need to have the prothrombin time evaluated prior to the procedure, not
after the procedure.
4
A bronchoscopy is the insertion of a tube in the airways to view airway structure and
obtain tissue sample for biopsy or culture. The patient will need to be NPO for eight
hours prior to the procedure to decrease the risk for aspiration.
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PTS: 1
CON: Oxygenation
3. ANS: 2
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
Heading: Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation; Assessment
Difficulty: Easy
Feedback
1
Hemoptysis often occurs with tuberculosis and does not indicate airway irritation.
2
A dry, hacking cough indicates the patient is experiencing airway irritation or
obstruction.
3
A harsh, barky cough suggests upper airway obstruction.
4
A loose-sounding cough indicates secretions.
PTS: 1
CON: Oxygenation | Assessment
4. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
NURSINGKING.COM
Heading: Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
Foul smelling sputum indicates an infection process.
2
Clear, whitish, or yellow sputum is often found for patients diagnosed with chronic
obstructive pulmonary disease especially in the early morning hours.
3
Large amounts of frothy pink tinged sputum support the diagnosis of pulmonary edema
which is characterized by a persistent cough.
4
Clear to grey sputum with brown specks indicates the patient is a smoker.
PTS: 1
CON: Oxygenation
5. ANS: 2
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
Heading: Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
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Concept: Oxygenation
Difficulty: Easy
Feedback
1
Wheezing is the term used to describe the musical sounds auscultated during
assessment and indicate some degree of airway obstruction that occurs with asthma and
emphysema.
2
Tuberculosis is characterized by hemoptysis, which is the term for coughing up of
blood or blood-tinged sputum from the respiratory tract.
3
Grey sputum often occurs in patients who are cigarette smokers.
4
Clear, slightly whitish, and viscous sputum are often normal findings.
PTS: 1
CON: Oxygenation
6. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
Heading: Assessment
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Dull in not an appropriate term to describe this assessment finding.
NURSINGKING.COM
2
Tympany is a drum-like loud empty quality heard over a gas filled stomach or intestine.
3
Low pitched sounds heard over normal lungs during percussion indicate resonance.
4
Hyperresonance is a loud lower pitched sound heard when percussing hyperinflated
lungs, which can occur in patients who are experiencing an acute asthma exacerbation.
PTS: 1
CON: Oxygenation
7. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Correlating relevant diagnostic examinations to respiratory function
Chapter page reference: 431-438
Heading: Diagnostic Studies
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Knowledge [Remembering]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
A lung biopsy involves taking a sample of tissue, not fluid, for analysis.
2
A bronchoscopy involves the use of a flexible fiberoptic scope for diagnosis, biopsy, or
specimen collection.
3
A thoracentesis is a diagnostic procedure used to remove pleural fluid for analysis or to
instill medication.
4
Sputum studies are obtained by expectoration and tracheal suction.
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PTS: 1
CON: Oxygenation
8. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Correlating relevant diagnostic examinations to respiratory function
Chapter page reference: 431-438
Heading: Diagnostic Studies
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
Sputum studies are not used to diagnose asthma, lung cancer, or chronic obstructive
pulmonary disease.
2
Sputum studies are not used to diagnose asthma, lung cancer, or chronic obstructive
pulmonary disease.
3
A sputum study is often used to diagnose bacterial lung infections via a culture and
sensitivity.
4
Sputum studies are not used to diagnose asthma, lung cancer, or chronic obstructive
pulmonary disease.
PTS: 1
CON: Oxygenation
9. ANS: 4
Chapter number and title: 23, Assessment of Respiratory Function
NURSINGKING.COM
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
Heading: Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty:
1
2
3
4
Feedback
Rhonchi are observed in patients with bronchiectasis.
Diminished breath sounds are observed in pleural effusion.
Coarse crackles are observed in patients with pulmonary edema.
Wheezes are continuous high-pitched squeaking or rapid sounds caused by the rapid
vibration of the bronchial walls, which is caused by a blockage in airways which often
occurs with chronic obstructive pulmonary disease.
PTS: 1
CON: Oxygenation
10. ANS: 1
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Heading: Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation; Assessment
Difficulty: Moderate
Feedback
1
2
3
-metabolic pattern
the appropriate question to ask is if the patient has experienced any weight loss.
Asking about trouble getting to the toilet assesses the effect that COPD has on the
Asking the patient about waking in the middle of the night with breathing issues
-rest.
4
and perception.
PTS: 1
CON: Oxygenation | Assessment
11. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
Heading: Assessment
Integrated Processes: Nursing Process Assessment
NUR
SINGKINAdaptation
G.COM
Client Need: Physiological Integrity
Physiological
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
Pursed lip breathing, inability to lie in flat position, and use of accessory muscles to
assist in breathing are findings observed in patients with asthma and chronic obstructive
pulmonary disease.
2
Voluntary decrease in tidal volume to reduce pain on chest expansion is referred as
splinting, which is a common manifestation of chest trauma or pleurisy.
3
Tachypnea and clubbing of the fingers are assessment findings that support the
diagnosis of chronic hypoxemia.
4
Pursed lip breathing, inability to lie in flat position, and use of accessory muscles to
assist in breathing are findings observed in patients with asthma and chronic obstructive
pulmonary disease.
PTS: 1
CON: Oxygenation
12. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
Heading: Assessment
Integrated Processes: Nursing Process Assessment
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
Wheezing and hyperresonance on percussion support the diagnosis of asthma.
2
Tachypnea, diminished or absent breath sounds, and dullness on percussion support the
diagnosis of pleural effusion.
3
Dyspnea, cyanosis, fine crackles and dullness on percussion all support the diagnosis of
pulmonary edema.
4
Tachypnea, crackles, and resonance on percussion support the diagnosis of pulmonary
fibrosis.
PTS: 1
CON: Oxygenation
13. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Discussing the function of the respiratory system
Chapter page reference: 427-431
Heading: Assessment
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Knowledge [Understanding]
Concept: Oxygenation; Communication
Difficulty: Easy
Feedback
NURSINGKING.COM
1
Vesicular sound is relatively soft, low pitched, gentle, rustling sounds.
2
Bronchial sounds are louder, higher pitched and resemble air blowing through a hollow
pipe.
3
Adventitious is the term used to describe abnormal breath sounds such as crackles,
rhonchi, wheezes, and a pleural friction rub.
4
Bronchovesicular sounds have a medium pitch and intensity and are heard anteriorly
over the main stem bronchi on either side of the sternum and posteriorly between the
scapulae.
PTS: 1
CON: Oxygenation | Communication
14. ANS: 1
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
Heading: Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Oxygenation; Assessment
Difficulty: Moderate
Feedback
1
Palpation is used to determine tracheal position.
2
Auscultation is used to determine breath sounds, both normal and adventitious.
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3
4
Percussion is used to assess lung density.
Auscultation is used to determine breath sounds, both normal and adventitious.
PTS: 1
CON: Oxygenation | Assessment
15. ANS: 1
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Explaining nursing considerations for diagnostic studies relevant to respiratory
function
Chapter page reference: 431-438
Heading: Diagnostic Studies
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Oxygenation; Assessment
Difficulty: Moderate
Feedback
1
A nursing action that is appropriate when providing care to a patient who is having
pulmonary function tests is to assess the patient for respiratory distress.
2
The nurse would avoid scheduling the procedure after a meal.
3
The nurse would provide rest for the patient after the procedure.
4
The nurse would avoid administering an inhaled bronchodilator six hours before the
procedure.
PTS: 1
CON: Oxygenation | Assessment
16. ANS: 3
NURSINGKING.COM
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Correlating relevant diagnostic examinations to respiratory function
Chapter page reference: 431-438
Heading: Diagnostic Studies
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
Chest x-ray is used to screen, diagnose, and evaluate changes in respiratory system.
2
Pulmonary angiogram is used to visualize vasculature and locate obstruction or
pathologic conditions.
3
Computed tomography (CT) is used in the diagnosis of lesions that are difficult to
assess by conventional x-ray studies. Common types of CT are helical or spiral. Spiral
CT is used to diagnose pulmonary embolism.
4
Magnetic resonance imaging is used for diagnosis of lesions that are difficult to assess
by CT scan.
PTS: 1
CON: Oxygenation
17. ANS: 2
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
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Chapter page reference: 427-431
Heading: Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation; Assessment
Difficulty: Moderate
Feedback
1
Generally, the auscultation should proceed from the lung apices to bases.
2
Listening at the lung bases is the most preferred method in a patient with respiratory
distress. This is due to the increased respiratory rate and shortness of breath, which may
tire the patient easily.
3
Listening comparing opposite areas of the chest is beneficial in patients with respiratory
distress.
4
For auscultation, place the stethoscope and listen to each cycle of inspiratory and
expiratory cycle.
PTS: 1
CON: Oxygenation | Assessment
18. ANS: 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Discussing the function of the respiratory system
Chapter page reference: 422-427
Heading: Overview of Anatomy and Physiology
Integrated Processes: Nursing Process Assessment
Client Need: Health Promotion and Maintenance
NURSINGKING.COM
Cognitive level: Knowledge [Remembering]
Concept: Oxygenation
Difficulty: Easy
1
2
3
4
Feedback
The olfactory nerve endings in the roof of the nose are responsible for the sense of
smell.
The bronchi and the trachea act as a pathway to conduct gases to the alveoli.
The nose functions to protect the lower airway by warming and humidifying air and
filtering small particles before the air enters the lungs.
The epiglottis is a small flap located behind the tongue that closes over the larynx
during swallowing. The function of the epiglottis is to prevent solids and liquids from
entering the lungs.
PTS: 1
CON: Oxygenation
19. ANS: 2
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Identifying key anatomical components of the respiratory system
Chapter page reference: 422-427
Heading: Overview of Anatomy and Physiology
Integrated Processes: Nursing Process Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Knowledge [Remembering]
Concept: Oxygenation
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Difficulty: Easy
Feedback
1
The main stem bronchi subdivide to form lobar, segmental and subsegmental bronchi.
Further divisions form bronchioles, which cause bronchoconstriction and
bronchodilation.
2
The alveoli are interconnected by pores of Kohn which allow the passage of air from
alveolus to alveolus.
3
Lungs are lined by a membrane called visceral pleura.
4
The chest cavity is lined with a membrane called parietal pleura.
PTS: 1
CON: Oxygenation
20. ANS: 1
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
Heading: Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Pulse oximetry is a noninvasive procedure that is used to measure oxygen levels in the
blood and thereby assess the efficiency of gas exchange in the lungs and tissue
NURSINGKING.COM
oxygenation.
2
Arterial and venous blood gas analysis are invasive methods to monitor oxygenation
status.
3
Arterial and venous blood gas analysis are invasive methods to monitor oxygenation
status.
4
A cardiopulmonary monitor is used to assess heart rate and respiratory rate. While it is
noninvasive, it will not allow the nurse to assess
PTS: 1
CON: Oxygenation
21. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
Heading: Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
Mild hypertension and cool, clammy skin are cardiovascular manifestations of
inadequate oxygenation.
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2
3
4
Mild hypertension and cool, clammy skin are cardiovascular manifestations of
inadequate oxygenation.
Dyspnea on exertion, or shortness of breath with activity, is a respiratory manifestation
that indicates inadequate oxygenation.
Unexplained apprehension is a central nervous system manifestation of inadequate
oxygenation.
PTS: 1
CON: Oxygenation
22. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Identifying key anatomical components of the respiratory system
Chapter page reference: 422-427
Heading: Overview of Anatomy and Physiology
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
The cough reflex, filtration of air, and mucociliary clearance are not the respiratory
defense mechanisms that failed in this scenario.
2
The cough reflex, filtration of air, and mucociliary clearance are not the respiratory
defense mechanisms that failed in this scenario.
3
Alveolar macrophages rapidly phagocytize inhaled foreign particles such as bacteria
and often fail as a result of cigarette smoking.
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4
The cough reflex, filtration of air, and mucociliary clearance are not the respiratory
defense mechanisms that failed in this scenario.
PTS: 1
CON: Oxygenation
23. ANS: 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Identifying key anatomical components of the respiratory system
Chapter page reference: 422-427
Heading: Overview of Anatomy and Physiology
Integrated Processes: Nursing Process Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Knowledge [Remembering]
Concept: Oxygenation
Difficulty: Easy
1
2
3
4
Feedback
Mechanical receptors such as juxtacapillary and irritant receptors are located in the
lungs, chest wall, and diaphragm.
The alveoli are interconnected by Pores of Kohn which allow movement of air from
alveolus to alveolus.
Olfactory nerve endings are located in the roof of the nose that are responsible for the
sense of smell.
Central chemoreceptors are located in the medulla oblongata and respond to changes in
pH in the cerebrospinal fluid.
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PTS: 1
CON: Oxygenation
24. ANS: 1
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Identifying key anatomical components of the respiratory system
Chapter page reference: 422-427
Heading: Overview of Anatomy and Physiology
Integrated Processes: Nursing Process Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Knowledge [Remembering]
Concept: Oxygenation
Difficulty: Easy
1
2
3
4
Feedback
Alveoli are structures found in the lower respiratory tract.
The larynx, trachea and pharynx are structures located in the upper respiratory tract.
The larynx, trachea and pharynx are structures located in the upper respiratory tract.
The larynx, trachea and pharynx are structures located in the upper respiratory tract.
PTS: 1
CON: Oxygenation
25. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Identifying key anatomical components of the respiratory system
Chapter page reference: 422-427
Heading: Overview of Anatomy and Physiology
NURSINGKING.COM
Integrated Processes: Nursing Process Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Knowledge [Remembering]
Concept: Oxygenation
Difficulty: Easy
1
2
3
4
Feedback
Accessory muscle is a relatively rare anatomic duplication of muscle that may appear
anywhere in the muscular system.
The intercostal muscles are several groups of muscles that run between the ribs and
help form and move their chest wall.
Diaphragm is the major muscle of respiration. It is a sheet of internal skeletal muscle.
Abdominal muscle supports the trunk, allows movement and hold organs in place by
regulating internal abdominal pressure and assist in expelling air during labored
breathing.
PTS: 1
CON: Oxygenation
MULTIPLE RESPONSE
26. ANS: 1, 3, 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Correlating relevant diagnostic examinations to respiratory function
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Chapter page reference: 431-438
Heading: Diagnostic Studies
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is correct. Eosinophilic airway inflammation occurs with COPD which results in elevated
levels of eosinophils.
This is incorrect. Viral disease like influenza decreases neutrophils count.
This is correct. COPD produces hypoxic stimulus which causes excessive production of
erythropoietin. It elevates the red blood cells count.
This is correct. COPD reduces level of oxygen in the blood and results in decreased partial
pressure of arterial oxygen.
This is incorrect. COPD elevates partial pressure of arterial carbon dioxide. Decreased partial
pressure of arterial carbon dioxide is observed in hyperventilation/respiratory alkalosis.
PTS: 1
CON: Oxygenation
27. ANS: 2, 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
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Heading: Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Application [Applying]
Concept: Oxygenation; Assessment
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is incorrect. Asking the patient about urinary incontinence with coughing is appropriate
when assessing elimination patterns.
This is correct. When assessing the effects that a respiratory diagnosis has on activity-exercise
patterns the nurse will ask the patient if walking is impacted by dyspnea and how many flights
of steps can be walked before dyspnea occurs.
This is incorrect. Asking the patient if the spouse wakes him or her in the middle of the night
due to snoring assess sleep-rest patterns.
This is correct. When assessing the effects that a respiratory diagnosis has on activity-exercise
patterns the nurse will ask the patient if walking is impacted by dyspnea and how many flights
of steps can be walked before dyspnea occurs.
This is incorrect. Asking the patient if there is a feeling of fullness quickly upon eating is
-metabolic pattern.
PTS: 1
CON: Oxygenation | Assessment
28. ANS: 1, 2
Chapter number and title: 23, Assessment of Respiratory Function
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Chapter learning objective: Describing the procedure for completing a history and physical assessment of
respiratory function
Chapter page reference: 427-431
Heading: Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is correct. Coarse crackles are often auscultated for patients diagnosed with pneumonia or
heart failure.
This is correct. Coarse crackles are often auscultated for patients diagnosed with pneumonia or
heart failure.
This is incorrect. Rhonchi is auscultated for patients diagnosed with cystic fibrosis.
This is incorrect. Wheezes are auscultated when the patient is experiencing bronchospasm.
This is incorrect. Discontinuous low pitched lung sounds are auscultated for patients
experiencing interstitial edema.
PTS: 1
CON: Oxygenation
29. ANS: 1, 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Discussing changes in respiratory function associated with aging
Chapter page reference: 438
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Heading: Age-Related Changes of the Respiratory System
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is correct. There are three categories of age-related changes that impact the respiratory
system, including changes in structure, defense mechanisms, and respiratory control. A
decrease in cilia function and cell-mediated immunity are both age-related defense mechanism
changes.
This is incorrect. Decreased chest wall compliance is a structural change.
This is incorrect. Decreased response to hypoxemia is a respiratory control change.
This is correct. There are three categories of age-related changes that impact the respiratory
system, including changes in structure, defense mechanisms, and respiratory control. A
decrease in cilia function and cell-mediated immunity are both age-related defense mechanism
changes
This is incorrect. Decreased respiratory muscle strength is an age-related structural change.
PTS: 1
CON: Oxygenation
30. ANS: 3, 5
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: Discussing changes in respiratory function associated with aging
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Chapter page reference: 438
Heading: Age-Related Changes of the Respiratory Assessment
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
This is incorrect. A less forceful cough is an age-related change to respiratory defense
mechanisms.
This is incorrect. Calcification of the costal cartilage and a decrease in functional alveoli are
age-related structural changes to the respiratory system.
This is correct. Age-related changes to respiratory control include decreased responses to
hypoxemia and hypercapnia.
This is incorrect. Calcification of the costal cartilage and a decrease in functional alveoli are
age-related structural changes to the respiratory system.
This is correct. Age-related changes to respiratory control include decreased responses to
hypoxemia and hypercapnia.
1.
2.
3.
4.
5.
PTS: 1
CON: Oxygenation
NURSINGKING.COM
Chapter 24: Coordinating Care for Patients With Infectious Respiratory Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. The nurse is assessing several patients at a community clinic. Which patient should not receive an annual
influenza vaccination?
1) A 65-year-old woman
2) A 3-year-old with cystic fibrosis
3) A 35-year-old man with a severe allergy to eggs
4) A 25-year-
____
2. A patient with the flu is experiencing tachypnea. What intervention is inappropriate to address in the nursing
diagnosis of Ineffective Breathing Pattern related to the flu?
1) Maintain adequate hydration
2) Keep the head of the bed elevated
3) Teach the patient coughing, deep breathing, and hydration
4) Prepare the patient for the possibility of a tracheostomy tube.
____
3. The nurse makes a home visit to a patient recovering from complications related to influenza. Which patient
statement indicates the need for further intervention by the nurse?
1)
2)
3)
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4)
____
4. The nurse is reviewing diagnostic and laboratory studies performed for an older adult patient with influenza.
Which result should the nurse recognize as being consistent with influenza?
1) Increased BUN
2) Decreased sodium level
3) Fluid-filled lungs on chest x-ray
4) Decreased white blood cell count
____
5. The nurse is planning care for a patient diagnosed with influenza. Which intervention should the nurse include
1)
2)
3)
4)
____
Placing a ventilator in the room
Notifying other departments of the diagnosis
Placing the patient in a negative air flow room
Placing droplet and contact precaution signs on the patient room door
6.
initial assessment?
1) Lethargy
2) Hemoptysis
3) Increased appetite
4) Increased respirations
____
7. A nurse is caring for an older adult patient admitted to the hospital with pneumonia. The patient asks the
nurse what can be done to decrease the risk for developing pneumonia in the future. Which response by the
nurse is inappropriate?
1)
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2) "You can start by not smoking."
3) "You can get the pneumonia vaccination, which may help to decrease your risk in the
future."
4) "You should drink a yogurt drink once a day that is supplemented with L. casei immunitas
cultures."
____
8. The nurse is caring for an older adult patient who is hospitalized with a second episode of pneumonia in the
past 18 months. The patient has expressed frustration to the nurse and states, "I never got sick when I was
younger. Why is this happening?" Which response by the nurse is most appropriate?
1)
2)
decrease in the immune response, which puts you at greater
3)
4)
____
r of B cells in the circulation, which
9. The nurse determines that the diagnosis of Ineffective Airway Clearance is appropriate for a patient with
pneumonia who is experiencing copious amounts of respiratory secretions. Which intervention should the
nurse include in this patient's plan of care?
1) Perform chest percussion every four hours and prn
2) Administer the pneumococcal vaccine prior to discharge
3) Limit fluid intake to 1,000 mL per day
4) Provide the patient with smoking cessation education
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____ 10. The nurse is providing discharge teaching to a patient recovering from pneumonia. Which patient statement
indicates that additional teaching is needed?
1)
2)
3)
4)
____ 11. The nurse is providing care to a patient with pneumonia and has a fever. Which intervention should the nurse
implement to attain the goal of normal body temperature?
1) Increase the temperature of the room environment to prevent shivering
2) Administer antipyretic medications
3) Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance
4) Use ice packs and a tepid bath every two hours
____ 12. The nurse is preparing to assess an older adult patient admitted with tuberculosis. Which manifestations does
the nurse anticipate for this patient?
1) Night sweats
2) Swollen lymph nodes
3) Cough
4) Hemoptysis
____ 13. An adolescent patient is brought to the emergency department (ED) with fatigue, weight loss, a dry cough,
and night sweats. The family just recently immigrated to the United States. Based on this data, for which
potential risk should the nurse include when planning care for this patient?
1) Pneumothorax
2) Pneumonia
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3) Renal failure
4) Septicemia
____ 14. The nurse in an inner city clinic is providing a health screening for a homeless patient with a history of drug
abuse. The patient has a chronic nonproductive cough. For which should the nurse expect to screen this
patient?
1) Herpes zoster
2) Sickle cell disease
3) Sick sinus syndrome
4) Tuberculosis
____ 15. The nurse is planning care for an older adult patient recently diagnosed with tuberculosis (TB). The patient
lives alone in an apartment and will continue treatment at home. Which nursing diagnosis is a priority for this
patient?
1) Ineffective Therapeutic Regimen Management
2) Deficient Knowledge
3) Ineffective Breathing Pattern
4) Risk for Injury
____ 16. An occupational health nurse is screening a new employee in a long-term care facility for tuberculosis (TB).
The employee questions why purified protein derivative (PPD) testing is done twice. Which is the most
appropriate response by the nurse?
1)
2)
want to make sure the first
3)
-
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4)
-negative response for people who work in long-term
care facilities. The two-
____ 17. The nurse is caring for a patient who is receiving multiple drugs for treatment of tuberculosis. The nurse
teaches the patient the rationale for the multiple-drug treatment and evaluates learning as effective when the
patient makes which statement?
1)
2)
3)
4)
____ 18. The nurse is caring for a patient who is admitted to the unit with tuberculosis (TB). The patient is placed in
isolation. To protect the caregivers and other patients on the unit, which type of isolation room is most
appropriate?
1) Single-door room with positive air flow (air flows out of the room.)
2) Isolation room with an anteroom and negative air flow (air flows into the room.)
3) Isolation room with an anteroom and normal airflow
4) Single-door room with normal airflow
____ 19. The charge nurse for a medical-surgical unit is notified that a patient with tuberculosis (TB) is being
transported to the unit. Which nursing action for infection prevention is the most appropriate in this
circumstance?
1)
2) Wear a respirator mask and gown when caring for the patient
3) Perform hand hygiene only after leaving the room
4) Test all staff members for TB immediately
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____ 20. A nurse is caring for a patient with tuberculosis (TB) who is taking Rifampin for treatment of the disease.
Which nursing intervention is most appropriate for this patient?
1) Administer the medication with meals to reduce gastrointestinal side effects
2) Record a baseline visual examination before initiating therapy
3) Administer the medication on an empty stomach
4) Administer the medication by deep intramuscular injection into a large muscle mass
____ 21. The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding supports this
diagnosis?
1) Wheezing
2) Hemoptysis
3) Grey sputum
4) Slightly whitish sputum
____ 22. During the respiratory assessment, the nurse notes coarse crackles upon auscultation of the lung fields. Which
diagnosis presents with this assessment finding?
1) Pneumonia
2) Cystic fibrosis
3) Bronchospasm
4) Interstitial edema
____ 23. The nurse is providing care to a patient who is diagnosed with pneumonia. The patient admits to smoking one
diagnosis?
1) Cough reflex
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2) Filtration of air
3) Alveolar macrophages
4) Mucociliary clearance system
____ 24. The nurse receives a phone call from the parent of a child who is prescribed rifampin (Rimactane) for
accurate?
1)
2)
3)
4)
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 25. The nurse caring for a homeless patient at risk for tuberculosis (TB) will include which symptoms of the
disease when educating the patient? Select all that apply.
1) Fatigue
2) Low-grade morning fever
3) Productive cough that later turns to a dry, hacking cough
4) Weight loss
5) Night sweats
____ 26. The nurse is assessing a patient with acute malaise and muscle aches. Which questions should the nurse ask to
determine whether the patient is experiencing influenza? Select all that apply.
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1)
2)
3)
4)
5)
____ 27. The school nurse is planning a teaching session with the parents of students to reduce the spread of the
influenza virus throughout the school. What should the nurse include when teaching the parents of a diverse
population about infection-control techniques? Select all that apply.
1)
2) Appropriate hand hygiene
3) Safe food preparation and storage
4) Sanitizing high-touch items to kill pathogens
5) Withholding immunizations for children with compromised immune systems
____ 28. The nurse is caring for a patient who develops a fever and productive cough after having an appendectomy.
Which prescriptions should the nurse expect from the health-care provider for this health problem? Select all
that apply.
1) Sputum cultures
2) Antibiotics
3) Chest physiotherapy
4) Bronchial washing for culture
5) Isolation precautions
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Chapter 24: Coordinating Care for Patients With Infectious Respiratory Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Describing the etiology of infectious airway disorders
Chapter page reference: 443-447
Heading: Influenza
Integrated Processes: Nursing Process Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1
People at increased risk of influenza or its complications include infants, young
children, and anyone age 50 or older; therefore, this patient should receive an annual
influenza vaccine.
2
Patients with chronic disorders, especially diabetes and cardiac, renal, or pulmonary
diseases, are more susceptible to complications from the flu; therefore, this patient
should receive an annual influenza vaccine.
3
A 35-year-old man with a severe allergy to eggs should not get a flu shot, because the
vaccine contains eggs and it is not recommended.
NUduring
RSIthe
NGsecond
KINGand
.CO
M trimesters, are at increased
4
Pregnant women, particularly
third
risk of complications from the flu; therefore, this patient should receive the annual
influenza vaccine.
PTS: 1
CON: Infection
2. ANS: 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with infectious
airway disorders
Chapter page reference: 443-447
Heading: Influenza
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Coughing, deep breathing, and hydration are essential for achieving airway clearance.
2
Keeping the head of the bed elevated improves lung excursion and reduces the work of
breathing.
3
Coughing, deep breathing, and hydration are essential for achieving airway clearance.
4
Insertion of a tracheostomy and oxygen are not primary treatments for ineffective
airway clearance.
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PTS: 1
CON: Oxygenation
3. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with infectious
airway disorders
Chapter page reference: 443-447
Heading: Influenza
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1
This patient statement does not indicate the need for further intervention by the nurse.
2
This patient statement does not indicate the need for further intervention by the nurse.
3
A patient who continues to be awoken during the night because of coughing may
require further intervention by the nurse.
4
This patient statement does not indicate the need for further intervention by the nurse.
PTS: 1
CON: Oxygenation
4. ANS: 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of infectious
airway disorders
Chapter page reference: 443-447
NURSINGKING.COM
Heading: Influenza
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1
Laboratory tests for BUN and sodium levels are not usually associated with influenza.
2
Laboratory tests for BUN and sodium levels are not usually associated with influenza.
3
Unless the patient with influenza develops complications, the chest x-ray is clear.
4
The white blood cell count of a patient with influenza will typically be decreased.
PTS: 1
CON: Infection
5. ANS: 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Influenza
Chapter page reference: 443-447
Heading: Influenza
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
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1
2
3
4
There is no indication that this patient will need a ventilator.
Placing signs on the door is the way to notify other departments of precautions.
Negative air flow rooms are for diseases such as chicken pox, measles, and SARS.
To prevent the spread of influenza, the patient is placed in a private room with signs for
droplet and contact precautions. It is appropriate for the health-care workers to use
appropriate PPE for these transmission-based precautions.
PTS: 1
CON: Infection
6. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Influenza
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
Frequently, caregivers or family members note that the patient looks generally ill. The
patient is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis
is seen in pneumonia, and the respiratory rate would be greater than 20.
2
Frequently, caregivers or family members note that the patient looks generally ill. The
patient is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis
is seen in pneumonia, and the respiratory rate would be greater than 20.
NURSINGKING.COM
3
A decreased, not increased, appetite is anticipated when providing care to a patient
diagnosed with pneumonia.
4
Frequently, caregivers or family members note that the patient looks generally ill. The
patient is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis
is seen in pneumonia, and the respiratory rate would be greater than 20.
PTS: 1
CON: Oxygenation
7. ANS: 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with infectious airway disorders
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Research indicates a high rate of pneumonia in patients with frequent exposure to
cigarette smoke and alcohol use. Alcohol interferes with the actions of macrophages.
2
Research indicates a high rate of pneumonia in patients with frequent exposure to
cigarette smoke and alcohol use. Smoking injures tissues in the airways and decreases
the action of cilia. Chemicals in cigarettes have a numbing effect on the cough reflex.
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3
4
Pneumonia vaccines can also be considered to decrease the risk of development in the
future.
There is not an established body of scientific evidence that supports the claim that L.
casei immunitas cultures can improve immune function.
PTS: 1
CON: Oxygenation
8. ANS: 2
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with infectious airway disorders
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
This is not an appropriate response by the nurse.
2
As a person grows older, there is an overall decrease in the speed and strength of the
immune response. The immune system does not quit working totally. There is a
decrease in the number of B cells in circulation.
3
This is not an appropriate response by the nurse.
4
This is not an appropriate response by the nurse.
NURSINGKING.COM
PTS: 1
CON: Oxygenation
9. ANS: 1
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Influenza
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Chest percussion can help clear secretions.
2
Providing education for smoking cessation and administering the pneumococcal
vaccine are important in treating a patient with pneumonia; however, they would be
aligned with a different nursing diagnosis.
3
Patients with pneumonia are encouraged to increase fluid intake.
4
Providing education for smoking cessation and administering the pneumococcal
vaccine are important in treating a patient with pneumonia; however, they would be
aligned with a different nursing diagnosis.
PTS: 1
CON: Oxygenation
10. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
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Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with infectious airway disorders
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1
Influenza vaccine is administered annually to healthy individuals and should not be
given to those with an allergy to eggs.
2
Influenza vaccine is administered annually to healthy individuals and should not be
given to those with an allergy to eggs.
3
The pneumococcal vaccine is administered once. Revaccination is only recommended
in persons with renal failure, those who have had splenectomies, those with
malignancies, and those with HIV/AIDS.
4
This statement indicates correct understanding of the information presented.
PTS: 1
CON: Oxygenation
11. ANS: 2
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Pneumonia
Chapter page reference: 447-451
Heading: Pneumonia
NURS
INGKING.COM
Integrated Processes: Nursing Process
Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution
and only as needed.
2
Hyperthermia is an expected consequence of the infectious disease process. Fever can
produce mild, short-term effects and, when prolonged, can cause life-threatening
effects. The nurse should administer antipyretic medications as indicated for elevated
temperatures and enforce frequent rest periods because rest increases energy reserve
that is depleted by increased metabolic, heart, and respiratory rates.
3
The nurse should encourage fluid intake rather than restrict fluids because of the risk of
electrolyte imbalance.
4
The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution
and only as needed.
PTS: 1
CON: Oxygenation
12. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Tuberculosis
Chapter page reference: 451-455
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Heading: Tuberculosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation; Infection
Difficulty: Easy
Feedback
1
Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting
symptoms of tuberculosis in the older adult.
2
Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting
symptoms of tuberculosis in the older adult.
3
Presenting symptoms of tuberculosis in the older adult are often vague and include
coughing, weight loss, diminished appetite, and periodic fevers.
4
Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting
symptoms of tuberculosis in the older adult.
PTS: 1
CON: Oxygenation | Infection
13. ANS: 1
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
NURSINGKING.COM
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
This patient was foreign-born, a risk factor for tuberculosis (TB), and has the classic
symptoms of tuberculosis. The nurse plans frequent respiratory assessments, as this
child is at risk for pneumothorax.
2
Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia.
3
Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia.
4
Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia.
PTS: 1
CON: Oxygenation
14. ANS: 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation; Infection
Difficulty: Easy
Feedback
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1
2
3
4
There is no evidence to support the need to screen the patient for sickle cell disease,
herpes zoster, or sick sinus syndrome.
There is no evidence to support the need to screen the patient for sickle cell disease,
herpes zoster, or sick sinus syndrome.
There is no evidence to support the need to screen the patient for sickle cell disease,
herpes zoster, or sick sinus syndrome.
The homeless patient who abuses drugs is at risk for contracting tuberculosis (TB);
therefore, the nurse would expect to screen this patient for TB.
PTS: 1
CON: Oxygenation | Infection
15. ANS: 1
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with infectious
airway disorders
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation; Infection
Difficulty: Difficult
Feedback
1
The treatment regimen for tuberculosis requires that the patient take many medications,
maintain nutrition, and be aware of potential side effects. Due to increased age and
normal forgetfulness, this patient is at risk for ineffective treatment in the home.
NURSINGKING.COM
2
The patient may have a knowledge deficit but the priority is the treatment regimen.
3
Since the patient is being treated in the home, there is not much risk for ineffective
breathing.
4
The patient is at risk for injury because of age, not TB.
PTS: 1
CON: Oxygenation | Infection
16. ANS: 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of infectious
airway disorders
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation; Infection
Difficulty: Moderate
Feedback
1
PPD testing is not done twice because different medication is used.
2
Treatment for TB for six months is not a reason to complete the PPD twice.
3
Evaluating the test at the wrong interval is not the reason that the PPD is done twice for
long-term care facility employees.
4
PPD testing is done in a two-step process for people who work in long-term care
facilities because of the risk of false-negative responses.
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PTS: 1
CON: Oxygenation | Infection
17. ANS: 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation; Infection
Difficulty: Difficult
Feedback
1
Multiple drugs are used for all cases of TB.
2
There is no indication that the patient contracted TB from an immigrant.
3
Treatment must be continued long after the patient is no longer contagious.
4
Tuberculosis bacilli are likely to develop resistance to one drug, so multiple drugs must
be used.
PTS: 1
CON: Oxygenation | Infection
18. ANS: 2
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
NURSINGKING.COM
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
Positive flow rooms are used for those patients who are immunosuppressed so that
microorganisms from the unit are not drawn into the room.
2
Patients with airborne infections such as meningococcemia, SARS, or TB are placed in
an isolation room with an anteroom and negative pressure airflow. Air flows into the
room and is vented in a special manner to prevent the organism from entering the rest
of the unit.
3
Single-door isolation with normal airflow might be used for a patient with droplet or
wound infection.
4
Single-door rooms are not equipped to have positive or negative airflow.
PTS: 1
CON: Infection
19. ANS: 2
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Safety and Infection Control
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Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
Supplies to prevent transmission of disease should be stocked at the end of the shift so
that adequate supplies will be available for the next health-care provider.
2
Masks and gowns should be worn when caring for patients who do not reliably cover
their mouths when coughing. When a patient has an airborne disease and must go
elsewhere in the hospital, the patient must wear a mask.
3
Hand hygiene should be performed before and after patient care.
4
Clinical staff receive TB testing annually. There is no reason to test all staff members at
this time.
PTS: 1
CON: Infection
20. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
NURSINGKING.COM
1
Rifampin is an oral antituberculosis medication that should be administered on an
empty, not full, stomach.
2
The nurse should monitor the CBC, liver function studies, and renal function studies. A
baseline visual examination before therapy is necessary with ethambutol, another
antituberculosis medication.
3
Rifampin is an oral antituberculosis medication that should be administered on an
empty stomach.
4
Rifampin is an oral antituberculosis medication.
PTS: 1
CON: Infection
21. ANS: 2
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
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1
2
3
4
Wheezing is the term used to describe the musical sounds auscultated during
assessment and indicate some degree of airway obstruction that occurs with asthma and
emphysema.
Tuberculosis is characterized by hemoptysis, which is the term for coughing up of
blood or blood-tinged sputum from the respiratory tract.
Grey sputum often occurs in patients who are cigarette smokers.
Clear, slightly whitish, and viscous sputum are often normal findings.
PTS: 1
CON: Oxygenation
22. ANS: 1
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Pneumonia
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
Coarse crackles are often auscultated for patients diagnosed with pneumonia.
2
Rhonchi is auscultated for patients diagnosed with cystic fibrosis.
3
Wheezes are auscultated when the patient is experiencing bronchospasm.
4
Discontinuous low pitched lung sounds are auscultated for patients experiencing
interstitial edema.
NURSINGKING.COM
PTS: 1
CON: Oxygenation
23. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Describing the etiology of infectious airway disorders
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
The cough reflex, filtration of air, and mucociliary clearance are not the respiratory
defense mechanisms that failed in this scenario.
2
The cough reflex, filtration of air, and mucociliary clearance are not the respiratory
defense mechanisms that failed in this scenario.
3
Alveolar macrophages rapidly phagocytize inhaled foreign particles such as bacteria
and often fail as a result of cigarette smoking.
4
The cough reflex, filtration of air, and mucociliary clearance are not the respiratory
defense mechanisms that failed in this scenario.
PTS: 1
CON: Oxygenation
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24. ANS: 2
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
Orange urine does not mean the child has a urinary tract infection, and a urinalysis,
radiograph, and encouragement of cranberry juice would not be options.
2
Rifampin can color the urine orange, so the parents and child should be taught that this
is an expected side effect.
3
Orange urine does not mean the child has a urinary tract infection, and a urinalysis,
radiograph, and encouragement of cranberry juice would not be options.
4
Orange urine does not mean the child has a urinary tract infection, and a urinalysis,
radiograph, and encouragement of cranberry juice would not be options.
PTS: 1
CON: Infection
MULTIPLE RESPONSE
25. ANS: 1, 4, 5
NURSINGKING.COM
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with infectious airway disorders
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation; Infection
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. Manifestations of tuberculosis often develop insidiously and are initially
nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that
the patient first seeks medical attention.
This is incorrect. A low-grade afternoon, not morning, fever is anticipated.
This is incorrect. A dry cough develops, which later becomes productive of purulent and/or
blood-tinged sputum.
This is correct. Manifestations of tuberculosis often develop insidiously and are initially
nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that
the patient first seeks medical attention.
This is correct. Manifestations of tuberculosis often develop insidiously and are initially
nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that
the patient first seeks medical attention.
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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PTS: 1
CON: Oxygenation | Infection
26. ANS: 1, 2, 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Influenza
Chapter page reference: 443-447
Heading: Influenza
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation; Infection
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. Based on the presenting symptoms, the nurse would ask whether the patient
has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is
nonproductive. A productive cough may indicate a different diagnosis.
This is correct. Based on the presenting symptoms, the nurse would ask whether the patient
has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is
nonproductive. A productive cough may indicate a different diagnosis.
This is correct. Based on the presenting symptoms, the nurse would ask whether the patient
has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is
nonproductive. A productive cough may indicate a different diagnosis.
This is incorrect. Insufficient voiding and dizziness are not routine manifestations of
influenza.
NURSI
NGKIand
NGdizziness
.COM are not routine manifestations of
This is incorrect. Insufficient
voiding
influenza.
PTS: 1
CON: Oxygenation | Infection
27. ANS: 1, 2, 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with infectious airway disorders
Chapter page reference: 443-447
Heading: Influenza
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
1.
Feedback
This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching
2.
education all control the growth and spread of microorganisms.
This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching
education all control the growth and spread of microorganisms.
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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3.
prevent the spread of microorganisms, but is not related to the flu virus.
This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching
4.
education all control the growth and spread of microorganisms. To prevent the spread of
communicable diseases, microorganisms must be killed or their growth controlled.
This is incorrect. Immunizations should not be withheld from immunocompromised children,
and this is not an infection-control strategy.
5.
PTS: 1
CON: Infection
28. ANS: 1, 2, 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Pneumonia
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and
perform chest physiotherapy to help clear the respiratory secretions.
This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and
NURSINGKING.COM
perform chest physiotherapy to help clear the respiratory secretions.
This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and
perform chest physiotherapy to help clear the respiratory secretions.
This is incorrect. Bronchial washings are not routine testing for this scenario.
This is incorrect. The patient likely has a noninfectious disease and is not contagious. Isolation
precautions are usually not ordered for noncontagious infections.
1.
2.
3.
4.
5.
PTS: 1
CON: Oxygenation
Chapter 24: Coordinating Care for Patients With Infectious Respiratory Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. The nurse is assessing several patients at a community clinic. Which patient should not receive an annual
influenza vaccination?
1) A 65-year-old woman
2) A 3-year-old with cystic fibrosis
3) A 35-year-old man with a severe allergy to eggs
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4) A 25-year____
2. A patient with the flu is experiencing tachypnea. What intervention is inappropriate to address in the nursing
diagnosis of Ineffective Breathing Pattern related to the flu?
1) Maintain adequate hydration
2) Keep the head of the bed elevated
3) Teach the patient coughing, deep breathing, and hydration
4) Prepare the patient for the possibility of a tracheostomy tube.
____
3. The nurse makes a home visit to a patient recovering from complications related to influenza. Which patient
statement indicates the need for further intervention by the nurse?
1)
2)
3)
4)
____
4. The nurse is reviewing diagnostic and laboratory studies performed for an older adult patient with influenza.
Which result should the nurse recognize as being consistent with influenza?
1) Increased BUN
2) Decreased sodium level
3) Fluid-filled lungs on chest x-ray
4) Decreased white blood cell count
____
5. The nurse is planning care for a patient diagnosed with influenza. Which intervention should the nurse include
1)
2)
3)
4)
Placing a ventilator in the room
Notifying other departments ofNthe
URdiagnosis
SINGKING.COM
Placing the patient in a negative air flow room
Placing droplet and contact precaution signs on the patient room door
____
6. An older adult patient is admitted with pneumonia. Which manifestation is unexpected durin
initial assessment?
1) Lethargy
2) Hemoptysis
3) Increased appetite
4) Increased respirations
____
7. A nurse is caring for an older adult patient admitted to the hospital with pneumonia. The patient asks the
nurse what can be done to decrease the risk for developing pneumonia in the future. Which response by the
nurse is inappropriate?
1)
2) "You can start by not smoking."
3) "You can get the pneumonia vaccination, which may help to decrease your risk in the
future."
4) "You should drink a yogurt drink once a day that is supplemented with L. casei immunitas
cultures."
____
8. The nurse is caring for an older adult patient who is hospitalized with a second episode of pneumonia in the
past 18 months. The patient has expressed frustration to the nurse and states, "I never got sick when I was
younger. Why is this happening?" Which response by the nurse is most appropriate?
1)
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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2)
older, there is a decrease in the immune response, which puts you at greater
3)
4)
____
rease in the number of B cells in the circulation, which
9. The nurse determines that the diagnosis of Ineffective Airway Clearance is appropriate for a patient with
pneumonia who is experiencing copious amounts of respiratory secretions. Which intervention should the
nurse include in this patient's plan of care?
1) Perform chest percussion every four hours and prn
2) Administer the pneumococcal vaccine prior to discharge
3) Limit fluid intake to 1,000 mL per day
4) Provide the patient with smoking cessation education
____ 10. The nurse is providing discharge teaching to a patient recovering from pneumonia. Which patient statement
indicates that additional teaching is needed?
1)
2)
3)
4)
____ 11. The nurse is providing care to a patient with pneumonia and has a fever. Which intervention should the nurse
implement to attain the goal of normal body temperature?
1) Increase the temperature of the room environment to prevent shivering
2) Administer antipyretic medications
NUhyperthermia
RSINGKIbecause
NG.CO
3) Restrict fluids during periods of
ofMthe risk of electrolyte imbalance
4) Use ice packs and a tepid bath every two hours
____ 12. The nurse is preparing to assess an older adult patient admitted with tuberculosis. Which manifestations does
the nurse anticipate for this patient?
1) Night sweats
2) Swollen lymph nodes
3) Cough
4) Hemoptysis
____ 13. An adolescent patient is brought to the emergency department (ED) with fatigue, weight loss, a dry cough,
and night sweats. The family just recently immigrated to the United States. Based on this data, for which
potential risk should the nurse include when planning care for this patient?
1) Pneumothorax
2) Pneumonia
3) Renal failure
4) Septicemia
____ 14. The nurse in an inner city clinic is providing a health screening for a homeless patient with a history of drug
abuse. The patient has a chronic nonproductive cough. For which should the nurse expect to screen this
patient?
1) Herpes zoster
2) Sickle cell disease
3) Sick sinus syndrome
4) Tuberculosis
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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____ 15. The nurse is planning care for an older adult patient recently diagnosed with tuberculosis (TB). The patient
lives alone in an apartment and will continue treatment at home. Which nursing diagnosis is a priority for this
patient?
1) Ineffective Therapeutic Regimen Management
2) Deficient Knowledge
3) Ineffective Breathing Pattern
4) Risk for Injury
____ 16. An occupational health nurse is screening a new employee in a long-term care facility for tuberculosis (TB).
The employee questions why purified protein derivative (PPD) testing is done twice. Which is the most
appropriate response by the nurse?
1)
2)
medication, and we want to make sure the first
3)
4)
-negative response for people who work in long-term
care facilities. The two-
____ 17. The nurse is caring for a patient who is receiving multiple drugs for treatment of tuberculosis. The nurse
teaches the patient the rationale for the multiple-drug treatment and evaluates learning as effective when the
patient makes which statement?
1)
2)
3)
4)
NUisRadmitted
SINGKtoIthe
NGunit
.CO
M tuberculosis (TB). The patient is placed in
____ 18. The nurse is caring for a patient who
with
isolation. To protect the caregivers and other patients on the unit, which type of isolation room is most
appropriate?
1) Single-door room with positive air flow (air flows out of the room.)
2) Isolation room with an anteroom and negative air flow (air flows into the room.)
3) Isolation room with an anteroom and normal airflow
4) Single-door room with normal airflow
____ 19. The charge nurse for a medical-surgical unit is notified that a patient with tuberculosis (TB) is being
transported to the unit. Which nursing action for infection prevention is the most appropriate in this
circumstance?
1)
2) Wear a respirator mask and gown when caring for the patient
3) Perform hand hygiene only after leaving the room
4) Test all staff members for TB immediately
____ 20. A nurse is caring for a patient with tuberculosis (TB) who is taking Rifampin for treatment of the disease.
Which nursing intervention is most appropriate for this patient?
1) Administer the medication with meals to reduce gastrointestinal side effects
2) Record a baseline visual examination before initiating therapy
3) Administer the medication on an empty stomach
4) Administer the medication by deep intramuscular injection into a large muscle mass
____ 21. The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding supports this
diagnosis?
1) Wheezing
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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2) Hemoptysis
3) Grey sputum
4) Slightly whitish sputum
____ 22. During the respiratory assessment, the nurse notes coarse crackles upon auscultation of the lung fields. Which
diagnosis presents with this assessment finding?
1) Pneumonia
2) Cystic fibrosis
3) Bronchospasm
4) Interstitial edema
____ 23. The nurse is providing care to a patient who is diagnosed with pneumonia. The patient admits to smoking one
diagnosis?
1) Cough reflex
2) Filtration of air
3) Alveolar macrophages
4) Mucociliary clearance system
____ 24. The nurse receives a phone call from the parent of a child who is prescribed rifampin (Rimactane) for
e nurse is
accurate?
1)
2)
3)
4)
NURSINGKING.COM
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 25. The nurse caring for a homeless patient at risk for tuberculosis (TB) will include which symptoms of the
disease when educating the patient? Select all that apply.
1) Fatigue
2) Low-grade morning fever
3) Productive cough that later turns to a dry, hacking cough
4) Weight loss
5) Night sweats
____ 26. The nurse is assessing a patient with acute malaise and muscle aches. Which questions should the nurse ask to
determine whether the patient is experiencing influenza? Select all that apply.
1)
2)
3)
4)
5)
____ 27. The school nurse is planning a teaching session with the parents of students to reduce the spread of the
influenza virus throughout the school. What should the nurse include when teaching the parents of a diverse
population about infection-control techniques? Select all that apply.
1)
2) Appropriate hand hygiene
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3) Safe food preparation and storage
4) Sanitizing high-touch items to kill pathogens
5) Withholding immunizations for children with compromised immune systems
____ 28. The nurse is caring for a patient who develops a fever and productive cough after having an appendectomy.
Which prescriptions should the nurse expect from the health-care provider for this health problem? Select all
that apply.
1) Sputum cultures
2) Antibiotics
3) Chest physiotherapy
4) Bronchial washing for culture
5) Isolation precautions
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Chapter 24: Coordinating Care for Patients With Infectious Respiratory Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Describing the etiology of infectious airway disorders
Chapter page reference: 443-447
Heading: Influenza
Integrated Processes: Nursing Process Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1
People at increased risk of influenza or its complications include infants, young
children, and anyone age 50 or older; therefore, this patient should receive an annual
influenza vaccine.
2
Patients with chronic disorders, especially diabetes and cardiac, renal, or pulmonary
diseases, are more susceptible to complications from the flu; therefore, this patient
should receive an annual influenza vaccine.
3
A 35-year-old man with a severe allergy to eggs should not get a flu shot, because the
vaccine contains eggs and it is not recommended.
NUduring
RSIthe
NGsecond
KINGand
.CO
M trimesters, are at increased
4
Pregnant women, particularly
third
risk of complications from the flu; therefore, this patient should receive the annual
influenza vaccine.
PTS: 1
CON: Infection
2. ANS: 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with infectious
airway disorders
Chapter page reference: 443-447
Heading: Influenza
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Coughing, deep breathing, and hydration are essential for achieving airway clearance.
2
Keeping the head of the bed elevated improves lung excursion and reduces the work of
breathing.
3
Coughing, deep breathing, and hydration are essential for achieving airway clearance.
4
Insertion of a tracheostomy and oxygen are not primary treatments for ineffective
airway clearance.
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PTS: 1
CON: Oxygenation
3. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with infectious
airway disorders
Chapter page reference: 443-447
Heading: Influenza
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1
This patient statement does not indicate the need for further intervention by the nurse.
2
This patient statement does not indicate the need for further intervention by the nurse.
3
A patient who continues to be awoken during the night because of coughing may
require further intervention by the nurse.
4
This patient statement does not indicate the need for further intervention by the nurse.
PTS: 1
CON: Oxygenation
4. ANS: 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of infectious
airway disorders
Chapter page reference: 443-447
NURSINGKING.COM
Heading: Influenza
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Infection
Difficulty: Easy
Feedback
1
Laboratory tests for BUN and sodium levels are not usually associated with influenza.
2
Laboratory tests for BUN and sodium levels are not usually associated with influenza.
3
Unless the patient with influenza develops complications, the chest x-ray is clear.
4
The white blood cell count of a patient with influenza will typically be decreased.
PTS: 1
CON: Infection
5. ANS: 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Influenza
Chapter page reference: 443-447
Heading: Influenza
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
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1
2
3
4
There is no indication that this patient will need a ventilator.
Placing signs on the door is the way to notify other departments of precautions.
Negative air flow rooms are for diseases such as chicken pox, measles, and SARS.
To prevent the spread of influenza, the patient is placed in a private room with signs for
droplet and contact precautions. It is appropriate for the health-care workers to use
appropriate PPE for these transmission-based precautions.
PTS: 1
CON: Infection
6. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Influenza
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
Frequently, caregivers or family members note that the patient looks generally ill. The
patient is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis
is seen in pneumonia, and the respiratory rate would be greater than 20.
2
Frequently, caregivers or family members note that the patient looks generally ill. The
patient is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis
is seen in pneumonia, and the respiratory rate would be greater than 20.
NURSINGKING.COM
3
A decreased, not increased, appetite is anticipated when providing care to a patient
diagnosed with pneumonia.
4
Frequently, caregivers or family members note that the patient looks generally ill. The
patient is lethargic and less coherent, and has stopped eating and drinking. Hemoptysis
is seen in pneumonia, and the respiratory rate would be greater than 20.
PTS: 1
CON: Oxygenation
7. ANS: 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with infectious airway disorders
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Research indicates a high rate of pneumonia in patients with frequent exposure to
cigarette smoke and alcohol use. Alcohol interferes with the actions of macrophages.
2
Research indicates a high rate of pneumonia in patients with frequent exposure to
cigarette smoke and alcohol use. Smoking injures tissues in the airways and decreases
the action of cilia. Chemicals in cigarettes have a numbing effect on the cough reflex.
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3
4
Pneumonia vaccines can also be considered to decrease the risk of development in the
future.
There is not an established body of scientific evidence that supports the claim that L.
casei immunitas cultures can improve immune function.
PTS: 1
CON: Oxygenation
8. ANS: 2
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with infectious airway disorders
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
This is not an appropriate response by the nurse.
2
As a person grows older, there is an overall decrease in the speed and strength of the
immune response. The immune system does not quit working totally. There is a
decrease in the number of B cells in circulation.
3
This is not an appropriate response by the nurse.
4
This is not an appropriate response by the nurse.
NURSINGKING.COM
PTS: 1
CON: Oxygenation
9. ANS: 1
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Influenza
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Chest percussion can help clear secretions.
2
Providing education for smoking cessation and administering the pneumococcal
vaccine are important in treating a patient with pneumonia; however, they would be
aligned with a different nursing diagnosis.
3
Patients with pneumonia are encouraged to increase fluid intake.
4
Providing education for smoking cessation and administering the pneumococcal
vaccine are important in treating a patient with pneumonia; however, they would be
aligned with a different nursing diagnosis.
PTS: 1
CON: Oxygenation
10. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
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Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with infectious airway disorders
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1
Influenza vaccine is administered annually to healthy individuals and should not be
given to those with an allergy to eggs.
2
Influenza vaccine is administered annually to healthy individuals and should not be
given to those with an allergy to eggs.
3
The pneumococcal vaccine is administered once. Revaccination is only recommended
in persons with renal failure, those who have had splenectomies, those with
malignancies, and those with HIV/AIDS.
4
This statement indicates correct understanding of the information presented.
PTS: 1
CON: Oxygenation
11. ANS: 2
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Pneumonia
Chapter page reference: 447-451
Heading: Pneumonia
NURS
INGKING.COM
Integrated Processes: Nursing Process
Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution
and only as needed.
2
Hyperthermia is an expected consequence of the infectious disease process. Fever can
produce mild, short-term effects and, when prolonged, can cause life-threatening
effects. The nurse should administer antipyretic medications as indicated for elevated
temperatures and enforce frequent rest periods because rest increases energy reserve
that is depleted by increased metabolic, heart, and respiratory rates.
3
The nurse should encourage fluid intake rather than restrict fluids because of the risk of
electrolyte imbalance.
4
The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution
and only as needed.
PTS: 1
CON: Oxygenation
12. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Tuberculosis
Chapter page reference: 451-455
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Heading: Tuberculosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation; Infection
Difficulty: Easy
Feedback
1
Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting
symptoms of tuberculosis in the older adult.
2
Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting
symptoms of tuberculosis in the older adult.
3
Presenting symptoms of tuberculosis in the older adult are often vague and include
coughing, weight loss, diminished appetite, and periodic fevers.
4
Night sweats, swollen lymph nodes, and hemoptysis are not considered presenting
symptoms of tuberculosis in the older adult.
PTS: 1
CON: Oxygenation | Infection
13. ANS: 1
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
NURSINGKING.COM
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
This patient was foreign-born, a risk factor for tuberculosis (TB), and has the classic
symptoms of tuberculosis. The nurse plans frequent respiratory assessments, as this
child is at risk for pneumothorax.
2
Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia.
3
Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia.
4
Patients with TB are not at particular risk for pneumonia, renal failure, or septicemia.
PTS: 1
CON: Oxygenation
14. ANS: 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation; Infection
Difficulty: Easy
Feedback
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1
2
3
4
There is no evidence to support the need to screen the patient for sickle cell disease,
herpes zoster, or sick sinus syndrome.
There is no evidence to support the need to screen the patient for sickle cell disease,
herpes zoster, or sick sinus syndrome.
There is no evidence to support the need to screen the patient for sickle cell disease,
herpes zoster, or sick sinus syndrome.
The homeless patient who abuses drugs is at risk for contracting tuberculosis (TB);
therefore, the nurse would expect to screen this patient for TB.
PTS: 1
CON: Oxygenation | Infection
15. ANS: 1
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with infectious
airway disorders
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation; Infection
Difficulty: Difficult
Feedback
1
The treatment regimen for tuberculosis requires that the patient take many medications,
maintain nutrition, and be aware of potential side effects. Due to increased age and
normal forgetfulness, this patient is at risk for ineffective treatment in the home.
NURSINGKING.COM
2
The patient may have a knowledge deficit but the priority is the treatment regimen.
3
Since the patient is being treated in the home, there is not much risk for ineffective
breathing.
4
The patient is at risk for injury because of age, not TB.
PTS: 1
CON: Oxygenation | Infection
16. ANS: 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of infectious
airway disorders
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation; Infection
Difficulty: Moderate
Feedback
1
PPD testing is not done twice because different medication is used.
2
Treatment for TB for six months is not a reason to complete the PPD twice.
3
Evaluating the test at the wrong interval is not the reason that the PPD is done twice for
long-term care facility employees.
4
PPD testing is done in a two-step process for people who work in long-term care
facilities because of the risk of false-negative responses.
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PTS: 1
CON: Oxygenation | Infection
17. ANS: 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation; Infection
Difficulty: Difficult
Feedback
1
Multiple drugs are used for all cases of TB.
2
There is no indication that the patient contracted TB from an immigrant.
3
Treatment must be continued long after the patient is no longer contagious.
4
Tuberculosis bacilli are likely to develop resistance to one drug, so multiple drugs must
be used.
PTS: 1
CON: Oxygenation | Infection
18. ANS: 2
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
NURSINGKING.COM
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
Positive flow rooms are used for those patients who are immunosuppressed so that
microorganisms from the unit are not drawn into the room.
2
Patients with airborne infections such as meningococcemia, SARS, or TB are placed in
an isolation room with an anteroom and negative pressure airflow. Air flows into the
room and is vented in a special manner to prevent the organism from entering the rest
of the unit.
3
Single-door isolation with normal airflow might be used for a patient with droplet or
wound infection.
4
Single-door rooms are not equipped to have positive or negative airflow.
PTS: 1
CON: Infection
19. ANS: 2
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Safety and Infection Control
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Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
Supplies to prevent transmission of disease should be stocked at the end of the shift so
that adequate supplies will be available for the next health-care provider.
2
Masks and gowns should be worn when caring for patients who do not reliably cover
their mouths when coughing. When a patient has an airborne disease and must go
elsewhere in the hospital, the patient must wear a mask.
3
Hand hygiene should be performed before and after patient care.
4
Clinical staff receive TB testing annually. There is no reason to test all staff members at
this time.
PTS: 1
CON: Infection
20. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
NURSINGKING.COM
1
Rifampin is an oral antituberculosis medication that should be administered on an
empty, not full, stomach.
2
The nurse should monitor the CBC, liver function studies, and renal function studies. A
baseline visual examination before therapy is necessary with ethambutol, another
antituberculosis medication.
3
Rifampin is an oral antituberculosis medication that should be administered on an
empty stomach.
4
Rifampin is an oral antituberculosis medication.
PTS: 1
CON: Infection
21. ANS: 2
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
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1
2
3
4
Wheezing is the term used to describe the musical sounds auscultated during
assessment and indicate some degree of airway obstruction that occurs with asthma and
emphysema.
Tuberculosis is characterized by hemoptysis, which is the term for coughing up of
blood or blood-tinged sputum from the respiratory tract.
Grey sputum often occurs in patients who are cigarette smokers.
Clear, slightly whitish, and viscous sputum are often normal findings.
PTS: 1
CON: Oxygenation
22. ANS: 1
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Pneumonia
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
Coarse crackles are often auscultated for patients diagnosed with pneumonia.
2
Rhonchi is auscultated for patients diagnosed with cystic fibrosis.
3
Wheezes are auscultated when the patient is experiencing bronchospasm.
4
Discontinuous low pitched lung sounds are auscultated for patients experiencing
interstitial edema.
NURSINGKING.COM
PTS: 1
CON: Oxygenation
23. ANS: 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Describing the etiology of infectious airway disorders
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
The cough reflex, filtration of air, and mucociliary clearance are not the respiratory
defense mechanisms that failed in this scenario.
2
The cough reflex, filtration of air, and mucociliary clearance are not the respiratory
defense mechanisms that failed in this scenario.
3
Alveolar macrophages rapidly phagocytize inhaled foreign particles such as bacteria
and often fail as a result of cigarette smoking.
4
The cough reflex, filtration of air, and mucociliary clearance are not the respiratory
defense mechanisms that failed in this scenario.
PTS: 1
CON: Oxygenation
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24. ANS: 2
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Tuberculosis
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
Orange urine does not mean the child has a urinary tract infection, and a urinalysis,
radiograph, and encouragement of cranberry juice would not be options.
2
Rifampin can color the urine orange, so the parents and child should be taught that this
is an expected side effect.
3
Orange urine does not mean the child has a urinary tract infection, and a urinalysis,
radiograph, and encouragement of cranberry juice would not be options.
4
Orange urine does not mean the child has a urinary tract infection, and a urinalysis,
radiograph, and encouragement of cranberry juice would not be options.
PTS: 1
CON: Infection
MULTIPLE RESPONSE
25. ANS: 1, 4, 5
NURSINGKING.COM
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with infectious airway disorders
Chapter page reference: 451-455
Heading: Tuberculosis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation; Infection
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. Manifestations of tuberculosis often develop insidiously and are initially
nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that
the patient first seeks medical attention.
This is incorrect. A low-grade afternoon, not morning, fever is anticipated.
This is incorrect. A dry cough develops, which later becomes productive of purulent and/or
blood-tinged sputum.
This is correct. Manifestations of tuberculosis often develop insidiously and are initially
nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that
the patient first seeks medical attention.
This is correct. Manifestations of tuberculosis often develop insidiously and are initially
nonspecific. Fatigue, weight loss, and night sweats are common. It is often at this stage that
the patient first seeks medical attention.
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TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
PTS: 1
CON: Oxygenation | Infection
26. ANS: 1, 2, 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Influenza
Chapter page reference: 443-447
Heading: Influenza
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation; Infection
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. Based on the presenting symptoms, the nurse would ask whether the patient
has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is
nonproductive. A productive cough may indicate a different diagnosis.
This is correct. Based on the presenting symptoms, the nurse would ask whether the patient
has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is
nonproductive. A productive cough may indicate a different diagnosis.
This is correct. Based on the presenting symptoms, the nurse would ask whether the patient
has had a flu shot or been exposed to the flu. Usually, the cough of an influenza patient is
nonproductive. A productive cough may indicate a different diagnosis.
This is incorrect. Insufficient voiding and dizziness are not routine manifestations of
influenza.
NURSI
NGKIand
NGdizziness
.COM are not routine manifestations of
This is incorrect. Insufficient
voiding
influenza.
PTS: 1
CON: Oxygenation | Infection
27. ANS: 1, 2, 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with infectious airway disorders
Chapter page reference: 443-447
Heading: Influenza
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment Safety and Infection Control
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
1.
Feedback
This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching
2.
education all control the growth and spread of microorganisms.
This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching
education all control the growth and spread of microorganisms.
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3.
prevent the spread of microorganisms, but is not related to the flu virus.
This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching
4.
education all control the growth and spread of microorganisms. To prevent the spread of
communicable diseases, microorganisms must be killed or their growth controlled.
This is incorrect. Immunizations should not be withheld from immunocompromised children,
and this is not an infection-control strategy.
5.
PTS: 1
CON: Infection
28. ANS: 1, 2, 3
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
Chapter learning objective: Discussing the medical management of: Pneumonia
Chapter page reference: 447-451
Heading: Pneumonia
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and
perform chest physiotherapy to help clear the respiratory secretions.
This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and
NURSINGKING.COM
perform chest physiotherapy to help clear the respiratory secretions.
This is correct. The nurse would expect to obtain sputum cultures, administer antibiotics, and
perform chest physiotherapy to help clear the respiratory secretions.
This is incorrect. Bronchial washings are not routine testing for this scenario.
This is incorrect. The patient likely has a noninfectious disease and is not contagious. Isolation
precautions are usually not ordered for noncontagious infections.
1.
2.
3.
4.
5.
PTS: 1
CON: Oxygenation
Chapter 25: Coordinating Care for Patients With Upper Airway Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. An adult patient diagnosed with sleep apnea has been prescribed a continuous positive airway pressure
(CPAP) machine as treatment. The nurse is instructing the patient on how to use the machine. Which
instruction should the nurse include?
1) Any size mask will work
2) Straps can be loose, if that feels more comfortable
3) Use relaxation exercises to reduce uncomfortable feelings from the mask
4) Do not use a humidifier at the same time
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____
2.
to communicate. Which item will the nurse request an order for from the health-care provider?
1) Cuffed tracheostomy tube
2) Uncuffed tracheostomy tube
3) Fenestrated tracheostomy tube
4) Obturator
____
3. The nurse is performing tracheostomy care. Which portion of the trach will the nurse use when tying the new
trach ties?
1) Inner cannula
2) Outer cannula
3) Obturator
4) Flange
____
4. The nurse is caring for a patient with a longstanding permanent tracheostomy that has been in place for
several years in order to provide mechanical ventilation. Which type of tracheostomy does the nurse
anticipate this patient may have based on the health history?
1) Uncuffed tracheostomy
2) Cuffed tracheostomy
3) Fenestrated tracheostomy
4) Uncuffed or fenestrated tracheostomy
____
5. The nurse is caring for a patient with a tracheostomy tube in place connected to a mechanical ventilator.
When facilitating communication, which strategy is inappropriate?
1) Using a fenestrated tracheostomy tube
2) Using writing materials
3) Using a communication boardNURSINGKING.COM
4) Using a Passy-Muir valve
____
6.
inappropriate before placing the valve?
1) Suctioning the oropharynx if there are any secretions present
2) Asking the patient to cough
3) Suctioning the tracheostomy tube
4) Deflating the cuffed tracheostomy tube
____
7.
sounds around the tube and hears no air leak. Which nursing action is the most appropriate based on this
assessment finding?
1) Allowing the cap to remain in place as long as the patient tolerates it
2) Documenting the placement of the cap and relevant data regarding patient assessment
3) Removing the valve and notifying the health-care provider
4) Assisting the patient out of bed
____
8. The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a first generation
antihistamine. Which drug should the nurse educate the patient about based on this data?
1) Loratadine
2) Fluticasone
3) Guaifenesin
4) Diphenhydramine
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____
9. The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a second generation
antihistamine. Which drug should the nurse educate the patient about based on this data?
1) Loratadine
2) Fluticasone
3) Guaifenesin
4) Diphenhydramine
____ 10. The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a decongestant. Which
drug should the nurse educate the patient about based on this data?
1) Loratadine
2) Fluticasone
3) Guaifenesin
4) Diphenhydramine
____ 11. The nurse is providing care to a patient who is diagnosed with rhinitis and prescribed a corticosteroid nasal
spray. Which drug should the nurse educate the patient about based on this data?
1) Loratadine
2) Fluticasone
3) Guaifenesin
4) Diphenhydramine
____ 12. The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion.
Which drug should the nurse include for a patient who requires a corticosteroid?
1) Saline
2) Azelastine
3) Fluticasone
NURSINGKING.COM
4) Oxymetazonline
____ 13. The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion.
Which drug should the nurse include for a patient who requires an antihistamine?
1) Saline
2) Azelastine
3) Fluticasone
4) Oxymetazonline
____ 14. The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion.
Which drug should the nurse include for a patient who requires a decongestant?
1) Saline
2) Azelastine
3) Fluticasone
4) Oxymetazonline
____ 15. The nurse is providing education to the patient regarding nasal sprays that can be used to treat congestion.
Which should the nurse recommend when the patient wants a natural?
1) Saline
2) Azelastine
3) Fluticasone
4) Oxymetazonline
____ 16. The nurse is providing care to a patient receiving radiation in the treatment of laryngeal cancer. Which patient
statement indicates the need for further education regarding radiation treatments?
1)
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2)
3)
4)
____ 17. The nurse is providing education to a patient receiving radiation therapy for the treatment of laryngeal cancer.
Which patient statement indicates the need for further education regarding oral care?
1)
2)
3)
4)
____ 18. The nurse is providing education to a patient who is receiving chemotherapy in the treatment of laryngeal
cancer. Which medication should the nurse include to decrease the risk for nausea and vomiting?
1) Antiemetic
2) Decongestant
3) Antihistamine
4) Corticosteroid
____ 19. The nurse is providing care to a patient receiving chemotherapy for the treatment of laryngeal cancer. Which
laboratory test should the nurse anticipate to monitor the patient for neutropenia?
1) Platelet count
2) Serum potassium
3) Red blood cell count
4) White blood cell count
____ 20. The nurse is providing education to the patient who is receiving treatment for laryngeal cancer. Which patient
statement regarding nutrition requires
from
the nurse?
NUfurther
RSINeducation
GKING.
COM
1)
2)
3)
4)
taste good and are easy to eat and swallow to get enough calories
____ 21. Which drug prescription does the nurse anticipate for empiric therapy when providing care to an adult patient
diagnosed with acute bacterial rhinosinusitis (ABRS)?
1) Azithromycin
2) Clarithromycin
3) Amoxicillin-clavulante
4) Intranasal corticosteriods
____ 22. Which drug prescription does the nurse anticipate for adjuvant therapy when providing care to an adult patient
diagnosed with acute bacterial rhinosinusitis (ABRS)?
1) Azithromycin
2) Clarithromycin
3) Amoxicillin-clavulante
4) Intranasal corticosteriods
____ 23. Which is the priority nursing diagnosis for a patient who experiences a laryngeal trauma?
1) Impaired comfort
2) Impaired swallowing
3) Ineffective airway clearance
4) Risk for impaired verbal communication
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____ 24. Which assessment data collected by the nurse indicates a patient with laryngeal trauma is experiencing issues
with airway clearance?
1) Tachypnea
2) Bradycardia
3) Hypotension
4) Increased oxygen saturation
____ 25. Which intervention should the nurse implement for a patient who is at risk for aspiration as a result of
laryngeal trauma?
1) Encouraging voice rest
2) Maintaining NPO status
3) Placing in high4) Providing humidified air via face mask
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. Which criteria is used to diagnosis acute bacterial rhinosinusitis (ABRS) in adult patients? Select all that
apply.
1) Facial pain that lasts for one day
2) Decrease in nasal discharge after six days
3) New onset of headache after five or six days
4) Symptoms that last more than 10 days without clinical improvement
5) Temperature greater than or equal to 102°F [39°C] with purulent nasal discharge for four
days
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____ 27. Which first-line medications should the nurse include in a teaching session for a patient who wants to quit
smoking? Select all that apply.
1) Clonidine
2) Bupropion
3) Varenicline
4) Nortriptyline
5) Nicotine gum
____ 28. Which patient statements accurately reflect the benefits of physical activity during the smoking cessation
process? Select all that apply.
1)
2)
3)
4)
5)
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Chapter 25: Coordinating Care for Patients With Upper Airway Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Developing a teaching plan for patients with upper airway disorders
Chapter page reference: 462-265
Heading: Obstructive Sleep Apnea
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Proper fitting of the mask to the face, including wearing the right size mask and
keeping the straps tight, is important.
2
Proper fitting of the mask to the face, including wearing the right size mask and
keeping the straps tight, is important.
3
Relaxation exercises can reduce the claustrophobic feelings caused by wearing the
mask.
4
Using a humidifier can minimize dry mouth and nose.
NURSINGKING.COM
PTS: 1
CON: Oxygenation
2. ANS: 3
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with upper airway
disorders
Chapter page reference: 466-471
Heading: Laryngeal Cancer
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Oxygenation; Communication
Difficulty: Moderate
Feedback
1
The cuffed tracheostomy would need to be deflated in order for the fenestrated tube to
function.
2
An uncuffed tube does not improve communication.
3
The fenestrated tracheostomy tube allows patients to speak, and could be safely used on
the patient who is being weaned from the ventilator.
4
An obturator is used to make the tracheostomy tube more rigid during insertion, and
must be removed as soon as the tube is in place, because it occludes the airway.
PTS: 1
CON: Oxygenation | Communication
3. ANS: 4
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Chapter learning objective: Developing a comprehensive plan of nursing care for patients with upper airway
disorders
Chapter page reference: 466-471
Heading: Laryngeal Cancer
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
1
2
3
4
Feedback
This is an inappropriate action by the nurse when tying the new trach ties.
This is an inappropriate action by the nurse when tying the new trach ties.
This is an inappropriate action by the nurse when tying the new trach ties.
The trach ties attach to the flange.
PTS: 1
CON: Oxygenation
4. ANS: 2
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Discussing the medical management of: Laryngeal cancer
Chapter page reference: 466-471
Heading: Laryngeal Cancer
Integrated Processes: Nursing Process Planning
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Comprehension [Understanding]
NURSINGKING.COM
Concept: Oxygenation
Difficulty: Easy
Feedback
1
The patient with a long-term tracheostomy who does not require mechanical ventilation
would be likely to have an uncuffed tube.
2
Cuffed tracheostomy tubes are essential when the patient requires mechanical
ventilation because they provide a seal so that air does not leak when the ventilator
provides a breath.
3
The patient with a long-term tracheostomy who does not require mechanical ventilation
would be likely to have a fenestrated tracheostomy.
4
Uncuffed and fenestrated tracheostomies are appropriate for a patient who does not
require mechanical ventilation.
PTS: 1
CON: Oxygenation
5. ANS: 1
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Discussing the medical management of: Laryngeal cancer
Chapter page reference: 466-471
Heading: Laryngeal Cancer
Integrated Processes: Communication and Documentation
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Communication; Oxygenation
Difficulty: Easy
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1
2
3
4
Feedback
Fenestrated tracheostomy tubes require placement of the inner cannula when the patient
requires mechanical ventilation, which defeats the speaking ability of the tube.
Although a fenestrated tube allows a patient to speak when weaning from the ventilator,
it will not improve communication for the ventilated patient.
Use of writing materials is useful for improving communication if the patient is alert
and strong enough to be able to use them.
A communication board is indicated if the patient is not strong enough to use writing
materials.
A Passy-Muir valve can be used when the patient is on or off of the ventilator, allowing
the patient to speak.
PTS: 1
CON: Communication | Oxygenation
6. ANS: 3
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with upper airway
disorders
Chapter page reference: 466-471
Heading: Laryngeal Cancer
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
NURSINGKING.COM
1
The tracheostomy tube would only be suctioned if indicated; this would not be a routine
step to perform at all times.
2
This nursing action is routinely performed prior to capping the tube.
3
This nursing action is routinely performed prior to capping the tube.
4
This nursing action is routinely performed prior to capping the tube.
PTS: 1
CON: Oxygenation
7. ANS: 3
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with upper airway
disorders
Chapter page reference: 466-471
Heading: Laryngeal Cancer
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
1
Feedback
The valve should be removed and the health-care provider notified because lack of an
air leak indicates the patient will not be able to exhale and, as a result, will not tolerate
the valve.
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2
3
4
Only after calling the health-care provider would the nurse document the inability to
use the valve.
The valve should be removed and the health-care provider notified because lack of an
air leak indicates the patient will not be able to exhale and, as a result, will not tolerate
the valve.
There would be no need to assist the patient out of bed.
PTS: 1
CON: Oxygenation
8. ANS: 4
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Discussing the medical management of: Rhinitis
Chapter page reference: 457-459
Heading: Rhinitis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Inflammation; Medication
Difficulty: Moderate
Feedback
1
Loratadine is a second generation antihistamine.
2
Fluticasone is a corticosteroid nasal spray.
3
Guaifenesin is a decongestant.
4
Diphenhydramine is a first generation antihistamine.
PTS: 1
CON: Inflammation
NURSI| NMedication
GKING.COM
9. ANS: 1
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Discussing the medical management of: Rhinitis
Chapter page reference: 457-459
Heading: Rhinitis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Inflammation; Medication
Difficulty: Moderate
Feedback
1
Loratadine is a second generation antihistamine.
2
Fluticasone is a corticosteroid nasal spray.
3
Guaifenesin is a decongestant.
4
Diphenhydramine is a first generation antihistamine.
PTS: 1
CON: Inflammation | Medication
10. ANS: 3
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Discussing the medical management of: Rhinitis
Chapter page reference: 457-459
Heading: Rhinitis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
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Cognitive level: Application [Applying]
Concept: Inflammation; Medication
Difficulty: Moderate
Feedback
1
Loratadine is a second generation antihistamine.
2
Fluticasone is a corticosteroid nasal spray.
3
Guaifenesin is a decongestant.
4
Diphenhydramine is a first generation antihistamine.
PTS: 1
CON: Inflammation | Medication
11. ANS: 2
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Discussing the medical management of: Rhinitis
Chapter page reference: 457-459
Heading: Rhinitis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Inflammation; Medication
Difficulty: Moderate
Feedback
1
Loratadine is a second generation antihistamine.
2
Fluticasone is a corticosteroid nasal spray.
3
Guaifenesin is a decongestant.
4
Diphenhydramine is a first generation
NURSINantihistamine.
GKING.COM
PTS: 1
CON: Inflammation | Medication
12. ANS: 3
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Discussing the medical management of: Rhinitis
Chapter page reference: 457-459
Heading: Rhinitis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Inflammation; Medication
Difficulty: Moderate
Feedback
1
Saline is a nasal spray; however, saline is not a corticosteroid.
2
Azelastine is an antihistamine nasal spray.
3
Fluticasone is a corticosteroid nasal spray.
4
Oxymetazoline is a decongestant nasal spray.
PTS: 1
CON: Inflammation | Medication
13. ANS: 2
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Discussing the medical management of: Rhinitis
Chapter page reference: 457-459
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Heading: Rhinitis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Inflammation; Medication
Difficulty: Moderate
Feedback
1
Saline is a nasal spray; however, saline is not an antihistamine.
2
Azelastine is an antihistamine nasal spray.
3
Fluticasone is a corticosteroid nasal spray.
4
Oxymetazoline is a decongestant nasal spray.
PTS: 1
CON: Inflammation | Medication
14. ANS: 4
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Discussing the medical management of: Rhinitis
Chapter page reference: 457-459
Heading: Rhinitis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Inflammation; Medication
Difficulty: Moderate
Feedback
1
Saline is a nasal spray; however, saline is not a decongestant.
NURSINGKING.COM
2
Azelastine is an antihistamine nasal spray.
3
Fluticasone is a corticosteroid nasal spray.
4
Oxymetazoline is a decongestant nasal spray.
PTS: 1
CON: Inflammation | Medication
15. ANS: 1
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Developing a teaching plan for patients with upper airway disorders
Chapter page reference: 457-459
Heading: Rhinitis
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Inflammation; Medication
Difficulty: Moderate
Feedback
1
Saline can be administered by nasal spray in the treatment of congestion. Saline is
considered a natural remedy. The saline liquefies the secretions and decreases the risk
of crusting in the nasal cavity.
2
Azelastine is an antihistamine nasal spray.
3
Fluticasone is a corticosteroid nasal spray.
4
Oxymetazoline is a decongestant nasal spray.
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PTS: 1
CON: Inflammation | Medication
16. ANS: 4
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Describing complications associated with selected upper airway disorders
Chapter page reference: 466-471
Heading: Laryngeal Cancer
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Cellular Regulation
Difficulty: Difficult
Feedback
1
This statement indicates correct understanding of the information related to radiation
therapy.
2
This statement indicates correct understanding of the information related to radiation
therapy.
3
This statement indicates correct understanding of the information related to radiation
therapy.
4
A mild, not harsh, soap should be used to cleanse the site receiving radiation. Lotion
should only be applied if prescribed by the radiologist.
PTS: 1
CON: Cellular Regulation
17. ANS: 4
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Describing complications associated with selected upper airway disorders
NURSINGKING.COM
Chapter page reference: 466-471
Heading: Laryngeal Cancer
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Analysis [Analyzing]
Concept: Comfort; Cellular Regulation
Difficulty: Difficult
Feedback
1
This patient statement indicates correct understanding of the information presented.
2
This patient statement indicates correct understanding of the information presented.
3
This patient statement indicates correct understanding of the information presented.
4
A soft-bristle brush should be used to decrease the risk of irritation and inflammation.
PTS: 1
CON: Comfort | Cellular Regulation
18. ANS: 1
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Discussing the medical management of: Laryngeal cancer
Chapter page reference: 466-471
Heading: Laryngeal Cancer
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Cellular Regulation; Medication
Difficulty: Moderate
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1
2
3
4
Feedback
An antiemetic agent is often prescribed to treat the nausea and vomiting that can occur
with chemotherapy.
A decongestant is more appropriate for a patient diagnosed with rhinitis.
An antihistamine may be administered during a scheduled chemotherapy session.
However, this drug is not prescribed for use between sessions. It is more appropriate for
a patient diagnosed with rhinitis.
A corticosteroid is more appropriate for a patient diagnosed with rhinitis. A
with chemotherapy.
PTS: 1
CON: Cellular Regulation | Medication
19. ANS: 4
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnoses of selected upper
airway disorders
Chapter page reference: 466-471
Heading: Laryngeal Cancer
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Concept: Cellular Regulation
Difficulty: Easy
Feedback
1
A platelet count is anticipated to monitor the patient for thrombocytopenia, which
NURSINGKING.COM
2
3
4
A serum potassium is anticipated to monitor the patient for electrolyte imbalances that
often occur due to the nausea and vomiting that can accompany chemotherapy.
A red blood cell count is anticipated to monitor the patient for anemia, which can cause
fatigue.
A white blood cell count is anticipated to monitor the patient for neutropenia, which
PTS: 1
CON: Cellular Regulation
20. ANS: 2
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Developing a teaching plan for patients with upper airway disorders
Chapter page reference: 466-471
Heading: Laryngeal Cancer
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Basic Care and Comfort
Cognitive level: Analysis [Analyzing]
Concept: Cellular Regulation; Nutrition
Difficulty: Difficult
Feedback
1
Small, frequent meals throughout the day ensure an adequate caloric intake.
2
Tomatoes are acid; therefore, should be avoided. Also, the patient does not like
tomatoes. Nonacid containing foods that the patient enjoys should be encouraged.
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3
4
used in additional to solid foods.
The patient is encouraged to eat foods that taste good and are easy to eat and swallow in
order to ensure an adequate caloric intake.
PTS: 1
CON: Cellular Regulation | Nutrition
21. ANS: 3
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Discussing the medical management of: Rhinosinusitis
Chapter page reference: 459-462
Heading: Rhinosinusitis
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Infection; Medication
Difficulty: Easy
Feedback
1
Azithromycin, a macrolide, is not recommended for empiric therapy of ABRS.
2
Clarithromycin, a macrolide, is not recommended for empiric therapy of ABRS.
3
Amoxicillin-clavulante is recommended over amoxicillin alone for five to seven days
for empiric therapy of ABRS.
4
Intranasal steroids are recommended as adjuvant, not empiric, therapy of ABRS.
PTS: 1
CON: Infection
22. ANS: 4
NURSINGKING.COM
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Discussing the medical management of: Rhinosinusitis
Chapter page reference: 459-462
Heading: Rhinosinusitis
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Comprehension [Understanding]
Concept: Infection; Medication
Difficulty: Easy
Feedback
1
Azithromycin, a macrolide, is not recommended for empiric therapy of ABRS.
2
Clarithromycin, a macrolide, is not recommended for empiric therapy of ABRS.
3
Amoxicillin-clavulante is recommended over amoxicillin alone for 5 to 7 days for
empiric therapy of ABRS.
4
Intranasal steroids are recommended as adjuvant, not empiric, therapy of ABRS.
PTS: 1
CON: Infection
23. ANS: 3
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with upper airway
disorders
Chapter page reference: 471-474
Heading: Laryngeal Trauma
Integrated Processes: Nursing Process Diagnosis
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Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1
While impaired comfort is an appropriate nursing diagnosis for this patient, it is not the
priority when using the ABCs (airway, breathing, circulation) method for prioritization
of care.
2
While impaired swallowing is an appropriate nursing diagnosis for this patient, it is not
the priority when using the ABCs (airway, breathing, circulation) method for
prioritization of care.
3
Ineffective airway clearance related to edema is the priority nursing diagnosis when
planning care for a patient who experiences a laryngeal trauma.
4
While risk for impaired verbal communication is an appropriate nursing diagnosis for
this patient, it is not the priority when using the ABCs (airway, breathing, circulation)
method for prioritization of care. Also, risk for nursing diagnosis are never prioritized
ahead of actual nursing diagnoses.
PTS: 1
CON: Oxygenation
24. ANS: 1
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Describing complications associated with selected upper airway disorders
Chapter page reference: 471-474
Heading: Laryngeal Trauma
Integrated Processes: Nursing Process Assessment
NUR
SINGKINAdaptation
G.COM
Client Need: Physiological Integrity
Physiological
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
An increased respiratory rate, or tachypnea, indicates respiratory distress and issues
with airway clearance.
2
Tachycardia, not bradycardia, indicates respiratory distress.
3
Changes in blood pressure are not expected for patients experiencing respiratory
distress due to issues with airway clearance.
4
Decreased, not increased, oxygen saturation indicates respiratory distress.
PTS: 1
CON: Oxygenation
25. ANS: 2
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with upper airway
disorders
Chapter page reference: 471-474
Heading: Laryngeal Trauma
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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1
2
3
4
Feedback
Encouraging voice rest is important to decrease inflammation and edema, not
aspiration.
Due to the edema and inflammation from the injury, an NPO status decreases the
reason.
Maintaining a highairway.
Cool, humidified air will decrease airway edema.
PTS: 1
CON: Oxygenation
MULTIPLE RESPONSE
26. ANS: 3, 4, 5
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of:
Rhinosinusitis
Chapter page reference: 459-462
Heading: Rhinosinusitis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Inflammation; Infection
Difficulty: Easy
NURSINGKING.COM
1.
2.
3.
4.
5.
Feedback
This is incorrect. Facial pain with fever that lasts longer than three to four days would indicate
ABRS.
This is incorrect. An increase, not decrease, in nasal discharge after six days would indicate
ABRS.
This is correct. A new onset of headache after this length of time with symptoms often
indicates ABRS.
This is correct. Symptoms that last more than 10 days without clinical improvement often
indicates ABRS.
This is correct. This data supports the diagnosis of ABRS.
PTS: 1
CON: Inflammation | Infection
27. ANS: 2, 3, 5
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Discussing the medical management of: Laryngeal cancer
Chapter page reference: 466-471
Heading: Laryngeal Cancer
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Medication
Difficulty: Moderate
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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Feedback
This is incorrect. Clonidine is a second, not first, line drug for smoking cessation.
This is correct. Bupropion is a first-line drug for smoking cessation.
This is correct. Varenicline is a first-line drug for smoking cessation.
This is incorrect. Nortriptyline is a second, not first, line drug for smoking cessation.
This is correct. Nicotine gum is a first-line drug for smoking cessation.
1.
2.
3.
4.
5.
PTS: 1
CON: Medication
28. ANS: 1, 2, 3
Chapter number and title: 25, Coordinating Care for Patients With Upper Airway Disorders
Chapter learning objective: Developing a teaching plan for patients with upper airway disorders
Chapter page reference: 466-471
Heading: Laryngeal Cancer
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive level: Analysis [Analyzing]
Concept: Promoting Health
Difficulty: Difficult
Feedback
This is correct. Exercise decreases stress that is often experienced during smoking cessation.
This is correct. Exercise decreases anxiety that is often experienced during smoking cessation.
This is correct. Exercise decreases cravings that are often experienced during smoking
cessation.
NURSINGKING.COM
This is incorrect. While exercise is known to reduce the weight gain postcessation it is not
known to increase weight loss.
port network.
1.
2.
3.
4.
5.
PTS: 1
CON: Promoting Health
Chapter 26: Coordinating Care for Patients With Lower Airway Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____
1. The student nurse is questioning the instructor about the different types of chemotherapeutic agents used to
treat cancer. Which statement by the instructor best explains why lung cancers are less sensitive to
antineoplastic agents than other types of cancers?
1)
cells have a low growth fraction, so they are less sensitive to antineoplastic
2)
3)
-oxygen environment, so they are not very sensitive to
time before detection, so they are less
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4)
____
2. The nurse is caring for a patient in a community clinic who wishes to quit smoking. The patient asks the
response by the nurse?
1)
2)
3)
4)
____
3. A male Hispanic patient has had a lung biopsy. The results indicate a poor prognosis for the patient. The
-care provider has told the
nurse that he needs to have the consent form signed for surgery. The patient has asked the nurse to allow the
family private time. What should the nurse do at this time?
1) Ask the family to come back later
2) Have the doctor get the consent with the family present
3) Provide the patient and family privacy
4) Take the patient to another room
____
4. The nurse is caring for an older adult patient who is very thin and emaciated. The patient reports new onset of
shortness of breath. A chest x-ray reveals a spot on the lungs that the physician believes is an inoperable lung
-care provider
also believes that the location of the cancer would make radiation therapy unsuccessful. In advocating for this
patient, what should the nurse encourage the health-care team to do?
URpatient
SINGcomfortable
KING.CO
M diagnostic testing
1) Provide palliative care to keepNthe
without
2) Perform any procedure necessary to diagnose the patient properly
3) Promote the use of blood tests to diagnose the suspected cancer
4)
____
5. A nurse is caring for a patient recovering from a wedge resection of the left lung for a tumor. Which is an
appropriate goal for the nursing diagnosis of ineffective airway clearance?
1) Participation in care by the patient
2) Maintain a patent airway
3) Maintain current weight
4) Express feelings and concerns
____
6. The nurse is caring for a patient who is undergoing diagnostic tests to rule out lung cancer. The patient asks
the nurse why a computed tomography (CT) scan was ordered. What is the best response by the nurse?
1)
2)
3)
4)
____
7. The nurse is providing care to a patient admitted after experiencing an acute asthma attack. Which assessment
findings indicate the need for immediate intervention by the nurse?
1) Retractions and fatigue
2) Tachycardia and tachypnea
3) Inaudible breath sounds
4) Diffuse wheezing and the use of accessory muscles when inhaling
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____
8. Friends of a patient hospitalized with asthma would like to bring the patient a gift. Which gift would the nurse
recommend for this patient?
1) A basket of flowers
2) A stuffed animal
3) Fruit and candy
4) A book
____
9. A nurse is teaching environmental control to the parents of a child with asthma. Which statement by the
parents indicates effective teaching?
1)
2)
3)
4)
____ 10. An older adult patient diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon
inspiration. Based on this data, which nursing diagnosis is the most appropriate?
1) Ineffective Airway Clearance
2) Impaired Tissue Perfusion
3) Ineffective Breathing Pattern
4) Activity Intolerance
____ 11.
attack was several months ago.
Which response by the nurse is appropriate?
1)
2)
according to your doctor, so you should
NURSINGKING.COM
3)
4)
n acute
____ 12. The nurse is instructing a patient who is prescribed ipratropium bromide (Atrovent) for asthma. Which should
1)
2)
3)
4)
Take no more than the prescribed number of doses each day.
Rinse the mouth after taking this medication.
Take on an empty stomach.
Take with meals or a full glass of water.
____ 13. The nurse instructs a patient with asthma on bronchodilator therapy. Which statement indicates patient
understanding?
1)
2)
3)
-or-flight response of
it decreases the production of histamine that
4)
____ 14. The nurse working on a pediatric unit is caring for a patient newly diagnosed with asthma. Which assessment
data indicates exhaustion and the need for immediate intervention?
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1)
2)
3)
4)
Slightly diminished breath sounds
Decreased wheezing
Increased crackles
Increased respiratory rate
____ 15. The nurse is providing care to an infant in the emergency department (ED). Initial assessment indicates that
the infant is experiencing an asthma attack. The infant is unresponsive to medication and a chest x-ray reveals
a foreign body partially obstructing the airway. While placing an oxygen mask on the infant, the nurse notes a
total obstruction of the airway. Which nursing action is appropriate?
1) Attempt to clear the obstruction by delivering back blows and chest thrusts.
2) Attempt to clear the obstruction by delivering back blows.
3) Attempt to clear the obstruction by delivering back blows and abdominal thrusts.
4) Attempt to clear the obstruction by delivering abdominal thrusts.
____ 16. The nurse is providing care to a patient newly diagnosed with
care, which intervention would be most appropriate to promote airway clearance?
1) Provide adequate rest periods
2) Reduce excessive stimuli
3) Assist with activities of daily living
4) Place in Fowler position
____ 17. The nurse is reviewing discharge instructions with a patient who is newly diagnosed with asthma. Which
patient statement indicates a need for further teaching?
1)
2)
3)
NURSINGKING.COM
4)
____ 18.
s suspicion that a patient is experiencing chronic obstructive
pulmonary disease (COPD)?
1) Dysrhythmias
2) Cyanotic nail beds
3) Clubbing of the fingers
4) Cough in the morning producing clear sputum
____ 19. The nurse is providing care to a patient diagnosed with chronic obstruction pulmonary disease (COPD) after
years of experiencing emphysema. Which clinical manifestation does the nurse anticipate when assessing this
patient?
1) Tachycardia
2) Cough
3) Barrel chest
4) Wheezing
____ 20. The nurse is planning care for the patient diagnosed with chronic obstructive pulmonary disease (COPD) who
has a breathing rate of 32 per minute, elevated blood pressure, and fatigue. Which nursing diagnosis is the
priority for this patient?
1) Ineffective Coping
2) Ineffective Airway Clearance
3) Anxiety
4) Ineffective Breathing Pattern
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____ 21. The nurse is providing care for a patient diagnosed with chronic obstructive pulmonary disease (COPD).
Which intervention is inappropriate to control the pati
1) Instruct in pursed-lip breathing
2) Teach visualization and meditation
3) Deep breathing and coughing every hour
4) Instruct in abdominal breathing
____ 22. A patient diagnosed with chronic obstructive pulmonary disease (COPD) has a pulse oximetry reading of
93%, increased red blood and white blood cell count, temperature of 101°F, pulse 100 bpm, respirations 35
bpm, and a chest x-ray that showed a flattened diaphragm with infiltrates. Based on this data, which
prescription does the nurse question for this patient?
1) Antibiotic therapy
2) Nonsteroidal anti-inflammatory agents
3) Oxygen by nasal cannula at 3-4 liters/minute
4) Bronchodilators such as an adrenergic stimulating drugs or anticholinergic agents
____ 23. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD). A
nursing diagnosis for this patient is Imbalanced Nutrition: Less than Body Requirements. Which intervention
is appropriate for this nursing diagnosis?
1) Encourage a diet high in protein and fats
2) Keep snacks to a minimum
3) Encourage carbohydrate-rich foods to provide needed calories for energy
4) Suggest the patient eat three meals per day to maintain energy needs
____ 24. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD).
Which observation would indicate that care provided to this patient has been effective?
URambulates
SINGKIinNroom
G.Cwhile
OM maintaining an oxygen
1) Patient conducts morning careNand
saturation of 92% on room air per oximetry reading.
2) Patient needs assistance with morning care and meals due to shortness of breath.
3) Patient states family members are discussing admission to a nursing home for continuing
care.
4) Patient leaves hospital unit to smoke outside four times a day.
____ 25. The nurse is teaching a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which patient
statement indicates a need for further teaching?
1)
2)
3)
4)
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. The nurse is planning care to address ineffective airway clearance for a patient with lung cancer. Which
Select all that apply.
1) Increase fluid intake to 3000 mL per day
2) Turn, cough, and deep breathe every two hours
3) Chest percussion every eight hours
4) Smoking cessation education
5) Administer pneumococcal vaccine
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____ 27. The nurse is planning care for a young adolescent patient diagnosed with asthma. Which evidence-based ageappropriate interventions will the nurse include in the plan of care? Select all that apply.
1) Referring to a peer-led support group
2) Teaching the parents how to administer maintenance medication prior to teaching the
patient
3) Assessing peer-support when planning care
4) Collaborating with teachers for support in the school setting
5) Telling the patient to avoid medication while at school
____ 28. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD)?
Select all that apply.
1) Working in an industrial environment
2) Working in an office setting with air conditioning
3) History of asthma
4) Current cigarette smoking
5) Playing golf several times a week
____ 29. Which assessment data would cause the nurse to suspect that an infant requires further testing for cystic
fibrosis? Select all that apply.
1) Rectal prolapse
2) Constipation
3) Steatorrheic stools
4) Meconium ileus
5) Diarrhea
____ 30. Which systems should the nurse anticipate will be affected when planning care for a patient diagnosed with
NURSINGKING.COM
cystic fibrosis? Select all that apply.
1) Respiratory
2) Neurological
3) Reproductive
4) Cardiovascular
5) Gastrointestinal
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Chapter 26: Coordinating Care for Patients With Lower Airway Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Describing the epidemiology of lower airway disorders
Chapter page reference: 489-491
Heading: Lung Cancer
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Cellular Regulation; Oxygenation
Difficulty: Moderate
Feedback
1
Growth fraction is a ratio of the number of replicating cells to the number of resting
cells. Antineoplastic drugs are much more toxic to tissues and tumors with high growth
fractions. Breast and lung cancers have low growth fractions.
2
A high-oxygen environment is not the reason why lung cancer cells are less sensitive to
antineoplastic agents.
3
Lung cancer cells may grow for a long time before detection, but this is not the primary
reason they are less susceptible to antineoplastic agents.
4
Lung cancer cells do not have a very erratic cell cycle.
NURSINGKING.COM
PTS: 1
CON: Cellular Regulation | Oxygenation
2. ANS: 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Describing the epidemiology of lower airway disorders
Chapter page reference: 489-491
Heading: Lung Cancer
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Cellular Regulation
Difficulty: Moderate
1
2
3
4
Feedback
The risk for someone who quits is known to be dramatically less than for someone who
continues to smoke.
smoking, it
will not drop to the level of someone who never smoked.
The risk for someone who quits is known to be dramatically less than for someone who
continues to smoke.
quitting
smoking.
PTS: 1
CON: Cellular Regulation
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3. ANS: 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway
disorders
Chapter page reference: 489-491
Heading: Lung Cancer
Integrated Processes: Nursing Process Implementation
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Cellular Regulation; Diversity
Difficulty: Moderate
Feedback
1
Asking the family to leave may cause extreme stress to the patient and family.
2
It would not be appropriate for the doctor to try to explain the surgery while the family
is grieving.
3
As the patient advocate, the nurse would allow this family to bond according to their
customs.
4
Taking the patient to another room would deprive the patient from participating in his
PTS: 1
CON: Cellular Regulation | Diversity
4. ANS: 4
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway
disorders
Chapter page reference: 489-491 NURSINGKING.COM
Heading: Lung Cancer
Integrated Processes: Nursing Process Implementation
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Application [Applying]
Concept: Cellular Regulation; Nursing Roles
Difficulty: Moderate
1
2
3
Feedback
An older adult emaciated patient may have few options for treatment of cancer, if
confirmed. The best course of treatment may be palliative care, but it is the choice of
the patient and family that should direct the plan of care and choices of diagnostic
testing.
An older adult emaciated patient may have few options for treatment of cancer, if
confirmed. The best course of treatment may be palliative care, but it is the choice of
the patient and family that should direct the plan of care and choices of diagnostic
testing.
An older adult emaciated patient may have few options for treatment of cancer, if
confirmed. The best course of treatment may be palliative care, but it is the choice of
the patient and family that should direct the plan of care and choices of diagnostic
testing.
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4
An older adult emaciated patient may have few options for treatment of cancer, if
confirmed. The best course of treatment may be palliative care, but it is the choice of
the patient and family that should direct the plan of care and choices of diagnostic
testing.
PTS: 1
CON: Cellular Regulation | Nursing Roles
5. ANS: 2
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway
disorders
Chapter page reference: 489-491
Heading: Lung Cancer
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Cellular Regulation; Oxygenation
Difficulty: Difficult
1
2
3
4
Feedback
All of the outcomes for this patient are viable, but appropriate outcomes for the
diagnosis of ineffective airway clearance are maintaining a patent airway and
minimizing the accumulation of fluid.
All of the outcomes for this patient are viable, but appropriate outcomes for the
diagnosis of ineffective airway clearance are maintaining a patent airway and
minimizing the accumulation of fluid.
URSare
INviable,
GKINbut
G.appropriate
COM
All of the outcomes for this N
patient
outcomes for the
diagnosis of ineffective airway clearance are maintaining a patent airway and
minimizing the accumulation of fluid.
All of the outcomes for this patient are viable, but appropriate outcomes for the
diagnosis of ineffective airway clearance are maintaining a patent airway and
minimizing the accumulation of fluid.
PTS: 1
CON: Cellular Regulation | Oxygenation
6. ANS: 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Describing the diagnostic results used to confirm the diagnosis of lower airway
disorders
Chapter page reference: 489-491
Heading: Lung Cancer
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Reduction of Risk Potential
Cognitive level: Application [Applying]
Concept: Cellular Regulation
Difficulty: Moderate
Feedback
1
Physician preference is not a factor as to why this diagnostic test is prescribed.
2
A chest x-ray can be used to diagnose pneumonia.
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3
Computed tomography (CT) is used to evaluate and localize tumors, particularly tumors
in the lung parenchyma and pleura. It also is done before needle biopsy to localize the
tumor. In addition, CT scanning can detect distant tumor metastasis and evaluate tumor
response to treatment.
4
is having concerns about the test.
PTS: 1
CON: Cellular Regulation
7. ANS: 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Asthma
Chapter page reference: 476-482
Heading: Asthma
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1
Retractions and fatigue are also a progression of symptoms that occur with an asthma
attack and represent a more severe episode. But they are not the worst or most serious
set of symptoms listed, because air is still moving and exchanging.
2
During an asthma attack, tachycardia, tachypnea, and prolonged expirations are
common. They are early symptoms of the disease process and can be addressed without
urgency.
NURSINGKING.COM
3
Inaudible breath sounds, reduced wheezing, and ineffective cough indicate that little or
no air movement into and out of the lungs is taking place. Therefore, this set of
symptoms represents the most urgent need, which is immediate intervention by the
nurse to open up the lungs with drug management to prevent total respiratory failure.
4
Diffuse wheezing and the use of accessory muscles when inhaling indicate a
progression of the severity of the symptoms, but airflow is still occurring; therefore,
they do not require the most urgent action.
PTS: 1
CON: Oxygenation
8. ANS: 4
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with lower airway disorders
Chapter page reference: 476-482
Heading: Asthma
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
A patient with asthma must not be exposed to items that can exacerbate their disease
process. Specific allergens, chemicals, and foods must be avoided. Flowers, food, and
items that may contain dust, such as a stuffed animal, should be avoided.
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2
3
4
A patient with asthma must not be exposed to items that can exacerbate their disease
process. Specific allergens, chemicals, and foods must be avoided. Flowers, food, and
items that may contain dust, such as a stuffed animal, should be avoided.
A patient with asthma must not be exposed to items that can exacerbate their disease
process. Specific allergens, chemicals, and foods must be avoided. Flowers, food, and
items that may contain dust, such as a stuffed animal, should be avoided.
Objects void of irritants, such as a book, would be an appropriate gift.
PTS: 1
CON: Oxygenation
9. ANS: 2
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with lower airway disorders
Chapter page reference: 476-482
Heading: Asthma
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
1
2
3
4
Feedback
Smoke from fireplaces should be eliminated.
bedroom with tile
NURSINGKING.COM
flooring will reduce dust.
Plants are often an allergen that can induce symptoms of asthma; therefore, this is not
appropriate.
When possible, pets and plants should not be kept in the home.
PTS: 1
CON: Oxygenation
10. ANS: 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway
disorders
Chapter page reference: 476-482
Heading: Asthma
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
The patient is experiencing an increased respiratory rate and is wheezing, which is an
ineffective breathing pattern.
2
Not enough information is provided to determine whether the patient has ineffective
airway clearance, activity intolerance, or impaired tissue perfusion.
3
Not enough information is provided to determine whether the patient has ineffective
airway clearance, activity intolerance, or impaired tissue perfusion.
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4
Not enough information is provided to determine whether the patient has ineffective
airway clearance, activity intolerance, or impaired tissue perfusion.
PTS: 1
CON: Oxygenation
11. ANS: 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Discussing the medical management of: Asthma
Chapter page reference: 476-482
Heading: Asthma
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Telling a patient that lungs will be severely damaged is nontherapeutic; the inability to
prevent an acute attack in this patient is not true.
2
3
4
physician.
Effective treatment of asthma includes long-term treatment to prevent attacks and
decrease inflammation, as well as short-term treatment when an attack occurs.
Long-term treatment of asthma continues indefinitely, not for just 1 year.
PTS: 1
CON: Oxygenation
12. ANS: 1
NURSINGKING.COM
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Discussing the medical management of: Asthma
Chapter page reference: 476-482
Heading: Asthma
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
Appropriate teaching for a patient prescribed ipratropium bromide (Atrovent) includes
only taking the prescribed number of doses each day to prevent a drug overdose.
2
The mouth does not need to be rinsed after taking this medication.
3
This medication does not need to be taken with meals or a full glass of water, or on an
empty stomach.
4
This medication does not need to be taken with meals or a full glass of water, or on an
empty stomach.
PTS: 1
CON: Oxygenation
13. ANS: 2
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Discussing the medical management of: Asthma
Chapter page reference: 476-482
Heading: Asthma
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
TEST BANK FOR MEDICAL SURGICAL NURSING 2ND EDITION BY HOFFMAN
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1
Bronchodilators act on the sympathetic nervous system, not the parasympathetic
nervous system.
2
During the fight-or-flight response, beta2-adrenergic receptors of the sympathetic
nervous system are stimulated, the bronchiolar smooth muscle relaxes, and
bronchodilation occurs.
3
Bronchodilators do not decrease the production of mucus or the production of
histamine.
4
Bronchodilators do not decrease the production of mucus or the production of
histamine.
PTS: 1
CON: Oxygenation
14. ANS: 2
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Asthma
Chapter page reference: 476-482
Heading: Asthma
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
NURSINGKING.COM
Concept: Oxygenation
Difficulty: Easy
Feedback
1
Respiratory status can change rapidly during an acute asthma attack. Slowed, shallow
respirations with significantly, not slightly, diminished breath sounds may indicate
exhaustion and impending respiratory failure.
2
Respiratory status can change rapidly during an acute asthma attack. Slowed, shallow
respirations with significantly diminished breath sounds and decreased wheezing may
indicate exhaustion and impending respiratory failure. Immediate intervention is
necessary.
3
Increased crackles are usually associated with heart failure and are not an indication of
exhaustion.
4
An increased respiratory rate indicates respiratory compromise, but not exhaustion.
PTS: 1
CON: Oxygenation
15. ANS: 1
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Discussing the medical management of: Asthma
Chapter page reference: 476-482
Heading: Asthma
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
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Difficulty: Moderate
Feedback
1
When a life-threatening total airway obstruction occurs, efforts to clear the obstruction
include back blows and chest thrusts in an infant; therefore, the appropriate action for
the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are
appropriate in older children.
2
When a life-threatening total airway obstruction occurs, efforts to clear the obstruction
include back blows and chest thrusts in an infant; therefore, the appropriate action for
the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are
appropriate in older children.
3
When a life-threatening total airway obstruction occurs, efforts to clear the obstruction
include back blows and chest thrusts in an infant; therefore, the appropriate action for
the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are
appropriate in older children.
4
When a life-threatening total airway obstruction occurs, efforts to clear the obstruction
include back blows and chest thrusts in an infant; therefore, the appropriate action for
the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are
appropriate in older children.
PTS: 1
CON: Oxygenation
16. ANS: 4
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway
disorders
Chapter page reference: 476-482
NURSINGKING.COM
Heading: Asthma
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1
Providing adequate rest periods prevents fatigue and reduces oxygen demands.
2
Reducing excessive stimuli promotes rest.
3
Assisting with activities of daily living conserves energy and reduces oxygen demands.
4
Placing the patient in Fowler position facilitates breathing and lung expansion,
promoting airway clearance.
PTS: 1
CON: Oxygenation
17. ANS: 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with lower airway disorders
Chapter page reference: 476-482
Heading: Asthma
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Oxygenation
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Difficulty: Moderate
Feedback
1
This statement is accurate and requires no further education.
2
This statement is accurate and requires no further education.
3
Herbal preparations that include atropa belladonna (the natural form of atropine) or
ephedra (also called ma huang), an herb that contains ephedrine, should not be used, as
they can interact with prescribed medications, indicating a need for further teaching.
4
This statement is accurate and require no further education.
PTS: 1
CON: Oxygenation
18. ANS: 4
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Chronic
obstructive pulmonary disease
Chapter page reference: 482-485
Heading: Chronic Obstructive Pulmonary Disease (COPD)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
Enlargement and thickening of the right ventricle of the heart often results in
dysrhythmias.
2
With the progression of COPD,
body
compensates
by producing extra red blood
NURtheSI
NGK
ING.COM
cells. These extra blood cells clog the small blood vessels of the fingers, leading to the
development of cyanotic nail beds and clubbing of the fingertips.
3
With the progression of COPD, the body compensates by producing extra red blood
cells. These extra blood cells clog the small blood vessels of the fingers, leading to the
development of cyanotic nail beds and clubbing of the fingertips.
4
The earliest-presenting symptom of COPD is coughing in the morning with clear
sputum unless the patient develops an infection, in which case the sputum would
become yellow or green in color.
PTS: 1
CON: Oxygenation
19. ANS: 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Chronic
obstructive pulmonary disease
Chapter page reference: 482-485
Heading: Chronic Obstructive Pulmonary Disease (COPD)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
While coughing, wheezing, and tachycardia may also be experienced by a patient
diagnosed with COPD, these are not specific to COPD caused by emphysema.
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2
3
4
While coughing, wheezing, and tachycardia may also be experienced by a patient
diagnosed with COPD, these are not specific to COPD caused by emphysema.
Barrel chest occurs because the lungs are chronically overinflated with air, so the rib
cage stays partially expanded.
While coughing, wheezing, and tachycardia may also be experienced by a patient
diagnosed with COPD, these are not specific to COPD caused by emphysema.
PTS: 1
CON: Oxygenation
20. ANS: 4
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway
disorders
Chapter page reference: 482-485
Heading: Chronic Obstructive Pulmonary Disease (COPD)
Integrated Processes: Nursing Process Diagnosis
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
1
2
3
4
Feedback
There is no information to support Ineffective Airway Clearance, as there is no mention
that the patient is coughing.
There is no information to support Anxiety or Ineffective Coping.
There is no information to support Anxiety or Ineffective Coping.
NURSINGKING.COM
breathing pattern. The elevated blood pressure and fatigue are indications of a
compromised respiratory status. The diagnosis of Ineffective Breathing Pattern would
be the priority for the patient at this time.
PTS: 1
CON: Oxygenation
21. ANS: 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway
disorders
Chapter page reference: 482-485
Heading: Chronic Obstructive Pulmonary Disease (COPD)
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
1
2
Feedback
Techniques used to instruct a patient to control the breathing pattern include pursed-lip
breathing, abdominal breathing, and relaxation such as visualization and meditation.
Techniques used to instruct a patient to control the breathing pattern include pursed-lip
breathing, abdominal breathing, and relaxation such as visualization and meditation.
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3
4
Deep breathing and coughing should be done every two hours to help keep the airway
clear and prevent the pooling of secretions, not to control the breathing pattern.
Techniques used to instruct a patient to control the breathing pattern include pursed-lip
breathing, abdominal breathing, and relaxation such as visualization and meditation.
PTS: 1
CON: Oxygenation
22. ANS: 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Discussing the medical management of: Chronic obstructive pulmonary disease
Chapter page reference: 482-485
Heading: Chronic Obstructive Pulmonary Disease (COPD)
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
The order for antibiotic therapy is expected, as the patient is febrile with an increase in
white blood cells.
2
Nonsteroidal anti-inflammatory agents are commonly ordered to decrease the
inflammation and swelling of lung tissues to maximize oxygen and carbon dioxide
exchange and to improve symptoms, and would be expected for this patient.
3
The nurse should be concerned about the order for oxygen to be provided at 3-4
liters/minute. This amount of oxygen is too much for a patient with COPD because the
p
NURSINGKING.COM
body to retain carbon dioxide. Providing this much oxygen can result in an increase in
carbon dioxide levels, leading to respiratory failure. Oxygen for this patient should be
at a lower rate, such as 1breathing status.
4
Bronchodilators will keep the alveoli open and increase exchange of oxygen and carbon
dioxide more effectively and would be expected for this patient.
PTS: 1
CON: Oxygenation
23. ANS: 1
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway
disorders
Chapter page reference: 482-485
Heading: Chronic Obstructive Pulmonary Disease (COPD)
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
A diet high in protein and fats without excess carbohydrates is recommended to
minimize carbon dioxide production during metabolism. Frequent small meals help
maintain intake and reduce fatigue associated with eating.
2
The patient should be encouraged to eat frequent snacks, not limit snacks.
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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3
4
Carbohydrateworsen the symptoms of the disease.
The patient should be encouraged to eat frequent small meals, not three meals a day.
PTS: 1
CON: Oxygenation
24. ANS: 1
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Chronic
obstructive pulmonary disease
Chapter page reference: 482-485
Heading: Chronic Obstructive Pulmonary Disease (COPD)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
1
2
3
Feedback
Evidence that care provided to a patient with COPD was successful would be the
patient conducting morning care and ambulating in the room while maintaining an
adequate oxygenation and perform activities of daily living.
The patient who needs assistance with morning care and meals because of shortness of
breath needs additional interventions.
The patient who states that his family would prefer he go to a nursing home may or
NURSINGKING.COM
may not have been positively affected by the interventions; not enough information is
provided to know.
4
PTS: 1
CON: Oxygenation
25. ANS: 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Designing a teaching plan that includes pharmacological, dietary, and lifestyle
considerations for patients with lower airway disorders
Chapter page reference: 482-485
Heading: Chronic Obstructive Pulmonary Disease (COPD)
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1
This statement is accurate and does not indicate a need for further teaching.
2
This statement is accurate and does not indicate a need for further teaching.
3
Adequate fluid intake is at least 2-2.5 quarts of fluid daily, so the statement about
drinking 1-1.5 quarts daily indicates the need for further teaching.
4
This statement is accurate and does not indicate a need for further teaching.
PTS: 1
CON: Oxygenation
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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MULTIPLE RESPONSE
26. ANS: 1, 2, 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway
disorders
Chapter page reference: 489-491
Heading: Lung Cancer
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
1.
2.
3.
4.
5.
Feedback
This is correct. An adequate fluid intake is needed. Patients with pneumonia should increase
their fluid intake in order to decrease the viscosity of respiratory secretions.
This is correct. Turning, coughing, deep breathing, and chest percussion can help clear
secretions.
This is correct. Turning, coughing, deep breathing, and chest percussion can help clear
secretions.
This is incorrect. Administering the pneumococcal vaccine and educating the patient on
smoking cessation are important in treating a patient with pneumonia, but they would be
aligned with a different
nursing
NU
RSINdiagnosis.
GKING.COM
This is incorrect. Administering the pneumococcal vaccine and educating the patient on
smoking cessation are important in treating a patient with pneumonia, but they would be
aligned with a different nursing diagnosis.
PTS: 1
CON: Oxygenation
27. ANS: 1, 3, 4
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Developing a comprehensive plan of nursing care for patients with lower airway
disorders
Chapter page reference: 476-482
Heading: Asthma
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation; Evidence-Based Practice
Difficulty: Moderate
1.
2.
Feedback
This is correct. Age-appropriate, evidence-based interventions for a young adolescent patient
diagnosed with asthma include referral to a peer-led support group, assessing peer-support of
the patient, and collaborating with teachers to ensure the patient has the necessary support in
the school setting.
This is incorrect. While it is appropriate to include the parents in the educational process, the
patient should be taught how to administer medications prior to teaching the parents.
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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3.
4.
5.
This is correct. Age-appropriate, evidence-based interventions for a young adolescent patient
diagnosed with asthmas include referral to a peer-led support group, assessing peer-support of
the patient, and collaborating with teachers to ensure the patient has the necessary support in
the school setting.
This is correct. Age-appropriate, evidence-based interventions for a young adolescent patient
diagnosed with asthmas include referral to a peer-led support group, assessing peer-support of
the patient, and collaborating with teachers to ensure the patient has the necessary support in
the school setting.
This is incorrect. Avoiding medication administration while in school could lead to an acute
asthma attack.
PTS: 1
CON: Oxygenation | Evidence-Based Practice
28. ANS: 1, 3, 4
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Describing the epidemiology of lower airway disorders
Chapter page reference: 482-485
Heading: Chronic Obstructive Pulmonary Disease (COPD)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is correct. Risk factors associated with the development of COPD include working in an
NU
RSINof
GKasthma,
ING.and
COcigarette
M
industrial environment,
a history
smoking.
This is incorrect. Working in an office setting with air conditioning and playing golf several
times a week are not risk factors for the development of COPD.
This is correct. Risk factors associated with the development of COPD include working in an
industrial environment, a history of asthma, and cigarette smoking.
This is correct. Risk factors associated with the development of COPD include working in an
industrial environment, a history of asthma, and cigarette smoking.
This is incorrect. Working in an office setting with air conditioning and playing golf several
times a week are not risk factors for the development of COPD.
PTS: 1
CON: Oxygenation
29. ANS: 1, 3
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Cystic
fibrosis
Chapter page reference: 486-489
Heading: Cystic Fibrosis
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation; Inflammation
Difficulty: Easy
Feedback
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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1.
This is correct. Steatorrhea and rectal prolapse might be signs of cystic fibrosis in an older
infant or child.
This is incorrect. Constipation is not a symptom of cystic fibrosis.
This is correct. Steatorrhea and rectal prolapse might be signs of cystic fibrosis in an older
infant or child.
This is correct. Newborns with cystic fibrosis might present in the first 48 hours with
meconium ileus.
This is incorrect. Diarrhea is not a symptom of cystic fibrosis.
2.
3.
4.
5.
PTS: 1
CON: Oxygenation | Inflammation
30. ANS: 1, 3, 5
Chapter number and title: 26, Coordinating Care for Patients With Lower Airway Disorders
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Cystic
fibrosis
Chapter page reference: 486-489
Heading: Cystic Fibrosis
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation; Inflammation
Difficulty: Easy
Feedback
This is correct. Cystic fibrosis is a multisystem disease that produces increased amounts of
thick mucus in the respiratory, gastrointestinal (GI), and reproductive systems. The disease is
NURSINGKING.COM
characterized by thick, viscous mucus that clogs the lungs and obstructs the pancreas. Other
organs that are affected include the liver, salivary glands, and testes.
This is incorrect. The neurological system is not directly affected by cystic fibrosis.
This is correct. Cystic fibrosis is a multisystem disease that produces increased amounts of
thick mucus in the respiratory, gastrointestinal (GI), and reproductive systems. The disease is
characterized by thick, viscous mucus that clogs the lungs and obstructs the pancreas. Other
organs that are affected include the liver, salivary glands, and testes.
This is incorrect. The cardiovascular system is not directly affected by cystic fibrosis.
This is correct. Cystic fibrosis is a multisystem disease that produces increased amounts of
thick mucus in the respiratory, gastrointestinal (GI), and reproductive systems. The disease is
characterized by thick, viscous mucus that clogs the lungs and obstructs the pancreas. Other
organs that are affected include the liver, salivary glands, and testes.
1.
2.
3.
4.
5.
PTS: 1
CON: Oxygenation | Inflammation
Chapter 27: Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Multiple Choice
Identify the choice that best completes the statement or answers the question.
NURSINGKING.COM #1 U.S NURSING TEST BANKS STORE
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____
1. The nurse is providing care to a patient who is diagnosed with acute respiratory distress syndrome (ARDS).
Which clinical manifestation does the nurse anticipate for this patient who is experiencing hypoxia as a result
of the ARDS diagnosis?
1) Fluid imbalance
2) Hypertension
3) Bradycardia
4) Dyspnea
____
2. The nurse is providing care to a patient with an infected leg wound. The patient is exhibiting symptoms of a
1)
2)
3)
4)
ch does the nurse suspect the patient is experiencing?
Allergic response from antibiotic therapy
Deep vein thrombosis
Acute respiratory distress syndrome
Anemia
____
3. A patient with a respiratory rate of eight breaths per minute has an oxygen saturation of 82%. Which nursing
diagnosis is a priority for this patient?
1) Risk for Infection
2) Impaired Spontaneous Ventilation
3) Risk for Acute Confusion
4) Decreased Cardiac Output
____
4. A patient with acute respiratory distress syndrome (ARDS) is being weaned from mechanical ventilation.
Which nursing action is appropriate for this patient?
1) Increase percentage of oxygen being provided through the ventilator
2) Place in the Fowler position NURSINGKING.COM
3) Provide morning care during the weaning procedures
4) Medicate with morphine for pain as needed
____
5. A patient is brought into the emergency department (ED) after being in a motor vehicle accident. The patient
has suffered traumatic injury that may involve multiple body systems. Which is the priority nursing
assessment for this patient?
1) Breathing and ventilation
2) Circulation with hemorrhage control
3) Airway maintenance with cervical spine protection
4) Disability and neurological assessment
____
6. The nurse caring for a newborn on a ventilator for acute respiratory distress syndrome (ARDS) informs the
condition?
1) Increased PCO2
2) Oxygen saturation of 92%
3) Pulmonary vascular resistance increases
4) Less than 1 mL/kg/hour urine output
____
7. The nurse caring for a patient admitted with septic shock is aware of the need to assess for the development of
acute respiratory distress syndrome (ARDS). Which early clinical manifestation would indicate the
development of ARDS?
1) Intercostal retractions
2) Cyanosis
3) Tachypnea
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4) Tachycardia
____
8. A patient admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress
syndrome (ARDS). Which health-care provider prescription does the nurse anticipate for this patient?
1) Mechanical ventilation
2) Oxygen via a nasal cannula
3) Face mask oxygen administration
4) Continuous positive airway pressure
____
9. The nurse in the intensive care unit (ICU) is caring for a patient diagnosed with acute respiratory distress
syndrome (ARDS). Vital signs prior to endotracheal intubation: HR 108 bpm, RR 32 bpm, BP 88/58 mm Hg,
and oxygen saturation 82%. The patient is intubated and placed on mechanical ventilation with positive
pressure ventilation. Which assessment finding indicates a further decrease of cardiac output secondary to
positive pressure ventilation?
1) Blood pressure 90/60 mm Hg
2) Urine output 25mL/hr
3) Heart rate 110 bpm
4) Oxygen saturation 90%
____ 10. The nurse caring for a patient recovering from an abdominal hysterectomy suspects the patient is experiencing
1)
2)
3)
4)
Nausea
Decreased urine output
Dyspnea and shortness of breath
Activity intolerance
____ 11. The nurse is concerned that a patient
a total
is at risk for thrombus formation and
NUadmitted
RSINGforKI
NG.hip
COreplacement
M
pulmonary embolism. Which assessment finding supports the
1) Body mass index (BMI) 35.8
2) Former cigarette smoker
3) Blood pressure 132/88 mm Hg
4) Age 45 years
____ 12. The nurse is providing discharge instructions to an older adult patient who is going home after having a total
knee
developing a thrombosis or pulmonary embolism?
1) Place pillows under the knees when in bed
2) Use compression stockings
3) Limit ambulation
4) Limit fluids
____ 13. A patient diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and
dyspnea. Which is the priority nursing diagnosis for this patient?
1) Ineffective Tissue Perfusion
2) Anxiety
3) Impaired Gas Exchange
4) Impaired Physical Mobility
____ 14. The nurse is planning care for a patient with a pulmonary embolism. Which intervention would assist with the
1) Provide oxygen
2) Keep protamine sulfate at the bedside
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3) Monitor pulmonary arterial pressures
4) Assess for bleeding
____ 15. The nurse has instructed a patient recovering from a pulmonary embolism on long-term anticoagulant therapy.
Which patient statement indicates that instruction has been effective?
1)
2)
3)
4)
____ 16. A patient scheduled for surgery is being instructed in leg exercises and the pneumatic compression device.
The nurse includes these instructions to decrease which postoperative complication?
1) Infection
2) Delayed wound healing
3) Contractures
4) Deep vein thrombosis
____ 17. The nurse is preparing to discharge a patient recovering from a pulmonary embolism. Which topics are
appropriate for the nurse to include in the teaching session?
1) Resume the use of any over-the-counter medications
2) Diet to include green leafy vegetables
3) Anticoagulant administration schedule
4) Resume normal activity level
____ 18. The nurse is providing care to several patients on a medical-surgical unit. Which patient is at highest risk for a
nonthrombotic pulmonary embolism?
1) The patient who is receiving intravenous
pain
NURSING
KImedication
NG.COM
2) The patient who is postoperative from a femur fracture repair
3) The patient with a primary lung tumor
4) The patient who uses intravenous illicit drugs
____ 19. A nurse caring for a patient with a pulmonary embolism expects to find which diagnostic result?
1) Patchy infiltrates on chest x-ray
2) Metabolic alkalosis on arterial blood gas
3) Elevated CO2 level found on end-tidal carbon dioxide monitor
4) Tachycardia and nonspecific T-wave changes on EKG
____ 20. The nurse is planning care for a newly admitted patient diagnosed with pulmonary embolism. The nurse
anticipates the patient will need anticoagulant therapy. What is true regarding this therapy for the treatment of
this condition?
1) It is considered second-line treatment.
2) Major hemorrhage is common.
3) Heparin and warfarin (Coumadin) are usually initiated at the same time.
4) Heparin alters the synthesis of vitamin K dependent clotting factors, preventing further
clots.
____ 21. The nurse working with a student nurse is providing care for a patient requiring mechanical ventilation. The
student nurse asks the meaning of assist control. Which response by the nurse is the most appropriate?
1)
2)
patient
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3)
4)
____ 22. The nurse is providing care for the patient requiring mechanical ventilation. Which action by the nurse would
be inappropriate when providing care to this patient?
1) Confirming airway placement by auscultating the lungs and checking the length marking
of the tube at the lip
2) Assuring that tube cuff inflation is no greater than 15 cm H2O, and that there is no audible
air leak
3) Assuring ventilator tubing is secured and does not pull on the
4) Verifying correct ventilator settings
____ 23. The nurse working in the intensive care unit is assigned a patient requiring mechanical ventilation. When
responding to the ventilator alarm, the nurse sees a high-pressure alarm. Which nursing action is the priority?
1) Silencing the alarm
2) Removing the patient from the ventilator and using a bag-valve device to oxygenate the
patient until the respiratory therapist can be summoned
3) Emptying the collected water from the ventilator tubing
4) Assessing the patient
____ 24. The nurse is providing care for a patient requiring mechanical ventilation. When the nurse enters the room at
f 88%.
Which nursing action is the priority?
1) Increasing the oxygen concentration and quickly assessing the patient
2) Removing the patient from the ventilator and hyperoxygenating and hyperventilating the
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patient
3) Assessing the patient for airway obstruction
4) Checking ventilator settings
Completion
Complete each statement.
25. The nurse is providing care to a patient admitted to the emergency department with the diagnosis of acute
respiratory distress syndrome (ARDS). When educating the
order will the nurse present the material? (Enter the number of each step in the proper sequence; do not use
punctuation or spaces. Example: 1234)
1) Initiation of ARDS
2) Onset of pulmonary edema
3) End-stage ARDS
4) Alveolar collapse
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. The nurse educator prepares to speak to a group of nursing students about direct and indirect insults to the
lungs that may lead to the development of acute respiratory distress syndrome (ARDS). Which conditions will
the nurse include in the teaching session? Select all that apply.
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1)
2)
3)
4)
5)
Septic shock
Viral pneumonia
Aspirin overdose
Head injury
Angioplasty
____ 27. A patient receiving treatment for acute respiratory distress syndrome (ARDS) is demonstrating anxiety and
fear of having to stay on the ventilator indefinitely. Which interventions by the nurse are appropriate? Select
all that apply.
1) Explain about care areas specifically designed for long-term ventilatory support.
2) Dim the lights and reduce distracting noise, such as the television.
3) Instruct that intubation and ventilation are temporary measures.
4) Encourage family visits and participation in care.
5) Remain with the patient as much as possible.
____ 28. Which assessment data would cause the nurse to document the patient is experiencing early respiratory
distress? Select all that apply.
1) Dyspnea
2) Restlessness
3) Tachycardia
4) Confusion
5) Cyanosis
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Chapter 27: Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Acute
respiratory distress syndrome
Chapter page reference: 503-508
Heading: Acute Respiratory Distress Syndrome (ARDS)
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
Fluid and electrolyte imbalances occur due to the nutritional imbalances associated with
ARDS.
2
Hypertension is not an anticipated clinical manifestation for this patient.
3
The nurse would expect tachycardia, not bradycardia, as a result of hypoxia.
4
Dyspnea is a clinical manifestation that patients experiencing hypoxia secondary to
ARDS.
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PTS: 1
CON: Oxygenation
2. ANS: 3
Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Acute
respiratory distress syndrome
Chapter page reference: 503-508
Heading: Acute Respiratory Distress Syndrome (ARDS)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
1
2
3
Feedback
Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may
not be associated with a systemic infection from an infected leg wound and are not
associated with the development of ARDS.
Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may
not be associated with a systemic infection from an infected leg wound and are not
associated with the development of ARDS.
Sepsis is the most common cause of acute respiratory distress syndrome (ARDS). The
patient has a systemic infection, which is sepsis, and is complaining that it is getting
hard to breathe. The nurse should suspect the patient is developing acute respiratory
distress.
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4
Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may
not be associated with a systemic infection from an infected leg wound and are not
associated with the development of ARDS.
PTS: 1
CON: Oxygenation
3. ANS: 2
Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Chapter learning objective: Developing a comprehensive plan of nursing care for critically ill patients with
respiratory dysfunction
Chapter page reference: 499-503
Heading: Acute Respiratory Failure
Integrated Processes: Nursing Process Diagnosis
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1
This nursing diagnosis may be appropriate; however, this is not the priority.
2
A priority nursing diagnosis for a patient with a respiratory rate of eight breaths per
minutes and an oxygen saturation of 82% is Impaired Spontaneous Ventilation. If the
current pattern continues without intervention, the patient could experience respiratory
arrest.
3
This nursing diagnosis may be appropriate; however, this is not the priority.
4
This nursing diagnosis may be appropriate; however, this is not the priority.
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PTS: 1
CON: Oxygenation
4. ANS: 2
Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Chapter learning objective: Developing a comprehensive plan of nursing care for critically ill patients with
respiratory dysfunction
Chapter page reference: 503-508
Heading: Acute Respiratory Distress Syndrome (ARDS)
Integrated Processes: Nursing Process Implementation
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
The percentage of oxygen is typically reduced during the weaning process.
2
Weaning a patient from mechanical ventilation should begin in the morning when the
patient is well-rested. The patient should be in the Fowler or high-Fowler position, as
this facilitates lung expansion and reduces the work of breathing.
3
Activities and care should be limited during the weaning process to reduce the demand
for oxygen.
4
The patient should not be given any medication known to suppress respirations, as this
would interfere with the weaning process. Medicating for pain would be appropriate
when the patient is back on the ventilator after concluding the weaning procedures.
PTS: 1
CON: Oxygenation
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5. ANS: 3
Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Chapter learning objective: Developing a comprehensive plan of nursing care for critically ill patients with
respiratory dysfunction
Chapter page reference: 508-512
Heading: Chest Trauma
Integrated Processes: Nursing Process Assessment
Client Need: Safe and Effective Care Environment Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Difficult
Feedback
1
Assessing breathing and ventilation are important; however, this is not the priority
assessment at this time.
2
Assessing breathing and ventilation are important; however, this is not the priority
assessment at this time.
3
When caring for the trauma victim the nurse must always prioritize assessments, with
the ABCDEs as the highestconcern is airway maintenance with cervical spine protection.
4
Assessing breathing and ventilation are important; however, this is not the priority
assessment at this time.
PTS: 1
CON: Oxygenation
6. ANS: 2
Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
NURthe
SIdiagnostic
NGKING
.COused
M in the management of critically ill patients
Chapter learning objective: Describing
results
with respiratory dysfunction
Chapter page reference: 503-508
Heading: Acute Respiratory Distress Syndrome (ARDS)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Moderate
1
2
3
4
Feedback
An expected outcome for a patient being treated for ARDS is maintaining an oxygen
saturation of greater than 90%. The newborn diagnosed with ARDS with an oxygen
saturation of 92% is improving.
Increased PCO2 and pulmonary vascular resistance are indicative of continued distress.
Increased PCO2 and pulmonary vascular resistance are indicative of continued distress.
Urine output of less than 1 mL/kg/hour is an abnormal finding and does not support that
the newborn is improving.
PTS: 1
CON: Oxygenation
7. ANS: 3
Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Chapter learning objective: Correlating clinical manifestations to pathophysiological processes of: Acute
respiratory distress syndrome
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Chapter page reference: 503-508
Heading: Acute Respiratory Distress Syndrome (ARDS)
Integrated Processes: Nursing Process Assessment
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
As the distress progresses, the patient would demonstrate an increasing respiratory rate,
intercostal retractions, and use of accessory muscles, as well as tachycardia.
2
Cyanosis is a late manifestation.
3
Dyspnea and tachypnea are early clinical manifestations of ARDS.
4
As the distress progresses, the patient would demonstrate an increasing respiratory rate,
intercostal retractions, and use of accessory muscles, as well as tachycardia.
PTS: 1
CON: Oxygenation
8. ANS: 1
Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Chapter learning objective: Discussing the medical management of: Acute respiratory distress syndrome
Chapter page reference: 503-508
Heading: Acute Respiratory Distress Syndrome (ARDS)
Integrated Processes: Nursing Process Planning
Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation
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Difficulty: Easy
1
2
3
4
Feedback
With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
therapy alone. With mechanical ventilation, the FiO2 (fraction of inspired oxygen the
percentage of oxygen administered) is set at the lowest possible level to maintain a
PaO2 higher than 60 mm Hg and oxygen saturation of approximately 90%. It is
important to remember that mechanical ventilation does not cure ARDS; it simply
supports respiratory function while the underlying problem is identified and treated.
With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
therapy alone.
With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
therapy alone.
Continuous positive airway pressure will not provide the patient with the oxygenation
that is required.
PTS: 1
CON: Oxygenation
9. ANS: 2
Chapter number and title: 27, Coordinating Care for Critically Ill Patients With Respiratory Dysfunction
Chapter learning objective: Describing the diagnostic results used in the management of critically ill patients
with respiratory dysfunction
Chapter page reference: 503-508
Heading: Acute Respiratory Distress Syndrome (ARDS)
Integrated Processes: Nursing Process Assessment
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Client Need: Physiological Integrity Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Oxygenation; Perfusion
Difficulty: Easy
1
2
3
4
Feedback
Although hypotension and tachycardia are indicative of a decreased cardiac output, this
is not a change from the previous assessment and would not indicate a further decrease
in cardiac output due to mechanical ventilation.
Decreased cardiac output is supported by a decrease of urine output. Expected urine
finding supports the diagnosis of decreased cardiac output.
Although hypotension and tachycardia are indicative of a decreased cardiac output, this
is not a change from the previous assessment and would