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Contents
Chapter 1: Foundations for Medical-Surgical Nursing ....................................................................................................................... 13
Multiple Choice .......................................................................................................................................................................... 13
Multiple Response ...................................................................................................................................................................... 15
Chapter 1: Foundations for Medical-Surgical NursingAnswer Section .............................................................................................. 17
MULTIPLE CHOICE................................................................................................................................................................. 17
MULTIPLE RESPONSE ........................................................................................................................................................... 26
Chapter 2: Interprofessional Collaboration and Care Coordination .................................................................................................... 30
Multiple Choice .......................................................................................................................................................................... 30
Multiple Response ...................................................................................................................................................................... 33
Chapter 2: Interprofessional Collaboration and Care CoordinationAnswer Section ........................................................................... 35
MULTIPLE CHOICE................................................................................................................................................................. 35
MULTIPLE RESPONSE ........................................................................................................................................................... 45
Chapter 3: Cultural Considerations .................................................................................................................................................... 48
Multiple Choice .......................................................................................................................................................................... 48
Multiple Response ...................................................................................................................................................................... 51
Chapter 3: Cultural ConsiderationsAnswer Section............................................................................................................................ 53
MULTIPLE CHOICE................................................................................................................................................................. 53
MULTIPLE RESPONSE ........................................................................................................................................................... 62
Chapter 4: Ethical Concepts ............................................................................................................................................................... 66
Multiple Choice .......................................................................................................................................................................... 66
Multiple Response ...................................................................................................................................................................... 69
Chapter 4: Ethical ConceptsAnswer Section ...................................................................................................................................... 70
MULTIPLE CHOICE................................................................................................................................................................. 70
MULTIPLE RESPONSE ........................................................................................................................................................... 79
Chapter 5: Palliative Care and End-of-Life Issues .............................................................................................................................. 82
Multiple Choice .......................................................................................................................................................................... 82
Multiple Response ...................................................................................................................................................................... 85
Chapter 5: Palliative Care and End-of-Life IssuesAnswer Section..................................................................................................... 87
MULTIPLE CHOICE................................................................................................................................................................. 87
MULTIPLE RESPONSE ........................................................................................................................................................... 96
Chapter 6: Geriatric Implications for Medical-Surgical Nursing...................................................................................................... 100
Multiple Choice ........................................................................................................................................................................ 100
Multiple Response .................................................................................................................................................................... 102
Chapter 6: Geriatric Implications for Medical-Surgical NursingAnswer Section............................................................................. 104
MULTIPLE CHOICE............................................................................................................................................................... 104
MULTIPLE RESPONSE ......................................................................................................................................................... 113
Chapter 7: Oxygen Therapy Management ........................................................................................................................................ 116
Multiple Choice ........................................................................................................................................................................ 116
Multiple Response .................................................................................................................................................................... 119
Chapter 7: Oxygen Therapy ManagementAnswer Section ............................................................................................................... 121
MULTIPLE CHOICE............................................................................................................................................................... 121
MULTIPLE RESPONSE ......................................................................................................................................................... 132
Chapter 8: Fluid and Electrolyte Management ................................................................................................................................. 135
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Multiple Choice ............................................................................................................................................................................ 135
Multiple Response ........................................................................................................................................................................ 139
Chapter 8: Fluid and Electrolyte ManagementAnswer Section ........................................................................................................ 141
MULTIPLE CHOICE................................................................................................................................................................... 141
MULTIPLE RESPONSE .............................................................................................................................................................. 155
Feedback: ..................................................................................................................................................................................... 160
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Chapter 10: Overview of Infusion Therapies .................................................................................................................................... 170
Multiple Choice ............................................................................................................................................................................ 170
Multiple Response ........................................................................................................................................................................ 174
Completion ................................................................................................................................................................................... 175
Chapter 10: Overview of Infusion TherapiesAnswer Section........................................................................................................... 176
MULTIPLE CHOICE................................................................................................................................................................... 176
MULTIPLE RESPONSE ............................................................................................................................................................. 188
COMPLETION ............................................................................................................................................................................ 192
Chapter 11: Pain Management .......................................................................................................................................................... 194
Multiple Choice ........................................................................................................................................................................ 194
Multiple Response .................................................................................................................................................................... 197
Chapter 11: Pain ManagementAnswer Section ................................................................................................................................. 199
MULTIPLE CHOICE............................................................................................................................................................... 199
MULTIPLE RESPONSE ......................................................................................................................................................... 209
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Chapter 12: Complementary and Alternative Care Initiatives .......................................................................................................... 212
Multiple Choice ........................................................................................................................................................................ 212
Multiple Response .................................................................................................................................................................... 214
Chapter 12: Complementary and Alternative Care InitiativesAnswer Section ................................................................................. 216
MULTIPLE CHOICE............................................................................................................................................................... 216
MULTIPLE RESPONSE ......................................................................................................................................................... 225
Chapter 13: Overview of Cancer Care .............................................................................................................................................. 228
Multiple Choice ........................................................................................................................................................................ 228
Multiple Response .................................................................................................................................................................... 231
Chapter 13: Overview of Cancer CareAnswer Section ..................................................................................................................... 233
MULTIPLE CHOICE............................................................................................................................................................... 233
MULTIPLE RESPONSE ......................................................................................................................................................... 243
Chapter 14: Overview of Shock and Sepsis...................................................................................................................................... 247
Multiple Choice ........................................................................................................................................................................ 247
Multiple Response .................................................................................................................................................................... 250
Chapter 14: Overview of Shock and SepsisAnswer Section ............................................................................................................. 252
MULTIPLE CHOICE............................................................................................................................................................... 252
MULTIPLE RESPONSE ......................................................................................................................................................... 261
Chapter 15: Priorities for the Preoperative Patient ........................................................................................................................... 266
Multiple Choice ........................................................................................................................................................................ 266
Multiple Response .................................................................................................................................................................... 268
Chapter 15: Priorities for the Preoperative PatientAnswer Section................................................................................................... 270
MULTIPLE CHOICE............................................................................................................................................................... 270
MULTIPLE RESPONSE ......................................................................................................................................................... 278
Chapter 16: Priorities for the Intraoperative Patient ......................................................................................................................... 282
Multiple Choice ........................................................................................................................................................................ 282
Completion ............................................................................................................................................................................... 284
Multiple Response .................................................................................................................................................................... 284
Chapter 16: Priorities for the Intraoperative PatientAnswer Section ................................................................................................ 287
MULTIPLE CHOICE............................................................................................................................................................... 287
COMPLETION ........................................................................................................................................................................ 295
MULTIPLE RESPONSE ......................................................................................................................................................... 295
Chapter 17: Priorities for the Postoperative Patient .......................................................................................................................... 300
Multiple Choice ........................................................................................................................................................................ 300
Multiple Response .................................................................................................................................................................... 302
Chapter 17: Priorities for the Postoperative PatientAnswer Section ................................................................................................. 304
MULTIPLE CHOICE............................................................................................................................................................... 304
MULTIPLE RESPONSE ......................................................................................................................................................... 313
Chapter 19: Coordinating Care for Patients with Immune Disorders ............................................................................................... 332
Multiple Choice ............................................................................................................................................................................ 332
Multiple Response ........................................................................................................................................................................ 335
Chapter 19: Coordinating Care for Patients with Immune DisordersAnswer Section ...................................................................... 337
MULTIPLE CHOICE................................................................................................................................................................... 337
MULTIPLE RESPONSE .............................................................................................................................................................. 351
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Chapter 20: Coordinating Care for Patients With Immune Disorders............................................................................................... 355
Multiple Choice ........................................................................................................................................................................ 355
Multiple Response .................................................................................................................................................................... 358
Chapter 20: Coordinating Care for Patients With Immune DisordersAnswer Section ...................................................................... 360
MULTIPLE CHOICE............................................................................................................................................................... 360
MULTIPLE RESPONSE ......................................................................................................................................................... 370
Chapter 21: Coordinating Care for Patients with Multidrug-ResistantOrganism Infectious
Disorders ...................................................................................................................................................................................... 373
Multiple Choice ................................................................................................................................................................. 373
Multiple Response........................................................................................................................................................... 376
Chapter 21: Coordinating Care for Patients with Multidrug-ResistantOrganism Infectious
Disorders ...................................................................................................................................................................................... 378
MULTIPLE CHOICE ............................................................................................................................................................ 378
MULTIPLE RESPONSE ...................................................................................................................................................... 389
Chapter 22: Coordinating Care for Patients with HIV ...................................................................................................................... 395
Multiple Choice ............................................................................................................................................................................ 395
Completion ................................................................................................................................................................................... 398
Multiple Response ........................................................................................................................................................................ 399
Chapter 22: Coordinating Care for Patients with HIVAnswer Section ............................................................................................. 401
MULTIPLE CHOICE................................................................................................................................................................... 401
COMPLETION ............................................................................................................................................................................ 413
MULTIPLE RESPONSE .............................................................................................................................................................. 414
Chapter 23: Assessment of Respiratory Function ............................................................................................................................. 419
Multiple Choice ............................................................................................................................................................................ 419
Multiple Response ........................................................................................................................................................................ 422
Chapter 23: Assessment of Respiratory FunctionAnswer Section.................................................................................................... 424
MULTIPLE CHOICE................................................................................................................................................................... 424
MULTIPLE RESPONSE ............................................................................................................................................................. 436
Chapter 24: Coordinating Care for Patients With Infectious Respiratory Disorders......................................................................... 442
Multiple Choice ........................................................................................................................................................................ 442
Multiple Response .................................................................................................................................................................... 445
Chapter 24: Coordinating Care for Patients With Infectious Respiratory DisordersAnswer Section ............................................... 447
MULTIPLE CHOICE............................................................................................................................................................... 447
MULTIPLE RESPONSE ......................................................................................................................................................... 457
Chapter 25: Coordinating Care for Patients With Upper Airway Disorders ..................................................................................... 461
Multiple Choice ........................................................................................................................................................................ 461
Multiple Response .................................................................................................................................................................... 464
Chapter 25: Coordinating Care for Patients With Upper Airway DisordersAnswer Section ............................................................ 466
MULTIPLE CHOICE............................................................................................................................................................... 466
MULTIPLE RESPONSE ......................................................................................................................................................... 476
Chapter 26: Coordinating Care for Patients With Lower Airway Disorders..................................................................................... 478
Multiple Choice ........................................................................................................................................................................ 478
Multiple Response .................................................................................................................................................................... 482
Chapter 26: Coordinating Care for Patients With Lower Airway DisordersAnswer Section............................................................ 483
MULTIPLE CHOICE............................................................................................................................................................... 483
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MULTIPLE RESPONSE ......................................................................................................................................................... 495
Chapter 27: Coordinating Care for Critically Ill Patients With Respiratory Dysfunction ................................................................. 499
Multiple Choice ........................................................................................................................................................................ 499
Completion ............................................................................................................................................................................... 502
Multiple Response .................................................................................................................................................................... 503
Chapter 27: Coordinating Care for Critically Ill Patients With Respiratory DysfunctionAnswer Section........................................ 504
MULTIPLE CHOICE............................................................................................................................................................... 504
COMPLETION ........................................................................................................................................................................ 515
MULTIPLE RESPONSE ......................................................................................................................................................... 516
Chapter 28: Assessment of Cardiovascular Function ........................................................................................................................ 519
Multiple Choice ............................................................................................................................................................................ 519
Completion ................................................................................................................................................................................... 522
Multiple Response ........................................................................................................................................................................ 523
Chapter 28: Assessment of Cardiovascular FunctionAnswer Section .............................................................................................. 525
MULTIPLE CHOICE................................................................................................................................................................... 525
COMPLETION ............................................................................................................................................................................ 536
MULTIPLE RESPONSE ............................................................................................................................................................. 537
Chapter 29: Complementary and Alternative Care Initiatives .......................................................................................................... 542
Multiple Choice......................................................................................................................................................................... 542
Multiple Response .................................................................................................................................................................... 545
Completion ............................................................................................................................................................................... 545
Chapter 29: Coordinating Care for Patients With Cardiac Dysrhythmia AnswerSection.................................................................. 546
MULTIPLE CHOICE..................................................................................................................................................................... 546
MULTIPLE RESPONSE ................................................................................................................................................................ 556
COMPLETION ............................................................................................................................................................................ 558
Chapter 30: Coordinating Care for Patients with Cardiac Disorders ................................................................................................ 560
Multiple Choice ............................................................................................................................................................................ 560
Multiple Response ........................................................................................................................................................................ 563
Chapter 30: Coordinating Care for Patients with Cardiac DisordersAnswer Section ....................................................................... 565
MULTIPLE CHOICE................................................................................................................................................................... 565
MULTIPLE RESPONSE ............................................................................................................................................................. 577
Chapter 31: Coordinating Care for Patients with Vascular Disorders ............................................................................................... 583
Multiple Choice ............................................................................................................................................................................ 583
Multiple Response ........................................................................................................................................................................ 586
Completion ................................................................................................................................................................................... 587
Chapter 31: Coordinating Care for Patients with Vascular DisordersAnswer Section ...................................................................... 588
MULTIPLE CHOICE................................................................................................................................................................... 588
MULTIPLE RESPONSE .............................................................................................................................................................. 601
COMPLETION ............................................................................................................................................................................ 605
Chapter 32: Coordinating Care for Critically Ill Patients with Cardiovascular Dysfunction ............................................................ 607
Multiple Choice ............................................................................................................................................................................ 607
Completion ................................................................................................................................................................................... 610
Multiple Response ........................................................................................................................................................................ 610
Chapter 32: Coordinating Care for Critically Ill Patients with Cardiovascular DysfunctionAnswer Section ................................... 612
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MULTIPLE CHOICE................................................................................................................................................................... 612
COMPLETION ............................................................................................................................................................................ 624
MULTIPLE RESPONSE ............................................................................................................................................................. 625
Chapter 33: Assessment of Hematological Function ........................................................................................................................ 630
Multiple Choice ........................................................................................................................................................................ 630
Multiple Response .................................................................................................................................................................... 632
Completion ............................................................................................................................................................................... 633
Chapter 33: Assessment of Hematological FunctionAnswer Section ............................................................................................... 634
MULTIPLE CHOICE............................................................................................................................................................... 634
MULTIPLE RESPONSE ......................................................................................................................................................... 642
COMPLETION ........................................................................................................................................................................ 644
Chapter 34: Coordinating Care for Patients with Hematological Disorders ..................................................................................... 645
Multiple Choice ............................................................................................................................................................................ 645
Multiple Response ........................................................................................................................................................................ 649
Chapter 34: Coordinating Care for Patients with Hematological DisordersAnswer Section ............................................................ 651
MULTIPLE CHOICE................................................................................................................................................................... 651
MULTIPLE RESPONSE .............................................................................................................................................................. 666
Chapter 35: Assessment of Neurological Function ........................................................................................................................... 670
Multiple Choice ........................................................................................................................................................................ 670
Multiple Response .................................................................................................................................................................... 672
Chapter 35: Assessment of Neurological FunctionAnswer Section ................................................................................................. 674
MULTIPLE CHOICE............................................................................................................................................................... 674
MULTIPLE RESPONSE ......................................................................................................................................................... 682
Chapter 36: Coordinating Care for Patients With Brain Disorders ................................................................................................... 685
Multiple Choice ........................................................................................................................................................................ 685
Multiple Response .................................................................................................................................................................... 688
Numeric Response .................................................................................................................................................................... 688
Chapter 36: Coordinating Care for Patients With Brain DisordersAnswer Section .......................................................................... 690
MULTIPLE CHOICE............................................................................................................................................................... 690
MULTIPLE RESPONSE ......................................................................................................................................................... 700
NUMERIC RESPONSE ........................................................................................................................................................... 702
Chapter 37: Coordinating Care for Patients with Spinal Cord Disorders.......................................................................................... 703
Multiple Choice ............................................................................................................................................................................ 703
Multiple Response ........................................................................................................................................................................ 706
Chapter 37: Coordinating Care for Patients with Spinal Cord DisordersAnswer Section ................................................................ 708
MULTIPLE CHOICE................................................................................................................................................................... 708
MULTIPLE RESPONSE ............................................................................................................................................................. 720
Chapter 38: Coordinating Care for Patients With Peripheral Nervous System Disorders ................................................................ 726
Multiple Choice ........................................................................................................................................................................ 726
Multiple Response .................................................................................................................................................................... 729
Numeric Response .................................................................................................................................................................... 729
Chapter 38: Coordinating Care for Patients With Peripheral Nervous System DisordersAnswer Section ....................................... 730
MULTIPLE CHOICE............................................................................................................................................................... 730
MULTIPLE RESPONSE ......................................................................................................................................................... 739
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NUMERIC RESPONSE ........................................................................................................................................................... 741
Chapter 39: Coordinating Care for Critically Ill Patients With Neurological Dysfunction............................................................... 743
Multiple Choice ........................................................................................................................................................................ 743
Multiple Response .................................................................................................................................................................... 746
Numeric Response .................................................................................................................................................................... 747
Chapter 39: Coordinating Care for Critically Ill Patients With Neurological DysfunctionAnswer Section ..................................... 748
MULTIPLE CHOICE............................................................................................................................................................... 748
MULTIPLE RESPONSE ......................................................................................................................................................... 758
NUMERIC RESPONSE ........................................................................................................................................................... 760
Chapter 40: Assessment of Endocrine Function ............................................................................................................................... 761
Multiple Choice ........................................................................................................................................................................ 761
Multiple Response .................................................................................................................................................................... 763
Chapter 40: Assessment of Endocrine FunctionAnswer Section ...................................................................................................... 765
MULTIPLE CHOICE............................................................................................................................................................... 765
MULTIPLE RESPONSE ......................................................................................................................................................... 773
Chapter 41: Coordinating Care for Patients With Pituitary Disorders .............................................................................................. 776
Multiple Choice ........................................................................................................................................................................ 776
Multiple Response .................................................................................................................................................................... 779
Chapter 41: Coordinating Care for Patients With Pituitary DisordersAnswer Section ..................................................................... 781
MULTIPLE CHOICE............................................................................................................................................................... 781
MULTIPLE RESPONSE ......................................................................................................................................................... 790
Chapter 42: Coordinating Care for Patients With Adrenal Disorders ............................................................................................... 794
Multiple Choice ........................................................................................................................................................................ 794
Multiple Response .................................................................................................................................................................... 797
Chapter 42: Coordinating Care for Patients With Adrenal DisordersAnswer Section .......................................................................... 799
MULTIPLE CHOICE............................................................................................................................................................... 799
MULTIPLE RESPONSE ......................................................................................................................................................... 808
Chapter 43: Coordinating Care for Patients with Thyroid and Parathyroid Disorders ...................................................................... 812
MULTIPLE CHOICE ................................................................................................................................................................... 812
MULTIPLE RESPONSE.............................................................................................................................................................. 826
Chapter 44: Coordinating Care for Patients With Diabetes Mellitus ................................................................................................ 832
Multiple Choice ........................................................................................................................................................................ 832
Multiple Response .................................................................................................................................................................... 835
Numeric Response .................................................................................................................................................................... 836
Chapter 44: Coordinating Care for Patients With Diabetes MellitusAnswer Section ....................................................................... 837
MULTIPLE CHOICE............................................................................................................................................................... 837
MULTIPLE RESPONSE ......................................................................................................................................................... 846
NUMERIC RESPONSE ........................................................................................................................................................... 849
Chapter 45: Assessment of Visual Function ..................................................................................................................................... 850
Multiple Choice ........................................................................................................................................................................ 850
Multiple Response .................................................................................................................................................................... 852
Completion ............................................................................................................................................................................... 853
MULTIPLE CHOICE............................................................................................................................................................... 854
MULTIPLE RESPONSE ......................................................................................................................................................... 862
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COMPLETION ........................................................................................................................................................................ 864
Chapter 46: Coordinating Care for Patients With Visual Disorders.................................................................................................. 866
Multiple Choice ........................................................................................................................................................................ 866
Multiple Response .................................................................................................................................................................... 869
Chapter 46: Coordinating Care for Patients With Visual DisordersAnswer Section ......................................................................... 871
MULTIPLE CHOICE............................................................................................................................................................... 871
MULTIPLE RESPONSE ......................................................................................................................................................... 880
Chapter 47: Assessment of Auditory Function.................................................................................................................................. 884
Multiple Choice ........................................................................................................................................................................ 884
Multiple Response .................................................................................................................................................................... 886
Completion ............................................................................................................................................................................... 887
MULTIPLE CHOICE............................................................................................................................................................... 888
MULTIPLE RESPONSE ......................................................................................................................................................... 896
COMPLETION ........................................................................................................................................................................ 898
Chapter 48: Coordinating Care for Patients With Hearing Disorders ............................................................................................... 899
Multiple Choice ........................................................................................................................................................................ 899
Multiple Response .................................................................................................................................................................... 902
Numeric Response .................................................................................................................................................................... 903
Chapter 48: Coordinating Care for Patients With Hearing DisordersAnswer Section ...................................................................... 904
MULTIPLE CHOICE............................................................................................................................................................... 904
MULTIPLE RESPONSE ......................................................................................................................................................... 913
NUMERIC RESPONSE ........................................................................................................................................................... 916
Chapter 49: Assessment of Integumentary Function......................................................................................................................... 917
Multiple Choice ........................................................................................................................................................................ 917
Multiple Response .................................................................................................................................................................... 919
Chapter 49: Assessment of Integumentary FunctionAnswer Section ............................................................................................... 921
MULTIPLE CHOICE............................................................................................................................................................... 921
MULTIPLE RESPONSE ......................................................................................................................................................... 929
Chapter 50: Coordinating Care for Patients With Skin Disorders..................................................................................................... 933
Multiple Choice ........................................................................................................................................................................ 933
Multiple Response .................................................................................................................................................................... 936
Numeric Response .................................................................................................................................................................... 936
Chapter 50: Coordinating Care for Patients With Skin DisordersAnswer Section............................................................................ 938
MULTIPLE CHOICE............................................................................................................................................................... 938
MULTIPLE RESPONSE ......................................................................................................................................................... 947
NUMERIC RESPONSE ........................................................................................................................................................... 949
Chapter 51: Coordinating Care for Patients With Burns ................................................................................................................... 951
Multiple Choice ........................................................................................................................................................................ 951
Multiple Response .................................................................................................................................................................... 955
Numeric Response .................................................................................................................................................................... 955
Chapter 51: Coordinating Care for Patients With BurnsAnswer Section ......................................................................................... 956
MULTIPLE CHOICE............................................................................................................................................................... 956
MULTIPLE RESPONSE ......................................................................................................................................................... 966
NUMERIC RESPONSE ........................................................................................................................................................... 968
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Chapter 52: Assessment of Musculoskeletal Function ...................................................................................................................... 969
Multiple Choice ........................................................................................................................................................................ 969
Multiple Response .................................................................................................................................................................... 971
Chapter 52: Assessment of Musculoskeletal FunctionAnswer Section ............................................................................................ 973
MULTIPLE CHOICE............................................................................................................................................................... 973
MULTIPLE RESPONSE ......................................................................................................................................................... 981
Chapter 53: Coordinating Care for Patients With Musculoskeletal Disorders .................................................................................. 984
Multiple Choice ........................................................................................................................................................................ 984
Multiple Response .................................................................................................................................................................... 986
Chapter 53: Coordinating Care for Patients With Musculoskeletal DisordersAnswer Section ......................................................... 989
MULTIPLE CHOICE............................................................................................................................................................... 989
MULTIPLE RESPONSE ......................................................................................................................................................... 998
Chapter 54: Coordinating Care for Patients With Musculoskeletal Trauma ................................................................................... 1002
Multiple Choice ...................................................................................................................................................................... 1002
Multiple Response .................................................................................................................................................................. 1004
Chapter 54: Coordinating Care for Patients With Musculoskeletal TraumaAnswer Section .......................................................... 1006
MULTIPLE CHOICE............................................................................................................................................................. 1006
MULTIPLE RESPONSE ....................................................................................................................................................... 1014
Chapter 55: Assessment of Gastrointestinal Function..................................................................................................................... 1017
Multiple Choice ...................................................................................................................................................................... 1017
Multiple Response .................................................................................................................................................................. 1019
Chapter 55: Assessment of Gastrointestinal FunctionAnswer Section ........................................................................................... 1021
MULTIPLE CHOICE............................................................................................................................................................. 1021
MULTIPLE RESPONSE ....................................................................................................................................................... 1029
Chapter 56: Coordinating Care for Patients With Oral and Esophageal Disorders ......................................................................... 1032
Multiple Choice ...................................................................................................................................................................... 1032
Multiple Response .................................................................................................................................................................. 1035
Chapter 56: Coordinating Care for Patients With Oral and Esophageal DisordersAnswer Section ................................................ 1036
MULTIPLE CHOICE............................................................................................................................................................. 1036
MULTIPLE RESPONSE ....................................................................................................................................................... 1045
Chapter 57: Coordinating Care for Patients With Stomach Disorders ............................................................................................ 1047
Multiple Choice ...................................................................................................................................................................... 1047
Multiple Response .................................................................................................................................................................. 1050
Chapter 57: Coordinating Care for Patients With Stomach DisordersAnswer Section ................................................................... 1051
MULTIPLE CHOICE............................................................................................................................................................. 1051
MULTIPLE RESPONSE ....................................................................................................................................................... 1059
Chapter 58: Coordinating Care for Patients With Intestinal Disorders ........................................................................................... 1062
Multiple Choice ...................................................................................................................................................................... 1062
Multiple Response .................................................................................................................................................................. 1066
Chapter 58: Coordinating Care for Patients With Intestinal DisordersAnswer Section .................................................................. 1068
MULTIPLE CHOICE............................................................................................................................................................. 1068
MULTIPLE RESPONSE ....................................................................................................................................................... 1079
Chapter 59: Coordinating Care for Patients With Hepatic Disorders ............................................................................................. 1082
Multiple Choice ...................................................................................................................................................................... 1082
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Multiple Response .................................................................................................................................................................. 1085
Completion ............................................................................................................................................................................. 1086
Chapter 59: Coordinating Care for Patients With Hepatic DisordersAnswer Section..................................................................... 1087
MULTIPLE CHOICE............................................................................................................................................................. 1087
MULTIPLE RESPONSE ....................................................................................................................................................... 1097
COMPLETION ...................................................................................................................................................................... 1098
Chapter 60: Coordinating Care for Patients With Biliary and Pancreatic Disorders ....................................................................... 1100
Multiple Choice ...................................................................................................................................................................... 1100
Multiple Response .................................................................................................................................................................. 1103
Chapter 60: Coordinating Care for Patients With Biliary and Pancreatic DisordersAnswer Section.............................................. 1105
MULTIPLE CHOICE............................................................................................................................................................. 1105
MULTIPLE RESPONSE ....................................................................................................................................................... 1115
Chapter 61: Assessment of Renal and Urinary Function ................................................................................................................ 1118
Multiple Choice ...................................................................................................................................................................... 1118
Multiple Response .................................................................................................................................................................. 1121
Chapter 61: Assessment of Renal and Urinary FunctionAnswer Section ....................................................................................... 1122
MULTIPLE CHOICE............................................................................................................................................................. 1122
MULTIPLE RESPONSE ....................................................................................................................................................... 1131
Chapter 62: Coordinating Care for Patients With Renal Disorders................................................................................................. 1134
Multiple Choice ...................................................................................................................................................................... 1134
Multiple Response .................................................................................................................................................................. 1138
Chapter 62: Coordinating Care for Patients With Renal DisordersAnswer Section........................................................................ 1139
MULTIPLE CHOICE............................................................................................................................................................. 1139
MULTIPLE RESPONSE ....................................................................................................................................................... 1150
Chapter 63: Coordinating Care for Patients with Urinary Disorders .............................................................................................. 1153
MULTIPLE CHOICE ................................................................................................................................................................ 1153
MULTIPLE RESPONSE ........................................................................................................................................................... 1171
Chapter 64: Assessment of Reproductive Function ........................................................................................................................ 1177
Multiple Choice ...................................................................................................................................................................... 1177
Multiple Response .................................................................................................................................................................. 1180
Chapter 64: Assessment of Reproductive FunctionAnswer Section ............................................................................................... 1182
MULTIPLE CHOICE............................................................................................................................................................. 1182
MULTIPLE RESPONSE ....................................................................................................................................................... 1192
Chapter 65: Coordinating Care for Female Patients With Reproductive and Breast Disorders ...................................................... 1195
Multiple Choice ...................................................................................................................................................................... 1195
Multiple Response .................................................................................................................................................................. 1198
Chapter 65: Coordinating Care for Female Patients With Reproductive and Breast DisordersAnswer Section ............................. 1200
MULTIPLE CHOICE............................................................................................................................................................. 1200
MULTIPLE RESPONSE ....................................................................................................................................................... 1211
Chapter 66: Coordinating Care for Male Patients With Reproductive and Breast Disorders.......................................................... 1214
Multiple Choice ...................................................................................................................................................................... 1214
Multiple Response .................................................................................................................................................................. 1217
Chapter 66: Coordinating Care for Male Patients With Reproductive and Breast DisordersAnswer Section ................................ 1219
MULTIPLE CHOICE............................................................................................................................................................. 1219
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MULTIPLE RESPONSE ....................................................................................................................................................... 1230
Chapter 67: Coordinating Care for Patients With Sexually Transmitted Infection ......................................................................... 1233
Multiple Choice ...................................................................................................................................................................... 1233
Multiple Response .................................................................................................................................................................. 1236
Chapter 67: Coordinating Care for Patients With Sexually Transmitted InfectionAnswer Section ................................................ 1237
MULTIPLE CHOICE............................................................................................................................................................. 1237
MULTIPLE RESPONSE ....................................................................................................................................................... 1247
Chapter 68: Managing Care for the Adult Patient With Obesity ..................................................................................................... 1249
Multiple Choice ...................................................................................................................................................................... 1249
Completion ............................................................................................................................................................................. 1252
Multiple Response .................................................................................................................................................................. 1252
Chapter 68: Managing Care for the Adult Patient With ObesityAnswer Section .......................................................................... 1253
MULTIPLE CHOICE............................................................................................................................................................. 1253
COMPLETION ...................................................................................................................................................................... 1263
MULTIPLE RESPONSE ....................................................................................................................................................... 1263
Chapter 69: Substance Use Disorders in the Adult Population ....................................................................................................... 1265
Multiple Choice ...................................................................................................................................................................... 1265
Multiple Response .................................................................................................................................................................. 1268
Chapter 69: Substance Use Disorders in the Adult PopulationAnswer Section .............................................................................. 1270
MULTIPLE CHOICE............................................................................................................................................................. 1270
MULTIPLE RESPONSE ....................................................................................................................................................... 1282
Chapter 70: Emergency, Trauma, and Environmental Injuries ....................................................................................................... 1286
Multiple Choice ...................................................................................................................................................................... 1286
Multiple Response .................................................................................................................................................................. 1289
Completion ............................................................................................................................................................................. 1289
Chapter 70: Emergency, Trauma, and Environmental InjuriesAnswer Section .............................................................................. 1291
MULTIPLE CHOICE............................................................................................................................................................. 1291
MULTIPLE RESPONSE ....................................................................................................................................................... 1302
COMPLETION ...................................................................................................................................................................... 1304
Chapter 71: Mass Casualty and Disaster Preparedness ................................................................................................................... 1306
Multiple Choice ...................................................................................................................................................................... 1306
Multiple Response .................................................................................................................................................................. 1309
Chapter 71: Mass Casualty and Disaster PreparednessAnswer Section .......................................................................................... 1311
MULTIPLE CHOICE............................................................................................................................................................. 1311
MULTIPLE RESPONSE ....................................................................................................................................................... 1322
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Medical Surgical Nursing 2nd Edition Hoffman Test Bank
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
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
Commission’s (TJC) National Patient Safety Goals (NPSG)?
1) Silencing a cardiorespiratory monitor
2) Identifying each patient using one source
3) Determining patient safety issues upon admission
4) 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
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?
13
1)
2)
3)
4)
Level I
Level II
Level III
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. Which statement should the nurse make when communicating the “S” in the SBAR approach for effective
communication?
1) “The patient presented to the emergency department at 0200 with lower left abdominal
pain.”
2) “The patient rated the pain upon admission as a 9 on a 10-point numeric scale.”
3) “The patient has no significant issues in the medical history.”
4) “The patient was given a prescribed opioid analgesic at 0300.”
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) “The patient’s heartrate is 110.”
2) “I think this patient needs to be transferred to the critical care unit.”
3) “The patient is a 68-year-old male patient admitted last night.”
4) “The patient is complaining of chest pain.”
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) Considering the patient’s culture when planning care
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
3) Disease pathophysiology
4) Therapeutic communication
14. Which statement regarding the use of the nursing process in clinical practice is accurate?
1) “The nursing process is closely related to clinical decision-making.”
2) “The nursing process is used by all members of the interprofessional team to plan care.”
3) “The nursing process has 4 basic steps: assessment, planning, implementation, evaluation.”
14
4) “The nursing process is being replaced by the implementation of evidence-based practice.”
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
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
verifying the patient’s identification using at least two sources?
1) Prior to delivering a meal tray
2) Prior to passive range of motion
3) Prior to medication administration
4) 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
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) “A hand-off is required prior to administering a medication.”
15
2)
3)
4)
5)
“A hand-off is required during change of shift.”
“A hand-off is required for a patient is transferred to the surgical suite.”
“A hand-off is required whenever the nurse receives a new patient assignment.”
“A hand-off is required prior to family visitation.”
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) Holding a medication if the patient’s diagnosis does not support its use
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
24. The nurse is planning an interprofessional care conference for a patient who is approaching discharge from
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
16
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
provide the strongest evidence to support a practice change.
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
Feedback
Evaluation is a step in the nursing process; however, this is not an action that supports
the patient-centered care model.
17
2
3
4
Assessment is a step in the nursing process; however, this is not an action that supports
the patient-centered care model.
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.
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
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.
18
3
4
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.
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
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
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.
19
3
4
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.
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
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
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.
20
4
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
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
1
2
3
4
Feedback
The “S” reflects the patient’s current situation which is communicated by providing a
brief statement of the issue. This statement by the nurse exemplifies the current situation.
The “A” reflects the patient’s assessment data. This statement by the nurse exemplifies
the patent’s assessment data.
The “B” reflects the patient’s medical history. This statement by the nurse exemplifies
communicating the patient’s history related to the current problem.
The “R” reflects specific actions needed to address the situation. This statement by the
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
Heading: Box 1.6 The SBAR Approach for Effective Communication
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment/Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Communication
Difficulty: Moderate
1
2
3
4
Feedback
This statement is the “A” in the SBAR communication. This is an assessment finding by
the staff nurse.
This statement is the “R” in the SBAR communication. This is the recommendation by
the staff nurse.
This statement is the “B” in the SBAR communication. This is the background
information.
This statement is the “S” in the SBAR communication. This is the situation information.
21
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
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
Advocating for a patient who is in pain exemplifies the QSEN competency of patientcentered care, not safety.
Considering the patient’s cultural background exemplifies the QSEN competency of
patient-centered care, not safety.
Evaluating the patient’s learning style prior to implementing discharge instructions
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]
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
22
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
2
3
4
Feedback
Patient advocacy is not identified as an academic-practice gap for new graduate nurses.
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 Nursing Practice”
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
1
2
3
4
Feedback
The nursing process is closely related to the nurse’s decision-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.
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
23
Cognitive level: Knowledge [Remembering]
Concept: Evidence-Based Practice
Difficulty: Easy
1
2
3
4
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.
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
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
24
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
CON: Quality Improvement
18. ANS: 1
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
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
25
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
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
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
26
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
medication. The nurse would, however, verify the patient’s identity using two sources.
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.
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
correlates to 30 minutes before or 30 minutes after the scheduled time. This nursing action
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
27
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.
3.
4.
5.
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.
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.
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.
28
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.
2.
3.
4.
5.
PTS: 1
Feedback
This is correct. Effective clinical reasoning is a skill required for the nurse to assume the role of
care coordinator.
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.
CON: Collaboration
29
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
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) “We only want what's best for you.”
2) “We will leave you alone to discuss your options.”
3) “Perhaps you did not understand the recommendations.”
4) “Let's discuss other options that might work well for you and your family.”
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 health-care provider’s order for PT, which would be the nurse's
initial 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.
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
30
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) The view among the general population that nurses’ contributions to patients’ care is less
important to their health and well-being compared to the contribution of physicians
2) The nurses’ and physicians’ perceptions of inequity in their roles, with nurses assuming a
subservient role and physicians assuming leadership and superior role in health-care
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
patient’s continued care, who will the nurse notify regarding the patient’s needs after discharge?
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) “I cannot alter the critical pathway plan.”
2) “I must be able to meet goals that are set for me.”
3) “My insurance plan can deny payment if I do not meet goals.”
4) “The chosen critical pathway can be altered to meet my needs.”
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
nursing staff, the rehabilitation center, the patient’s family members, and other care providers to assist with a
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
2) To track a patient’s progress to ensure that appropriate care is provided until discharge
3) To manage concerns that are related to the patient’s medical care and treatment regimen
only
4) To provide a continuum of clinical services in order to help contain costs and improve
patient outcomes
31
11. The patient’s case manager, diabetes educator, and dietician meet to discuss the patient’s needs in preparation
for discharge to home. The patient’s primary health-care provider arrives and states, “I will be making all
decisions regarding the patient’s discharge care.” With the primary health-care provider’s decision to lead 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 patient’s care and the scene is chaotic. The parents are extremely anxious and want to
know what is happening. The case manager asks for an interdisciplinary team meeting to speak with the
patient’s parents. Which is the rationale for this meeting?
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 decision regarding the patient’s care
4) To prevent the parents from trying to change the plan of care
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.
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.
32
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 focus on to increase access to care that is coordinated, safe, and
focused on the patient’s unique needs across all care settings?
1) Pediatric patients
2) Older adult patients
3) Young adult patients
4) 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. The hospital’s nurse case manager has been extensively involved with a shooting victim and members of the
patient’s family in coordinating care of providers from many disciplines as the patient progressed from the
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
3) Increased overall cost of health-care services
4) Decreased patient morbidity and mortality
33
5) Decreased level of job satisfaction
22. The case manager assembles a team of health-care professionals, including the patient’s primary 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) The patient’s taking a shower
3) The patient’s visit with family
4) The extra dose of pain medication
5) The patient’s response to ambulation
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.
2) Read the order back to the prescriber.
3) Know agency policy for telephone orders.
4) Sign the prescriber’s name and credentials.
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
34
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
collaboration is a more inclusive definition of what is occurring 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.
35
2
3
4
By leaving the room, the nurse and doctor have turned their backs on the patient.
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
that form of therapy.
4
The nurse best exhibits the characteristic that the patient has a right to self-determination
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
36
4
patient would need.
The number of patients with chronic diseases with health-care needs is increasing
rapidly, and nurses and primary health-care providers cannot meet all of these patients’
needs. 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.
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
37
3
4
delegate to UAPs.
This individual does not provide definitive answers regarding tasks that nurses can
delegate to UAPs.
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
Evidence does not suggest that the general population views nurses’ contributions to the
care of patients as less important, thus this is not considered a primary barrier to nursephysician collaboration.
2
A primary and historical barrier to effective nurse-physician collaboration has been
nurses’ and physicians’ perceptions of inequity in their roles, with nurses assuming a
subservient role and medical providers perceiving their role to be superior in the
provision of health-care services.
3
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.
4
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
The patient’s needs and progress have changed. The nurse notifies the case manager to
38
3
4
coordinate changes in care needed after discharge. This patient’s exercise program 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.
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
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
39
services is provided. The goal of case management is to improve patient outcomes and to
help contain costs.
PTS: 1
CON: Management
11. ANS: 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
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
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
Interdisciplinary collaboration engages each professional’s contribution to joint care
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
Interdisciplinary collaboration engages each professional’s contribution to joint care
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.
40
3
4
Interdisciplinary collaboration engages each professional’s contribution to joint care
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.
Interdisciplinary collaboration engages each professional’s contribution to joint care
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.
Complementary is not a type of team, although team members’ efforts can be
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
41
2
3
4
communicating with the patient independently, asking the same or similar questions
needed to develop their plan of care.
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
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.
42
2
3
4
Ineffective communication is the primary cause of sentinel events, making patient safety
the primary objective of the handoff communication process.
Analysis of handoff communication may be a quality improvement criterion, not a
primary objective.
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
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
following an acute hospitalization. The patient’s needs may go unmet, and there is the
risk for medication errors and adverse clinical events; however, these are not the focus of
an education session regarding readmission rates.
2
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.
43
3
4
The safety of the patient is at risk during transitions between care settings, particularly
following an acute hospitalization. The patient’s needs may go unmet, and there is the
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.
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
Access to care that is coordinated, safe, and focused on the patient’s unique needs across
all care settings has eluded many patients, particularly the elderly and chronically ill.
3
The young adult patient population is not identified as a group where access to
coordinated, safe, and focused care is lacking across care settings.
4
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
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
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.
44
4
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
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 sense
of autonomy. This increase in sense of autonomy has been linked to nurses’ greater job
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
45
1.
2.
3.
4.
5.
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.
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.
This is correct. In order to provide for the patient’s safety, the nurse would pass on the patient’s
response to ambulation so that the oncoming staff can take fall precautions.
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.
Feedback
This is correct. When receiving a telephone order from a provider, the nurse should ask the
46
2.
3.
4.
5.
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 correct. It is also important for the nurse to know the agency’s policy regarding
telephone orders.
This is incorrect. The nurse does not sign the prescriber’s name and credentials; the nurse only
transcribed the prescription and the prescriber countersigns it within a time period prescribed by
the agency’s policy.
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
1.
2.
3.
4.
5.
PTS: 1
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.
This is incorrect. There is increased safety with the discharge transition process, not 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.
CON: Collaboration
47
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
abdominal pain and vaginal bleeding. The patient’s spouse asks that only a female examines the patient.
Which is the most culturally appropriate statement by the nurse in response to this request?
1) “Your spouse will be covered so it will not matter what the gender of the examiner is.”
2) “The male and female providers here both respect privacy.”
3) “Your request is unreasonable and cannot be honored at this time.”
4) “Every attempt will be made to honor your request regarding the care of your spouse.”
2. The nurse is caring for a Chinese patient who is one day postoperative for abdominal surgery. The patient’s
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 health-care provider about administering medication without the patient’s
knowledge
3) Offering the medication again stating that providing comfort is a priority
4) Allowing the patient to suffer in silence
3. The nurse is providing care to an infant who is experiencing colic. The infant’s family immigrated to the
United States six months ago. The mother explains that she believes that an herbal remedy, prepared by the
village doctor, is the best way to treat the infant’s colic. Which action by the nurse is most appropriate?
1) Ask the mother what the ingredients are in the remedy.
2) Give the mother an alternate remedy for colic.
3) Explain how herbal ingredients may be harmful to the infant.
4) Tell the mother not to use the remedy because there is no way to know what the
ingredients’ scientific effect may be.
4. During a sexual history the patient states, “I have always felt like a man trapped in a woman’s body.” Which
conclusion about the patient is potentially accurate?
1) Bisexuality
2) Heterosexuality
3) Homosexuality
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
48
4) Inpatient hospital-based care
7. The novice nurse working in an inner-city hospital that serves a diverse patient population states, “I want to
learn everything possible about all of the patients.” Which response by the seasoned nurse is appropriate?
1) “I will give you a great book that describes all of the critical factors.”
2) “You should always be nonjudgmental.”
3) “This will come with time as you get to know clients and then encounter problems.”
4) “You need to first understand who you are.”
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.
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. A male nurse enters the room of a female patient to obtain the patient's vital signs. The patient’s spouse
appears uncomfortable with the nurse and moves closer to the patient. Which action by the nurse is most
appropriate?
1) Ask a female staff member to obtain the patient’s vital signs.
2) Ask the spouse to leave the patient’s room to obtain the vital signs.
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) Confront the patient’s mother to state the importance of the patient making her own
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.
3) Achieved when every person has the opportunity to attain his or her health potential and 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?
49
1)
2)
3)
4)
Cupping
Moxibustion
Acupuncture
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?
1) Cupping
2) Moxibustion
3) Acupuncture
4) 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
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 patient’s surname with a title
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) Stereotyping concepts related to the patient’s culture
50
2) Evaluating the concepts in isolation from one another
3) Determining how each aspect of the patient’s culture interacts
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
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
5) Mental health issues hold a stigma and are hidden
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.
51
1)
2)
3)
4)
5)
“Do you smoke tobacco products?”
“How many alcoholic beverages do you drink each day?”
“Who makes the health-care decisions within your family?”
“Do you use any herbal medications that we should be aware of?”
“Are there any foods you would like to include in your diet during hospitalization?”
52
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
2
3
4
Feedback
The response of covering the client or stating the request is unreasonable shows
insensitivity to the patient’s cultural need.
Although both male and female staff have professional and ethical responsibilities to
respect a patient’s privacy, the nurse must still make efforts to meet the request of the
client.
The response of covering the patient or stating the request is unreasonable shows
insensitivity to the patient’s cultural need.
Many cultures have religious beliefs that prohibit examination 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.
3
Members of the Chinese culture will typically not complain of pain or physical problems
53
4
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.
2
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.
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.
54
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
The term “vulnerable population” refers to groups of people in our culture who are at
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
While adolescents are often at risk for low levels of health care, this population isn’t at
the greatest risk.
3
While older adults are often at risk for low levels of health care, this population isn’t at
the greatest risk.
4
While newborns are often at risk for low levels of health care, this population isn’t at 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.
55
PTS: 1
CON: Health Care System
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
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
56
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: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Diversity
Difficulty: Moderate
Feedback
1
Asking another staff member to obtain the patient’s vital signs is inappropriate.
2
The patient’s spouse should not be asked to leave the room unless the patient prefers this
procedure to be done with privacy.
3
Performing an intervention without first discussing it and asking for permission may be
interpreted as assault.
4
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
1
2
3
4
Feedback
This action is inappropriate and do not consider the patient’s cultural or family values.
The nurse should accept this behavior as a cultural norm.
This action is inappropriate and do not consider the patient’s cultural or family values.
This action is inappropriate and do not consider the patient’s cultural or family values.
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
57
1
2
3
4
Determinants of health is defined as factors that help explain why some people
experience poorer health than others.
Health status is described the health of a person or community along with the many
measures that contribute to this health.
Health equity is achieved when every person has the opportunity to attain his or her
health potential and no one is disadvantaged.
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
appropriate; however, this is not the nurse’s focus to decrease health disparities for this
population.
Nutritional education, pediatric immunizations, and hypertension prevention may all be
appropriate; however, this is not the nurse’s focus to decrease health disparities for this
population.
Nutritional education, pediatric immunizations, and hypertension prevention may all be
appropriate; however, this is not the nurse’s focus to decrease health disparities 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
58
1
2
3
4
Feedback
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.
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.
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.
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
59
2
3
4
that is generated is used to treat joint pain.
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.
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
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
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 (literally, “rubbing out the wind”) is used for treating colds, sore throats, flu,
sinusitis, and similar ailments.
2
Be bao or bar gio (skin pinching) is a treatment for headache or sore throat.
60
3
4
Giac (cup suctioning), another dermabrasive procedure, is used to relieve stress,
headaches, and joint and muscle pain.
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
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
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
61
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;
therefore, communication is formal and using the patient’s surname with a title is a way
of gaining trust.
2
This is an individualistic, not collectivistic, cultural attribute related to communication.
3
This is an individualistic, not collectivistic, cultural attribute related to communication.
4
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
While information related to the patient’s identified culture is a starting point,
stereotyping based on culture should be avoided.
2
Concepts monitored during a cultural assessment should not be evaluated in isolation.
3
Concepts should be assessed together because they affect one another.
4
Assumptions should not be made regarding patient care based on the identified culture.
PTS: 1
CON: Diversity | Assessment
MULTIPLE RESPONSE
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
62
Difficulty: Moderate
1.
2.
3.
4.
5.
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.
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.
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
63
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 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.
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.
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
1.
2.
3.
4.
5.
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.
This is incorrect. This would be anticipated for a patient with collectivistic cultural attributes.
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
64
Integrated Processes: Nursing Process – Planning
Client Need: Psychosocial Integrity
Cognitive level: Comprehension [Understanding]
Concept: Diversity
Difficulty: Easy
1.
2.
3.
4.
5.
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.
PTS: 1
CON: Diversity
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
1.
2.
3.
4.
5.
PTS: 1
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.
CON: Diversity | Assessment
65
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
treatment and go home. The patient’s family, however, wants to continue treatment. The nurse agrees to be
present while the patient tells the family. Which ethical patient principle is the nurse supporting?
1) Beneficence
2) Autonomy
3) Nonmaleficence
4) Justice
3. Which statement best describes the American Nurses Association (ANA) Code of Ethics for professional
nurses?
1) “It alleviates suffering for those cared for by professional nurses.”
2) “It provides standards for professional nursing practice.”
3) “It reflects legal judgments in professional nursing practice.”
4) “It serves as legal standards for professional nursing practice.”
4. Which statement regarding the American Nurses Association (ANA) Code of Ethics for professional nurses is
accurate?
1) “It is used by all health-care professionals.”
2) “It guides nurses in their professional behavior and relationships.”
3) “It forms the basis for possible lawsuits.”
4) “It is the only code of ethics available 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 care to a terminal patient who has 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?
66
1)
2)
3)
4)
Euthanasia has legal implications along with moral and ethical ones.
Passive euthanasia is an easy decision to arrive at.
Active euthanasia is supported in the Code for Nurses.
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,
which has metastasized. There is a conflict between the child’s parents and the rest of the family. Which
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. A patient is diagnosed with a sexually transmitted infections (STI) and states to the nurse, “Promise you will
not tell anyone about my condition.” Which action should the nurse take, when considering the Health
Insurance Portability and Accountability Act (HIPAA) of 1996?
1) Honor the patient’s wishes
2) Respect the patient’s privacy and confidentiality.
3) Communicate only necessary information.
4) Not disclosing any information to anyone.
10. The nurse is providing care to an older adult patient who has decided to discontinue the prescribed
hemodialysis. The patient’s family, however, is not supportive of this decision. When using the theory of
principles-based reasoning, which statement from the nurse is appropriate?
1) “The patient understands the decision and the advanced stage of the disease. If the patient
quits treatment, the patient will die.”
2) “I need to try to help the family understand the patient’s decision so they can work through
this situation together.”
3) “This patient is of sound mind and is capable of making independent decisions regarding
health care. It really is the patient’s decision to make.”
4) “This patient’s health is so deteriorated that the treatment is not saving the patient's life. It
is prolonging the ultimate outcome, which is death.”
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. The nurse is providing care to a patient who states, “My doctor is refusing to treat me because I am
noncompliant with his recommendations.” Which is the priority nursing action in this situation?
1) Have the patient contact a consumer agency.
2) Advise the patient to sue the health-care provider.
3) Take the patient’s issue to the hospital ethics committee.
4) Notify the health-care provider of the patient’s complaints.
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?
67
1)
2)
3)
4)
The nurse is morally obligated to care for the patient unless the risk exceeds responsibility.
The nurse has the responsibility to ensure the patient gets adequate medical care.
The patient has the right to choose not to disclose his or her condition to staff.
The patient is morally bound to disclose every aspect of his or her condition to staff.
14. An adolescent patient diagnosed with leukemia decides to stop chemotherapy treatments. The patient’s
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 the parents and telling them not to be “selfish” in their child’s time of need
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 nurse, “I don’t really like the nurse on the first shift; she treats me bad.” Which action by
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.
16. The nurse is providing care for a postpartum patient who states, “I know my rights and you have to do what I
tell you!” Which response by the nurse is appropriate?
1) “I don't mind doing anything within reason, but you have a responsibility to be considerate
to the staff as well.”
2) “That statement is not included in your patient rights; don't yell at me.”
3) “Why do you feel angry … did I do something you did not like?”
4) “Do you want me to take the baby to the nursery so you can calm down?”
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 the nurse to be accountable for commitments made to self or others?
1) Beneficence
2) Autonomy
3) Justice
68
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
health-care team is the nurse’s primary commitment? Select all that apply.
1) Patient
2) Family
3) Physician
4) Community
5) Surgeon
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) Loyalty to the nurse’s employer
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) Running the test without the patient’s knowledge
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.
69
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
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: Caring
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Comprehension [Understanding]
Concept: Ethics
Difficulty: Easy
Feedback
1
Beneficence means “doing good.”
2
Autonomy refers to the right to make one’s own decisions. The nurse is supporting this
principle by supporting the client in his decision.
3
Nonmaleficence is the duty to “do no harm.”
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
70
Integrated Processes: Caring
Client Need: Safe and Effective Care Environment – Management of Care
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
The ANA Code of Ethics is a formal statement of the group’s ideals and values. It is a set
of ethical principles that serves as a standard for professional actions.
3
Codes of ethics do not necessarily reflect legal judgments.
4
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 a guide for nurses in their work 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.
71
3
4
Altruism is concern for the welfare and well-being of others.
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.
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 ethical dilemmas associated with the care of the acutely ill adult
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.
72
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
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
The nurse is respectful with the rest of the family but should consider the parents’
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
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.
73
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
Cognitive level: Application [Applying]
Concept: Ethics
Difficulty: Moderate
Feedback
1
The patient’s understanding of his decision and its consequences does not address the
patient’s right to make a decision autonomously.
2
Caring theories, or relationship theories, stress courage, generosity, commitment, and the
need to nurture and maintain relationships. Caring theories promote the common good or
the welfare of the group. Trying to help the family understand the patient’s decision is an
example of a caring-based theory in practice.
3
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
Considering the patient’s condition and the outcome of treatment is an example of
consequence-based reasoning, in which the nurse looks at the outcomes of the patient’s
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]
Concept: Ethics
Difficulty: Easy
1
2
3
4
Feedback
The patient’s age and health problems are not the reasons for the nurse to take action.
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 surgery explained for the client’s sake, not because the
nurse signed the form.
The nurse should notify the surgeon because the patient has the right to informed
consent.
PTS: 1
12. ANS: 3
CON: Ethics
74
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
1
2
3
4
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.
Acting as a patient advocate and protecting the patient’s rights, the nurse should enlist
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 by the ANA Code of Ethics.
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]
75
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 need to seek guidance from the agency’s ethics
committee.
2
Confronting the parents is likely to do more harm than good especially in the context of
telling the parents they are being selfish in their child’s time of need.
3
There is no need to contact the authorities.
4
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 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
76
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.
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
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
77
1
2
3
4
One alternative solution is not the recommended number when implementing ethical
decision-making.
Two alternative solutions are not the recommended number when implementing ethical
decision-making.
The nurse should ensure that three alternative solutions are available when implementing
ethical decision-making.
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
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
Autonomy examines an individual person’s right to make decisions while providing
acknowledgement and respect for the person’s choices.
3
Justice examines who will be vulnerable from any actions taken.
4
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
1
Beneficence asks the question who benefits from the actions taken by others.
2
Autonomy examines an individual person’s right to make decisions while providing
acknowledgement and respect for the person’s choices.
3
Justice examines who will be vulnerable to any actions taken.
4
Fidelity requires the nurse to be accountable for commitments made to others and self.
PTS: 1
CON: Ethics
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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
1.
2.
3.
4.
5.
Feedback
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.
This is correct. The hospital’s patient rights statement will assist the nurse to act as a patient
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.
This is incorrect. The unit’s policy manual will not have a separate policy statement from the
hospital regarding the patient’s rights.
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
1.
2.
3.
4.
Feedback
This is correct. The patient is the nurse’s primary commitment according to the ANA Code of
Ethics.
This is correct. The family is the nurse’s primary commitment according to the ANA Code of
Ethics.
This is incorrect. The physician is not the nurse’s primary commitment according to the ANA
Code of Ethics.
This is correct. The community is the nurse’s primary commitment according to the ANA Code
79
5.
of Ethics.
This is incorrect. The surgeon is not the nurse’s primary commitment according to the ANA
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
1.
2.
3.
4.
5.
Feedback
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 counseling and consistently encouraging testing are recommended.
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
80
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.
PTS: 1
Feedback
This is correct. A nurse’s role as educator is crucial to ethical practice.
This is incorrect. Inaccurate reassurance or avoidance does not respect the patient’s rights.
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 incorrect. Inaccurate reassurance or avoidance does not respect the patient’s rights.
CON: Ethics
81
Chapter 5: Palliative Care and End-of-Life Issues
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A competent older adult patient has a living will that expresses the patient’s desire to avoid resuscitation and
heroic life support measures. The patient’s family, however, is not supportive of this directive and plans to
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) Place the document on the patient’s medical record.
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
the terminal diagnosis was given. Which should be the nurse’s focus when planning care?
1) Hopelessness
2) Caregiver role strain
3) Anticipatory grieving
4) 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) Ignore the child’s question and change 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.
4) Offer to bring in the child life therapist to help explain the situation.
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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) Tell the patient that the decision is her parents’ and she has to participate in the study.
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
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
13. The nurse is assessing the patient for palliative care. When assessing the cultural domain, which question
should the nurse include?
83
1)
2)
3)
4)
“Do you have any financial concerns regarding your care?”
“Are you currently experiencing pain?”
“Are you experiencing any depression or anxiety?”
“Do you have any specific dietary preferences that affect your care?”
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 nurse tell the family to administer to treat the patient’s pain?
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
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) “A loss of appetite often occurs during this stage.”
2) “Respirations may sound loud and wet during this stage.”
3) “I might notice that he will begin to sleep more during this stage.”
4) “Confusion or disorientation may begin to occur during this stage.”
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) “A loss of appetite often occurs during this stage.”
2) “Respirations may sound loud and wet during this stage.”
3) “I might notice that he will begin to sleep more during this stage.”
4) “Confusion or disorientation may begin to occur during this stage.”
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) “I can see this is difficult for you.”
2) “Thank you for taking such good care of your mother.”
3) “Your mother is experiencing quite a bit of pain at the moment.”
4) “A social worker will be able to answer all the questions that you have.”
20. Which concept exemplifies a well-managed death experience for a terminal patient and family members?
1) Allowing the patient to die alone
2) Withholding pain medication to decrease addiction
84
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
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) “You can bring in pictures of the family to comfort your loved one.”
2) “Apply lip balm to your loves one’s mouth if you feel the lips are dry.”
85
3) “You can massage your loved one’s arms and legs to provide comfort.”
4) “Bring in music that your loved one likes to listen to with headphones.”
5) “Your child can call your loved one if you don’t want to expose him to this process.”
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.
86
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 document
should be placed on the patient’s medical record and the health-care provider notified.
A lack of support by the family, or a plan to contest, does not invalidate the document
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
3. ANS: 3
CON: Spirituality
87
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 – 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
Difficulty: Moderate
Feedback
1
2
3
4
“Comfort measures only” indicates that the patient does not want extraordinary 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 the
patient’s life.
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
elevated as tolerated would be the first step to address the patient’s symptoms. The 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
88
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
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 for the child’s care.
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
Feedback
1
Avoiding the subject is not an option. Changing the subject or ignoring the child is not
appropriate.
2
Telling the child he is dying would be going against the parents’ wishes.
3
Offering to set up a meeting with the health-care team to discuss the parents’ fears and
concerns about telling their child the truth is the best action by the nurse.
4
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]
89
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.
3
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.
4
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
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
90
1
2
3
4
Feedback
Home health care provides skilled care to patients who are home bound. This is not the
best choice for the patient.
Palliative care is a specialized form of care that focuses on relief of pain and other
symptoms and stress associated with a severe illness.
Hospice care focuses on the care of a terminally patient with less than 6 months to live.
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
Assessing the patient’s financial concerns is included when conducting an assessment for
the social aspects related to palliative care.
2
Assessing the patient’s pain is included when conducting an assessment for the physical
aspects of palliative care.
3
Assessing the patient for depression is included when conducting an assessment for the
psychosocial and psychiatric aspects of palliative care.
4
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
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
Assessing the patient’s financial concerns is included when conducting an assessment for
the social aspects related to palliative care.
2
Assessing the patient’s pain is included when conducting an assessment for the physical
aspects of palliative care.
3
Assessing the patient for depression is included when conducting an assessment for the
91
4
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
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
Assessing the patient’s financial concerns is included when conducting an assessment for
the social aspects related to palliative care.
2
Assessing the patient’s pain is included when conducting an assessment for the physical
aspects of palliative care.
3
Assessing the patient for depression is included when conducting an assessment for the
psychosocial and psychiatric aspects of palliative care.
4
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
Cognitive level: Application [Applying]
Concept: Assessment; Diversity
Difficulty: Moderate
Feedback
1
Assessing the patient’s financial concerns is included when conducting an assessment for
the social aspects related to palliative care.
2
Assessing the patient’s pain is included when conducting an assessment for the physical
aspects of palliative care.
3
Assessing the patient for depression or anxiety is included when conducting an
assessment for the psychosocial and psychiatric aspects of palliative care.
4
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
92
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
Feedback
1
Morphine is an opiate administered to treat the patient’s pain, not delirium.
2
Haloperidol is a drug that is administered to treat delirium that can occur at the end of
life.
3
Diphenhydramine is an anticholinergic agent administered to dry the patient’s secretions,
not to treat delirium.
4
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
Diphenhydramine is an anticholinergic agent administered to dry the patient’s secretions,
not to treat pain.
4
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]
93
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.
Diphenhydramine is an anticholinergic agent administered to dry the patient’s secretions,
not to treat delirium.
Lorazepam, a benzodiazepine, is administered for a patient who is experiencing
hyperactive delirium at the end of life.
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
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.
94
2
3
4
Respirations often sound loud and wet during the late stage of the physical and
psychological changes that occur prior to death.
Sleeping more often occurs during the early stage of the physical and psychological
changes that occur prior to death.
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
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
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.
95
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.
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
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
96
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.
5.
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.
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
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
97
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.
3.
4.
5.
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.
This is incorrect. The nurse would not assess the patient’s blood pressure to determine the cause
of delirium.
This is incorrect. The nurse would not assess the patient’s respiratory rate to determine the
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.
This is correct. Certain medications are known to cause delirium; therefore, the nurse should
assess the patient’s medication regimen prior to administering the prescribed drug.
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.
PTS: 1
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
the patient’s psychosocial, not physical, needs.
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.
CON: Grief and Loss
98
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.
4.
5.
PTS: 1
Feedback
This is incorrect. While this data supports that the patient is alert and oriented it does not
indicate the patient’s decisional capacity.
This is incorrect. The patient stating that he or she does not want to be a burden on the family is
not data that supports the patient’s decisional capacity.
This is correct. Being able to communicate a decision with the health-care team supports the
patient’s decisional capacity.
This is correct. Understanding the nature and the consequences of treatment supports the
patient’s decisional capacity.
This is correct. Stating the benefits and risks associated with the treatment supports the patient’s
decisional capacity.
CON: Grief and Loss
99
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 adult patient who is diagnosed with congestive heart failure (CHF).
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) “Dementia causes impaired judgment.”
2) “Dementia causes fluctuations in alertness.”
3) “Symptoms of dementia cause day-night reversal.”
4) “Symptoms of dementia do not last more than one month.”
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
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
100
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) Accounting for all personal items in the patient’s room
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
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?
1) Atrophy
2) Stenosis
3) Sclerosis
4) 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
101
15. Which nursing action supports The Joint Commission (TJCs) safety goals for providing home care to an older
adult patient?
1) Verifying the patient’s first and last name during each visit
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 should the nurse monitor an older 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
patient tells the nurse, “I feel so tired all the time and my daughter says I look pale.” Based on this data,
which 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)
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
102
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
4) Polypharmacy
5) Poor dietary intake
24. Which items found by a nurse during a home health visit increase the older adult patient’s risk for physical
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
103
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.
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.
104
PTS: 1
CON: Perfusion
3. ANS: 4
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
Integrated Processes: Teaching and Learning
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
105
Cognitive level: Comprehension [Understanding]
Concept: Digestion
Difficulty: Easy
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
Decreased speed of foot movement increases the patient’s risk for falls.
2
Decreased vitamin D absorption caused the development of osteoporosis.
3
Increased intramuscular fat causes a loss of muscle mass.
4
Increased subcutaneous fat causes a loss of muscle mass.
PTS: 1
CON: Fluid and Electrolyte Balance
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.
106
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
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
the risk for patient falls. The 4 P’s of hourly rounding include pain, potty, positioning,
and possessions. Obtaining vital signs is not an action included in the 4 P’s of hourly
rounding.
2
Hourly rounding is evidence-based practice that increases patient safety and decreases
the risk for patient falls. The 4 P’s of hourly rounding include pain, potty, positioning,
and possessions. Assisting the patient to the bathroom an action included in the 4 P’s of
hourly rounding.
3
Hourly rounding is evidence-based practice that increases patient safety and decreases
the risk for patient falls. The 4 P’s of hourly rounding include pain, potty, positioning,
and possessions. Accounting for essential, not all, personal items is an action included in
the 4 P’s of hourly rounding. Essential items include the call bell, tissues, eye glasses,
etc.
4
Hourly rounding is evidence-based practice that increases patient safety and decreases
the risk for patient falls. The 4 P’s of hourly rounding include pain, potty, positioning,
and possessions. Documenting the amount of intake at the last meal is not an action
included in the 4 P’s of hourly rounding.
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.
107
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
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.
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
108
1
2
3
4
Feedback
Atrophy is the term used to describe a wasting away or decrease in the size of an organ.
Stenosis is the term used to describe the narrowing or constricting of a passage of orifice.
Sclerosis is the term used to describe the hardening of tissue due to fibrous tissue
overgrowth.
Calcification is the term used to describe abnormal deposits of calcium salts on organs.
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
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
109
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
Feedback
1
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.
2
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, usually
accomplished with a “mediplanner” pill container.
3
Throw rugs are discouraged as these increase the risk for patient falls, according to the
TJC safety goals when providing home care.
4
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
Heading: Parkinson’s Disease
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Neurologic Regulation
Difficulty: Easy
Feedback
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
110
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 associated with impaired renal diluting capacity and
concentrating ability.
4
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
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
111
3
4
fatigue and pale skin.
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.
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
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
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 loss that is greater than five percentage of the patient’s weight is anticipated for 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
112
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
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.
PTS: 1
Feedback
This is correct. Falls are a priority safety concern the 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.
CON: Safety
113
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.
2.
3.
4.
5.
Feedback
This is correct. Rugs increase the risk for falls for older adult patients; therefore, this is a
physical safety risk.
This is correct. Electrical cords increase the risk for falls for older adult patients; therefore, this
is a physical safety risk.
This is incorrect. A nonskid appliance in the bathtub decreases the older adult patient’s risk for
falls.
This is incorrect. Medications that are stored in a weekly divider decrease the patient’s risk for
physical injury.
This is incorrect. A telephone with emergency numbers listed decreases the patient’s risk for
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
1.
2.
3.
4.
5.
Feedback
This is correct. Decreased memory often interferes with the patient’s ability to remember if a
medication has been taken, which is a safety risk.
This is correct. Decreased visual acuity can interfere with the patient’s ability to read the
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.
This is correct. Decreased physical strength impedes the patient’s ability to safety administer
prescribed medications.
114
PTS: 1
CON: Safety
115
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?
1) Narrow bronchi
2) Narrow trachea passages
3) Inflamed pleural surfaces
4) 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
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
116
7. The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease
(COPD). The nurse assesses the patient’s breathing rate at 32 breaths per minute. The patient is also
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
(COPD). The patient’s pulse oximetry is 93% on room air with a current respiratory rate of 35 breaths per
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
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 the accuracy of the detected waveform when monitoring a patient’s oxygen
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. Which did the nurse auscultate when conducting a patient’s respiratory assessment if wheezing is
documented?
1) Snoring sounds
2) Gurgling sounds
3) Low-pitched bubbling
4) High-pitched squeaking
12. Which did the nurse auscultate when conducting a patient’s respiratory assessment if rhonchi is documented?
1) Snoring sounds
2) Gurgling sounds
3) Low-pitched bubbling
4) High-pitched squeaking
13. Which position should the nurse place a patient prior to performing in-line suctioning?
1) Prone
2) Supine
3) Fowler’s
4) Semi-Fowler’s
117
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
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 to a patient who is prescribed oxygen in the home environment. Which
statement made by the patient indicates the need for further education?
1) “I will ensure that the oxygen is kept six feet away from the stove.”
2) “I placed a no smoking sign on the door and several places within the house.”
3) “I will store the oxygen on its side, per the instructions provided by the agency.”
4) “I will keep a fire extinguisher in the house and keep it close to where the oxygen is
stored.”
118
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) “I should be in a sitting position when using this device.”
2) “I will use this device 20 times per hour while I am awake each day.”
3) “I will exhale completely prior to placing my lips around the mouthpiece.”
4) “I will hold my breath for 3 seconds after I feel like I cannot inhale any more breath.”
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
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
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
119
2)
3)
4)
5)
Ensuring a sedation vacation each day
Conducting a readiness to wean assessment
Administering a prescribed peptic ulcer prophylactic regimen
Avoiding the use of compression stockings during immobility
28. Which information should the nurse document when monitoring a patient’s oxygen saturation via oximetry?
Select all that apply.
1) The SpO2 result
2) The current vital signs
3) The presence of family or visitors at the patient’s bedside
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) The patient’s response to the procedure
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
120
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
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
121
3. ANS: 1
Chapter number and title: 7, Oxygen Therapy Management
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]
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
122
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.
2
With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
therapy alone; therefore, oxygen via a Venturi mask is not anticipated.
3
With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
therapy alone; therefore, oxygen via nasal cannula is not anticipated.
4
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.
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.
123
3
4
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.
There is no information to support Ineffective Airway Clearance, as there is no mention
that the client is coughing.
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
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
124
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
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
While using a site with adequate perfusion is important, this action does not determine
the accuracy of the detected waveform when monitoring a patient’s oxygen saturation via
oximetry.
While ensuring that any nail polish is removed is important, this action does not
determine the accuracy of the detected waveform when monitoring a patient’s oxygen
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 detected waveform when monitoring a patient’s
oxygen saturation via oximetry.
Assessing the heart rate and comparing it with the displayed pulse is the nursing action
that determines the accuracy of the wave form when monitoring a patient’s oxygen
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
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
125
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
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
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
A Fowler’s position is not appropriate for a patient who requires in-line suctioning.
4
A high-Fowler’s position is appropriate for a patient who requires in-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
126
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.
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 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
127
1
2
3
4
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
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 highpressure 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
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-
128
3
4
pressure alarm for a patient who is being mechanically ventilated.
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.
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
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 highpressure 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
statement indicates correct understanding of the information presented.
2
A “no smoking” sign should be placed in the home if oxygen is stored, or in use. This
statement indicates correct understanding of the information presented.
3
Oxygen should be stored upright, not on its side. This statement indicates the need for
further education.
4
A fire extinguisher should be maintained in the home and stored close to where the
129
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 high-Fowler’s, position is recommended when using an incentive
spirometer. This statement indicates correct understanding of the information presented.
2
The device should be used 5 to 10 times each hour while awake. This statement indicates
the need for further education.
3
The patient exhales completely prior to placing the mouth on the device. This statement
indicates correct understanding of the information presented.
4
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.
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
130
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.
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
Chapter learning objective: Describing methods of oxygen delivery
Chapter page reference: 077
131
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
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
Integrated Processes: Nursing Process – Planning
132
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
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.
2.
3.
4.
5.
Feedback
This is correct. The SpO2 result is documented in the medical record when monitoring a
patient’s oxygen saturation via oximetry.
This is correct. The current vital signs are documented in the medical record when monitoring a
patient’s oxygen saturation via oximetry.
This is incorrect. The presence of family or visitors at the patient’s bedside is not information
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
record when monitoring a patient’s oxygen saturation via oximetry.
This is correct. The education provided to the patient and family is documented in the medical
record when monitoring a patient’s oxygen saturation via oximetry.
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
133
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.
2.
3.
4.
5.
Feedback
This is correct. The amount of secretions collected during in-line suctioning is documented in
the patient’s medical record.
This is correct. The color of secretions collected during in-line suctioning is documented in the
patient’s medical record.
This is correct. The consistency of secretions collected during in-line suctioning is documented
in the patient’s medical record.
This is correct. The patient’s response to the procedure is documented in the medical record.
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
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
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.
CON: Oxygenation
134
Chapter 8: Fluid and Electrolyte Management
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A patient presents in the emergency department (ED) with fever, nausea, and vomiting over the
past 2 days. The nurse monitors for which laboratory result in this patient?
1. Urine specific gravity of 1.040
2. Serum potassium of 4.8 mEq/L
3. Serum sodium of 135 mEq/L
4. Urine positive for glucose and ketones
2. Which assessment data collected by the nurse indicate that an older adult patient is at risk for
dehydration?
1. Poor skin turgor
2. Body mass index of 20.5
3. Blood pressure of 140/98 mm Hg
4. Oral intake of 48 ounces per day
3. The nurse plans care for a hospitalized patient. Which data necessitate the inclusion of
interventions to address a fluid volume deficit?
1. Urine output of 30 mL/hour
2. Heart rate of 110 bpm
3. Weight gain of 10 pounds in 3 days
4. Plus-3 edema in bilateral lower extremities
4. In reviewing laboratory results for a female patient suspected of having a fluid imbalance, the
nurse correlates which laboratory value with a diagnosis of dehydration?
1. Hemoglobin of 10.5 g/dL
2. Hematocrit 49%
3. Serum potassium 3.8 mEq/L
4. Serum osmolality 230 mOsm/kg
5. 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.
6. The nurse provides care to a patient who is prescribed 0.45% normal saline (NS) by intravenous
(IV) infusion. Which data cause the nurse to question the healthcare provider regarding this IV
fluid order?
1. Urine output 40 mL/hour
2. Blood pressure 100/60 mm Hg
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3. Respiratory rate 12 breaths/min
4. Serum sodium level of 145 mEq/L
7. The nurse is caring for a patient who is receiving intravenous fluids postoperatively after cardiac
surgery. The nurse correlates the patient’s risk for fluid volume excess to which cause?
1. Decreased mobility as a result of surgery and pain
2. Administration of intravenous fluids
3. Decreased levels of aldosterone
4. Increased levels of antidiuretic hormone
8. The nurse is planning care for the patient with acute renal failure and incorporates the nursing
diagnosis of Excess Fluid Volume. Which assessment data support this nursing diagnosis?
1. Wheezing in the lungs
2. Generalized weakness
3. Urine output of 20 mL/hour
4. Pitting edema in the lower extremities
9. The nurse is providing care to an older adult patient who is receiving intravenous (IV) fluids at 150
mL/hour. It is important that the nurse assess for which clinical manifestations that could indicate
fluid volume excess in this patient?
1. Flattened neck veins
2. Elevated blood pressure
3. Bradycardia
4. Skin tenting
10. The nurse provides care to a patient whose serum potassium level is 3.2 mEq/L. Which healthcare
provider order does the nurse question based on this data?
1. Serum chemistries (basic metabolic panel) every morning
2. Continuous cardiac monitoring
3. 10 mEq KCl (potassium chloride) in 100 mL normal saline slow IVP (intravenous
pyelogram)
4. 25 mg spironolactone (Aldactone) by mouth daily
11. In reviewing laboratory results for a patient presenting to the Emergency Department with changes
in level of consciousness, the nurse correlates which value as placing the patient at greatest risk for
seizures?
1. Serum calcium of 12 mg/dL
2. Serum potassium of 3.0 mEq/L
3. Serum sodium of 135 mEq/L
4. Serum magnesium of 2.6 mEq/L
12. The nurse is providing care to a patient who seeks emergency treatment for headache and nausea.
The patient works in a mill without air conditioning. The patient states, “I drink water several
times each day, but I seem to sweat more than I am able to replace.” Which suggestions does the
nurse provide to this patient?
1. Drink juices and carbonated sodas.
2. Eat something salty when drinking water.
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3. Eat something sweet when drinking water.
4. Double the amount of water being ingested.
13. A nurse is reviewing the serum chemistry results on a patient who has a nasogastric tube to low
intermittent suction secondary to a gunshot to the abdomen 2 days ago. Which electrolyte value
does the nurse correlate to the NG suctioning?
1. Serum chloride of 90 mEq/L
2. Serum sodium of 148 mEq/L
3. Serum potassium of 5.2 mEq/L
4. Serum calcium of 11.3 mg/dL
14. The nurse is caring for a patient with congestive heart failure who is admitted to the medicalsurgical unit with acute hypokalemia. Which prescribed medication may have contributed to the
patient’s current hypokalemic state?
1. Cortisol
2. Oxycodone
3. Flexeril
4. Nonsteroidal anti-inflammatory drugs (NSAIDs)
15. A patient is prescribed 20 mEq of potassium chloride because of excessive vomiting. The nurse
includes which information in explaining the rationale for this medication?
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.
16. The nurse is caring for a patient with congestive heart failure who is admitted to the medicalsurgical unit with acute hypokalemia. Which prescribed medication may have contributed to the
patient’s current hypokalemic state?
1. Cortisol
2. Oxycodone
3. Flexeril
4. Nonsteroidal anti-inflammatory drugs (NSAIDs)
17. In reviewing a patient’s laboratory results before administering digoxin, which laboratory result
places the patient at greatest risk for digoxin toxicity?
1. Serum sodium 156 mEq/L
2. Serum potassium 3.0 mEq/L
3. Serum phosphorus of 1.5 mg/dL
4. Serum creatinine of 1.6 mg/dL
18. The nurse is providing care to a patient who is prescribed furosemide for treatment of congestive
heart failure (CHF). The patient’s serum potassium level is 3.4 mEq/L. Which food should the
nurse encourage the patient to eat based on this data?
1. Peas
2. Iced tea
3. Bananas
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4. Baked fish
19. 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 may cause the client to retain fluid.
3. They may interfere with the hemodialysis.
4. They may interact with the client's antihypertensive medications.
20. The nurse is caring for a patient with a potassium level of 5.9 mEq/L. The healthcare provider
prescribes both glucose and insulin for the patient. The patient’s spouse asks, “Why is insulin
needed?” Which response by the nurse is the most appropriate?
1. “The insulin will help his kidneys excrete the extra potassium.”
2. “The insulin is safer than other medications that can lower potassium levels.”
3. “The insulin lowers his blood sugar levels, and this is how the extra potassium is
excreted.”
4. “The insulin will cause his extra potassium to move into his cells, which will lower
potassium in the blood.”
21. The nurse provides care for a patient who is experiencing hypomagnesemia. Which food choice is
best for this patient?
1. A medium-sized banana
2. One medium-sized baked potato
3. Three ounces of cooked halibut
4. A half-cup of cooked black-eyed peas
22. The nurse monitors for which clinical manifestations in the patient admitted with
hypermagnesemia?
1. Elevated blood pressure
2. Bradycardia
3. Increased deep tendon reflexes
4. Hyperventilation
23. The nurse is monitoring laboratory results on assigned patients. The patient with which laboratory
has the highest risk of laryngospasm?
1. Serum calcium 7.5 mg/dL
2. Serum magnesium 3.0 mg/dL
3. Serum potassium 5.6 mEq/L
4. Serum phosphorus 1 mg/dL
24. The nurse is providing care to a patient whose serum calcium levels have increased since a surgical
procedure performed 3 days ago. Which intervention does the nurse implement to decrease the risk
for the development of hypercalcemia?
1. Monitor vital signs every 8 hours.
2. Encourage ambulation three times a day.
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3. Irrigate the Foley catheter one time a day.
4. Recommend turning, coughing, and deep breathing every 2 hours.
25. The nurse recognizes which intervention as the priority in the care of the patient with a serum
phosphorus level of 2.0 mg/dL?
1. Decrease fluid intake.
2. Strain all urine for kidney stones.
3. Encourage consumption of milk and yogurt.
4. Discourage consumption of a high-calorie diet.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
26. The nurse recognizes which clinical manifestations as age-related changes that may impact fluid
and electrolyte in the older adult? Select all that apply.
1. Increased salivation
2. Increased urine output
3. Decreased sense of smell
4. Decreased visual acuity
5. Changes in taste sensation
27. The nurse is preparing an educational session for members of a community health center that
focuses 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 a.m. and 2 p.m.
28. The nurse is providing care to a patient who is exhibiting clinical manifestations of a fluid and
electrolyte deficit. Which of the following orders does the nurse implement to address this
disorder? Select all that apply.
1. Administer diuretics
2. Administer antibiotics
3. Place the patient in high-Fowler’s position
4. Monitor patient’s I&O
5. Initiate intravenous therapy
29. The nurse correlates which clinical manifestations to the patient at risk for hypovolemic shock?
Select all that apply.
1. Blood pressure of 110/70
2. Heart rate of 146
3. Urine output of 0 to 10 mL/hour
4. Cool, clammy skin
5. Increased bowel sounds
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30. A patient's serum sodium level is 150 mg/dL. Based on this information, which interventions
should the nurse plan 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.
31. The nurse educates a patient who is prescribed furosemide (Lasix) for congestive heart failure on
foods rich in potassium. Which patient menu choices indicate to the nurse a correct understanding
of the information presented? Select all that apply.
1. Pasta
2. Spinach
3. Applesauce
4. A sweet potato
5. Low-fat milk
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Chapter 8: Fluid and Electrolyte Management
Answer Section
MULTIPLE CHOICE
1. ANS: 1
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 3. Explaining the significance of osmolality, osmolarity, blood urea
nitrogen (BUN), creatinine, and urine specific gravity related to fluid and electrolyte status
Chapter page reference: 115 - 116
Heading: Fluid and Electrolyte Regulation/Indicators of Fluid Status
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
The normal range for specific gravity is 1.005 to 1.030. High specific gravity
values indicate concentrated urine and can be seen in patients with decreased
renal perfusion or dehydration.
Serum potassium is not related to fluid volume status and this is a normal value.
The normal range is 3.5 to 5.0 mEq/L.
Serum sodium is elevated with fluid loss and this value is low. The normal range
is 135 to 145 mEq/L.
Urine that is positive for glucose and ketones is observed in patients with
diabetes mellitus.
PTS: 1
CON: Assessment
2. ANS: 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 4. Discussing changes in fluid and electrolyte balance associated with
aging
Chapter page reference: 116
Heading: Fluid and Electrolyte Regulation/Age-Related Changes
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
Skin turgor is a poor indicator of fluid balance in an older adult patient.
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2
3
4
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, because fat cells contain little or no water.
An elevated blood pressure could indicate fluid volume overload or sodium
sensitivity.
A poor intake of water could indicate a loss of the thirst response, which occurs
as a normal age-related change. Because the patient only ingests 48 ounces of
water each day, this could indicate a reduction in the normal thirst response.
PTS: 1
CON: Assessment
3. ANS: 2
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: Reviewing basic concepts related to fluid and electrolyte balance
Chapter page reference: 117
Heading: Fluid Imbalances/Hypovolemia: Fluid Volume Deficit/Clinical Manifestations
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
Expected urine output for an adult patient is 30 mL/hour. A decreased urine
output would necessitate interventions to address a fluid volume deficit.
An increased heart rate is indicative of a fluid volume deficit.
Weight loss, not weight gain, supports the inclusion of interventions to address a
fluid volume deficit.
Dependent edema supports the inclusion of interventions to address fluid
volume excess, not a fluid volume deficit.
PTS: 1
CON: Assessment
4. ANS: 2
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 5. Describing the pathophysiology, clinical presentations, and
management of dehydration, hypovolemia, and hypervolemia
Chapter page reference: 117
Heading: Hypovolemia: Fluid Volume Deficit/ 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
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Feedback
1
2
3
4
A normal hemoglobin value for a female is 11.7 to 15.5 g/dL. The hemoglobin is
not directly affected by fluid volume status.
The hematocrit measures the volume of whole blood that is composed of red
blood cells. 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. The normal hematocrit value for a female is
36% to 48%.
Serum potassium is not an electrolyte used to determine an alteration in fluid
balance. Serum sodium values usually change related to fluid volume changes.
Serum osmolality is a measure of the solute concentration of the blood and is
used to evaluate fluid balance. Normal values are 275 to 295 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
5. ANS: 3
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 7. Explaining nursing considerations related to patients with fluid and
electrolyte disorders
Chapter page reference: 117 - 118
Heading: Hypovolemia: Fluid Volume Deficit/ Medical Management
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
Difficulty: Difficult
Feedback
1
2
3
4
Treatment has been effective.
A diuretic is not needed because the patient is being treated for dehydration.
Urinary output is normally equivalent to the amount of fluids ingested; the usual
range is 1,500 to 2,000 mL in 24 hours, or 40 to 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/hour,
which is within the normal range.
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
6. ANS: 2
CON: Assessment
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Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 6. Correlating laboratory data and clinical manifestations of sodium
balance.
Chapter page reference: 119
Heading: Hypovolemia: Fluid Volume Deficit /Medical Management Table 8.4 Common IV
Fluids: Crystalloids and Colloids
Integrated Processes: NP Analysis
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
This urine output is within normal limits; therefore, there is no reason to
question the intravenous (IV) prescription based on this data.
Hypotonic IV fluid, such as 0.45% normal saline (NS), shifts fluid out of the
vessels and into the cells. Because of this fluid shift, hypotension may be
worsened. Therefore, the patient’s blood pressure causes the nurse to question
the healthcare provider about this prescription.
A respiratory rate of 12 breaths/min is within normal limits; therefore, there is
no reason to question the IV prescription based on this data.
Hypotonic IV fluid, such as 0.45% NS, shifts fluid out of the vessels and into
the cells. This may cause hyponatremia to occur. The patient’s serum sodium
level is on the high end of normal; therefore, this data does not cause the nurse
to question this prescription. A low-serum-sodium level would necessitate the
nurse to question this order.
PTS: 1
CON: Assessment
7. ANS: 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 2. Describing the role of endocrine, renal, and respiratory systems in
the regulation of fluid and electrolyte balance
Chapter page reference: 120
Heading: Hypervolemia: Fluid Volume Excess/Causes
Integrated Processes: NP Analysis
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
2
Fluid volume excess is not caused by inactivity.
It is unlikely that the fluid volume excess experienced by the patient is caused
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3
4
by intravenous fluids.
Aldosterone secretion is increased in stressful conditions like surgery.
Antidiuretic hormone (ADH) and aldosterone levels are commonly increased as
a result of the stress response before, during, and immediately after surgery. This
increase leads to sodium and water retention.
PTS: 1
CON: Fluid and Electrolyte Balance
8. ANS: 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 2, Describing the role of endocrine, renal, and respiratory systems in
the regulation of fluid and electrolyte balance
Chapter page reference: 120
Heading: Hypervolemia: Fluid Volume Excess/Clinical Manifestations
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
2
3
4
Wheezing in the lungs is an assessment consistent with asthma.
Generalized weakness is not typically observed in patients with fluid volume
excess.
Urine output of 20 mL/hour is low and is associated with fluid volume deficit.
The patient in acute renal failure will likely be edematous, as the kidneys are not
producing urine.
PTS: 1
CON: Fluid and Electrolyte Balance
9. ANS: 2
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 4. Discussing changes in fluid and electrolyte balance associated with
aging
Chapter page reference: 120
Heading: Hypervolemia: Fluid Volume Excess/Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
Flat neck veins are indicative of fluid volume deficit/hypovolemia
The blood pressure may increase if fluids are administered too quickly, and
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3
4
older adults may not be able to tolerate the increased fluid.
Bradycardia is not associated with fluid volume excess.
Skin tenting is associated with fluid volume deficit. Assessing skin turgor may
not be as effective in the older adult because of loss of skin elasticity associated
with aging.
PTS: 1
CON: Assessment
10. ANS: 3
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 6. Correlating laboratory data and clinical manifestations related to
disorders in: Potassium Balance
Chapter page reference: 122 – 123
Heading: Electrolyte Disorders/Potassium/Table 8.7 Common Electrolyte Disturbances
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
2
3
4
A chemistry panel/basic metabolic panel is prescribed to monitor kidney status,
electrolyte and acid–base balance, and blood glucose level. This is an
appropriate order for the patient who is experiencing hypokalemia.
Potassium imbalances cause electrocardiogram changes; therefore, continuous
cardiac monitoring is an appropriate prescription for this patient.
Although this is an appropriate dose of KCl, it is never given by intravenous
pyelogram (IVP). The nurse questions this order.
A potassium-sparing diuretic, such as spironolactone, is an appropriate
prescription for the patient experiencing hypokalemia.
PTS: 1
CON: Fluid and Electrolyte Balance
11. ANS: 3
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 6. Correlating laboratory data and clinical manifestations related to
disorders in sodium balance
Chapter page reference: 124
Heading: Electrolyte Disorders /Hyponatremia: Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Fluid and Electrolyte Balance
Difficulty: Difficult
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Feedback
1
2
3
4
Hypercalcemia presents with anorexia, nausea, vomiting, lethargy, non-specific
joint and muscle aches, and confusion. Seizure activity may be observed in
patients with hypocalcemia.
Patients with hypokalemia may experience weakness, lethargy, hyporeflexia,
nausea/vomiting, constipation, abdominal cramping and electrocardiographic
(ECG) changes (ST depression).
Neurological changes such as confusion, muscle twitching, lethargy, and
seizures can indicate low sodium levels, especially in older adults.
Patients with hypermagnesemia may present with hypotension, bradycardia,
drowsiness, lethargy, muscle weakness, and loss of deep tendon reflexes.
PTS: 1
CON: Fluid and Electrolyte Balance
12. ANS: 2
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 5. Describing the pathophysiology, clinical presentations, and
management of dehydration, hypovolemia, and hypervolemia
Chapter page reference: 124 - 125
Heading: Electrolyte Disorders/Hyponatremia: Medical Management
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback
1
2
3
4
Juices and carbonated sodas will not help to replace the loss of sodium.
Both salt and water are lost through sweating. When only water is replaced, the
individual is at risk for salt depletion. Clinical manifestations include fatigue,
weakness, headache, and gastrointestinal symptoms such as loss of appetite and
nausea. The patient should be instructed to eat something salty when drinking
water to help replace the loss of sodium.
Eating something sweet will not help replace the loss of sodium.
Doubling the amount of water being ingested could lead to hyponatremia and
further manifestations.
PTS: 1
CON: Nutrition
13. ANS: 1
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 6. Correlating laboratory data and clinical manifestations related to
disorders in chloride.
Chapter page reference: 127
Heading: Electrolyte Disorders /Hypochloremia
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Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis
Concept: Fluid and Electrolyte Balance
Difficulty: Difficult
Feedback
1
2
3
4
Serum chloride decreases in patients with severe vomiting, burns, chronic
respiratory acidosis, nasogastric suctioning, metabolic alkalosis, and Addison’s
disease (adrenal cortex insufficiency). The normal range for serum chloride is 97
to 107 mEq/L.
Serum sodium does not increase secondary to nasogastric suctioning. The
normal range for serum sodium is 135 to 145 mEq/L
Serum potassium usually decreases with nasogastric suctioning. This value is
high because the normal range of serum potassium is 3.5 to 5.0 mEq/L.
Serum calcium levels are not impacted by nasogastric suctioning. The normal
range for serum calcium is 8.2 to 10.2 mg/dL.
PTS: 1
CON: Fluid and Electrolyte Balance
14. ANS: 1
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 6. Correlating laboratory data and clinical manifestations related to
disorders in: Potassium balance
Chapter page reference: 128 - 129
Heading: Electrolyte Disorders /Hypokalemia
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Medication
Difficulty: Easy
Feedback
1
2
3
4
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.
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.
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PTS: 1
CON: Medication
15. ANS: 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 7. Explaining nursing considerations related to patients with fluid and
electrolyte disorders
Chapter page reference: 130
Heading: Electrolyte Disorders /Hypokalemia: Nursing Management
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parental Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Medication
Difficulty: Moderate
Feedback
1
2
3
4
Sodium controls and regulates water balance in the body.
Magnesium is used in the body to synthesize ingested protein.
Calcium is vital in regulating muscle contraction and relaxation.
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.
PTS: 1
CON: Medication
16. ANS: 1
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 6. Correlating laboratory data and clinical manifestations related to
disorders in: Potassium balance
Chapter page reference: 8-40-8-41
Heading: Hypokalemia
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Pharmacological and Parental Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Medication
Difficulty: Easy
Feedback
1
2
3
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.
NSAIDs, narcotics, and muscle relaxers would not bring about potassium loss to
cause hypokalemia.
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4
NSAIDs, narcotics, and muscle relaxers would not bring about potassium loss to
cause hypokalemia.
PTS: 1
CON: Medication
17. ANS: 2
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 7. Explaining nursing considerations related to patients with fluid and
electrolyte disorders
Chapter page reference: 130
Heading: Electrolyte Disorders /Hypokalemia: Nursing Management
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Fluid and Electrolyte Balance
Difficulty: Difficult
Feedback
1
Hypernatremia does not increase the risk of digoxin toxicity.
2
Hypokalemia can potentiate the effects of digitalis by increasing blood levels of
digoxin, leading to digoxin toxicity. Symptoms of digoxin toxicity include loss
of appetite, nausea, vomiting, cardiac dysrhythmias, and visual disturbances.
Hypophosphatemia does increase the risk of digoxin toxicity.
3
4
Elevations of blood urea nitrogen (BUN) and creatinine indicate decreased renal
function, which can result in decreased potassium excretion and hyperkalemia.
There is no risk of digoxin toxicity with elevated creatinine levels.
PTS: 1
CON: Fluid and Electrolyte Balance
18. ANS: 3
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 7. Explaining nursing considerations related to patients with fluid and
electrolyte disorders
Chapter page reference: 130
Heading: Electrolyte Disorders/Hypokalemia// Nursing Management
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback
1
Peas are not a potassium-rich food, which is currently needed based on the
patient’s serum potassium level.
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2
3
4
Iced tea is not a potassium-rich food, which is currently needed based on the
patient’s serum potassium level.
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.
Baked fish is not a potassium-rich food, which is currently needed based on the
patient’s serum potassium level.
PTS: 1
CON: Nutrition
19. ANS: 1
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 5. Explaining nursing considerations related to patients with fluid and
electrolyte disorders
Chapter page reference: 130
Heading: Electrolyte Disorders /Hyperkalemia
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback
1
2
3
4
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.
Increases in weight do need to be reported to the healthcare provider as a
possible indication of fluid volume excess, but this is not the reason why salt
substitute is to be avoided.
Salt substitutes do not impact hemodialysis.
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: Nutrition
20. ANS: 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 7. Explaining nursing considerations related to patients with fluid and
electrolyte disorders
Chapter page reference: 131 - 132
Heading: Electrolyte Disorders /Hyperkalemia: Medical Management
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
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Difficulty: Moderate
Feedback
1
2
3
4
Insulin does not promote renal excretion of potassium.
Giving insulin to decrease serum potassium levels is not considered a safer
method than other medications that can be used.
Serum potassium is lowered by entering the cells; this is not controlled by serum
glucose.
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: Medication
21. ANS: 3
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 7. Explaining nursing considerations related to patients with fluid and
electrolyte disorders
Chapter page reference: 133
Heading: Electrolyte Disorders/Hypomagnesemia/Nursing Management/ Box 8.3 Food Sources for
Magnesium
Integrated Processes: Nursing Process: Nursing Implementation
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Analysis [Analyzing]
Concept: Nutrition
Difficulty: Moderate
Feedback
1
2
3
4
A medium-sized banana contains 30 mg of magnesium. This is not the best food
choice for the patient.
A medium-sized baked potato with the skin contains 50 mg of magnesium. This
is not the best food choice for the patient.
Three ounces of cooked halibut contains 90 mg of magnesium. Of the foods
provided, this choice is the most magnesium rich.
One-half cup of cooked black-eyed peas contains 45 mg of magnesium. This is
not the best food choice for the patient.
PTS: 1
CON: Nutrition
22. ANS: 2
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 6. Correlating laboratory data and clinical manifestations related to
disorders in magnesium.
Chapter page reference: 134
Heading: Electrolyte Disorders /Hypermagnesemia: Clinical Manifestations
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Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
Cardiac symptoms in hypermagnesemia include hypotension caused by
vasodilation and dysrhythmias such as bradycardia, atrial fibrillation, and
intraventricular conduction delays exhibited by widening of the QRS
complexes.
Cardiac symptoms in hypermagnesemia include hypotension caused by
vasodilation and dysrhythmias such as bradycardia, atrial fibrillation, and
intraventricular conduction delays exhibited by widening of the QRS
complexes.
Central nervous system clinical manifestations include drowsiness, lethargy,
muscle weakness, loss of deep tendon reflexes, paralysis, and coma.
Respiratory signs include a decrease in respiratory rate that can lead to complete
respiratory suppression.
PTS: 1
CON: Assessment
23. ANS: 1
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 6. Correlating laboratory data and clinical manifestations related to
disorders in calcium
Chapter page reference: 135
Heading: Electrolyte Disorders /Hypocalcemia: Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Fluid and Electrolyte Balance
Difficulty: Difficult
Feedback
1
2
3
4
Clinical manifestations of hypocalcemia include positive Trousseau’s and
Chvostek’s signs, tetany, and laryngospasm.
Respiratory signs of hypermagnesemia include a decrease in respiratory rate that
can lead to complete respiratory suppression, not laryngospasm.
Clinical manifestations of hyperkalemia include generalized fatigue, muscle
cramps, palpitations, paresthesia, and weakness.
Clinical manifestations include alterations in neurological, cardiac, and
musculoskeletal function. The most common manifestation of
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hypophosphatemia is skeletal or smooth muscle weakness, including respiratory
insufficiency from diaphragmatic dysfunction. Laryngospasm is not associated
with hypophosphatemia.
PTS: 1
CON: Fluid and Electrolyte Balance
24. ANS: 2
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 7. Explaining nursing considerations related to patients with fluid and
electrolyte disorders
Chapter page reference: 136
Heading: Electrolyte Disorders /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
2
3
4
This intervention has no effect on the development of hypercalcemia. Patients
with hypercalcemia may develop bradycardia.
Hypercalcemia can occur from immobility. Encouraging early and frequent
ambulation of patients at risk for hypercalcemia, as well as adequate hydration,
assists in preventing elevated serum calcium.
This intervention is not related to the risk for the development of hypercalcemia.
This intervention is not related to decreasing the risk for the development of
hypercalcemia but is routine post-operative nursing care.
PTS: 1
CON: Fluid and Electrolyte Balance
25. ANS: 3
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 7. Explaining nursing considerations related to patients with fluid and
electrolyte disorders
Chapter page reference: 137
Heading: Electrolyte Disorders /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
2
Fluid intake does not directly impact phosphorus levels.
Decreased phosphorus levels are not associated with renal calculi.
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3
4
PTS:
A phosphorus level of 2.0 is low, and the patient needs additional dietary
phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good
way to provide that additional phosphorus.
Caloric consumption is not associated with phosphorus levels.
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: 4. Discussing changes in fluid and electrolyte balance associated with
aging
Chapter page reference: 116
Heading: Fluid an Electrolyte Regulation/Age-Related Changes
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
5
This is incorrect. Alterations in smell also affect taste, impacting oral intake,
especially fluids, of older adults. This would lead to dry mucous membranes.
This is incorrect. Alterations in smell also affect taste, impacting oral intake,
especially fluids, of older adults. These patients typically have decreased urine
output secondary to decreased fluid intake.
This is correct. With aging, there is a decrease in taste, smell, and thirst, which
can impact fluid and electrolyte balance because it affects intake of fluids and
food. With aging, there is a decline in olfactory function as a result of the
decrease in olfactory fibers and receptors. Loss of these fibers and receptors
results in a decrease in olfactory function and the ability to discriminate smells.
This is correct. Loss of olfactory fibers and receptors results in a decrease in
olfactory function and the ability to discriminate smells. Alterations in smell
also affect taste, impacting oral intake, especially fluids, of older adults.
This is correct. Alterations in smell also affect taste, impacting oral intake,
especially fluids, of older adults.
PTS: 1
CON: Assessment
27. ANS: 2, 3, 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 7. Explaining nursing considerations related to patients with fluid and
electrolyte disorders
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Chapter page reference: 117 - 118
Heading: Fluid Imbalances/Hypovolemia: Medical Management
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
4
5
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 a.m. and 2 p.m., considered
the hottest time of the day, should be avoided.
PTS: 1
CON: Fluid and Electrolyte Balance
28. ANS: 3, 4, 5
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 5. Describing the pathophysiology, clinical presentations, and
management of dehydration, hypovolemia, and hypervolemia
Chapter page reference: 117 – 118
Heading: Fluid Imbalances /Hypovolemia: Medical Management
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
4
5
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. There is no indication for a high-Fowler’s position. The patient
may be placed in the supine position with severe fluid volume deficit.
This is correct. Monitoring patient’s intake and output (I&O) is one of several
ways to assess the patient’s fluid status.
This is correct. Intravenous fluids may be ordered for the patient with a fluid
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volume deficit if replacement oral fluids cannot be taken in sufficient quantity.
PTS: 1
CON: Fluid and Electrolyte Balance
29. ANS: 2, 3, 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 4. Discussing changes in fluid and electrolyte balance associated with
aging
Chapter page reference: 118
Heading: Fluid Imbalances/ Hypovolemia: Fluid Volume Deficit—Complications
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment
Difficulty: Difficult
Feedback
1
2
3
4
5
This is incorrect. This blood pressure is within normal limits. Hypovolemic
shock is manifested by hypotension, tachycardia, and signs of organ
hypoperfusion.
This is correct. The heart rate is increased. Complications of fluid volume deficit
occur with losses of large amounts of fluid volume. Hypovolemic shock can
develop as evidenced by hypotension, tachycardia, and signs of organ
hypoperfusion such as cool, clammy skin, oliguria progressing to anuria (lack of
urine output), decreased level of consciousness, and tachypnea.
This is correct. Complications of fluid volume deficit occur with losses of large
amounts of fluid volume. Hypovolemic shock can develop as evidenced by
hypotension, tachycardia, and signs of organ hypoperfusion such as cool,
clammy skin, oliguria progressing to anuria (lack of urine output), decreased
level of consciousness, and tachypnea.
This is correct. Complications of fluid volume deficit occur with losses of large
amounts of fluid volume. Hypovolemic shock can develop as evidenced by
hypotension, tachycardia, and signs of organ hypoperfusion such as cool,
clammy skin, oliguria progressing to anuria (lack of urine output), decreased
level of consciousness, and tachypnea.
This is incorrect. Bowel sounds decrease in hypovolemic shock as a result of
decreased perfusion of the gastrointestinal tract.
PTS: 1
CON: Assessment
30. ANS: 2, 4
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 6. Correlating laboratory data and clinical manifestations related to
disorders in: Sodium balance
Chapter page reference: 126 - 127
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Heading: Electrolyte Disorders/Hypernatremia: Medical Management
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
1
2
3
4
5
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.
PTS: 1
CON: Fluid and Electrolyte Balance
31. ANS: 2, 4, 5
Chapter number and title: 8, Fluid and Electrolyte Management
Chapter learning objective: 7. Explaining nursing considerations related to patients with fluid and
electrolyte disorders
Chapter page reference: 120
Heading: Potassium/Table 8.2 – Potassium Content of Common Foods
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Difficult
1
2
3
4
Feedback
This is incorrect. Pasta is a low-potassium food; therefore, this choice indicates a
need for additional teaching regarding foods rich in potassium.
This is correct. Spinach contains 839 mg of potassium in 1 cup cooked; therefore,
this choice indicates a correct understanding of the information presented.
This is incorrect. Applesauce is a low-potassium food; therefore, this choice
indicates a need for additional teaching regarding foods rich in potassium.
This is correct. A sweet potato contains 475 mg potassium in 1/2 cup cooked;
therefore, this choice indicates a correct understanding of the information
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5
PTS:
presented.
This is correct. Low-fat milk contains 407 mg of potassium in 1 cup; therefore,
this choice indicates a correct understanding of the information presented.
1
CON: Nutrition
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1.A client develops interstitial edema as a result of decreased:
A)
Vascular volume
B)
Hydrostatic pressure
C)
Capillary permeability
D)
Colloidal osmotic pressure
Ans:
D
Feedback:
Edema can be defined as palpable swelling produced by an increased interstitial fluid
volume. The physiologic mechanisms that contribute to edema formation include factors
that (1) increase capillary filtration (hydrostatic) pressure, (2) decrease the capillary
colloid osmotic pressure, (3) increase capillary permeability, or (4) produce obstruction to
lymph flow.
2.A client has been receiving intravenous normal saline at a rate of 125 mL/hour since her
surgery 2 days earlier. As a result, she has developed an increase in vascular volume and
edema. Which of the following phenomena accounts for this client's edema?
A)
Obstruction of lymph flow
B)
Increased capillary permeability
C)
Decreased capillary colloidal osmotic pressure
D)
Increased capillary filtration pressure
Ans:
D
Feedback:
An increase in vascular volume results in an increase in capillary filtration pressure.
Consequently, movement of vascular fluid into the interstitial spaces increases and edema
ensues. An increase in vascular volume does not directly result in obstruction of lymph
flow, increased capillary permeability, or decreased capillary colloidal osmotic pressure.
3.The most reliable method for measuring body water or fluid volume increase is by
assessing:
A)
Tissue turgor
B)
Intake and output
C)
Body weight change
D)
Serum sodium levels
Ans:
C
Feedback:
Daily weights are a reliable index of water volume gain (1 L of water weighs 2.2
pounds). Daily weight measurements taken at the same time each day with the same
amount of clothing provide a useful index of water gain due to edema. When an
unbalanced distribution of body water exists in the tissues and organs, assessment of
surface skin tissue turgor will be inaccurate. Measurement of renal output is unreliable
because fluid retention may be a compensatory response, or the renal system may be
dysfunctional. Serum sodium levels are affected by multiple variables other than body
water volume.
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4.A client with a diagnosis of liver cirrhosis secondary to alcohol abuse has a distended
abdomen as a result of fluid accumulation in his peritoneal cavity (ascites). Which of the
following pathophysiologic processes contributes to this third spacing?
A)
Abnormal increase in transcellular fluid volume
B)
Increased capillary colloidal osmotic pressure
C)
Polydipsia
D)
Impaired hormonal control of fluid volume
Ans:
A
Feedback:
Third spacing represents the loss or trapping of extracellular fluid (ECF) in the
transcellular space and a consequent increase in transcellular fluid volume. The serous
cavities are part of the transcellular compartment located in strategic body areas where
there is continual movement of body structures—the pericardial sac, the peritoneal cavity,
and the pleural cavity. Polydipsia and increased fluid intake alone are insufficient to
cause third spacing, and increased capillary colloidal osmotic pressure would result in
increased intracellular fluid (ICF). The etiology of third spacing does not normally
include alterations in hormonal control of fluid balance.
5.A 2-week-old infant (full-term at birth) is admitted to the pediatrics unit with “spitting up
large amounts of formula” and diarrhea. The infant has developed a weak suck reflex.
Which of the following statements about total body water (TBW) is accurate in this
situation?
A)
About 52% of the infants' weight accounts for the amount of water in their body.
B)
Because of the infants' higher fat ratio, one should anticipate an increased TBW to
as high as 90%.
C)
Most full-term infants have a TBW of approximately 75% due to their high
metabolic rate.
D)
Most of an infant's TBW remains in the ICF compartment, so they should be able
to transfer needed water into the ECF space.
Ans:
C
Feedback:
Infants normally have more TBW than older children or adults. TBW constitutes
approximately 75% to 80% of body weight in full-term infants and an even greater
percentage in premature infants. In males, the TBW decreases in the elderly population to
approximately 52% TBW. Obesity decreases TBW, with levels as low as 30% to 40% of
body weight in adults. Infants have more than half of their TBW in their ECF
compartment, as compared to adults.
A)
B)
6.A client diagnosed with schizophrenia has been admitted to the emergency department
(ED) after ingesting more than 2 gallons of water in one sitting. Which of the following
pathophysiologic processes may result from the sudden water gain?
Hypernatremia
Water movement from the extracellular to the intracellular compartment
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161
C)
D)
Ans:
Syndrome of inappropriate secretion of ADH (SIADH)
Isotonic fluid excess in the extracellular fluid compartment
B
Feedback:
Excess water ingestion coupled with impaired water excretion (or rapid ingestion at a rate
that exceeds renal excretion) in persons with psychogenic polydipsia can lead to water
intoxication (hyponatremia). A disproportionate gain of water with no accompanying gain
in sodium results in the movement of water from the extracellular to the intracellular
compartment. Hyponatremia accompanies this process. Because of the lack of sodium
increase, accumulated fluid is hypotonic, not isotonic. SIADH is not a consequence of
excess water intake.
7.A nurse caring for a client with a diagnosis of diabetes insipidus (DI) should prioritize the
close monitoring of which of the following electrolyte levels?
A)
Potassium
B)
Sodium
C)
Magnesium
D)
Calcium
Ans:
B
Feedback:
The high water intake and high urine output that characterize diabetes insipidus create a
risk of sodium imbalance. DI may present with hypernatremia and dehydration,
especially in persons without free access to water, or with damage to the hypothalamic
thirst center and altered thirst sensation.
8. The syndrome of inappropriate antidiuretic hormone (SIADH) is characterized by:
A)
B)
C)
D)
Ans:
Increased osmolality level of 360 mOsm/kg
Excessive thirst with fluid intake of 7000 mL/day
Copious dilute urination with output of 5000 mL/day
Low serum sodium level of 122 mEq/L
D
Feedback:
SIADH results from a failure of the negative feedback system that regulates the release
and inhibition of antidiuretic hormone (ADH). ADH secretion continues even when
serum osmolality is decreased, causing water retention and dilutional hyponatremia.
Diabetes insipidus, deficiency or decreased response to ADH, is characterized by
increased serum osmolality, excessive thirst, and polyuria. Urine output decreases in
SIADH despite adequate or increased fluid intake.
9. In isotonic fluid volume deficit, changes in
A)
B)
C)
total body water are accompanied by:
Intravascular hypotonicity
Increased intravascular water
Increases in intracellular sodium
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D)
Ans:
Proportionate losses of sodium
D
Feedback:
Isotonic fluid volume deficit causes a proportionate loss of sodium and water.
Hypotonicity results from water retention or sodium loss. Increased intravascular water
causes sodium to move into the cell excessively.
10.A client with a history of heart and kidney failure is brought to the emergency
department. Upon assessment/diagnosis, it is determined the client is in decompensated
heart failure. Of the following assessment findings, which are associated with excess
intracellular water? Select all that apply.
A)
Lethargy
B)
Confusion
C)
Hyperactive deep tendon reflexes
D)
Seizures
E)
Firm, rubbery tissue when palpating lower extremities
Ans:
A, B, D
Feedback:
Hyponatremia is usually defined as a serum sodium concentration of less than 135
mEq/L. Muscle cramps, weakness, and fatigue reflect the effects of hyponatremia on
skeletal muscle function and are often early signs of hyponatremia. The cells of the brain
and nervous system are the most seriously affected by increases in intracellular water.
Symptoms include apathy, lethargy, and headache, which can progress to disorientation,
confusion, gross motor weakness, and depression of deep tendon reflexes. Seizures and
coma occur when serum sodium levels reach extremely low levels. Hypovolemia, third
spacing (maldistribution of body fluid), and dehydration are associated with
hypernatremia and/or hypertonicity.
11. Which of the following assessments should be prioritized in the care of a client who is
A)
B)
C)
D)
Ans:
being treated for a serum potassium level of 2.7 mEq/L?
Detailed fluid balance monitoring checking for pitting edema
Arterial blood gases looking for respiratory alkalosis
Cardiac monitoring looking for prolonged PR interval and flattening of the T wave
Monitoring of hemoglobin levels and oxygen saturation
C
Feedback:
The most serious effects of hypokalemia are on the heart, a fact that necessitates frequent
electrocardiography or cardiac telemetry. Hypokalemia produces a decrease in the resting
membrane potential, causing prolongation of the PR interval. It also prolongs the rate of
ventricular repolarization, causing depression of the ST segment, flattening of the T
wave, and appearance of a prominent U wave. This supersedes the importance of fluid
balance monitoring, arterial blood gases, oxygen saturation, or hemoglobin levels.
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12. Of the following clients, which would be at highest risk for developing hyperkalemia?
A)
B)
C)
D)
Ans:
A male admitted for acute renal failure following a drug overdose
A client diagnosed with an ischemic stroke with multiple sensory and motor
deficits
An elderly client experiencing severe vomiting and diarrhea as a result of influenza
A postsurgical client whose thyroidectomy resulted in the loss of some of the
parathyroid glands
A
Feedback:
There are three main causes of hyperkalemia: (1) decreased renal elimination; (2) a shift
in potassium from the ICF to ECF compartment; and (3) excessively rapid rate of
administration. The most common cause of serum potassium excess is decreased renal
function. Stroke does not typically have a direct influence on potassium levels, whereas
vomiting and diarrhea can precipitate hypokalemia. Loss of the parathyroid influences
calcium, not potassium, levels.
13.A heart failure client has gotten confused and took too many of his “water pills”
(diuretics). On admission, his serum potassium level was 2.6 mEq/L. Of the following
assessments, which correlate to this hypokalemia finding? Select all that apply.
A)
Polyuria
B)
Constipation
C)
Bradycardia
D)
Paresthesia with numbness of the lips/mouth
E)
ECG showing short runs of ventricular fibrillation
Ans:
A, B, D
Feedback:
The manifestations of hypokalemia include alterations in neuromuscular, gastrointestinal,
renal, and cardiovascular function. There are numerous signs and symptoms associated
with gastrointestinal function, including anorexia, nausea, and vomiting. Atony of the
gastrointestinal smooth muscle can cause constipation, abdominal distention, and, in
severe hypokalemia, paralytic ileus. Urine output and plasma osmolality are increased;
urine specific gravity is decreased; and complaints of polyuria, nocturia, and thirst are
common. The most serious effects of hypokalemia are on the heart. The first symptom
associated with hyperkalemia typically is paresthesia (a feeling of numbness and
tingling). Hyperkalemia results in prolongation of the PR interval; widening of the QRS
complex with no change in its configuration; and decreased amplitude, widening, and
eventual disappearance of the P wave. The heart rate may be slow. Ventricular fibrillation
and cardiac arrest are terminal events.
14.A client has been admitted for deterioration of her renal function due to chronic renal
failure. Her admission K+ level is 7.8 mEq/L. The nurse would expect to see which of the
following abnormalities on her telemetry (ECG) strip? Select all that apply.
A)
Tachycardia (fast rate) with frequent early ventricular beats (PVCs)
B)
Prolonged PR interval with widening of the QRS complex
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C)
D)
Ans:
Ventricular fibrillation
Atrial flutter with a 2:1 conduction ratio
B, C
Feedback:
Hyperkalemia decreases membrane excitability, producing a delay in atrial and
ventricular depolarization, and it increases the rate of ventricular repolarization. If serum
K+ levels continue to rise (above 6 mEq/L), there is a prolongation of the PR interval;
widening of the QRS complex with no change in its configuration; and decreased
amplitude and widening and eventual disappearance of the P wave. The heart rate may be
slow. Ventricular fibrillation and cardiac arrest are terminal events.
15.Hypoparathyroidism causes hypocalcemia by:
A)
Increasing serum magnesium
B)
Increasing phosphate excretion
C)
Blocking release of calcium from bone
D)
Blocking action of intestinal vitamin D
Ans:
C
Feedback:
The most common causes of hypocalcemia are abnormal losses of calcium by the kidney,
impaired ability to mobilize calcium from bone due to hypoparathyroidism, and increased
protein binding or chelation such that greater proportions of calcium are in the
nonionized form. Magnesium deficiency inhibits PTH release and impairs PTH action on
bone resorption. Phosphate and calcium are inversely related, and PTH does not control
phosphate excretion. PTH does not exert control of vitamin D action in the intestine, but
elevated vitamin D levels can suppress PTH release.
16.A female client with a history of chronic renal failure has a total serum calcium level of
7.9 mg/dL. While performing an assessment, the nurse should focus on which of the
following clinical manifestations associated with this calcium level?
A)
Complaints of shortness of breath on exertion with decreased oxygen saturation
levels
B)
Difficulty arousing the client and noticing she is disoriented to time and place
C)
Heart rate of 120 beats/minute associated with diaphoresis (sweaty)
D)
Intermittent muscle spasms and complaints of numbness around her mouth
Ans:
D
Feedback:
Spasms and numbness are characteristic of hypocalcemia. Respiratory effects,
tachycardia, and diaphoresis are not associated with low calcium levels, whereas
decreased level of consciousness can be indicative of hypercalcemia.
17. An elderly client is admitted with elevated magnesium level related to a history of renal
insufficiency and excess use of antacids and laxatives containing magnesium. On
admission assessment, the nurse notes which clinical manifestations that correlate to
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A)
B)
C)
D)
E)
Ans:
hypermagnesemia? Select all that apply.
Hyporeflexia
Blood pressure 180/90
Tetanic muscle contractions
Muscle weakness causing shallow breathing
Paresthesia of the lips
A, D
Feedback:
The signs and symptoms occur only when serum magnesium levels exceed 4.0 mg/dL.
Hypermagnesemia affects neuromuscular and cardiovascular function. Increased levels of
magnesium cause hyporeflexia and muscle weakness. Blood pressure is decreased, and
the ECG shows an increase in the PR interval, a shortening of the QT interval, T-wave
abnormalities, and prolongation of the QRS and PR intervals. Severe hypermagnesemia
is associated with muscle and respiratory paralysis, complete heart block, and cardiac
arrest. Signs of magnesium deficiency are not usually apparent until the serum
magnesium is less than 1.0 mEq/L. Hypomagnesemia is characterized by an increase in
neuromuscular excitability as evidenced by hyperactive deep tendon reflexes,
paresthesias (i.e., numbness, pricking, tingling sensation), muscle fasciculations, and
tetanic muscle contractions.
18. Magnesium is important for the overall function of the body because of its direct role in:
A)
B)
C)
D)
Ans:
Cell membrane permeability
Somatic cell growth control
Sodium and tonicity regulation
DNA replication and transcription
D
Feedback:
Magnesium is essential to all reactions that require ATP, for every step related to
replication and transcription of DNA, and for translation of messenger RNA. Magnesium
does not have a direct role in controlling the growth of cells, extracellular tonicity and
sodium balance, or permeability of the cell surface.
19. Which of the following scenarios place the client at a high risk for developing
A)
B)
C)
D)
Ans:
hypoparathyroidism and require close supervision for assessing for development of
muscle cramps, carpopedal spasm, convulsions, and paresthesia in the hands and feet?
Select all that apply.
A neck cancer client returning from OR after having a radical neck dissection
A hyperthyroid client experiencing a “thyroid storm” requiring urgent
thyroidectomy
A client with seizure experiencing some anoxic deficits and memory loss
A client with a history of human papillomavirus (HPV) in the uvula
A, B
Feedback:
Hypoparathyroidism reflects deficient PTH secretion, resulting in low serum levels of
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ionized calcium. PTH deficiency may occur because of a congenital absence of all of the
parathyroid glands or because of an acquired disorder due to inadvertent removal or
irreversible damage to the glands during thyroidectomy, parathyroidectomy, or radical
neck dissection for cancer. Seizures or history of HPV is not associated with this disorder.
20. As other mechanisms prepare to respond to a pH imbalance, immediate buffering is a
A)
B)
C)
D)
Ans:
result of increased:
Intracellular albumin
Hydrogen/potassium binding
Sodium/phosphate anion absorption
Bicarbonate/carbonic acid regulation
D
Feedback:
The bicarbonate buffering system, which is the principal ECF buffer, uses H2CO3 as its
weak acid and bicarbonate salt such as sodium bicarbonate (NaHCO3) as its weak base. It
substitutes the weak H2CO3 for a strong acid such as hydrochloric acid or the weak
bicarbonate base for a strong base such as sodium hydroxide. The bicarbonate buffering
system is a particularly efficient system because its components can be readily added or
removed from the body. Hydrogen and potassium exchange freely across the cell
membrane to regulate acid–base balance. Sodium is not part of the buffering system.
Intracellular protein is part of the body protein buffer system; albumin is extracellular.
21. Arterial blood gases of a client with a diagnosis of acute renal failure reveal a pH of 7.25,
A)
B)
C)
D)
Ans:
HCO3– level of 21 mEq/L, and decreased PCO2level accompanied by a respiratory rate of
32. This client is most likely experiencing which disorder of acid–base balance?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
A
Feedback:
Metabolic acidosis involves a decreased serum HCO3– concentration along with a
decrease in pH. In metabolic acidosis, the body compensates for the decrease in pH by
increasing the respiratory rate in an effort to decrease PCO2 and H2CO3 levels.
22.A client is brought to the emergency department semicomatose and a blood glucose
reading of 673. He is diagnosed with diabetic ketoacidosis (DKA). Blood gas results are
as follows: serum pH 7.29 and HCO3– level 19 mEq/dL; PCO2level 32 mm Hg. The
nurse should anticipate that which of the following orders may correct this diabetic
ketosis?
A)
Administration of potassium chloride
B)
Initiating an insulin IV infusion along with fluid replacement
C)
Administering supplemental oxygen and rebreathing from a paper bag
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D)
Ans:
Instituting a cough and deep breathing schedule for every hour while awake to
improve ventilation
B
Feedback:
The treatment of metabolic acidosis focuses on correcting the condition that is causing
the disorder and restoring the fluids and electrolytes that have been lost from the body.
For example, insulin administration and fluid replacement are frequently sufficient to
correct a low pH in persons with diabetic ketosis. Administration of potassium chloride is
used as a treatment of metabolic alkalosis. Administering supplemental oxygen and
rebreathing from a paper bag are usual treatment of respiratory alkalosis. Instituting a
cough and deep breathing schedule for every hour while awake to improve ventilation is
usual treatment of respiratory acidosis.
23.A 77-year-old woman has been brought to the emergency department by her daughter
because of a sudden and unprecedented onset of confusion. The client admits to ingesting
large amounts of baking soda this morning to treat some “indigestion.” How will the
woman's body attempt to resolve this disruption in acid–base balance?
A)
Increase the depth of inspiration
B)
Increasing renal H+ excretion
C)
Increased renal HCO 3– reabsorption
D)
Hypoventilation
Ans:
D
Feedback:
When neurologic manifestations occur with metabolic alkalosis, they include mental
confusion, hyperactive reflexes, tetany, and carpopedal spasm. Respiratory compensation
will take place in an effort to counteract the client's metabolic alkalosis. This will involve
hypoventilation. In addition, her kidneys are likely to decrease H+ excretion and HCO3–
reabsorption.
24.A client has received too much morphine (narcotic) in the postsurgical recovery room.
Blood gas results reveal the patient has developed respiratory acidosis. Which of the
following assessment findings correlate with acute primary respiratory acidosis? Select
all that apply.
A)
Irritability
B)
Tingling/numbness in the fingers and toes
C)
Muscle twitching
D)
Respiratory depression
E)
Cardiac palpitations
Ans:
A, C, D
Feedback:
The signs and symptoms of respiratory acidosis depend on the rapidity of onset and
whether the condition is acute or chronic. Elevated levels of CO2 produce vasodilation of
cerebral blood vessels, causing headache, blurred vision, irritability, muscle twitching,
and psychological disturbances. If severe and prolonged, it can cause an increase in CSF
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pressure and papilledema. Impaired consciousness, ranging from lethargy to coma,
develops as the PCO2 rises to extreme levels. Paralysis of extremities may occur, and
there may be respiratory depression. Respiratory alkalosis is associated with lightheadedness, dizziness, tingling, and numbness of the fingers and toes. These
manifestations may be accompanied by sweating, palpitations, panic, air hunger, and
dyspnea.
25.A very ill client has been admitted to the hospital for testing for possible septic shock.
The client reports light-headedness, dizziness, and tingling/numbness of the fingers and
toes. The nurse understands that this is likely due to which physiological phenomenon?
A)
Decrease in cerebral blood flow
B)
Impaired alveolar ventilation
C)
Gain in bicarbonate
D)
Inability of the kidney to excrete the body's fixed acids
Ans:
A
Feedback:
The sign/symptoms of respiratory alkalosis are associated with hyperexcitability of the
nervous system and a decrease in cerebral blood flow. A decrease in the CO2 content of
the blood causes constriction of cerebral blood vessels. CO2 crosses the blood–brain
barrier rather quickly; the manifestations of acute respiratory alkalosis are usually of
sudden onset. The person often experiences light-headedness, dizziness, tingling, and
numbness of the fingers and toes. Impaired alveolar ventilation is associated with
respiratory acidosis. A gain in bicarbonate is associated with metabolic alkalosis. Inability
of the kidney to excrete the body's fixed acids occurs with metabolic acidosis.
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Chapter 10: Overview of Infusion Therapies
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse anticipates which fluid movement when administering an isotonic IV fluid to a patient?
1. Fluid moves from the cells into the intravascular space
2. Fluid moves from the intravascular space into the intracellular space
3. Causes no or equal movement of fluid into or out of cells
4. Fluid moves from the intravascular space into the interstitial spaces
2. The nurse is reviewing new healthcare provider orders on a patient admitted for treatment of
severe dehydration. The patient’s serum osmolality is 300 mOsm/kg. It is a priority for the nurse to
follow up with the provider if which solution is ordered?
1. 5% Dextrose in lactated Ringer’s solution (D5LR)
2. Dextrose 5% in 0.45% normal saline
3. 0.45% Normal saline
4. Dextrose 5% in 0.9% normal saline
3. In providing care to a patient with a severe fluid deficit, which prescribed intravenous solution
does the nurse recognize as most effective in expanding plasma volume?
1. 0.9 % Normal saline
2. Dextrose 10%
3. 0.45 % Normal saline
4. Albumin
4. 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 Ringer’s
5. Which intravenous (IV) fluid should the nurse prepare when a patient requires a hypertonic
solution?
1. 0.9% Normal saline
2. 2.5% Dextrose in water
3. 0.33% Sodium chloride
4. 5% Dextrose in lactated Ringer’s
6. 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 Ringer’s
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7. The nurse prepares to initiate intravenous (IV) access for an older adult patient who requires a
blood transfusion. Which gauge needle is best for the nurse to use for this procedure?
1. 18
2. 20
3. 22
4. 24
8. 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
9. The nurse is initiating intravenous (IV) therapy for an adult patient who requires IV fluid infusion
for 2 to 3 days and might require blood administration. Which would the nurse choose as the best
option for IV catheterization?
1. Butterfly
2. Midline catheter
3. Short over-the-needle catheter
4. Implantable venous access device
10. The nurse is caring for a patient who needs to have a peripheral intravenous catheter placed. When
the patient requests to have the intravenous (IV) started in the foot, what is the best response by the
nurse?
1. “There is an increased risk of infection if an IV is started in your feet or legs.”
2. “There is an increased risk of a clot or inflammation if an IV is started in your
foot.”
3. “Placing an IV in your foot decreases blood flow to your feet.”
4. “Placing an IV in your foot is more painful.”
11. The nurse is caring for a patient who is to have a peripherally inserted central catheter (PICC) line
inserted tomorrow. Because the patient’s current peripheral access line is infiltrated and needs to be
restarted, which site would the nurse avoid using?
1. Radial vein
2. Cephalic vein
3. Median cubital vein
4. Dorsal metacarpal veins
12. The nurse performs an hourly check of a patient’s intravenous site and notes erythema. The patient
denies pain or discomfort. Based on this data, what should the nurse document in the patient’s
medical record?
1. Grade 1 phlebitis
2. Grade 2 phlebitis
3. Grade 3 phlebitis
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4. Grade 4 phlebitis
13. 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. Occlusion
14. The nurse correlates the administration of which blood component to the patient with acute blood
loss?
1. Platelets
2. Albumin
3. Fresh frozen plasma
4. Packed red blood cells
15. 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
16. Which component should the nurse anticipate will be prescribed for a patient who is not
responding to crystalloids for volume expansion?
1. Platelets
2. Albumin
3. Fresh frozen plasma
4. Packed red blood cells
17. 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
18. The nurse provides care to several patients on a medical-surgical unit. Which situation requires the
nurse to follow up with the healthcare provider before administering the prescribed treatment?
1. The patient who requires volume expansion and who is prescribed albumin
2. The patient diagnosed with thrombocytopenia who is prescribed fresh frozen
plasma
3. The patient diagnosed with symptomatic anemia who is prescribed packed red
blood cells
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4. The patient diagnosed with neutropenia and infection that is resistant to antibiotics
who is prescribed granulocytes
19. The nurse administers a blood transfusion to a patient who begins to experience itching and
shortness of breath. The nurse notes the patient has hives and facial flushing. Which is the priority
action by the nurse?
1. Monitoring vital signs
2. Stopping the transfusion
3. Elevating the head of the bed
4. Administering prescribed antihistamine
20. In monitoring a patient receiving a blood transfusion, the nurse correlates which clinical
manifestation as indicative of a hemolytic transfusion reaction?
1. Increased blood pressure
2. Itching
3. Fever
4. Facial flushing
21. 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. On 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. Stopping the transfusion
2. Preparing for a full resuscitation
3. Notifying the healthcare provider
4. Decreasing the rate of the transfusion
22. The nurse is administering a blood transfusion to an adult patient. The patient reports feeling cold
and is shivering 15 minutes after the initiation of the transfusion. The patient’s blood pressure has
decreased since the last assessment. Which is the nurse's priority action?
1. Slowing the infusion rate and notifying the healthcare provider
2. Slowing the infusion rate and continuing to monitor the blood pressure every 5
minutes
3. Stopping the blood infusion, and infusing normal saline through the existing
intravenous (IV) tubing
4. Stopping the blood infusion, removing the tubing from the IV catheter, and
replacing it with normal saline
23. The patient who has been receiving Total Parenteral Nutrition (TPN) is being tapered from this
therapy. It is important for the nurse to monitor for which complication if the solution is
discontinued too rapidly?
1. Hyperkalemia
2. Hypernatremia
3. Hypoglycemia
4. Hypocalcemia
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
24. 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. Using sites distal to joints
4. Using the dominant arm whenever possible
5. Avoiding areas of the vein with a valve
25. The nurse educator is developing a class on different types of intravenous catheters for an
orientation for new staff. The nurse includes which types of catheters as examples of central
venous devices? Select all that apply.
1. Midline catheters
2. PICC lines
3. 20-gauge over-the-needle IVAD
4. Implanted ports
5. Butterfly catheters
26. 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.
27. In monitoring a patient’s intravenous (IV) site, the nurse correlates which findings to an
infiltration? Select all that apply.
1. Redness at the insertion site
2. Purulent discharge the insertion site
3. Leaking of fluid from the insertion site
4. Blanched skin near the insertion site
5. Skin cool to touch near the insertion site
28. 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-Lok 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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29. The nurse should intervene if a patient receiving a blood transfusion develops the following
clinical manifestations of circulatory overload. Select all that apply.
1. Dyspnea
2. Decreased urine output
3. Bradycardia
4. Increased blood pressure
5. Jugular venous distention
Completion
Complete each statement.
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30. The nurse provides care to a patient requiring intravenous fluid administration for dehydration. The
healthcare provider prescribes 1,000 mL of lactated Ringer’s solution over 8 hours. The nurse sets
the pump to deliver
mL/hour.
Chapter 10: Overview of Infusion Therapies
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 10. Overview of Infusion Therapies
Chapter learning objective: 2. Describing the characteristics of common IV solutions
Chapter page reference: 156 - 158
Heading: Solutions Used in Infusion Therapy
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
2
3
4
Hypertonic solutions have concentrations higher than plasma and cause fluid to
move from the cells into the intravascular space.
Hypotonic solutions have a lower solution concentration than plasma and cause
fluid to move from the intravascular space into both the intracellular and
interstitial spaces.
Isotonic solutions have the same or nearly the same osmolarity as plasma and
cause no movement of fluid into or out of cells. Isotonic solutions remain in the
extracellular compartment in either the intravascular or interstitial
compartments.
Hypotonic solutions have a lower solution concentration than plasma and cause
fluid to move from the intravascular space into both the intracellular and
interstitial spaces.
PTS: 1
CON: Fluid and Electrolyte Balance
2. ANS: 3
Chapter number and title: 10. Overview of Infusion Therapies
Chapter learning objective: 5. Describing the potential complications of infusion therapy and
strategies to prevent these complications
Chapter page reference: 157
Heading: Solutions Used in Infusion Therapies/Table 10.1 – Osmolarity of Intravenous Solutions
Integrated Processes: Nursing Process: Analysis
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Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Medication
Difficulty: Difficult
Feedback
1
2
3
4
5% Dextrose in lactated Ringer’s solution (D5LR) is a hypertonic fluid that is
indicated in patients with severe dehydration because it promotes fluid to move
into the intravascular space.
Dextrose 5% in 0.45% normal saline is a hypertonic fluid that is indicated in
patients with severe dehydration because it promotes fluid to move into the
intravascular space.
0.45% Normal saline is not the best solution in this situation because the patient
is in need of replacement of intravascular volume. Because this solution is
hypotonic, it would cause fluid to move from the intravascular space into the
both the intracellular and interstitial spaces.
Dextrose 5% in 0.9% normal saline is a hypertonic fluid that is indicated in
patients with severe dehydration because it promotes fluid to move into the
intravascular space.
PTS: 1
CON: Medication
3. ANS: 4
Chapter number and title: 10. Overview of Infusion Therapies
Chapter learning objective: 2. Describing the characteristics of common IV solutions
Chapter page reference: 156 - 158
Heading: Solutions Used for Infusion Therapy
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Fluid and Electrolyte Balance
Difficulty: Difficult
Feedback
1
0.9% Normal saline is an isotonic fluid and is a crystalloid solution.
2
Dextrose 10% is a hypertonic crystalloid solution and would not be used as a
plasma volume expander.
0.45% Normal saline is a hypotonic crystalloid and promotes fluid moving out
of the intravascular space leading to depletion of intravascular fluid volume.
Colloidal solutions are often referred to as plasma volume expanders because
the larger molecules do not diffuse through cell membranes and draw fluid into
the intravascular space. Colloidal solutions are used to maintain intravascular
volume and prevent shock after major blood or fluid losses. Examples of
3
4
Copyright © 2020 F. A. Davis Company
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colloidal solutions include albumin, dextran, and mannitol.
PTS: 1
CON: Fluid and Electrolyte Balance
4. ANS: 1
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 2. Describing the characteristics of common IV solutions
Chapter page reference: 156 - 158
Heading: Solutions Used in Infusion Therapy
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension
Concept: Medication
Difficulty: Easy
Feedback
1
2
3
4
An example of an isotonic solution is 0.9% normal saline.
An example of a hypotonic solution is 2.5% dextrose in water.
An example of a hypotonic solution is 0.33% sodium chloride.
An example of a hypertonic solution is 5% dextrose in lactated Ringer’s
solution.
PTS: 1
CON: Medication
5. ANS: 4
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 2. Describing the characteristics of common IV solutions
Chapter page reference: 156 – 158
Heading: Solutions Used in Infusion Therapy/Table 10.1 – Osmolarity of Intravenous Solutions
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
Feedback
1
2
3
4
0.9% Normal saline is an isotonic solution.
2.5% Dextrose in water is a hypotonic solution
0.33% Sodium chloride is a hypotonic solution.
5% Dextrose in lactated Ringer’s is a hypertonic solution.
PTS: 1
CON: Fluid and Electrolyte Balance
6. ANS: 3
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 2. Describing the characteristics of common IV solutions
Copyright © 2020 F. A. Davis Company
178
Chapter page reference: 156 - 158
Heading: Solutions Used in Infusion Therapy/Table 10.1 – Osmolarity of Intravenous Fluids
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
Feedback
1
0.9% Normal saline is an isotonic solution.
5% Dextrose in water is a hypotonic solution.
0.33% Sodium chloride is a hypotonic solution.
5% Dextrose in lactated Ringer’s is a hypertonic solution.
2
3
4
PTS: 1
CON: Fluid and Electrolyte Balance
7. ANS: 2
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 3. Comparing peripheral and central venous access, including
indications, access devices and potential complications
Chapter page reference: 159 - 160
Heading: Types of Intravenous Access Devices/Peripheral Venous Access/Table 10.3 – Peripheral
Catheter Gauge Selections
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1
2
3
4
Although an 18-gauge catheter is appropriate for the administration of blood,
this is not the best choice given the patient’s age.
A 20-gauge catheter is appropriate for blood transfusion. Because the patient is
an older adult, this is the best choice for the nurse to use for this procedure.
A 22-gauge catheter is appropriate for continuous or intermittent infusions in
small veins but too small for blood transfusion.
A 24-gauge catheter is appropriate for continuous or intermittent infusions in
fragile veins but too small for blood transfusion.
PTS: 1
CON: Medication
8. ANS: 1
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 4. Describing the equipment used to provide infusion therapy
Chapter page reference: 159 - 161
Copyright © 2020 F. A. Davis Company
179
Heading: Types of Intravenous Access Devices /Peripheral Venous Access
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Medication
Difficulty: Moderate
Feedback
1
2
3
4
An 18-gauge catheter is appropriate to initiate IV access for a patient who
requires both rapid administration of large volumes of fluid and a blood
transfusion.
A 20-gauge catheter is appropriate for blood transfusion but is not best for the
rapid administration of large volumes.
A 22-gauge catheter is too small for blood and rapid fluid administration.
A 24-gauge catheter is too small for blood and rapid fluid administration.
PTS: 1
CON: Medication
9. ANS: 3
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 4. Describing the equipment used to provide infusion therapy
Chapter page reference: 159 - 161
Heading: Types of Intravenous Access Devices/Peripheral Venous Access
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1
2
3
4
This steel-winged device, often referred to as a butterfly because of the
appearance of wings on each side of the needle, is indicated only for short-term
or single-dose therapy because the rigid steel needle is more likely to puncture
the vein and lead to fluid or medication leaking out of the vein.
Midline catheters are inserted in a peripheral vein in the upper extremities with
tips that terminate distal to the shoulder in either the basilica, cephalic, or
brachial vein. Midlines are appropriate for therapies expected to last between 1
and 4 weeks.
The short over-the-needle IV catheter 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.
Implantable venous access devices are used when IV fluid needs are anticipated
for several months.
Copyright © 2020 F. A. Davis Company
180
PTS: 1
CON: Medication
10. ANS: 2
Chapter number and title: 10. Overview of Infusion Therapies
Chapter learning objective: 8. Developing a teaching plan for a patient receiving infusion therapy
Chapter page reference: 159 - 161
Heading: Types of Intravenous Access Devices/Peripheral Venous Access
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension
Concept: Skin Integrity
Difficulty: Moderate
Feedback
1
There is an increased risk of thrombophlebitis, not infection.
2
Veins in the lower extremities are not recommended for infusion therapy in the
adult patient because of the high risk for thrombophlebitis.
Placing an IV in the foot increases the risk of thrombophlebitis but does not
impact arterial blood flow to the lower extremities.
Placing an IV in the foot does not produce any difference in pain compared with
the upper extremities.
3
4
PTS: 1
CON: Skin Integrity
11. ANS: 3
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 3. Comparing peripheral and central venous access, including
indications, access devices, and potential complications
Chapter page reference: 161 - 164
Heading: Types of Intravenous Access Devices /Central Venous Access
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
2
The radial vein can be used because the veins used for peripherally inserted
central catheter (PICC) insertion are usually the larger veins in the upper
extremities. If infusion therapy using short peripheral therapy with repeated
venipunctures has compromised these veins, PICC placement is much more
difficult.
The cephalic vein can be used because the veins used for PICC insertion are
usually the larger veins in the upper extremities. If infusion therapy using short
Copyright © 2020 F. A. Davis Company
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3
4
peripheral therapy with repeated venipunctures has compromised these veins,
PICC placement is much more difficult.
The median cubital vein, a larger vein in the upper extremity, is often used for
PICC lines, so the nurse should attempt to avoid this site to maintain it for the
central line.
The dorsal metacarpal veins can be used because the veins used for PICC
insertion are usually the larger veins in the upper extremities.
PTS: 1
CON: Fluid and Electrolyte Balance
12. ANS: 1
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 5. Describing the potential complications of infusion therapy and
strategies to prevent these complications
Chapter page reference: 165
Heading: Nursing Management of Infusion Therapy/Phlebitis and Infiltration/Table 10.4 – Infusion
Nurses Society Phlebitis Scale
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Skin Integrity
Difficulty: Easy
Feedback
1
2
3
4
Grade 1 phlebitis is documented when erythema is noted at the access site with
or without pain.
Pain at the access site with erythema and/or edema is documented as grade 2
phlebitis.
Pain at the access site with erythema, streak formation, and/or palpable cord is
documented as grade 3 phlebitis.
Pain at the access site with erythema, streak formation, palpable venous cord
greater than 1 in. in length, and/or purulent drainage is documented as grade 4
phlebitis.
PTS: 1
CON: Skin Integrity
13. ANS: 1
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 5. Describing the potential complications of infusion therapy and
strategies to prevent these complications
Chapter page reference: 165
Heading: Nursing Management of Infusion Therapy/Monitoring and Preventing Complications
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Copyright © 2020 F. A. Davis Company
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Concept: Skin Integrity
Difficulty: Moderate
Feedback
1
2
3
4
Redness, warmth, edema, and pain that runs along the course of the vein
characterize phlebitis.
An infiltrate is defined as fluid entering the tissues, resulting in swelling,
coolness, pallor, and discomfort at the site.
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.
An occlusion develops when the there is no flow through the IV catheter, and
the site is not warm and red.
PTS: 1
CON: Skin Integrity
14. ANS: 4
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 6. Explaining the procedure for safely administering blood products
Chapter page reference: 169 - 171
Heading: Nursing Management of Infusion Therapy/Administration of Blood Products/Table 10.5
– Indicators for Blood Component Transfusion
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Medication
Difficulty: Moderate
Feedback
1
2
3
4
Platelets are administered for patients who are bleeding as a result of
thrombocytopenia or platelet abnormalities.
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
15. ANS: 3
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 6. Explaining the procedure for safely administering blood products
Chapter page reference: 169 – 171
Heading: Nursing Management of Infusion Therapy/Administration of Blood Products/Table 10-5
– Indications for Blood Component Transfusion
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183
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Medication
Difficulty: Moderate
Feedback
1
2
3
4
Platelets are administered for patients who are bleeding as a result of
thrombocytopenia or platelet abnormalities.
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
16. ANS: 2
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 6. Explaining the procedure for safely administering blood products
Chapter page reference: 169 – 171
Heading: Nursing Management of Infusion Therapy/Administration of Blood Products/Table 10.5
Indications for Blood Component Transfusion
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Medication
Difficulty: Moderate
Feedback
1
2
3
4
Platelets are administered for patients who are bleeding as a result of
thrombocytopenia or platelet abnormalities.
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
17. ANS: 1
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 6. Explaining the procedure for safely administering blood products
Copyright © 2020 F. A. Davis Company
184
Chapter page reference: 169 – 171
Heading: Indications for Blood Component Transfusion /Administration of Blood Products/Table
10.5 Indications for Blood Component Transfusion
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Medication
Difficulty: Moderate
Feedback
1
2
3
4
Platelets are administered for patients who are bleeding as a result of
thrombocytopenia or platelet abnormalities.
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: 2
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 5. Describing the potential complications of infusion therapy and
strategies to prevent these complications
Chapter page reference: 169 – 171
Heading: Indications for Blood Component Transfusion/Administration of Blood Products/Table
10.5 Indications for Blood Component Transfusion
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
Volume expansion when crystalloid solutions are not adequate necessitates an
albumin transfusion.
Bleeding caused by thrombocytopenia or platelet abnormalities is treated with a
platelet transfusion, not a fresh frozen plasma transfusion.
Symptomatic anemia along with acute and chronic blood loss is treated with a
packed red blood cell transfusion.
Neutropenia with infection unresponsive to appropriate antibiotics is treated
with a granulocyte transfusion.
Copyright © 2020 F. A. Davis Company
185
PTS: 1
CON: Assessment
19. ANS: 2
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 6. Explaining the procedure for safely administering blood products
Chapter page reference: 171
Heading: Nursing Management of Infusion Therapy/Administration of Blood Products/Table 10.7
Types of Transfusion Reactions
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Safety
Difficulty: Moderate
Feedback
1
2
3
4
Although monitoring the patient’s vital signs is an appropriate nursing action,
this is not the priority action by the nurse. When in distress the priority is not to
assess.
The priority intervention in this situation is to stop the transfusion and notify the
healthcare provider.
Although this may be an appropriate intervention given the patient is
experiencing dyspnea, this is not the priority action. The nurse stops the
transfusion because the patient is likely experiencing an allergic reaction.
Although administering the prescribed antihistamine is an appropriate
intervention, this is not the priority. The priority action is to stop the transfusion
and notify the healthcare provider.
PTS: 1
CON: Safety
20. ANS: 3
Chapter number and title: 9, Overview of Transfusion Therapy
Chapter learning objective: 6. Explaining the procedure for safely administering blood products
Chapter page reference: 171
Heading: Nursing Management of Infusion Therapy/Administration of Blood Products/ Table 10.7
- Types of Transfusion Reactions
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension
Concept: Assessment
Difficulty: Moderate
Feedback
1
Hypotension is a clinical manifestation of a hemolytic transfusion reaction.
2
Itching is a clinical manifestation of an allergic transfusion reaction.
Copyright © 2020 F. A. Davis Company
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3
Fever is a clinical manifestation of a hemolytic transfusion reaction.
4
Facial flushing is a clinical manifestation of an allergic transfusion reaction.
PTS: 1
CON: Assessment
21. ANS: 1
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 6. Explaining the procedure for safely administering blood products
Chapter page reference: 171
Heading: Nursing Management of Infusion Therapy/Administration of Blood Products/ Table 10.7
- Types of Transfusion Reactions
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Moderate
Feedback
1
2
3
4
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.
Although the nurse would contact the healthcare 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.
PTS: 1
CON: Safety
22. ANS: 4
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 6. Explaining the procedure for safely administering blood products
Chapter page reference: 171
Heading: Nursing Management of Infusion Therapy/Administration of Blood
Products/Administration of Blood Products/ Table 10.7 - Types of Transfusion Reactions
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Moderate
Feedback
1
2
The patient is demonstrating clinical manifestations of a transfusion reaction,
and the transfusion must be stopped. Then the provider can be contacted.
The patient is demonstrating clinical manifestations of a transfusion reaction,
and the transfusion must be stopped. The patient will need to be continuously
Copyright © 2020 F. A. Davis Company
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3
4
monitored, but stopping the transfusion is the priority action.
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 before beginning the blood infusion with new tubing.
PTS: 1
CON: Safety
23. ANS: 3
Chapter number and title: 10. Overview of Infusion Therapies
Chapter learning objective: 7. Describing the special precautions required to safely administer
parenteral nutrition
Chapter page reference: 171 - 172
Heading: Administration of Total Parenteral Nutrition
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback
1
There is no risk of changes in potassium levels related to tapering of TPN.
2
There is no risk of changes in sodium levels related to tapering of TPN.
3
Because of the high concentrations of dextrose, TPN therapy is initiated and
discontinued gradually. If the TPN solution is abruptly stopped, the patient may
experience hypoglycemia because the body needs time to adjust to the decreased
glucose in the solution.
There is no risk of changes in calcium levels related to tapering of TPN.
4
PTS:
1
CON: Fluid and Electrolyte Balance
MULTIPLE RESPONSE
24. ANS: 1, 2, 3, 5
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 3. Comparing peripheral and central venous access, including
indications, access devices, and potential complications
Chapter page reference: 159 - 160
Heading: Types of Intravenous Access Devices/Peripheral Venous Access
Integrated Processes: Nursing Process: Implementation
Copyright © 2020 F. A. Davis Company
188
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Skin Integrity
Difficulty: Moderate
1
2
3
4
5
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.
This is incorrect. It is best, when possible, to use the patient’s nondominant arm
because movement might be somewhat limited, so the patient should be allowed to
use the dominant arm.
This is correct. Areas of the vein containing a valve should be avoided because the
valve acts as an obstruction for the needle to go through the vein.
PTS: 1
CON: Skin Integrity
25. ANS: 2, 4
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 3. Comparing peripheral and central venous access, including
indications, access devices, and potential complications
Chapter page reference: 161 - 164
Heading: Types of Intravenous Access Devices/Central Venous Access
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Easy
Feedback
1
2
3
4
5
This is incorrect. Midline catheters are a type of infusion device that are inserted
in a peripheral vein in the upper extremities with tips that terminate distal to the
shoulder in either the basilica, cephalic, or brachial vein. Midlines are
appropriate for therapies expected to last between 1 and 4 weeks.
This is correct. Types of IVADs used to obtain central venous access include
nontunneled percutaneous central catheters, tunneled catheters, implanted ports,
and peripherally inserted central catheters (PICCs).
This is incorrect. A 20-gauge over-the-needle IVAD is a type of peripheral
intravenous catheter and is not used for central venous access.
This is correct. Types of IVADs used to obtain central venous access include
nontunneled percutaneous central catheters, tunneled catheters, implanted ports,
and peripherally inserted central catheters (PICCs).
This is incorrect. The steel-winged device (often referred to as a butterfly
Copyright © 2020 F. A. Davis Company
189
because of the appearance of wings on each side of the needle) is indicated only
for short-term or single-dose therapy because the rigid steel needle is more
likely to puncture the vein and lead to fluid or medication leaking out of the
vein. This is not a central venous catheter.
PTS: 1
CON: Fluid and Electrolyte Balance
26. ANS: 1, 2, 4, 5
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 3. Comparing peripheral and central venous access, including
indications, access devices, and potential complications
Chapter page reference: 161 - 164
Heading: Types of Intravenous Access Devices/Central Venous Access
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
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 shortterm 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 multiple-port central venous access device can provide the best
option.
This is correct. Patients who are unstable and require rapid administration of
medications 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: Fluid and Electrolyte Balance
27. ANS: 3, 4, 5
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 5. Describing the potential complications of infusion therapy and
strategies to prevent these complications
Chapter page reference: 165 - 166
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190
Heading: Nursing Management of Infusion Therapy/ Monitoring and Preventing
Complications/Phlebitis and Infiltration
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Skin Integrity
Difficulty: Moderate
Feedback
1
2
3
4
5
This is incorrect. Redness is seen in patients with phlebitis. Phlebitis,
inflammation of the vein, is characterized by pain and erythema along the vein.
This is incorrect. Purulent drainage around the site is indicative of an infectious
or inflammatory process.
This is correct. Infiltration occurs when solution or medication is inadvertently
infused into the tissue surrounding the vein. Clinical manifestations of
infiltration include blanched skin, skin cool to the touch, edema, unexpected
pain or burning at the insertion site or along the path of the vein, and leaking of
fluid from the insertion site.
This is correct. Infiltration occurs when solution or medication is inadvertently
infused into the tissue surrounding the vein. Clinical manifestations of
infiltration include blanched skin, skin cool to the touch, edema, unexpected
pain or burning at the insertion site or along the path of the vein, and leaking of
fluid from the insertion site.
This is correct. Infiltration occurs when solution or medication is inadvertently
infused into the tissue surrounding the vein. Clinical manifestations of
infiltration include blanched skin, skin cool to the touch, edema, unexpected
pain or burning at the insertion site or along the path of the vein, and leaking of
fluid from the insertion site.
PTS: 1
CON: Skin Integrity
28. ANS: 1, 2, 4
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 5. Describing the potential complications of infusion therapy and
strategies to prevent these complications
Chapter page reference: 166 - 167
Heading: Nursing Management of Infusion Therapy/Monitoring and Preventing
Complications/Central Line Complications
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Fluid and Electrolyte Balance
Difficulty: Difficult
Copyright © 2020 F. A. Davis Company
191
1
2
3
4
5
Feedback
This is correct. The nurse should use Luer-Lok connections to prevent an air
embolism.
This is correct. The nurse should frequently check all connections to prevent air
from entering the IV line.
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.
PTS: 1
CON: Fluid and Electrolyte Balance
29. ANS: 1, 4, 5
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 5. Describing the potential complications of infusion therapy and
strategies to prevent these complications
Chapter page reference:
Heading: Nursing Management of Infusion Therapy/Administration of Blood Products/Table 10.7
- Types of Transfusion Reactions
Integrated Processes: Nursing Process: Assessment
Client Need: Psychological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Safety
Difficulty: Moderate
Feedback
1
2
3
4
5
This is correct. Clinical manifestations of circulatory overload include dyspnea,
headache, jugular vein distention, edema, and increased blood pressure.
This is incorrect. Urine output would most likely increase with circulatory
overload.
This is incorrect. The heart rate may remain at baseline or increase with
circulatory overload.
This is correct. Clinical manifestations of circulatory overload include dyspnea,
headache, jugular vein distention, edema, and increased blood pressure.
This is correct. Clinical manifestations of circulatory overload include dyspnea,
headache, jugular vein distention, edema, and increased blood pressure.
PTS:
1
CON: Safety
COMPLETION
30. ANS:
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192
125
Chapter number and title: 10, Overview of Infusion Therapies
Chapter learning objective: 4. Describing the equipment used to provide infusion therapy
Chapter page reference: 164 - 165
Heading: Equipment Used in Infusion Therapy
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Fluid and Electrolyte Balance
Difficulty: Moderate
Feedback: x mL/hour = 1,000 mL/8 hour = 125 mL/hour
PTS:
1
CON: Fluid and Electrolyte Balance
Copyright © 2020 F. A. Davis Company
193
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?
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 patient to “sleep off” the anesthesia, and then offer pain medication.
6. The patient with a sprained ankle is complaining of pain in the injured area. Which term will the nurse use
when documenting this patient’s pain?
1) Somatic pain
2) Visceral pain
3) Neuropathic pain
4) Physiological pain
7. Which term should the nurse use to document the maximum amount of pain is able to tolerate?
1) Allodynia
2) Hyperalgesia
3) Pain tolerance
194
4) Pain threshold
8. The nurse is using a nonpharmacologic method to manage a patient’s pain, and applies a unit that applies lowvoltage 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 patient’s pain, which term will the nurse
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
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, the patient states, “It hurts, but I do not want to take any more drugs. I
do not want to end up addicted.” Which response by the nurse is most appropriate?
1) “Don’t worry about getting addicted. I will make sure you don’t get addicted.”
2) “If you don’t take the pain medication on a regular schedule, you won’t get addicted.”
3) “People who have real pain are unlikely to become addicted to analgesics provided to treat
the pain.”
4) “You are wise to be concerned; it is probably time to stop taking narcotics if you can
manage the pain in other ways.”
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. A nurse overhears another nurse say, “That patient is asking for pain medication again. He is constantly on the
call bell, always reporting how severe his pain is, and I think he is just drug-seeking. I am going to make him
wait the full 4 hours before I give this medication again.” Which action by the nurse is the most appropriate in
this situation?
1) Informing the charge nurse of what was overheard
2) Reprimanding the nurse and completing an incident or variance report
3) Ignoring the situation because the patient is not this nurse’s responsibility
4) Reminding the nurse, in private, that the sensation of pain is whatever the patient says it is
195
14. The hospice nurse is making a home visit to a patient with terminal cancer. The patient reports poor pain
control when the spouse says, “I am giving such big doses of medication, I am afraid she is going to overdose
if I give her more.” Which response by the nurse is the most appropriate?
1) “You are not giving adequate pain relief, and she is in severe pain as a result.”
2) “You are wise to be concerned. These are very strong medications you’re administering.”
3) “Let's talk about the medication you’re giving and warning signs to be concerned about.”
4) “You are not giving enough pain medication, so she is in severe pain. You need to give
more.”
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) Documenting “no complaints of pain offered” and assessing that the patient is comfortable
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
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) “Is the pain minor?”
2) “Do you have anything else that hurts?”
3) “I will note that in the record. Is there anything else I should know?”
4) “Tell me more about the pain and what you do for it when it hurts.”
18. Which data collected by the nurse is nonessential when conducting a patient pain history?
1) Intensity, quality, and patterns
2) Significant other’s assessment of the pain
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 to use to assess this patient’s pain?
1) An interpreter.
2) The patient’s affect.
3) The patient’s vital signs.
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
3) Polypharmacy
196
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
activity would the nurse consider to help relieve the patient’s discomfort until the analgesic takes effect?
1) Crossword puzzles
2) Slow rhythmic breathing
3) Reading or watching TV
4) Video or computer games
Multiple Response
Identify one or more choices that best complete the statement or answer the 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) “Does anything other than your back hurt?”
2) “I'm sorry you're hurting. I want to make you feel better.”
3) “Why don't you try another position until it's time for more pain medication?”
4) “You had medication for your pain at 4 p.m., so I can't give you any more until 8 p.m.”
5) “People with back pain experience very different symptoms. Tell me more about your back
pain.”
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
198
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.
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
199
3. 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 – 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
Integrated Processes: Teaching and Learning
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
200
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
1
2
3
4
Feedback
Anticipating a patient’s pain will ensure a more manageable pain experience than 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
postoperative pain, or “sleeping off” anesthesia.
Pain management needs to be implemented prior to the patient's describing specific
postoperative pain, or “sleeping off” anesthesia.
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
Somatic pain originates in the skin, muscles, bone, or connective tissue, and would best
describe this client’s pain.
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
201
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.
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
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
The terminology is not used to document this patient’s pain.
2
The terminology is not used to document this patient’s pain.
3
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
The terminology is not used to document this patient’s pain.
202
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
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
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
203
Client Need: Physiological Integrity – Pharmacological and Parenteral Therapies
Cognitive level: Application [Applying]
Concept: Comfort
Difficulty: Moderate
1
2
3
4
Feedback
Pain perception is what the patient says it is, and the nurse should medicate the patient
based on the patient’s description of the pain, not what the nurse anticipates. If the
patient reports severe pain, the nurse should administer strong analgesics.
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 nurse’s assessment
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
4
Feedback
Informing the charge nurse would only be necessary if the nurse who was overheard did
not respond constructively to the nurse’s correction.
This is not an appropriate response by the nurse.
It is every nurse’s responsibility to speak up and advocate for the client when situations
arise that place the client at risk of incorrect treatment.
The nurse would address the situation privately, and not in front of others at the nurses’
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
204
Client Need: Physiological Integrity – Basic Care and Comfort
Cognitive level: Application [Applying]
Concept: Comfort; Communication
Difficulty: Moderate
1
2
3
4
Feedback
This response is likely to make the spouse feel guilty and does not provide information to
provide the best care possible.
Telling the patient’s spouse that his or her concern is warranted is untrue.
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
3
4
Feedback
Some patients might feel that admitting to pain is a sign of weakness, and might not
bring it up unless the nurse specifically refers to the patient’s apparent discomfort and
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.
It is the nurse’s responsibility to assess for pain and not wait for the patient to mention it.
The patient’s body language indicates the likelihood of pain.
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
205
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
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
regarding the patient’s pain.
This is a closed question and will not allow the nurse to gather the information needed
regarding the patient’s pain.
This is a closed question and will not allow the nurse to gather the information needed
regarding the patient’s pain.
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
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: Assessment; Comfort
Difficulty: Easy
1
2
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.
During a pain history, it is the patient’s description of the pain that is most important, not
the significant other’s.
206
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
Client Need: Physiological Integrity – Basic Care and Comfort
Cognitive level: Comprehension [Understanding]
Concept: Comfort
Difficulty: Easy
1
2
3
4
Feedback
If an interpreter is available the nurse can ask the interpreter to discuss the pain in more
detail, but the FACES rating scale will help the nurse to respond to the patient’s pain
appropriately and quickly without waiting for an interpreter.
Affect and vital signs might not be accurate indicators of the patient’s discomfort.
Affect and vital signs might not be accurate indicators of the patient’s discomfort
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
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.
207
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.
3
Ibuprofen is administered over acetaminophen when anti-inflammatory properties are
desired for pain management.
4
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
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
208
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, lowstimuli 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, lowstimuli environment.
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, lowstimuli 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 drug first.
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-relieving drugs should be given “by the clock” (every 3-6 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.
209
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
1.
2.
3.
4.
5.
Feedback
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
Difficulty: Moderate
1.
2.
3.
4.
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
210
5.
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]
Concept: Comfort
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
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.
CON: Comfort
211
Chapter 12: Complementary and Alternative Care Initiatives
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. Which is a guiding principle when using the Recipient/Practitioner Partnership 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
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
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) “It promotes relaxation.”
2) “It helps to reduce stress.”
3) “It will decrease my stamina.”
4) “It will relieve musculoskeletal discomfort.”
7. Which gastrointestinal (GI) issue might benefit from the nurse educating the patient about the use of herbal
medicine?
1) Reflux
212
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?
1) “I will ask the provider if he or she accepts my insurance plan.”
2) “None of these providers are licensed so I need to be very careful.”
3) “I will ask the provider to provide education regarding any side effects.”
4) “Sessions may be required several times per month, so I will ask about frequency of
visits.”
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
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) “The goals of care for CAM and conventional medicine are very different.”
2) “The term alternative is used when the treatment is outside of conventional methods.”
3) “The term complementary refers to CAM practices that are paired with conventional
medicine.”
4) “The top ten reasons adult seek CAM include things such as pain, anxiety, depression, and
headaches.”
13. Which nursing action indicates a holistic approach to patient care?
1) Refusing a patient assignment because of differing religious beliefs
2) Telling the patient’s family that spiritual beliefs should be kept to themselves
3) Asking the patient to limit responses to information that is pertinent to today’s visit
4) Providing housing information for a family who seeks care for their child’s ear infection
213
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?
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?
1) Natural
2) Artificial
3) Alternative
4) 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) A physician’s desk reference (PDR).
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.
214
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.
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
3) Decreases heart rate
4) Facilitates mental clarity
5) Increases range of motion
215
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.
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.
216
PTS: 1
CON: Promoting Health
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
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.
217
PTS: 1
CON: Nursing
5. 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
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
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
218
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
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
The patient should be encouraged to ask the provider if he or she accepts the patient’s
health insurance plan.
2
Many CAM providers are licensed; therefore, this statement indicates the need for
further education by the nurse.
3
The patient should be sure that he or she is educated regarding any possible side effects
associated with the CAM treatment.
4
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
219
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.
2
A limited, not large, number of patients involved in clinical trials is a research barrier for
the implementation of CAM into practice.
3
Personalized, not generic, treatment plans is a research barrier for the implementation of
CAM into practice.
4
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.
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
Feedback
Western, not eastern, medicine is another term for the traditional health-care system
within the United States.
220
2
3
4
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
CON: Health Care System
12. 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: 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
Integrated Processes: Nursing Process – Implementation
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
1
2
3
Feedback
Refusing a patient assignment due to differing religious beliefs does not indicate a
holistic approach to patient care.
Telling a patient’s family that their spiritual beliefs should be kept to themselves does not
indicates a holistic approach to patient care.
Asking the patient to limit responses to information that is pertinent to today’s visit does
not indicates a holistic approach to patient care.
221
4
Providing information to a family about housing, when they seek care for their child’s
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
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 patient diagnosis that contraindicates 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
222
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.
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.
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]
223
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
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
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
224
2
3
4
to administering this combination of prescribed therapies.
The nurse should consult with the provider, pharmacist, or herbalist prior to
administering any herbal product with a prescribed drug.
While a PDR is an appropriate reference for prescribed drugs, this resource many not
have information regarding the prescribed herbal product.
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
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
Heading: Classification of CAM
Integrated Processes: Nursing Process – Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
225
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
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
Chapter page reference: 203-209
Heading: Classifications of CAM
Integrated Processes: Nursing Process – Planning
Client Need: Psychosocial Integrity
Cognitive level: Application [Applying]
Concept: Communication
226
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
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
1.
2.
3.
4.
5.
PTS: 1
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.
CON: Promoting Health
227
Chapter 13: Overview of Cancer Care
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
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) “I stopped using tanning booths.”
2) “I have reduced my intake of fiber.”
3) “I have increased the amount of lean red meat in my diet.”
4) “I began drinking two glasses of red wine a day with dinner.”
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?
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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.
4) African-Americans are less likely to develop cancer than any other ethnic or racial group 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
planning this patient’s care?
1) Powerlessness
2) Ineffective Coping
3) Activity Intolerance
4) Imbalanced Nutrition, Less than Body Requirements
9. The nurse accompanies the health-care provider into the patient’s room and listens as the diagnosis of cancer
is shared with the patient and family. Once the health-care provider leaves the room, the nurse notes that the
patient and family are teary-eyed regarding the diagnosis. What is the nurse’s most appropriate intervention at
this 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.
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
cancer. Which nursing diagnosis should the nurse use to plan this patient’s preoperative nursing care?
1) Knowledge Deficit
2) Anticipatory Grieving
3) Risk for Disuse Syndrome
4) 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) “It might be quite painful.”
2) “The procedure will only take about one hour.”
3) “The physician might take tissue samples for further analysis.”
4) “I will likely have medications that will make me drowsy during the test.”
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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 to four hours after treatment.
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) Take the case to the hospital’s ethics committee.
2) Honor the family’s wishes and have them sign a consent form.
3) Honor the patient’s refusal and help the family come to terms with the situation.
4) Talk to the physician so he or she can move forward with the family’s wishes.
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
weeks ago. The patient requires protective isolation. Which statement by the patient’s family indicates
understanding of this type of isolation?
1) “It will be important to restrict all visitors.”
2) “We will encourage oral hygiene twice a day.”
3) “You will have to administer all medications by IM injection.”
4) “We will encourage meticulous hand washing among all visitors.”
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
to ensure this patient’s safety?
1) Place patient in reverse isolation
2) Place patient in standard precaution isolation
3) Administer a prophylactic gram-negative antibiotic
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4) Administer neutrophil colony-stimulating factor (N-CSF) as ordered
21. A nurse is planning care for a patient with leukemia. The nurse chooses “Risk for Bleeding” as the nursing
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
3) Apply pressure to arterial puncture sites for 5 minutes
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) “The doctor prefers this test.”
2) “Why are you concerned about this test?”
3) “It is more specific in diagnosing your condition.”
4) “To rule out the possibility that your problems are caused by pneumonia.”
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) ‘Your sexual partners will need to be notified.”
2) “You will need to avoid strenuous activity for 24 hours.”
3) “You will not have any restrictions following the biopsy.”
4) “You will likely experience discomfort for 24-48 hours after the procedure.”
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.
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) “Malignant tumors can grow back.”
2) “Benign tumors stay in one area.”
3) “Benign tumors grow slowly.”
4) “Malignant tumors are easy to remove.”
5) “Malignant tumors push other tissue out of the way.”
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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) “Have you noticed a change in your appetite?”
2) “Have you noticed any cuts that have not healed?”
3) “Have you had any changes in bowel or bladder habits?”
4) “Have you experienced any problems swallowing?”
5) “Do you have a cough that is not associated with seasonal allergies?’
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) “I need to cut down on my smoking.”
2) “I need to get my home tested for radon.”
3) “I need to keep my children away from smokers.”
4) ‘Sunscreen should be applied before spending time outdoors.”
5) “I should eat at least two servings of fruits or vegetables each day.”
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.
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.
Copyright © 2017 F. A. Davis Company
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PTS: 1
CON: Promoting Health
3. 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: 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
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
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Heading: Treatment
Integrated Processes: Nursing Process – Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
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 red meat and drinking two 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.
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3
4
Mortality rates for cancer are the lowest in the Asian/Pacific Islander population.
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
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
Powerlessness is the lack of control over current situations, but this is not the patient’s
current problem. Her needs/symptoms are physical, and according to Maslow’s theory
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
Powerlessness is the lack of control over current situations, but this is not the patient’s
current problem. Her needs/symptoms are physical, and according to Maslow’s theory
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.
3
The symptoms (fatigue, pallor, progressive weakness, exertional dyspnea, headache, and
tachycardia) are caused by aplastic anemia from bone marrow suppression, which is a
side effect of the chemotherapy drugs. Decreased red blood cells cause less oxygen 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.
4
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
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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.
2
This is not an opportune time to teach, set goals, or make decisions regarding power of
attorney.
3
This is not an opportune time to teach, set goals, or make decisions regarding power of
attorney.
4
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.
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.
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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
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
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]
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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.
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 competent
patients’ refusal of food and fluids. This position is supported by the ANA’s Code of
Ethics for Nurses, through the nurse’s role as a patient advocate and through the moral
principle of autonomy.
4
The physician may or may not be involved, but would not disregard the patient’s refusal.
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
Copyright © 2017 F. A. Davis Company
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1
2
3
4
Feedback
Thrombocytopenia occurs with a hematological emergency.
Space-occupying lesions can cause respiratory distress and upper-extremity edema.
Space-occupying lesions can cause respiratory distress and upper-extremity edema.
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
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
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
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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
2
3
4
Feedback
Fluid intake should be encouraged.
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: Safety
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
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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
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
The patient’s question is valid and should not be minimized by asking why the patient is
having concerns about the test.
3
Computed tomography (CT) is used to evaluate and localize tumors, particularly tumors
in the lung parenchyma and pleura.
4
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
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.
Copyright © 2017 F. A. Davis Company
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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
1.
2.
3.
4.
5.
Feedback
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]
Concept: Cellular Regulation
Difficulty: Easy
1.
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
Copyright © 2017 F. A. Davis Company
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2.
3.
4.
5.
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.
This is correct. Increased rest and sleep give the patient’s body more energy to fight the cancer
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
Cognitive level: Analysis [Analyzing]
Concept: Cellular Regulation
Difficulty: Difficult
1.
2.
3.
4.
5.
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.
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
1.
2.
Feedback
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
Copyright © 2017 F. A. Davis Company
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3.
4.
5.
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.
PTS: 1
CON: Cellular Regulation
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
1.
2.
3.
4.
5.
PTS: 1
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.
CON: Cellular Regulation
Copyright © 2017 F. A. Davis Company
245
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
1.
2.
3.
4.
5.
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.
PTS: 1
CON: Cellular Regulation
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
1.
2.
3.
4.
5.
PTS: 1
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.
CON: Cellular Regulation
Copyright © 2017 F. A. Davis Company
246
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
patient with septicemia. Which intervention will address this patient’s health problem?
1) Monitor for cyanosis.
2) Monitor heart rate every hour.
3) Assess temperature every four hours.
4) 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.
4) Place the Foley drainage on the bed at the patient’s feet
4. A patient is prescribed epinephrine for the prevention of anaphylactic shock. The patient states, “I thought
shock was about heart failure.” Which response by the nurse is most appropriate?
1) “There are many kinds of shock that also include infection, nervous system damage, and
loss of blood.”
2) “Heart failure is the most serious kind of shock; others include infection, kidney failure,
and loss of blood.”
3) “There are many kinds of shock: heart failure, nervous system damage, loss of blood, and
respiratory failure.”
4) “Allergic response is the most fatal type of shock; other types involve loss of blood, heart
failure, and liver failure.”
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
247
7. The nurse is administering albumin 5% to a patient in shock. Which nursing action is appropriate when
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) “It is a protein that pulls water into my blood vessels.”
2) “It is a protein that causes my kidneys to conserve fluid.”
3) “It is a super-concentrated salt solution that helps me conserve body fluid.”
4) “It is a liquid that has electrolytes in it to pull water into my blood vessels.”
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
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) “This is the medication of choice to treat airway obstruction.”
2) “This medication will help relieve your itching and runny nose.”
3) “This medication will prevent you from going into anaphylactic shock.”
4) “This medication will take a while to be effective but will control your symptoms for
several hours.”
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) “I will carry an epi-pen with me at all times.”
2) “I will check the expiration date on my epi-pen regularly.”
3) “I should hold the epi-pen in place for 10 seconds after injection.”
4) “I should use the epi-pen to inject the drug into my abdominal wall.”
248
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
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) Raising the patient’s head to a 30-degree angle
3) Positioning the patient in the left-lateral recumbent position
4) Turning the patient’s head to one side if no neck injury is suspected
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 18-gauge intravenous catheter in the patient’s nondominant hand
2) Ordering a type and cross-match of packed red blood cells
3) Preparing to assist with central line placement
4) Inserting a nasogastric tube
249
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) Calling the patient’s physician to report the changes
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) The patient’s mean arterial pressure (MAP) is 60 mmHg.
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
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
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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
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
findings support the nurse’s concern? 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
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.
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.
252
PTS: 1
CON: Infection | Perfusion
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
The Foley drainage bag is always kept below the level of the patient’s bladder to 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
Client Need: Physiological Integrity – Physiological Adaptation
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
253
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Perfusion
Difficulty: Difficult
Feedback
1
Assessing the cause of bleeding would also occur after establishing invasive cardiac
monitoring.
2
Replacement of volume would occur after invasive cardiac monitoring is established.
3
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.
4
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.
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
254
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
2
Hyperresonance is assessed by percussion, not auscultation.
3
Stridor is auscultated with airway obstruction, not pulmonary edema.
4
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.
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,
255
4
leading to vasodilation and an increased blood flow through the kidneys.
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
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
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
256
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.
3
Antihistamines do not prevent anaphylactic shock; they are used to relieve the histaminerelated symptoms associated with an allergic reaction.
4
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.
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
257
2
3
4
interventions used when treating a patient experiencing an MI.
Interventions are performed to prevent further damage, but this is not the primary
rationale for their use when treating a patient experiencing an MI.
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.
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
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 affect the patient’s core temperature; however,
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
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.
258
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]
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
Turing the patient’s head to one side protects the airway in case of vomiting.
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.
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
259
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
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
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
260
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.
2
Unconsciousness may result from the mechanism of injury and is not indicative of the
need for further intervention.
3
Large amounts of fluid may be required.
4
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
Early recognition of the clinical manifestations of shock can save the patient’s life and is
the priority action.
3
While oxygen is often administered in the treatment of shock this is not the priority
nursing action.
4
While the nurse may need additional help this is not the priority nursing action.
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
261
Integrated Processes: Nursing Process – Implementation
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Perfusion
Difficulty: Difficult
1.
2.
3.
4.
5.
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.
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 mechanism for decreased tissue oxygenation is the attempt to
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
262
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.
5.
6.
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.
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, tachycardia, and anorexia are 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,
263
2.
3.
4.
5.
6.
and decreased urine output.
This is correct. Late-phase manifestations include shallow respirations, lethargic mental status,
and decreased urine output.
This is correct. Late-phase manifestations include shallow respirations, lethargic mental status,
and decreased urine output.
This is incorrect. Early-phase manifestations include normal blood pressure, rapid and deep
respirations, and warm or flushed skin.
This is incorrect. Early-phase manifestations include normal blood pressure, rapid and deep
respirations, and warm or flushed skin.
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
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.
This is correct. Manifestations of early hypovolemic shock include a slight increase in pulse,
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.
264
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.
3.
4.
5.
PTS: 1
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.
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.
CON: Perfusion
265
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. The nurse is completing the preoperative checklist on the night shift in preparation for the patient’s surgery,
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
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
266
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 six hours prior to surgery
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) A Caucasian Jehovah’s Witness patient.
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
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?
267
1)
2)
3)
4)
Asking the patient to describe the reaction that occurs
Documenting the information on the patient’s medical record
Placing an alert bracelet on the patient prior to leaving the unit
Verifying the information with the patient’s family members at the bedside
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) Allowing formula to be included in the child’s intake for up to six hours prior to the
surgical procedure
4) Allowing breast milk to be included in the child’s intake for up to six hours prior to the
surgical procedure
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 time-out, the “pause for cause”?
1) “What is the name of your surgeon?”
2) “Which procedure are you having done today?”
3) “Is the information on your identification band correct?”
4) “Which side of the body is your procedure going to be completed on?”
5) “Have you signed your informed consent for the scheduled procedure?”
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
268
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
preparing this patient’s preoperative teaching? Select all that apply.
1) Level of hearing
2) Transportation needs of the patient after discharge
3) Teaching on deep breathing and coughing
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
269
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 has
been administered, because it affects the patient’s ability to reason.
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 elective
surgery requires the patient’s signature if she is capable of making a reasoned decision.
The nurse cannot send the patient to the holding area without a signed consent form.
The nurse will notify the health-care provider, who will need to cancel surgery until the
preoperative medication is excreted and no longer affecting the patient’s ability 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.
270
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
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
271
Cognitive level: Application [Applying]
Concept: Perioperative
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
action is to monitor the patient’s blood pressure.
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
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.
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
272
management.
PTS: 1
CON: Perioperative
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
The prescribed drug is administered to control the patient’s blood glucose level;
therefore, the nurse should monitor the patient’s blood glucose level closely during the
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
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 to
the procedure. NPO status is meant to decrease the patient’s risk for aspiration.
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
273
Heading: Introduction
Integrated Processes: Nursing Process – Implementation
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Analysis [Analyzing]
Concept: Perioperative
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
A patient who is a Jehovah’s Witness is not likely to provide consent to receive blood
products during the perioperative period.
4
This patient is likely to provide consent to receive blood 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
The patient’s first and last name, not maiden name, are identifiers the nurse should use to
determine the right patient during the initial time-out conducted during the preoperative
274
3
4
period.
The patient’s social security number, not medical record number, is an identifier the
nurse should use to determine the right patient during the initial time-out conducted
during the preoperative period.
A photo placed on the patient’s identification band, not medical record, is an identifier
the nurse should use to determine the right patient during the initial time-out conducted
during the preoperative period.
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
The date of the patient’s last sexual encounter is not needed.
4
The patient’s previous response to anesthesia should be determined at this time.
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
Integrated Processes: Nursing Process – Planning
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Perioperative; Oxygenation
Difficulty: Moderate
Feedback
1
This parameter is not required when planning this patient’s care.
2
This parameter is not required when planning this patient’s care.
3
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.
4
This parameter is not required when planning this patient’s care.
PTS: 1
15. ANS: 3
CON: Perioperative | Oxygenation
275
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
Feedback
1
While it is important to determine the type of reaction the patient experiences, this is not
the priority nursing action.
2
While it is important to document the information in the patient’s medical record, this is
not the priority nursing action.
3
The nurse should immediately place an alert bracelet on the patient and communicate
this information with the surgical team.
4
It is not necessary to verify the information with the patient’s family members at the
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.
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]
276
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.
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
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
277
2
3
4
is the gauge preferred for the administration of blood products.
This is not an appropriate gauge for the nurse to use when initiating IV access for a
perioperative patient.
This is not an appropriate gauge for the nurse to use when initiating IV access for a
perioperative patient.
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
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
1.
2.
3.
4.
5.
Feedback
This is correct. This question is included in the initial time-out, the “pause for cause.”
This is correct. This question is included in the initial time-out, the “pause for cause.”
This is correct. This question is included in the initial time-out, the “pause for cause.”
This is correct. This question is included in the initial time-out, the “pause for cause.”
This is incorrect. This question is not included in the initial time-out. This information is
included in the preoperative checklist.
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
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
1.
Feedback
This is incorrect. Maintaining a patent airway is a nursing action that is performed during the
postoperative phase of surgical care.
278
2.
3.
4.
5.
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.
PTS: 1
CON: Perioperative
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
1.
2.
3.
4.
5.
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.
PTS: 1
CON: Perioperative
23. ANS: 1, 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: Teaching and Learning
Client Need: Safe and Effective Care Environment – Management of Care
Cognitive level: Application [Applying]
Concept: Perioperative
279
Difficulty: Moderate
1.
2.
3.
4.
5.
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.
PTS: 1
CON: Perioperative
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
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
280
Cognitive level: Analysis [Analyzing]
Concept: Perioperative
Difficulty: Difficult
1.
2.
3.
4.
5.
PTS: 1
Feedback
This is incorrect. The nurse evaluates the patient’s understanding through the questions asked
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.
This is correct. The nurse evaluates the patient’s understanding through the questions asked and
the return demonstration of skills performed.
This is correct. The nurse evaluates the patient’s understanding through the questions asked and
the return demonstration of skills performed.
This is correct. The nurse evaluates the patient’s understanding through the questions asked and
the return demonstration of skills performed.
CON: Perioperative
281
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
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
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
282
3) 4
4) 5
8. Which American Society of Anesthesiologists’ classification should the circulating nurse document for a
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
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
3) A depolarizing muscle relaxant
4) A nondepolarizing muscle relaxant
283
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) Securing the patient’s airway
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) Securing the patient’s airway
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) Securing the patient’s airway
2) Administering oxygen to the patient by face mask
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) Securing the patient’s airway
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
Identify one or more choices that best complete the statement or answer the question.
284
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
performing surgical hand asepsis. Which are known advantages of the hand rub over the scrub? Select all that
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) Supporting the patient’s head in a headrest
3) Placing the patient’s feet on a padded footboard
4) Placing the patient’s arms at the sides with palms down
5) Lowering the foot of the bed flexing the patient’s knees
27. Which actions by the nurse are appropriate when preparing a patient for a surgical procedure that requires
Fowler’s positioning? Select all that apply.
1) Placing the patient in a lateral position
2) Supporting the patient’s head in a headrest
285
3) Placing the patient’s feet on a padded footboard
4) Placing the patient’s arms at the sides with palms down
5) Lowering the foot of the bed flexing the patient’s knees
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
286
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.
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
287
3. 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: 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
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
288
1
2
3
4
Feedback
This is the appropriate classification for a patient with mild systemic disease.
This is the appropriate classification for a patient with severe systemic disease.
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 | Perioperative
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
289
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
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
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
290
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
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
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.
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.
291
3
4
Succinylcholine is a depolarizing muscle relaxant.
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
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.
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
292
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.
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
The patient’s airway is secured during the intubation phase of general anesthesia.
2
Oxygen is administered to the patient by face mask during the induction of general
anesthesia.
3
The patient is maintained with balanced anesthesia during maintenance phase of general
anesthesia.
4
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 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
The patient’s airway is secured during the intubation phase of general anesthesia.
2
Oxygen is administered to the patient by face mask during the induction of general
anesthesia.
3
The patient is maintained with balanced anesthesia during maintenance of general
293
4
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
Cognitive level: Application [Applying]
Concept: Perioperative
Difficulty: Moderate
Feedback
1
The patient’s airway is secured during the intubation phase of general anesthesia.
2
Oxygen is administered to the patient by face mask during the induction of general
anesthesia.
3
The patient is suctioned to decrease the incidence of aspiration during emergence phase
of general anesthesia.
4
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
The patient’s airway is secured during the intubation phase of general anesthesia.
2
Oxygen is administered to the patient by face mask during the induction of general
anesthesia.
3
The patient is given drugs for balanced anesthesia during maintenance of general
anesthesia.
4
The patient is suctioned to decrease the incidence of aspiration during emergence phase
of general anesthesia.
PTS: 1
CON: Perioperative
294
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
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
1.
2.
3.
4.
5.
Feedback
This is correct. The surgeon performs the procedure.
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
monitors the patient’s physiologic status.
This is incorrect. The social worker will not be in attendance during the procedure but may
become involved in the patient’s care during the preoperative and postoperative phases.
295
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.
2.
3.
4.
5.
Feedback
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 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.
Feedback
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.
296
5.
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
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]
Concept: Perioperative
Difficulty: Easy
1.
2.
3.
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.
297
4.
5.
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
1.
2.
3.
4.
5.
Feedback
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 appropriate for Fowler’s position during a surgical
procedure.
This is incorrect. This nursing action is appropriate for Fowler’s position during a surgical
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 appropriate for Fowler’s position during a surgical
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.
2.
3.
4.
Feedback
This is incorrect. The lateral position is side-lying and would not be used if the surgical
procedure required the patient to be positioned in Fowler’s position.
This is correct. This nursing action is appropriate for Fowler’s position during a surgical
procedure.
This is correct. This nursing action is appropriate for Fowler’s position during a surgical
procedure.
This is incorrect. This is an appropriate nursing action when using the supine position during a
298
5.
surgical procedure.
This is correct. This nursing action is appropriate for Fowler’s position during a surgical
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
1.
2.
3.
4.
5.
PTS: 1
Feedback
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.
CON: Perioperative
299
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
2) Serum potassium
3) Prothrombin (PT) time
4) Blood urea nitrogen (BUN)
2. The nurse is assessing a patient’s 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
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. The patient arrives at the surgeon’s office one week after surgery to have the sutures removed. Which
classification would the nurse use when documenting care for this patient?
1) Preoperative
2) Postoperative
3) Perioperative
4) Intraoperative
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) Notify the family of the patient’s return to the room
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
300
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)
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
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
301
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 scale. Which prescribed 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
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
diagnoses should the nurse select to plan for this patient’s immediate care needs? Select all that apply.
302
1)
2)
3)
4)
5)
Risk for Impaired Gas Exchange
Risk for Decreased Cardiac Output
Risk for Ineffective Airway Clearance
Risk for Imbalanced Nutrition: Less than Body Requirements
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 complete exercises
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
303
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 blood
losses during surgery. A BUN should also be monitored 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
304
3. 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: 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
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
305
Cognitive level: Analysis [Analyzing]
Concept: Perioperative
Difficulty: Difficult
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 to perform a thorough assessment of the patient’s
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.
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
facility, but more frequent assessment may be determined by the patient’s condition, 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
306
1
2
3
4
Feedback
The patient with pneumonia is likely to have a fever, but usually will not display sharp
chest pain.
Atelectasis can cause respiratory distress, but will not cause chest pain.
Hypovolemia does not produce chest pain either, and will usually be displayed by
tachycardia, decreased urine output, and drop in blood pressure.
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.
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
307
3
4
losses and for patients who may have been overhydrated.
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.
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
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
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.
308
3
4
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.
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
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
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.
309
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
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.
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
310
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.
3
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is appropriate for mild
pain in the postoperative period.
4
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.
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
311
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.
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.
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
312
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
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
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.
PTS: 1
CON: Perioperative
22. ANS: 2, 3, 4
Chapter number and title: 17, Priorities for the Postoperative Patient
313
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.
5.
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.
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,
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
314
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.
5.
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.
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
1.
2.
3.
4.
5.
PTS: 1
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.
CON: Perioperative
315
Chapter 18: Assessment of Immune Function
1. A 37-year-old woman is being treated aggressively with a chemotherapeutic regimen to fight
breast cancer. As a result of this regimen, she has an inability to fight infection due to the fact
her bone marrow is unable to produce a sufficient amount of:
A) Lymphocytes
B) Cytoblasts
C) Antibodies
D) Capillaries
Ans: A
Chapter: 50
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 1
Patient Needs: D-3
Feedback: The white blood cells (WBCs) involved in immunity are produced in the bone
marrow. Like other blood cells, lymphocytes are generated from stem cells, which are
undifferentiated cells. Descendants of stem cells become lymphocytes, B lymphocytes, and T
lymphocytes. B lymphocytes mature in the bone marrow and then enter the circulation. T
lymphocytes move from the bone marrow to the thymus, where they mature into several kinds
of cells with different functions. Cytoblasts are the protoplasm of the cell outside the nucleus.
Capillaries are small blood vessels. Antibodies are protein substances that respond in the
presence of an antigen. Antibodies are found in normal circulation.
2. A patient who is exposed to a mumps outbreak in the Midwest has previously been
immunized for mumps. She possesses which type of immunity?
A) Acquired immunity
B) Natural immunity
C) Phagocytic immunity
D) Humoral immunity
Ans: A
Chapter: 50
Cognitive Level: Comprehension
Difficulty: Moderate
Integrated Process: Nursing Process
316
Objective: 2
Patient Needs: B
Feedback: Acquired immunity usually develops as a result of prior exposure to an antigen
through immunization. When the body is attacked by bacteria, viruses, or other pathogens, it
has three means of defense. The first line of defense, the phagocytic immune response,
involves the WBCs which have the ability to ingest foreign particles. A second protective
response is the humoral immune response which begins when the B lymphocytes transform
themselves into plasma cells that manufacture antibodies. The natural immune response
system is rapid nonspecific immunity present at birth.
3 . A patient is being treated in the emergency department following an injury which resulted
in a 6-cm laceration of the right antecubital that was sustained when the patient fell through
the glass of a storm door. The site of the injury will have an invasion of:
A) Interferon
B) Phagocytic cells
C) Apoptosis
D) Cytokines
Ans: B
Chapter: 50
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 2
Patient Needs: A-2
Feedback: Monocytes also function as phagocytic cells, engulfing, ingesting, and destroying
greater numbers and quantities of foreign bodies or toxins than granulocytes. This occurs in
response to the foreign bodies that have invaded the laceration from the dirt on the broken
glass. Interferon, one type of biologic response modifier, is a nonspecific virucidal protein that is
naturally produced by the body and is capable of activating other components of the immune
system. Apoptosis, or programmed cell death, is the body's way of destroying worn-out cells,
such as blood or skin cells, or cells that need to be renewed. Helper T cells are activated upon
recognition of antigens and stimulate the rest of the immune system. When activated, helper T
cells secrete cytokines that attract and activate B cells, cytotoxic T cells, natural killer cells,
macrophages, and other cells of the immune system.
4. The patient with a severe laceration has significant bruising around the site. The
immune response which destroys worn-out cells is: A) The phagocytic immune response
B) The humoral or antibody response
C) The cellular immune response
D) Apoptosis
317
Ans: D
Chapter: 50
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 2
Patient Needs: A-2
Feedback: Apoptosis, or programmed cell death, is the body's way of destroying worn out cells,
such as blood or skin cells, or cells that need to be renewed. Apoptosis involves the digestion of
DNA by endonucleases, resulting in the cells being targeted for phagocytosis. The first line of
defense, the phagocytic immune response, involves the WBCs, which have the ability to ingest
foreign particles. Theses cells move to the point of attack, where they engulf and destroy the
invading agents. Phagocytes also remove the body's own dying or dead cells. Cells in necrotic
tissue that are dying release substances that trigger an inflammatory response. A second
protective response, the humoral immune response, begins with B lymphocytes, which can
transform themselves into plasma cells that manufacture antibodies. The third mechanism of
defense, the cellular immune response, also involves the T lymphocytes, which can turn into
special cytotoxic (or killer) T cells that can attack the pathogens.
5. A patient who has sustained a deep laceration while gardening requires sutures. Her last
tetanus shot was more than 10 years ago. Based on this information, the patient will receive a
tetanus immunization that will allow for the release of an:
A) Antibody
B) Antigen
C) Bacteria
D) Virus
Ans: A
Chapter: 50
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 3
Patient Needs: A-2
Feedback: The structural part of the invading or attacking organism that is responsible for
stimulating antibody production is called an antigen. An antigen can be a small patch of
proteins on the outer surface of the microorganism, for example. Not all antigens are naturally
immunogenic and must be coupled to other molecules to stimulate the immune response. A
single bacterium or large molecule, such as diphtheria or tetanus toxin, may have several
318
antigens, or markers, on its surface, thus inducing the body to produce a number of different
antibodies. Bacteria are microorganisms. A virus is an organism which can cause disease.
6. A patient develops a virulent staphylococci infection of the right leg. The circulating
lymphocyte containing the antigenic message returns to the nearest lymph node. This is known
as the:
A) Recognition stage
B) Proliferation stage
C) Response stage
D) Effector stage
Ans: B
Chapter: 50
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 3
Patient Needs: A-2
Feedback: In the proliferation stage, the circulating lymphocyte containing the antigenic
message returns to the nearest lymph node. Once in the node, the sensitized lymphocyte
stimulates some of the resident dormant T and B lymphocytes to enlarge, divide, and
proliferate. The recognition stage of antigens as foreign, or nonself, by the immune system is
the initiating event in any immune response. The body must first recognize invaders as foreign
before it can react to them. In the response stage, the differentiated lymphocytes function
either in a humoral or a cellular capacity. In the effector stage, either the antibody of the
humoral response or the cytotoxic (killer) T cell of the cellular response reaches and connects
with the antigen on the surface of the foreign invader.
7. A woman who has received a double lung transplant for cystic fibrosis is experiencing signs
of rejection. The immune response which predominates is the:
A) Humoral
B) Nonspecific
C) Cellular
D) Mitigated
Ans: C
Chapter: 50
Cognitive Level: Application
Difficulty: Difficult
319
Integrated Process: Nursing Process
Objective: 3
Patient Needs: A-2
Feedback: Most immune responses to antigens involve both humoral and cellular responses,
although only one predominates. During transplantation rejection, the cellular response
predominates; whereas in bacterial pneumonias and sepsis, the humoral response plays the
dominant role. Mitigated and nonspecific cell response is not noted in this situation.
8. An 88-year-old male patient is suffering from urosepsis. The immune response which
predominates is the: A) Mitigated
B) Nonspecific
C) Cellular
D) Humoral
Ans: D
Chapter: 50
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 3
Patient Needs: A-2
Feedback: Most immune responses to antigens involve both humoral and cellular responses,
although only one predominates. For example, in bacterial pneumonias and sepsis, the humoral
response plays the dominant role; during transplantation rejection, the cellular response
predominates. Mitigated and nonspecific cell response is not noted in this situation.
9. A 44-year-old woman is suffering from bacterial pneumonia. In the first stages of her illness,
she suffered from chest pain and had a high fever with diminished breath sounds. Currently she
is feeling better and no longer has these symptoms. She is in which stage of the immune
response?
A) Recognition stage
B) Proliferation stage
C) Response stage
D) Effector stage
Ans: D
Chapter: 50
Cognitive Level: Application
Difficulty: Difficult
320
Integrated Process: Nursing Process
Objective: 4
Patient Needs: A-2
Feedback: In the effector state, either the antibody of the humoral response or the cytotoxic
(killer) T cell of the cellular response reaches and connects with the antigen on the surface of
the foreign invader. The connection initiates a series of events that in most instances results in
total destruction of the invading microbes or the complete neutralization of the toxin.
Recognition of antigens as foreign, or nonself, by the immune system is the initiating event in
any immune response. In the proliferation stage the circulating lymphocyte containing the
antigenic message returns to the nearest lymph node. In the response stage, the differentiated
lymphocytes function either in a humoral or a cellular capacity.
10. A woman suffers from multiple sclerosis. To assist in the treatment of her illness, she is
lobbying her state and local governments for the legalization and use of:
A) Embryonic stem cells
B) Bone marrow transplantation
C) Immunopathology
D) Euthanasia
Ans: A
Chapter: 50
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 2
Patient Needs: B
Feedback: Stem cells are potentially immortal cells capable of self-renewal and differentiation;
they continually replenish the body's entire supply of both red and white cells. Research has
shown that stem cells can restore an immune system that has been destroyed. Stem cell
transplantation has been carried out in humans with certain types of immune dysfunction, such
as severe combined immunodeficiency; clinical trials using stem cells are underway in patients
with a variety of disorders having an autoimmune component, including systemic lupus
erythematosus, rheumatoid arthritis, scleroderma, and multiple sclerosis. The use of stem cells
addresses many ethical challenges in regard to concerns about safety, efficacy, resource
allocation, and human cloning. The term immunopathology refers to the study of diseases that
result from dysfunctions within the immune system. Disorders of the immune system may stem
from excesses or deficiencies of immunocompetent cells, alterations in the function of these
cells, immunologic attack self-antigens, or inappropriate or exaggerated responses to specific
antigens. Euthanasia is the practice of ending life when the disease is incurable. Bone marrow
321
transplantation is already an acceptable practice for care of certain types of cancer, but it is not
an effective treatment for multiple sclerosis.
11 . A 48-year-old patient suffering from multiple sclerosis is receiving interferon injections.
The purpose of interferon injections is to:
A) Modify the immune response by suppressing antibody production and cellular immunity
B) Give rise to numerous cell types able to form tissues in three germ layers
C) Complement receptors and, as a result, play an important role in the clearance of antigens
D) Complement components, prostaglandins, leukotrienes, and other inflammatory mediators
Ans: A
Chapter: 50
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 4
Patient Needs: D-3
Feedback: Interferons are thought to modify the immune response by suppressing antibody
production and cellular immunity. The red blood cells and platelets also have a role in the
immune response. Red blood cells and platelets have complement receptors and, as a result,
play an important role in the clearance of immune complexes that consist of antigen, antibody,
and components of the complement system. Embryonic stem cells have pluripotent capacity
and give rise to numerous cell types able to form tissues of all three germ layers. Complement
components, prostaglandins, leukotrienes, and other inflammatory mediators all contribute to
the immune response.
12 . An elderly patient is more likely to develop infections than a younger individual due to the :
A) Decreased hormone levels
B) Decreased function of T lymphocytes
C) Increased function of B lymphocytes
D) Increased humoral immunity
Ans: B
Chapter: 50
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 4
322
Patient Needs: D-3
Feedback: The frequency and severity of infections are increased in elderly people, possibly
due to the decreased ability to respond adequately to invading organisms. Both the production
and the function of T and B lymphocytes may be impaired. Aging has an impact on the immune
system that can best be summarized as immunosenescence, a problem thought to be a result
of involution of the thymus. Decreasing hormone levels do not place the elderly in an
immunocompromised state. The greatest impact of aging on the immune system is on
cellmediated immunity; age has a lesser but substantial impact on humoral immunity.
13 . The elderly male patient is at greater risk for urinary tract infection related to :
A) Inability to drink sufficient amounts of fluid
B) Decreased gastric secretions and slower motility
C) Prostate enlargement or neurogenic bladder
D) The ineffectiveness of cilia and decreased circulation
Ans: C
Chapter: 50
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 4
Patient Needs: D-3
Feedback: Declining function of various organ systems associated with increasing age also
contributes to impaired immunity. Decreased gastric secretions and motility allow normal
intestinal flora to proliferate and produce infection, causing gastroenteritis and diarrhea.
Decreased renal circulation, filtration, absorption, and excretion contribute to risk for urinary
tract infections. Moreover, prostatic enlargement or neurogenic bladder can impede urine
passage and impair bacterial clearance through the urinary system. Urinary stasis, common in
elderly people, permits the growth of microorganisms. Prolonged exposure to tobacco and
environmental toxins impairs pulmonary function. These factors cause cilia to be ineffective.
Advancing age also decreases circulation but does not provide a primary reason for urinary
tract infection.
14. A 55-year-old male patient has high cholesterol and triglycerides. He is at risk for infection
related to:
A) Protein-calorie deficiency
B) Regulation of cellular proliferation
C) Excess of trace elements
323
D) Excess fatty acids
Ans: D
Chapter: 50
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 4
Patient Needs: D-3
Feedback: Fatty acids are the building blocks that make up the structural components of cell
membranes. Lipids are precursors of vitamins A, D, E, and K as well as cholesterol. Both excess
and deficit of fatty acids have been found to suppress immune function. Inadequate intake of
vitamins that are essential for DNA and protein synthesis may lead to protein-calorie deficiency
and subsequently to impaired immune function. Vitamins also help in the regulation of cell
proliferation and maturation of immune cells. Excess or deficit of trace elements in the diet
suppresses immune function.
15 . The infection control nurse understands that this term is used when referring to the
clumping effect occurring when an antibody acts like a cross-link between two antigens?
A) Agglutination
B) Cellular immune response
C) Humoral response
D) Phagocytic immune response
Ans: A
Chapter: 50
Cognitive Level: Comprehension
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 1
Patient Needs: D-4
Feedback: Agglutination refers to the clumping effect occurring when an antibody acts as a
cross-link between two antigens. Cellular immune response, the immune system's third line of
defense, involves the attack of pathogens by T cells. Humoral response is the immune system's
second line of defense, often termed the antibody response. The phagocytic immune response,
or immune response, is the system's first line of defense, involving white blood cells that have
the ability to ingest foreign particles.
324
16. Upon evaluation of a patient's laboratory studies, the nurse notes an increase in several cell
counts on the complete blood count. Which of the following cell counts increase because they
are the first cells to arrive at the site of inflammation?
A) Eosinophils
B) Red blood cell
C) Lymphocytes
D) Neutrophils
Ans: D
Chapter: 50
Cognitive Level: Analysis
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 1
Patient Needs: D-4
Feedback: Neutrophils are the first cells to arrive at the site where inflammation occurs.
17 . A nurse educator is discussing the immune response with a group of nursing students. Which
of the following terms does the nursing instructor use to describe the immune system's first line
of defense? A) Agglutination
B) Cellular immune response
C) Humoral response
D) Phagocytic immune response
Ans: D
Chapter: 50
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 3
Patient Needs: D-4
Feedback: The phagocytic immune response is the system's first line of defense, involving
white blood cells that have the ability to ingest foreign particles. Agglutination refers to the
clumping effect occurring when an antibody acts as a cross-link between two antigens. Cellular
immune response, the immune system's third line of defense, involves the attack of pathogens
by T cells. Humoral response is the immune system's second line of defense, often termed the
antibody response.
325
18. The nurse caring for a patient who was admitted with an infection in an abdominal wound
is aware that the third mechanism of defense involves the T lymphocytes turning into cytotoxic
T cell cells and attacking the pathogens. This is defined as the:
A) Antibody immune response
B) Phagocytic immune response
C) Humoral response
D) Cellular immune response
Ans: D
Chapter: 50
Cognitive Level: Comprehension
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 3
Patient Needs: D-4
Feedback: During cellular immune response, the third mechanism of defense, T lymphocytes
can turn into special cytotoxic (killer) T cells that attack the pathogens themselves.
19 . The nurse who notes an increase in a patient's white blood cell count is aware that during
the immune response pathogens are engulfed by white blood cells that ingest foreign particles.
This process is known as: A) Apoptosis
B) Phagocytosis
C) Antibody response
D) Cellular immune response
Ans: B
Chapter: 50
Cognitive Level: Analysis
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 1
Patient Needs: D-4
Feedback: During the first mechanism of defense, white blood cells, which have the ability to
ingest foreign particles, move to the point of attack, where they engulf and destroy the
invading agents. This is known as phagocytosis.
326
20. Nursing students in a microbiology class discuss the four defined stages of an immune
response. During this stage of the immune response, the students learn that the antibody or
cytotoxic T cells combine and potentially destroy the invading microbes or neutralize toxins:
A) Recognition stage
B) Proliferation stage
C) Response stage
D) Effector stage
Ans: D
Chapter: 50
Cognitive Level: Comprehension
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 2
Patient Needs: D-4
Feedback: In the effector stage, either the antibody of the humoral response or the cytotoxic
(killer) T cell of the cellular response reaches and couples with the antigen on the surface of the
foreign invader. The coupling initiates a series of events that in most instances results in total
destruction of the invading microbes or the complete neutralization of the toxin.
21 . T lymphocytes are believed to have a specific role in :
A) Transplant rejection
B) Allergic hay fever and asthma
C) Anaphylaxis
D) Bacterial infections
Ans: A
Chapter: 50
Cognitive Level: Comprehension
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 1
Patient Needs: D-4
Feedback: Some specific roles of T lymphocytes (cellular response) include transplant rejection;
delayed hypersensitivity (tuberculin reaction); graft-versus-host disease; tumor surveillance or
destruction; intracellular infections; and viral, fungal, and parasitic infections. Some specific
roles of B lymphocytes (humoral responses) include bacterial phagocytosis and lysis,
anaphylaxis, allergic hay fever and asthma, immune complex disease, and bacterial and some
viral infections.
327
22. B cells, which are responsible for humoral responses, have a specific role in which of the
following?
A) Graft-verses-host disease
B) Anaphylaxis
C) Tumor surveillance or destruction
D) Intracellular infections
Ans: B
Chapter: 50
Cognitive Level: Comprehension
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 1
Patient Needs: D-4
Feedback: Some specific roles of B lymphocytes (humoral responses) include bacterial
phagocytosis and lysis, anaphylaxis, allergic hay fever and asthma, immune complex disease,
and bacterial and some viral infections. Some specific roles of T lymphocytes (cellular response)
include transplant rejection; delayed hypersensitivity (tuberculin reaction); graft-versus-host
disease; tumor surveillance or destruction; intracellular infections; and viral, fungal, and
parasitic infections.
23. When a patient is given a vaccination for rubella, the nurse anticipates that the healthy
patient will develop: A) Natural immunity
B) Active acquired immunity
C) The disease rubella
D) Hypersensitivity
Ans: B
Chapter: 50
Cognitive Level: Analysis
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-4
Feedback: Active acquired immunity usually develops as a result of vaccination or contracting a
disease. Natural immunity is present at birth and provides a nonspecific response to any foreign
invader. Passive acquired immunity is temporary immunity transmitted from another source
that has developed immunity through previous disease or immunization.
328
24. The nurse administers which of the following substances to provide passive acquired
immunity to a patient?
A) Gamma globulin
B) Antibiotics
C) Albumin
D) Measles-mumps-rubella vaccine
Ans: A
Chapter: 50
Cognitive Level: Analysis
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 4
Patient Needs: D-2
Feedback: Gamma globulin, obtained from the blood plasma of people with acquired
immunity, is used in emergencies to provide immunity to diseases when the risk for contacting
a specific disease is great and there is not enough time for a person to develop adequate active
immunity.
25. The nurse recognizes that when she administers this classification of drugs, it will lead to
immunosuppression:
A) Antibiotics (in large doses)
B) Nonsteroidal anti-inflammatory drugs (NSAIDs in large doses)
C) Antineoplastics
D) Antithyroids
Ans: C
Chapter: 50
Cognitive Level: Analysis
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 4
Patient Needs: D-2
Feedback: Adrenocortical steroids, antineoplastics, and antimetabolites cause
immunosuppression. Antibiotics in large doses cause bone marrow suppression. NSAIDs inhibit
prostaglandin synthesis or release.
329
26. The nurse is performing an admission assessment on a patient admitted with cancer who
has recently finished a course of chemotherapy. Which of the following assessment findings
may indicate that the patient is possibly experiencing immune dysfunction?
A) Hypotension
B) Hypoventilation
C) Bradycardia
D) Dry mucous membranes
Ans: A
Chapter: 50
Cognitive Level: Analysis
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-4
Feedback: Hypotension, tachycardia, hyperventilation, vomiting, diarrhea, and hematuria are
indicators of immune dysfunction.
27. Removal of specific organs may place the patient at risk for impaired immune function.
During the health history, the nurse asks the patient if he has had surgical removal of which
organ that may lead to impairment of the immune system?
A) Lung
B) Spleen
C) Colon
D) Pancreas
Ans: B
Chapter: 50
Cognitive Level: Comprehension
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-3
Feedback: A history of surgical removal of the spleen, lymph nodes, or thymus may place the
patient at risk for impaired immune function.
330
28 . The nurse who is concerned about a patient's poor nutritional intake and his risk for infection
bases this worry on the fact that depletion of which nutrient increases a patient's susceptibility
to infection? A) Vitamin B
B) Fats
C) Proteins
D) Vitamin C
Ans: C
Chapter: 50
Cognitive Level: Analysis
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-4
Feedback: Depletion of protein reserves results in atrophy of lymphoid tissues, depression of
antibody response, reduction in the number of circulating T cells, and impaired phagocytic
function. As a result, the patient has an increased susceptibility to infection.
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Chapter 19: Coordinating Care for Patients with Immune Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse is providing care for a patient diagnosed with agammaglobulinemia and correlates
management of this disorder includes which medication? Which is the anticipated treatment for
this patient?
1. Oral diphenhydramine
2. Topical corticosteroids
3. Subcutaneous epinephrine
4. Intravenous immunoglobulin (IVIG)
2. The nurse is providing care to a patient diagnosed with X-linked agammaglobulinemia (XLA).
Which information does the nurse include in the patient’s plan of care?
1. Immunization with inactivated polio vaccine (IPV)
2. Administration of intravenous immunoglobulin every 6 months
3. Education regarding the use of high-dose prophylactic antibiotics
4. Periodic magnetic resonance imagery (MRI) to monitor for respiratory
complications
3. The nurse provides education to the parents of a pediatric patient who is diagnosed with X-linked
agammaglobulinemia (XLA). Which statement indicates a need for additional teaching?
1. “I will take my child to the pediatrician if he begins to pull at his ear.”
2. “My other children can receive the live attenuated oral polio vaccine.”
3. “I will clean all vegetables and fruits before giving them to my child.”
4. “My child will likely require intravenous antibiotics for respiratory infections.”
4. The nurse monitors for which clinical manifestations in the patient diagnosed with X-linked
agammaglobulinemia (XLA)?
1. Wheezes
2. Stridor
3. Tachypnea
4. Hyper-resonant breath sounds
5. What is the priority nursing diagnosis for a patient diagnosed with X-linked agammaglobulinemia
(XLA)?
1. Risk for Infection
2. Decreased Cardiac Output
3. Body Image Disturbance
4. Fatigue
6. The nurse monitors for which clinical manifestation in the patient diagnosed with DiGeorge’s
syndrome?
1. Muscle stiffness
2. Weight gain
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3. Shortness of breath
4. Aphasia
7. The nurse correlates which laboratory value as a complication in the patient diagnosed with
DiGeorge’s syndrome?
1. Sodium 150 mEq/L
2. Calcium 6.5 mg/dL
3. Potassium 3.0 mEq/L
4. Magnesium 2.5 mg/dL
8. The nursing diagnosis Potential for Ineffective Airway Clearance is most relevant to a patient with
which immune disorder?
1. B-cell deficiency
2. T-cell deficiency
3. Type I hypersensitivity reaction
4. X-linked agammaglobulinemia
9. Which is the priority nursing action to decrease the risk for infection for a patient diagnosed with
DiGeorge’s syndrome?
1. Hand hygiene
2. Reverse isolation
3. Prokinetic agents
4. Droplet precautions
10. Which immune disorder does the nurse include in the plan of care for a patient who is receiving
chemotherapeutic agents for the treatment of cancer?
1. B-cell deficiency
2. T-cell deficiency
3. Excessive immune response
4. Secondary immune deficiency
11. The nurse educates a patient who is diagnosed with therapy-induced immune dysfunction. Which
patient statement indicates the need for additional teaching?
1. “My husband cleans the cat's litter box.”
2. “We are planning to get our son an iguana for his birthday.”
3. “I ensure that my steak is well done when I eat out at a restaurant.”
4. “When I need to go shopping, I will go early in the morning to avoid crowds.”
12. The nurse is assessing a patient who is receiving intravenous (IV) antibiotics. Which item in the
patient’s 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
13. The nurse provides care to several patients with a history of hypersensitivity reactions. Which
patient requires education regarding a type I reaction?
1. The patient with allergic rhinitis
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2. The patient with myasthenia gravis
3. The patient with rheumatoid arthritis
4. The patient with a suspected latex allergy
14. The nurse recognizes which immunoglobulin (Ig) as the mediator for a type I hypersensitivity
reaction?
1. IgA
2. IgE
3. IgG
4. IgM
15. The nurse correlates systemic hypotension to which hypersensitivity mediator?
1. Kinins
2. Leukotrienes
3. Platelet-activating factor
4. Prostaglandin
16. A nurse is caring for a 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
17. The nurse is caring for a patient who is experiencing anaphylactic shock after 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’s position
18. 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. Notify the healthcare provider.
2. Administer prescribed diphenhydramine (Benadryl) by mouth every 4 hours.
3. Administer prescribed epinephrine 1:1,000 by subcutaneous injection per the
healthcare provider's orders.
4. Obtain a complete set of vital signs.
19. A nurse has been providing a 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. “I make sure the EpiPen has not expired.”
2. “It's fine to leave the EpiPen out in the sun.”
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3. “No one else in my family knows how to use the EpiPen.”
4. “I don't need a medical alert tag.”
20. A nurse is caring for a patient with seasonal hypersensitivity reactions. What teaching does the
nurse include in the patient’s plan of care?
1. Keep doors and windows open to circulate air.
2. Maintain a clean, dust-free environment.
3. Avoid the use of diphenhydramine hydrochloride (Benadryl).
4. Stop taking oral corticosteroids once symptoms disappear.
21. The nurse working on the maternal-child unit understands that erythroblastosis fetalis, which is
due to Rh sensitization, is an example of which type of hypersensitivity reaction?
1. Type I hypersensitivity reaction
2. Type II hypersensitivity reaction
3. Type III hypersensitivity reaction
4. Type IV hypersensitivity reaction
22. The nurse correlates which type of hypersensitivity reaction to a patient with myasthenia gravis?
1. Type I
2. Type II
3. Type III
4. Type IV
23. What is the priority nursing action to decrease the risk of a blood transfusion reaction from a
patient receiving incompatible blood?
1. Assessing the patient’s vital signs before starting the transfusion
2. Documenting the procedure in the health record
3. Verifying the patient’s identity using two identifiers
4. Checking the bag to ensure it is the correct blood type
24. The nurse is preparing to assess a patient when one of the patient’s family members begins
showing symptoms of a mild latex sensitivity. Which action by the nurse is best?
1. Asking the family member to leave the unit
2. Transferring the patient to a department that does not use latex products
3. Reporting the problem to the supervisor of the unit
4. Obtaining latex-free products for the patient’s room
25. The nurse recognizes that the local reaction typical of a positive tuberculosis test, including a
wheal and flare reaction, is observed in which type of hypersensitivity reaction?
1. Type I
2. Type II
3. Type III
4. Type IV
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
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26. The nurse is providing care to a patient who is being evaluated for an immune deficiency. Which
information in the patient’s health history supports this diagnosis? Select all that apply.
1. Persistent oral thrush
2. Rare need for antibiotics in the past
3. One occurrence of pneumonia last year
4. Eight new infections in a 1-year period
5. Two serious sinus infections in a 1-year period
27. The nurse monitors for which clinical manifestations in the patient experiencing a histaminemediated hypersensitivity reaction? Select all that apply.
1. A report of itching
2. Elevated blood pressure
3. The presence of hives
4. The presence of vomiting
5. Wheezing on auscultation
28. A nurse is working in a summer camp. One of the campers comes to the clinic with several bee
stings. Which clinical manifestations would require administration of 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. Hyperactive and hyperverbal behavior
4. Wheezing
5. Restlessness and confusion
29. In preparing a patient for a blood transfusion, the nurse recognizes that a patient with blood type B
can receive which blood types? Select all that apply.
1. Type A
2. Type B
3. Type AB
4. Type O
5. Only autologous blood
30. The nurse correlates which disorders to type III systemic hypersensitivity reactions? Select all that
apply.
1. Anaphylactic shock
2. Myasthenia gravis
3. Rheumatoid arthritis
4. Serum sickness
5. Systemic lupus erythematous (SLE)
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Chapter 19: Coordinating Care for Patients with Immune Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 5. Discussing the medical management of: B-cell deficiencies
Chapter page reference: 359
Heading: X-Linked Agammaglobulinemia/Treatment
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1
2
3
4
Diphenhydramine is indicated in the treatment of hypersensitivity reactions.
Corticosteroids are not part of the pharmacological treatment plan for this
patient. This medication is an anti-inflammatory medication.
Epinephrine is not the anticipated pharmacological treatment for this patient. It
is indicated in the treatment of hypersensitivity reactions.
Intravenous immunoglobulin (IVIG) is the anticipated pharmacological
treatment for this patient because it provides short-term passive immunity. The
dosage and the schedule are individualized, but typically IVIG is given every 3
or 4 weeks.
PTS: 1
CON: Medication
2. ANS: 1
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 6. Describing complications associated with selected immune
dysfunctions
Chapter page reference: 359
Heading: X-Linked Agammaglobulinemia/Treatment/Safety Alert
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Moderate
Feedback
1
Patients diagnosed with XLA should be immunized with IPV versus oral polio
vaccine because of the risk of developing vaccine-acquired polio.
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2
3
4
IVIG should be administered every 3 to 4 weeks, not every 6 months.
Education regarding low-dose, not high-dose, prophylactic antibiotics is
required.
Periodic chest x-ray examinations, not MRIs, to monitor for respiratory
complications are included in the plan of care.
PTS: 1
CON: Immunity
3. ANS: 2
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 8. Developing a teaching plan for a patient with immune dysfunction
Chapter page reference: 359-360
Heading: X-Linked Agammaglobulinemia/Treatment/Safety Alert/Nursing Interventions/Teaching
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
3
4
This statement indicates a correct understanding of the information presented.
Frequent infections occur for the patient diagnosed with XLA. A common
manifestation of an ear infection is a child who pulls at his or her ear.
This statement indicates the need for additional teaching. The patient and the
siblings should not receive the live, attenuated oral polio vaccine because this
increases the patient’s risk for developing polio.
This statement indicates a correct understanding of the information presented.
Precautions to prevent infection and minimize any source of infection in the
environment at home related to foods (particularly raw foods) and water,
domestic animals, or unsanitary conditions are necessary for the patient who is
diagnosed with XLA.
This statement indicates a correct understanding of the information presented.
Patients diagnosed with XLA often require the use of intravenous antibiotics for
infections.
PTS: 1
CON: Immunity
4. ANS: 3
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 6. Describing complications associated with selected immune
dysfunctions
Chapter page reference: 360
Heading: X-Linked Agammaglobulinemia/Nursing Interventions/Assessments
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
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Cognitive Level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
2
3
4
Wheezing is associated with hypersensitivity reactions.
Stridor is associated with decreased airway, and this is not expected in patients
with XLA.
Tachypnea, or increased respiratory rate, is anticipated for this patient with
XLA, usually related to a respiratory infection.
Absent or decreased breath sounds, not increased, or hyperresonance, are
anticipated for this patient.
PTS: 1
CON: Infection
5. ANS: 1
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 7. Developing a comprehensive plan of nursing care for patients with
immune dysfunction
Chapter page reference: 360
Heading: X-Linked Agammaglobulinemia/Nursing Diagnosis
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1
2
3
4
The priority nursing diagnosis for a patient diagnosed with XLA is Increased
Risk for Infection. Chronic respiratory infections such as sinus infections and
pulmonary disease are common clinical manifestations. Serious infections can
develop in the bloodstream and internal organs.
Decreased cardiac output is not associated with this disease process.
This disease does not affect the patient’s physical appearance.
Although the patient may develop fatigue as a result of chronic infection, the
priority is still to address the risk for infection.
PTS: 1
CON: Infection
6. ANS: 3
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 3. Correlating clinical manifestations to pathophysiological processes
of: B-cell deficiencies
Chapter page reference: 362
Heading: DiGeorge’s Syndrome/Clinical Manifestations
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Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
Poor muscle tone, not muscle stiffness, is a clinical manifestation of DiGeorge’s
syndrome.
Inability to gain weight and failure to thrive are clinical manifestations of
DiGeorge’s syndrome, not weight gain.
Shortness of breath is a respiratory clinical manifestation of DiGeorge’s
syndrome.
The patient’s ability to speak may be impacted if there are issues with the palate,
but there is not total loss of speech.
PTS: 1
CON: Assessment
7. ANS: 2
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 4. Describing the diagnostic results used to confirm the diagnoses of
selected immune dysfunctions
Chapter page reference: 362
Heading: DiGeorge’s Syndrome/Medical Management/Treatment
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
Hypernatremia is not associated with DiGeorge’s syndrome. Elevated serum
sodium is seen in patient with dehydration or fluid volume deficit.
A patient with DiGeorge’s syndrome may have hypoparathyroidism resulting in
a decreased serum calcium level; therefore, the nurse would monitor the
patient’s calcium. This is a low calcium level; the normal range is 8.2 to 10.2
mg/dL
Hypokalemia is not associated with DiGeorge’s syndrome.
Hypermagnesemia is not associated with DiGeorge’s syndrome.
PTS: 1
CON: Assessment
8. ANS: 2
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
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Chapter learning objective: 7. Developing a comprehensive plan of nursing care for patients with
immune dysfunction
Chapter page reference: 363
Heading: Primary Immune Dysfunction: T-Cell Deficiencies/Nursing Management/Nursing
Diagnosis
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Immunity
Difficulty: Difficult
Feedback
1
2
3
4
B-cell deficiency does not impact the parathyroid gland or calcium levels. The
primary nursing diagnosis with these disorders is related to the risk of infection.
T-cell deficiencies lead to infections and other problems that are more severe
than B-cell deficiencies. Chronic mucocutaneous candidiasis is a T-cell disorder
that is autosomal recessive. There is a combination of endocrine failure and
immunodeficiency. Problems include hypocalcemia and tetany as a result of
hypofunction of the parathyroid glands.
Clinical manifestations associated with a type I hypersensitivity reaction include
hypotension, wheezing, gastrointestinal or uterine spasm, stridor, and urticaria.
X-linked agammaglobulinemia is an example of B-cell deficiency and does not
impact the parathyroid or calcium levels.
PTS: 1
CON: Immunity
9. ANS: 1
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 7. Developing a comprehensive plan of nursing care for patients with
immune dysfunction
Chapter page reference: 395
Heading: DiGeorge’s Syndrome/Nursing Interventions/Actions
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Infection
Difficulty: Moderate
Feedback
1
2
3
Hand hygiene is the priority nursing action to decrease this patient’s risk for
infection.
Reverse isolation decreases the risk for infection for a patient who is
neutropenic.
Prokinetic agents are administered to this patient for gastrointestinal symptoms.
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4
Droplet precautions are implemented for a patient with an airborne,
communicable disease.
PTS: 1
CON: Infection
10. ANS: 4
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 2. Describing pathophysiological processes of immune dysfunction
Chapter page reference: 366
Heading: Secondary Immune Dysfunction: Therapy-Induced Deficiencies—Epidemiology
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
3
4
B-cell deficiency relates to altered antibody responses.
T-cell deficiency leads to infections and other problems that are more severe
than B-cell deficiencies.
Chemotherapy causes an immunosuppressive response.
Secondary immune deficiencies are caused by a variety of factors, such as
medication-induced immunosuppression, radiation, and surgery. The most
common is medication-induced immunosuppression. Immunosuppression is also
a side effect of chemotherapy in the treatment of cancer.
PTS: 1
CON: Immunity
11. ANS: 2
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 8. Developing a teaching plan for a patient with immune dysfunction
Chapter page reference: 367
Heading: Secondary Immune Dysfunction: Therapy-Induced Deficiencies—Nursing Interventions
Teaching
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Infection
Difficulty: Moderate
Feedback
1
2
This patient statement indicates a correct understanding of the information
presented. Litter boxes expose the patient to toxoplasmosis.
This patient statement indicates a need for additional teaching. Patients with
therapy-induced immune dysfunction are taught to avoid turtles and reptiles as
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3
4
pets because they carry bacteria such as Salmonella.
This patient statement indicates a correct understanding of the information
presented. The patient is taught to eat a low-bacteria diet by avoiding salads, raw
fruits and vegetables, undercooked meat, fish, and eggs. These foods carry
bacteria that can cause infection.
This patient statement indicates a correct understanding of the information
presented. The patient is taught to avoid exposure to infection by avoiding
crowds or large gatherings and to anyone with an obvious illness.
PTS: 1
CON: Infection
12. ANS: 3
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 2. Describing the pathophysiological processes of immune dysfunction
Chapter page reference: 367
Heading: Excessive Immune Response
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
3
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.
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.
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.
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.
PTS: 1
CON: Immunity
13. ANS: 1
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 7. Developing a comprehensive plan of nursing care for patients with
immune dysfunction
Chapter page reference: 369-370
Heading: Type I Hypersensitivity Reaction: Immediate—Epidemiology
Integrated Processes: Teaching and Learning
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Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
3
4
The patient experiencing allergic rhinitis requires education regarding type I
hypersensitivity reactions.
The patient diagnosed with myasthenia gravida requires education regarding
type II, not type I, hypersensitivity reactions.
The patient diagnosed with rheumatoid arthritis requires education regarding
type III, not type I, hypersensitivity reactions.
The patient with a suspected latex allergy requires education regarding type IV,
not type I, hypersensitivity reactions.
PTS: 1
CON: Immunity
14. ANS: 2
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 2. Describing pathophysiological processes of immune dysfunction
Chapter page reference: 369-379
Heading: Type I Hypersensitivity Reaction: Immediate/Pathophysiology/ Table 19.4 Types of
Hypersensitivity Reactions
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Moderate
Feedback
1
3
Immunoglobulin A (IgA) is the primary immunoglobulin found in secretory
gland secretions and is not involved in type I hypersensitivity reactions.
The primary mediator of type I hypersensitivity reactions is immunoglobulin E
(IgE). The first time a patient is exposed to an allergen, IgE is produced. The
IgE antibodies attach to mast cells.
IgG and IgM are involved in type II hypersensitivity reactions.
4
IgG and IgM are involved in type II hypersensitivity reactions.
2
PTS: 1
CON: Immunity
15. ANS: 3
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 2. Describing pathophysiological processes of immune dysfunction
Chapter page reference: 370-371
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Heading: Type I Hypersensitivity Reaction: Immediate/Pathophysiology/ Table 19.5 Mediators of
Hypersensitivity Reactions
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Difficult
Feedback
1
2
3
4
Kinins stimulate mucus secretion and increase vascular permeability. This
results in bronchial constriction, wheezing, and angioedema with painful
swelling.
Leukotrienes enhance the effect of histamine on the smooth muscle, leading to
bronchial constriction and wheezing.
Platelet-activating factor results in platelet aggregation and stimulates
vasodilation. This may result in systemic hypotension, as well as increased
pulmonary artery pressure.
Serotonin increases vascular permeability and stimulates smooth muscle
contraction. This results in mucosal edema, bronchial constriction, and
wheezing.
PTS: 1
CON: Immunity
16. ANS: 4
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 3. Correlating clinical manifestations to pathophysiological processes
of: Excessive immune response
Chapter page reference: 370
Heading: Type I Hypersensitivity Reaction: Immediate/Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Inflammation
Difficulty: Easy
Feedback
1
2
3
4
Erythema and fever are associated with type IV hypersensitivity reactions.
Fever and joint pain are associated with a type III hypersensitivity reactions.
Fever and joint pain are associated with a type III hypersensitivity reactions.
Clinical manifestations associated with a type I hypersensitivity reaction include
hypotension, wheezing, gastrointestinal or uterine spasm, stridor, and urticaria.
PTS: 1
17. ANS: 4
CON: Inflammation
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Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 7. Developing a comprehensive plan of nursing care for patients with
immune dysfunction
Chapter page reference: 372-373
Heading: Type I Hypersensitivity Reaction: Immediate/Nursing Interventions/Actions
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Inflammation
Difficulty: Moderate
Feedback
1
2
3
4
The Trendelenburg position places the head below the feet and would further
compromise airway and breathing.
Lying flat is not recommended because this does not aid in airway and
breathing.
A person in a supine position may not be able to maintain an open airway.
Placing the patient in Fowler’s or high-Fowler’s position allows optimal lung
expansion and ease of breathing.
PTS: 1
CON: Inflammation
18. ANS: 3
Chapter number and title: 19, Coordinating Care for Patients With Immune Disorders
Chapter learning objective: 5. Discussing the medical management of: Excessive immune response
Chapter page reference: 372-373
Heading: Type I Hypersensitivity Reaction: Immediate/Nursing Interventions/Actions
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Inflammation
Difficulty: Difficult
Feedback
1
2
3
The priority is providing care to the patient; the healthcare provider can be
notified after the patient is treated.
Diphenhydramine is often given as well, but by injection, not by mouth. The
patient requires an immediate intervention to address the airway and breathing.
For mild reactions with wheezing, pruritus, urticaria, and angioedema, a
subcutaneous injection of 0.3 to 0.5 mL of 1:1,000 epinephrine is generally
sufficient. The nurse should give the epinephrine first because of the clinical
manifestations. Epinephrine is the medication of choice to counteract
anaphylactic shock by causing blood vessel constriction, raising blood pressure,
and improving cardiac output through inotropic and chronotropic activity. It also
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4
acts as a beta-2 agonist to promote bronchial smooth muscle relaxation.
There is sufficient data for administration of epinephrine. Vital sign data would
not provide additional information needed to guide treatment at this time.
PTS: 1
CON: Inflammation
19. ANS: 1
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 8. Developing a teaching plan for a patient with immune dysfunction
Chapter page reference: 373
Heading: Excessive Immune Response/Nursing Interventions/Teaching
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Medication
Difficulty: Difficult
Feedback
1
2
3
4
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.
Proper storage of the kit is important and includes avoiding exposure to sun or
high temperature.
In addition to the patient, someone else should always know how to use the kit
as well.
The patient should be encouraged to wear a medical alert bracelet or tag.
PTS: 1
CON: Medication
20. ANS: 2
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 8. Developing a teaching plan for a patient with immune dysfunction
Chapter page reference: 373
Heading: Type I Hypersensitivity Reaction: Immediate/Nursing Interventions/Teaching
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Inflammation
Difficulty: Moderate
Feedback
1
2
The nurse should instruct the patient to keep doors and windows closed on highallergen days and to remain indoors if possible.
A patient with seasonal hypersensitivity should be educated regarding
prevention and comfort measures. The nurse should also include teaching on
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3
4
maintaining a clean, dust-free environment.
Diphenhydramine hydrochloride (Benadryl) is a histamine receptor blocker that
is indicated in the treatment of type I hypersensitivity reactions.
The patient should be instructed to taper oral corticosteroids as ordered, not to
immediately stop taking them.
PTS: 1
CON: Inflammation
21. ANS: 2
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 1. Describing the epidemiology of immune dysfunction
Chapter page reference: 373
Heading: Type II Hypersensitivity Reaction: Cytotoxic—Epidemiology
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
3
4
Type I hypersensitivity reactions are rapid or immediate allergic reactions. The
most common is allergic rhinitis or hay fever, a local reaction. The most severe
form is anaphylaxis, a systemic reaction.
Type II hypersensitivity reaction is an antibody-mediated reaction. One example
of type II hypersensitivity reaction that causes cell destruction is erythroblastosis
fetalis, which is due to Rh sensitization.
Type III hypersensitivity reactions are immune complex–mediated reactions.
Examples of systemic immune complex reactions are systemic lupus
erythematous, rheumatoid arthritis, and serum sickness.
Type IV hypersensitivity reactions are known as cell-mediated immune memory
response or antibody independent. Examples are poison ivy, the Mantoux test
for tuberculosis, and a latex allergy.
PTS: 1
CON: Immunity
22. ANS: 2
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders Assessment
of Immune Function
Chapter learning objective: 1. Describing the epidemiology of immune dysfunction
Chapter page reference: 373
Heading: Type II Hypersensitivity Reaction: Cytotoxic—Epidemiology
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Inflammation
Copyright © 2020 F. A. Davis Company
348
Difficulty: Moderate
Feedback
1
Anaphylaxis is an example of a systemic type I hypersensitivity reaction.
2
Myasthenia gravis is an example of a type II hypersensitivity reaction. It is an
antibody-mediated cellular dysfunction that results from a hypersensitivity
reaction where the antibodies bind to cell surface receptors.
Type III hypersensitivity reactions are immune complex–mediated reactions.
These immune complex allergic disorders are mediated by the formation of
antigen-antibody complexes. Examples of systemic immune complex reactions
are systemic lupus erythematous (SLE), rheumatoid arthritis, and serum
sickness.
Type IV hypersensitivity reactions are known as cell-mediated immune memory
response or antibody independent. Examples are poison ivy, the Mantoux test
for tuberculosis, and a latex allergy.
3
4
PTS: 1
CON: Inflammation
23. ANS: 4
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 6. Describing complications associated with selected immune
dysfunctions
Chapter page reference: 374
Heading: Type II Hypersensitivity Reaction: Cytotoxic/Safety Alert Blood Transfusions
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
3
4
Although assessing the patient’s vital signs is important, this is not the priority
nursing action to decrease the risk of a transfusion reaction.
Although documenting the procedure in the medical record is important, this is
not the priority nursing action to decrease the risk of a transfusion reaction.
Although verifying the patient’s identity using two identifiers is important, this
is not the priority nursing action to decrease the risk of a transfusion reaction.
The priority nursing action to decrease the risk of a transfusion reaction
secondary to incompatible blood is to ensure the bag contains the correct blood
type for the patient.
PTS: 1
CON: Immunity
24. ANS: 4
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Copyright © 2020 F. A. Davis Company
349
Chapter learning objective: 7. Developing a comprehensive plan of nursing care for patients with
immune dysfunction
Chapter page reference: 376
Heading: Type IV Hypersensitivity Reactions /Epidemiology
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
3
4
Latex-free products can be made available, rather than requiring the family
member to leave the unit.
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.)
Although the nurse may let the nurse manager know, this does not directly
address the issue of removing the latex gloves from the environment.
When symptoms of sensitivity to latex occur on exposure, latex-free products
should be supplied.
PTS: 1
CON: Immunity
25. ANS: 4
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 3. Correlating clinical manifestations to pathophysiological processes
of excessive immune responses
Chapter page reference: 376-377
Heading: Type IV Hypersensitivity Reactions/Pathophysiology and Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
Clinical manifestations associated with a type I hypersensitivity reaction include
hypotension, wheezing, gastrointestinal or uterine spasm, stridor, and urticaria.
Type II hypersensitivity destroys or damages cells. Clinical manifestations are
dependent on subtype. Examples include Rh sensitization, blood transfusion
reactions, and the development of myasthenia gravis.
Clinical manifestations depend on whether the reaction is local (vasculitis) or
systemic (rheumatoid arthritis and systemic lupus erythematous).
Type IV cell-mediated/delayed-type hypersensitivity is also known as cell-
Copyright © 2020 F. A. Davis Company
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mediated or antibody-independent immune memory response. This reaction is
different than the previous reactions in that it is mediated by cells rather than
antibodies. Clinical manifestations of a local reaction typical of a positive
tuberculosis test include a wheal and flare reaction. This reaction is a raised area
containing edematous fluid surrounded by red flare.
PTS:
1
CON: Assessment
MULTIPLE RESPONSE
26. ANS: 1, 4, 5
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 6. Describing complications associated with selected immune
dysfunctions
Chapter page reference: 357
Heading: Overview of Primary Immune and Secondary Immune Dysfunction/ Table 19.1 Warning
Signs of Primary Immune Dysfunction
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
1
2
3
4
5
Feedback
This is correct. Persistent oral thrush is a warning sign of primary immune
deficiency.
This is incorrect. History of the need for IV antibiotics to treat infections is a
warning sign for primary immune deficiency.
This is incorrect. Two, not one, occurrences of pneumonia in a 1-year period is a
warning sign for primary immune deficiency.
This is correct. Eight new infections is a warning sign of primary immune
deficiency.
This is correct. Two or more serious sinus infections in a 1-year period supports
the diagnosis of immune deficiency.
PTS: 1
CON: Assessment
27. ANS: 1, 3, 4, 5
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 3. Correlating clinical manifestations to pathophysiological processes
of Excessive Immune Response
Chapter page reference: 370-371
Heading: Type I Hypersensitivity Reaction: Immediate: Clinical Manifestations/Table 19.5
Mediators of Hypersensitivity Reactions, Pathophysiology, and Symptoms
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351
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
1
2
3
4
5
Feedback
This is correct. Pruritus is expected for the patient experiencing a histaminemediated hypersensitivity reaction.
This is incorrect. Hypotension, not elevated blood pressure, and shock may
develop in the patient experiencing a histamine-mediated hypersensitivity
reaction.
This is correct. Urticaria is expected for the patient experiencing a histaminemediated hypersensitivity reaction.
This is correct. Nausea, vomiting, and diarrhea are all expected for the patient
experiencing a histamine-mediated hypersensitivity reaction.
This is correct. Bronchial constriction resulting in wheezing is expected for the
patient who experiences a histamine-mediated hypersensitivity reaction.
PTS: 1
CON: Assessment
28. ANS: 1, 4, 5
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 3. Correlating clinical manifestations to pathophysiological processes
of: Excessive immune response
Chapter page reference: 370
Heading: Type I Hypersensitivity Reaction: Immediate/Clinical Manifestations
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment
Difficulty: Moderate
1
2
3
4
5
Feedback
This is correct. General clinical manifestations of anaphylactic shock that
necessitate an epinephrine injection include behavioral changes such as
restlessness, anxiety, confusion, depression, and apathy. Other clinical
manifestations include wheezing, crackles, nausea, and vomiting. 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. Wheezing, along with shortness of breath and dyspnea, may
indicate bronchospasm.
This is correct. General clinical manifestations of anaphylactic shock that
Copyright © 2020 F. A. Davis Company
352
necessitate an epinephrine injection include behavioral changes such as
restlessness, anxiety, confusion, depression, and apathy. Other clinical
manifestations include wheezing, crackles, nausea, and vomiting. The skin may
feel cold and clammy in shock.
PTS: 1
CON: Assessment
29. ANS: 2, 4
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 2. Describing pathophysiological processes of immune dysfunction
Chapter page reference: 375
Heading: Type II Hypersensitivity Reaction: Cytotoxic/Table 19.6 – Blood Types and Related
Antigens
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
3
4
5
This is incorrect. The patient cannot receive type A blood because they have
anti-A antibodies. This patient is not limited to autologous transfusions, which
use the patient’s own blood.
This is correct. Patients with type B blood can receive type B and type O blood.
Types A and AB are contraindicated because the patient has anti-A antibodies.
This patient is not limited to autologous transfusions, which use the patient’s
own blood.
This is incorrect. The patient cannot receive type AB blood because they have
anti-A antibodies. This patient is not limited to autologous transfusions, which
use the patient’s own blood.
This is correct. Patients with type B blood can receive type B and type O blood.
Types A and AB are contraindicated because the patient has anti-A antibodies.
This patient is not limited to autologous transfusions, which use the patient’s
own blood.
This is incorrect. This patient is not limited to autologous transfusions, which
use the patient’s own blood.
PTS: 1
CON: Immunity
30. ANS: 3, 4, 5
Chapter number and title: 19, Coordinating Care for Patients with Immune Disorders
Chapter learning objective: 1. Describing the epidemiology of immune dysfunction
Chapter page reference: 376
Heading: Type III Hypersensitivity Reaction: Immune Complex/Epidemiology
Integrated Processes: Nursing Process: Assessment
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353
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
3
4
5
PTS:
This is incorrect. Anaphylaxis is an example of a systemic type I
hypersensitivity reaction.
This is incorrect. Myasthenia gravis is an example of a type II hypersensitivity
reaction. It is an antibody-mediated cellular dysfunction that results from a
hypersensitivity reaction where the antibodies bind to cell surface receptors.
This is correct. Type III hypersensitivity reactions are immune complex–
mediated reactions. These immune complex allergic disorders are mediated by
the formation of antigen-antibody complexes. Examples of systemic immune
complex reactions are systemic lupus erythematous (SLE), rheumatoid arthritis,
and serum sickness.
This is correct. Type III hypersensitivity reactions are immune complex–
mediated reactions. These immune complex allergic disorders are mediated by
the formation of antigen-antibody complexes. Examples of systemic immune
complex reactions are systemic lupus erythematous (SLE), rheumatoid arthritis,
and serum sickness.
This is correct. Type III hypersensitivity reactions are immune complex–
mediated reactions. These immune complex allergic disorders are mediated by
the formation of antigen-antibody complexes. Examples of systemic immune
complex reactions are systemic lupus erythematous (SLE), rheumatoid arthritis,
and serum sickness.
1
CON: Immunity
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354
Chapter 20: Coordinating Care for Patients With Immune Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
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. The nurse is assessing a patient who is receiving intravenous (IV) antibiotics. Which item in the patient’s
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
patient’s family speaks very little English. The interpreter has arrived and the nurse is obtaining a health
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
4. The nurse is caring for a patient in an allergy clinic. After completing the patient history, the nurse selects the
nursing diagnosis of Risk for Shock. Which item in the patient’s history supports the need for this nursing
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. The nurse is preparing to assess a patient when one of the patient’s family members 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-free products for the patient’s room
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
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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
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) “I make sure the EpiPen is always available.”
2) “It's fine to leave the EpiPen out in the sun.”
3) “No one else in my family knows how to use the EpiPen.”
4) “I don't need a medical alert tag.”
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) “This medication does not come prefilled and must be measured.”
2) “Keep the medication in the car at all times.”
3) “Frequently check the expiration date of the medication.”
4) “Keep the medication in one location that is easy to remember.”
10. A nurse is caring for a patient with seasonal hypersensitivity reactions. What teaching would the nurse
provide to improve this patient’s comfort?
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
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) Indirect Coombs’ showing no agglutination
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
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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
3) Cyclosporine
4) Mycophenolate mofetil
15. Which is the priority nursing action to decrease the risk of a transfusion reaction?
1) Assessing the patient’s vital signs per policy
2) Documenting the procedure in the medical record
3) Verifying the patient’s identity using two identifiers
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
the nurse include in the patient’s plan of care?
1) Immunization with inactivated polio vaccine (IPV)
2) Administration of intravenous immunoglobulin every six months
3) Education regarding the use of high dose prophylactic antibiotics
4) 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)?
1) Wheezes
2) Rhonchi
3) Tachypnea
4) 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
DiGeorge’s syndrome?
1) Poor muscle tone
2) Failure to thrive
3) Shortness of breath
4) Delayed development
21. Which respiratory manifestation should the nurse anticipate when providing care to a patient diagnosed with
DiGeorge’s syndrome?
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1)
2)
3)
4)
Poor muscle tone
Failure to thrive
Shortness of breath
Delayed development
22. Which should the nurse plan to monitor when providing care to a patient who is diagnosed with DiGeorge’s
syndrome?
1) Sodium
2) Calcium
3) Potassium
4) Magnesium
23. Which is the priority nursing action to decrease the risk for infection for a patient diagnosed with DiGeorge’s
syndrome?
1) Hand hygiene
2) Reverse isolation
3) Prokinetic agents
4) Droplet precautions
24. Which should the nurse include in the plan of care for a patient diagnosed with DiGeorge’s syndrome to treat
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
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
in the patient’s health history supports this suspected diagnosis? Select all that apply.
1) Persistent oral thrush
2) Tinea infection of the feet
3) One occurrence of pneumonia last year
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4) Four or more infections in a one-year period
5) Two serious sinus infections in a one-year period
28. The nurse is providing care to a pediatric patient who is diagnosed with DiGeorge’s syndrome. Which data
indicates a cardiovascular abnormality? Select all that apply.
1) Murmur
2) Cyanosis
3) Polycythemia
4) Failure to thrive
5) Cleft lip and palate
Copyright © 2017 F. A. Davis Company
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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
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
Copyright © 2017 F. A. Davis Company
360
than previous exposure.
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
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
Copyright © 2017 F. A. Davis Company
361
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
1
Asking the family member to leave would be a violation of the patient’s rights.
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
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
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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.
3
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.
4
The nurse does not have time to collect a detailed history, because of the severity of the
patient’s 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 | Medication
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.
Copyright © 2017 F. A. Davis Company
363
3
4
The expiration date should be checked frequently to ensure accurate strength.
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
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 high-allergen
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
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
Indirect Coombs’ test detects the presence of circulating antibodies against RBCs. No
agglutination is considered a normal finding.
2
An area of erythema after a patch test indicates a positive response to a specific antigen.
3
An eosinophil count of 2% is within the normal range.
4
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
Copyright © 2017 F. A. Davis Company
364
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
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, 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
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
Copyright © 2017 F. A. Davis Company
365
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
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
While assessing the patient’s vital signs per policy is important, this is not the priority
nursing action to decrease the risk of a transfusion reaction.
2
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
While verifying the patient’s identity using two identifiers is important, this is not the
priority nursing action to decrease the risk of a transfusion reaction.
4
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
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.
Copyright © 2017 F. A. Davis Company
366
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
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 rate, is anticipated for 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
Copyright © 2017 F. A. Davis Company
367
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
CON: Infection
20. ANS: 2
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
Poor muscle tone is classified as an “other” manifestation of DiGeorge’s syndrome.
2
Failure to thrive is a general manifestation of DiGeorge’s syndrome.
3
Shortness of breath is a respiratory manifestation of DiGeorge’s syndrome.
4
Delayed development is classified as an “other” manifestation of DiGeorge’s 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
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
Poor muscle tone is classified as an “other” manifestation of DiGeorge’s syndrome.
2
Failure to thrive is a general manifestation of DiGeorge’s syndrome.
3
Shortness of breath is a respiratory manifestation of DiGeorge’s syndrome.
4
Delayed development is classified as an “other” manifestation of DiGeorge’s syndrome.
Copyright © 2017 F. A. Davis Company
368
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
1
Sodium is not an electrolyte the nurse should plan to monitor when providing care to this
patient.
2
A patient with DiGeorge’s syndrome often has hypoparathyroidism resulting in a
decreased serum calcium level; therefore, the nurse would plan to monitor the patient’s
calcium.
3
Potassium is not an electrolyte the nurse should plan to monitor when providing care to
this patient.
4
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
Hand hygiene is the priority nursing action to decrease this patient’s risk for infection.
2
Reverse isolation decreases the risk for infection for a patient who is neutropenic.
3
Prokinetic agents are administered to this patient for gastrointestinal symptoms.
4
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
Copyright © 2017 F. A. Davis Company
369
Integrated Processes: Nursing Process – Implementation
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection; Medication
Difficulty: Moderate
Feedback
1
Hand hygiene is the priority nursing action to decrease this patient’s risk for infection.
This is not appropriate to treat GERD.
2
Reverse isolation decreases the risk for infection for a patient who is neutropenic.
3
Prokinetic agents are administered to treat GERD for this patient.
4
Droplet precautions are implemented for a patient with a communicable disease.
PTS: 1
CON: Infection
25. 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: 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
Heading: Excessive Immune Response
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Comprehension [Understanding]
Concept: Inflammation
Difficulty: Easy
Feedback
Copyright © 2017 F. A. Davis Company
370
1.
2.
3.
4.
5.
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
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
1.
2.
3.
4.
5.
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.
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
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
Copyright © 2017 F. A. Davis Company
371
1.
2.
3.
4.
5.
PTS: 1
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.
CON: Infection
Copyright © 2017 F. A. Davis Company
372
Chapter 21: Coordinating Care for Patients with Multidrug-Resistant
Organism Infectious Disorders
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 patients in the hospital environment. Which is a risk
factor for a patient 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 community-acquired 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
The patient diagnosed with
3)
Acinetobacter
373
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
The patient diagnosed with
3)
Acinetobacter
The patient diagnosed with
4)
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)
Administering prescribed doses of
3)
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
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
374
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)
“The bacteria cause the
inflammation.”
2)
“Toxins released from the bacteria
cause inflammation.”
“The bacteria directly affect the
3)
blood vessels, causing
inflammation.”
4)
“The toxins are released from the
pseudomembrane causing
inflammation.”
14. The nurse is teaching a patient about the different routes of transmission. Which patient
statement indicates correct understanding of contact transmission?
“It occurs when I get bit by a tick or
1)
other insect.”
2)
“It occurs when I come in direct
contact with a pathogen.”
3)
“It occurs when I come into contact
with pathogens in the air.”
“It occurs when I ingest food
4)
containing a disease-carrying
organism.”
15. The nurse is teaching a patient about the different routes of transmission. Which patient
statement indicates correct understanding of vector-borne transmission?
1)
“It occurs when I get bit by a tick or
other insect.”
“It occurs when I come in direct
2)
contact with a pathogen.”
“It occurs when I come into contact
3)
with pathogens in the air.”
4)
“It occurs when I ingest food
containing a disease-carrying
organism.”
16. The nurse is teaching a patient about the different routes of transmission. Which patient
statement indicates correct understanding of airborne transmission?
“It occurs when I get bit by a tick or
1)
other insect.”
2)
“It occurs when I come in direct
contact with a pathogen.”
“It occurs when I come into contact
3)
with pathogens by breathing.”
4)
“It occurs when I ingest food
containing a disease-carrying
375
organism.”
17. The nurse is teaching a patient about the different routes of transmission. Which patient
statement indicates correct understanding of vehicle transmission?
“It occurs when I get bit by a tick or
1)
other insect.”
2)
“It occurs when I come in direct
contact with a pathogen.”
3)
“It occurs when I come into contact
with pathogens in the air.”
4)
“It occurs when I ingest food
containing a disease-carrying
organism.”
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)
“Contact transmission is the most
common mode.”
2)
“Vehicle transmission is the most
common mode.”
“Airborne transmission is the most
3)
common mode.”
4)
“Vector-borne transmission is the
most common mode.”
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.
376
1)
2)
3)
4)
5)
Decreasing the length of the
hospital stay
Decreasing the frequency of
adverse events
Increasing the risk for antibiotic
resistance
Decreasing the risk for hospitalacquired infection
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 multi-drug 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
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
377
2)
3)
4)
5)
hours
Keeping the sample at room
temperature
Sending the sample to the
laboratory immediately
Preparing a requisition for a culture
and sensitivity
Using an alcohol-based hand gel
before and after care
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 hospitalacquired MRSA.
4
A prolonged rehabilitation stay
increases the risk for VRE.
PTS: 1
CON: Infection
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
378
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 hospitalacquired 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
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 hospitalacquired 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]
379
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.
Current or recent hospitalization
increases the risk for hospitalacquired MRSA.
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 community-acquired MRSA.
A patient who is older than 65 years
of age is not at an increased risk for
community-acquired MRSA.
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
380
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 should include
education regarding these topics in
the patient’s plan of care.
PTS: 1
CON: Infection
7. ANS: 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 multidrug-resistant 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 nurse should monitor
this patient’s respiratory status
closely.
4
This patient is at risk for both fluid
and electrolyte imbalances, not
respiratory issues.
PTS: 1
8. ANS: 1
CON: Infection | Oxygenation
381
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 multidrug-resistant organism infectious disorders
Chapter page reference: 404-406
Heading: Nursing Management
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
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.
382
3
4
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
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
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
383
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 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.
2
Metronidazole is a drug that the
nurse anticipates administering
384
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.
3
4
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
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 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.
1
2
3
4
PTS: 1
CON: Infection
385
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.
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.
386
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
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
1
This statement indicates correct
understanding of vector-borne
transmission.
2
This statement indicates correct
387
3
4
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
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
388
Feedback
While MRSA colonization often
occurs in the throat, this is not the
most common site of colonization.
While MRSA colonization often
occurs in the axillae, this is not the
most common site of colonization.
While MRSA colonization often
occurs in the perineum, this is not
the most common site of
colonization.
The most common site of MRSA
colonization is the anterior nares.
1
2
3
4
PTS: 1
CON: Infection
20. 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
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
21. ANS: 1, 2, 4, 5
389
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 multidrug-resistant 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.
4.
5.
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.
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
390
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.
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 multidrug-resistant 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.
3.
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.
This is correct. Tachycardia, or an
increased heart rate, is an
391
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.
4.
5.
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 multidrug-resistant 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
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 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.
1.
2.
3.
4.
5.
PTS: 1
CON: Infection
392
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 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; Oxygenation
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. The nurse should
include ambulation in the patient’s
plan of care to decrease the risk for
atelectasis.
This is correct. The nurse should
include administration of prescribed
oxygen in the patient’s plan of care
to increase oxygen saturation.
This is correct. The nurse should
include chest physiotherapy in the
patient’s plan of care to 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.
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
393
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 dif 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 dif
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 dif.
This is incorrect. Any patient who is
suspected of having C dif 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
394
Chapter 22: Coordinating Care for Patients with HIV
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. A nurse is performing an admission assessment on a patient with clinical manifestations that
indicate human immunodeficiency virus (HIV). Which question from the nurse addresses a major
risk factor for contracting HIV?
1. “Has your partner been experiencing these symptoms?”
2. “When was your first sexual experience?”
3. “Have you had any fever, diarrhea, or chills over the last 48 hours?”
4. “Have you ever experimented with intravenous drugs?”
2. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV),
with a CD4+ count of 500 cells/mL. The nurse documents this as which stage of HIV infection?
1. Pre-HIV
2. Stage 1
3. Stage 2
4. Stage 3
3. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV),
with a CD4+ count of 300 cells/mL. The nurse documents this as which stage of HIV infection?
1. Pre-HIV
2. Stage 1
3. Stage 2
4. Stage 3
4. The nurse is providing care to a patient, diagnosed with human immunodeficiency virus (HIV),
with a CD4+ count of less than 200 cells/mL. The nurse documents this as which stage of HIV
infection?
1. Pre-HIV
2. Stage 1
3. Stage 2
4. Stage 3
5. The nurse is screening patients for the risk of developing HIV infection. The nurse considers which
patient at greatest risk?
1. African American female with a history of intravenous drug use
2. African American male with a history of sex with men
3. Caucasian female with a history of multiple blood transfusions
4. Caucasian male with a history of multiple heterosexual partners
6. The nurse provides care to a patient who is diagnosed with HIV. Which assessment finding
necessitates immediate notification to the healthcare provider?
1. Weakness
2. Nausea and vomiting
Copyright © 2020 F. A. Davis Company
395
3. Temperature of 102.2°F (39°C)
4. Weight drops from 150 to 140 lbs. (68 to 63.5 kg)
7. In completing discharge teaching for a patient recently diagnosed with HIV infection, the nurse
instructs the patient to have tuberculosis (TB) screening at what interval?
1. Every 6 months
2. Every 12 months
3. Every 18 months
4. Every 24 months
8. The nurse is caring for an HIV-positive patient who has been on prophylaxis to reduce the risk of
opportunistic infections. In reviewing the patient’s health record, the nurse correlates that
prophylaxis can be stopped based on which data?
1. CD4+ count greater than 50 cells/mL for at least 2 months
2. CD4+ count greater than 100 cells/mL for at least 3 months
3. CD4+ count greater than 200 cells/mL for at least 3 months
4. CD4+ count greater than 500 cells/mL for at least 2 months
9. In evaluating an HIV-positive patient’s response to antiviral therapy, which data indicates a
positive response?
1. Increased viral load
2. Increased BUN
3. Increased CD4+ count
4. Increased creatinine
10. The nurse is assessing a patient diagnosed with human immunodeficiency virus (HIV) who
presents with a rash. Which assessment question is most important?
1. “Are you taking Bactrim?”
2. “Have you recently used a new soap?”
3. “What have you eaten in the last few days?”
4. “Did you have unprotected sex within the last week?”
11. The nurse is discharging a patient who was recently diagnosed with acquired immunodeficiency
syndrome (AIDS). Because the patient has a young child at home, which immunization is
contraindicated for the child at this time?
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)
12. Which immunization should the nurse encourage for a patient who is diagnosed with stage 2 HIV?
1. Measles, mumps, and rubella (MMR) vaccine
2. Oral polio vaccine (OPV)
3. Influenza vaccine
4. Varicella vaccine
13. Which is the priority action for a nurse who is exposed to a needle-stick injury while providing
patient care?
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1.
2.
3.
4.
Washing the injury under running water
Squeezing the site to remove the patient’s blood
Taking two or three drugs for 28 days
Consenting to an HIV test
14. What is the recommendation for HIV testing in HIV-negative individuals who are at high risk for
HIV infection?
1. Every 3 months
2. Every 6 months
3. Every 12 months
4. Every 24 months
15. Which finding in the history of a patient prescribed to receive Truvada for pre-exposure
prophylaxis (PrEP) requires the nurse to contact the provider who ordered the medication?
1. Hepatitis A
2. Hepatitis B
3. Hepatitis C
4. Hepatitis D
16. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV). The
patient’s CD4+ count is currently 480 cells/mL. Which complication is this patient at risk for
developing?
1. Toxoplasmosis
2. Herpes zoster virus
3. Pneumocystis carinii pneumonia (PCP)
4. Severe bacterial infection
17. The nurse is providing care to a patient diagnosed with human immunodeficiency virus (HIV).
Because the patient’s CD4+ count is greater than 500 cells/mL, the nurse monitors for which
complication?
1. Toxoplasmosis
2. Herpes zoster virus
3. Vaginal candidiasis
4. Severe bacterial infection
18. A nurse is developing a plan of care for a patient diagnosed with human immunodeficiency virus
(HIV). The patient states, “I don’t plan on giving up sex just because I am HIV positive.” Based on
this data, which is the priority nursing diagnosis for this patient?
1. Risk for Infection
2. Anxiety
3. Knowledge Deficit
4. Social Isolation
19. 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 antiviral therapy because of a diagnosis of a low CD4
cell count
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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 weight loss who needs modifications and education regarding
dietary changes
4. A patient who is receiving IV antibiotics daily for toxoplasmosis
20. 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
21. 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. “I will eat small, frequent meals.”
2. “I will use condoms for every sexual encounter.”
3. “It important that I take my medications as scheduled at least 90% of the time.”
4. “It is important that I ask my spouse to clean the cat litter.”
22. In providing care to an HIV-positive patient, the nurse correlates which finding to a therapeutic
response to antiretroviral therapy (ART) medications?
1. 90% adherence with medical regimen
2. Increased CD4+ count
3. Increased viral load
4. Increased white blood cell count
Completion
Complete each statement.
23. 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. Symptomatic/AIDS
2. Death
3. Seroconversion
4. Viral transmission
5. Acute viral infection
6. Asymptomatic chronic infection
24. In providing care to a patient with HIV who initially weighed 50 kg, at what weight does the nurse
determine that the patient’s condition is deteriorating and requires immediate attention regarding
weight loss? (Express as the number of kilograms.)
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
25. The nurse correlates which comorbidities as impacting length of time from infection to death in
patients who are not receiving treatment for human immunodeficiency virus (HIV) infection?
Select all that apply.
1. Asthma
2. Malaria
3. Malnutrition
4. Pancreatitis
5. Tuberculosis
26. In preparing an education program for staff about human immunodeficiency virus (HIV), the nurse
includes which information? Select all that apply.
1. In HIV-infected patients who do not receive treatment, the time from infection and
death is approximately 12 years.
2. In HIV-infected patients from resource-limited countries, the time from infection to
death is less than 2 years.
3. Malnutrition is a comorbidity of HIV infection.
4. In adults, HIV is categorized into three different stages.
5. With treatment for HIV, patients may be categorized into a less severe stage.
27. According to the Centers for Disease Control and Prevention, which states in the United States
have the highest incidence of HIV infections? Select all that apply.
1. California
2. Georgia
3. Louisiana
4. Nevada
5. New York
28. The nurse provides care to a patient diagnosed with HIV. Which clinical manifestations cause the
nurse to ask the patient if sulfamethoxazole/trimethoprim (Bactrim) was prescribed
prophylactically within the last 2 weeks? Select all that apply.
1. Emesis
2. Nausea
3. Anemia
4. Diarrhea
5. Skin rash
29. In administering antiretroviral therapy medications to patients with HIV infections, the nurse
correlates the mechanism of action of preventing viral RNA from becoming viral DNA by
impacting the enzyme reverse transcriptase to which classes of medication? Select all that apply.
1. CCR5 antagonists
2. Fusion inhibitors
3. Non-nucleoside reverse transcriptase inhibitor (NNRTI)
4. Nucleoside reverse transcriptase inhibitors (NRTI)
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5. Protease inhibitors
30. The nurse is planning care for a patient diagnosed with human immunodeficiency virus (HIV). The
nurse selects Risk for Infection as a priority nursing diagnosis for this patient. Based on this
nursing diagnosis, which actions by the nurse are appropriate? Select all that apply.
1. Administering tuberculosis skin tests every 6 months
2. Teaching proper food-handling techniques to the family
3. Instructing on the importance of using nonbleach cleaners for blood spills at home
4. Assessing the health status of all visitors
5. Monitoring hand-washing techniques used by the family
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Chapter 22: Coordinating Care for Patients with HIV
Answer Section
MULTIPLE CHOICE
1. ANS: 4
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 1. Describing the etiology of HIV disorders
Chapter page reference: 425 - 426
Heading: Overview of the HIV/AIDS Continuum
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
2
3
4
Assessing recent symptoms, and asking if the patient’s partner is experiencing
the same symptoms, does not assess the patient’s risk factors for HIV
transmission.
The patient’s first sexual experience is not applicable to the patient’s current risk
for HIV.
Assessing recent symptoms, and asking if the patient’s partner is experiencing
the same symptoms, does not assess the patient’s risk factors for HIV
transmission.
One risk factor for contracting HIV is the use of intravenous recreational drugs.
This question is appropriate to determine the patient’s risk for HIV.
PTS: 1
CON: Infection
2. ANS: 2
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 4. Describing diagnostic results used to confirm the diagnosis of HIV
Chapter page reference: 425 - 426
Heading: Overview of the HIV/AIDS Continuum
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
Pre-HIV is not a stage of HIV classification.
The criteria for stage 1 HIV infection is a CD4+ count of at least 500 cells/mL.
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3
4
The criteria for stage 2 HIV infection is a CD4+ count of 200 to 499 cells/mL.
The criteria for stage 3 HIV infection is a CD4+ count of less than 200 cells/mL.
PTS: 1
CON: Assessment
3. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 4. Describing diagnostic results used to confirm the diagnosis of HIV
Chapter page reference: 425 - 426
Heading: Overview of the HIV/AIDS Continuum
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
Pre-HIV is not a stage of HIV classification.
The criteria for stage 1 HIV infection is a CD4+ count of at least 500 cells/mL.
The criteria for stage 2 HIV infection is a CD4+ count of 200 to 499 cells/mL.
The criteria for stage 3 HIV infection is a CD4+ count of less than 200 cells/mL.
PTS: 1
CON: Assessment
4. ANS: 4
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 4. Describing diagnostic results used to confirm the diagnosis of HIV
Chapter page reference: 425 - 426
Heading: Overview of the HIV/AIDS Continuum
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
Pre-HIV is not a stage of HIV classification.
The criteria for stage 1 HIV infection is a CD4+ count of at least 500 cells/mL.
The criteria for stage 2 HIV infection is a CD4+ count of 200 to 499 cells/mL.
The criteria for stage 3 HIV infection is a CD4+ count of less than 200 cells/mL.
PTS: 1
CON: Assessment
5. ANS: 2
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 2. Discussing the epidemiology of HIV
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Chapter page reference: 426 - 427
Heading: Human Immunodeficiency Virus/Epidemiology
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
3
4
According to the Centers for Disease Control and Prevention (CDC), the highest
rate of new infections was in African American men, especially men who were
having sex with men. In the early 2000s, the highest new infection rates were
via intravenous drug use and heterosexual transmission.
According to the CDC (2016), the highest rate of new infections among
different racial and ethnic groups was in African American men, especially men
who were having sex with men. The new infection rate among gay men was
67% of new HIV infections, the highest of any group.
A very small number of individuals are still infected with HIV by blood
transfusions.
Multiple heterosexual partners may be a risk factor, but the highest risk factors
are in African American men, especially men who were having sex with men.
PTS: 1
CON: Immunity
6. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 3. Comparing and contrasting clinical presentations of the disease
spectrum of HIV
Chapter page reference: 429
Heading: Clinical Manifestations/Table 22.2 Clinical Manifestations of HIV and Probable Cause
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
Weakness is a common manifestation indicative of an opportunistic infection
(OI); however, it does not require immediate notification of the healthcare
provider.
Nausea and vomiting is a common manifestation indicative of an opportunistic
infection (OI); however, it does not require immediate notification of the
healthcare provider.
A temperature greater than 102.2°F (39°C) indicates deterioration in status
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4
necessitating immediate notification of the healthcare provider.
Weight loss greater than 10% of previous recorded weight is an indicator of
deterioration necessitating the immediate notification to the healthcare provider.
The current weight loss is less than 10%.
PTS: 1
CON: Assessment
7. ANS: 1
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 5. Developing a comprehensive plan of nursing care including
pharmacological, dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 429 - 430
Heading: Medical Management/Diagnostic Testing
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Immunity
Difficulty: Easy
Feedback
1
Ongoing screening for TB should be routinely done every 6 months.
Ongoing screening for TB should be routinely done every 6 months.
Ongoing screening for TB should be routinely done every 6 months.
Ongoing screening for TB should be routinely done every 6 months.
2
3
4
PTS: 1
CON: Immunity
8. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 4. Describing diagnostic results used to confirm the diagnosis of HIV
Chapter page reference: 430
Heading: Medications/Prophylaxis
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
3
4
The CD4+ count needs to be greater than 50 cells/mL for at least 3 months.
Prophylaxis for toxoplasmosis and PCP can be discontinued in individuals when
their CD4+ count has been greater than 200 cells/mL for at least 3 months.
The CD4+ count needs to be greater than 50 cells/mL for at least 3 months.
The CD4+ count needs to be greater than 50 cells/mL for at least 3 months.
Copyright © 2020 F. A. Davis Company
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PTS: 1
CON: Immunity
9. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 3. Comparing and contrasting clinical presentations of the disease
spectrum of HIV
Chapter page reference: 430
Heading: Medications/Prophylaxis
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1
2
3
4
Once antiretroviral therapy (ART) is begun, the HIV viral load will decrease to
nondetectable levels.
An increased blood urea nitrogen (BUN) level indicates renal compromise.
Once ART is begun, the CD4+ count will increase and the HIV viral load will
decrease to nondetectable levels. This is generally achieved in 6 to 8 weeks. The
CD4+ counts and viral loads are followed at regular intervals, as recommended
in the Department of Health and Human Services guidelines.
Increased creatinine indicates potential renal impairment that could be related to
the ART medications.
PTS: 1
CON: Medication
10. ANS: 1
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 5. Developing a comprehensive plan of nursing care including
pharmacological, dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 430
Heading: Medications/Safety Alert
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
A new-onset rash for a patient diagnosed with HIV is often a delayed reaction to
a prophylactic antibiotic, such as sulfamethoxazole/trimethoprim (Bactrim).
This question is the most important.
Although new soaps can cause a rash, this is not the most important question for
a patient diagnosed with HIV who presents with a rash.
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3
4
Although new soaps can cause a rash, this is not the most important question for
a patient diagnosed with HIV who presents with a rash.
Unprotected sex is unlikely to be the cause of a rash.
PTS: 1
CON: Assessment
11. ANS: 1
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 5. Developing a comprehensive plan of nursing care including
pharmacological, dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 432
Heading: Medical Management/Immunizations
Integrated Processes: Nursing Process: Planning
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
2
3
4
Live virus vaccines are generally contraindicated in HIV-infected individuals
with a CD4+ count <200 and in household members.
DTaP, HIB, and hepatitis B vaccinations are not live vaccines and should be
given on schedule.
DTaP, HIB, and hepatitis B vaccinations are not live vaccines and should be
given on schedule.
DTaP, HIB, and hepatitis B vaccinations are not live vaccines and should be
given on schedule.
PTS: 1
CON: Infection
12. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 5. Developing a comprehensive plan of nursing care including
pharmacological, dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 432
Heading: Treatment/Immunizations
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Immunity
Difficulty: Moderate
Feedback
1
This is a live virus vaccine and is contraindicated for a patient diagnosed with
HIV.
Copyright © 2020 F. A. Davis Company
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2
3
4
This is a live virus vaccine and is contraindicated for a patient diagnosed with
HIV.
The influenza vaccine is not a live virus vaccine and should be offered yearly.
Patients are encouraged to receive it early in the season so they can develop
antibodies.
This is a live virus vaccine and is contraindicated for a patient diagnosed with
HIV.
PTS: 1
CON: Immunity
13. ANS: 1
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 5. Developing a comprehensive plan of nursing care including
pharmacological, dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 432
Heading: Safety Alert [Occupational Exposure]
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
2
3
4
The priority nursing action in this situation is to wash the injury under running
water. If there is visible blood or fluids, washing the area under running water is
recommended.
The nurse should avoid squeezing the injury because this is likely to increase the
risk for infection.
The nurse may be prescribed several drugs for 28 days; however, this is not the
priority action at the time of exposure. The exact drugs depend on the risk of the
exposure and the patient’s HIV treatment status if HIV positive.
The nurse is likely to consent to an HIV test; however, this is not the priority
action. An HIV test to ascertain seropositivity is offered. If positive, a referral
for care is initiated. If negative, antiretroviral medications are prescribed. HIV
testing is done at 6 weeks, 12 weeks, and 4 to 6 months after exposure.
PTS: 1
CON: Safety
14. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 4. Describing diagnostic results used to confirm the diagnosis of HIV
Chapter page reference: 433
Heading: Prevention
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Infection Control
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Cognitive Level: Knowledge [Remembering]
Concept: Infection
Difficulty: Easy
Feedback
1
2
3
4
In HIV-negative individuals, yearly testing is recommended for those at high
risk.
In HIV-negative individuals, yearly testing is recommended for those at high
risk.
In HIV-negative individuals, yearly testing is recommended for those at high
risk. High risk is defined as being in a community with a greater than 1%
prevalence of HIV. Examples of high-risk communities include sexually
transmitted infection clinic attendees and incarcerated individuals.
In HIV-negative individuals, yearly testing is recommended for those at high
risk.
PTS: 1
CON: Infection
15. ANS: 2
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 5. Developing a comprehensive plan of nursing care including
pharmacological, dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 433
Heading: Prevention
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Infection
Difficulty: Moderate
Feedback
1
2
3
4
Before initiation of pre-exposure prophylaxis (PrEP), hepatitis B, not hepatitis
A, must be ruled out.
Before initiation of PrEP, acute and chronic hepatitis B must be ruled out.
Before initiation of PrEP, hepatitis B, not hepatitis C, must be ruled out.
Before initiation of PrEP, hepatitis B, not hepatitis D, must be ruled out.
PTS: 1
CON: Infection
16. ANS: 2
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 4. Describing diagnostic results used to confirm the diagnosis of HIV
Chapter page reference: 434
Heading: Complications
Integrated Processes: Nursing Process: Assessment
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Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
2
3
4
Toxoplasmosis is a complication that occurs when the patient’s CD4+ count
drops to less than 200 cells/mL. This complication typically indicates the patient
has progressed from HIV to acquired immunodeficiency syndrome (AIDS).
Herpes zoster virus is a complication that occurs when the patient’s CD4+ is
between 500 and 350 cells/L.
Pneumocystis carinii pneumonia (PCP) is a complication that occurs when the
patient’s CD4+ count drops to less than 200 cells/mL. This complication
typically indicates the patient has progressed from HIV to acquired
immunodeficiency syndrome (AIDS).
Severe bacterial infection is a complication that occurs when the patient’s CD4+
is 350 and 200 cells/mL.
PTS: 1
CON: Infection
17. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 3. Comparing and contrasting clinical presentations of the disease
spectrum of HIV
Chapter page reference: 434
Heading: Complications
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
2
3
4
Toxoplasmosis is a complication that occurs when the patient’s CD4+ count
drops to less than 200 cells/mL. This complication typically indicates the patient
has progressed from HIV to acquired immunodeficiency syndrome (AIDS).
Herpes zoster virus is a complication that occurs when the patient’s CD4+ is
between 500 and 350 cells/mL.
Vaginal candidiasis is a complication that occurs when the patient’s CD4+ count
is greater than 500 cells/mL.
Severe bacterial infection is a complication that occurs when the patient’s CD4+
is between 350 and 200 cells/mL.
PTS:
1
CON: Infection
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18. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 5. Developing a comprehensive plan of nursing care including
pharmacological, dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 434
Heading: Nursing Management/Nursing Diagnoses
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1
2
3
4
Although all options are appropriate nursing diagnoses, the priority diagnosis is
Knowledge Deficit. This patient is already infected, so the risk of infection is
more related to secondary infections caused by immunosuppression or infection
transmission.
Although all options are appropriate nursing diagnoses, the priority diagnosis is
Knowledge Deficit. Anxiety is expected, but the priority is to decrease risk of
infection transmission.
Although all options are appropriate nursing diagnoses, the priority diagnosis is
Knowledge Deficit because of the patient statement, “I don’t plan on giving up
sex just because I am HIV positive.” The patient requires education regarding
safer sex practices to decrease the risk of transmission to potential sexual
partners.
Although all options are appropriate nursing diagnosis, the priority diagnosis is
Knowledge Deficit. The patient may experience Social Isolation and the nurse
needs to incorporate this into the plan of care, but based on the patient’s
statement, the priority is to decrease the risk of infection transmission.
PTS: 1
CON: Infection
19. ANS: 2
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 2. Comparing and contrasting clinical presentations of the disease
spectrum of HIV
Chapter page reference: 434 - 435
Heading: Nursing Interventions/Assessments
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Nursing Roles
Difficulty: Difficult
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Feedback
1
2
3
4
The home health nurse should see the patient with Pneumocystis carinii
pneumonia (PCP) first because of the complaint of shortness of breath and 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.
The home health nurse should see the patient with PCP first because of the
complaint of shortness of breath and new onset of fever. Hypoxemia, or
decreased oxygen-carrying capacity, may occur as a result of a deceased number
of functional alveoli secondary to a respiratory infection such as PCP. Fever is
often the first indicator of an infection, and in patients with low CD4+
lymphocytes, there is an inability to release pyrogens, resulting in a low-grade
fever even in the face of a significant infection.
This patient needs to be seen by the nurse; however, based on the ABCs (airway,
breathing, and circulation), this patient is not the priority.
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: Nursing Roles
20. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 5. Developing a comprehensive plan of nursing care including
pharmacological, dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 435 - 436
Heading: Nursing Interventions/Actions
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Moderate
Feedback
1
2
3
4
Droplet precautions are not necessary because HIV is not transmitted via this
route.
Reverse precautions are needed for a patient who is experiencing neutropenia.
Healthcare workers can prevent most exposures to HIV by using standard
precautions. With standard precautions, the healthcare 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.
Contact precautions are not necessary because HIV does not require additional
precautions aside from standard precautions.
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PTS: 1
CON: Safety
21. ANS: 3
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 5. Developing a comprehensive plan of nursing care including
pharmacological, dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 436
Heading: Nursing Interventions: Teaching
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
Feedback
1
2
3
4
Anorexia, nausea, and vomiting are common in individuals with HIV/AIDS as a
result of medications or HIV infection. Small, frequent meals or snacks
incorporating foods such as nuts or nutritional supplements will increase caloric
intake and provide protein and essential micronutrients.
Consistent use of condoms with every sexual encounter reduce the risk of
transmitting HIV.
An adherence rate of 95% or greater is essential to achieve viral suppression and
prevent the development of resistance to one or more antiretroviral drugs. If an
individual misses one dose of even one drug during a day, the adherence rate for
that day is 0%.
Animal excrement should be taken care of by a non–HIV-infected, nonpregnant
individual to avoid exposure to toxoplasmosis and other animal-borne illnesses.
PTS: 1
CON: Infection
22. ANS: 2
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 3. Comparing and contrasting clinical presentations of the disease
spectrum of HIV
Chapter page reference: 436
Heading: Nursing Management/Evaluating Care Outcomes
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
Difficulty: Moderate
Feedback
1
2
95% adherence with the medication regimen is required.
Once antiretroviral therapy (ART) is begun, the CD4+ count will increase and
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3
4
the HIV viral load will decrease to nondetectable levels.
Once ART is begun, the CD4+ count will increase and the HIV viral load will
decrease to nondetectable levels.
An elevated white blood cell count indicates infection, not effectiveness of
treatment.
PTS:
1
CON: Medication
COMPLETION
23. ANS:
453612
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 3. Comparing and contrasting clinical presentations of the disease
spectrum of HIV
Chapter page reference 427 - 428
Heading: Viral Transmission, Acute Viral Infection, and Seroconversion/Box 22.1 – Progression
Through HIV/AIDS Stage
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Immunity
Difficulty: Difficult
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; last, the patient dies.
PTS: 1
24. ANS:
45
CON: Immunity
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 3. Comparing and contrasting clinical presentations of the disease
spectrum of HIV
Chapter page reference: 434 - 435
Heading: Nursing Interventions/Assessments
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Immunity
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Difficulty: Moderate
Feedback: A clinical manifestation indicating a deterioration in status requiring immediate
attention by a healthcare provider includes weight loss of greater than 10% of the previously
recorded weight.
PTS:
1
CON: Immunity
MULTIPLE RESPONSE
25. ANS: 2, 3, 5
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 1. Describing the etiology of HIV disorders
Chapter page reference: 425 - 426
Heading: Overview of the HIV/AIDS Continuum
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Infection
Difficulty: Moderate
Feedback
1
2
3
4
5
This is incorrect. Asthma is not a comorbidity associated with length of time
from infection to death in HIV infected patients. A history of asthma may
exacerbate any respiratory manifestations associated with HIV.
This is correct. Malnutrition, tuberculosis (TB), and malaria are comorbidities
that shorten the time the untreated patient survives.
This is correct. Malnutrition, tuberculosis (TB), and malaria are comorbidities
that shorten the time the untreated patient survives.
This is incorrect. Pancreatitis is not a comorbidity associated with length of time
from infection to death in HIV-infected patients. A history of pancreatitis may
exacerbate any nutritional issues associated with HIV.
This is correct. Malnutrition, tuberculosis (TB), and malaria are comorbidities
that shorten the time the untreated patient survives.
PTS: 1
CON: Infection
26. ANS: 1, 3, 4
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 1. Describing the etiology of HIV disorders
Chapter page reference: 425 - 426
Heading: Overview of the HIV/AIDS Continuum
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
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Cognitive Level: Comprehension [Understanding]
Concept: Immunity
Difficulty: Moderate
Feedback
1
2
3
4
5
This is correct. In an HIV-infected individual who does not receive treatment,
the length of time from infection to death is approximately 12 years.
This is incorrect. In resource-limited countries, the time from infection to death
is approximately 5 years.
This is correct. Malnutrition, tuberculosis (TB), and malaria are comorbidities
that shorten the time the untreated patient survives.
This is correct. In adults, HIV is categorized into three different stages on the
basis of their CD4+ lymphocyte count, CD4+ percentage of total lymphocytes, or
the presence or absence of certain infections commonly found in individuals
with compromised immune systems, an AIDS-defining condition.
This is incorrect. HIV disease progression is from less severe to more severe.
Once individuals are classified in a more severe stage, they cannot be
reclassified into a less severe surveillance stage.
PTS: 1
CON: Immunity
27. ANS: 2, 3, 4
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 2. Discussing the epidemiology of HIV
Chapter page reference: 426 - 427
Heading: Epidemiology
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Adaptation: Reduction of Risk Potential
Cognitive Level: Knowledge [Remembering]
Concept: Assessment
Difficulty: Easy
Feedback
1
2
3
4
5
This is incorrect. The highest incidences of HIV infections in the United States
are found in Georgia, Louisiana, and Nevada, whereas the lowest is in Vermont.
This is incorrect. The highest incidences of HIV infections in the United States
are found in Georgia, Louisiana, and Nevada, whereas the lowest is in Vermont.
This is correct. The highest incidences of HIV infections in the United States are
found in Georgia, Louisiana, and Nevada, whereas the lowest is in Vermont.
This is correct. The highest incidences of HIV infections in the United States are
found in Georgia, Louisiana, and Nevada, whereas the lowest is in Vermont.
This is incorrect. The highest incidences of HIV infections in the United States
are found in Georgia, Louisiana, and Nevada, whereas the lowest is in Vermont.
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PTS: 1
CON: Assessment
28. ANS: 3, 5
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 5. Developing a comprehensive plan of nursing care including
pharmacological, dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 430
Heading: Medications/Safety Alert
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Medication
Difficulty: Difficult
Feedback
1 This is incorrect. Emesis is not an indication of a delayed allergic response to
sulfamethoxazole/trimethoprim (Bactrim) that is prescribed prophylactically for
the patient who is diagnosed with HIV.
2 This is incorrect. Nausea is not an indication of a delayed allergic response to
sulfamethoxazole/trimethoprim (Bactrim) that is prescribed prophylactically for
the patient who is diagnosed with HIV.
3 This is correct. The sudden onset of anemia in an individual who has recently
started Bactrim may be a sign of another serious manifestation of an adverse
reaction to the sulfa component. A hemolytic anemia caused by glucose-6phosphate dehydrogenase (G6PD) deficiency (an enzyme that supports the
functions of red blood cells) can be precipitated by an allergic reaction to sulfa.
4 This is incorrect. Diarrhea is not an indication of a delayed allergic response to
sulfamethoxazole/trimethoprim (Bactrim) that is prescribed prophylactically for
the patient who is diagnosed with HIV.
5 This is correct. Individuals who have an allergic reaction to the sulfa component in
sulfamethoxazole/trimethoprim (Bactrim), a medication that is used for
prophylaxis, may have a delayed manifestation of their allergy. The rash
associated with an allergic reaction to Bactrim may not occur for 7 to 14 days after
starting the medication. When assessing the patient who presents with a new rash,
the nurse should ask about starting Bactrim within the past 2 weeks.
PTS: 1
CON: Medication
29. ANS: 3, 4
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 5. Developing a comprehensive plan of nursing care including
pharmacological, dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 430 - 432
Heading: Medications/Antiviral Therapy/Table 22.3 – Classes of Retroviral Medications
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
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Cognitive Level: Comprehension [Understanding]
Concept: Medication
Difficulty: Difficult
Feedback
1
2
3
4
5
This is incorrect. CCR5 antagonists prevent HIV from entering target cells by
blocking receptors.
This is incorrect. Fusion inhibitors prevent the HIV virus from entering target
cells.
This is correct. Nucleoside reverse transcriptase inhibitors (NRTI) and nonnucleoside reverse transcriptase inhibitor (NNRTI) prevent viral RNA from
becoming viral DNA by impacting the enzyme reverse transcriptase.
This is correct. Nucleoside reverse transcriptase inhibitors (NRTI) and NNRTI
prevent viral RNA from becoming viral DNA by impacting the enzyme reverse
transcriptase.
This is incorrect. Protease inhibitors prevent functional viral proteins from
assembling into a new virus.
PTS: 1
CON: Medication
30. ANS: 2, 4, 5
Chapter number and title: 22, Coordinating Care for Patients with HIV
Chapter learning objective: 5. Developing a comprehensive plan of nursing care including
pharmacological, dietary, and lifestyle considerations for patients with HIV disease
Chapter page reference: 436
Heading: Nursing Interventions/Teaching
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1 This is incorrect. Tuberculosis skin tests should be administered annually, not
every 6 months.
2 This is correct. A patient with HIV is at risk for myriad 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 patient and also instructs them in proper hand-washing technique and
proper food handling to prevent infection.
3 This is incorrect. Blood spills should be cleaned with a bleach solution.
4 This is correct. A patient with HIV is at risk for myriad 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 patient and also instructs them in proper hand-washing technique and
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5
proper food handling to prevent infection.
This is correct. A patient with HIV is at risk for myriad 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
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Chapter 23: Assessment of Respiratory Function
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse recognizes that which process occurs as oxygen and carbon dioxide are exchanged at the
level of the alveoli.
1. Diffusion
2. Perfusion
3. Respiration
4. Ventilation
2. Which structure of the respiratory system is responsible for filtering, warming, and humidifying
inhaled air?
1. Alveoli
2. Pharynx
3. Sinuses
4. Turbinates
3. In providing health education to a group of middle school students, how does the nurse describe
the function of the epiglottis?
1. Aids in the sensation of smell
2. Conducts gases to the alveoli
3. Filters small particles before air enters the lungs
4. Prevents the entry of solids and liquids into the lungs
4. The nurse is conducting a respiratory assessment for a patient who is diagnosed with asthma.
Which assessment finding does the nurse monitor for with this diagnosis?
1. Hemoptysis
2. Dry cough
3. Productive cough
4. Coarse crackles
5. The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding
supports this diagnosis?
1. Wheezing
2. Hemoptysis
3. Pleural friction rub
4. Slightly whitish sputum
6. The nurse uses palpation during respiratory assessment to determine which clinical finding?
1. Tracheal position
2. Bronchovesicular sounds
3. Lung density
4. Adventitious sounds
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7. 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 patient to sit in an upright position
3. Instructing the patient to breathe slowly through mouth
4. Beginning auscultation from lung apices and moving toward intercostal spaces
8. The nurse uses which the term to describe abnormal breath sounds?
1. Vesicular
2. Bronchial
3. Adventitious
4. Bronchovesicular
9. Which percussion sound does the nurse expect when conducting percussion between the ribs
during a respiratory assessment?
1. Flat
2. Dull
3. Tympany
4. Resonance
10. When percussing the patient’s lung fields, the nurse notes a long, hollow, loud pitched sound over
the chest. The nurse uses which term to describe this in the health record?
1. Dull
2. Tympany
3. Resonance
4. Hyperresonance
11. The nurse correlates which percussion sound to the patient diagnosed with emphysema?
1. Flat
2. Dull
3. Tympany
4. Hyperresonance
12. Where does the nurse auscultate bronchial vesicular sounds?
1. Neck
2. Trachea
3. First to second intercoastal spaces
4. Peripheral lung fields
13. The nurse is assessing a patient who is admitted with pulmonary edema and presents with a
persistent cough. Which assessment finding is consistent with this diagnosis?
1. Foul-smelling sputum
2. Wheezing
3. Coarse crackles
4. Stridor
14. While auscultating a patient’s chest, the nurse notes wheezing, and correlates this finding with
which disorder?
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1.
2.
3.
4.
Bronchitis
Pleural effusion
Pulmonary edema
Chronic obstructive pulmonary disease
15. Before an arterial blood gas is collected from the radial artery, an Allen’s test is preformed to
access the patency of which artery?
1. Brachial
2. Medial
3. Radial
4. Ulnar
16. A patient is admitted for evaluation of complaints of difficulty breathing and is scheduled for a
sputum study to assist in providing data for which diagnosis?
1. Asthma
2. Lung cancer
3. Bacterial lung infection
4. Chronic obstructive pulmonary disease
17. How does the nurse interpret these arterial blood gas results?
pH 7.48
PaCO2 30 mm Hg
HCO3 24 mEq/L
1. Metabolic acidosis
2. Respiratory acidosis
3. Metabolic alkalosis
4. Respiratory alkalosis
18. The nurse correlated respiratory acidosis in a patient with which arterial blood gas result?
1. pH 7.50
2. PaCO2 50 mm Hg
3. PaO2 80 mm Hg
4. HCO3– 20 mEq/L
19. In reviewing capnography data, the nurse monitors for increased end-tidal volume CO2 in patients
with which disorder?
1. Sepsis
2. Hypothermia
3. Esophageal intubation
4. Cardiac arrest
20. A patient is scheduled for pulmonary function testing. Which nursing action is most appropriate for
the patient?
1. Assessing for respiratory distress
2. Scheduling the test after a meal
3. Providing rest before the procedure
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4. Administering an inhaled bronchodilator 6 hours before procedure
21. The nurse is providing care to a patient who will need a bronchoscopy. Which patient statement
indicates that pre-procedure teaching was effective?
1. “I will be awake and fully conscious during the procedure.”
2. “I will require mechanical ventilation after the procedure.”
3. “I will need to have my prothrombin time drawn after the test.”
4. “I will abstain from eating or drinking for 8 hours before the procedure.”
22. The nurse prepares the patient for which diagnostic procedure that is used to remove pleural fluid
for analysis?
1. Lung biopsy
2. Bronchoscopy
3. Thoracentesis
4. Sputum studies
23. The nursing diagnosis “Ineffective Breathing Pattern related to decreased chest wall compliance”
is most relevant to the older adult patient with which condition?
1. Decreased diaphragmatic strength
2. Delays in gas exchange
3. Depressed cough reflex
4. Kyphosis
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
24. The nurse conducts a respiratory assessment for an adult patient who presents with a productive
cough. Which additional data require the nurse to request the healthcare provider to test the patient
for tuberculosis? Select all that apply.
1. A low-grade fever
2. Reports of night sweats
3. Reports of coughing up blood
4. Reports of heart palpitations
5. Weight loss from previous visit
25. The nurse assesses for coarse crackles (coarse rales) in patients admitted with which respiratory
disorders? Select all that apply.
1. Asthma
2. Bronchitis
3. Chronic obstructive pulmonary disease (COPD)
4. Pneumonia
5. Pulmonary edema
26. The nurse assesses for fine crackles (fine rales) in patients admitted with which respiratory
disorders? Select all that apply.
1. Pneumonia
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2.
3.
4.
5.
Pulmonary edema
Fibrosis
Chronic obstructive pulmonary disease (COPD)
Asthma
27. The nurse assesses for rhonchi in patients admitted with which respiratory disorders? Select all
that apply.
1. Asthma
2. Chronic obstructive pulmonary disease (COPD)
3. Foreign body in airway
4. Lung cancer
5. Pneumonia
28. The nurse assesses for stridor in patients admitted with which respiratory disorders? Select all that
apply.
1. Allergic reactions
2. Chronic obstructive pulmonary disease (COPD)
3. Epiglottis
4. Laryngitis
5. Pleurisy
29. Which finding in a patient with dyspnea requires an immediate intervention by the nurse? Select
all that apply.
1. Accessory muscle use
2. Cyanosis
3. Hyperventilation
4. Tachypnea
5. Vesicular breath sounds
30. The nurse correlates which of the following assessment findings to age-related changes of the
respiratory system? Select all that apply.
1. Decreased airway reactivity
2. Decreased chest compliance
3. Decreased intercostal strength
4. Increased risk for hypocapnia
5. Increased neutrophils in respiratory tissue
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Chapter 23: Assessment of Respiratory Function
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 2. Discussing the function of the respiratory system
Chapter page reference: 440
Heading: Functions of the Respiratory System
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
2
3
4
Diffusion is a general term that relates to the movement of gases across a
membrane but is not as specific as respiration.
Perfusion is the movement of oxygenated blood into the tissues by the
circulatory system.
The process of respiration occurs as oxygen and carbon dioxide are exchanged
at the level of the alveoli.
Ventilation occurs as air moves into and out of the respiratory system through
the process of inspiration and exhalation. During ventilation, the structures of
the respiratory system filter and humidify the air entering the system.
PTS: 1
CON: Oxygenation
2. ANS: 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 1. Identifying key anatomical components of the respiratory system
Chapter page reference: 440-442
Heading: Anatomy of Respiratory System
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaption
Cognitive Level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
The alveoli are in the terminal bronchioles and are the location for gas
exchange.
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2
3
4
The oropharynx is the mucous membrane located directly behind the mouth.
Within the oropharynx are the palatine tonsils, which are responsible for
filtering out foreign objects or microorganisms that passed the turbinates.
The sinuses are empty air-filled cavities that humidify and warm inspired air;
absorb shock, providing protection from facial trauma; provide voice resonance;
and decrease the weight of the skull.
Turbinates filter the air, and any foreign matter is filtered out through the cilia.
In addition to filtering the air entering the nostril, turbinates are responsible for
humidifying and warming the air.
PTS: 1
CON: Oxygenation
3. ANS: 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 1. Identifying key anatomical components of the respiratory system.
Chapter page reference: 440-442
Heading: Overview of Anatomy and Physiology/Anatomy of the Respiratory System
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
Concept: Oxygenation
Difficulty: Easy
Feedback
1
2
3
4
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
4. ANS: 2
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical
assessment of respiratory function
Chapter page reference: 446
Heading: Assessment/Cough/Table 23.4 – Abnormal or Adventitious Lung Sounds
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment
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Difficulty: Moderate
Feedback
1
2
3
4
Hemoptysis often occurs with tuberculosis and is not typically observed in
patients with asthma.
A dry cough may be from asthma, a viral infection, or seasonal allergies.
A productive cough may occur in patients with disorders that result in thickened
secretions such as pneumonia and tuberculosis.
Coarse crackles are associated with fluid or secretions in lower airways and may
be auscultated in patients with chronic obstructive pulmonary disease (COPD),
pneumonia, and pulmonary edema.
PTS: 1
CON: Assessment
5. ANS: 2
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical
assessment of respiratory function
Chapter page reference: 446
Heading: Assessment/Safety Alert
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment
Difficulty: Moderate
Feedback
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.
Pleural friction rubs are described as grating or squeaking sounds auscultated
over the chest and are caused by inflammation in the pleural space usually
associated with pneumonia, pleurisy, or lung cancer.
Clear, slightly whitish, and viscous sputum are often normal findings.
PTS: 1
CON: Assessment
6. ANS: 1
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical
assessment of respiratory function
Chapter page reference: 448
Heading: Assessment/Palpation
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
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Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
Palpation is used to determine tracheal position.
Auscultation is used to determine breath sounds, both normal and adventitious.
Percussion is used to assess lung density.
Auscultation is used to determine breath sounds, both normal and adventitious.
PTS: 1
CON: Assessment
7. ANS: 1
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical
assessment of respiratory function
Chapter page reference: 448
Heading: Assessment/Auscultation
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Easy
Feedback
1
2
3
4
Auscultation is performed to identify fluid, mucus, or obstruction in the
respiratory system. The nurse should avoid auscultating sound over bony
structures because it interferes with the sound quality.
Upright position optimizes airflow and allows chest expansion, which facilitates
clear respiratory sounds during auscultation.
Breathing slowly through an open mouth prevents transmission of turbulent
sound and helps to hear clear sound.
Beginning auscultation from lung apices and moving toward intercostal spaces
to the lung bases helps to compare one lung with the other at the same level.
PTS: 1
CON: Assessment
8. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 2. Discussing the function of the respiratory system
Chapter page reference: 448
Heading: Auscultation
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Knowledge [Understanding]
Concept: Assessment
Difficulty: Easy
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Feedback
1
2
3
4
Vesicular sound is relatively soft, low-pitched, gentle, rustling sounds.
Bronchial sounds are louder, higher-pitched, and sound like air blowing through
a hollow pipe.
Adventitious is the term used to describe abnormal breath sounds such as
crackles, rhonchi, wheezes, and a pleural friction rub.
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
9. ANS: 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical
assessment of respiratory function
Chapter page reference: 448
Heading: Assessment/Percussion
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
A flat sound is expected when percussing over bone.
A dull sound is expected when percussing over the liver, heart, kidney, and
diaphragm.
A tympany sound is expected when percussing over the stomach.
The nurse expects a resonance sound when percussing between the rib during a
respiratory assessment.
PTS: 1
CON: Assessment
10. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical
assessment of respiratory function
Chapter page reference: 448-449
Heading: Assessment/Percussion/Table 23.1 – Percussion Sounds
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Easy
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Feedback
1
2
3
4
Dull sounds are medium pitched, thud sounds observed when percussing over
the liver, heart, kidney, or diaphragm. Dull sounds may be assessed in patient
with pneumonia, atelectasis, or a lung mass.
Tympany is a drum-like, loud, empty quality heard over a gas-filled stomach or
intestine.
Low-pitched sounds heard over normal lungs during percussion indicate
resonance.
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: Assessment
11. ANS: 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical
assessment of respiratory function
Chapter page reference: 448-449
Heading: Physical Assessment/Percussion/Table 23.2 Percussion Sounds and Associated
Respiratory Conditions
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
A flat percussion sound is anticipated when assessing the patient who is
diagnosed with pleural effusion.
A dull percussion sound is anticipated when assessing the patient who is
diagnosed with pneumonia, atelectasis, or a lung mass.
A tympany percussion sound is anticipated when assessing the patient who is
diagnosed with a large pneumothorax.
A hyperresonance percussion sound is anticipated when assessing the patient
who is diagnosed with emphysema, chronic asthma, or a pneumothorax.
PTS: 1
CON: Assessment
12. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical
assessment of respiratory function
Chapter page reference: 448-449
Heading: Auscultation/Table 23.3 – Normal Lung Sounds
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429
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Easy
Feedback
1
2
3
4
Bronchial sounds, described as hollow with loud intensity, are auscultated over
the neck and trachea.
Bronchial sounds, described as hollow with loud intensity, are auscultated over
the neck and trachea.
Bronchovesicular sounds, described as tubular with moderate intensity are
auscultated from the first to the second intercoastal spaces.
Vesicular sounds, described as a gentle breeze with soft intensity, are auscultated
below the second and peripheral lung fields.
PTS: 1
CON: Assessment
13. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical
assessment of respiratory function
Chapter page reference: 448-450
Heading: Assessment/ Auscultation/ Table 23.4 Abnormal or Adventitious Lung Sounds
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
Foul-smelling sputum indicates an infection process often seen in patients with
pneumonia.
Wheezing is associated with inflammation and bronchoconstriction and often
observed in patients with asthma or COPD.
Coarse rhonchi (rales) are caused by secretions in the lower airway and often
observed in patients with pulmonary edema, congestive heart failure,
pneumonia, and COPD.
Stridor is caused by an obstruction of the throat or upper airway and often
observed in patients with laryngitis, epiglottis, and allergic reactions.
PTS: 1
14. ANS: 4
CON: Assessment
Copyright © 2020 F. A. Davis Company
430
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical
assessment of respiratory function
Chapter page reference: 448-450
Heading: Assessment/Auscultation/ Table 23.4 Abnormal or Adventitious Lung sounds
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
Rhonchi, described as snoring sounds, are observed in patients with bronchitis.
Diminished breath sounds are observed in patients with 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
that often occurs with chronic obstructive pulmonary disease.
PTS: 1
CON: Assessment
15. ANS: 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 5. Explaining nursing considerations for diagnostic studies relevant to
respiratory function
Chapter page reference: 449-451
Heading: Diagnostic Studies/ABG/Nursing Implications
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Risk of Risk Reduction
Cognitive Level: Comprehension [Understanding]
Concept: Safety
Difficulty: Moderate
Feedback
1
2
3
4
The ulnar, not the brachial, artery is assessed for collateral circulation when an
Allen’s test is performed before a radial artery stick.
The ulnar, not the radial, artery is assessed for collateral circulation when an
Allen’s test is performed before a radial artery stick.
The ulnar, not the radial, artery is assessed for collateral circulation when an
Allen’s test is performed before a radial stick.
If the nurse elects to use the radial artery, assessment of the ulnar circulation
needs to be evaluated using Allen’s test to ensure adequate collateral circulation.
Copyright © 2020 F. A. Davis Company
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PTS: 1
CON: Safety
16. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 4. Correlating relevant diagnostic examinations to respiratory function
Chapter page reference: 452-455
Heading: Diagnostic Studies/Sputum Analysis/Table 23.7 – Disease Processes and Pulmonary
Function Test Results
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
Asthma is often diagnosed based on pulmonary function tests.
Lung cancer is usually definitively diagnosed based on findings from a biopsy.
A sputum study is often used to diagnose bacterial lung infections via a culture
and sensitivity analysis.
A sputum analysis is not typically used in the diagnosis of chronic obstructive
pulmonary disease (COPD), which is diagnosed based on physical assessment
findings, chest x-ray examination results, and arterial blood gas results.
PTS: 1
CON: Assessment
17. ANS: 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 4. Correlating relevant diagnostic examinations to respiratory function
Chapter page reference: 449-450
Heading: Diagnostic Tests/Arterial Blood Gas/ Table 23.5 – Respiratory Conditions that Cause
Acid-Base Abnormalities
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: pH Regulation
Difficulty: Difficult
Feedback
1
2
3
4
–
Metabolic acid–base disorders are based on changes in HCO3 (elevated in
alkalosis and decreased in acidosis).
PaCO2 greater than 45 mm Hg and pH less than 7.35 correlate with respiratory
acidosis.
–
Metabolic acid–base disorders are based on changes in HCO3 (elevated in
alkalosis and decreased in acidosis).
PaCO2 less than 35 mm Hg and pH greater than 7.45 correlate with respiratory
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alkalosis.
PTS: 1
CON: pH Regulation
18. ANS: 2
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 4. Correlating relevant diagnostic examinations to respiratory function
Chapter page reference: 449-450
Heading: Diagnostic Tests/Arterial Blood Gas Table 23.5 – Respiratory Conditions that Cause
Acid-Base Abnormalities
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: pH Regulation
Difficulty: Difficult
Feedback
1
2
3
4
PaCO2 less than 35 mm Hg and pH greater than 7.45 correlate with respiratory
alkalosis.
PaCO2 greater than 45 mm Hg and pH less than 7.35 correlate with respiratory
acidosis.
This is a normal PaO2 and does indicate an acid–base imbalance. Abnormal or
low PaO2 levels indicate hypoxemia.
–
HCO3 is the metabolic component of the arterial blood gas result. Normal range
is 22 to 26 mEq/L. This is a low value that is consistent with metabolic acidosis.
PTS: 1
CON: pH Regulation
19. ANS: 1
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 5. Explaining nursing considerations for diagnostic studies relevant to
respiratory function
Chapter page reference: 452
Heading: Diagnostic Testing/Capnography and Capnometry
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment
Difficulty: Moderate
Feedback
1
Increases in end-tidal CO2 levels may be from an increase in cellular
metabolism, resulting in an increase in CO2 production or hyperventilation that
causes an increase in the excretion of CO2 from the lungs. Disease processes that
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2
3
4
result in increased CO2 levels are hyperthermia, trauma, burns, or sepsis.
Decreases in the end-tidal CO2 levels result from inadequate ventilation,
respiration, or pulmonary perfusion. Disease processes that result in lower endtidal CO2 levels are hypothermia, sedation, pulmonary embolism, hypoperfusion
of the pulmonary system, endotracheal tube placement in the esophagus,
systemic hypotension, and cardiac arrest.
Decreases in the end-tidal CO2 levels result from inadequate ventilation,
respiration, or pulmonary perfusion. Disease processes that result in lower endtidal CO2 levels are hypothermia, sedation, pulmonary embolism, hypoperfusion
of the pulmonary system, endotracheal tube placement in the esophagus,
systemic hypotension, and cardiac arrest.
Decreases in the end-tidal CO2 levels result from inadequate ventilation,
respiration, or pulmonary perfusion. Disease processes that result in lower endtidal CO2 levels are hypothermia, sedation, pulmonary embolism, hypoperfusion
of the pulmonary system, endotracheal tube placement in the esophagus,
systemic hypotension, and cardiac arrest.
PTS: 1
CON: Assessment
20. ANS: 1
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 5. Explaining nursing considerations for diagnostic studies relevant to
respiratory function
Chapter page reference: 451-452
Heading: Diagnostic Studies/Pulmonary Function Test
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
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.
The patient should not eat for 4 to 6 hours before the test.
There are not activity restrictions before the test.
The nurse would avoid administering an inhaled bronchodilator 6 hours before
the procedure because this may interfere with the test results.
PTS: 1
CON: Assessment
21. ANS: 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 5. Explaining nursing considerations for diagnostic studies relevant to
respiratory function
Copyright © 2020 F. A. Davis Company
434
Chapter page reference: 453-455
Heading: Diagnostic Studies/Bronchoscopy/Patient Prep
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Difficult
Feedback
1
2
3
4
The patient will be sedated during the procedure. Moderate sedation involves
giving the patient an intravenous pain medication and sedative. The patient may
be able to respond to verbal stimuli but is not fully awake.
The patient will not require mechanical ventilation after this procedure.
The patient will need to have the prothrombin time evaluated before the
procedure, not after the procedure.
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 8 hours before the procedure to decrease the risk for aspiration.
PTS: 1
CON: Safety
22. ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 4. Correlating relevant diagnostic examinations to respiratory function
Chapter page reference: 455
Heading: Diagnostic Studies/Thoracentesis
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Easy
Feedback
1
2
3
4
A lung biopsy involves taking a sample of tissue, not fluid, for analysis.
A bronchoscopy involves the use of a flexible fiberoptic scope for diagnosis,
biopsy, or specimen collection.
A thoracentesis is a diagnostic procedure used to remove pleural fluid for
analysis or to instill medication.
Sputum studies are obtained by expectoration and tracheal suction.
PTS: 1
CON: Assessment
23. ANS: 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 6. Discussing changes in respiratory function associated with aging
Chapter page reference: 456-457
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435
Heading: Age-Related Changes of the Respiratory System/Table 23.8 – Age-Related Changes of
the Respiratory System
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Assessment
Difficulty: Difficult
Feedback
1
2
3
4
PTS:
The decrease in function and strength of the intercostals and diaphragm
increases inspiratory effort to maintain adequate ventilation.
Delays in gas exchange and depressed cough reflex increased the potential for
episodes of hypercapnia and hypoxia.
Delays in gas exchange and depressed cough reflex increased the potential for
episodes of hypercapnia and hypoxia.
Kyphosis and osteoporosis of the thoracic vertebrae cause a decrease in chest
wall compliance.
1
CON: Assessment
MULTIPLE RESPONSE
24. ANS: 1, 2, 3, 5
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical
assessment of respiratory function
Chapter page reference: 446
Heading: Cough/Safety Alert
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Infection
Difficulty: Difficult
1
2
3
4
Feedback
This is correct. The patient who presents with a productive cough in addition to a
low-grade fever should be tested for tuberculosis.
This is correct. The patient who presents with a productive cough in addition to
reports of night sweats should be tested for tuberculosis.
This is correct. The patient who presents with a productive cough in addition to
hemoptysis (coughing up blood) should be tested for tuberculosis.
This is incorrect. Heart palpations with a productive cough is not an indicator of
Copyright © 2020 F. A. Davis Company
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5
tuberculosis. Although the report of palpitations should be reported to the
healthcare provider, this does not support a need to test the patient for tuberculosis.
This is correct. The patient who presents with a productive cough in addition to
reported or actual weight loss should be tested for tuberculosis.
PTS: 1
CON: Infection
25. ANS: 3, 4, 5
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical
assessment of respiratory function
Chapter page reference: 448-450
Heading: Assessment/Auscultation/Table 23.4 – Abnormal or Adventitious Lung Sounds
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
5
This is incorrect. Patients with asthma typically develop wheezing that is
described as a squeaky musical instrument caused by bronchoconstriction and
inflammation.
This is incorrect. Patients with bronchitis may have fine rhonchi (fine rales),
described as the sound of rubbing hair follicles together caused by inflation of
previously deflated lung tissue, or rhonchi, described as snoring sounds caused
by obstruction in the airways.
This is correct. Coarse crackles (coarse rales), described as a popping/coarse
sound caused by fluid or secretions in lower airways, may be observed in
patients with COPD, sputum in the airways, pneumonia, pulmonary edema, and
congestive heart failure.
This is correct. Coarse crackles (coarse rales), described as a popping/coarse
sound caused by fluid or secretions in lower airways, may be observed in
patients with COPD, sputum in the airways, pneumonia, pulmonary edema, and
congestive heart failure.
This is correct. Coarse crackles (coarse rales), described as a popping/coarse
sound caused by fluid or secretions in lower airways, may be observed in
patients with COPD, sputum in the airways, pneumonia, pulmonary edema, and
congestive heart failure.
PTS: 1
CON: Assessment
26. ANS: 1, 3, 4
Chapter number and title: 23, Assessment of Respiratory Function
Copyright © 2020 F. A. Davis Company
437
Chapter learning objective: 3. Describing the procedure for completing a history and physical
assessment of respiratory function
Chapter page reference: 448-450
Heading: Assessment/Auscultation/Table 23.4 - Abnormal or Adventitious Lung Sounds
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
5
This is correct. Patients with bronchitis, COPD, fibrosis, and pneumonia may
have fine crackles (fine rales) that are described as the sound of rubbing hair
follicles together caused by inflation of previously deflated lung tissue.
This is incorrect. Patients with pulmonary edema usually manifest with coarse
crackles as a result of fluid in the lower airways.
This is correct. Patients with bronchitis, COPD, fibrosis, and pneumonia may
have fine crackles (fine rales) that are described as the sound of rubbing hair
follicles together caused by inflation of previously deflated lung tissue.
This is correct. Patients with bronchitis, COPD, fibrosis, and pneumonia may
have fine crackles (fine rales) that are described as the sound of rubbing hair
follicles together caused by inflation of previously deflated lung tissue.
This is incorrect. Patients with asthma typically develop wheezing that is
described as a squeaky musical instrument caused by bronchoconstriction and
inflammation.
PTS: 1
CON: Assessment
27. ANS: 3, 4, 5
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical
assessment of respiratory function
Chapter page reference: 448-450
Heading: Assessment/Auscultation/Table 23.4 - Abnormal or Adventitious Lung Sounds
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
This is incorrect. Patients with asthma typically develop wheezing that is
described as a squeaky musical instrument caused by bronchoconstriction and
inflammation.
Copyright © 2020 F. A. Davis Company
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2
3
4
5
This is incorrect. Patients with COPD typically have fine or coarse crackles on
auscultation.
This is correct. Rhonchi are auscultated in patients with bronchitis, foreign body
obstruction, masses or malignancies in the lungs, and pneumonia.
This is correct. Rhonchi are auscultated in patients with bronchitis, foreign body
obstruction, masses or malignancies in the lungs, and pneumonia.
This is correct. Rhonchi are auscultated in patients with bronchitis, foreign body
obstruction, masses or malignancies in the lungs, and pneumonia.
PTS: 1
CON: Assessment
28. ANS: 1, 3, 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical
assessment of respiratory function
Chapter page reference: 448-450
Heading: Assessment/Auscultation/Table 23.4 - Abnormal or Adventitious Lung Sounds
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
4
5
This is correct. Stridor, described as a high-pitched sound during inspiration
caused by airway obstruction of the throat or upper airway or spasm of the
airway, may be auscultated in patients with allergic reactions, epiglottis, and
laryngitis.
This is incorrect. Patients with COPD typically have fine or coarse crackles on
auscultation.
This is correct. Stridor, described as a high-pitched sound during inspiration
caused by airway obstruction of the throat or upper airway or spasm of the
airway, may be auscultated in patients with allergic reactions, epiglottis, and
laryngitis.
This is correct. Stridor, described as a high-pitched sound during inspiration
caused by airway obstruction of the throat or upper airway or spasm of the
airway, may be auscultated in patients with allergic reactions, epiglottis, and
laryngitis.
This is incorrect. Pleural friction rubs are auscultated in patients with pleurisy.
These sounds, described as grating or squeaking, are caused by inflammation in
the pleural space.
PTS: 1
29. ANS: 1, 2, 4
CON: Assessment
Copyright © 2020 F. A. Davis Company
439
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 4. Correlating relevant diagnostic examinations to respiratory function
Chapter page reference: 448
Heading: Auscultation/Safety Alert: Dyspnea
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1
2
3
4
5
This is correct. Patients who are reporting dyspnea demonstrate accessory
muscle use, adventitious breath sounds, cyanosis, retractions, and tachypnea and
should be referred for immediate medical intervention.
This is correct. Patients who are reporting dyspnea demonstrate accessory
muscle use, adventitious breath sounds, cyanosis, retractions, and tachypnea and
should be referred for immediate medical intervention.
This is incorrect. Patients with dyspnea who have worsening of respiratory
status will manifest tachypnea, not hyperventilation.
This is correct. Patients who are reporting dyspnea demonstrate accessory
muscle use, adventitious breath sounds, cyanosis, retractions, and tachypnea and
should be referred for immediate medical intervention.
This is incorrect. Vesicular are normal breath sounds.
PTS: 1
CON: Oxygenation
30. ANS: 2, 3, 5
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 6. Discussing changes in respiratory function associated with aging
Chapter page reference: 456-457
Heading: Age-Related Changes of the Respiratory System/Table 23.8 – Age-Related Changes of
the Respiratory System
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1
2
3
This is incorrect. The airways of older adults are more reactive than those of
younger adults.
This is correct. Kyphosis and osteoporosis of the thoracic vertebrae cause a
decrease in chest wall compliance.
This is correct. The decrease in function and strength of the intercostals and
Copyright © 2020 F. A. Davis Company
440
diaphragm increases inspiratory effort to maintain adequate ventilation.
4
5
This is incorrect. Older adults have an increased potential for hypercapnia and
hypoxia related to age-related changes that depress the cough reflex and
ventilatory response.
This is correct. There is an increase in neutrophils, along with a decrease in
macrophages that create chronic inflammation of the lung tissue in older adults.
PTS:
1
CON: Assessment
Copyright © 2020 F. A. Davis Company
441
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-old pregnant woman at 20 weeks’ gestation
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) “I went back to work.”
2) “I'm eating healthy foods now.”
3) “I continue to wake up coughing at night.”
4) “I have not had chills since I left the hospital.”
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
when planning this patient’s care?
1) Placing a ventilator in the room
2) Notifying other departments of the diagnosis
3) Placing the patient in a negative air flow room
4) Placing droplet and contact precaution signs on the patient room door
6. An older adult patient is admitted with pneumonia. Which manifestation is unexpected during the nurse’s
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?
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1) "You should avoid alcohol.”
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) “As you grow older, your immune system just quits working.”
2) “As you grow older, there is a decrease in the immune response, which puts you at greater
risk for developing an infection.”
3) “As you grow older, there in an overall increase in the speed and strength of your immune
response.”
4) “As you grow older, there is an increase in the number of B cells in the circulation, which
hinders the immune response.”
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) “I can't get the influenza vaccine due to my allergy to eggs.”
2) “I will get the influenza vaccine every year.”
3) “I will get the pneumococcal vaccine every fall.”
4) “I will get the pneumococcal vaccine as soon as I recover from this pneumonia.”
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
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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
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) “Different medication is used in the second PPD.”
2) “The treatment for TB is six months of medication, and we want to make sure the first
results of the first PPD were accurate.”
3) “The first PPD was not interpreted in the correct time frame of 48-72 hours.”
4) “There is an increased risk for a false-negative response for people who work in long-term
care facilities. The two-step is recommended to accurately screen for TB.”
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) “Multiple drugs are necessary to develop immunity to tuberculosis.”
2) “Multiple drugs are necessary because I became infected from an immigrant.”
3) “Multiple drugs will be required as long as I am contagious.”
4) “Multiple drugs are necessary because of the risk of resistance.”
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) Stock the patient’s supply cart at the beginning of each shift
2) Wear a respirator mask and gown when caring for the patient
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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
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
pack of cigarettes per day. Which respiratory defense mechanism may have failed to cause the patient’s
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
treatment of tuberculosis because she saw that the child’s urine was orange. Which response by the nurse is
accurate?
1) “Encourage your child to drink cranberry juice.”
2) “An orange discoloration of urine is expected while your child is on this medication.”
3) “Bring your child to the clinic for a urinalysis.”
4) “Bring your child to the clinic for a radiograph of the kidneys.”
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
445
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) “Have you had a flu shot this year?”
2) “Is your cough productive?”
3) “Have you been exposed to anyone with the flu?”
4) “Are you having any trouble urinating?”
5) “Do you have dizziness?”
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) “Cover your cough” education
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
446
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.
4
Pregnant women, particularly during the second and third trimesters, are at increased 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
447
clearance.
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
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
448
Cognitive level: Application [Applying]
Concept: Infection
Difficulty: Moderate
Feedback
1
There is no indication that this patient will need a ventilator.
2
Placing signs on the door is the way to notify other departments of precautions.
3
Negative air flow rooms are for diseases such as chicken pox, measles, and SARS.
4
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.
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
449
1
2
3
4
Feedback
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.
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.
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.
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.
450
3
4
Patients with pneumonia are encouraged to increase fluid intake.
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
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
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
451
4
electrolyte imbalance.
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
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
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
452
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
1
There is no evidence to support the need to screen the patient for sickle cell disease,
herpes zoster, or sick sinus syndrome.
2
There is no evidence to support the need to screen the patient for sickle cell disease,
herpes zoster, or sick sinus syndrome.
3
There is no evidence to support the need to screen the patient for sickle cell disease,
herpes zoster, or sick sinus syndrome.
4
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.
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
453
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.
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
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.
454
2
3
4
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.
Single-door isolation with normal airflow might be used for a patient with droplet or
wound infection.
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
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
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
455
4
stomach.
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
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
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.
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
456
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
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
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
457
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.
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.
This is incorrect. Insufficient voiding and dizziness are not routine manifestations of influenza.
PTS: 1
CON: Oxygenation | Infection
27. ANS: 1, 2, 4
Chapter number and title: 24, Coordinating Care for Patients With Infectious Respiratory Disorders
458
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.
2.
3.
4.
5.
Feedback
This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching
children to wash their hands, and appropriate respiratory etiquette such as “cover your cough”
education all control the growth and spread of microorganisms.
This is correct. Sanitizing high-touch items such as toys and all contact surfaces, teaching
children to wash their hands, and appropriate respiratory etiquette such as “cover your cough”
education all control the growth and spread of microorganisms.
This is incorrect. Teaching parents’ safe food preparation and storage is another tool to 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
children to wash their hands, and appropriate respiratory etiquette such as “cover your cough”
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.
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
1.
2.
3.
4.
5.
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
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
459
precautions are usually not ordered for noncontagious infections.
PTS: 1
CON: Oxygenation
460
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
2. The nurse is caring for a patient being weaned from the ventilator, and wants to improve the patient’s ability
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 board
4) Using a Passy-Muir valve
6. When preparing to cap the patient’s tracheostomy tube with a speaking valve, which nursing action is
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
461
7. When capping the patient’s tracheostomy tube with a speaking valve, the nurse assesses the patient’s breath
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
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
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
462
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) “My skin may become red, tender, and peel.”
2) “I should avoid the sun while I am receiving this therapy.”
3) “I will wear soft, loose fitting clothing made of cotton to limit irritation.”
4) “My therapy includes washing my skin with a harsh soap and applying lotion.”
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) “I should increase my oral intake of water.”
2) “I will avoid spicy foods to decrease my discomfort.”
3) “I can chew gum to decrease the dry mouth that may occur.”
4) “I should use a firm-bristle toothbrush to ensure food particles are removed.”
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 further education from the nurse?
1) “I will eat small, frequent meals to ensure I get enough calories each day.”
2) “Even though I don’t like tomatoes, I will eat them since they are not acidic.”
3) “Liquid supplements are easy to swallow and will increase my caloric intake.”
4) “I will eat foods that taste good and are easy to eat and swallow to get enough calories each
day.”
463
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
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 high-Fowler’s position
4) 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
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
464
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) “Exercise decreases stress.”
2) “Exercise decreases anxiety.”
3) “Exercise decreases cravings.”
4) “Exercise increases weight loss.”
5) “Exercise increases my support network.”
465
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.
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
3. ANS: 4
CON: Oxygenation | Communication
466
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: 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]
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
467
Cognitive level: Comprehension [Understanding]
Concept: Communication; Oxygenation
Difficulty: Easy
Feedback
1
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.
2
Use of writing materials is useful for improving communication if the patient is alert and
strong enough to be able to use them.
3
A communication board is indicated if the patient is not strong enough to use writing
materials.
4
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
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
468
1
2
3
4
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.
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 | Medication
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
10. ANS: 3
CON: Inflammation | Medication
469
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
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 antihistamine.
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.
470
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
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.
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
471
1
2
3
4
Feedback
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.
Azelastine is an antihistamine nasal spray.
Fluticasone is a corticosteroid nasal spray.
Oxymetazoline is a decongestant nasal spray.
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
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
472
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
Feedback
1
An antiemetic agent is often prescribed to treat the nausea and vomiting that can occur
with chemotherapy.
2
A decongestant is more appropriate for a patient diagnosed with rhinitis.
3
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.
4
A corticosteroid is more appropriate for a patient diagnosed with rhinitis. A corticosteroid
can increase the patient’s risk of infection is prescribed and administered 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
increases the patient’s risk for bleeding.
2
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.
3
A red blood cell count is anticipated to monitor the patient for anemia, which can cause
fatigue.
4
A white blood cell count is anticipated to monitor the patient for neutropenia, which
increases the patient’s risk for infection.
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
473
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.
3
Liquid supplements are easy to swallow and increase the patient’s caloric intake when
used in additional to solid foods.
4
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
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.
474
2
3
4
Clarithromycin, a macrolide, is not recommended for empiric therapy of ABRS.
Amoxicillin-clavulante is recommended over amoxicillin alone for 5 to 7 days for
empiric therapy of ABRS.
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
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
Client Need: Physiological Integrity – Physiological Adaptation
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
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4
due to issues with airway clearance.
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
Feedback
1
Encouraging voice rest is important to decrease inflammation and edema, not aspiration.
2
Due to the edema and inflammation from the injury, an NPO status decreases the
patient’s risk for aspiration. NPO status is also encouraged prior to surgery for the same
reason.
3
Maintaining a high-Fowler’s position will decrease edema and maintain a patent airway.
4
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
1.
2.
3.
4.
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
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5.
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
1.
2.
3.
4.
5.
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.
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
1.
2.
3.
4.
5.
PTS: 1
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.
This is incorrect. While exercise is known to reduce the weight gain postcessation it is not
known to increase weight loss.
This is incorrect. Support groups, not exercise, increase the patient’s support network.
CON: Promoting Health
477
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) “Lung cancer cells have a low growth fraction, so they are less sensitive to antineoplastic
agents.”
2) “Lung cancer cells grow in a high-oxygen environment, so they are not very sensitive to
antineoplastic agents.”
3) “Lung cancer cells have been growing for a long time before detection, so they are less
sensitive to antineoplastic agents.”
4) “Lung cancer cells have a very erratic cell cycle, so they are not very sensitive to
antineoplastic agents.”
2. The nurse is caring for a patient in a community clinic who wishes to quit smoking. The patient asks the
nurse, “If I quit smoking, will my risk of lung cancer be the same as a nonsmoker?” Which is the best
response by the nurse?
1) “No one knows for sure what the risk is for someone who quits smoking.”
2) “Your risk of lung cancer will be equal to that of a nonsmoker.”
3) “Your risk of lung cancer will decline if you quit, but it will remain higher than a
nonsmoker’s.”
4) “Your risk of lung cancer will never drop because the damage has already been done.”
3. A male Hispanic patient has had a lung biopsy. The results indicate a poor prognosis for the patient. The
family is at the patient’s bedside and begins to moan and cry loudly. The health-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
cancer. Due to the patient’s poor nutritional status, chemotherapy is not an option. The health-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?
1) Provide palliative care to keep the patient comfortable without diagnostic testing
2) Perform any procedure necessary to diagnose the patient properly
3) Promote the use of blood tests to diagnose the suspected cancer
4) Determine the patient’s and family’s wishes regarding diagnostic testing
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
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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) “The doctor prefers this test.”
2) “To rule out the possibility that your problems are caused by pneumonia.”
3) “It is more specific in diagnosing your condition.”
4) “Why are you concerned about this test?”
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
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) “We’ll be sure to use the fireplace often to keep the house warm in the winter.”
2) “We will replace the carpet in our child’s bedroom with tile.”
3) “We’ll keep the plants in our child’s room dusted.”
4) “We’re glad the dog can continue to sleep in our child’s room.”
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. A patient asks why asthma medication is needed even though the patient’s last attack was several months ago.
Which response by the nurse is appropriate?
1) “The medication needs to be taken or your lungs will be severely damaged and we will not
be able to prevent an acute attack.”
2) “The medication needs to be taken indefinitely according to your doctor, so you should
discuss this with him.”
3) “The medication is still needed to decrease inflammation in your airways and help prevent
an attack.”
4) “The medication needs to be taken for at least a year; then, if you have not had an acute
attack, you can stop it.”
12. The nurse is instructing a patient who is prescribed ipratropium bromide (Atrovent) for asthma. Which should
be included in this patient’s teaching?
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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) “The medication widens the airways because it acts on the parasympathetic nervous
system.”
2) “The medication widens the airways because it stimulates the fight-or-flight response of
the nervous system.”
3) “The medication widens the airways because it decreases the production of histamine that
narrows the airways.”
4) “The medication widens the airways because it decreases the production of mucous that
narrows the airways.”
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?
1) Slightly diminished breath sounds
2) Decreased wheezing
3) Increased crackles
4) 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 asthma. When developing the patient’s plan of
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) “I need to rinse my mouth after every use of my inhaler.”
2) “I need to take my Singulair at least one hour before I eat.”
3) “I can resume my ephedra when I return home.”
4) “Because I am on theophylline, I will need to have therapeutic blood levels drawn.”
18. Which assessment finding supports the nurse’s suspicion that a patient is experiencing chronic obstructive
pulmonary disease (COPD)?
1) Dysrhythmias
2) Cyanotic nail beds
3) Clubbing of the fingers
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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
21. The nurse is providing care for a patient diagnosed with chronic obstructive pulmonary disease (COPD).
Which intervention is inappropriate to control the patient’s breathing pattern?
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 observ